Browse site A to Z

Search results

Go To Advanced Search

Featured research: fighting lung disease

Description: Auto Generated Title Southampton researchers are looking for healthy people between 60 and 85 years of age to take part in a study ai
Url: /ClinicalResearchinSouthampton/Public-and-patients/Featured-research-studies/Featured-research-fighting-lung-disease.aspx

UHS register of interests June 2025

Description: Employee Name Aarvold, Dr Alice Beatrice Rachel Aarvold, Dr Alice Beatrice Rachel Adam, Dr Robert Dhugald (Rob) Adam, Dr Robert Dhugald (Rob) Adam, Dr Robert Dhugald (Rob) Adam, Dr Robert Dhugald (Rob) Adam, Dr Robert Dhugald (Rob) Adam, Dr Robert Dhugald (Rob) Adam, Dr Robert Dhugald (Rob) Afzal, Dr Nadeem Ahmad Afzal, Dr Nadeem Ahmad Afzal, Dr Nadeem Ahmad Afzal, Dr Nadeem Ahmad Afzal, Dr Nadeem Ahmad Afzal, Dr Nadeem Ahmad Afzal, Dr Nadeem Ahmad Afzal, Dr Nadeem Ahmad Afzal, Dr Nadeem Ahmad Afzal, Dr Nadeem Ahmad Afzal, Dr Nadeem Ahmad Akerman, Dr Catherine Mary Elizabeth Akerman, Dr Catherine Mary Elizabeth Akerman, Dr Henry (Harry) Akerman, Dr Henry (Harry) Akerman, Dr Henry (Harry) Al Rawi, Dr Samar Othman Abed Al Baki (Samar) Al Rawi, Dr Samar Othman Abed Al Baki (Samar) Al Rawi, Dr Samar Othman Abed Al Baki (Samar) Al Rawi, Dr Samar Othman Abed Al Baki (Samar) Al Rawi, Dr Samar Othman Abed Al Baki (Samar) Al-Azzawi, Dr Omar Muataz Shnasi Alderton, Dr Mark Vernon Alderton, Dr Mark Vernon Alderton, Dr Mark Vernon Allan, Dr Charlotte Georgina Allan, Dr Charlotte Georgina Allen, Dr David Charles Allen, Dr David Charles Amerasinghe, Ms. Nishani Amerasinghe, Ms. Nishani Amerasinghe, Ms. Nishani Amerasinghe, Ms. Nishani Amerasinghe, Ms. Nishani Amerasinghe, Ms. Nishani Amerasinghe, Ms. Nishani Amerasinghe, Ms. Nishani Amerasinghe, Ms. Nishani Amerasinghe, Ms. Nishani Amerasinghe, Ms. Nishani Amerasinghe, Ms. Nishani Amerasinghe, Ms. Nishani Amerasinghe, Ms. Nishani Amerasinghe, Ms. Nishani Amerasinghe, Ms. Nishani Amerasinghe, Ms. Nishani Amerasinghe, Ms. Nishani Amerasinghe, Ms. Nishani Amerasinghe, Ms. Nishani Amerasinghe, Ms. Nishani Amerasinghe, Ms. Nishani Amerasinghe, Ms. Nishani Amerasinghe, Ms. Nishani Amerasinghe, Ms. Nishani Amerasinghe, Ms. Nishani Amerasinghe, Ms. Nishani Amerasinghe, Ms. Nishani Amerasinghe, Ms. Nishani Amerasinghe, Ms. Nishani Amerasinghe, Ms. Nishani Amerasinghe, Ms. Nishani Amerasinghe, Ms. Nishani Amerasinghe, Ms. Nishani Amerasinghe, Ms. Nishani Amerasinghe, Ms. Nishani Amerasinghe, Ms. Nishani Amerasinghe, Ms. Nishani Amerasinghe, Ms. Nishani Amerasinghe, Ms. Nishani Anderson, Mr. David Frederick Anderson, Mr. David Frederick Anderson, Mr. David Frederick Anderson, Mr. David Frederick Role Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Consultant Interest Declared Y Y Interest Category Financial interests Financial interests Y Financial interests Y Financial interests Y Indirect interests Y Indirect interests Y Indirect interests Y Indirect interests Y Indirect interests Y Financial interests Y Financial interests Y Financial interests Y Financial interests Y Financial interests Y Financial interests Y Financial interests Y Financial interests Y Financial interests Interest Situation Clinical private practice Clinical private practice Outside employment Outside employment Hospitality Outside employment Outside employment Outside employment Sponsored events Clinical private practice Clinical private practice Clinical private practice Clinical private practice Donations Sponsored events Sponsored events Sponsored events Sponsored research Y Financial interests Sponsored research Y Financial interests Sponsored research Y Indirect interests Clinical private practice Shareholdings and other Y Indirect interests ownership interests Y Financial interests Clinical private practice Shareholdings and other Y Financial interests ownership interests Shareholdings and other Y Financial interests ownership interests Y Financial interests Clinical private practice Y Financial interests Clinical private practice Y Financial interests Clinical private practice Y Financial interests Clinical private practice Y Indirect interests Clinical private practice Shareholdings and other Y Financial interests ownership interests Y Indirect interests Clinical private practice Non-financial Y professional interest Outside employment Non-financial Y professional interest Outside employment Non-financial personal Y interests Loyalty interests Y Y Financial interests Clinical private practice Y Indirect interests Donations Y Financial interests Clinical private practice Y Financial interests Clinical private practice Y Financial interests Donations Y Financial interests Hospitality Y Financial interests Hospitality Y Financial interests Hospitality Shareholdings and other Y Financial interests ownership interests Y Financial interests Sponsored events Y Financial interests Sponsored events Y Financial interests Sponsored events Y Financial interests Sponsored events Y Financial interests Sponsored events Y Financial interests Sponsored events Y Financial interests Sponsored events Y Financial interests Sponsored events Y Financial interests Sponsored events Y Financial interests Sponsored events Y Financial interests Sponsored events Y Financial interests Sponsored events Y Financial interests Sponsored events Y Financial interests Sponsored events Y Financial interests Sponsored events Y Financial interests Sponsored events Y Financial interests Sponsored events Y Financial interests Sponsored events Y Financial interests Sponsored events Y Financial interests Sponsored events Y Financial interests Sponsored events Y Financial interests Sponsored events Y Financial interests Sponsored events Y Financial interests Sponsored events Y Financial interests Sponsored events Y Financial interests Sponsored events Y Financial interests Sponsored events Y Financial interests Sponsored research Non-financial personal Y interests Sponsored events Non-financial Y professional interest Hospitality Non-financial Y professional interest Outside employment Non-financial Y professional interest Sponsored events Non-financial Y professional interest Sponsored research Y Financial interests Outside employment Y Financial interests Clinical private practice Y Financial interests Sponsored events Y Financial interests Sponsored events Interest Description I have a private orthopaedic list once per month. I have a private list once a month . - Attended a educational event at the Abbott research facility in Sylmar, California, USA. - All travel cost, accomidation and meals were provided for by Abbott. - During the trip I provided 2.5 hours of feedback on future product development which I recieved a consultation fee for. In September 2022 I was part of the expert panel at the New Evidence based approach to Implementing the Four Pillars of HFrEF training event and I received HCP honorarium fees of £250 from AstraZeneca to participating in the event. On the 15th of November 2022 I attended a dinner/update event at the Harbour Hotel in Southampton that was sponsored by Medtronic LTD. I recieved a consultancy fee from AstraZenaza for speaking of cardiovscualar risk in COPD. I recieved a speakers fee from Astra Zeneca for apprearing at a Cardiometabolic GP Symposium. I recieved a speakers fee from Zoll for giving a presentation at EHRA. In September 2023 I attended a CRT training course in Denmark which was funded by Merit Medical. CANDOVER CLINIC BASINGSTOKE I do private work at Candover clinic, Basingstoke and North Hampshire Hospital, Aldermaston Road, Basingstoke RG24 9NA I have a private practice at Candover Clinic in Basingstoke and Spire Southampton. However, my practice at Spire Southampton is minimal, as it was intended for private endoscopies, which have not been possible due to a lack of support from the Spire hospital team. I practice at the Candover Basingstoke and the Spire A sum of 9,750 £ received from Dana Fry, a parent for purchase of a Paediatric Fibroscan probe. This is to be used for NHS practice. The moneys were deposited in Charity fund I sought sponsorship from Nutricia to organise a regional Wessex Gastroenterology meeting. The aim of this meeting is to maintain effective regional communication, discuss guidelines and standards of practice, and include presentations with key learning points for our day-to-day work. Comments This does not impact on my NHS work This is a regular list that has no impact on my NHS practice. - The trip was approved by to my line manager. - Merit funded all travel, accommodation and hospitality cost Private practice outside working hours for UHS I see patients with paediatric gastroenterology conditions in the clinic The fibroscan probe will be exceptionally useful for managing and treating children with liver fibrosis CoI Date From CoI Date To 16/09/2024 25/07/2022 25/07/2023 20/07/2022 24/09/2022 21/09/2022 21/09/2022 15/11/2022 15/11/2023 12/09/2024 12/09/2024 22/05/2024 22/05/2024 30/03/2025 30/03/2025 16/09/2023 18/09/2023 01/05/2021 04/10/2022 01/05/2021 01/12/2023 18/10/2024 01/12/2022 19/11/2021 27/02/2024 27/02/2024 Talk on national symposium sponsored by Falk, UK. However I haven't received any moneys yet. I declared my conflict of interest at the talk and the sponsorship didn't influence the content of my talk. WESSEX PAEDIATRIC GI NETWORK MEETING CI for The ACTIVE-IBD Study RHM CHI1102 Awarded 400£ for the study by CICRA - Childhood Crohns Research Association PAID TO PROVIDE LUNCH AND TEA FOR DELEGATES ATTENDING MEETING THE NETWORK MEETING IS FOR TEACHING AND DISCUSSION OF NETWORK PROTOCOLS - THIS TIME WE ARE DISCUSSING MANAGEMENT OF GI BLEEDING IN CHILDREN Ethics REC - Sep 2021 Study started - Nov 2021 35/50 recruited into study 19/10/2023 18/10/2022 18/10/2022 01/02/2022 EnablExercise in Crohns: A qualitativE study to uNderstAnd the Barriers and faciLitators to physical activity and Exercise IN children and adolescents with CROHN’S disease – perceptions of patients, caregivers and clinicians The aim of this project is to understand the barriers to and facilitators of physical activity and exercise training in children and adolescents with Crohn’s disease – incorporating the views of young people with Chrohns, their parents/guardians and doctors. Awarded 25K by GUTS UK (national bidding) Principal applicant DR Zoe Saynor - i m co-applicant SPONSORED RESEARCH My husband works as an anaesthetist in private practice moneys not awarded yet still to commence Granted 25K from GUTS UK to conduct research on Crohns in children with IBD 01/02/2022 01/11/2021 04/10/2022 30/11/2023 My husband has developed an app that allocates staff to vacancies in healthcare. Private healthcare providers are using this currently. I undertake private practice in my own at all the local private hospitals I have shares in Zelemiq Life Science Limited which is a local electronics company that helps other companies navigate through regulatory pathways. They also are creating the Ripple- a non invasive continuous glucose and lactate monitor I part own Alloc8tor that is a company linking together healthcare professionals with available outside work. We currently do no business with UHS or with the NHS. We have a contact with the Nuffield Hospital chain nationally and some other smaller contacts with other private hospitals. We have no plans to sell the company currently 30/11/2023 20/01/2022 01/01/2030 18/02/2024 26/02/2030 20/01/2022 01/04/2025 I am a member of SAS partnership and as such provide anaesthesia services locally. I work with a few surgeons closely and may pick up some as hoc sessions when offered to the group 04/01/2022 04/01/2023 I am part of SAS LLP which includes many colleagues from my trust. We provide anaesthetic services individually and as a group to local surgeons as well as other local providers such as ECT for the RSH. 04/11/2024 I have practicing privileges at both the Nuffield and Spire hospitals. In the past this included choose and book NHS patients but more recently the large majority is insured or self funding. Practicing privileges at both the Nuffield and Spire hospitals I continue to work in local private sectors and will occasionally have UHS outsourced patients on some of my lists 01/12/2020 31/12/2021 01/01/2022 01/01/2023 01/01/2023 31/12/2023 I am the sole shareholder and director of two companies. The first one is Al-Azzawi Trading Limited (Company number 13862060), which is an E-Commerce company that trades medical items such as stethoscopes, ophthalmoscopes, and consumer ECG monitors, as well as non-medical items. The suppliers are exclusively dealt with through eBay, Aliexpress, and Alibaba, while buyers are sold to through I would like to state that this is a declaration of interest rather than a declaration of conflict of interest. None of the time spent directing eBay. The second company is Al-Azzawi Businesses Limited (Company number 13829506), which is a property investment company in the form of Buy-To-Let. either of the two companies is part of my contracted time with the trust, nor does it happen on the trust premises. 