Browse site A to Z

Search results

Go To Advanced Search

Papers Trust Board 28 March 2019

Description: Agenda Group Name: Date of Meeting: Venue: Time: Apologies to: Trust Board – Open Session 28 March 2019 Conference Room, Heartbeat Education Centre, F Level, North Wing, SGH 9.00am Sue Diduch, Corporate Affairs Administrator 9.00 1. Chair’s Welcome, Apologies and Declarations of Interest 2. Minutes of Previous Meeting held on 28 February 2019 3. Matters Arising/Summary of Agreed Actions 9.15 9.30 9.35 9.40 9.45 10.30 10.40 10.50 4. Quality, Performance and Finance 4.1 Patient Story (Derek Sandeman, Medical Director) 4.2 Briefing from Chair of Audit & Risk Committee for review (Simon Porter, Chair, A&RC) 4.3 Briefing from Chair of Quality Committee for review (Mike Sadler, Chair, QC) 4.4 Briefing from Chair of Strategy & Finance Committee for review (Jane Bailey, Chair, S&FC) 4.5 Integrated Performance Report for Month 11 including Quarterly Patient Experience Report (QIF) for review 4.6 Informatics Update for review (Jane Hayward, Director of Transformation & Improvement/ Adrian Byrne, Director of Informatics) 4.7 2018 NHS National Staff Survey Results for review (Paula Head, Chief Executive/Steve Harris, Director of Human Resources) 4.8 Finance Report for Month 11 for review (David French, Chief Financial Officer) Oral Oral Oral Oral 11.00 5. Chair’s and Chief Executive’s Reports 5.1 Chief Executive’s Report for review and Chair’s Actions for ratification (Paula Head, Chief Executive/Peter Hollins, Trust Chair) 11.05 6. Corporate Governance, Risk and Internal Control 6.1 Feedback from Council of Governors’ Meeting 12 March Oral 2019 to note (Peter Hollins, Trust Chair) 11.15 7. Any other business 8. To note the date of the next meeting: Tuesday, 30 April 2019 in the Conference Room, Heartbeat Education Centre, F Level, North Wing, SGH In Attendance: Adrian Byrne, Director of Informatics Steve Harris, Director of Human Resources Vicki Havercroft-Dixon, Head of Patient Relations (shadowing Gail Byrne) EXCLUSION OF PRESS, PUBLIC AND OTHERS The public and representatives of the press may attend all meetings of the Trust, but shall be required to withdraw upon the Board of Directors resolving as follows “that representatives of the press, and other members of the public, be excluded from the remainder of this meeting as publicity would be prejudicial to the public interest by reason of the confidential nature of the business to be transacted” 11.30-11.45 Follow-up discussion with governors Items Circulated: The following items have been circulated to the Board since the last meeting. Executive directors are happy to take questions from individual members, before the meeting, by e-mail or telephone, or to meet separately to discuss in more detail. 25 February 2019 Press Release: Hospital first to offer all patients chance to manage healthcare online 7 March 2019 Press Release: Eight-week breastfeeding supplement prevents weight loss in premature babies after discharge 12 March 2019 Press Release: Leading doctor warns use of blood test to diagnose heart attacks is “flawed” 15 March 2019 Press Release: Healthcare scientists “hamstrung” by lack of awareness and investment Trust Board Minutes – Open Session Minutes of the Open Trust Board meeting held on Thursday 28 February 2019, in the Conference Room, Heartbeat Education Centre, North Wing, University Hospital Southampton, commencing at 0900 and concluding at 1100. Present: Mr P Hollins, Trust Chair Mrs P Head, Chief Executive Mr D French, Chief Financial Officer & Deputy Chief Executive Mrs G Byrne, Director of Nursing & Organisational Development Ms J Hayward, Director of Transformation & Improvement Dr C Marshall, Chief Operating Officer Dr D Sandeman, Medical Director Mr S Porter, Senior Independent Director/Deputy Chair Ms J Bailey, Non-Executive Director Prof C Cooper, Non-Executive Director Ms J Douglas-Todd, Non-Executive Director Ms C Mason, Non-Executive Director Dr M Sadler, Non-Executive Director PTH PHe DAF GB JH CM DS SP JB CC JD-T CMa MS In Attendance: Mr C Helps, Interim Associate Director Corporate Affairs CH Mr N Pearce, Associate Medical Director for Patient Safety NP Mr M Green, Head of Bereavement Care MG Ms V Boland, Corporate Affairs Manager (minutes) VB Ms S Herbert, DHN/P, Division A (shadowing Mrs G Byrne) SH 1 member of staff 2 governors 19/19 20/19 Apologies Apologies were received from Jenni Douglas-Todd, Non-Executive Director. Chair’s Welcome, Opening Comments and Declarations of Interest The Chair welcomed everyone to the meeting, specifically welcoming back VB. The chair congratulated CMa for her successful appointment as Chair at Solent NHS Trust. Action By There were no declarations of a conflict of interest with any items on the agenda. 21/19 Minutes of Previous Meeting (Agenda item 2) The minutes of the meeting held on 31 January 2019 were AGREED as an accurate record subject to amendments to: 6/19c) the last sentence of the second paragraph was deemed inaccurate and should state that the key performance indicator (KPI) for emergency readmissions be reviewed for next year. 6/19g) date of the major incident that occurred on 30th November 2018 to be provided in full. 22/19 22/19 a) Matters Arising/Summary of Agreed Actions (Agenda item 3) Minute Ref 143/18a) Complexity of Employee Relations Cases and Minute Ref 159/18a) Integrated Performance Report (specifically relating to Diabetes) – It was agreed that the Trust Board Study Session forward plan would be discussed during the closed Board session, to include these items. Page 1 of 6 22/19 b) Minute Ref 6/19j) Staffing – GB confirmed that a more detailed update in relation to the appraisal target would be included in the next Human Resources Report. 22/19 c) The Board noted the latest position on the actions in summary of actions. 23/19 Quality, Performance and Finance Patient Story (agenda item 4.1) DS introduced the patient to the Board. The Board heard a first-hand account of their experience of the Trust’s services. It was noted that the patient felt their experience fell short of their expectations and provided specific examples where the standard of care was disappointing. The patient reported a high standard of care from medical staff. The importance of listening to patients and responding appropriately, and ensuring patients basic needs as well as medical needs were met was emphasised. The Board thanked the patient for attending and providing an overview of their experience noting the value of this. It was confirmed that this information would be used to improve the care provided by UHS. 24/19 Integrated Performance Report for Month 10 including Quarterly Infection Prevention & Control Report (Agenda item 4.2) a) Safe GB advised that there was nothing specific to highlight from the report. There were no further comments or questions. 24/19 b) Caring GB provided an update noting the initiatives being introduced to improve the quality of response to patient complaints and concerns. A patient panel has now been introduced to assist in collecting and understanding patient feedback. It was confirmed that this would be discussed in more detail at the March Quality Committee. The decrease in the percentage of patients with a nutrition care plan was noted. GB will be working with the matrons and ward leaders for areas that are not achieving the expected standard. 24/19 c) Effective DS advised that there was nothing specific to highlight from the report. MS sought additional detail in relation to the four national reports with areas of concern within section E1.2. DS gave a brief overview of these reports noting that diabetes will be scheduled for discussion at a future Trust Board Study Session. 24/19 d) Activity CM highlighted the increase in Emergency Department (ED) attendances compared to the previous January, the significant reduction in non-elective length of stay and the reduction in the percentage of elective operations cancelled as a result of this. The increase in ED attendances was attributed to the opening of the Paediatric ED. An increase had been anticipated however data was being reviewed to confirm the cause as increased paediatric attendances. PHe emphasised the importance of ensuring that the increased attendances do not adversely affect the patient experience. MS congratulated those involved in reducing non-elective length of stay. Page 2 of 6 24/19 e) Emergency Access CM provided an overview noting that ED performance was the average of our local peer group despite the significant increase in attendances. The time to initial assessment metric is currently under development following the introduction of a new triage process within ED. JB drew attention to the continued reduction in eye casualty performance noting the difficulties already within Ophthalmology. CM confirmed that this was being addressed and more detail could be provided if required. PHe introduced the “Best March Ever” concept. CM provided an overview of the steps being taken to achieve this including working with community providers to reduce delayed transfers of care and patients referred to ED, for example, by GPs. PHe added that ED targets were being reviewed and new targets were expected. 24/19 f) Referral to Treatment Time (RTT) CM summarised RTT performance noting improvements in the number of patients waiting over 18 weeks and the number of patients on an incomplete pathway. Patients waiting longer than 52 weeks had been reviewed; patient choice was the reason for delay and there were no clinical concerns due to delayed treatment. 24/19 g) Cancer CM provided an overview of Cancer performance noting a number of measures had not been achieved. CM outlined a recent visit to the Imperial group of hospitals to learn about data analysis that enables better forward prediction and therefore providing more insightful information for the organisation/Board. MS noted the 6-8% increase in cancer activity year on year and suggested that the executive team consider a more a transformational change to address this to ensure this does not have an adverse effect on patients. JH emphasised the increased pressure on services due to identification of cancer at an earlier stage and new initiatives such as lung cancer screening. This would provide better outcomes for patients however would increase the number of patients being treated; this therefore needs to be planned for as part of the Trust’s strategy. PHe summarised the work that is ongoing with commissioners and the Cancer alliance to enable providers to achieve the cancer targets with the increased activity. It was agreed that further information be provided to the Board in relation to this. Action: Update in relation to planning for cancer targets to be provided to the PHe Board. GB noted that a process for reviewing harm as a result of patients waiting longer than 104 days for cancer treatment was being agreed with commissioners. CC queried whether there was any data providing a longer term perspective i.e. over the past five years. JH confirmed this could be made available if requested. 24/19 h) Infection Prevention Report GB provided an update noting that there would be a hand hygiene campaign in March/April 2019 which should have a direct impact on infection control. 24/19 i) Staffing GB summarised the challenges currently being experienced with nurse staffing particularly due to vacancy levels and the steps taken to address this on a daily basis. Page 3 of 6 24/19 j) RESOLVED That the Board NOTE the Month 10 Integrated Performance Report including the Quarterly Infection Prevention & Control Report. 25/19 Learning from Deaths Quarter 3 Report (Agenda item 4.3) a) DS and NP introduced the report. MS thanked NP for a clear report and the reassurance provided by the small number of avoidable cases. MS sought clarification of the personnel involved in reviewing cases and whether any audits were undertaken to ensure the process was working effectively. NP described the process in use. A new medical examiner service would commence in April. PTH queried whether the process identified the consequences for patients who had experienced repeated delays in treatment. NP advised that previous admissions were reviewed however a more formal process would be instigated once the medical examiner service was in place. CC asked whether there was potential for external validation and comparison of availability. NP has been working with other Trusts to ensure their processes mirror UHS’ to allow a comparison between organisations. JH informed the Board that the Hospital Standardised Mortality Ratio (HSMR) is expected to change from April once Countess Mountbatten Hospital becomes independent from the Trust. 25/19 b) RESOLVED That the Board NOTE the Learning from Deaths Quarter 3 Report. 26/19 Freedom to Speak Up Report (Agenda item 4.4) a) GB presented the report summarising the work undertaken and cases received to date. CC confirmed that all cases appeared to have been dealt with appropriately and had not required his involvement. CMa queried whether any trends had been identified so far. GB advised that some cases were protracted Human Resource cases where action had previously been slow. Learning points were being shared when possible, given the need for confidentiality, and this was encouraging others to speak out. 26/19 b) RESOLVED That the Board NOTE the Freedom to Speak Up Report. 27/19 CRN: Wessex 2018/19 Quarter 3 Performance Report (Agenda item 4.5) a) DS provided an overview of the report noting the good performance of the network. MS asked when the last review by the National Institute for Health Research (NIHR) had taken place and the outcome of this. DS confirmed that this took place 6 to 8 weeks ago and positive feedback had been received. MS asked that this information be included in future reports. Action: Future reports to include the outcome of NIHR reviews. DS 27/19 b) RESOLVED That the Board Page 4 of 6 28/19 Briefing from Chair of Strategy & Finance Committee (Agenda item 4.6) a) JB provided an overview of items discussed at the February meeting: • Outcome of 2017/18 reference cost index submission. • Review of latest financial position. • Operational plan 2019/20 update. 28/19 b) RESOLVED That the Board NOTE the update. 29/19 Finance Report for Month 10 (Agenda item 4.7) a) DAF presented the month 10 Finance report, noting for January: • The Trust delivered a control total surplus excluding Provider Sustainability Fund (PSF) of £2.8m. Year to date the Trust is on plan. • In month once non-recurrent items were excluded was break-even, against a Plan target of £2.8m surplus. • Under the single oversight framework the Trust delivered a score for Finance and Use of Resource of a ’1’. • Cost Improvement Plan (CIP) delivery in the month was £2.5m against a target of £2.8m. • Pay has increased by £1m since month 9 due to an increase in substantive, bank and agency costs month-on-month. A proportion related to December pay enhancements for bank holidays. PTH highlighted elective income as £2.9m behind plan year to date. This was attributed to gaps in spinal and cardiac surgery; these tend to be high value cases. PHe noted that whilst the Trust performed well against the NHS Improvement temporary staff pay ceiling, the total head count had increased. DAF confirmed that the data will be reviewed to better present the overall position. CMa asked whether the invest-to-save negative variance related to delays in the replacement of Princess Anne Hospital (PAH) windows. DAF advised that this related to delays in some estates projects such as PAH windows and theatre modernisation due to the requirement to close services to enable work to be undertaken. 29/19 b) RESOLVED That the Board NOTE the month 10 Finance Report. Chair’s and Chief Executive’s Reports 30/19 Chief Executive’s Report (Agenda item 5.1) a) PHe provided an overview of the requirement for the Trust to formally report progress with the flu vaccination programme and approve the achievement of 7 day services standards self-assessment. MS drew the Board’s attention to the percentage of staff concerned about possible side effects from the flu vaccine despite the evidence available to support that they are limited and manageable. PHe highlighted the importance of influencing perceptions of the vaccine and the need for the Trust to target its messages. DS plans to target messages by staff group. 30/19 b) RESOLVED That the Board NOTE the Staff Flu Vaccinations Update and APPROVE the Achievement of 7 day Services Standards Self-Assessment. Page 5 of 6 30/19 c) Items for Ratification Actions taken by the Chair as set out in paragraphs 3.1 – 3.2 were ratified. Strategy and Business Planning 31/19 Revised Equality, Diversity and Inclusion (EDI) Strategy (agenda item 6.1) a) GB presented the updated strategy which has been consulted upon and comments considered and included where appropriate. MS supported the amended strategy. CMa identified that the ‘white other’ group was classified differently within different sections of the strategy. Action: Ethnic group classifications to be consistent within the Strategy. GB The Board discussed the difference between reducing equality and reducing inequity and how this can be addressed alongside the wider health system. 31/19 b) RESOLVED That the Board APPROVE the Equality, Diversity and Inclusion Strategy subject to one minor amendment as outlined above. 32/19 32/19 a) Any Other Business MS provided an update on the recent Diabetes screening event held at the Southampton FC v Cardiff FC football match. 103 people were tested and 2 cases of undiagnosed diabetes identified. The event raised awareness as well as highlighted the value of co-operation between the organisations involved. PHe thanked those involved for their hard work in organising this event. 33/19 Date and Time of Next Meeting Thursday, 28 March 2019 commencing at 0900 in the Conference Room, Heartbeat Education Centre, F Level, North Wing, SGH. Page 6 of 6 UHSFT – Directors’ Actions Summary for 28 March 2019 Trust Board – Open Session ___________________________________________________________________________________________________________________________________________ Action & Minute Reference By whom Target Date Current Status Trust Board 28 February 2019 Integrated Performance Report for Month 10 (Minute Ref 24/19 g) Cancer - Update in relation to planning for cancer targets to be PHe provided to the Board. CRN: Wessex 2018/19 Quarter 3 Performance Report (Minute Ref 27/19 a) Future reports to include the outcome of NIHR reviews. DS Revised Equality, Diversity and Inclusion (EDI) Strategy (Minute Ref 31/19 a) Ethnic group classifications to be consistent within the Strategy. GB as at 18/3/19 Page 1 of 1 Cover sheet for a report to the Trust Board of Directors dated Thursday, 28 March 2019 Title: Integrated Performance Report Month 11 Category Quality, Performance, and Finance Agenda item 4.5 Sponsor Director of Transformation and Improvement Author Trust Performance Manager Provenance Report to the Board provided by the Trust Executive. Purpose The paper is presented for the Board for Review The Board is requested to consider the performance metrics provided, identify any elements, trends or emerging themes it wishes to pursue further. Relevant to Board  Goal 1 – Trusted on  Goal 2 – Delivering for  Goal 3 – Excellence in goals Quality Taxpayers Healthcare Board Assurance This report relates to all of the aims and objectives contained in the Board Framework links Assurance Framework. Equality Impact Assessment The Trust aims to ensure that any change in performance does not affect one or more cohorts of people with specific protected characteristics. This equality monitoring is conducted operationally. Other standards affected NHS Provider Licence and Constitutional standards. Integrated KPI Board Report covering up to Feb 2019 Executive Sponsor - Jane Hayward, Director of Transformation Jane.Hayward@uhs.nhs.uk March 2019 Overview Safe Amber Caring Green Safe remains amber this month as UHS has failed some KPI's yet we have seen continued good performance in other areas. There were no never events reported in February. There were no avoidable high harm falls or MRSA infections/contaminants in February. C.Diff performance remains better than year to date target. In 18/19 the Trust planned to reduce pressure ulcers by 20% compared to last year, this trajectory has not be met in 18/19, however to date the number of pressure ulcers is very similar year on year. The themes are being collated and the learning is being shared through Pressure Ulcer Panel. VTE risk assessments remain an area of focus for the Trust with the new IT solution being piloted in AMU, Surgery and T&O in January 2019. A decision will be made in March by the Thrombosis committee to roll out trust wide. Complaints were low during November, December and January and increased slightly to levels seen previously in February. The rate of complaints against activity level remains consistent and within target range. Negative ratings through the FFT are under the trust threshold with patients continuing to rate their experience positively. Same Sex Accommodation breaches have fallen to under the trust target. Effective Green There were four national reports published and reviewed in Feburary, of these reports one raised an area of concern (National prostate Cancer Audit Annual Report 2018). There are now 218 outcomes being reported to TEC from 46 specialities. Of these the majority are green (78%) and only 7% graded red. Emergency readmissions was at 10.8% in December which is just below the average of last 2 years (11%). HSMR remained stable in November well below the national benchmark and crude mortality dropped slightly to 3.7% Activity Red Flow Amber New referrals recieved are following expected seasonal variation but continue to be higher than 18/19 in the month, quarter and year to date. New urgent cancer referrals in January did not decrease as seen last year instead are showing a 16% increase in the month. Main ED attendances remain exceptionally high in February compared to previous years. This is contrary to the normal seasonal trend which sees a reduction in the volume but not complexity of attendances, paediatric attendances have increased the most, but other streams also have increased compared to 17/18. There have been a number of changes year on year in services provided and how services are recorded that make year on year comparison difficult, this includes the Lymington surgical services and outpatients (up from August 17, impacts electives and outpatients), the change in TrehceoardveinrgagCeDnUucmhbaeirrso(df oDwelnayfreodmTrSaenpstfeemrsboefrC1a7r,eiminptahcetsTrounstnoinnFeelbercutiavreys)r,etmheairneecdoradti9n4g.oTfhtehenuremsbpeirraotofrpyacteiennttrsew(Ahporihla1v8e, dbaeyecnaisnehs otospoituatlpfaotriegnrtesa)t.er than or equal to 7 days / 21 days also increased yet remained lower than February 2018 by 2% and 4% respectively. Emergency Access Main ED (Type 1) performance reduced in February to 71.4%, compared to UHS February 2018 77.2%, and were 4.8% below the average of our local peer group. This performance was impacted by ED attendances significantly exceeding volumes in previous years and the onset of winter pressures in the inpatient service. Red RTT & Diagnostics Both RTT and diagnostic performance improved again in February. The trend of patients waiting greater than 52 weeks continues downwards and the patients waiting at the end of February have now been treated. Amber Diagnostic performance also improved and achieved the target in February. Pleasing to see Average weeks waited for first outpatient appointment continues to reduce. Cancer Red Cancer performance is currently rated red as we are not achieving a number of measures. Recovery of the Treatment started within 62 days of urgent GP referral wait, is likely to be slow and significant challenges are being experienced linked to significant growth in referrals and the number of additional cancers being treated (192 year to date). Improving trends in waiting times for initial appointment, waiting times for radiology and patients waiting for treatment are encouraging. Research & Dev Research and Development has been rated Amber this month. October recruitment benefitted from activity on a high recruiting meningitis prevention study. Whilst recruitment to this study has ended recruitment Amber projections to year end are satisfactory. Complexity (weighted) performance is also satisfactory with UHS ranked 2nd in the UK for a number of consecutive months. Staffing Amber Staffing remains amber overall because some key targets have been missed including those for turnover, non-medical appraisal completion, total nursing and registered nurse vacancy rates. However, UHS has seen improvements in the following: sickness absence (which has never been lower), turnover (the lowest rate since November 2017), decreases in total nursing and registered nurse vacancy rates and percentage of BME staff at Band 7+ (the highest rate it has been). CHPPD is within normal range this month as expected, after seasonal effects in January and it reflects high patient numbers. Estates Green Estates has been rated green this month as we are meeting all targets in February. The target missed on a 3 month rolling average is for percentage of help desk requests completed on time. Digital Green DigiRounds has demonstrated both time saving in reviewing the patient record during ward rounds, but also the quality of the review that is carried out, as clinicians are able to easily see all the significant elements of the record. It saves junior doctors time in preparing information for consultants (transcribing relevant results etc) prior to the ward round. Records accessed using Digirounds increased to 98,573 in February. Also in February the number of alerts sent using Medxnote increased again to 4079. 1 Chart Type Cumulative Column Example Cumulative Column Year on Year Line Benchmarked Line Percentiles Control Chart Variance from Target Report Guide Explanation A cumulative column chart is used to represent a total count of the variable and shows how the total count increases over time. This example shows quarterly updates. A cumulative year on year column chart is used to represent a total count of the variable throughout the year. The variable value is reset to zero at the start of the year because the target for the metric is yearly. The line benchmarked chart shows our performance compared to the average performance of a peer group. The number at the bottom of the chart shows where we are ranked in the group (1 would mean ranked 1st that month). A line percentiles chart is used to represent the distribution of a variable. The 50th percentile shows the median value, we also show the 5th, 25th (lower quartile), 75th (upper quartile) and 95th centiles. A control chart shows movement of a variable in relation to it's control limits (the 3 lines = Upper control limit, Mean and Lower control limit). When the value shows special variation (not expected) then it is highlighted green (leading to a good outcome) or red (leading to a bad outcome). Values are considered to show special variation if they -Go outside control limits -Have 6 points in a row above or below the mean, -Trend for 6 points, -Have 2 out of 3 points past 2/3 of the control limit, -Show a significant movement (greater than the average moving range). Variance from target charts are used to show how far away a variable is from it's target each month. Green bars represent the value the metric is achieving better than target and the red bars represent the distance a metric is away from achieving it's target. 2 March 2019 Safe Safe remains amber this month as UHS has failed some KPI's yet we have seen continued good performance in other areas. There were no never events reported in February. There were no avoidable high harm falls or MRSA infections/contaminants in February. C.Diff performance remains better than year to Amber date target. In 18/19 the Trust planned to reduce pressure ulcers by 20% compared to last year, this trajectory has not be met in 18/19, however to date the number of pressure ulcers is very similar year on year. The themes are being collated and the learning is being shared through Pressure Ulcer Panel. VTE risk assessments remain an area of focus for the Trust with the new IT solution being piloted in AMU, Surgery and T&O in January 2019. A decision will be made in March by the Thrombosis committee to roll out trust wide. MMoonntthhllyy Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Target YTD YTD Target S1.1 Never Events 1 1 1 - 3 0 1 S1.2 Avoidable High Harm Falls =95% 98% > =95% S1.12 % Thromboprophylaxis . Patients Assessed 95% 93.3% 92.8% > =95% 93% > =95% S1.12 - The IT solution within e prescribing was piloted from 24th January. This has demonstrated improvements in compliance particularly in AMU. This will be seen in April's report containing Feb data. There will be a discussion at thrombosis committee on 21st march about whether we can roll out the IT solution trust wide to increase compliance further. 100% S1.13 Patients appropriately . screened for sepsis 76% 76% 85% 98% 98% 60% 90% S1.14 Sepsis Patients Treated in a . timely manner 82% 77% 86% 82% 85% 60% 90% - - 90% - - 4 March 2019 Caring Green Complaints were low during November, December and January and increased slightly to levels seen previously in February. The rate of complaints against activity level remains consistent and within target range. Negative ratings through the FFT are under the trust threshold with patients continuing to rate their experience positively. Same Sex Accommodation breaches have fallen to under the trust target. C1.1 FFT response rate - Inpatients Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb 27% 15% 9% Monthly Target > =20% 0% 0.9% C1.2 FFT Negative Score - Inpatients 5% 0.9% =20% 2.4% =95% 75% C1.6 Although we are maintaining above 90% we are still not reaching 95%. Therefore some focus work to drive this is being done with the ward areas that are consistently achieving below this requirement, as this is reflective of a small pocket of areas. C1.7 Total Complaints Received . 37 48 40 33 44 37 43 44 44 32 50 28 31 32 42 - C1.8 Complaints per 1000 units . 0.50 0.42 0.00 500 C1.9 Bereavement Survey Response Count 0 15% C1.10 Bereavement Survey Negative Score Core Questions - % 0% C1.9/C1.10 - Figures will be updated quarterly (next month) 0.42 =7days Census average 550 Extended LOS Census average 300 256 RF1.8 (Patients with LOS > =21days) 94 =30% 20.9% 66.2% > =80% 95.5% 90-95% 2 8 4 44 46 44 41 42 19 1 12 15 29 32 8 56 40 3 - 150 77 84 - 0 YTD 23.84% 63.17% - RF1.13 - currently undertaking investigation to understand cancelled operations figures 55 RF1.14 Last minute cancelled operations not 5 . readmitted within 28 days 0 2 - - RF1.15 % elective operations cancelled and not 5% 6.5% . readmitted within 28 days 2.4% 314445224641146 70% 100% 92.3% 94.9% RE1.2 Eye Casualty (Type 2) 90.4% - RE1.3 Lymington MIU (Type 3) 85% 100% 99.7% 99.4% 99.6% - 95% RE1.4 UHS Total 85% . . 70% 97% RE1.5 Local Delivery System . . 80% 82.1% 87.5% 90.0% 81.5% 77.9% > =90% 95.0% 83.3% 85.9% > =95% UHS Total (RE1.4) includes SGH all types and lymington. Local Delivery System (RE1.5) is UHS Total and Southampton Treatment Centre (RSH MIU). 14 March 2019 Emergency Access Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Target R-3M RE1.6 % patients who left the department 5% 4.7% . before being seen UHS Total 6.8% =92% 80% 4700 4111 3993 RR1.2 Total patients waiting over 18 weeks (in . backlog) - 1700 7 RR1.3 . Patients waiting > 52 weeks for treatment 2 0 RR1.4 Total number of patients on an . incomplete pathway RR1.5 Patients on a surgical waiting List 36000 26000 6900 5900 7,700 RR1.6 Patients waiting for diagnostics RR1.7 . RR1.8 . 5,500 4% % of Patients waiting over 6 weeks for diagnostics 0% Average weeks waited for first outpatient 9.5 appointment 6.5 30978 6541 6651 3.65% 8.44 30037 31297 6701 - 7700 - 0.71% 93% 41 of 1513 90% RC1.2 . Breast symptoms referral seen in 2 weeks 69.1% 25.9% 50.7% => 93% 32 of 75 51% RC1.1 & RC1.2 - Performance has improved significantly in January and February following commencement of a new Consultant Radiologist in post in January. RC1.3 Treatment started within 62 days of . urgent GP referral 89.4% 79.9% 70.5% => 85% 71.4% 18 of 134.5 71% RC1.4 Treatment started within 62 days of . referral (Breast, Cervical & Bowel . Screening) 87.8% 72.0% RC1.4 - All 5 January breaches related to breast surgery RC1.5 62 Day - Consultant Upgrades 86.00% 54.2% => 90% 3 of 24 79% 79.17% 85.71% => 86% 0 of 3.5 86% 17 March 2019 Cancer Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Target no. patients to recover target QTD RC1.6 Treatment started within 31 days of . decision to treat 98.7% 94.9% 91.1% RC1.6 Half of the 41 breaches in January related to either Urology (mainly Prostate) or Breast Surgery => 96% 27 of 341 88% 87.98% Second or subsequent treatment (surgery) RC1.7 started within 31 days of decision to treat 89.5% 76.0% RC1.7 - Approximately 2/3 of the breached pathways in January were for skin surgery, and the remaining pathways were for prostate surgery => 94% 16 of 118 81% 80.51% Second or subsequent treatment (anti 100% RC1.8 cancer drugs) started within 31 days of decision to treat 95% 100% Second or subsequent treatment RC1.9 (radiotherapy) started within 31 days of decision to treat 95% 100.00% 100.00% 100.00% => 98% 0 of 172 100% 99.05% => 98% 0 of 211 99% RC1.10 104 day waits (treated in month) 16 16 16 11 18 20 17 23 26 17 - - - Principal reasons impacting RC1.10 are prostate surgery (same as RC1.3 & RC1.7), also late referrals of patients referred from other trusts and extended waits due to patient choice. 18 March 2019 Research and Development Amber Research and Development has been rated Amber this month. October recruitment benefitted from activity on a high recruiting meningitis prevention study. Whilst recruitment to this study has ended recruitment projections to year end are satisfactory. Complexity (weighted) performance is also satisfactory with UHS ranked 2nd in the UK for a number of consecutive months. CRN Recruitment WR1.1 Participants Recruited WR1.2 Weighted Recruitment WR1.3 Weighted National Ranking - All Studies WR1.4 Specialties Recruiting Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb 3000 YTD YTD Target 1602 500 13,729 7,501 1,273 10842 1 1 1 1 2 2 3 4 4 4 5 6 57 1236 12073 14473 60396 60217 - Top 5 53 - tbc The number of research active UHS specialties has been introduced as a new metric this year in response to implementing the new research strategy and the aim for all specialties to be research active. Having identified whether a specialty is research active or not, we are now trying to understand levels of activity in relation to size of department for this to be more meaningful. BRC 200 WR1.5 Papers published in partnership with UOS 0 94 99 153 120 112 Number of BRC papers published are in line with expectations and more detailed analysis is informing the next BRC bid preparations. Activity/Staffing Balance £8,000 6531 WR1.6 Income per WTE £4,000 385 400 4878 - - 19 March 2019 Staffing Amber Staffing remains amber overall because some key targets have been missed including those for turnover, non-medical appraisal completion, total nursing and registered nurse vacancy rates. However, UHS has seen improvements in the following: sickness absence (which has never been lower), turnover (the lowest rate since November 2017), decreases in total nursing and registered nurse vacancy rates and percentage of BME staff at Band 7+ (the highest rate it has been). CHPPD is within normal range this month as expected, after seasonal effects in January and it reflects high patient numbers. WS1.1 HR - Turnover - Rolling 12-months Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Monthly Target 13.67% 13.17% 13.1% 13.0% 92% WS1.4 . Nursing Vacancies (Total Clinical Wards) 11% 13.04% =76% WS1.7 Statutory & Mandatory Training . Achieving Target - 5 5 7 6 7 7 7 7 7 7 8 9 8 8 8 9.5 7 7 5 6 5 5 5 5 5 5 4 3 4 4 4 WS1.8 Total nursing staff all inpatient areas - 8.4 . Care hours per patient day (CHPPD) 8.0 8.3 - WS1.8 The CHPPD for ward based areas in the Trust has decreased from last month to RN 3.7 (previously 3.8) HCA 3.3 (previously 3.3) overall 7.0 (previously 7.2). 6.0 WS1.9 Registered nursing staff all inpatient . areas - CHPPD 5.1 5.0 3.5 3.3 WS1.10 Unregistered nursing staff all inpatient . areas - CHPPD 2.5 5.1 - 3.2 - 9% WS1.11 Black & Minority Ethnic Band 7+ . Percentage 7.5% 7% WS1.11 UHS has a target of 15% Band 7+ BME staff by 2023. WS1.12 Quality of practice experience for doctors . in training (annual report with quarterly . qualitative updates) Minor Risk Minor Risk Minor Risk Minor Risk 8.3% - Minor Risk No risk 21 March 2019 Estates Green Estates has been rated green this month as we are meeting all targets in February. The target missed on a 3 month rolling average is for percentage of help desk requests completed on time. Reactive Maintenance Monthly Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Target 2500 R-3M PE1.1 Number of defect work orders and 1300 2197 - - 2078 percentage completed on time 86.2% 86.7% > 85% 89.2% Preventative Maintenance 74.42% 200 PE1.2 Number of statutory maintenance jobs planned and percentage 50 69 - - 131 completed on time 98.6% 94.09% > 95% 98.3% 98.5% 600 308 PE1.3 Number of mandatory maintenance jobs planned and 250 percentage completed on time 98.8% 96.13% 419 - - 99.5% > 95% 99.5% PE1.4 Number of routine maintenance jobs planned and percentage completed on time 125 75 97.7% 92.29% 80 98.8% 88 - 100.0% > 85% 99.7% 2500 PE1.5 Number of Help desk requests and 1000 percentage completed on time 100% 85% Unresolved help desk requests PE1.6 Unresolved help desk requests PE1.7 (over 30 days old) 50% 1500 500 600 1000 200 0 1737 82.3% 1007 498 1640 - 86.6% > 85% 84.3% 569 =95% - - SD1.4 acknowledgment > =95% - - through eQUEST - rolling 3M 85% Release 29 of CHARTS goes live on 23rd January 2019. This includes enhancements to histopathology requesting from the Endoscopy Unit and should result in an increase in both requesting and acknowledgment - this will first appear in the April 2019 data extracts. SD1.5 digiRounds patient records accessed 200000 0 98573 eQuest Results Alerts Sent SD1.6 Decision support notifications (email alerts) 20,000 9345 0 5000 SD1.7 Medxnote 4079 0 SD1.8 InfoQlik (Daily) Activity 50 20.1 35.4 0 100 SD1.9 Sap BI (Daily) Activity 40.0 0 500 351 SD1.10 My Medical Record - UHS patient registrations 0 2,000 SD1.11 My Medical Record - UHS patient logins 968 0 23 March 2019 Changes and Corrections Page Staffing KPI WS1.11 KPI Name Type Black & Minority Ethnic Band 7+ Change - Display Percentage Detail Long term target added 24 • Improvements made to the processes for managing complaints have driven significantly better performance in the timeliness of responses. For January and February, the trust closed 82% of complaints within 35 working days, with an average response time of 30 working days. This is a significant improvement from Q3 where the trust closed just 42% of complaints in the timeframe, with an average response time of 38 working days. • The complaints quality improvement work continues to deliver benefits for patients. The trust has slightly increased the % of complaints being managed informally to 44% of the overall number received (compared to 42% this time last year). There is a plan to return to clearly distinguishing between the PALS function and formal complaints process, and this will likely improve this further and offer patients and families greater access to support in getting early resolution to their concerns. • Good progress is being made in improving how the trust supports patients and carers with disabilities through compliance with the Accessible Information Standard. A flag is now available in ECAMIS, which pulls through into other systems, to alert staff that a patient has information and / or communication support needs. There is also a Staffnet resource to guide staff in how to meet needs. The Experience of Care team are currently working on a number of projects to enable needs to be identified and recorded on the system, while project teams on E2 ward and Princess Anne Outpatients work on embedding and testing the processes and resources. • Patient feedback remains generally high, although with more local variation in FFT feedback scores. Response rates have declined generally, with a significant factor being survey fatigue experienced by both patients and staff. While the FFT remains mandatory, it is often too generic to gain a sense of local ownership. With a new survey contract, the FFT will be augmented with more locally-relevant questions to better empower staff to use feedback to identify improvements, and this sense of ownership will drive better staff engagement and improve responses. Low recommend scores in ED are due to extremely low response rates. • A review of the trust’s provision of interpreting services is underway, with the aim of ensuring that patient needs are being met effectively and that the trust is receiving value for money. Part of this work is looking at the variability of interpreting provision across the trust, identifying areas for piloting efficiency improvement projects. There is a lack of data on how the impact of poor provision of interpreters (as well as other communication support) affects attendance rates, involvement in care, and overall experience- and this review will look at capturing some of this information. • The number of people applying to volunteer increased in Q3 to 98 (from 57 in Q2). Overall for the year to date, the trust has had 242 applications with 115 of these starting and a number of applications still being processed. Retention of volunteers continues to be an issue, with too many new volunteers still leaving within the first 6 months. The team is reviewing its support and supervision processes, but with 824 active volunteers, it remains an ongoing challenge. • The trust successfully bid for funding from the Pears Foundation to develop and grow a youth volunteering programme. The funding will be for two years and will pay for a project worker to lead on collaboration with local schools and colleges to provide short to medium term placements for young volunteers (16-18). • The trust welcomed the first cohort of employee volunteers from the local NHS England team in March. NHSE staff are able to take up to five days each year in order to volunteer within their local community and the trust has agreed a pilot with NHSE to test out new volunteer roles with the group to assess feasibility and value. This includes getting qualitative feedback from patients and carers, a new role in AMU, and supporting the pharmacy team. 25 Complaints PALS Friends & Family Test Volunteers Indicator Complaints received Complex concerns received Complaints closed within 35 days Average working day to close PALS contacts Inpatient positive score Outpatient positive score Maternity positive score ED positive score Applications received New starters Target Q1 Q2 Q3 Q4* n/a 124 120 109 74 n/a 88 91 110 42 = > 66% 64% 59% 42% 82% 95% 97% 97% 96% 97% = > 95% 95% 96% 96% 93% = > 95% 99% 97% 90% NA = > 95% 94% 96% 85% 71% n/a 87 57 98 NA n/a 57 28 30 NA * Data is provisional and for the quarter to date. NA denotes data not yet available. Jan 32 24 81% 31 324 Feb 42 19 78% 30 275 26 Nursing and midwifery staffing hours - February 2019 Report notes Our staffing levels are monitored daily and we will risk assess and fill any gaps to ensure that safe staffing levels are always maintained The total hours planned is our planned staffing levels to deliver care across all of our areas but does not represent a baseline safe staffing level. We plan for an average of one registered nurse to every five or seven patients in most of our areas but this can change as we regularly review the care requirements of our patients and adjust our staffing accordingly. Staffing on intensive care and high dependency units is always adjusted depending on the number of patients being cared for and the level of support they require. Therefore the numbers will fluctuate considerably across the month when compared against our planned numbers. Enhanced Care (also known as Specialling) Occurs when patients in an area require more focused care than we would normally expect. In these cases extra, unplanned staff are assigned to support a ward. If enhanced care is required the ward may show as being over filled. If a ward has an unplanned increase or decrease in bed availability the ward may show as being under or over filled, even though it remains safely and appropriately staffed. CHPPD (Care Hours Per Patient Day) is a measure which shows on average how many hours of care time each patient receives on a ward /department during a 24 hour period - this will vary across wards and departments based on the specialty, interventions, acuity and dependency levels of the patients being cared for. The maternity workforce consists of teams of midwives who work both within the hospital and in the community offering an integrated service and are able to respond to women wherever they choose to give birth. This means that our ward staffing and hospital birth environments have a core group of staff but the numbers of actual midwives caring for women increases responsively during a 24 hour period depending on the number of women requiring care. WARD C4 (Solent ward) C4 (Solent ward) C6 C6 C6 (Teenage Cancer Trust unit) C6 (Teenage Cancer Trust unit) D2 D2 D3 D3 Surgical high dependency unit Surgical high dependency unit Registered nurses Total hours planned Registered nurses Total hours worked Unregistered staff Total hours planned Unregistered staff Total hours worked Registered nurses % Filled Day Night Day Night Day Night Day Night Day Night 1303.5 975.5 2572.1 1850.0 645.0 610.8 1196.0 943.0 1507.9 944.8 1230.8 910.8 2267.3 1740.5 661.3 513.0 1184.8 943.8 1325.9 932.4 915.0 644.0 174.5 0.0 332.2 0.0 1055.5 770.5 731.5 641.3 1281.3 829.0 209.5 99.5 166.2 79.0 1136.4 816.5 799.0 798.8 94.4% 93.4% 88.1% 94.1% 102.5% 84.0% 99.1% 100.1% 87.9% 98.7% Day Night 1962.1 1843.2 1865.4 1831.7 312.4 322.0 374.7 321.0 95.1% 99.4% Unregistered staff % Filled t Comments 140.0% Safe staffing levels maintained; Support workers used to maintain staffing numbers. 128.7% Safe staffing levels maintained; Support workers used to maintain staffing numbers. 120.1% Support workers used to maintain staffing numbers. Shift N/A Safe staffing levels maintained. 50.0% Safe staffing levels maintained; Staffing appropriate for number of patients. Shift N/A Staffing appropriate for number of patients; Staff moved to support other wards. 107.7% Safe staffing levels maintained. 106.0% 109.2% Safe staffing levels maintained. Safe staffing levels maintained. 124.6% Safe staffing levels maintained. 119.9% 99.7% Safe staffing levels maintained. Safe staffing levels maintained. Page 1 of 5 Cardiac intensive care unit Cardiac intensive care unit General intensive care unit A General intensive care unit A General intensive care unit B General intensive care unit B Neuro intensive care unit Neuro intensive care unit E5A E5A E5B E5B E8 E8 F11 F11 F6 F6 F5 F5 Acute medical unit Acute medical unit D5 D5 D6 D6 D7 D7 Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night 4911.3 4752.0 4116.4 3848.5 3657.1 3526.0 4334.7 3836.5 1151.2 645.0 1274.0 639.0 1961.3 961.0 1914.6 966.0 2016.5 966.5 1821.0 966.0 3826.1 3202.5 1621.6 972.6 1079.3 667.3 841.7 645.0 4309.8 3986.0 3757.0 3793.5 3438.1 3140.0 4218.1 3649.5 904.2 587.0 1117.0 622.5 1356.9 978.3 1236.9 814.0 1535.9 887.0 1172.9 828.0 3750.9 2871.3 1027.5 794.5 987.0 668.8 816.7 634.0 1123.8 794.3 890.5 644.0 507.8 322.0 694.3 587.0 615.4 322.0 727.5 322.0 1496.0 860.0 726.2 322.0 620.9 644.0 876.4 644.0 3032.7 1808.5 957.0 524.0 1451.7 690.5 949.3 300.0 607.8 472.5 722.9 453.5 373.6 274.5 510.0 545.0 707.0 472.5 724.0 398.2 1592.6 1208.4 629.6 587.5 962.5 736.5 1415.2 1068.0 3772.3 2468.3 1250.1 1077.0 1373.0 777.0 1030.3 323.0 87.8% 83.9% 91.3% 98.6% 94.0% 89.1% 97.3% 95.1% 78.5% 91.0% 87.7% 97.4% 69.2% 101.8% 64.6% 84.3% 76.2% 91.8% 64.4% 85.7% 98.0% 89.7% 63.4% 81.7% 91.5% 100.2% 97.0% 98.3% 54.1% 59.5% 81.2% 70.4% 73.6% 85.2% 73.5% 92.8% 114.9% 146.7% 99.5% 123.7% 106.5% 140.5% 86.7% 182.4% 155.0% 114.4% 161.5% 165.8% 124.4% 136.5% 130.6% 205.5% 94.6% 112.5% 108.5% 107.7% Beds flexed to match staffing; Safe staffing levels maintained. Beds flexed to match staffing; Safe staffing levels maintained. Beds flexed to match staffing; Safe staffing levels maintained. Beds flexed to match staffing; Safe staffing levels maintained. Beds flexed to match staffing; Safe staffing levels maintained. Beds flexed to match staffing; Safe staffing levels maintained. Beds flexed to match staffing; Safe staffing levels maintained. Beds flexed to match staffing; Safe staffing levels maintained. Safe staffing levels maintained; Band 4 staff working to support registered nurse numbers. Safe staffing levels maintained;Additional staff used for enhanced care - Support workers. Support workers used to maintain staffing numbers; Band 4 staff working to support registered nurse numbers. Safe staffing levels maintained; Additional staff used for enhanced care - Support workers. Support workers used to maintain staffing numbers; Band 4 staff working to support registered nurse numbers. Safe s
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Trust-governance-and-corporate-docs/2019/Papers-Trust-Board-28-March-2019.pdf