28/03/2022 I have worked within the joint NHS/Private Palforzia peanut immunotherapy clinic. This is joint with Southampton NHS Trust however the immunotherapy is not offered via NHS services and it was felt best option to be able to offer this to some of our patients within the region. It does not impact on NHS duties running on a weekend and my role is very much supporting the service rather than leading it. I have not really worked in the service this year and will only support if staff sickness 18/01/2024 Designated doctor for child deaths for Hampshire, isle of Wight, Portsmouth and Southampton. Employed via HIOW ICS Potential COI but likely impact more for HIOW ICB 11/02/2020 NHSE SE Long COVID CYP lead No real conflict of interest to the hospital here 18/01/2024 Married to Mr Edward Gardner Consultant Orthopaedic Surgeon at UHS Asked to declare this at previous appraisals I undertake private clinical practice in Clinical Neurophysiology at the Sarum Road (Circle) Hospital Winchester I run one or two clinics per week, lasting 3 hrs each. We previously completed in a sponsored running event and raised money for the Smile for Wessex (Neuro) charity, which donated a few thousand pounds. We are currently potential beneficiaries of the Smile for Wessex charity, with regards to them funding equipment for a second VT bed. Continued work at Wessex Nuffield and Southampton Spire Also ad hoc work at Prema Clinic Portsmouth Do private practice at Southampton Spire and Nuffield wessex and Prema Laservision Educational Grant from Thea Pharmaceuticals £500 Attended list at Western Eye to watch Miniject insertion Moorfields international Glaucoma meeting - delegate iStent meeting - lecture given Hotel room booked by iStar Registration, dinner and hotel room for one night paid by Thea Pharmaceuticals Honorarium from Glaukos 01/11/2008 26/09/2022 26/09/2022 01/01/2010 12/03/2024 03/10/2021 12/03/2024 14/01/2024 08/02/2022 25/06/2023 02/11/2023 27/01/2024 15/09/2023 Paid a refundable deposit to buy shares in a new private non NHS hospital, where I hope to carry out private practice work in the future AbbVie Advisory Board Advisory Board on Durstyra Basic Glaucoma Course - organizer and facilitator - Alcon Basic Surgical Glaucoma Course, held at Alcon Education Centre, Barcelona Booth talk and podcast at European Society of Cataract and Refractive Surgeons Conference on Elios Chair and organiser of Corneal & Glaucoma Southern Meeting Sponsered by Thea Pharmaceuticals Chair of Wessex Glaucoma Forum Chair of Wessex Glaucoma Meeting Chaired Nguenity 1.5 meeting Chaired Southern Glaucoma and Corneal Meeting Educational Grant Elios Advisory Board Glaukos Advisory Board Honoria from Alcon for Advanced Glaucoma Surgical Course Hydrus Meeting Chaired Honorarium received Alcon Eye Care Hydrus Workshop Hydrus Workshop Course facilitator and lecturer International Glaucoma Consortium - participant Interview for Ophthalmologist magazine Interview on Gemini Study for the Ophthalmologist magazine Lecture series x 4 lectures in Singapore Speaker Lecture to Singapore Audience "More than meets the Eye" MIGS unplugged interview On advisory board for AbbVie Allergan for intracameral drugs use Preserflo User Group Meeting Chair of meeting Speaker at Cataract and Glaucoma Update meeting Wessex Glaucoma Meeting Real world data study in Glaucoma Honorarium paid by AbbVie Honoria received from AbbVie Advice on novel drug delivery to NHS Travel Hotel and dinners paid Honoria paid Course organizer and facilitator/lecturer Honorarium paid Course sponsored Accommodation, flights paid Honorarium paid by Elios Conference registration paid by Elios Hotel room & Dinner paid by Thea Pharmaceuticals Honoria paid Educational event for Wessex Glaucoma consultants Honoria received from Thea Pharmatceuticals Honoria received from Thea Pharmaceuticals Honorarium paid by Alcon Honorarium paid by Thea including hotel room for one night Educational Grant from Thea Pharmaceuticals to attend WGC Educational Event Honorarium from Elios travel , hotel and dinner paid Honoria paid Payments on 13th and 20th May 2025 Educational event for new technique being introduced to Trust Attended event registration, travel and accommodation covered by Alcon UK Honorarium paid by Alcon Honorarium paid by ICG Honorarium from Sight Sciences Honorarium paid by Sight Sciences Honorarium , flights , accommodation x 2 nights paid by AbbVie Honorarium received from AbbVie Honorarium paid by International Glaucoma Consortium Honorarium paid by Santen Hotel room booked Honoria received from Scope Chaired meeting Honoria received from Santen Educational event Sponsorship of data analysis and research methodology from AbbVie 12/05/2025 23/04/2024 01/12/2022 01/12/2022 08/01/2025 10/01/2025 17/04/2024 19/04/2024 07/09/2024 14/03/2025 14/03/2025 12/10/2022 12/10/2022 25/11/2022 25/11/2022 07/09/2024 08/12/2023 27/06/2023 01/07/2023 09/09/2023 10/04/2025 11/04/2025 23/04/2025 24/04/2025 06/07/2023 20/04/2023 21/04/2023 14/06/2024 31/05/2024 08/09/2023 07/09/2024 04/03/2024 05/03/2024 16/08/2023 02/06/2024 07/02/2022 21/11/2023 17/05/2023 17/05/2023 16/05/2023 16/05/2023 01/10/2022 Sponsorship of Charitable endeavor - Everest in the Alps to raise money for Glaucoma UK Sponsorship gained from ELIOS Vision; Santen UK; Thea Pharmaceuticals; iStar Medical Benefit to NHS - raises profile of Glaucoma 28/02/2023 03/03/2023 Sight Sciences Dinner WGC 2023 28/06/2023 28/06/2023 President-Elect UK & Eire Glaucoma Society Professional body affiliated to Glaucoma UK charity 04/05/2022 Educational event - Hydrus Workshop Registration , travel and accommodation covered by Alcon UK 20/04/2023 21/04/2023 Real world study of glaucoma data with Medisoft and research sponsored (no direct financial payment) by AbbVie Consultancy agreement between DFA and Leica Microsystems 20/04/2022 on-going private practice as detailed in Job Plan Leica Microsystems Visualization Summit October 2022 Southampton Corneal Meeting sponsored by Thea Pharmaceuticals Standard NDA and consultancy agreement for advice and presentation to Leica Microsystems from 2022Evening lecture 05/12/2021 20/04/2022 27/09/2023 24/07/2024 13/10/2022 13/10/2022 23/03/2023 23/03/2023 Anjum, Mr. Syed Neshat Anjum, Mr. Syed Neshat Anjum, Mr. Syed Neshat Ansell, Dr Gillian Lindsay (Gilly) Antonakis, Dr Serafeim Antonakis, Dr Serafeim Antonakis, Dr Serafeim Antonakis, Dr Serafeim Antony, Mrs. Shaibi Armstrong, Mr. Thomas Armstrong, Mr. Thomas Armstrong, Mr. Thomas Armstrong, Mr. Thomas Armstrong, Mr. Thomas Armstrong, Mr. Thomas Arshad, Mr. Ali Ahmed Osman Ali (Ali) Arshad, Mr. Ali Ahmed Osman Ali (Ali) Ayer, Miss Mavis Grace (Mavis) Ayer, Miss Mavis Grace (Mavis) Ayer, Miss Mavis Grace (Mavis) Ayer, Miss Mavis Grace (Mavis) Ayer, Miss Mavis Grace (Mavis) Ayer, Miss Mavis Grace (Mavis) Ayer, Miss Mavis Grace (Mavis) Ayer, Miss Mavis Grace (Mavis) Ayer, Miss Mavis Grace (Mavis) Ayer, Miss Mavis Grace (Mavis) Ayer, Miss Mavis Grace (Mavis) Ayer, Miss Mavis Grace (Mavis) Ayer, Miss Mavis Grace (Mavis) Ayer, Miss Mavis Grace (Mavis) Ayer, Miss Mavis Grace (Mavis) Ayer, Miss Mavis Grace (Mavis) Ayer, Miss Mavis Grace (Mavis) Ayer, Miss Mavis Grace (Mavis) Ayer, Miss Mavis Grace (Mavis) Ayer, Miss Mavis Grace (Mavis) Ayer, Miss Mavis Grace (Mavis) Ayer, Miss Mavis Grace (Mavis) Ayer, Miss Mavis Grace (Mavis) Ayer, Miss Mavis Grace (Mavis) Ayer, Miss Mavis Grace (Mavis) Ayer, Miss Mavis Grace (Mavis) Ayer, Miss Mavis Grace (Mavis) Ayer, Miss Mavis Grace (Mavis) Ayer, Miss Mavis Grace (Mavis) Ayer, Miss Mavis Grace (Mavis) Ayer, Miss Mavis Grace (Mavis) Ayer, Miss Mavis Grace (Mavis) Ayer, Miss Mavis Grace (Mavis) Ayer, Miss Mavis Grace (Mavis) Ayer, Miss Mavis Grace (Mavis) Ayer, Miss Mavis Grace (Mavis) Ayer, Miss Mavis Grace (Mavis) Ayer, Miss Mavis Grace (Mavis) Ayer, Miss Mavis Grace (Mavis) Ayer, Miss Mavis Grace (Mavis) Ayer, Miss Mavis Grace (Mavis) Ayer, Miss Mavis Grace (Mavis) Ayer, Miss Mavis Grace (Mavis) Ayer, Miss Mavis Grace (Mavis) Ayer, Miss Mavis Grace (Mavis) Ayer, Miss Mavis Grace (Mavis) Ayer, Miss Mavis Grace (Mavis) Ayer, Miss Mavis Grace (Mavis) Ayer, Miss Mavis Grace (Mavis) Ayer, Miss Mavis Grace (Mavis) Ayer, Miss Mavis Grace (Mavis) Ayer, Miss Mavis Grace (Mavis) Baker, Mr. Peter Stuart Balabanidou, Miss Eleni Balabanidou, Miss Eleni Barker, Dr Ruth Emily Barker, Dr Ruth Emily Barker, Dr Ruth Emily Barker, Dr Ruth Emily Barker, Dr Ruth Emily Barker, Dr Ruth Emily Barker, Dr Ruth Emily Barker, Dr Ruth Emily Barratt, Mr. James Matthew Bateman, Dr Andrew Rea Consultant Y Consultant Y Consultant Y Consultant Y Consultant Y Consultant Y Consultant Y Consultant Y Specialist Nurse Practitioner Y Consultant Y Consultant Y Consultant Y Consultant Y Consultant Y Consultant Y Consultant Y Consultant Y Nurse Manager Y Nurse Manager Y Nurse Manager Y Nurse Manager Y Nurse Manager Y Nurse Manager Y Nurse Manager Y Nurse Manager Y Nurse Manager Y Nurse Manager Y Nurse Manager Y Nurse Manager Y Nurse Manager Y Nurse Manager Y Nurse Manager Y Nurse Manager Y Nurse Manager Y Nurse Manager Y Nurse Manager Y Nurse Manager Y Nurse Manager Y Nurse Manager Y Nurse Manager Y Nurse Manager Y Nurse Manager Y Nurse Manager Y Nurse Manager Y Nurse Manager Y Nurse Manager Y Nurse Manager Y Nurse Manager Y Nurse Manager Y Nurse Manager Y Nurse Manager Y Nurse Manager Y Nurse Manager Y Nurse Manager Y Nurse Manager Y Nurse Manager Y Nurse Manager Y Nurse Manager Y Nurse Manager Y Nurse Manager Y Nurse Manager Y Nurse Manager Y Nurse Manager Y Nurse Manager Y Nurse Manager Y Nurse Manager Y Nurse Manager Y Nurse Manager Y Nurse Manager Y Manager Y Consultant Y Consultant Y Manager Y Manager Y Manager Y Manager Y Manager Y Manager Y Manager Y Manager Y Dietitian Specialist Practitioner Y Consultant Y Financial interests Financial interests Non-financial professional interest Clinical private practice Clinical private practice Clinical private practice Indirect interests Financial interests Loyalty interests Clinical private practice Financial interests Financial interests Clinical private practice Shareholdings and other ownership interests Financial interests Non-financial professional interest Financial interests Financial interests Indirect interests Non-financial personal interests Non-financial personal interests Non-financial professional interest Indirect interests Non-financial professional interest Financial interests Financial interests Financial interests Financial interests Financial interests Financial interests Financial interests Financial interests Financial interests Financial interests Financial interests Financial interests Financial interests Financial interests Financial interests Financial interests Financial interests Financial interests Financial interests Financial interests Financial interests Financial interests Financial interests Financial interests Financial interests Financial interests Financial interests Financial interests Financial interests Financial interests Financial interests Financial interests Financial interests Financial interests Financial interests Financial interests Financial interests Financial interests Financial interests Financial interests Financial interests Financial interests Financial interests Financial interests Financial interests Financial interests Non-financial personal interests Non-financial personal interests Non-financial professional interest Non-financial professional interest Non-financial professional interest Non-financial professional interest Non-financial professional interest Sponsored events Hospitality Sponsored events Sponsored events Sponsored events Loyalty interests Sponsored events Clinical private practice Clinical private practice Clinical private practice Hospitality Hospitality Outside employment Outside employment Outside employment Outside employment Outside employment Outside employment Outside employment Outside employment Outside employment Outside employment Outside employment Outside employment Outside employment Outside employment Outside employment Outside employment Outside employment Outside employment Outside employment Outside employment Outside employment Outside employment Outside employment Outside employment Outside employment Outside employment Outside employment Outside employment Outside employment Outside employment Outside employment Outside employment Outside employment Outside employment Outside employment Outside employment Outside employment Outside employment Outside employment Outside employment Outside employment Outside employment Outside employment Outside employment Hospitality Hospitality Hospitality Hospitality Sponsored events Sponsored events Outside employment Financial interests Non-financial personal interests Non-financial professional interest Non-financial professional interest Non-financial professional interest Non-financial professional interest Non-financial professional interest Non-financial professional interest Non-financial professional interest Non-financial professional interest Outside employment Loyalty interests Sponsored posts Sponsored posts Sponsored posts Sponsored posts Sponsored posts Sponsored posts Sponsored posts Sponsored posts Indirect interests Financial interests Sponsored events Clinical private practice I have got private practice privilege in Spire Southampton & Wessex Nuffield Hospitals My private practice mirrors NHS practice I do private practice in Spire & Nuffield hospital and my practice mirrors my NHS practice. I am joint owner of a LLP company with my spouse. His private practice income (HealthShare Winchester, Nuffield Hospital, Chandlers Ford) is paid directly into that company. My spouse also works in industry for a small company called OCG (orthopaedic Consulting Group) as a CMO and this income is also paid directly into the LLP. He does 1 day a week in industry and 1/2 day a week private practice. I have private practice privileges at Spire Southampton Hospital I see patients and do private Vitreoretinal and Cataract surgery through self-referral or/and insured work. Overall Time Commitment: Dedicated session on Job plan or weekends. (Information included in my previous portfolio appraisal documents) I perform cataract surgery un the ICS (NHS pathway) with the following providers: - Newmedica (since October 2020) I stopped working with the following providers: - Optegra (November 2020 - July 2022) - SpaMedica (June 2021 - June 2022) Overall time commitment: Dedicated session on job plan for private work or/and weekends with no on-call commitment or/and non-working time of NHS job plan. (already included in my previous portfolio documents) (14-6-2023: updated status) Service Contract Agreement with New Medical Systems Ltd as Shareholder and Joint Venture Partner in Newmedica Solent OJV. (Contract agreement signed - Newmedica Solent OJV will start offering its services from mid-September 2023) Sponsorship by Alimera to attend American Academy of Ophthalmology (virtual) Congress. As it is stated in the agreement document with Alimera, sponsorship does not constitute an inducement to prescribe, recommend, buy or sell any medicine or product. (Agreement document and details of sponsorship already included in my portfolio appraisal documents.) I have attended MS Trust conference from 23/03/2025 to 25/03 /2025 ENETS Honorarium paid by AAA to lecture at UKINETs symposium Ipsen