Papers Trust Board 6 June 2024

Description: Date Time Location Chair Apologies Agenda Trust Board – Open Session 06/06/2024 9:00 - 13:00 Conference Room, Heartbeat/Microsoft Teams Jenni Douglas-Todd Diana Eccles, Tim Peachey (from 12:00) 1 Chair’s Welcome, Apologies and Declarations of Interest 9:00 Note apologies for absence, and to hear any declarations of interest relating to any item on the Agenda. 2 Patient Story The patient or staff story provides an opportunity for the Board to reflect on the experiences of patients and staff within the Trust and understand what the Trust could do better. 3 Minutes of Previous Meeting held on 28 March 2024 9:15 Approve the minutes of the previous meeting held on 28 March 2024 4 Matters Arising and Summary of Agreed Actions To discuss any matters arising from the minutes, and to agree on the status of any actions assigned at the previous meeting. 5 QUALITY, PERFORMANCE and FINANCE Quality includes: clinical effectiveness, patient safety, and patient experience 5.1 Briefing from the Chair of the Audit and Risk Committee (Oral) 9:20 Keith Evans, Chair 5.2 Briefing from the Chair of the Finance and Investment Committee (Oral) 9:25 Dave Bennett, Chair 5.3 Briefing from the Chair of the People and Organisational Development 9:30 Committee (Oral) Jane Harwood, Chair 5.4 Briefing from the Chair of the Quality Committee (Oral) 9:35 Tim Peachey, Chair 5.5 Chief Executive Officer's Report 9:40 Receive and note the report Sponsor: David French, Chief Executive Officer 5.6 Performance KPI Report for Month 1 10:00 Review and discuss the report Sponsor: David French, Chief Executive Officer 5.7 Finance Report for Month 1 10:30 Review and discuss the report Sponsor: Ian Howard, Chief Financial Officer 5.8 Break 10:45 5.9 People Report for Month 1 10:55 Review and discuss the report Sponsor: Steve Harris, Chief People Officer 5.10 Infection Prevention and Control 2023-24 Annual Report 11:10 Receive and discuss Sponsor: Gail Byrne, Chief Nursing Officer Attendees: Julian Sutton, Interim Lead Infection Control Director/Sue Dailly, Infection Prevention Matron 5.11 Learning from Deaths 2023-24 Quarter 4 Report 11:20 Review and discuss the report Sponsor: Paul Grundy, Chief Medical Officer Attendee: Jenny Milner, Associate Director of Patient Experience 5.12 Freedom to Speak Up Report 11:30 Review and discuss the report Sponsor: Gail Byrne, Chief Nursing Officer Attendee: Christine Mbabazi, Equality & Inclusion Adviser/Freedom to Speak Up Guardian 5.13 Fuller Inquiry Report 11:45 Receive and note the report Sponsor: David French, Chief Executive Officer Attendee: Gavin Hawkins, Divisional Director of Operations, Division B 6 STRATEGY and BUSINESS PLANNING 6.1 CRN Wessex 2023-24 Annual Performance Report 11:55 Receive and note the annual report Sponsor: Paul Grundy, Chief Medical Officer Attendee: Clare Rook, Chief Operating Officer, CRN: Wessex 6.2 Board Assurance Framework (BAF) Update 12:10 Review and discuss the update Sponsor: Gail Byrne, Chief Nursing Officer Attendees: Craig Machell, Associate Director of Corporate Affairs and Company Secretary/Lauren Anderson, Corporate Governance and Risk Manager Page 2 7 CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Feedback from the Council of Governors' (CoG) Meeting 1 May 2024 12:25 (Oral) Sponsor: Jenni Douglas-Todd, Trust Chair 7.2 Register of Seals and Chair's Actions Report 12:30 Receive and ratify In compliance with the Trust Standing Orders, Financial Instructions, and the Scheme of Reservation and Delegation. Sponsor: Jenni Douglas-Todd, Trust Chair 8 Any other business 12:35 Raise any relevant or urgent matters that are not on the agenda 9 Note the date of the next meeting: 25 July 2024 10 Resolution regarding the Press, Public and Others Sponsor: Jenni Douglas-Todd, Trust Chair To agree, as permitted by the National Health Service Act 2006 (as amended), the Trust's Constitution and the Standing Orders of the Board of Directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. 11 Follow-up discussion with governors 12:45 Page 3 Minutes Trust Board – Open Session Date Time 28/03/2024 9:00 – 13:00 Location Chair Microsoft Teams Jenni Douglas-Todd (JD-T) Present Dave Bennett, NED (DB) Gail Byrne, Chief Nursing Officer (GB) Jenni Douglas-Todd, Chair (JD-T) Keith Evans, Deputy Chair and NED (KE) David French, Chief Executive Officer (DAF) Paul Grundy, Chief Medical Officer (PG) Steve Harris, Chief People Officer (SH) Jane Harwood, NED/Senior Independent Director (JH) Ian Howard, Chief Financial Officer (IH) Tim Peachey, NED (TP) Joe Teape, Chief Operating Officer (JT) In attendance Martin De Sousa, Director of Strategy and Partnerships (MDeS) Craig Machell, Associate Director of Corporate Affairs and Company Secretary (CM) Lauren Anderson, Corporate Governance and Risk Manager (LA) (item 6.1) Ceri Connor, Director of OD and Inclusion (CC) (item 4.12) Diana Hulbert, Guardian of Safe Working Hours and Emergency Department Consultant (DH) (item 4.14) Sophie Limb, HR Project Manager (SL) (item 4.12) 1 member of the public (item 5) 6 governors (observing) 5 members of staff (observing) 1 members of the public (observing) Apologies Diana Eccles, NED (DE) 1. Chair’s Welcome, Apologies and Declarations of Interest The Chair welcomed attendees to the meeting. There were no interests to declare in the business to be transacted at the meeting. It was noted that apologies had been received from Diana Eccles. The Chair provided an overview of her activities since February 2024, including visits to hospital departments, meetings with peers and other key stakeholders. 2. Minutes of the Previous Meeting held on 30 January 2024 The draft minutes tabled to the meeting were agreed to be an accurate record of the meeting held on 30 January 2024, subject to amending a reference to ‘radiology’ on page four to ‘radiotherapy’. 3. Matters Arising and Summary of Agreed Actions It was noted that all actions had been completed or were not yet due. Page 1 In terms of action 1102, the service was provided by NHS Blood and Transfusion, and funding had been removed. 4. QUALITY, PERFORMANCE and FINANCE 4.1 Briefing from the Chair of the Audit and Risk Committee The chair of the Audit and Risk Committee was invited to provide an overview of the meeting held on 18 March 2024. It was noted that: • The committee had reviewed the losses and special payments report and noted that although the individual size of each occurrence was not material, these instances nonetheless did have a significant impact on individual patients. • The committee reviewed the Board Assurance Framework (item 6.1). • The committee reviewed an internal audit report on data quality and noted that there were only some minor matters to address. In addition, there were no outstanding actions from previous reports. • The committee reviewed the internal audit plan for 2024/25, which would include examination of long waiters, the discharge process and rostering. • The external audit plan for the 2023/24 financial year was agreed. 4.2 Briefing from the Chair of the Charitable Funds Committee Steve Harris was invited to provide an overview of the meeting held on 27 March 2024. It was noted that: • The charity was in a position to transfer to the new charitable company. • Gail Byrne would be appointed as a director of the new charitable company on a temporary basis to represent the Trust. • The annual report and accounts for 2023/24 would be the final item of business requiring Board approval. 4.3 Briefing from the Chair of the Finance and Investment Committee The chair of the Finance and Investment Committee was invited to provide an overview of the meeting held on 25 March 2024. It was noted that: • The committee reviewed the Finance Report for Month 11 (item 4.10) and the planning for 2024/25, noting that the underlying position presented a challenge for 2024/25. • The committee reviewed the Trust’s productivity assessed against that in 2018/19. The NHS England formula showed a 18% decline in the Trust’s performance. However, the basis of the formula was open to debate and the perception in the organisation was different given the demands on the Trust’s capacity. The Trust’s modified formula showed a lower decline in productivity and work was ongoing with the central team. • The committee reviewed the maintenance requirements in the Trust’s estate, which were significant owing to its age. • The committee reviewed the proposed capital prioritisation for 2024/25 and 2025/26. 4.4 Briefing from the Chair of the People and Organisational Development Committee The chair of the People and Organisational Development Committee was invited to provide an overview of the meeting held on 20 March 2024. It was noted that: • The committee reviewed the People Report for Month 11 (item 4.11) and noted that the additional recruitment controls were having an impact. Page 2 • The committee reviewed the Staff Survey results (item 4.12), noting that key themes were staff burnout and morale. 4.5 Briefing from the Chair of the Quality Committee The chair of the Quality Committee was invited to provide an overview of the meeting held on 18 March 2024. It was noted that: • The committee reviewed the patient safety and experience reports for the third quarter and noted some concerns regarding infection prevention control and pressure ulcers. In addition, there was some concern about overcrowding in the resuscitation area. • The committee had carried out a thematic review of never events, especially in Dermatology. • The committee reviewed the Trust’s performance in terms of its quality priorities for 2023/24. The Trust had achieved all its objectives, except one, which had been partially achieved. It was intended that there would be eight quality priorities in 2024/25. • It had been confirmed that the Integrated Care Board would fund the tobacco dependency programme in 2024/25. • Work was also taking place to provide additional capacity in the Paediatric Intensive Care Unit. 4.6 Chief Executive Officer’s Report David French was invited to present the Chief Executive Officer’s Report, the content of which was noted. It was further noted that: • The Hampshire and Isle of Wight Integrated Care Board (HIOW ICB) had launched a consultation on how it will re-shape itself for the future. The ICB had been required to reduce its running costs by 20% during 2024/25 and by a further 10% during 2025/26. • Junior doctors had voted to continue industrial action for a further six months. • In the Spring Budget, the Chancellor announced additional funding for the NHS, although, once inflation had been taken into account, the NHS budget would remain broadly flat. • The NHS England Workforce Race Equality Standard data report showed some improvements, but further work was required. • Steve Brine, the Member of Parliament for Winchester and Chandler’s Ford had been hosted by the Trust on a visit the week before. This afforded an opportunity to discuss the Hampshire County Council consultation, social care and non-criteria to reside. • The latest NHS patient survey showed a reduction in satisfaction, but this was largely due to waiting to get into the system. • There was significant pressure from NHS England for trusts to achieve the targets set. The Trust has demonstrated strong performance during 2023/24 across the six targets. • A nurse from the Trust has received a national recognition award based on their work on the ‘Diabasics’ initiative and the first episode of ‘Surgeons at the Edge of Life’, filmed at Southampton General Hospital, had been broadcast on BBC2. • Thanks were expressed to all staff for their performance during the year. 4.7 Performance KPI Report for Month 11 Joe Teape was invited to present the Performance KPI Report for Month 11, the content of which was noted. It was further noted that: • In terms of the Trust’s performance compared with comparators, the Trust was top quartile for the majority of indicators and top half for others. Page 3 • There were 19 patients who would breach the 78-week wait target at year end, 18 of which were corneal patients where materials were unavailable. It was noted that there was a national shortage of materials. • There were expected to be about 50 breaches of the 65-week wait target, of which around 30 were corneal patients. • The Trust had achieved diagnostic performance of 92% achieving the sixweek target. • There had been high volumes of patients in the Emergency Department during February and March 2024. However, the Trust had achieved 70.6% for type 1 performance and expected to achieve the 76% target by the end of March 2024. • The Trust’s Referral To Treatment metric was beginning to improve and there were some examples of very good waiting list management in Trauma and Orthopaedics and in Women and New Born. • The key point to emphasise was that, although it might not seem so at times, the Trust was out-performing most other comparable organisations. It was considered appropriate that staff communications should be worked on to reinforce this message. In terms of the Trust’s Key Performance Indicators: • The Quality Committee had seen significant improvements in diagnostic performance. • The two-week wait cancer target performance had also improved since April 2023. • Unfortunately, due to significant challenges with flow, overnight ward move performance had dropped significantly during the month, leading to poor patient experience. • In addition, the rate of pressure ulcers appeared to be increasing. 4.8 Non-Criteria to Reside Spotlight Report Joe Teape was invited to present the Non-Criteria to Reside Spotlight Report, the content of which was noted. It was further noted that: • Management of non-criteria to reside patients was one of the Trust’s biggest risks in terms of its operational and financial performance and achievement of its targets. • The Trust has seen 20%+ of beds occupied by patients without criteria to reside, which significantly impacted patient flow in the Emergency Department and has led to ambulance handover delays. • In addition, stays in hospital of longer duration were known to lead to worse patient outcomes. • The Trust was unable to have a significant impact on this issue, as the main driver was insufficient funding availability in local authorities. • In terms of what the Trust could do, work was ongoing to improve the discharge process by having conversations about care needs early on as part of the Trust’s flow transformation programme. 4.9 Break 4.10 Finance Report for Month 11 Ian Howard was invited to present the Finance Report for Month 11, the content of which was noted. It was further noted that: Page 4 • The Trust had received £24.6m of cash support from NHS England and £5m in funding in relation to the impact of industrial action between December 2023 and February 2024. • A year-end deficit of £1.4m was forecast. • The Trust’s underlying monthly deficit was currently £4m, and the Trust’s underlying deficit had been £4-5m a month during 2023/24. • Cost Improvement Programme delivery was expected to be £62m at year end, an increase of £17m compared to the previous year. 4.11 People Report for Month 11 Steve Harris was invited to present the People Report for Month 11, the content of which was noted. It was further noted that: • Total workforce had reduced by 20 whole-time equivalents (WTE) during the month, although the Trust remained 266 WTE above plan. • Use of bank staff had reduced, although it was expected that more bank staff would be used in March 2024 as substantive staff used leftover annual leave before year end. • Average turnover was 11%, below the target of 13.6%. The Board discussed the report and noted that it was necessary to review training expectations in order to make best use of staff time. In addition, it was noted that funding for internationally recruited nurses was likely to reduce and that apprentice and student nurse numbers had reduced. 4.12 UHS Staff Survey Results 2023 Report Ceri Connor, Sophie Limb and Steve Harris were invited to present the UHS Staff Survey Results 2023 Report, the content of which was noted. It was further noted that: • The Trust scored above average in all of the People Promise areas and there had been an improvement in the areas regarding managers and appraisals. • However, the overall NHS average had increased, thus narrowing the gap. • The participation rate was lower than in the previous year and the overall scores hid pockets of concern. The Board discussed the results of the Staff Survey. It was noted in particular that the Trust had invested significant sums into wellbeing, but that morale was low. It was considered that this demonstrated the importance of local management to staff morale. In addition, the Board discussed the impact of the change in approach from granting significant autonomy during the pandemic to increasing levels of control, which had been received negatively by staff. However, it was noted that, whilst in some areas, such as with regard to patients, there was a general culture of accountability, there appeared to be less of a general culture of accountability with respect to finances and budgets. The possibility of ‘earned’ autonomy was considered as a means of mitigating against those who had acted properly being penalised by the actions of others. Page 5 4.13 Maternity and Neonatal Perinatal Quality Surveillance Dashboard Report The Maternity and Neonatal Perinatal Quality Surveillance Dashboard Report was noted. It was further noted that the additional information in respect of post-partum haemorrhage data (action 1101) was contained within the report and had been discussed at a maternity safety champions’ meeting. 4.14 Guardian of Safe Working Hours Quarterly Report Diana Hulbert was invited to present the Guardian of Safe Working Hours Quarterly Report, the content of which was noted. It was further noted that: • There had been seven exception reports constituting a breach and resulting in a financial penalty, which were due to exceeding the maximum 13-hour shift duration. All reports were from General Surgery. • There were also concerns in Gynaecology due to the complicated rotas, inadequate rest provision and facilities. • The position of a junior doctor was a difficult one due to a lack of patient contact during the pandemic, industrial action and changes in the assignment of foundation posts. Action: Paul Grundy and Diana Hulbert agreed to include an item regarding junior doctors on a future Trust Board Study Session agenda. 5. Patient Story David Livermore was invited to relate his experience of attending an appointment at the Eye Unit in October 2023 and, in particular, the difficulties he encountered as a wheelchair user. It was noted that his treatment had been carried out in a room inappropriate for his needs and that he had been asked personal questions in the waiting room. Following discussion with the Board of his experiences, David Livermore offered his services to the Trust to advise on disability access as an ‘expert patient’. 6. STRATEGY and BUSINESS PLANNING 6.1 Board Assurance Framework (BAF) Update Lauren Anderson was invited to present the Board Assurance Framework (BAF) update, the content of which was noted. It was further noted that: • The Trust’s Risk Management Policy and Strategy had been updated, with the main changes being in relation to the Trust’s risk appetite following the Trust Board Study Session held in December 2023. • Work was being carried out to improve the Board’s visibility of operational risks and to improve links between operational risks and the BAF. Page 6 7. CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Register of Seals and Chair’s Actions Report The paper ‘Register of Seals and Chair’s Actions Report’ was presented to the meeting, the content of which was noted. Decision: The Board agreed to ratify the application of the Trust Seal to the documents listed in the ‘Register of Seals and Chair’s Actions Report’. 7.2 Remuneration and Appointment Committee Terms of Reference It was noted that the Remuneration and Appointment Committee had reviewed its terms of reference at its meeting held on 28 March 2024. It was further noted that some minor changes were proposed, largely to update references to documentation and NHS organisations, and, in terms of the executive pay guidance, to better reflect current practice and the available frameworks. Decision: Having reviewed the Remuneration and Appointment Committee terms of reference tabled to the meeting, it was agreed to approve these terms of reference. 8. Any other business There was no other business. 9. Note the date of the next meeting: 6 June 2024 10. Resolution regarding the Press, Public and Others Decision: The Board resolved that, as permitted by the National Health Service Act 2006 (as amended), the Trust’s Constitution and the Standing Orders of the board of directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. The meeting was adjourned. Page 7 List of action items Agenda item Assigned to Deadline Status Trust Board – Open Session 28/03/2024 4.14 Guardian of Safe Working Hours Quarterly Report 1127. Junior Doctors Grundy, Paul Hulbert, Diana 27/06/2024 Pending Explanation action item Paul Grundy and Diana Hulbert agreed to include an item regarding junior doctors on a future Trust Board Study Session agenda. Page 1 of 1 Report to the Trust Board of Directors Title: Agenda item: Sponsor: Date: Purpose: Issue to be addressed: Response to the issue: Chief Executive Officer’s Report 5.5 David French, Chief Executive Officer 6 June 2024 Assurance Approval or reassurance Ratification Information X My report this month covers updates on the following items: • Infected Blood Inquiry • General Election • Industrial Action • HEFMA Award • Capital Funding • 2024/25 Planning The response to each of these issues is covered in the report. Implications: Any implications of these issues are covered in the report. (Clinical, Organisational, Governance, Legal?) Summary: Conclusion The Board is asked to note the report. and/or recommendation Page 1 of 9 Infected Blood Inquiry On 20 May 2024, the Infected Blood Inquiry published its report into more than 30,000 people becoming infected with HIV and hepatitis C after being given contaminated blood products in the 1970s and 1980s. The report said that: • Too little was done to stop importing blood products from abroad, which used blood from high- risk donors such as prisoners and drug addicts; • In the UK, blood donations were accepted from high-risk groups until 1986; • Blood products were not heat treated to eliminate HIV until the end of 1985, although the risks were known in 1982; and • There was too little testing to reduce the risk of hepatitis from the 1970s onwards. The UK Government has established a compensation scheme for those impacted. The report can be read at: http://www.infectedbloodinquiry.org.uk/reports NHS England’s formal response to the report is attached as Appendix 1. During the Inquiry, the Trust was made aware of patient cases which would be cited in the report and was offered an opportunity to comment. We chose not to comment in detail on individual cases, primarily due to the time elapsed since they happened. NHS England has commissioned an ongoing patient support service for those affected and it is likely that UHS will be one of two providers in the region offering this service. Funding for a fiveyear period has been confirmed. General Election The Prime Minister has announced that a general election will be held on 4 July 2024. There are a number of practical implications for the Trust as a public body to maintain political impartiality and to ensure that public resources are not used for the purposes of political parties or campaign groups during the pre-election period which commenced on 25 May 2024 and will continue until the day after the election. During this period, the following key principles should apply: • No activity should be undertaken which could be considered politically controversial or influential. • NHS trusts have discretion in their approach, but must be able to demonstrate the same approach for every political party, official candidate and designated campaign group. • The NHS may be under media spotlight, locally and nationally, so it is advisable to have a plan in place for how the organisation will manage the pre-election period and the potential for the organisation to be singled out in the media. Normal business and regulation needs to continue during the pre-election period. However, where a board meeting needs to take place, the agenda should be confined to those matters requiring a board decision or oversight. Matters of future strategy or future deployment of resources may be construed as favouring one party over another and should be avoided. Use of the confidential part of the agenda to discuss matters which may be politically controversial is not recommended. Care should be taken not to comment on the policies of political parties or campaign groups. Page 2 of 9 Organisations should not start long-term initiatives or undertake major publicity campaigns unless time critical (such as a public health emergency). Public consultations should not be launched during the pre-election period, and it is advisable to extend the period for those already running to take into account the pre-election period. The timing of the election means that formal Secretary of State approval for the Solent / Southern transaction is unlikely to happen before the election and therefore the formation of the new Trust, previously scheduled for 1 June, is likely to be delayed. Industrial Action On 29 May 2024, it was announced that junior doctors would stage a five-day strike, commencing on 27 June 2024 and ending on 2 July 2024. This will be the eleventh walkout by junior doctors since March 2023. As during previous periods of industrial action, the Trust will seek to minimise any impact on patient care by organising consultant cover wherever possible. HEFMA Award Paula Melhuish, Deputy Director of Estates and Capital Development, received the Outstanding Service Award from the Health Estates and Facilities Management Association on 13 May 2024. Paula has been a long-serving and esteemed colleague at UHS and has recently announced her retirement. Capital Funding Due to its Emergency Department performance at the end of 2023/24, the Trust was awarded an additional £2m in capital departmental expenditure limit (CDEL) as part of a scheme to reward high-performing trusts. There were several categories where the top-10 performing trusts received additional CDEL, including absolute ED 4-hour % performance and most improved ED 4-hour performance. NHS England agreed that the type 3 Urgent Treatment Centre attendances at RSH and Lymington should be included in the overall UHS performance and that, combined with significantly improved 4-hour performance at SGH, this meant that UHS was in the national top-10 for absolute ED 4-hour performance. terms of using the CDEL allowance, plans are being developed to increase the department’s same day emergency care (SDEC) capacity. The additional CDEL is not cash-backed so we are in discussions with NHSE regarding the cash funding. 