paid for registration, travel and accommodation to ENETs in Vienna sponsored by AAA Committee member for UKINETs IPSEN Funded attendance at ENETS Conference 2022 and honorarium for supporting an educational event I do private practice in the same clinical sphere private practice I undertake clinical private practice at Spire Hospital Southampton Attending meeting for Merck conference Sponsorship to Conference (CMSC) Roche Ad board Sanofi Advisory Board Novartis Advisory board £420 Advisory board ( Roche) Advisory board Biogen CHARMS steering committee 5-7pm £540 Chairing an evening meeting Roche Chairing and speaking at a Biogen symposium at conference Chairing and speaking at an evening meeting/debate. Novartis Chairing national meeting Chairing sponsored symposium Charing evening meeting ( Merck) Evening Steering committee meeting with Novartis Filming for Merck Interview for market research for Roche paid £100 MS Nursing Connections ad board Meeting for an hour at 2pm Merck Advisory Board Merck Steering Committee Merck Steering committee meeting ( evening) Nursing Practice conference speaker Paid speaking engagement at REALMS Paid speaking engagement ( evening meeting with Novartis) Paid speaking engagement at Get Smart ( Novartis) Paid speaking engagement at INFORM MS Recording of podcast with Biogen Roche Steering committee Roche steering committee meeting ( paid) Roche- chairing a national meeting Roche- promotional material consultancy Roche- sponsorship to attend CMSC ( international conference) and chairing meetings Sanofi advisory board Sanofi- roundtable consultancy Speaker at an evening meeting, sponsored by Novartis Speaker conference Speaking at Biogen meeting for Saudi Nurses. Two separate days 45 mins each Speaking at a conference( Roche) Speaking at a conference, Nurse at the Limits Speaking at a meeting for Merck Speaking at a symposium ( Janssen) Speaking at an evening meeting Steering Committee meeting Steering committee 23rd of March and 27th of March £300 Virtual Advisory Board 5-8pm Biogen £452 ongoing commitment 6pm-7pm 2 hour evening meeting Sponsorship to CMSC Sponsorship to ECTRIMs Milan ( biogen) Sanofi- delegation to ECTRIMS international conference Speaker at conference and hospitality Sponsorship to International Conference Unknown amount Sponsorship to International conference unknown amount 01.05.25: Appointment as Director of YMCA Fairthorne Housing Trustee position of a local charity. I do not consider this to create a conflict of interest with my role at UHS Since the 1st of June 2021 I have started working with Practice Plus Group in Southampton as a Consultant. I hold a part time contract with the company of 20hrs a week. I treat NHS patients there as well. It currently keeps my elective operating skills up to date as my SUHT Contract is purely trauma operating. I am married to another Orthopaedic Hand Surgeon who is currently an employee of Practice Plus Group in Southampton Community Manager: Community Manager (a peer-support and forum) for ‘Healthcare Professionals in Research’ group - unpaid role. Early Career Working Group committee chair: Chair of international committee with American Thoracic Society Pulmonary Rehabilitation Assembly - unpaid role. National co-lead: National co-lead for /AHP's Everywhere’ group - unpaid role. Visiting Fellow: Visiting Fellow contract with UoS - unpaid role. Community Manager: Community Manager (a peer-support and forum) for ‘Healthcare Professionals in Research’ group - unpaid role. Early Career Working Group committee chair: Chair of international committee with American Thoracic Society Pulmonary Rehabilitation Assembly - unpaid role. National co-lead: National co-lead for /AHP's Everywhere’ group - unpaid role. Visiting Fellow: Visiting Fellow contract with UoS - unpaid role. Sponsorship of BIMDG conference by Nutricia Metabolics Private Oncology practice conduct at Spire Southampton and Genesis Southampton private clinical practice mirrors NHS practice i.e. Clinical Oncology for GI cancer Is ongoing 09/11/2024 22/06/2022 22/06/2022 22/06/2022 09/01/2020 20/09/2020 28/10/2020 09/06/2023 12/11/2021 13/11/2021 23/03/2025 25/03/2025 12/03/2024 14/03/2024 04/12/2022 04/12/2022 22/03/2023 24/05/2023 05/02/2022 05/03/2035 09/03/2022 11/03/2022 05/02/2022 16/05/2023 01/01/2021 07/02/2022 26/04/2024 26/04/2024 21/04/2023 22/04/2023 27/05/2024 02/06/2024 11/12/2024 11/12/2024 30/11/2022 30/11/2022 12/05/2022 19/06/2024 19/06/2024 01/12/2022 01/12/2022 08/11/2021 09/11/2021 21/11/2024 21/11/2024 26/03/2023 24/01/2023 24/01/2025 25/01/2025 17/09/2022 17/09/2022 03/04/2025 03/04/2025 21/02/2023 13/08/2024 13/08/2024 13/10/2021 13/10/2021 05/02/2025 05/02/2025 22/10/2024 22/10/2024 27/07/2022 27/07/2022 06/09/2022 06/09/2022 27/02/2025 27/02/2025 09/11/2022 09/11/2022 09/06/2023 09/06/2023 28/11/2023 28/11/2023 11/11/2023 11/11/2023 21/09/2023 21/09/2023 07/02/2023 18/04/2023 18/04/2023 03/10/2023 03/10/2023 20/06/2025 21/06/2025 23/04/2025 23/04/2025 26/05/2025 02/06/2025 28/02/2023 23/04/2025 23/04/2025 28/11/2023 28/12/2023 30/09/2022 01/10/2022 04/03/2023 05/03/2023 10/02/2024 10/02/2024 16/11/2024 16/11/2024 13/11/2024 13/11/2024 19/03/2024 19/03/2024 16/10/2024 16/10/2024 03/09/2024 03/09/2024 23/03/2022 25/11/2021 25/11/2021 29/05/2023 03/06/2023 11/10/2023 13/10/2023 23/09/2025 26/09/2025 17/09/2024 20/09/2024 31/05/2022 04/06/2022 31/05/2022 04/06/2022 01/05/2025 01/05/2028 01/06/2021 30/06/2022 06/05/2012 10/11/2021 01/01/2020 01/04/2022 01/07/2022 19/04/2021 01/01/2020 01/04/2022 01/07/2022 19/04/2021 11/06/2024 12/06/2024 01/10/2007 22/11/2024 Bateman, Professor Adrian Calvin Bateman, Professor Adrian Calvin Bates, Dr Andrew Tom Bates, Dr Andrew Tom Bates, Dr Andrew Tom Bates, Dr Andrew Tom Baxter, Dr Mark Alan Beck, Mr. Nicholas Edward Beecham, Mr. Ryan Christopher Beedle, Mr. Matthew Ian (Matt) Belgi, Dr Geeta Belgi, Dr Geeta Berry, Mrs. Lisa Jane Bevan, Ms. Amanda Bhargava, Dr Vidhi (Vidhi) Bhatnagar, Dr Adityanarayan Bhatnagar, Dr Adityanarayan Birch, Mr. Brian Robert Peter Birkett, Mr. Lewis Terence Blackwell, Ms. Nicola (Nicky) Blackwell, Ms. Nicola (Nicky) Blake, Mrs. Sinead Patricia (Sinead) Boswell, Dr Owen David Boulos, Mr. Nabil Adel Aziz Bowley, Mr. Adam Marcus Haydon Boyce, Dr Sara Rosalind (Sara) Boyce, Dr Sara Rosalind (Sara) Boyce, Dr Sara Rosalind (Sara) Boyce, Dr Sara Rosalind (Sara) Brain, Dr Amanda Rachel Brander, Mr. Matt Lee Breen, Dr David John Breen, Dr David John Breen, Dr David John Briant, Mr. Jason Scott (Jase) Broadbent, Miss Bethany (Beth) Broadley, Dr Rachel Jane Broadley, Dr Rachel Jane Bromby, Mr. Mark David Brooks, Mrs. Julie Bryant, Dr Timothy Bryant, Dr Timothy Bryant, Dr Timothy Bryant, Dr Timothy Bujanova, Dr Jana Bull, Mr. Colin Lawrence Bulters, Mr. Diederik Olivier Bulters, Mr. Diederik Olivier Bulters, Mr. Diederik Olivier Burke, Dr Georgina Burke, Dr Georgina Burke, Dr Hannah Burke, Mr. Martin James Burke, Mr. Martin James Burke, Mr. Martin James Butler, Mrs. Eleanor Mary (Eleanor) Byrne, Dr James Patrick Consultant Y Consultant Y Consultant Y Consultant Y Consultant Y Consultant Y Consultant Y Consultant Y Analyst Y Manager Y Consultant Y Consultant Y Nurse - Advanced Practitioner Y Pharmacist Y Consultant Y Consultant Y Consultant Y Consultant Y Manager Y Occupational Therapy Specialist Practitioner Y Occupational Therapy Specialist Practitioner Y Specialist Nurse Practitioner Y Consultant Y Pharmacist Y Physiotherapist Specialist Practitioner Y Consultant Y Consultant Y Consultant Y Consultant Y Associate Specialist (Closed to new entrants) Y Manager Y Consultant Y Consultant Y Consultant Y Analyst Y Specialist Healthcare Science Practitioner Y Consultant Y Consultant Y Specialist Healthcare Science Practitioner Y Nurse Manager Y Consultant Y Consultant Y Consultant Y Consultant Y Consultant Y Manager Y Consultant Y Consultant Y Consultant Y Consultant Y Consultant Y Consultant Y Manager Y Manager Y Manager Y Physiotherapist Manager Y Consultant Y Financial interests Financial interests Financial interests Financial interests Financial interests Indirect interests Non-financial professional interest Clinical private practice Loyalty interests Clinical private practice Hospitality Hospitality Loyalty interests Clinical private practice Financial interests Clinical private practice Financial interests Outside employment Non-financial professional interest Financial interests Financial interests Financial interests Financial interests Financial interests Financial interests Financial interests Hospitality Clinical private practice Clinical private practice Loyalty interests Sponsored events Clinical private practice Clinical private practice Outside employment Financial interests Non-financial personal interests Sponsored events Gifts Indirect interests Clinical private practice Indirect interests Outside employment Financial interests Indirect interests Outside employment Clinical private practice Non-financial professional interest Sponsored events Financial interests Financial interests Financial interests Financial interests Financial interests Non-financial personal interests Non-financial personal interests Financial interests Financial interests Non-financial professional interest Non-financial personal interests Clinical private practice Outside employment Outside employment Outside employment Sponsored events Outside employment Gifts Sponsored events Sponsored events Sponsored events Gifts Financial interests Financial interests Financial interests Financial interests Non-financial professional interest Financial interests Gifts Outside employment Shareholdings and other ownership interests Clinical private practice Loyalty interests Hospitality Financial interests Financial interests Hospitality Hospitality Financial interests Indirect interests Financial interests Financial interests Financial interests Financial interests Financial interests Non-financial professional interest Financial interests Non-financial personal interests Outside employment Sponsored events Outside employment Clinical private practice Outside employment Outside employment Sponsored events Sponsored events Sponsored events Gifts Non-financial personal interests Hospitality Non-financial personal interests Financial interests Financial interests Hospitality Clinical private practice Outside employment I undertake private practice at the Spire Southampton and Wessex Nuffield Hospitals I am registered with Source Bioscience and Backlogs - which are remote locum companies in cellular pathology I am the Editor in Chief of the journal Diagnostic Histopathology and receive an honorarium for this. Private Practice with admitting rights at UHS, Spire Southampton Hospital and Genesis Care Southampton. 3 hours per week on Wednesday am in Job Plan. Honoraria for talk to Astra Zeneca Sponsored Satellite Symposium at BTOG January 2022. £800 Hospitality from Genesis Care: Dinner Lainston House Hotel 2/12/21 Dinner Ennios Restaurant, Southampton 6/10/22 Mr wife, Claire Walsh (Bates) is a GP Partner at Stockbridge Surgery. Chemotherapy mostly delivered at UHS in Solent Suite. Radiotherapy delivered at UHS and Genesis Care. Most of my Private Practice radiotherapy is now with Genesis Care at Spire Southampton Hospital. Previously most of my Private radiotherapy was delivered at UHS, but the waits are now too long. Patients from Stockbridge Surgery are referred to UHS 05/02/2022 01/09/2024 05/02/2022 01/09/2024 01/06/2006 31/12/2025 27/01/2022 27/01/2022 02/12/2021 06/10/2022 01/01/2010 31/12/2025 I do a weekly private outpatient clinic at Spire/Nuffield. This takes about 4 hours per week This has been ongoing for many years, no change and doesn't impact my NHS practice 25/09/2022 31/03/2023 General and colorectal surgeon including outpatients, endoscopy/colonoscopy, operating. Practicing at: Spire Southampton Hospital, Chalybeate Close, Southampton SO16 6UY Nuffield Health Wessex Hospital, Winchester Road, Chandlers Ford, Eastleigh SO53 2DW Tuesday pm colonoscopy Spire hospital Tuesday evening Outpatients Nuffield hospital (variable/ad hoc surgery) Updated 04.09.24 confirmed private practice as outlined. 01/10/2004 04/09/2024 Looking to be Part Time self employed (weekend work) to be a system analyst for other UK Hospital Sites which use the same software we use in critical care (MetaVision). The skills I have built within my First time filling one of these in so i am happy to reply with more information if needed. I have set the date to a year as i am unsure how the current role within the trust would aide in my Part Time self employment i.e. analysing databases and building reporting solutions I would currently remain as a full time member of UHS. part time self employment will last for in its early stages. 11/05/2023 11/05/2024 Flights, accommodation and conference attendance at the the CPSI (TruBridge) conference in the USA in May 2024. TruBridge are the supplier we partner with to develop My Medical Record. This conference will include an in-person user group (with other TruBridge customers). It will also include meetings with the TruBridge product team, where we will discuss alignment (including potential blockers) of the TruBridge and My Medical Record product roadmaps. I notified my line manger (David Cable) as soon as I received the invite and I also have a approval from Jason Teoh (CIO). I do private work at nuffield. This work is on a wednesday and is documented in the job plan My work at Spire is in NHS hours only. I have private practice to declare I notified my line manger (David Cable) as soon as I received the invite and I also have a approval from Jason Teoh (CIO). I've added this as 'non-financial professional interest' although I'm not sure if that is the correct category? It seemed the best fit from the options. I have private practice to declare. My practice is at the nuffield and Spire hospitals 28/04/2024 03/05/2024 01/06/2022 06/06/2023 01/06/2023 07/06/2024 Advisory Board Member for: DGH Pharma (Europe) Ltd Kemp House 160 City Road London United Kingdom EC1v 2NX Payment received for education session at meeting sponsored by Chiesi. I work for Spire Southampton, Nuffield Wessex hospitals outside of NHS hours. I do remote reporting for Backlogs limited. I work in the private hospital as a consultant oncologist. Private hospitals include Spire Southampton, Genesis radiotherapy, new hall hospital Salisbury. I also undertake private patient work at UHS Southampton Working with GCUK - private radiotherapy provider. Working as a clinical oncologist for approximately 3 to 4 hours a week as MR -Linac specialist. Currently UHS does not have MR Linac therefore there is no direct conflict of interest. have either received research grants, honoraria to speak at, chair and attend meetings or liaised/received educational material from representatives of the following companies over the last 20 years: · Astellas · Pfizer · Ipsen · Glaxo Smith Kline · Sanofi · Lilly · Bayer · Amgen · Ferring · Takeda · Comvita · AstraZenecaJanssen-Cilag · Janssen The latest were from 1. Janssen to attend (as faculty) the prostate cancer summit in the UK (2020) 2. Laborie for providing a presentation to be used at the ICS meeting in Melbourne (20210) (2020) Christmas food box from a supplier - Softcat – of mostly perishable items (crisps, chocolate, cranberry sauce, biscuits, bottle of wine). The market value of the items is estimated at less than £15. Generally thee support provide has been to attend conferences or fund research. I do not hold shares (directly) in any companies providing health care resources of any kind to the NHS or other like companies. I have a Private Practice based at the Wessex Nuffield that might be considered a potential conflict of interest to my work with the NHS and UHS but I manage this along NHS and UHS guidelines and do not perform any procedures there that I do not perform on the NHS other than reversal of vasectomy as this is not generally funded by the NHS. Given the relatively low value, perishable nature, and inconvenience of returning the item to the supplier, it was deemed appropriate for the team to keep this food box. 01/06/2022 31/12/2022 01/04/2021 31/03/2022 20/02/2023 24/03/2025 01/01/2009 31/03/2025 01/04/2024 31/03/2025 07/02/2002 08/07/2022 20/12/2023 20/12/2023 Private OT consultations, on an as and when basis. This is not advertised through verbal or printed advertisements, social media or verbally mentioned, within my current role 27/03/2024 Sole Trade Home/ Mobile Beauty Therapist Case Support/ Brilliant Minds- Epilepsy Teaching (Self Employed) The Grove, North Road Dibden/ Longview, Fryern Court Road Private Epilepsy Awareness and emergency medication training sessions No committed hours/ as and when needed (approx. 4-10 hours per month) Private practice and member of SAS Received sponsorship for flight and hotel accommodation relating to a professional conference in Madrid, Spain. Sponsorship covered only the two days of the conference. Conference details: XLH international conference. Date: 18-19th April 2024. Sponsor: Kyowa Kirin. I prescribe burosumab at UHS, a biological therapy for children with a rare condition (XLH). The therapy is manufactured by Kyowa Kirin. I am an associate of MDT Rehab providing private clinical physiotherapy in an intermittent capacity. 1/ training as AstraZeneca speaker - 19/3/24 £1080 2/talk for AstraZeneca - 16/10/24 £405 Speaker fee- AstraZeneca £500 speaker fee for Sanofi - £760 Advisory board for CSL Behring Sponsorship to attend ISTH congress by Sanofi This is an ongoing Profession before i initially started my first employment at UHS Dec 2008 I will not advertise or provide information about private practice unless specifically asked. If the information is requested I will offer a number of options and not declare which company I am associated with. 17/10/2023 07/06/2022 13/07/2023 14/07/2023 17/04/2024 19/04/2024 01/11/2023 01/01/2024 01/01/2025 21/09/2023 21/09/2023 03/07/2023 03/07/2023 17/01/2023 I have my own business as a sole trader - making and selling dichroic glass jewellery. This is entirely conducted in my own time. Christmas food box from a supplier - Softcat – of mostly perishable items (crisps, chocolate, cranberry sauce, biscuits, bottle of wine). The market value of the items is estimated at less than £15. Proctor and advisory board to Neuwave/Johnson&Johnson. Proctoring for Boston Scientific on image-guided Cryoablation Given the relatively low value, perishable nature, and inconvenience of returning the item to the supplier, it was deemed appropriate for the team to keep this food box. On-site proctoring on image-guided microwave ablation. Payment made to UoS Southampton Charitable fund. Onsite proctoring- payments made to UoS Southampton charitable fund. 04/01/2024 21/12/2023 21/12/2023 07/06/2018 22/06/2022 Advisory panel to Varian/Siemens healthcare systems. Christmas food box from a supplier - Softcat – of mostly perishable items (crisps, chocolate, cranberry sauce, biscuits, bottle of wine). The market value of the items is estimated at less than £15. Technical advice. Usually consulted at conferences. Given the relatively low value, perishable nature, and inconvenience of returning the item to the supplier, it was deemed appropriate for the team to keep this food box. 01/06/2021 22/06/2022 21/12/2023 21/12/2023 One-time receipt of cheque to value of £152 payable to myself from Mortuary Fund. Mortuary fund accrues voluntary donations from various/multiple external bodies (namely funeral directors) to UHS mortuary in recognition of additional assistance provided to these companies by mortuary team outside of their contracted role (e.g. patient handling & chasing paperwork). The total amount donated to the fund in each calendar year is divided equally amongst all mortuary employees annually, with all members of team (9x staff B3-B8a) receiving an equal share. No interests as received from multiple & various different donors on a voluntary basis. No service contracts are in place between UHS mortuary & donors and so no opportunity for influence in decision making. Terema Ltd: provision of teaching for Human Factors training company. Paid daily rate on attendance. No financial stake in business. As above 01/04/2021 31/03/2022 06/02/2022 31/12/2024 Founder of REN Think Ltd Facilitation of education and training in team skills, human factors, leadership; speaker 13/04/2025 30/04/2034 Spire Southampton Hospital Chalybeate Close Southampton SO16 6UY Occasional spinal cord monitoring performed during spinal operations (usually scoliosis correction). 2-3 cases per year. 01/01/2015 Coordinator of the Wessex Branch of the Infection Prevention society Infection Prevention society Blackburn House, Redhouse Road, Seafield, Bathgate, West Lothian, EH4 7AQ BSIR 2022 attenda
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Trust-governance-and-corporate-docs/UHS-register-of-interests-June-2025.pdf

Remuneration & Appointment Committee ToR March 2026

Description: Remuneration and Appointment Committee Terms of Reference Date Issued: 10 March 2026 Review Date: March 2027 Document Type: Committee Terms of Reference Version: 8 Contents Paragraph 1 2 3 4 5 6 7 8 9 10 Role and Purpose Constitution Membership Attendance and Quorum Frequency of Meetings Conduct and Administration of Meetings Duties and Responsibilities Accountability and Reporting Review of Terms of Reference and Performance and Effectiveness References Appendices Appendix A Executive Director Pay Principles Page 2 2 2 3 3 3 3 5 5 5 Page 6 Document Status This is a controlled document. Whilst this document may be printed, the electronic version posted on the intranet is the controlled copy. Any printed copies of this document are not controlled. As a controlled document, this document should not be saved onto local or network drives but should always be accessed from the intranet. Page 1 of 8 1. Role and Purpose 1.1 The Remuneration and Appointment Committee (the Committee) is responsible for identifying and appointing candidates to fill all the executive director positions on the board of directors (the Board) of University Hospital Southampton NHS Foundation Trust (UHS or the Trust) and for determining their remuneration and other conditions of service. 1.2 The Committee provides the board of directors of the Trust (the Board) with a means of independent and objective review of remuneration and executive director appointments in accordance with relevant laws, regulations and Trust policies. 1.3 The duties and responsibilities of the Committee are more fully described in paragraph 7 below. 2. Constitution 2.1 The Committee has been established by the Board. The Committee has no executive powers other than those set out in these terms of reference. 2.2 The Committee is authorised by the Board to investigate any activity within its terms of reference. It is authorised to seek any information it requires from any member of staff and all members of staff are directed to cooperate with any request made by the Committee. 2.3 The Committee is authorised to seek reports and assurance from executive directors and managers and will maintain effective relationships with the chairs of other Board committees to understand their processes of assurance and links with the work of the Committee. 2.4 The Committee is authorised to obtain external legal or other independent professional advice if it considers this necessary, taking into consideration any issues of confidentiality and the Trust’s standing financial instructions. 3. Membership 3.1 The members of the Committee will be appointed by the Board and will be the non- executive directors of the Trust except as provided in paragraph 3.2 below. 3.2 For any decisions relating to the appointment or removal of the executive directors, membership of the Committee will include the Chief Executive Officer, as required under Schedule 7 of the National Health Service Act 2006, who will count in the quorum for the meeting. The Chief Executive Officer will not be present when the Committee is dealing with matters concerning their appointment or removal, remuneration or terms of service. 3.3 The chair of the Board will chair the Committee (the Committee Chair). In the absence of the Committee Chair and/or an appointed deputy, the remaining non-executive directors present will elect one of themselves to chair the meeting. 3.4 Only members of the Committee have the right to attend and vote at Committee meetings. However, the following will be invited to attend meetings of the Committee on a regular basis: 3.4.1 Chief People Officer; and 3.4.2 Associate Director of Corporate Affairs/Company Secretary. 3.5 Other individuals may be invited to attend for all or part of any meeting, as and when appropriate and necessary, particularly when the Committee is considering areas that are the responsibility of a particular executive director or manager. Any attendee will be Page 2 of 8 asked to leave the meeting when the Committee is dealing with matters concerning their appointment or removal, remuneration or terms of service. 4. Attendance and Quorum 4.1 Members should aim to attend every meeting and should attend a minimum of 75% of meetings held in each financial year. Where a member is unable to attend a meeting they should notify the Committee Chair or Company Secretary in advance. 4.2 The quorum for a meeting will be four members, including the chair of the Board (or the Deputy Chair in their absence). A duly convened meeting of the Committee at which a quorum is present will be competent to exercise all or any of the authorities, powers and discretions vested in or exercisable by the Committee. 5. Frequency of Meetings 5.1 The Committee will meet as required, which will usually be four times each year. 5.2 The Committee may establish a sub-committee for a specific purpose where it would be impractical for the Committee to be involved, for example the appointment of an executive director following agreement by the Committee of the process, job description and person specification. 6. Conduct and Administration of Meetings 6.1 Meetings of the Committee will be convened by the Company Secretary at the request of the Committee Chair or any of its members. 6.2 The agenda of items to be discussed at the meeting will be agreed by the Committee Chair with support from the Chief People Officer and the Company Secretary. The agenda and supporting papers will be distributed to each member of the Committee and the regular attendees no later than three working days before the date of the meeting. Distribution of any papers after this deadline will require the agreement of the Committee Chair. 6.3 The Company Secretary will minute the proceedings of all meetings of the Committee, including recording the names of those present and in attendance and any declarations of interest. 6.4 Draft minutes of Committee meetings and a separate record of the actions to be taken forward will be circulated promptly to all members of the Committee. Once approved by the Committee, minutes will be circulated to all other members of the Board unless it would be inappropriate to do so in the opinion of the Committee Chair. 