2024/25 Planning The CFO and I will update the Board on the status of the 2024/25 planning round which is not yet finalised. At a meeting in London with NHS England executives, the ICS was asked to improve its position further in return for some financial incentives. This challenge was accepted, although the allocation of this further stretch to individual providers has not yet been agreed. The structure and leadership of the ICS-wide transformation programmes has been reviewed and changed. The structure of the programmes was considered by CEO, Chairs and ICB colleagues and it was agreed there should be six programmes for 2024/25, as set out below. The Board should note that I requested to retain the leadership role on the Planned Care programme, mostly because we have an agreed way forward, have good traction and can now see improvement happening. In addition, I was asked to take on leadership of the Workforce programme which, following discussion with the Chair, I have agreed to do. Page 3 of 9 Programme Mental Health Discharge Urgent and Emergency Care Local Care Planned Care Workforce CEO lead Ron Shields, SHFT Penny Emerit, PHU David Eltringham, SCAS Alex Whitfield, HHFT David French, UHS David French, UHS Each programme has been asked to set out its objectives and deliverables for the year ahead by 18 June 2024. I will share the results of this exercise with the Board in due course. Page 4 of 9 Appendix 1 Classification: Official To: • All integrated care boards and NHS trusts: - chairs - chief executives - medical directors - chief nurses - chief operating officers - chief people officers - heads of primary care - directors of medical education • Primary care networks: - clinical directors cc. • NHS England regions: - directors - chief nurses - medical directors - directors of primary care and community services - directors of commissioning - workforce leads - regional heads of nursing - regional heads of communications NHS England Wellington House 133-155 Waterloo Road London SE1 8UG 20 May 2024 Dear colleagues, Publication of the Infected Blood Inquiry final report Earlier today, the Infected Blood Inquiry published its final report at: www.infectedbloodinquiry.org.uk/reports. The Prime Minister has subsequently issued an apology on behalf of successive Governments and the entire British state. On behalf of the NHS in England, now and over previous decades, Amanda Pritchard issued a public apology, saying: Publication reference: PRN01368 Page 5 of 9 “Today’s report brings to an end a long fight for answers and understanding that those people who were infected and their families, should never have had to face. “We owe it to all those affected by this scandal, and to the thorough work of the Inquiry team and those who have contributed, to take the necessary time now to fully understand the report’s conclusions and recommendations. “However, what is already very clear is that tens of thousands of people put their trust in the care they got from the NHS over many years, and they were badly let down. “I therefore offer my deepest and heartfelt apologies for the role the NHS played in the suffering and the loss of all those infected and affected. “In particular, I want to say sorry not just for the actions which led to life-altering and lifelimiting illness, but also for the failures to clearly communicate, investigate and mitigate risks to patients from transfusions and treatments; for a collective lack of openness and willingness to listen, that denied patients and families the answers and support they needed; and for the stigma that many experienced in the health service when they most needed support. “I also want to recognise the pain that some of our staff will have experienced when it became clear that the blood products many of them used in good faith may have harmed people they cared for. “I know that the apologies I can offer now do not begin to do justice to the scale of personal tragedy set out in this report, but we are committed to demonstrating this in our actions as we respond to its recommendations.” The report is sobering reading, documenting failings over multiple decades, and making recommendations across a wide range of areas, including recognition, support and compensation; education and training; monitoring of and testing for Hepatitis C; the safety of blood transfusions; preventing future harm, via duty of candour and regulation; as well as giving patients a voice. We write now to set out the initial steps we are taking in response. Support for those affected The Department of Health and Social Care is providing £19 million over five years to provide a bespoke Infected Blood Psychological Support Service which is expected to be rolled out later this summer. We have listened to the experiences of those involved, including patients, their families and staff, and are working with them to design and develop this service, which will provide dedicated support for those affected, located around the country. Copyright © NHS England 2024 2 Page 6 of 9 This service will include talking therapies, peer support, and psychosocial support, as well as access to other treatments or support for physical or mental health needs where appropriate. In the interim, the existing England Infected Blood Support Service remains available here: www.nhsbsa.nhs.uk/england-infected-blood-support-scheme. Further information about existing testing and support services, including those commissioned by the Government, can be found at: www.nhs.uk/infected-blood-support. Supporting affected staff It is important to also recognise that some of our colleagues may be affected by the publication of today’s report in some way, whether through personal or professional connection to the issue. Employers may therefore wish to increase promotion of their local health and wellbeing support for staff. Details of nationally-commissioned routes of support, including the 24/7 text helpline Shout and NHS Practitioner Health, can be found at NHS England - Support available for our NHS People. Continuing to find and treat people with blood-borne viruses Although it is likely that the majority of those who were directly affected have now been identified and started appropriate treatment given the time that has elapsed since the last use of infected blood products, there may be people who have not yet been identified, particularly where they are living with asymptomatic Hepatitis C. We ask that systems continue to work with partners, including community groups and charities, as well as Hepatitis C Operational Delivery Networks, to promote local testing options for anyone at risk, or anyone who is concerned. This should include promotion of the new national service for at-home Hepatitis C self-testing kits, available via hepctest.nhs.uk. For those who are concerned about the risk of HIV infection, further information can be found here: information on HIV diagnosis and the HIV testing services search tool. Hepatitis B, another infection that can be linked to infected blood, usually clears up on its own without treatment; however, people concerned about Hepatitis B infection should be directed towards relevant hepatitis B information or their local sexual health clinic or GP practice. Today's report highlights that in some cases those affected by infected blood products were told of their diagnosis in ways which were insensitive and inappropriate. We would therefore ask you to ensure that patients and their families are supported through the process of receiving test results – of whatever kind - in a compassionate and considerate way. Copyright © NHS England 2024 3 Page 7 of 9 Ensuring patients can access the right information. We recognise following the publication of this report, some patients may raise questions directly with their primary and/or secondary care teams, or through other points of contact with the NHS. We will be sharing materials with relevant service providers to ensure frontline clinicians and other colleagues in patient-facing roles are able to provide appropriate information or signposting. We expect that this will be particularly relevant to: • Providers of NHS 111 services • GP practices and community pharmacies • Trusts providing services where blood products are used • Mental health providers Maintaining confidence in current blood and blood products and related treatment The infected blood and blood products that have been the subject of this Inquiry were withdrawn in 1991. In the intervening decades, comprehensive systems have been put in place to ensure the safety of both donors and recipients of blood and blood-derived products. Today, blood and blood products are distributed to NHS hospitals by NHS Blood and Transplant (NHSBT), which was established in 2005 to provide a national blood and transplantation service to the NHS. NHSBT’s services follow strict guidelines and testing to protect both donors and patients. NHS Blood and Transplant has published clear information about these processes here: Infected Blood Inquiry - NHS Blood and Transplant (nhsbt.nhs.uk). Nationally, NHS England will work with NHS Blood and Transplant and others to communicate the safety of current blood products. Assessing further recommendations and next steps As set out above, the final Inquiry report includes a number of important recommendations for the NHS. NHS England will be considering these in detail alongside the Department for Health and Social Care and other relevant bodies. In addition, an Extraordinary Clinical Reference Group is being convened to inform any immediate actions which should be taken. The next steps from this work will be shared as soon as possible, including through relevant clinical networks. Copyright © NHS England 2024 4 Page 8 of 9 Yours sincerely, Amanda Pritchard NHS Chief Executive NHS England Professor Sir Stephen Powis National Medical Director NHS England Dame Ruth May Chief Nursing Officer England Dr Emily Lawson DBE Chief Operating Officer NHS England Copyright © NHS England 2024 5 Page 9 of 9 Report to the Trust Board of Directors Title: Agenda item: Sponsor: Author Date: Purpose Issue to be addressed: Performance KPI Report 2024-25 Month 1 5.6 David French, Chief Executive Sam Dale, Associate Director of Data and Analytics 6 June 2024 Assurance or reassurance Y Approval Ratification Information The report aims to provide assurance: • Regarding the successful implementation of our strategy. • That the care we provide is safe, caring, effective, responsive, and well led. Response to the issue: The Performance KPI Report reflects the current operating environment and is aligned with our strategy. Implications: (Clinical, Organisational, Governance, Legal?) Risks: (Top 3) of carrying out the change / or not: Summary: Conclusion and/or recommendation This report covers a broad range of trust performance metrics. It is intended to assist the Board in assuring that the Trust meets regulatory requirements and corporate objectives. This report is provided for the purpose of assurance. This report is provided for the purpose of assurance. Page 1 of 24 Report to Trust Board in June 2024 Performance KPI Board Report Covering up to April 2024 Sponsor – David French, Chief Executive Officer Author – Sam Dale, Associate Director of Data and Analytics Page 2 of 24 Report to Trust Board in June 2024 Report guide Chart type Example Cumulative Column Cumulative Column Year on Year Line Benchmarked Line & bar Benchmarked Control Chart Variance from Target Explanation A cumulative column chart is used to represent a total count of the variable and shows how the total count increases over time. This example shows quarterly updates. A cumulative year on year column chart is used to represent a total count of the variable throughout the year. The variable value is reset to zero at the start of the year because the target for the metric is yearly. The line benchmarked chart shows our performance compared to the average performance of a peer group. The number at the bottom of the chart shows where we are ranked in the group (1 would mean ranked 1st that month). The line shows our performance, and the bar underneath represents the range of performance of benchmarked trusts (bottom = lowest performance, top = highest performance) A control chart shows movement of a variable in relation to its control limits (the 3 lines = Upper control limit, Mean and Lower control limit). When the value shows special variation (not expected) then it is highlighted green (leading to a good outcome) or red (leading to a bad outcome). Values are considered to show special variation if they -Go outside control limits -Have 6 points in a row above or below the mean, -Trend for 6 points, -Have 2 out of 3 points past 2/3 of the control limit, -Show a significant movement (greater than the average moving range). Variance from target charts is used to show how far away a variable is from its target each month. Green bars represent the value the metric is achieving better than target and the red bars represent the distance a metric is away from achieving its target. Page 3 of 24 Report to Trust Board in June 2024 Introduction The Performance KPI Report is presented to the Trust Board each month to provide assurance: • regarding the successful implementation of our strategy; and • that the care we provide is safe, caring, effective, responsive, and well led. The content of the report includes the following: • The ‘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, performance concerns, and requests from the Board. • An ‘NHS Constitution Standards’ section, summarising the standards and performance in relation to service waiting times; and • An ‘Appendix,’ with indicators presented monthly, aligned with the five themes within our strategy. Due to the timing of the April 2024 Board meeting, the following referral to treatment data points were not included in the March KPI report. They have now been updated for March 2024 and April 2024: - • 31 - Patients on an open 18 week pathway (within 18 weeks) • 33 - Patients on an open 18 week pathway (within 52 weeks) • 34 - Patients on an open 18 week pathway (within 65 weeks) • 35 - Patients on an open 18 week pathway (within 78 weeks) • 35a - Patients on an open 18 week pathway (within 104 weeks) • 32 - Total number of patients on a waiting list (18 week referral to treatment pathway) Changes of note within the report itself: • 53 – The digital metric monitoring page loading time for the CHARTS system has been tightened from under five seconds to under three seconds • 55 – The metric monitoring the rollout of inpatient noting for nurses has been removed as this is now considered complete. This will be revisited when the noting solution is rolled out for doctors • 39 - The 2024/25 national cancer target changes will be reflected next month when April 2024 data is made available • 40 - The 2024/25 national cancer target changes will be reflected next month when April 2024 data is made available • 37 - The metric now reflects the published 2024/25 national year-end target of 5% of patients waiting over 6 weeks for diagnostics Page 4 of 24 Report to Trust Board in June 2024 Summary This month’s spotlight report covers diagnostic performance. It highlights that UHS consistently increased the volume of elective diagnostic tests delivered throughout the 2023/24 financial year and into the start of the 2024/25 financial year. The diagnostic waiting list reduced by 12% in 2023/24 and in April 2024, 89.6% of patients received their diagnostics within six weeks. The national performance target has been set at 95% by March 2025 and the organisation is working with all services to ensure we maintain waiting times for services that are compliant and address any demand and capacity barriers preventing achievement. The paper describes the activity and performance trends for the hospital and explores modality sites in more detail. Areas of note in the appendix of performance metrics include: 1. The Emergency Department (ED) four hour performance position reduced to 66.0% (April 2024) from 71.7% (March 2024) for type 1 attendances, however UHS remain in the top quartile when compared to peer teaching hospitals across the country. 2. In April, the overall RTT waiting list increased by 2.4% to 59,485. 3. The trust continues to report zero patients waiting over 104 weeks and reported 15 patients waiting over 78 weeks for April 2024. All 15 patients are within ophthalmology and impacted by the ongoing national shortage of corneal graft tissue which is being overseen by NHS Blood and Transplant service. The longest waiting patients will be booked for surgery as soon tissue has been confirmed. 4. The trust reported 66 patients waiting over 65 weeks which predominantly reflects corneal transplant patients again and low volumes within gynaecology and several surgical specialties. The trust is committed to achieving the national target of zero patients waiting over 65 weeks by September 2024 and the ambition to achieve zero patients waiting over 52 weeks by March 2025. 5. The volume of patients not meeting the Criteria to Reside in hospital decreased in April averaging 216 which is a 10% reduction compared to March 2024, yet this remains a significant impact on patient flow through the organisation. 6. There were zero never events reported for April 2024. 7. The volume of medication errors reduced to two in April 2024 which is now below the monthly target following the increase seen in March 2023. 8. The number of Gram-negative bloodstream infections continues to be marginally above the monthly target of 19. The increased incidence in cases continues to be reported both nationally and locally across the Hampshire and Isle of Wight integrated care system. 9. The digital metric to monitor page loading times on CHARTS system has successfully remained at 99% despite increasing the time target by 40%. Ambulance response time performance The latest unvalidated weekly data is provided by the South Coast Ambulance Service (SCAS). In the week commencing 13th May 2024, our average handover time was 16 minutes 56 seconds across 725 emergency handovers and 22 minutes across 52 urgent handovers. There were 44handovers over 30 minutes, and six handovers taking over 60 minutes within the unvalidated data. The volume of weekly handovers over 60 minutes increased by 73% from March 2024 (averaging 7.5 per week) to April 2024 (averaging 13 per week). Page 5 of 24 Report to Trust Board in June 2024 Spotlight Report Spotlight: Diagnostic Performance The following report is based on the validated April 2024 submission. Introduction Diagnostics are a critical component of a patient’s pathway, facilitating an accurate and complete diagnosis, personalised treatment plans and the appropriate monitoring of a patient’s condition. Timely access to diagnostic tests is essential for ensuring that patients re ceive an early diagnosis whilst improving patient experience and delivering an efficient use of NHS resources. The 2024/24 NHS priorities and operational planning guidance confirmed that “systems are asked to continue to work towards the elective care recovery plan target of 95% of patients receiving their tests within 6 weeks”. The national ambitions acknowledged that the NHS delivered record diagnostic activity in 2023, but also highlighted that additional capacity in community diagnostic centres had been partly offset by an unprecedented increase in unscheduled diagnostic activity in acute trusts. This national diagnostic target applies to 15 different diagnostic tests, although performance is measured at a Trust level. These tests are broadly divided into three categories: • endoscopy (e.g. gastroscopy, cystoscopy); • imaging (e.g. CT, MRI, barium enema); • physiological measurement (e.g. echocardiogram, sleep studies). Our teams prioritise diagnostic procedures based on clinical urgency (for example patients with cancer) but aligned to this is a continual review of the longest waiting diagnostic patients. This spotlight paper highlights the current diagnostic performance position for UHS against the national targets and other hospitals. It also describes the current volumes of activity being delivered and the impact on the waiting list. We explore any performance concerns across the different modalities, outlining the challenges that services are facing and the steps being taken to achieve the 2024/25 target. In summary, there was an overall reduction in the diagnostic waiting list across the 2023/24 financial year as UHS successfully increased the delivery of diagnostic activity to manage current levels of demand. The diagnostic waiting list currently stands at 8,849 patients (April 2024) which is a reduction of 12% since April 2023 (10,033 patients) and 24% since the peak levels seen in June 2022 (11,671 patients). The April 2024 performance position is 89.6% for the percentage of patients receiving diagnostic tests within six weeks. The latest comparison data available (March 2024) placed the hospital 5th when ranked against peer teaching hospitals across the country. All organisations are facing challenges due to high demand, workforce shortages and equipment limitations and funding, but the organisation is striving to achieve the 95% target set for 2024/25. Page 6 of 24 Report to Trust Board in June 2024 Spotlight Report Activity and Waiting List Elective diagnostic activity being delivered at UHS consistently increased throughout 2023/24 and into 2024/25 helping to manage the waiting list despite high referral volumes and the complications caused by industrial action throughout the previous year. Graph 1 illustrates that diagnostic activity levels delivered in 2023/24 were 6% higher than 2022/23 and 17% higher than pre-pandemic levels. Overall there was a 12% reduction in the diagnostic waiting list across the 2023/24 financial year (graph 2) despite some levelling off in winter months and a small recent increase which is being closely monitored. The waiting list stands at 8849 patients for April 2024 which breaks down into
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Trust-governance-and-corporate-docs/2024-Trust-documents/Papers-Trust-Board-6-June-2024.pdf