7. Duties and Responsibilities 7.1 The Committee will carry out the duties below for the Trust. Remuneration Role 7.2 The Committee will: 7.2.1 establish and keep under review a remuneration policy in respect of executive directors (as set out in Appendix A); 7.2.2 consult the Chief Executive Officer about proposals relating to the remuneration of the other executive directors; 7.2.3 in accordance with relevant laws, regulations and Trust policies, decide and keep under review the terms and conditions of office of the Trust’s executive directors, including salary, any performance-related pay or bonus, provisions for other benefits, Page 3 of 8 including pensions and cars, allowances, payable expenses and compensation payments; 7.2.4 adhering to all relevant laws, regulations and Trust policies: 7.2.4.1 establish levels of remuneration that are sufficient to attract, retain and motivate executive directors of the quality and with the skills and experience required to lead the Trust successfully, without paying more than is necessary for this purpose, and at a level that is affordable to the Trust; 7.2.4.2 decide whether a proportion of executive director remuneration should be structured so as to link reward to corporate and individual performance; 7.2.4.3 make sure that any performance-related elements of executive remuneration are stretching and promote the long-term sustainability of the Trust, and take as a baseline for performance any competencies required and specified in the job description for the post; 7.2.4.4 consider all relevant and current directors relating to contractual benefits such as pay and redundancy entitlements; 7.2.4.5 use national guidance and market benchmarking analysis in the annual determination of remuneration of executive directors while ensuring that increases are not made where Trust or individual performance do not justify them; 7.2.4.6 be sensitive to pay and employment conditions elsewhere in the Trust; 7.2.5 monitor and assess the output of the evaluation of the performance of individual executive directors, and consider this output when reviewing changes to remuneration levels; 7.2.6 on an annual basis monitor the remuneration of non-clinical senior leadership roles remunerated at levels above those specified in the NHS agenda for change terms and conditions; 7.2.7 approve the level of remuneration or any proposed change to remuneration for a senior leadership role referred to in 7.2.6 where the proposed remuneration for the role would exceed that of any executive director; and 7.2.8 consider issues of equality and diversity when evaluating and setting remuneration. 7.2.9 Ensure decision making is consistent with NHS England guidance such as the NHS Very Senior Managers Pay Framework issued in June 2025. Appointment Role 7.3 The Committee will: 7.3.1 regularly review the structure, size and composition (including the skills, knowledge, experience and diversity) of the Board, making use of the output of the Board evaluation process as appropriate, and make recommendations to the Board and the Governors’ Nomination Committee, as applicable, with regard to any changes; 7.3.2 give full consideration to and make plans for succession planning for the executive directors, taking into account the challenges and opportunities facing the Trust and the skills and expertise needed on the Board in the future; 7.3.3 keep the leadership needs of the Trust under review at executive director level to ensure the continued ability of the Trust to operate effectively in the health economy; 7.3.4 be responsible for identifying the and appointing candidates to fill posts within its remit as and when they arise; Page 4 of 8 7.3.5 when a vacancy is identified, evaluate the balance of skills, knowledge and experience of the Board, and its diversity, and in the light of this evaluation, prepare a description of the role and capabilities required for the particular appointment. In identifying suitable candidates the Committee will use open advertising or the services of external advisers to facilitate the search, consider candidates from a wide range of backgrounds and consider candidates on merit against objective criteria; 7.3.6 ensure that a proposed executive director is a ‘fit and proper’ person as defined in law and regulation and monitor procedures to ensure that executive directors remain ‘fit and proper’ persons; 7.3.7 ensure that a proposed executive director’s other significant commitments (if applicable) are disclosed before appointment and that any changes to their commitments are reported to the Board as they arise; 7.3.8 ensure that proposed appointees disclose any business interests that may result in a conflict of interest prior to appointment and that any future business interests that could result in a conflict of interest are reported; 7.3.9 carefully consider what compensation commitments (including pension contributions) the executive directors’ terms of office would give rise to in the event of early termination to avoid rewarding poor performance. Contracts should allow for compensation to be reduced to reflect a departing executive director’s obligation to mitigate loss. Appropriate clawback provisions should be considered in the case of an executive director returning to the NHS within the period of putative notice; and 7.3.10 consider any matter relating to the continuation in office of any executive director, including the suspension or termination of service of an individual as an employee of the Trust, subject to the provisions of the law and their service contract. The Committee shall assure itself that any regulatory responsibilities of the trust relating to continuation of office of any executive director have been appropriately discharged. This includes notification of regulatory bodies such as NHSE where appropriate. 8. Accountability and Reporting 8.1 The Committee Chair will report to the Board following each meeting, drawing the Board’s attention to any matters of significance or where actions or improvements are needed. 8.2 The Trust’s annual report will include sections describing the work of the Committee including its remuneration policies, details of the remuneration paid to executive directors and the process it has used in relation to the appointment of executive directors. 9. Review of Terms of Reference and Performance and Effectiveness 9.1 At least once a year the Committee will review its collective performance and its terms of reference. Any proposed changes to the terms of reference will be recommended to the Board for approval. 10. References 10.1National Health Service Act 2006 10.2Code of Governance for NHS Provider Trusts 10.3NHS Very Senior Managers Pay Framework Page 5 of 8 Appendix A UHS Executive Director Pay Principles 1. The importance of executive director pay The delivery of the Trust’s 5-year strategy and annual Trust objectives is predicated on ensuring talent is available at all levels of the Trust. Good senior leadership is vital, and therefore a key strategy for UHS must be to recruit and retain the best executive director talent into the Trust. This will be from a combination of both good internal succession planning, bringing top talent from the NHS and also seeking high calibre individuals from other sectors. 2. Determination of pay levels of posts Pay for executive director posts will be determined by: • Use of NHS England (NHSE) data on pay for executive director (Very Senior Manager – VSM) positions in comparable trusts (Figure 1). • Any other available NHSE frameworks for setting of executive pay • Use of other salary benchmarking exercises, particularly from comparable NHS organisations • Job evaluation as required. • The conditions required to attract suitably qualified individuals, particularly where commercial, financial or other niche business skills are required. Pay levels will be reviewed not less frequently than annually by the Committee in accordance with the Trust’s pay review cycle to ensure that salary levels are both appropriate and provide value for money. 3. Setting salary of executive directors The following principles will apply: • UHS will aim to pay at a point consistent with the VSM pay framework that attracts suitable candidates • UHS will review pay based on performance, changes in the NHSE framework levels, comparable NHS Trust benchmarking and, in particular, the need to retain key individuals likely to be of interest to the external market. • UHS will not recognise relevant changes of NHSE framework levels in respect of individuals where this is not justified by individual performance. • UHS will be mindful of equality and diversity, particularly in relation to gender and ethnicity in pay levels. • UHS will ensure all VSM nationally applicable cost of living pay awards are reflected in executive director pay each year, as decided by the Committee. The committee may choose to withhold a national pay increase where individual performance has been unsatisfactory and where the guidance permits this. • Any decision to introduce performance-related pay, or bonuses, will be subject to decision by the Committee based on a sound business case and adherence to NHSE guidance on executive pay. 4. Approval process All decisions on pay for executive directors will be managed in line with the terms of reference for the Committee. The Committee, supported by the Chief People Officer, will also ensure that the NHSE prevailing guidance on setting executive director pay, including any required approval process, will be followed as appropriate. Page 6 of 8 Figure 1 – NHS England Pay Thresholds 2025/26 Pay Ranges for Organisations with Annual Turnover above £1bn Role Minimum Operational Maximum Chief Executive Officer £245,663 £279,163 Executive Directors £156,331 £206,581 (reporting to CEOs) Executive Directors £122,832 £150,749 (reporting to a board director) Exception Zone £308,976 £227,667 £157,199 Note: The committee will use the latest published NHS England pay thresholds. The table above was correct as of the date of issue of these terms of reference for organisations with annual turnover above £1bn. Page 7 of 8 Remuneration and Appointment Committee Terms of Reference Version: 8 Document Monitoring Information Approval Committee: Board of Directors Date of Approval: 10 March 2026 Responsible Committee: Remuneration and Appointment Committee Monitoring (Section 9) for Completion and Presentation to Approval Committee: Target audience: Key words: Main areas affected: Summary of most recent changes if applicable: Consultation: Number of pages: Type of document: Does this document replace or revise an existing document? Should this document be made available on the public website? Is this document to be published in any other format? March 2027 Board of Directors, Remuneration and Appointment Committee, NHS Regulators, Staff and Public Remuneration, Appointment, Nomination, Committee, Board, Terms of Reference Trust-wide Updates to 7 to include reference to VSM Pay. Guidance and role of third parties in 7.3.10. Update to Appendix 3 and to pay table based on latest NHSE VSM Pay Ranges and reference to the NHSE VSM pay framework in 10.3. Remuneration and Appointment Committee 8 Committee Terms of Reference Yes Yes No Page 8 of 8
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Trust-governance-and-corporate-docs/2026-Trust-documents/Remuneration-Appointment-Committee-ToR-March-2026.pdf

Remuneration and Appointment Committee ToR March 2025

Description: Remuneration and Appointment Committee Terms of Reference Date Issued: 11 March 2025 Review Date: March 2026 Document Type: Committee Terms of Reference Version: 7 Contents Paragraph 1 2 3 4 5 6 7 8 9 10 Role and Purpose Constitution Membership Attendance and Quorum Frequency of Meetings Conduct and Administration of Meetings Duties and Responsibilities Accountability and Reporting Review of Terms of Reference and Performance and Effectiveness References Appendices Appendix A Executive Director Pay Principles Page 2 2 2 3 3 3 3 5 5 5 Page 6 Document Status This is a controlled document. Whilst this document may be printed, the electronic version posted on the intranet is the controlled copy. Any printed copies of this document are not controlled. As a controlled document, this document should not be saved onto local or network drives but should always be accessed from the intranet. Page 1 of 8 1. Role and Purpose 1.1 The Remuneration and Appointment Committee (the Committee) is responsible for identifying and appointing candidates to fill all the executive director positions on the board of directors (the Board) of University Hospital Southampton NHS Foundation Trust (UHS or the Trust) and for determining their remuneration and other conditions of service. 1.2 The Committee provides the board of directors of the Trust (the Board) with a means of independent and objective review of remuneration and executive director appointments in accordance with relevant laws, regulations and Trust policies. 1.3 The duties and responsibilities of the Committee are more fully described in paragraph 7 below. 2. Constitution 2.1 The Committee has been established by the Board. The Committee has no executive powers other than those set out in these terms of reference. 2.2 The Committee is authorised by the Board to investigate any activity within its terms of reference. It is authorised to seek any information it requires from any member of staff and all members of staff are directed to cooperate with any request made by the Committee. 2.3 The Committee is authorised to seek reports and assurance from executive directors and managers and will maintain effective relationships with the chairs of other Board committees to understand their processes of assurance and links with the work of the Committee. 2.4 The Committee is authorised to obtain external legal or other independent professional advice if it considers this necessary, taking into consideration any issues of confidentiality and the Trust’s standing financial instructions. 3. Membership 3.1 The members of the Committee will be appointed by the Board and will be the non- executive directors of the Trust except as provided in paragraph 3.2 below. 3.2 For any decisions relating to the appointment or removal of the executive directors, membership of the Committee will include the Chief Executive Officer, as required under Schedule 7 of the National Health Service Act 2006, who will count in the quorum for the meeting. The Chief Executive Officer will not be present when the Committee is dealing with matters concerning their appointment or removal, remuneration or terms of service. 3.3 The chair of the Board will chair the Committee (the Committee Chair). In the absence of the Committee Chair and/or an appointed deputy, the remaining non-executive directors present will elect one of themselves to chair the meeting. 3.4 Only members of the Committee have the right to attend and vote at Committee meetings. However, the following will be invited to attend meetings of the Committee on a regular basis: 3.4.1 Chief People Officer; and 3.4.2 Associate Director of Corporate Affairs/Company Secretary. 3.5 Other individuals may be invited to attend for all or part of any meeting, as and when appropriate and necessary, particularly when the Committee is considering areas that are the responsibility of a particular executive director or manager. Any attendee will be Page 2 of 8 asked to leave the meeting when the Committee is dealing with matters concerning their appointment or removal, remuneration or terms of service. 4. Attendance and Quorum 4.1 Members should aim to attend every meeting and should attend a minimum of 75% of meetings held in each financial year. Where a member is unable to attend a meeting they should notify the Committee Chair or Company Secretary in advance. 4.2 The quorum for a meeting will be four members, including the chair of the Board (or the Deputy Chair in their absence). A duly convened meeting of the Committee at which a quorum is present will be competent to exercise all or any of the authorities, powers and discretions vested in or exercisable by the Committee. 5. Frequency of Meetings 5.1 The Committee will meet as required, which will usually be four times each year. 5.2 The Committee may establish a sub-committee for a specific purpose where it would be impractical for the Committee to be involved, for example the appointment of an executive director following agreement by the Committee of the process, job description and person specification. 6. Conduct and Administration of Meetings 6.1 Meetings of the Committee will be convened by the Company Secretary at the request of the Committee Chair or any of its members. 6.2 The agenda of items to be discussed at the meeting will be agreed by the Committee Chair with support from the Chief People Officer and the Company Secretary. The agenda and supporting papers will be distributed to each member of the Committee and the regular attendees no later than three working days before the date of the meeting. Distribution of any papers after this deadline will require the agreement of the Committee Chair. 6.3 The Company Secretary will minute the proceedings of all meetings of the Committee, including recording the names of those present and in attendance and any declarations of interest. 6.4 Draft minutes of Committee meetings and a separate record of the actions to be taken forward will be circulated promptly to all members of the Committee. Once approved by the Committee, minutes will be circulated to all other members of the Board unless it would be inappropriate to do so in the opinion of the Committee Chair. 7. Duties and Responsibilities 7.1 The Committee will carry out the duties below for the Trust. Remuneration Role 7.2 The Committee will: 7.2.1 establish and keep under review a remuneration policy in respect of executive directors (as set out in Appendix A); 7.2.2 consult the Chief Executive Officer about proposals relating to the remuneration of the other executive directors; 7.2.3 in accordance with relevant laws, regulations and Trust policies, decide and keep under review the terms and conditions of office of the Trust’s executive directors, including salary, any performance-related pay or bonus, provisions for other benefits, Page 3 of 8 including pensions and cars, allowances, payable expenses and compensation payments; 7.2.4 adhering to all relevant laws, regulations and Trust policies: 7.2.4.1 establish levels of remuneration that are sufficient to attract, retain and motivate executive directors of the quality and with the skills and experience required to lead the Trust successfully, without paying more than is necessary for this purpose, and at a level that is affordable to the Trust; 7.2.4.2 decide whether a proportion of executive director remuneration should be structured so as to link reward to corporate and individual performance; 7.2.4.3 make sure that any performance-related elements of executive remuneration are stretching and promote the long-term sustainability of the Trust, and take as a baseline for performance any competencies required and specified in the job description for the post; 7.2.4.4 consider all relevant and current directors relating to contractual benefits such as pay and redundancy entitlements; 7.2.4.5 use national guidance and market benchmarking analysis in the annual determination of remuneration of executive directors while ensuring that increases are not made where Trust or individual performance do not justify them; 7.2.4.6 be sensitive to pay and employment conditions elsewhere in the Trust; 7.2.5 monitor and assess the output of the evaluation of the performance of individual executive directors, and consider this output when reviewing changes to remuneration levels; 7.2.6 on an annual basis monitor the remuneration of non-clinical senior leadership roles remunerated at levels above those specified in the NHS agenda for change terms and conditions; 7.2.7 approve the level of remuneration or any proposed change to remuneration for a senior leadership role referred to in 7.2.6 where the proposed remuneration for the role would exceed that of any executive director; and 7.2.8 consider issues of equality and diversity when evaluating and setting remuneration. Appointment Role 7.3 The Committee will: 7.3.1 regularly review the structure, size and composition (including the skills, knowledge, experience and diversity) of the Board, making use of the output of the Board evaluation process as appropriate, and make recommendations to the Board and the Governors’ Nomination Committee, as applicable, with regard to any changes; 7.3.2 give full consideration to and make plans for succession planning for the executive directors, taking into account the challenges and opportunities facing the Trust and the skills and expertise needed on the Board in the future; 7.3.3 keep the leadership needs of the Trust under review at executive director level to ensure the continued ability of the Trust to operate effectively in the health economy; 7.3.4 be responsible for identifying the and appointing candidates to fill posts within its remit as and when they arise; 7.3.5 when a vacancy is identified, evaluate the balance of skills, knowledge and experience of the Board, and its diversity, and in the light of this evaluation, prepare a description of the role and capabilities required for the particular appointment. In Page 4 of 8 identifying suitable candidates the Committee will use open advertising or the services of external advisers to facilitate the search, consider candidates from a wide range of backgrounds and consider candidates on merit against objective criteria; 7.3.6 ensure that a proposed executive director is a ‘fit and proper’ person as defined in law and regulation and monitor procedures to ensure that executive directors remain ‘fit and proper’ persons; 7.3.7 ensure that a proposed executive director’s other significant commitments (if applicable) are disclosed before appointment and that any changes to their commitments are reported to the Board as they arise; 7.3.8 ensure that proposed appointees disclose any business interests that may result in a conflict of interest prior to appointment and that any future business interests that could result in a conflict of interest are reported; 7.3.9 carefully consider what compensation commitments (including pension contributions) the executive directors’ terms of office would give rise to in the event of early termination to avoid rewarding poor performance. Contracts should allow for compensation to be reduced to reflect a departing executive director’s obligation to mitigate loss. Appropriate clawback provisions should be considered in the case of an executive director returning to the NHS within the period of putative notice; and 7.3.10 consider any matter relating to the continuation in office of any executive director, including the suspension or termination of service of an individual as an employee of the Trust, subject to the provisions of the law and their service contract. 8. Accountability and Reporting 8.1 The Committee Chair will report to the Board following each meeting, drawing the Board’s attention to any matters of significance or where actions or improvements are needed. 8.2 The Trust’s annual report will include sections describing the work of the Committee including its remuneration policies, details of the remuneration paid to executive directors and the process it has used in relation to the appointment of executive directors. 9. Review of Terms of Reference and Performance and Effectiveness 9.1 At least once a year the Committee will review its collective performance and its terms of reference. Any proposed changes to the terms of reference will be recommended to the Board for approval. 10. References 10.1National Health Service Act 2006 10.2Code of Governance for NHS Provider Trusts 10.3NHS England Guidance on pay for very senior managers Page 5 of 8 Appendix A UHS Executive Director Pay Principles 1. The importance of executive director pay The delivery of the Trust’s 5-year strategy and annual Trust objectives is predicated on ensuring talent is available at all levels of the Trust. Good senior leadership is vital, and therefore a key strategy for UHS must be to recruit and retain the best executive director talent into the Trust. This will be from a combination of both good internal succession planning, bringing top talent from the NHS and also seeking high calibre individuals from other sectors. 2. Determination of pay levels of posts Pay for executive director posts will be determined by: • Use of NHS England (NHSE) data on pay for executive director (Very Senior Manager – VSM) positions in comparable trusts (Figure 1). • Any other available NHSE frameworks for setting of executive pay • Use of other salary benchmarking exercises, particularly from comparable NHS organisations • Job evaluation as required. • The conditions required to attract suitably qualified individuals, particularly where commercial, financial or other niche business skills are required. Pay levels will be reviewed not less frequently than annually by the Committee in accordance with the Trust’s pay review cycle to ensure that salary levels are both appropriate and provide value for money. 3. Setting salary of executive directors The following principles will apply: • UHS will aim to pay at around mid-point of NHSE levels for trusts of a comparable nature and scale. • UHS will review pay based on performance, changes in the NHSE framework levels, comparable NHS Trust benchmarking and, in particular, the need to retain key individuals likely to be of interest to the external market. • UHS will not recognise relevant changes of NHSE framework levels in respect of individuals where this is not justified by individual performance. • UHS will be mindful of equality and diversity, particularly in relation to gender and ethnicity in pay levels. • UHS will ensure all VSM nationally applicable cost of living pay awards are reflected in executive director pay each year, as decided by the Committee. The committee may choose to withhold a national pay increase where individual performance has been unsatisfactory and where the guidance permits this. • Any decision to introduce performance-related pay, or bonuses, will be subject to decision by the Committee based on a sound business case and adherence to NHSE guidance on executive pay. 4. Approval process All decisions on pay for executive directors will be managed in line with the terms of reference for the Committee. The Committee, supported by the Chief People Officer, will also ensure that the NHSE prevailing guidance on setting executive director pay, including any required approval process, will be followed as appropriate. Page 6 of 8 Figure 1 – Current NHS England Pay Thresholds Supra large acute NHS trusts and foundation trusts (£750m+) Chief executive Deputy chief executive Director of finance/Chief finance officer Director of workforce Medical director/Chief medical officer Director of nursing/Chief nursing officer Chief operating officer Director of corporate affairs/governance Director of strategy/planning Director of estates and facilities Lower quartile £236,000 £185,500 £166,000 £142,500 £205,000 £150,000 £143,500 £113,000 £135,000 £129,500 Median £250,000 £188,000 £172,500 £155,000 £214,000 £163,500 £162,500 £117,500 £144,000 £137,000 Upper quartile £265,000 £195,500 £190,500 £165,500 £233,500 £168,000 £174,500 £134,000 £152,500 £146,500 Page 7 of 8 Remuneration and Appointment Committee Terms of Reference Version: 7 Document Monitoring Information Approval Committee: Board of Directors Date of Approval: 11 March 2025 Responsible Committee: Remuneration and Appointment Committee Monitoring (Section 9) for Completion and Presentation to Approval Committee: Target audience: Key words: Main areas affected: Summary of most recent changes if applicable: Consultation: Number of pages: Type of document: Does this document replace or revise an existing document? Should this document be made available on the public website? Is this document to be published in any other format? March 2026 Board of Directors, Remuneration and Appointment Committee, NHS Regulators, Staff and Public Remuneration, Appointment, Nomination, Committee, Board, Terms of Reference Trust-wide No changes are proposed. Remuneration and Appointment Committee 8 Committee Terms of Reference Yes Yes No Page 8 of 8
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Trust-governance-and-corporate-docs/2025-Trust-documents/Remuneration-and-Appointment-Committee-ToR-March-2025.pdf

RLP Guidance Notes Cohort 5 Final