Finance and Performance Reports 2023-24 Month 10 - January 2024

Description: Report to the Trust Board of Directors Title: Agenda item: Sponsor: Author: Date: Purpose: Finance Report 2023-24 Month 10 10.3 Ian Howard – Chief Financial Officer Philip Bunting – Director of Operational Finance David O’Sullivan – Assistant Director of Finance – Financial Performance 29 February 2024 Assurance or reassurance Approval Ratification Information X Issue to be addressed: Response to the issue: The finance report provides a monthly summary of the key financial information for the Trust. It has recently been announced that NHS England is set to give around £650m to some health systems to offset planned financial deficits, and with that ease pressure on cashflow. We have since been informed by the HIOW ICB that a proportion of that money has been allocated to this system, and via that to UHS. The amount has recently been confirmed as £24.6m. We are grateful to be receiving funding which will reduce, but not eliminate, our financial deficit for financial year 23/24. Unfortunately, this still leaves us with, an albeit reduced, deficit going into the next financial year, so our work to restore financial balance for UHS remains key to supporting our recovery and protecting the interests of our patients and staff. Forecast Prior to the above announcement, UHS was forecasting an adjusted deficit of £29.7m. The impact of Industrial Action in December and January has been estimated at £4.8m (increased from £3.8m). Excluding the impact of Industrial Action, UHS was forecasting a deficit of £25m (previously £26m). A further deterioration in forecast is anticipated relating to further Industrial Action in February. UHS M10 Forecast Recovery Original Plan Plan Forecast Financial Position (26.0) (26.0) (29.7) • Note – forecast will change as a result of additional funding and impacts of further industrial action. In line with South East Region reporting guidelines, we expect to formally change our forecast to NHSE in our M10 reporting. M10 Financial Position UHS is reporting a financial position as outlined in the table below: UHS M10 Financial Position Original Plan (1.0) In Month Recovery Plan (2.2) Actual (4.7) Year to Date Original Recovery Plan Plan Actual (25.0) (23.9) (27.6) Page 1 of 4 The in-month position includes £3.2m of non-recurrent industrial action (IA) pressures, which trusts nationally have been advised to report as a variance. This has been offset by additional non recurrent savings of £0.7m resulting in the position being £2.5m adverse to the recovery plan trajectory. Impact of Industrial Action (IA) The impact of industrial action for December 2023 and January 2024 is shown in the table below. IA Impact M9 Cost of Cover (0.4) Impact of reduction on ERF & lost efficiency opportunity (1.2) Total (1.6) M10 Total (0.9) (1.3) (2.3) (3.5) (3.2) (4.8) ERF In month ERF performance was above target at 115% and is 117% YTD. The revised target is now 109% after a further 2% reduction has now been applied (so 4% reduction applied in year). This overperformance has generated c£1.1m of additional ERF income in month with overperformance now £14.5m YTD. Industrial action in the month of January has reduced activity and the scale of overperformance was lower than had been anticipated as part of financial recovery. In addition to IA pressures, significant non elective pressures continue to cause strain on elective delivery. Further industrial action is scheduled in February representing future risk to the delivery of ERF overperformance achievement with a run rate of £2m per month overperformance targeted. Underlying Position The underlying position for January deteriorated when compared to average levels for the YTD to £5.2m. Last months restated underlying deficit was £4m following ERF income being greater than had been first anticipated. The primary drivers of the month on month movement relate to: • Reduced ERF activity – this dropped by £1m following significant non elective pressures in January. Historically there has however been a lag in reported ERF once all activity is counted and coded. • Pay – the underlying rate of pay expenditure has been stable when removing one off costs for industrial action. This has remained flat for the last four months following the introduction of financial recovery plan actions followed by increased recruitment controls. • Non pay costs increased (£0.5m) offset by slightly increased other income (£0.3m). This mainly relates to increased energy costs and clinical supplies. The previous monthly average underlying deficit had been c£4.5m per month once the impact of industrial action and other one offs are removed. This includes ERF of c£1.5m per month overperformance. The target exit run rate for 2023/24 is a deficit of no worse than £4m per month, which could reasonably be delivered by improved ERF performance. Whilst pay costs, in an absolute sense, have increased in January by £0.7m, much of this relates to bank holiday enhancements, and TOIL provisions linked to industrial action. Adjusting for these items, pay costs have stabilised significantly in-month as a result of the additional controls implemented in December. Temporary staffing costs have increased marginally by £0.15m in month, but remain significantly below November levels, with the movement relating to the seasonal decrease seen in the December holiday period. Page 2 of 4 In month, some reduction on HCA agency and bank has been achieved following targeted efforts on the criteria of requests for mental health support staff and additional workforce controls taking effect. Deficit Drivers The underlying deficit continues to be driven by a number of underlying system pressures seen in 22/23, for which we have not been able to recover to date: • Non-pay inflation beyond funded levels • Impact of energy prices (with gas prices impacting UHS particularly hard) • High-cost drugs spend (previously pass-through) • Number of patients not meeting criteria to reside, impacting capacity (opening expensive “surge” capacity / bed capacity restricting elective activity) In 23/24, we are now seeing further pressures, notably: • Unfunded elements of pay awards - £0.4m per month. • Workforce pressures as substantive recruitment is not offset with temporary staffing reductions £0.9m per month. • Mental health nursing pressures - £0.2m per month. • Tariff efficiency reductions not offset by recurrent CIP delivery - £0.7m per month. • Further growth in the number of patients not meeting the criteria to reside. These have been consistently at 200 with some weeks peaking at over 250. This has generated costs in opening surge capacity. Unfunded additional activity is a further pressure for UHS where we are YTD providing activity above block funded level for free in the following areas: • £9.6m of outpatient follow up appointments • £10.0m of non-elective • £4.1m of other treatments This is likely to be between £25m and £30m across 2023/24 and remains a key component of the Trust’s deficit. This will form a key part of contracting discussions for 2024/25 as this is clearly unsustainable in the medium to long term with focused efforts required either to reduce demand or acknowledge costs that require mitigation via other means. Cost Improvement Plans The most-likely risk assessed position of cost improvement delivery sits at £64m (5%). This includes the £5.5m targeted improvement within the financial recovery plan. Whilst we have made good progress with CIP performance, it is heavily supported by non-recurrent delivery that cannot be relied upon for underlying financial improvement. The aim is now to shift this into recurrent delivery. Financial recovery plan actions continue to be monitored and are included within appendix 1. Capital The 2023/24 capital programme is currently £12.0m behind plan YTD (spend of £32.1m compared to planned delivery of £44.1m). Currently there is confidence in forecast delivery of the planned level of expenditure, which totals nearly £60m including externally funded schemes for 2023/24. This does however require spend of c£27m in the remaining two months of the year. A month-on-month trajectory has been developed and is being tracked with project managers particularly in estates to ensure risks are understood at the earliest opportunity and mitigations put in place where possible. Page 3 of 4 Prioritisation for 2024/25 and 2025/26 has been discussed at Trust Investment Group and will be shared with Trust Board in February. This presents significant challenges as demands for capital increase year on year correlating with increased critical infrastructure, equipment and capacity risks. Cash As reported in previous finance report the trusts cash balance remains a significant concern and for the first time has dropped below the internal target minimum threshold of £30m, being £25m as at the close of January. The forecast was £28m however timing delays to PDC drawdowns and donated income receipts means this was slightly below planned levels. This now means there are periods in the month when cash levels are below £10m and require day to day management and overview. Short term increases are expected as several significant payments are due from commissioners in addition to £10m of external funding relating to the Neonatal capital project which has already had some costs incurred. The year end forecast therefore is expected to close at £40m. The additional cash support outlined above will improve this position further. Moving into 2024/25 additional vigilance will be applied and early warning systems maintained in order to assess the ongoing viability of the capital programme and also ensure the NHS England draw down process is ready if and when required. Implications: • Financial implications of availability of funding to cover growth, cost pressures and new activity. • Organisational implications of remaining within statutory duties. Risks: (Top 3) of carrying out the change / or not: • Financial risk relating to the underlying run rate and projected potential deficit if the run rate continues. • Investment risk related to the above • Cash risk linked to volatility above • Inability to maximise CDEL (which cannot be carried forward) and the risk of a reducing internal CDEL allocation for 2024/25 due to the forecast deficit for 2023/24. Summary: Trust Board is asked to: Conclusion and/or • Note the finance position. recommendation Page 4 of 4 Report to the Trust Board of Directors Title: Agenda item: Sponsor: Author Date: Purpose Performance KPI Report 2023-24 Month 10 10.1 David French, Chief Executive Officer Sam Dale, Associate Director of Data and Analytics 29 February 2024 Assurance or Approval reassurance Y Ratification Information Issue to be addressed: The report aims to provide assurance: • Regarding the successful implementation of our strategy • That the care we provide is safe, caring, effective, responsive, and well led Response to the issue: The Performance KPI Report reflects the current operating environment and is aligned with our strategy. Implications: This report covers a broad range of trust performance metrics. It is (Clinical, intended to assist the Board in assuring that the Trust meets Organisational, regulatory requirements and corporate objectives. Governance, Legal?) Risks: (Top 3) of carrying out the change / or not: This report is provided for the purpose of assurance. Summary: Conclusion and/or recommendation This report is provided for the purpose of assurance. Page 1 of 24 Report to Trust Board in February 2024 Performance KPI Board Report Covering up to January 2023 Sponsor – David French, Chief Executive Officer Author – Sam Dale, Associate Director of Data and Analytics Page 2 of 24 Report to Trust Board in February 2024 Report guide Chart type Example Cumulative Column Cumulative Column Year on Year Line Benchmarked Line & bar Benchmarked Control Chart Variance from Target Explanation A cumulative column chart is used to represent a total count of the variable and shows how the total count increases over time. This example shows quarterly updates. A cumulative year on year column chart is used to represent a total count of the variable throughout the year. The variable value is reset to zero at the start of the year because the target for the metric is yearly. The line benchmarked chart shows our performance compared to the average performance of a peer group. The number at the bottom of the chart shows where we are ranked in the group (1 would mean ranked 1st that month). The line shows our performance, and the bar underneath represents the range of performance of benchmarked trusts (bottom = lowest performance, top = highest performance) A control chart shows movement of a variable in relation to its control limits (the 3 lines = Upper control limit, Mean and Lower control limit). When the value shows special variation (not expected) then it is highlighted green (leading to a good outcome) or red (leading to a bad outcome). Values are considered to show special variation if they -Go outside control limits -Have 6 points in a row above or below the mean, -Trend for 6 points, -Have 2 out of 3 points past 2/3 of the control limit, -Show a significant movement (greater than the average moving range). Variance from target charts is used to show how far away a variable is from its target each month. Green bars represent the value the metric is achieving better than target and the red bars represent the distance a metric is away from achieving its target. Page 3 of 24 Report to Trust Board in February 2024 Introduction The Performance KPI Report is presented to the Trust Board each month to provide assurance: • regarding the successful implementation of our strategy; and • that the care we provide is safe, caring, effective, responsive, and well led. The content of the report includes the following: • The ‘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, performance concerns, and requests from the Board. • An ‘NHS Constitution Standards’ section, summarising the standards and performance in relation to service waiting times; and • An ‘Appendix,’ with indicators presented monthly, aligned with the five themes within our strategy. Adjustments of note within the report include: • 11 – Medication Errors (severe/moderate) were revalidated for December 2023 and reduced to four from five in the last publication • 54 – Cyber Security: the data labels used on the bar chart required correction to align with the multiplication factor stated in the description Page 4 of 24 Report to Trust Board in February 2024 Summary This month’s spotlight report covers diagnostic performance. It highlights that UHS has consistently reduced the diagnostic waiting list throughout the 2023 calendar year and the hospital’s waiting time performance is now consistently in the second quartile compared to peer teaching hospitals across the country. The paper describes the high level activity and performance trends for the hospital over recent months and explores modality sites in more detail, outlining the specific challenges and actions taken by Care Groups to understand and improve performance. Areas of note in the appendix of performance metrics include: 1. The Emergency Department (ED) four hour performance metric further improved in January 2024 increasing to 63.7% placing UHS as second highest performing trust when compared to twenty teaching hospitals across the country. The January performance is above our H2 recovery target for the month, but we recognise there is significant improvement required for the remainder of the year to reach our March 2024 target. 2. The trust is reporting zero patients waiting over 104 weeks for the first time this financial year as the longest waiting corneal patients have now been issued grafts by the national transplant service and treated. The trust reported 27 patients waiting over 78 weeks which mainly reflects the next cohort of corneal transplant patients waiting for national tissue to be issued. 3. UHS continues to focus on the national target of zero patients waiting over 65 weeks by March 2024. In December 2023, UHS ranked in the top quartile for patients waiting over 65 weeks and also patients waiting over 52 weeks compared to twenty comparative teaching hospitals across the country. 4. Cancer services have maintained strong waiting time performances in December 2023 as the Trust continues to rank as the top teaching hospital for 28 day faster diagnosis (87.2%) and second for 62 day performance (79.5%). Whilst the two week waiting times are no longer a nationally reported metric, the Trust continues to publish the metric and performance is now the highest of the year at 93.6%. 5. The volume of patients not meeting the Criteria to Reside in hospital increased further in January (averaging 234 across the month) continuing to place constraints on patient flow through the hospital. Ambulance response time performance The latest unvalidated weekly data is provided by the South Coast Ambulance Service (SCAS). Due to the significant challenges within the ED department, and the wider challenge with flow experienced in the trust since the New Year, we have seen a concerning increase in handover times. For all weeks commencing in January 2024, we averaged 32 handovers per week taking over 60 minutes and 67 handovers per week taking over 30 minutes. As a comparison, in the same period in 2023, we averaged just 3 handovers taking over 60 minutes per week. The graph below illustrates volumes of handovers reported by time cohort for the last two years. Page 5 of 24 Report to Trust Board in February 2024 The unvalidated aspect of the SCAS handover data is an ongoing concern caused by numerous factors including: • Overcrowding in the department causing delays to entry and exit flows particularly through the pitstop area. • Inaccurate recording of handover delays where multiple patients arrived under the responsibility of one ambulance crew • The impact of improved waiting room triage times (particularly for those self-presenting) which has created a bottle neck with patients waiting on chairs and trolleys within pitstop • General concerns around inaccuracy of handover time stamps captured by ambulance and hospital nursing staff during busy periods. A series of actions are being jointly worked on to address the situation which include the development of a Standard Operating Procedure (SOP) for patient cohorting to be approved and adopted by both NHS bodies. Pitstop processes are being scrutinised with the transformation team to improve efficiency and may include the allocation of an additional nurse within pitstop. The position has also highlighted the need for a renewed focus on recording accuracy from all responsible staff. Page 6 of 24 Report to Trust Board in February 2024 Spotlight – Diagnostic Performance Spotlight: Diagnostic Performance The following report is based on the validated January 2024 submission. Introduction Diagnostics are a critical component of a patient’s pathway, facilitating an accurate and complete diagnosis, personalised treatment plans and the appropriate monitoring of a patient’s condition. Timely access to diagnostic tests is essential for ensuring that patients receive an early diagnosis whilst improving patient experience and delivering an efficient use of NHS resources. The Elective Care guidance from NHS England and Improvement (NHSE/I) states the "ambition is that 95% of patients needing a diagnostic test receive it within six weeks by March 2025". This outcome is aligned with the principle that diagnostic activity levels must support plans to address elective and cancer backlogs as Trusts aim to eliminate waits of over 65 weeks for elective care by March 2024. This diagnostic target applies to 15 different diagnostic tests, although performance is measured at a Trust level. These tests are broadly divided into three categories: • endoscopy (e.g. gastroscopy, cystoscopy); • imaging (e.g. CT, MRI, barium enema); • physiological measurement (e.g. echocardiogram, sleep studies). This spotlight paper highlights the current diagnostic performance position for UHS against the national targets and other hospitals. It also describes the recent volumes of activity delivered and the impact on the waiting list. We explore the key modalities in more depth outlining the challenges faced by services and the mitigating actions being put in place for the remainder of the financial year and beyond. In summary, there has been a consistent reduction in the diagnostic waiting list throughout 2023 as UHS has been able to increase the delivery of diagnostic activity to manage current levels of demand. The diagnostic waiting list reduced to 8052 patients in January 2024. This is a reduction of 45% since the high levels seen in June 2022 (11,671 patients) and is the lowest waiting list size since July 2020. Throughout the 2023 calendar year, the waiting list has decreased by 2,473 patients which is a 31% reduction. Our January 2024 performance position is 85.5%. Page 7 of 24 Report to Trust Board in February 2024 Spotlight – Diagnostic Performance Activity and Waiting List Elective diagnostic activity being delivered at UHS has consistently increased throughout 2023/24 helping to reduce the waiting list despite high referral volumes and the complications caused by industrial action throughout the year. Whilst the consultant and junior doctor strikes have impacted endoscopic services, the impact on radiology activity has been limited. Graph 1 illustrates how recent diagnostic activity being delivered at UHS is approximately 33% higher than the 2019/20 baseline (approximately 18,000 procedures per month vs baseline of 13,500). There is a clear reduction in the diagnostic waiting list throughout the year (graph 2) with some levelling off in winter months attributed to the festive period. The waiting list reached its recent lowest point in December going below 8000 patients for the first time since July 2020. January’s finalised waiting list position was 8052 patients. The care groups developed plans at the start of 2023/24 to increase activity levels and appropriately manage service demand. These have proved successful in several areas particularly where transformation colleagues have supported with opportunity identification and clinician engagement. We have seen a reduction in DNAs in certain services, improved booking processes and served notice to Portsmouth and Salisbury for referrals within Cardiac MRI. Nevertheless certain services are still challenged due to vacancies and recruitment delays and the ongoing demand on services both electively and non electively. Graph 1: Diagnostic Activity Delivered by Month 14,000 12,000 10,000 8,000 6,000 4,000 2,000 0 We explore modality performance positions and service plans in more detail in section four. Graph 2: Waiting List Size by Month Page 8 of 24 Report to Trust Board in February 2024 Spotlight – Diagnostic Performance Performance Position The Trust submitted performance position (Graph 3) demonstrates a continuous and positive, upward trajectory reaching 85.5% in January 2024. This reflects significant progress throughout the year and contradicts the dip in performance seen over the festive period this time last year. When benchmarking our performance against other peer teaching hospitals (graph 4), the Trust has historically been in the third quartile. Our December performance is in the second quartile and UHS has ranked seven out of twenty teaching hospitals for the last three months. It should be noted there is a wide spread of diagnostic performance with some trusts delivering fewer than 50% of tests within the six-week target. Graph 3: Graph Diagnostic Performance % by Month 90% 85% 80% 75% 70% 65% 60% 55% 50% Jan-21 Jul-21 Jan-22 Jul-22 Jan-23 Jan-24, 85.5% Jul-23 Jan-24 Graph 4: UHS Diagnostic Performance compared to peer teaching hospitals Page 9 of 24 Report to Trust Board in February 2024 Spotlight – Diagnostic Performance Modality Focus: Physiological modality This modality includes Audiology, Echocardiography, Neurophysiology and Sleep Studies. Across the modality group, the performance position and waiting list has improved significantly following a decline in the performance position in the first half of the 2023 calendar year. The January 2024 performance position is 74.5% with the waiting list at 1,925 patients. This compares to the position in August 2023, where the reported performance had dipped to 53.7% and the waiting list was 2,395 patients which reflects a 20% reduction. Audiology performance remains consistently at 100%, but overall performance is offset by continued pressures across other key services in particular sleep studies (60%) and neurophysiology (66%). Graph 5: Performance trend and waits for all physiological metrics:- The neurophysiology department has been under service review since June 2023 which is a collaboration between the department and the transformation team this has been instrumental in addressing some long term performance issues including the legacy of a COVID backlog. By fostering open communications and leveraging the team’s own expertise, a series of bottlenecks and inefficient work practices were identified and addressed. The result has seen performance improve from 47% in June 2023 to 66% in January 2023. This will be further enhanced by the introduction of an internally built Apex system that will aid in day to day patient flow management. A decision was made to invest in an insourcing solution at weekends from November 2023 which has reduced the neurophysiology waiting list from 1083 to 723. The focus is now on developing a more sustainable solution with a focus on department capacity versus demand and a review of consultant job plans. The sleep study service has seen referral numbers increase from on average 15 a week to 35 over the last two years. Overall performance is continuing to improve supported by actions again developed by the transformation and operational teams. Within the previous twelve months the highest number of diagnostic breaches reached 215, since September 2023 total breaches average at 136 per month. The project reviewing the DNA rate within sleeps studies is also complete. The DNA rate prior to project completion was 22.5% and this has now reduced to 8%. Root causes were the distance to travel to Lymington, text reminder services not fully established and mutually agreed appointments not being fully implemented. The services have also completed recruitment of a band 6 Physiologist with an expected start date in February, this will supported an upward trajectory for activity and support backlog reduction. The service is also scoping out the purchase of another inpatient testing kit through charitable funding. Page 10 of 24 Report to Trust Board in January 2023 Spotlight Modality Focus: Imaging Services This modality includes include computed tomography (CTs), MRIs, Barium Enema and Non-Obstetric Ultrasounds The Trust has seen an improved performance position across the 2023 calendar year. Performance in January 2024 was 89.9% and recent levels came close to achieving the national target (95%) by reaching 92.4% in November 2023. Activity levels have remained consistent in recent months averaging 13855 per month across all imaging services despite the interruptions caused by the industrial action and winter pressures. The waiting list has reduced by 22% across the last twelve months from 6,898 in February 2023 to 5,405 in January 2024. Graph 6: Performance trend and waits for all imaging services CT performance is extremely positive achieving the national target in the last three months and reporting 98% in January 2024 with a waiting list of 741 compared to 1113 in February 2023. MRI performance has remained at around 85% in recent months and this is predominantly driven down by Cardiac MRI performance (53% in January 2024). Whilst we served notice to Salisbury and Portsmouth to originally prevent Cardiac MRI referrals to UHS from November 2023, we agreed a staggered timescale to ensure both hospitals were in a position to appropriately deliver both stress and non-stress MRIs fully by March 2024. Recent performance has also been impacted by urgent equipment repairs and recruitment delays which were planned to enable a seven day service. General MRI performance is consistently at 96% or above supported by the use of a relocatable MRI scanner seven days a week and additional in-house lists. Despite the positive performance across all imaging services, the recent demand on non elective work alongside current recruitment restrictions and high staff sickness levels may impact the ability to consistently maintain high levels of performance across all services. Page 11 of 24 Report to Trust Board in January 2023 Spotlight Modality Focus: Endoscopy This modality includes colonoscopy, cystoscopy, flexi-sigmoidoscopy and gastroscopy across both adult and paediatric services. Diagnostic performance was 82% in January 2024 and has been in the range of 80-85% over the last six months which is a significant improvement since the first half of the year where performance averaged at 78%. Graph 7: Performance trend and waits for all endoscopy services Historically the cystoscopy service has been the key endoscopic service significantly reducing the overall modality performance. The service reported 49% at the start of this financial year (April 2023) but this has now improved significantly to 76% in December 2023 and 70% in January 2024. During that same period, the waiting list for adult and paediatric cystoscopies reduced from 406 patients (April 2023) to 101 patients (January 2024). The success is attributed to the service embedding a clerk solely dedicated to booking processes for cystoscopy patients. This is alongside additional capacity solely assigned to addressing the concerning back log of patients. The paediatric endoscopy service has continued to face demand and capacity challenges throughout 2023. January 2024 performance stands at 45% which is a significant improvement since June 2023 where performance was as low as 24% due to scope equipment failure and lists taken down for strikes and anaesthetic gaps. The service continues to use waiting list initiatives to maintain the position alongside regular consultant engagement and patient validation to ensure patient prioritisation processes are improving the waiting time position. Further long term demand and capacity modelling is underway and a business case for an additional consultant is also being explored. Page 12 of 24 Report to Trust Board in January 2023 NHS Constitution NHS Constitution - Standards for Access to services within waiting times The NHS Constitution* and the Handbook to the NHS Constitution** together set out a range of rights to which people are entitled, and pledges that the NHS is committed to achieve, including: The right to access certain services commissioned by NHS bodies within maximum waiting times, or for the NHS to take all reasonable steps to offer you a range of suitable alternative providers if this is not possible • Start your consultant-led treatment within a maximum of 18 weeks from referral for non-urgent conditions • Be seen by a cancer specialist within a maximum of 2 weeks from GP referral for urgent referrals where cancer is suspected The NHS pledges to provide convenient, easy access to services within the waiting times set out in the Handbook to the NHS Constitution • All patients should receive high-quality care without any unnecessary delay • Patients can expect to be treated at the right time and according to their clinical priority. Patients with urgent conditions, such as cancer, will be able to be seen and receive treatment more quickly The handbook lists eleven of the government pledges on waiting times that are relevant to UHS services, such pledges are monitored within the organisation and by NHS commissioners and regulators. Performance against the NHS rights, and a range of the pledges, is summarised below. Further information is available within the Appendix to this report. * https://www.gov.uk/government/publications/the-nhs-constitution-for-england/the-nhs-constitution-for-england ** https://www.gov.uk/government/publications/supplements-to-the-nhs-constitution-for-england/the-handbook-to-the-nhs-constitution-for-england Page 13 of 24 Report to Trust Board in February 2024 NHS Constitution Monthly Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan target YTD 75% % Patients on an open 18 week pathway (within 18 weeks ) 31 UHSFT 63.2% 62.5% 5 5 5 5 4 4 4 4 5 4 4 4 4 ≥92% Teaching hospital average (& rank of 20) South East average (& rank of 17) 5 50% 5 5 5 6 6 5 5 6 6 6 5 4 63.0% 100% % Patients following a GP referral for suspected cancer seen by a specialist within 17 14 13 15 17 17 17 16 16 16 13 2 weeks (Most recently externally reported 79.5% 38 data, unless stated otherwise below) UHSFT Teaching hospital average (& rank of 20) 18 10 11 13 16 19 18 16 13 9 10 South East average (& rank of 17) 55% 93.6% ≥93% Cancer waiting times 62 day standard - 100% Urgent referral to first definitive treatment 79.5% (Most recently externally reported data, 39 unless stated otherwise below) 14 17 18 14 14 9 14 13 10 15 6 11 7 6 UHSFT Teaching hospital average (& rank of 19) South East average (& rank of 17) 40% 7 551.62% 11 7 14 5 9 7 3 6 1 3 2 2 ≥85% 100% Patients spending less than 4hrs in ED - (Type 1) 28 UHSFT 6 61.5% 7 6 5 4 9 12 9 8 63.7% 8 12 10 11 8 4 ≥95% Teaching hospital average (& rank of 16) South East average (& rank of 16) 4 4 3 3 3 5 7 5 5 5 7 7 7 5 2 25% 40% 29.6% % of Patients waiting over 6 weeks for diagnostics 37 UHSFT Teaching Hospital average (& rank of 20) 11 12 12 12 12 11 11 11 7 9 7 7 7 6 10 7 8 8 8 7 7 8 10 10 8 7 7 14.5% 7 ≤1% South East Average (& rank of 18) 0% 76.7% 66.7% 61.1% 19.5% Page 14 of 24 Report to Trust Board in February 2024 Outstanding Patient Outcomes,Safety and Experience Outcomes 1 HSMR - UHS HSMR - SGH 2 HSMR - Crude Mortality Rate Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan 89.77 87.52 88.07 86.11 75 3.1% 2.8% 2.7% Monthly target ≤100 <3% 2.5% 15% 3 Percentage non-elective readmissions within 28 days of discharge from hospital 10% 11.4% 12.0% - Cumulative Specialties with 4 Outcome Measures Developed (Quarterly) Q4 22-23 75 71 70 65 Q1 23-24 72 Q2 23-24 72 Q3 23-24 73 Q4 23-24 74 Quarterly target +1 Specialty per quarter Developed Outcomes RAG ratings (Quarterly) 5 Red Amber Green 100% 35 34 37 41 41 81 82 75 67 64 75% 336 340 333 337 338 50% YTD 90.7 2.7% 12.2% Red : below the national standard or 10% lower than the local target Amber : below the national standard or 5% lower than the local target Green : within the national standard or local target YTD target ≤100 <3% Appendix Page 15 of 24 Report to Trust Board in February 2024 Outstanding Patient Outcomes,Safety and Experience Safety Monthly Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan target YTD Cumulative Clostridium difficile 6 Most recent 12 Months vs. Previous 12 Months 90 7177 7484 94 1112 1827 2435 49 28 60 35 66 47 72 55 6581 7391 ≤5 91 0 5 7 MRSA bacteraemia 0 7 01 1 0 0 0 0 0 0 1 0 0 1 2 1 2 80 YTD target ≤50 0 8 Gram negative bacteraemia ≤18 192 0 24 16 17 14 32 14 19 27 16 21 15 25 18 17 20 Monthly Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan target YTD 1 0.56 9 Pressure ulcers category 2 per 1000 bed days 0.46 <0.3 0.41 0 ≤173 YTD target <0.3 1 Pressure ulcers category 3 and above 10 0.25 per 1000 bed days 0 10 0.52 0.32 <0.3 0.42 <0.3 11 Medication Errors (severe/moderate) 3 3 ≤3 23 30 0 Watch & Reserve antibiotics, usage per 12 1,000 adms Most recent months vs. 2018*95.5% 3,500 1,500 2,7625,769 2,787 2,900 2,787 27,617 25,859 12 - For 2022/23 and forward, a new requirement is applied: Reduction of 4.5% from calendar year 2018 usage in combined WHO/NHSE AWaRE subgroups for “watch” and “reserve” agents. The performance data relate to successive FINANCIAL years, however the comparator denominator remains CALENDAR year 2018 (we are not using 2020 or 2021 due to the disruptive effect of COVID on both usage and admissions). Appendix Page 16 of 24 Report to Trust Board in February 2024 Outstanding Patient Outcomes,Safety and Experience Safety Monthly Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan target YTD Serious Incidents Requiring 40 13 Investigation (SIRI) (based upon month 3 reported as SIRI, excluding Maternity) 0 - 27 0 13 From October 2023, as part of move to PSIRF, reporting of SIRIs was stopped. Patient Safety Incident Investigations (PSII) are reported going forward 5 Serious Incidents Requiring 14 Investigation - Maternity 0 0 0.2 Number of falls investigated per 1000 15 0.12 bed days 0.0 - 4 0 0.11 - 0.09 100% % patients with a nutrition plan in place 93.1% 94.2% 16 (total checks conducted included at ≥90% 95% chart base) 669 711 1624 780 1600 844 871 788 806 798 772 770 894 879 956 80% 100 17 Red Flag staffing incidents 28 26 - 169 Maternity 0 Monthly Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan target YTD 600 Birth rate and Bookings 18 Birth Rate - total number of women birthed Bookings - Total number of women booked - - 483 406 392 428 469 409 446 467 442 400 424 400 382 417 450 418 477 402 449 416 513 387 432 383 453 436 363 440 498 412 300 10 19 Staffing: Birth rate plus reporting / opel status - number of days (or shifts) at Opel 4. 1 5 1 0 2 1 1 4 6 1 3 3 1 4 4 - - 0 100% 39.2% 47.3% 38.6% 49.3% 43.5% 45.2% 43.5% 44.3% 43.0% 43.5% 44.8% 44.8% 43.7% 38.6% 43.3% 43.3% 32.6% 53.0% 40.6% 46.9% 36.7% 48.8% 36.0% 54.8% 37.2% 49.3% 37.5% 48.2% 35.7% 48.5% Mode of delivery 20 % number of normal birthed (women) 50% % number of caesarean sections (women) % other - - 0% YTD target - - ≥90% - YTD target - - - Appendix Page 17 of 24 Report to Trust Board in February 2024 Outstanding Patient Outcomes,Safety and Experience Patient Experience 21 FFT Negative Score - Inpatients Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan 3% 1.0% 0.8% 0% 10% FFT Negative Score - Maternity 22 (postnatal ward) 1.5% 2.7% 0% 50% 23 Total UHS women booked onto a continuity of carer pathway 0% 80% 24 Total BAME women booked onto a continuity of carer pathway 12.9% 85.9% 16.6% 21.9% 5% 100% % Patients reporting being involved in 25 87% 87% decisions about care and treatment 80% % Patients with a disability/ additional needs reporting those 87% 26 needs/adjustments were met (total 86% number questioned included at chart base) 80% 26 - Performance is a scored metric with a "Yes" response scoring 1, "Yes, to some extent" receiving 0.5 score and other responses scoring 0. 200 Overnight ward moves with a reason 78 96 27 marked as non-clinical (excludes moves from admitting wards with LOS<12hrs) 0 Monthly target ≤5% ≤5% ≥35% ≥51% ≥90% ≥90% - YTD 0.6% 2.4% 13.8% 28.6% 87.2% 90.2% 692 YTD target ≤5% ≤5% ≥35% ≥51% ≥90% ≥90% - Appendix Page 18 of 24 Report to Trust Board in February 2024 Outstanding Patient Outcomes,Safety and Experience Access Standards Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan 100% Patients spending less than 4hrs in ED - (Type 1) 28 UHSFT 6 61.75% 5 6 4 9 12 9 8 63.7% 8 12 10 11 8 4 Teaching hospital average (& rank of 20) South East average (& rank of 16) 4 4 3 3 3 5 7 5 5 5 7 7 7 5 2 25% Monthly target ≥95% 05:00 29 Average (Mean) time in Dept - nonadmitted patients 02:00 08:00 30 Average (Mean) time in Dept - admitted patients 03:07 05:50 04:37 ≤04:00 06:39 ≤04:00 01:00 75% % Patients on an open 18 week pathway (within 18 weeks ) 64.0% 62.5% 31 UHSFT 5 5 5 4 4 4 4 5 4 4 4 4 Teaching hospital average (& rank of 20) 5 4 South East average (& rank of 17) 5 50% 5 5 5 6 6 5 5 6 6 6 5 4 4 ≥92% 60,000 Total number of patients on a waiting list 32 (18 week referral to treatment pathway) 54,254 57,725 - 40,000 Patients on an open 18 week pathway (waiting 52 weeks+ ) 8,000 5 5 5 5 4 4 4 4 3 3 3 2 2 2 33 UHSFT 2,156 1,672 ≤2,011 Teaching hospital average (& rank of 20) South East average (& rank of 17) 0 12 12 12 12 11 11 11 9 8 8 8 8 8 9 YTD 61.1% 03:39 06:01 63.0% 57,725 1,672 YTD target ≥95% ≤04:00 ≤04:00 ≥92% - ≤2011 Appendix Page 19 of 24 Report to Trust Board in February 2024 Outstanding Patient Outcomes,Safety and Experience Monthly Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan target 4,000 Patients on an open 18 week pathway (waiting 65 weeks+ ) 6 6 6 5 5 4 4 4 4 5 5 3 3 3 34 UHSFT 827 - Teaching hospital average (& rank of 20) 245 South East average (& rank of 17) 0 13 12 13 12 12 11 11 10 9 9 9 8 8 8 Patients on an open 18 week pathway 1,400 7 7 7 (waiting 78 weeks+ ) 6 35 UHSFT Teaching hospital average (& rank of 20) 271 4 4 5 8 8 7 6 5 6 5 27 0 South East average (& rank of 17) 0 15 15 15 15 12 10 11 12 11 10 9 9 9 9 200 Patients on an open 18 week pathway (waiting 104 weeks+ ) 35a UHSFT 0 Teaching hospital average (& rank of 20) South East average (& rank of 17) 1 0 1 0 1 0 1 1 0 1 0 8 1 14 4 157 15 2 16 2 12 1 13 1 13 1 0 0 0 11 1 1 1 1 13 13 17 13 14 10 11 9 15,500 36 Patients waiting for diagnostics 11,500 10,634 - 8,052 7,500 % of Patients waiting over 6 weeks for diagnostics 40% 28.7% 12 12 11 12 12 11 11 11 7 9 7 7 6 7 37 UHSFT Teaching hospital average (& rank of 20) 10 7 8 8 8 77 8 10 10 8 7 14.5% 7 7 ≤1% South East average (& rank of 18) 0% YTD 245 27 8,052 19.5% YTD target - 0 0 ≤1% Appendix Page 20 of 24 Report to Trust Board in February 2024 Outstanding Patient Outcomes,Safety and Experience Monthly Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan target % Patients following a GP referral for 100% suspected cancer seen by a specialist within 17 2 weeks (Most recently externally reported 14 13 79.5% 15 17 17 17 16 16 16 13 38 data, unless stated otherwise below) UHSFT Teaching hospital average (& rank of 20) 18 10 11 13 16 19 18 16 13 9 10 93.6% ≥93% South East average (& rank of 17) 55% YTD 76.7% YTD target ≥93% Beginning December 2023, NHSE published Cancer data no longer includes 2 week wait as a cancer standard for benchmarking. Data shown for October 2023 onwards will 38 reflect internally reported UHS position for each month, but will not include Teaching Hospital/South East Hospital data 100% Cancer waiting times 62 day standard - Urgent referral to first definitive treatment 79.5% (Most recently externally reported data, 39 unless stated otherwise below) 14 17 14 18 14 9 14 13 10 15 6 11 7 6 UHSFT Teaching hospital average (& rank of 20) South East average (& rank of 17) 40% 7 551.62% 11 7 14 5 9 7 3 6 1 3 2 2 ≥85% 66.7% ≥85% From October 2023 data onwards, the 62 day standard metric published in NHS england data combines Urgent Suspected Cancer and Breast Symptomatic with previously excluded Screening and 39 Upgrade routes. 100% Cancer 28 day faster diagnosis 87.2% Percentage of patients treated within 40 standard UHSFT Teaching hospital average (& rank of 20) South East average (& rank of 17) 78.6% 3 8 4 7 8 7 7 6 3 1 2 3 3 2 5 5 5 8 7 5 3 2 1 1 1 1 ≥75% 81.5% ≥75% 50% 100% 31 day cancer wait performance - decision to treat to first definitive treatment (Most 16 16 89.5% 16 18 16 15 17 15 13 13 11 15 12 13 recently externally reported data, unless 90.0% 41 stated otherwise below) UHSFT Teaching hospital average (& rank of 20) 13 12 20 12 10 14 11 5 14 9 6 9 15 8 South East average (& rank of 17) 78% ≥96% 88.4% ≥96% 41 From October 2023 data onwards, the 31 day standard metric published in NHS england data combines First Treatment and Subsequent Treatment routes. Appendix Page 21 of 24 Report to Trust Board in February 2024 Pioneering Research and Innovation R&D Performance 43 Comparative CRN Recruitment Performance - non-weighted Monthly Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan target YTD 25 21 19 19 17 14 15 15 13 14 17 17 16 15 15 Top 10 - 7 44 Comparative CRN Recruitment Performance - weighted 0 15 10 10 10 11 9 9 12 14 15 12 11 12 9 6 11 Top 5 - 0 100% Study set up times - 80% target for 45 issuing Capacity & Capability within 40 50% Days of Site Selection 0% 88% 59% 64% 60% 67% 47% 46% 46% 55% 25% - - 200% 166.3% Achievement compared to R+D 150% 85.2% 104.1% 133.3% 133.3% 46 Income Baseline Monthly income increase % 100% 71.4% 79.2% 50% 69.5% 84.7% 65.2% 35.6% 50.7% 45.8% 84.7% 65.2% ≥5% - 6.5% YTD income increase % 0% Appendix YTD target - - - - Page 22 of 24 Report to Trust Board in February 2024 Integrated Networks and Collaboration Appendix Local Integration Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Monthly target 250 197 Number of inpatients that were 47 medically optimised for discharge (monthly average) 0 234 ≤80 Emergency Department 48 activity - type 1 This year vs. last year 13000 11000 9000 10,116 10,089 11,591 - 10,459 Percentage of virtual appointments as a 49 proportion of all outpatient consultations This year vs. last year 40% 29.8% 29.9% 20% 29.8% 29.4% ≥25% YTD 202 114,095 29.3% YTD target - - ≥25% Page 23 of 24 Report to Trust Board in February 2024 Foundations for the Future Digital Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan My Medical Record - UHS patient 200,000 50 accounts (cumulative number of accounts in place at the end of each 100,000 month) 0 144,668 188,436 40000 My Medical Record - UHS patient 51 logins (number of logins made within 30000 each month) 20000 30,515 34,454 3090 Average age of IT estate 3000 2490 52 Distribution of computers per age 2000 863 1080 1170 in years 1000 0 0 27 39 84 136 375 0 1820 730 14 13 12 11 10 9 8 7 6 5 4 3 2 1 Monthly target - - - YTD 188,436 32,150 - YTD target - - - 99.75% 99.72% 99.73% 99.81% 99.77% 99.82% 99.74% 99.79% 99.80% 99.79% 100% 53 CHARTS system average load times - % of pages loaded under 5s 95% 53 Data only available from April 2023 onwards Q4 22-23 Q1 23-24 Q2 23-24 Q3 23-24 Q4 23-24 Cyber attacks / phishing / incidents blocked 30 Average # Malware attempts blocked 25 per month (10s) 20 25 22 20 54 Average # Phishing emails blocked per 15 10 month (100s) 10 61 Average # Ransomware attempts 5 2 blocked per month 0 71 3 40 1 - 10 26 1 70 - - Inpatient noting progress Left axis: 55 IP Noting data recorded (100s) IP Noting unique user views Right axis: IP pages scanned (1000s) NEU go live 5000 EYE go live CV&T gTo&liOvego live 4000 3000 2000 1000 0 Med go live Sur go live 55 IP Noting went live in Oct-22. CGs going live are marked on green line. Can go live 800 600 - - - 400 200 0 Page 24 of 24 Appendix
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Trust-governance-and-corporate-docs/2024-Trust-documents/Finance-and-Performance-Reports-2023-24-Month-10-January-2024.pdf