Description: University Hospital Southampton Research Leaders Programme (RLP) Award Scheme Application Guidance Notes for Cohort 5 – April 2025 Please complete the application form and submit via MS forms https://forms.office.com/e/cE834Azafh by no later than 5.00pm on Friday 25th October 2024 (This includes emailing completed annexes A and B to RLP@uhs.nhs.uk) Applicants will be notified of the outcome by Friday 3rd January 2025. Introduction University Hospital Southampton Research & Development (R&D) secured a significant investment from University Hospital Southampton Trust Board in 2021 to establish a Research Leaders Programme (RLP), overseen and managed by the Southampton Academy of Research. This programme aims to identify staff of all clinical disciplines with research leadership potential, and provide them with time, training, and personal development to enable progression towards their agreed research career pathway. The purpose of the programme is to enable substantively employed UHS health care professionals to build a portfolio of research activity that will attract funding and facilitate research to become a significant and sustainable component of the award holder’s job plan within 3 years. The Awards are offered competitively. We are now seeking applications for the fifth cohort only. Individuals must be in the position and have the support of their manager to start week commencing Monday 7th April 2025. Types of awards The RLP comprises 2 different types of awards (with an option for these to be combined if explicitly agreed by discussion, ahead of application, with the RLP team) (see Figure 1): 1. Group A - Research Delivery Focused/Growing Principal Investigators (PI) 1 To build capacity to enable delivery of clinical research by providing protected time to undertake PI- related activities on externally funded NIHR CRN portfolio research studies, supported by a research team funded by external study income. Goal: To establish/significantly expand a portfolio of externally funded research studies, commercial and non-commercial. 2. Group B - Clinical Academic Focused/Growing Chief investigators (CI) To support healthcare professionals with significant potential to become independent researchers and fulfil the role of Chief Investigator2 by generating income through personal fellowships and/or leadership of grant applications. Goal: To secure external funding and lead a programme of externally funded research, in the context of a clinical academic position. OR: A combination of Group A and B (Mixed), explicitly agreed, with outcomes reflecting the blend. An application to this pathway MUST be discussed ahead of application with the RLP team. 1 Principal investigator: An individual responsible for the conduct of the research at a research site. There should be one PI for each research site. In the case of a single-site study, the chief investigator and the PI will normally be the same person. 2 Chief Investigator: the overall lead researcher for a research project and the lead applicant on the grant application in addition to their responsibilities if they are members of a research team, chief investigators are responsible for the overall conduct of a research project. They are responsible for intellectual leadership of the research project and for the overall management of the research (some funders refer to this as the PI 1 Updated on 7/8/24 Successful applicants will commit to a programme of activity utilising RLP funded protected time, with the goal of recovering investment through writing their time into grant applications and/or securing commercial income. They will, in turn, be supported to develop/augment a research delivery team through the external funding generated by the research they pursue. Participants will be selected through a competitive application process, with competitions spaced annually. The Award Scheme Each award will comprise several different elements – some are core (such as backfill, mentorship and leadership development) and others dependent on an individual’s learning, development, and support needs (e.g., fees for short courses, methodological support, coaching, explicit connections with UHS/UoS infrastructure). Two types of costs will be met: • Funds to cover the cost of salary backfill • Funds to support access to learning and development These are as follows: Type of support Funded protected time (core) Type of RLP fellow Both i.e. Group A and Group B Notes Minimum commitment expected of the award holder is 20% WTE. • For Medical Consultants, the protected time offered is 2PAs. Overall consultant PAs in job plan including RLP PAs must not exceed 12 PAs. Funding allocation Based on basic salary cost (Including employment costs) of individual. • For other HCP a higher WTE of up to 40% WTE will be considered. Even if the applicant works part time, they must be released for 1 full day per week. This will not be a pro rata arrangement. Please Note: If you choose to have protected time for less than the full 36 Months, you must still agree to attend the LaunchPad2Leadership Programme (L2L) for the full 3-year duration. Launchpad Both 2 Leadership Programme (core) Affiliated to, and supported by, the Trust Leadership Programmes. The L2L will run one half day per quarter, with a facilitator supporting shared learning amongst those enrolled on the scheme. Attendance at L2L is mandatory. No individual allocation. Costs of L2L met by programme budget. Attendance at SoAR Autumn/Spring Schools is also anticipated. 2 Updated on 7/8/24 The L2L team will signpost towards available programmes and resources (not funded as a component of the programme) bespoke to a training needs analysis for each person: e.g., AMS/NIHR Leadership Academy, UKRI Future Leadership, Florence Nightingale Foundation, Clinical Research Network (CRN) and local and national NHS Clinical Leadership Programmes. These can be undertaken in RLP time, personal time or SPA as agreed and recorded in the learning objectives of the award holder. Where required, these additional activities can be funded through either the RLP training budget (see below) or the individual’s existing study budget where applicable. Type of support Fees to support training needs in specific areas not already available free of charge through SoAR, UHS or UoS Type of RLP fellow Both see notes Notes Research Delivery (Group A) PG Cert, PGDip, or MRes that meet requirements of NIHR AoMRC Credentialing framework Funding allocation Applicants are expected to apply for NHS staff bursaries offered to support these activities where these exist. Should these not be available or the applicant be unsuccessful, funding support from RLP will be reviewed by the RLP team, based on the individuals needs assessment. Methodological Support Clinical Academic Clinical Academic (Group B) Accessing short courses to extend skills and knowledge necessary to develop high quality grant/fellowship applications. This may also extend to conferences where research work is being presented, following prior discussion with the RLP team. Any proposed activity should have been agreed in advance in the individual training needs/scoping review with the RLP team and Research Advisor (RA) – see below. Clinical Academic pathway: The RLP team will facilitate access to methodology and PPIE support from existing infrastructure where this is needed to support grant and fellowship applications. Funds to secure time from individuals with specific methodological expertise overcoming a specific barrier to grant/fellowship application success may be available on a case-by-case basis, following prior discussion with the RLP team. For example: complex statistics, health economics, trial design, qualitative methods. Each RLP award holder can apply for up to £1,000 per annum. (max 3 yrs.) This will be allocated on a first come, first served basis via our RLP request for training and development funding form. Via NIHR Research Support Service (RSS SC)/to be individually determined 3 Updated on 7/8/24 Coaching Both Should it be deemed by the RLP team that an Up to £1000 individual is facing a specific challenge for which executive coach would be appropriate, the individual may be offered the opportunity to work with a coach. This will be offered on a needs basis only. Mentorship Both (core) All applicants will be expected to have a named These roles will not be Research Advisor (RA) who will provide oversight, remunerated. guidance, and mentorship. The RA will be expected to attend the training needs/scoping analysis at the commencement of the programme, and annual reviews of progress where appropriate. The RLP Research Advisor Role Descriptor document is available to download. https://www.soar-southampton.org/researchleaders-programme Access to support from UHS/UoS infrastructure (As appropriate) Both As indicated by an individual’s scope of RLP After enrolment individuals will be supported to identify an appropriate named career support mentor in addition. Including but not limited to: 1. The Southampton Academy of Research (SoAR) 2. Joint Research Function including: a. Grant application support b. Quality assurance and governance c. Finance d. Contracting 3. Southampton Centre for Research Engagement and Impact (SCREI) a. Public and Patient involvement b. Specialist research Communications 4. NIHR Southampton Clinical Research Facility (CRF) 5. NIHR Southampton Biomedical Research Centre (BRC) 6. NIHR Applied Research Collaboration Wessex (ARC Wessex) 7. Research Support Service South Central (RSS SC) (see above) 8. Southampton Clinical Research Delivery teams and support departments Met by infrastructure 4 Updated on 7/8/24 Figure 1: Schematic representation of Research Leaders Programme components 5 Updated on 7/8/24 Award Length Applications will be considered for up to a maximum of 36 months, and for no less than 20% WTE (irrespective of whether the person currently works full or part time). For Medical Consultants the allocation will be 2 PA. For other groups a greater WTE can be applied for but no more than 40% WTE. Applicants are advised to discuss their proposed WTE and Award Length with the RLP team, contactable via SoAR, prior to submitting an application. Eligibility The RLP programme is open to all healthcare professionals employed (who hold a substantive as opposed to honorary employment contract) by University Hospital Southampton NHS Trust, including nurses, midwives, pharmacists, allied health professionals, clinical scientists, and doctors (including Consultants, SAS, and Specialty Doctors). Individuals must have the explicit support of their manager for their application, who will agree to ensure arrangements are in place for backfill of RLP funded time. The manager must also agree that the individual will be released to attend all cohort meetings of the L2L Programme. Potential applicants are therefore advised to speak to their manager early to ensure this assurance can be provided in the application process. The panel will consider applications for award stream Group B (Clinical Academic) from individuals who are already registered for, and currently completing a programme of work towards an MD/PhD. The expectation for these individuals, is that the MD/PhD will be submitted early in the RLP fellowship, with a view to proceeding towards a competitive postdoctoral fellowship application (or similar) to sustain funding beyond the RLP. RLP awards are not appropriate as full MD/PhD fellowships but are intended to enable transition to post-doctoral research and secure future research funding. As such, RLP fellowships will not fund MD/PhD fees. Applicants in this position are advised to contact SoAR to clarify eligibility. Selection Procedure Applications will be reviewed by a panel composed of representatives from across the Trust and University. Detailed review of each application will focus on: 1. The potential for the applicant to become a health research leader of the future – the applicant will need to make a strong case as to why they would merit an RLP award. For example: Outputs from previous research experience and training relative to career stage and background, suitability, and commitment of applicant to a career as an independent researcher or leader of a research delivery team. 2. Suitability and scope of proposed objectives for RLP and the alignment of these objectives with Trust research objectives. (as set out in the UHS Clinical Strategy 2020-2025, and UHS Research For Impact Strategy 2023-2028). 3. Quality and relevance of training and development plans (research skills, experience, and research career). 4. Suitability and experience of research advisor in relation to the applicants proposed career pathway. 5. Quality of plans to support career progression and fund research activity beyond the award. Please note: Costings will be done by UHS Research Grants team after the shortlisting has taken place, so there is no requirement to ask your line managers or contact UHS Research Grants team. This will be done using the information from your application form, and access to the nominal roll. 6 Updated on 7/8/24 Conditions and Reporting Successful applicants will be expected to agree to the following conditions upon acceptance of the award. If these conditions are not met, then the award can be terminated at any stage by the UHS R&D Director or Clinical Director. 1. Comply with the funding requirements of the scheme throughout the duration of the award Individuals must remain backfilled during this period. Any proposed changes should be discussed and agreed in advance with the RLP team. Where individuals secure significant grant or fellowship income, this should be disclosed to the RLP team early, to facilitate discussion regarding the proportion and duration of RLP funded time alongside any other funded research time. 2. Engage with the core elements of the programme. Attendance at the L2L Leadership Gatherings is a mandatory component of an RLP award. Individuals who miss more than one session in an annual cycle will be asked to justify non-attendance. The RLP Oversight Board will then review whether these individuals can remain on the programme. 3. Annual progress report and review meeting. Individuals on the programme will also be expected to report outputs through the University of Southampton Pure system (award holders will be supported to gain access and training). 4. Provide evidence that the award holder’s line manager will support changes to the individual’s job plan which allow backfilled time to be devoted to the RLP. A line manager signature and support statement will be required both at the time of application, and upon acceptance of an award if successful. Capturing Return on Investment (ROI) resulting from the UHS Research Leaders Programme (RLP) Return on investment (ROI) has several facets– including, but not limited to: financial, academic, clinical, cultural, and reputational impact. RLP Award Holders are expected to communicate fully and in a timely way with the RLP team around the progress, and success, of any funding applications (including grants and fellowships). The RLP relies on the contributions of its Award Holders to shape the future design of the programme and monitor its impact. RLP Award Holders will be asked to provide examples and evidence of activities, supported by, or allied to the RLP which have had an impact on areas including, but not limited to: • Trust reputation • Safety, quality, efficiency, and effectiveness of patient care • Culture (aligned with Trust People Strategy) • Workforce (e.g., attracting good people to work at UHS, retention and sustainability of the workforce) As part of this activity, individuals will be asked to engage with a ‘Strategic Task’, which aims to raise the profile of research in their clinical area and provide evidence of how they are working towards research being a fully integrated part of day-to-day clinical care. 7 Updated on 7/8/24 Contractual obligations Maternity Leave, Parental Leave, extended Sick Leave or other period of prolonged absence RLP payments will continue throughout the absence with an extension to the end date of up to 12 months. The RLP Award Holder’s Manager would be informed of this decision and would be responsible, along with the RLP Award Holder, for liaising with the relevant Division accordingly. AfC banding promotions during RLP Award Consultant award holders already have salary scale progression automatically built into their RLP award at the outset. In line with this, any healthcare professional on an AfC contract, who applies for a promotion and is successful, would have the corresponding uplift to their salary as part of their RLP award. 8 Updated on 7/8/24