Papers Trust Board - 13 January 2026

Description: Date Time Location Chair Apologies Agenda Trust Board – Open Session 13/01/2026 9:00 - 13:00 Conference Room, Heartbeat Education Centre Jenni Douglas-Todd Diana Eccles 1 Chair’s Welcome, Apologies and Declarations of Interest 9:00 Note apologies for absence, and to hear any declarations of interest relating to any item on the Agenda. 2 Patient Story The patient story provides an opportunity for the Board to reflect on the experiences of patients and staff within the Trust and understand what the Trust could do better. 3 Minutes of Previous Meeting held on 11 November 2025 9:15 Approve the minutes of the previous meeting held on 11 November 2025 4 Matters Arising and Summary of Agreed Actions To discuss any matters arising from the minutes, and to agree on the status of any actions assigned at the previous meeting. 5 QUALITY, PERFORMANCE and FINANCE Quality includes: clinical effectiveness, patient safety, and patient experience 5.1 Briefing from the Chair of the Finance, Investment & Cash Committee 9:20 David Liverseidge, Chair 5.2 Briefing from the Chair of the People and Organisational Development 9:30 Committee Jane Harwood, Chair 5.3 Briefing from the Chair of the Quality Committee 9:40 including Maternity and Neonatal Safety 2025-26 Quarter 2 Report Tim Peachey, Chair 5.4 Chief Executive Officer's Report 9:50 Receive and note the report Sponsor: David French, Chief Executive Officer 5.5 Performance KPI Report for Month 8 10:20 Review and discuss the report Sponsor: Andy Hyett, Chief Operating Officer 5.6 11:00 5.7 11:15 5.8 11:25 5.9 11:30 5.10 11:45 5.11 11:55 5.12 12:05 5.13 12:15 6 6.1 12:25 7 12:35 8 Break Finance Report for Month 8 Review and discuss the report Sponsor: Ian Howard, Chief Financial Officer ICB System Report for Month 8 Receive and discuss the report Sponsor: Ian Howard, Chief Financial Officer People Report for Month 8 Review and discuss the report Sponsor: Steve Harris, Chief People Officer Learning from Deaths 2025-26 Quarter 2 Report Review and discuss the report Sponsor: Paul Grundy, Chief Medical Officer Attendee: Jenny Milner, Associate Director of Patient Experience Infection Prevention and Control 2025-26 Quarter 2 Report Review and discuss the report Sponsor: Natasha Watts, Acting Chief Nursing Officer Attendees: Julian Sutton, Clinical Lead, Department of Infection/Julie Brooks, Deputy Director of Infection Prevention and Control Medicines Management Annual Report 2024-25 Receive and discuss the report Sponsor: Paul Grundy, Chief Medical Officer Attendee: James Allen, Chief Pharmacist Annual Ward Staffing Nursing Establishment Review 2025 Discuss and approve the review Sponsor: Natasha Watts, Acting Chief Nursing Officer CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL Annual Assurance for the NHS England Core Standards for Emergency Preparedness, Resilience and Response (EPRR) Review and discuss the report Sponsor: Andy Hyett, Chief Operating Officer Attendee: John Mcgonigle, Emergency Planning & Resilience Manager Any other business Raise any relevant or urgent matters that are not on the agenda Note the date of the next meeting: 10 March 2026 Page 2 9 Resolution regarding the Press, Public and Others Sponsor: Jenni Douglas-Todd, Trust Chair To agree, as permitted by the National Health Service Act 2006 (as amended), the Trust's Constitution and the Standing Orders of the Board of Directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. 10 Follow-up discussion with governors 12:45 Page 3 Agenda links to the Board Assurance Framework (BAF) 13 January 2026 – Open Session Overview of the BAF Risk 1a: Lack of capacity to appropriately respond to emergency demand, manage the increasing waiting lists for elective demand, and provide timely diagnostics, that results in avoidable harm to patients. 1b: Due to the current challenges, we fail to provide patients and their families / carers with a high-quality experience of care and positive patient outcomes. 1c: We do 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. 2a: We do not take full advantage of our position as a leading University teaching hospital with a growing, reputable, and innovative research and development portfolio, attracting the best staff and efficiently delivering the best possible treatments and care for our patients. 3a: We are unable to meet current and planned service requirements due to the unavailability of staff to fulfil key roles. 3b: We fail to develop a diverse, compassionate, and inclusive workforce, providing a more positive staff experience for all staff. 3c: We fail to create a sustainable and innovative education and development response to meet the current and future workforce needs identified in the Trust’s longer-term workforce plan. 4a: We do not implement effective models to deliver integrated and networked care, resulting in sub-optimal patient experience and outcomes, increased numbers of admissions and increases in patients’ length of stay. 5a: We are unable to deliver a financial breakeven position, resulting in: inability to move out of the NHS England Recovery Support Programme, NHS England imposing additional controls/undertakings, and a reducing cash balance impacting the Trust’s ability to invest in line with its capital plan, estates/digital strategies, and in transformation initiatives. 5b: We do not adequately maintain, improve and develop our estate to deliver our clinical services and increase capacity. 5c: Our digital technology or infrastructure fails to the extent that it impacts our ability to deliver care effectively and safely within the organisation, 5d: We fail to prioritise green initiatives to deliver a trajectory that will reduce our direct and indirect carbon footprint by 80% by 2028-2032 (compared with a 1990 baseline) and reach net zero direct carbon emissions by 2040 and net zero indirect carbon emissions by 2045. Agenda links to the BAF No Item Linked BAF risk(s) 5.5 Performance KPI Report for Month 8 5.7 Finance Report for Month 8 5.8 ICB System Report for Month 8 5.9 People Report for Month 8 5.10 Learning from Deaths 2025-26 Quarter 2 Report 5.11 Infection Prevention and Control 2025-26 Quarter 2 Report 5.12 Medicines Management Annual Report 2024-25 5.13 Annual Ward Staffing Nursing Establishment Review 2025 6.1 Annual Assurance for the NHS England Core Standards for Emergency Preparedness, Resilience and Response (EPRR) 1a, 1b, 1c 5a 5a 3a, 3b, 3c 1b 1c 1b 1b, 3a 1b Appetite (Category) Minimal (Safety) Current risk rating 4x5 20 Cautious (Experience) Minimal (Safety) 4x4 16 4x4 16 Open (Technology & Innovation) 3x4 12 Open (workforce) Open (workforce) Open (workforce) 4x5 20 4x3 12 4x4 16 Cautious (Effectiveness) 3x3 9 Cautious (Finance) 5x5 25 Target risk rating 4 x 2 Apr 6 27 3 x 2 Apr 6 27 2 x 3 Apr 6 27 3 x 2 Mar 6 27 4 x 3 Mar 12 30 4 x 2 Mar 8 30 3 x 2 Mar 6 29 3 x 2 Dec 6 25 3 x 3 Apr 9 30 Cautious (Effectiveness) Open (Technology & Innovation) Open (Technology & Innovation) 4x5 20 3x4 12 2x4 8 4 x 2 Apr 8 30 3 x 2 Apr 6 27 2 x 2 Dec 4 27 Does this item facilitate movement towards or away from the intended target risk score and appetite? Towards Away Neither x x x x x x x x x Minutes Trust Board – Open Session Date 11/11/2025 Time 9:00 – 13:00 Location Conference Room, Heartbeat Education Centre Chair Jenni Douglas-Todd (JD-T) Present Diana Eccles, NED (DE) Keith Evans, Deputy Chair and NED (KE) David French, Chief Executive Officer (DAF) Paul Grundy, Chief Medical Officer (PG) Steve Harris, Chief People Officer (SH) Jane Harwood, NED/Senior Independent Director (JH) Ian Howard, Chief Financial Officer (IH) Andy Hyett, Chief Operating Officer (AH) David Liverseidge, NED (DL) Tim Peachey, NED (TP) Alison Tattersall, NED (AT) Natasha Watts, Acting Chief Nursing Officer (NW) In attendance Craig Machell, Associate Director of Corporate Affairs and Company Secretary (CM) Lauren Anderson, Corporate Governance and Risk Manager (LA) (item 6.2) Martin de Sousa, Director of Strategy and Partnerships (MdS) (item 6.1) Lucinda Hood, Head of Medical Directorate (LH) (item 5.13) Diana Hulbert, Guardian of Safe Working Hours and Emergency Department Consultant (DH) (item 5.12) Vickie Purdie, Head of Patient Safety (VP) (item 7.3) Kate Pryde, Clinical Director for Improvement and Clinical Effectiveness (KP) (item 5.13) Scott Spencer, Health and Safety Advisor (SS) (item 7.3) 4 governors (observing) 2 members of staff (observing) 1. Chair’s Welcome, Apologies and Declarations of Interest The Chair welcomed attendees to the meeting. There were no interests to declare in the business to be transacted at the meeting. It was noted that no apologies had been received. The Chair provided an overview of meetings she had held and events that she had attended since the previous Board meeting. 2. Patient Story Item deferred to the next meeting. 3. Minutes of the Previous Meeting held on 9 September 2025 The draft minutes tabled to the meeting were agreed to be an accurate record of the meeting held on 9 September 2025, subject to a minor correction at 5.10. Page 1 4. Matters Arising and Summary of Agreed Actions The matters arising and actions were noted. • Actions 1281, 1283 and 1284 were closed. • Action 1282 was to be addressed through item 5.6 below. • In respect of action 1285, the Quality Committee would monitor progress on complaints response times. 5. QUALITY, PERFORMANCE and FINANCE 5.1 Briefing from the Chair of the Audit and Risk Committee Keith Evans was invited to present the Committee Chair’s Report in respect of the meeting held on 13 October 2025, the content of which was noted. It was further noted that: • In terms of the internal audit reports, which had been received by the committee, whilst there were a number of points for the Trust to address, no areas of significant concern had been identified. • There was a focus on ‘imposter fraud’ whereby individuals who had turned up to carry out a shift were not who they claimed to be. Whilst there had been no reported incidents at the Trust, the Trust had implemented controls at the ward level, which would be subject to testing during 2025/26. 5.2 Briefing from the Chair of the Finance, Investment & Cash Committee David Liverseidge was invited to present the Committee Chair’s Reports in respect of the meetings held on 22 September and 3 November 2025, the contents of which were noted. It was further noted that: • In September 2025, the Trust had reported that it was in line with its Financial Recovery Plan. Of the £110m Cost Improvement Programme (CIP) target, 76% had been fully developed. • The committee had reviewed the Finance Report for Month 6 (item 5.8), noting that the Trust had reported an in-month deficit of £5.4m, which was in line with the Financial Recovery Plan. • The committee had expressed concern that 17% of the CIP target was not fully developed and that the Trust was £2.5m off-track in terms of delivery of the target at Month 6. • Whilst progress had been made in terms of addressing patients with no criteria to reside and mental health patients, this remained an area of concern. • The committee considered the NHS England Medium Term Planning Framework, noting that the first submission by the Trust was due prior to Christmas 2025. 5.3 Briefing from the Chair of the People and Organisational Development Committee Jane Harwood was invited to present the Committee Chair’s Reports in respect of the meetings held on 22 September and 3 November 2025, the contents of which were noted. It was further noted that: • There continued to be little improvement in terms of the number of patients with no criteria to reside or mental health patients, which impacted staffing numbers. • The Trust was adopting a harder line in respect of its approach to violence and aggression, which included a greater willingness to exclude individuals. • The current participation rate in the Staff Survey was lower than the national average, which was likely indicative of staff morale and engagement. Page 2 • The Trust’s workforce numbers remained above plan, with limited options available to address this issue, especially in the absence of funding for restructuring costs. 5.4 Briefing from the Chair of the Quality Committee Tim Peachey was invited to present the Committee Chair’s Report in respect of the meeting held on 13 October 2025, the content of which was noted. It was further noted that: • The committee received an update in respect of mental health patients, noting that although there were significant issues in the Emergency Department, the whole pathway for these patients remained a problem. • The committee carried out a six-monthly review of the Trust’s progress against its Quality Priorities, noting that good progress had been made on four of the six priorities and two were slightly behind. 5.5 Chief Executive Officer’s Report David French was invited to present the Chief Executive Officer’s Report, the content of which was noted. It was further noted that: • NHS England had published the Medium Term Planning Framework, which was intended to encourage organisations to think beyond a 12-month time horizon and to progress the NHS 10-Year Plan. The Trust was expected to provide its first submission prior to Christmas 2025, but the detailed planning assumptions had yet to be received from NHS England. It was noted that a more detailed report on the Medium Term Planning Framework was to be received as part of the closed session of the meeting. • The Strategic Commissioning Framework had been published by NHS England, which provided welcome clarifications about the future role of integrated care boards. • The Trust had been placed into Tier 1 for both Urgent and Emergency Care and for Elective performance. There was a national expectation that trusts would have no patients waiting over 65 weeks for elective care by 21 December 2025. Where organisations had more than 100 such patients at the end of October 2025, they had been placed into Tier 1. The Trust was taking steps, including mutual aid, to attempt to address the number of long waiters, but there was insufficient capacity in the system. • Resident doctors were due to strike for a further five-day period commencing on 14 November 2025, having rejected the Government’s latest offer to resolve the ongoing dispute with the British Medical Association. • The Hampshire and Isle of Wight Integrated Care Board and NHS England South East Region had carried out a visit to the Trust’s paediatric hearing services in May 2025. The report, received in October 2025, had been positive about the service. • The Trust and the University of Southampton had been awarded £16.3m by the National Institute for Health and Care Research. The Trust was one of only four organisations out of 15 applications to receive an award. • The NHS Business Services Authority had announced the award of a £1.2bn contract to Infosys to deliver a new and enhanced workforce management system for the NHS to replace the existing Electronic Staff Record system. The 2030 target date for implementation was considered ambitious. Further details would be considered by the People and Organisational Development Committee when available. Page 3 5.6 Performance KPI Report for Month 6 Andy Hyett was invited to present the ‘spotlight’ report in respect of Diagnostics, the content of which was noted. It was further noted that: • Diagnostics performance was a key element of the pathway, as delays in diagnosis had a consequential impact on the overall length of pathways such as those for cancer and patients on a Referral To Treatment pathway. • Although there were some concerns with Diagnostics in the Trust, the Trust, generally, performed better than other organisations. The Board discussed the matters raised in the Diagnostics ‘spotlight’. This discussion is summarised below: • There had been a long-standing issue with waiting times for cystoscopy due to insufficient capacity. However, a plan was being developed to improve the situation, although it was considered appropriate that the plan should also address broader issues with urology as a whole. • There was concern regarding the availability of magnetic resonance imaging (MRI) scanners, particularly as two scanners were out-of-action. It was noted that the current set-up in terms of MRI scanners was not fit for the longer term and a strategy for the future needed to be developed. • There was a disparity between capacity and demand in respect of the neurophysiology service, as this service had previously relied on outsourcing. • Generally, activity was increasing, but overall performance appeared to be declining. There was also the additional financial challenge that Diagnostics was funded under a ‘block’ contract arrangement which did not fully take into account the demand for these services. • There were concerns about the electrical supply capacity at the Southampton General Hospital site and the ability of the Trust to expand its Diagnostic capacity with this limitation. It was considered that a better longer-term model would be for scanners at local community diagnostics centres. Actions Andy Hyett agreed to work on and present at either a future Board meeting or Trust Board Study Session the Trust’s longer-term strategy with respect to MRI scanners and imaging. Andy Hyett agreed to develop a longer-term plan for cystoscopy/urology and to report back to the Board during Quarter 4. Andy Hyett agreed to develop a long-term solution to the neurophysiology service. Andy Hyett was invited to present the Performance KPI Report for Month 6, the content of which was noted. It was further noted that: • The Trust’s Emergency Department had recorded performance of 67.6% against the four-hour standard during September 2025. The department remained busy with c.450 patients and 120 ambulance attendances per day. • There had been some initial performance impacts with the roll out of the MIYA system in the Emergency Department, but this appeared to have now been addressed with performance up to previous levels. • A number of initiatives were being introduced into the Emergency Department in order to improve performance. These included the layout of the service, pathway re-designs, having General Practitioners in the department, and arranging with non-urgent patients to attend at a scheduled time rather than waiting in the department. Page 4 • In October 2025, the Trust had recorded 363 patients waiting over 65 weeks on a Referral To Treatment pathway against a national target of no such patients by the end of December 2025. • The Trust was making use of the independent sector, weekend working, and was requesting capacity from other providers to address the number of patients waiting over 65 weeks. • The planned industrial action by resident doctors posed a challenge, noting that the national expectation was that trusts maintain 95% of their capacity during this period. It was noted that, in contrast to previous instances of industrial action, resident doctors were apparently less forthcoming in terms of whether they intended to participate in the industrial action. • The Trust continued to report one of the lowest Hospital Standardised Mortality Rates in England. • The Trust’s cancer performance, based on a BBC article, was 21 out of 121 trusts. It was noted that whilst the number of patients being referred on a cancer pathway had increased significantly, the number of patients diagnosed with cancer had not materially changed. • There appeared to have been an increase in the number of pressure ulcers and ‘red flag’ incidents. Work was ongoing to address the findings of the pressure ulcer audit which had been presented to the Quality Committee on 2 June 2025. • The number of patients having no criteria to reside and mental health patients remained high. Actions Andy Hyett agreed to clarify the basis of the calculation of the ‘Watch & Reserve antibiotics usage per 1,000 adms’ metric. 5.7 Break 5.8 Finance Report for Month 6 Ian Howard was invited to present the Finance Report for Month 6, the content of which was noted. It was further noted that: • The Trust had submitted its Financial Recovery Plan to NHS England in August 2025, which committed to an additional £23m improvement in the Trust’s financial position to deliver a full-year position of a £54.9m deficit. In the absence of these additional improvements, the Trust had been forecasting a year-end position of a £78m deficit. The revised target was subject to a number of assumptions, including the need for demand management and improvements in non-criteria to reside and mental health patient numbers. • There were a number of risks to the achievement of the Financial Recovery Plan, including whether there would be improvements in mental health and non-criteria to reside and/or steps taken to manage demand, high levels of activity, and whether it would be possible to reduce the workforce and close theatres. The need for the Trust to focus on achieving the 65-week wait target in particular could impact the Trust’s ability to close capacity. • The Trust had reported an in-month deficit of £5.4m (£30.8m year-to-date), which was in line with the trajectory set out in the Financial Recovery Plan. The Trust’s underlying deficit had seen some marginal improvement during the period. • The Trust’s cash position remains an area of significant concern. Cash requests had been made to NHS England, but the latest request for November 2025 had been rejected. It was therefore likely that the Trust would need to manage its supplier payments in accordance with its available cash. Page 5 5.9 ICS System Report for Month 6 Ian Howard was invited to present the ICS System Report for Month 6, the content of which was noted. It was further noted that: • The Hampshire and Isle of Wight Integrated Care System had reported a year- to-date deficit of £48m. • A significant improvement in the run-rate would be required for the system to be able to deliver its 2025/26 plan. • The system was one of the worst in England in terms of the number of beds occupied by patients having no criteria to reside with approximately 23% of beds being occupied by such patients compared with a national average of 12%. • The system was also below plan in terms of its targets for access to General Practitioners and targets relating to mental health patients. It was noted that the performance in these areas had a consequential impact on the Trust’s performance in areas such as urgent and emergency care performance. 5.10 People Report for Month 6 Steve Harris was invited to present the People Report for Month 6, the content of which was noted. It was further noted that: • The overall workforce fell by 73 whole-time-equivalents (WTE) during September 2025 and was reported as being 54 WTE above the Trust’s 2025/26 plan. The reduction in workforce had been driven through a combination of the impact of the recruitment controls, mutually agreed resignation scheme (MARS) leavers, and a significant drop in use of temporary staff during the month. • On 15 October 2025, the Trust had heard the collective grievance brought by the Royal College of Nursing in respect of the removal of enhanced NHS Professionals rates. It was decided not to reverse the decision in order to maintain equity with the rest of the workforce and consistency across other local providers. A number of actions had been agreed following the hearing. • Sickness rates had increased to 3.8%, although the Trust still benchmarked well against peers. • There were concerns about the potential impact of influenza during the winter period and therefore the Trust was taking a number of actions to promote vaccination of staff. The Trust was currently third in terms of uptake in the Region. • The level of participation in the national Staff Survey remained a challenge with only 32% of staff having completed the survey compared with a national average of 38%. It was considered likely that the recent difficult decisions taken and the impact on staff was impacting staff experience and engagement. • The People and Organisational Development Committee would be examining statutory and mandatory training levels together with the latest proposed national changes. Page 6 5.11 NHSE Audit and review of 'Developing Workforce Safeguards' including UHS Self-Assessment Return Natasha Watts was invited to present the NHS England audit and review of ‘Developing Workforce Safeguards’ (2018), including the Trust’s Self-Assessment Return, the content of which was noted. It was further noted that: • ‘Developing Workforce Safeguards’ was published in October 2018 and included a range of standards to assure safe staffing across the workforce. NHS England had initiated an audit, review and improvement plan amidst concern about a national reduction in compliance. • The Trust had submitted a self-assessment as part of this NHS England review. This assessment showed that the Trust continued to comply with the majority of the standards. • The audit exercise has been used as an opportunity to identify opportunities for improvement. Twelve recommendations have been developed, of which nine were assessed as ‘green’ and three as ‘amber’. 5.12 Guardian of Safe Working Hours Quarterly Report and Update on 10-Point Plan Diana Hulbert was invited to present the Guardian of Safe Working Hours Quarterly Report and Update on the 10-Point Plan, the content of which was noted. It was further noted that: • Resident doctors were due to strike for five days from 14 November 2025. This would be the thirteenth strike in recent years. It was noted that, in addition to pay, the dispute also concerned working conditions and the shortage of posts and consequent risk to resident doctors of unemployment. • The Trust had performed a self-assessment against the 10-Point Plan and it was noted that the majority of the plan’s contents had been considered by the Trust for some time. There were also a number of dependencies on the part of NHS England in areas such as lead employer models. • A national review of statutory and mandatory training was expected to enable portability of training records to facilitate staff moving between NHS organisations. • There had been significant improvements in respect of gaps in rotas. 5.13 Annual Clinical Outcomes Summary Luci Hood and Kate Pryde were invited to present the Annual Clinical Outcomes Summary Report, the content of which was noted. It was further noted that: • The paper provided an overview of the clinical outcomes reviewed by the Clinical Assurance Meeting for Effectiveness and Outcomes (CAMEO) over the 12-month period to September 2025. • The majority of specialities provide reports to CAMEO, although outcome data can be more difficult in some areas to capture than in others. • The outcomes reviewed by the CAMEO and outputs from this body were also influencing the development of the Trust’s clinical strategy. • The strains on the capacity of services posed a risk to clinical outcomes. Page 7 • There was potential that a ‘quality’ override could form part of the NHS Oversight Framework in the future, operating in a similar manner to the ‘financial’ override by limiting the segmentations available to an organisation. 6. STRATEGY and BUSINESS PLANNING 6.1 Corporate Objectives 2025-26 Quarter 2 Review Martin De Sousa was invited to present the review of Corporate Objectives 2025/26 for the second quarter, the content of which was noted. It was further noted that: • Of the 12 objectives agreed for 2025/26, six were rated ‘green’, four were ‘amber’ and two were ‘red’. • The ‘red’ rated risks were that relating to the Trust’s financial performance and that relating to the Trust’s achievement of its workforce plan for 2025/26. 6.2 Board Assurance Framework (BAF) Update Lauren Anderson was invited to present the Board Assurance Framework update, the content of which was noted. It was further noted that: • BDO had completed its audit of the Trust’s risk maturity and had presented its report to the Audit and Risk Committee on 13 October 2025. The audit had highlighted a number of strengths including the Board Assurance Framework, risk definition, and use of risk in decision-making. In terms of opportunities for improvement, the audit report suggested some improvements in articulation of operational risks and use of ‘SMART’ methodology for actions. • The Board Assurance Framework had been reviewed by relevant executive directors and committees since it was last presented to the Board. There had been no changes to the ratings or target dates. 7. CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Feedback from the Council of Governors’ (COG) Meeting 28 October 2025 The Chair presented a summary of the Council of Governors’ meeting held on 28 October 2025. It was noted that the meeting had considered the following matters: • Chief Executive Officer’s Performance Report • Governor attendance at Council of Governors’ meetings • Review of the Council of Governors’ Expenses Reimbursement Protocol • Appointment of Jane Harwood as Deputy Chair with effect from 1 October 2025 • Membership engagement • Feedback from the Governors’ Nomination Committee It was noted that the Trust’s work on violence and aggression received particular attention from the Governors. 7.2 Register of Seals and Chair’s Action Report The paper ‘Register of Seals and Chair’s Actions Report’ was presented to the meeting, the content of which was noted. Page 8 It was further noted that one further item had been sealed on 7 November: Deed of Guarantee between University Hospital Southampton NHS Foundation Trust (Guarantor) and CHG-Meridian UK Limited (Beneficiary) regarding the payment and due performance obligations of UHS Estates Limited (UEL) under the Guaranteed Contract and specifically the Stryker Power Tools delivered to UEL under the pre-contract open build period with CHG. Seal number 307 on 7 November 2025. Decision: The Board agreed to ratify the application of the Trust Seal to the documents listed in the ‘Register of Seals and Chair’s Actions Report’ and to the additional document referred to above. 7.3 Health and Safety Services Annual Report 2024-25 Spencer Scott was invited to present the Health and Safety Services Annual Report 2024/25, the content of which was noted. It was further noted that: • The number of incidents reportable pursuant to the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) had increased substantially to 68 such incidents compared to 39 in 2023/24. The majority of these incidents related to moving and handling or exposure to infectious diseases. • There was a concern that there had been a reduction in the number of health and safety related reports and escalations whilst at the same time the number of RIDDORs had increased. • Four areas of concern were highlighted: Entonox surveillance of maternity staff, display screen equipment compliance, the Southampton General Hospital loading bay, and workplace temperatures during the summer. 8. Any other business There was no other business. 9. Note the date of the next meeting: 13 January 2026 10. Items circulated to the Board for reading The item circulated to the Board for reading was noted. There being no further business, the meeting concluded. 11. Resolution regarding the Press, Public and Others Decision: The Board resolved that, as permitted by the National Health Service Act 2006 (as amended), the Trust’s Constitution and the Standing Orders of the board of directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. The meeting was adjourned. Page 9 List of action items Agenda item Assigned to Deadline Status Trust Board – Open Session 15/07/2025 - 5.11 Freedom to Speak Up Report 1267. Data Mbabazi, Christine 10/03/2026 Pending Explanation action item Christine Mbabazi to include data from other mechanisms for reporting concerns in future Freedom to Speak Up reports. Trust Board – Open Session 09/09/2025 - 8 Any other business 1286. Organ donation Machell, Craig 03/02/2026 Pending Explanation action item Craig Machell agreed to add organ donation to the agenda of a future Trust Board Study Session. Update: Scheduled for TBSS on 03/02/26. Trust Board – Open Session 11/11/2025 - 5.6 Performance KPI Report for Month 6 1293. MRI scanners and imaging Hyett, Andy 13/01/2026 Pending Explanation action item Andy Hyett agreed to work on and present at either a future Board meeting or Trust Board Study Session the Trust’s longer-term strategy with respect to MRI scanners and imaging. 1294. Cystopscopy/urology Hyett, Andy 13/01/2026 Pending Explanation action item Andy Hyett agreed to develop a longer-term plan for cystoscopy/urology and to report back to the Board during Quarter 4. Page 1 of 2 Agenda item Assigned to Deadline Status Trust Board – Open Session 11/11/2025 - 5.6 Performance KPI Report for Month 6 1295. Neurophysiology Hyett, Andy 13/01/2026 Pending Explanation action item Andy Hyett agreed to develop a long-term solution to the neurophysiology service. 1296. Watch & Reserve antibiotics usage Hyett, Andy 13/01/2026 Pending Explanation action item Andy Hyett agreed to clarify the basis of the calculation of the ‘Watch & Reserve antibiotics usage per 1,000 adms’ metric. Page 2 of 2 Agenda Item 5.1 i) Committee Chair’s Report to the Trust Board of Directors 13 January 2026 Committee: Finance, Investment and Cash Committee Meeting Date: 24 November 2025 Key Messages: Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) Any Other Matters: • The committee received an update in respect of the Trust’s commercial activities, noting that the Trust had robust systems in place to maximise cost recovery for private patient and overseas visitor income. The Trust’s private patient unit project continued to progress. The Trust was also seeking a partner to manage its parking provision. • The committee received the Finance Report for Month 7. The Trust had reported a £5.1m in-month deficit (£35.9m year-to-date), which was in line with the trajectory contained in the Financial Recovery Plan. The underlying deficit remained flat at £6.4m. Whilst there had been a slight reduction in the number of mental health patients, there were c.240 patients having no criteria to reside at any point during the period. There was an increased level of scrutiny in respect of non-pay expenditure. • The committee reviewed an update on the Trust’s measures for financial improvement, noting that the Trust was forecasting achievement of £85-95m against its target of £110m Cost Improvement Programme delivery for 2025/26. • The committee noted the Trust’s approach and the timelines associated with the Medium Term Planning submission. It was noted that the framework set ambitious financial and performance targets. • The committee received an update in respect of the Trust’s Theatre Experience Programme, noting that there had been a 3% increase in utilisation and a 3% reduction in cancellations. • The committee reviewed the Trust’s productivity, noting that the Trust’s productivity had fallen by 3.3% compared to the prior year due to high-cost growth. • The committee received an update in respect of the Trust’s cash position and forecast and supported a proposal to request further cash support for January 2026. • The committee received an update on Capital Planning for 2026/272029/30. It was noted that it was expected that the Trust would be allocated c.£40m per annum, although there were concerns about the impact of the Trust’s cash position and the ability of the Trust to meet this level of expenditure. N/A N/A Page 1 of 2 Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Limited Assurance Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. No Assurance There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Not Applicable Where assurance is not required and/or relevant. Risk Rating: Low Medium High Not Applicable Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda Item 5.1 ii) Committee Chair’s Report to the Trust Board of Directors 13 January 2026 Committee: Finance, Investment and Cash Committee Meeting Date: 15 December 2025 Key Messages: • • • • • • The committee received the Finance Report for Month 8 (see below). The committee discussed the Trust’s future transformation programmes, noting that the areas of focus would be: urgent and emergency care, elective care, and automation of administrative processes. The committee was assured that the programmes were felt to be suitably ‘bold and ambitious’ and were grounded in realistic opportunities, rather than ‘blue sky’ ideas. The committee reviewed the draft capital plan for 2026/27 – 2029/30, noting that the Trust had been allocated c.£40m of capital departmental expenditure limit (CDEL) per year. It was noted that the Trust’s cash position could place constraints on the Trust’s capital programme. The opportunity to secure funding from national programmes outside of CDEL should be pursued vigorously. The plan was to be discussed in a Trust Board Study Session prior to submission in February 2026. The committee reviewed, challenged and discussed the Trust’s medium-term plan ahead of the first submission to NHS England on 17 December 2025. The committee provided feedback in respect of the proposed submission noting that some of the assumptions within the 2025/26 plan had not materialised with regard to matters such as reductions in non-criteria to reside numbers and the committee sought assurance that learnings had been applied to the development of the medium-term plan submission. The committee was assured that such assumed reductions within the 2026/27 plan were based purely on actions which were deemed to be within the Trust’s control. The committee suggested some changes with regard to the plan, particularly around growth assumptions in the cost base, and agreed to recommend the revised plan to the Board for approval. It was noted that more detail and reviews would be required prior to the final submission date in February 2026. The committee received an update in respect of the Trust’s cash position and supported a proposal to make a further request for cash support from NHS England for January 2026. The Trust reviewed and supported a proposal for transforming the Southern Counties Pathology network. Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) 5.7 Finance Report for Month 8 Assurance Rating: Risk Rating: Substantial High • The Trust had reported an in-month deficit of £4.9m (£40m year-todate), which was consistent with the Trust’s Financial Recovery Plan. • November 2025 had been a challenging month due to costs associated with industrial action, patients with no criteria to reside and mental health patients. • The Trust had received c.£3m of income out of £6.1m for elective over-performance. • There had been a slight improvement in the Trust’s underlying deficit. Page 1 of 2 Any Other N/A Matters: Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Limited Assurance Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. No Assurance There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Not Applicable Where assurance is not required and/or relevant. Risk Rating: Low Medium High Not Applicable Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda Item 5.2 i) Committee Chair’s Report to the Trust Board of Directors 13 January 2026 Committee: People & Organisational Development Committee Meeting Date: 21 November 2025 Key Messages: • • • • The committee reviewed the People Report for Month 7 including progress against the workforce plan. During October 2025, the overall workforce grew by 14 whole-time-equivalents (WTE). Although the substantive workforce had reduced by 15 WTE, there had been lowerthan-expected turnover and increased temporary staffing usage due in part to high sickness levels. The Trust remained on track, however, with respect to its Financial Recovery Plan trajectory. There were concerns about the response rate to the Staff Survey, which was below the national average. The Trust’s vaccination campaign for staff had started well with the uptake rate for the flu vaccine amongst staff at 43%. The committee considered the outputs of the review by NHS England of statutory and mandatory training and the implications for UHS. It was noted that a revised framework would facilitate passporting of training between NHS organisations. The Trust was aligned to the Core Skills Training Framework across six out of eleven areas and ten out of eleven areas for the Utilising E-Learning for Health material. The committee received an update in respect of the Trust’s Inclusion and Belonging strategy. It was noted that resource constraints and the impact of the current financial and operational environment on staff morale had impacted progress towards achievement of the objectives set out in the strategy. The committee reviewed the People risks contained within the Trust’s Board Assurance Framework. Assurance: N/A (Reports/Papers reviewed by the Committee also appearing on the Board agenda) Any Other N/A Matters: Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Limited Assurance Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. Page 1 of 2 No Assurance Not Applicable Risk Rating: Low Medium High Not Applicable There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Where assurance is not required and/or relevant. Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda Item 5.2 ii) Committee Chair’s Report to the Trust Board of Directors 13 January 2026 Committee: People & Organisational Development Committee Meeting Date: 15 December 2025 Key Messages: Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) • The committee reviewed the People Report for Month 8 (see below) including progress against the workforce plan and Financial Recovery Plan. • The committee considered the workforce implications of the Trust’s medium term plan submission, noting that there were a number of national expectations and targets, such as those relating to sickness rates and elimination of agency spend. In addition, the committee noted the risks associated with the plan, including those where the Trust was reliant on progress with respect to non-criteria to reside and mental health numbers. • The committee received an update regarding the Trust’s Violence and Aggression workstream, noting that the Trust had adopted a revised approach to violence, aggression and abuse directed at staff with a greater willingness to take action against violent/abusive patients and members of the public. A violence and aggression board had been established to provide executive oversight and leadership, and the Trust’s policy was being revised. This work would be accompanied by a comprehensive communication plan for both staff and members of the public. • The committee reviewed the Trust’s progress against its objectives for Year 4 of its People Strategy. 5.9 People Report for Month 8 Assurance Rating: Risk Rating: Substantial High • The overall workforce fell during November 2025, with substantive numbers falling by 52 whole-time-equivalents (WTE). However, temporary staffing use had increased during the month due to increased sickness and operational pressures, which offset much of the reduction in substantive numbers. • The Trust was over its original plan by 214 WTE despite a decrease of nearly 400 WTE since 31 March 2025. In order to hit the Trust’s Financial Recovery Plan target, the overall workforce would need to fall by a further 137 WTE (including a 72 WTE reduction in temporary staffing) by the end of March 2026. • A forecast based on the previous year’s temporary staffing usage for the remaining months of the year indicated that the Trust would end the year approximately 500 WTE above the Trust’s 2025/26 plan. • The Trust had submitted a baseline assessment against the 10 Point Plan to improve Resident Doctors’ working lives in August 2025, which indicated that the Trust compared favourably against other organisations in the South East. The main issues concerned space available for doctors to work in and timeliness of reimbursement of course-related expenses. • The Trust was expected to meet a target of 95% of job plans having been signed off prior to 31 March 2026. At the start of December 2025, 55% of job plans had been signed off. Page 1 of 2 Any Other Matters: • Sickness absence had increased in November 2025 to 4.2% in month due to seasonal illnesses. • The staff survey closed on 28 November 2025. The completion rate for the staff survey had been lower t
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Trust-governance-and-corporate-docs/2026-Trust-documents/Papers-Trust-Board-13-January-2026.pdf

1 to 4 of 4

Browse site A to Z

Search results

Papers Trust Board 28 March 2019

Papers Trust Board 6 June 2024

Finance and Performance Reports 2023-24 Month 10 - January 2024

Papers Trust Board - 13 January 2026

Site policies

Contact details

Useful links