Url: /Media/Southampton-Clinical-Research/Downloads/RLP-Guidance-Notes-Cohort-5-Final.pdf

Remuneration and Appointment Committee ToR Feb 2023

Description: Remuneration and Appointment Committee Terms of Reference Date Issued: 28 February 2023 Review Date: February 2024 Document Type: Committee Terms of Reference Version: 5 Contents Paragraph 1 2 3 4 5 6 7 8 9 10 Role and Purpose Constitution Membership Attendance and Quorum Frequency of Meetings Conduct and Administration of Meetings Duties and Responsibilities Accountability and Reporting Review of Terms of Reference and Performance and Effectiveness References Appendices Appendix A Executive Director Pay Principles Page 2 2 2 3 3 3 3 5 5 5 Page 6 Document Status This is a controlled document. Whilst this document may be printed, the electronic version posted on the intranet is the controlled copy. Any printed copies of this document are not controlled. As a controlled document, this document should not be saved onto local or network drives but should always be accessed from the intranet. Page 1 of 8 1. Role and Purpose 1.1 The Remuneration and Appointment Committee (the Committee) is responsible for identifying and appointing candidates to fill all the executive director positions on the board of directors (the Board) of University Hospital Southampton NHS Foundation Trust (UHS or the Trust) and for determining their remuneration and other conditions of service. 1.2 The Committee provides the board of directors of the Trust (the Board) with a means of independent and objective review of remuneration and executive director appointments in accordance with relevant laws, regulations and Trust policies. 1.3 The duties and responsibilities of the Committee are more fully described in paragraph 7 below. 2. Constitution 2.1 The Committee has been established by the Board. The Committee has no executive powers other than those set out in these terms of reference. 2.2 The Committee is authorised by the Board to investigate any activity within its terms of reference. It is authorised to seek any information it requires from any member of staff and all members of staff are directed to cooperate with any request made by the Committee. 2.3 The Committee is authorised to seek reports and assurance from executive directors and managers and will maintain effective relationships with the chairs of other Board committees to understand their processes of assurance and links with the work of the Committee. 2.4 The Committee is authorised to obtain external legal or other independent professional advice if it considers this necessary, taking into consideration any issues of confidentiality and the Trust’s standing financial instructions. 3. Membership 3.1 The members of the Committee will be appointed by the Board and will be the non- executive directors of the Trust except as provided in paragraph 3.2 below. 3.2 For any decisions relating to the appointment or removal of the executive directors, membership of the Committee will include the Chief Executive Officer, as required under Schedule 7 of the National Health Service Act 2006, who will count in the quorum for the meeting. The Chief Executive Officer will not be present when the Committee is dealing with matters concerning their appointment or removal, remuneration or terms of service. 3.3 The chair of the Board will chair the Committee (the Committee Chair). In the absence of the Committee Chair and/or an appointed deputy, the remaining non-executive directors present will elect one of themselves to chair the meeting. 3.4 Only members of the Committee have the right to attend and vote at Committee meetings. However, the following will be invited to attend meetings of the Committee on a regular basis: 3.4.1 Chief People Officer; and 3.4.2 Associate Director of Corporate Affairs/Company Secretary. 3.5 Other individuals may be invited to attend for all or part of any meeting, as and when appropriate and necessary, particularly when the Committee is considering areas that are the responsibility of a particular executive director or manager. Any attendee will be Page 2 of 8 asked to leave the meeting when the Committee is dealing with matters concerning their appointment or removal, remuneration or terms of service. 4. Attendance and Quorum 4.1 Members should aim to attend every meeting and should attend a minimum of 75% of meetings held in each financial year. Where a member is unable to attend a meeting they should notify the Committee Chair or Company Secretary in advance. 4.2 The quorum for a meeting will be four members, including the chair of the Board (or the Deputy Chair in their absence). A duly convened meeting of the Committee at which a quorum is present will be competent to exercise all or any of the authorities, powers and discretions vested in or exercisable by the Committee. 5. Frequency of Meetings 5.1 The Committee will meet as required, which will usually be four times each year. 5.2 The Committee may establish a sub-committee for a specific purpose where it would be impractical for the Committee to be involved, for example the appointment of an executive director following agreement by the Committee of the process, job description and person specification. 6. Conduct and Administration of Meetings 6.1 Meetings of the Committee will be convened by the Company Secretary at the request of the Committee Chair or any of its members. 6.2 The agenda of items to be discussed at the meeting will be agreed by the Committee Chair with support from the Chief People Officer and the Company Secretary. The agenda and supporting papers will be distributed to each member of the Committee and the regular attendees no later than three working days before the date of the meeting. Distribution of any papers after this deadline will require the agreement of the Committee Chair. 6.3 The Company Secretary will minute the proceedings of all meetings of the Committee, including recording the names of those present and in attendance and any declarations of interest. 6.4 Draft minutes of Committee meetings and a separate record of the actions to be taken forward will be circulated promptly to all members of the Committee. Once approved by the Committee, minutes will be circulated to all other members of the Board unless it would be inappropriate to do so in the opinion of the Committee Chair. 7. Duties and Responsibilities 7.1 The Committee will carry out the duties below for the Trust. Remuneration Role 7.2 The Committee will: 7.2.1 establish and keep under review a remuneration policy in respect of executive directors (as set out in Appendix A); 7.2.2 consult the Chief Executive Officer about proposals relating to the remuneration of the other executive directors; 7.2.3 in accordance with relevant laws, regulations and Trust policies, decide and keep under review the terms and conditions of office of the Trust’s executive directors, including salary, any performance-related pay or bonus, provisions for other benefits, Page 3 of 8 including pensions and cars, allowances, payable expenses and compensation payments; 7.2.4 adhering to all relevant laws, regulations and Trust policies: 7.2.4.1 establish levels of remuneration that are sufficient to attract, retain and motivate executive directors of the quality and with the skills and experience required to lead the Trust successfully, without paying more than is necessary for this purpose, and at a level that is affordable to the Trust; 7.2.4.2 decide whether a proportion of executive director remuneration should be structured so as to link reward to corporate and individual performance; 7.2.4.3 make sure that any performance-related elements of executive remuneration are stretching and promote the long-term sustainability of the Trust, and take as a baseline for performance any competencies required and specified in the job description for the post; 7.2.4.4 consider all relevant and current directors relating to contractual benefits such as pay and redundancy entitlements; 7.2.4.5 use national guidance and market benchmarking analysis in the annual determination of remuneration of executive directors while ensuring that increases are not made where Trust or individual performance do not justify them; 7.2.4.6 be sensitive to pay and employment conditions elsewhere in the Trust; 7.2.5 monitor and assess the output of the evaluation of the performance of individual executive directors, and consider this output when reviewing changes to remuneration levels; 7.2.6 on an annual basis monitor the remuneration of non-clinical senior leadership roles remunerated at levels above those specified in the NHS agenda for change terms and conditions; 7.2.7 approve the level of remuneration or any proposed change to remuneration for a senior leadership role referred to in 7.2.6 where the proposed remuneration for the role would exceed that of any executive director; and 7.2.8 consider issues of equality and diversity when evaluating and setting remuneration. Appointment Role 7.3 The Committee will: 7.3.1 regularly review the structure, size and composition (including the skills, knowledge, experience and diversity) of the Board, making use of the output of the Board evaluation process as appropriate, and make recommendations to the Board and the Governors’ Nomination Committee, as applicable, with regard to any changes; 7.3.2 give full consideration to and make plans for succession planning for the executive directors, taking into account the challenges and opportunities facing the Trust and the skills and expertise needed on the Board in the future; 7.3.3 keep the leadership needs of the Trust under review at executive director level to ensure the continued ability of the Trust to operate effectively in the health economy; 7.3.4 be responsible for identifying the and appointing candidates to fill posts within its remit as and when they arise; 7.3.5 when a vacancy is identified, evaluate the balance of skills, knowledge and experience of the Board, and its diversity, and in the light of this evaluation, prepare a description of the role and capabilities required for the particular appointment. In Page 4 of 8 identifying suitable candidates the Committee will use open advertising or the services of external advisers to facilitate the search, consider candidates from a wide range of backgrounds and consider candidates on merit against objective criteria; 7.3.6 ensure that a proposed executive director is a ‘fit and proper’ person as defined in law and regulation and monitor procedures to ensure that executive directors remain ‘fit and proper’ persons; 7.3.7 ensure that a proposed executive director’s other significant commitments (if applicable) are disclosed before appointment and that any changes to their commitments are reported to the Board as they arise; 7.3.8 ensure that proposed appointees disclose any business interests that may result in a conflict of interest prior to appointment and that any future business interests that could result in a conflict of interest are reported; 7.3.9 carefully consider what compensation commitments (including pension contributions) the executive directors’ terms of office would give rise to in the event of early termination to avoid rewarding poor performance. Contracts should allow for compensation to be reduced to reflect a departing executive director’s obligation to mitigate loss. Appropriate clawback provisions should be considered in the case of an executive director returning to the NHS within the period of putative notice; and 7.3.10 consider any matter relating to the continuation in office of any executive director, including the suspension or termination of service of an individual as an employee of the Trust, subject to the provisions of the law and their service contract. 8. Accountability and Reporting 8.1 The Committee Chair will report to the Board following each meeting, drawing the Board’s attention to any matters of significance or where actions or improvements are needed. 8.2 The Trust’s annual report will include sections describing the work of the Committee including its remuneration policies, details of the remuneration paid to executive directors and the process it has used in relation to the appointment of executive directors. 9. Review of Terms of Reference and Performance and Effectiveness 9.1 At least once a year the Committee will review its collective performance and its terms of reference. Any proposed changes to the terms of reference will be recommended to the Board for approval. 10. References 10.1National Health Service Act 2006 10.2NHS Foundation Trust Code of Governance 10.3NHS Improvement Guidance on pay for very senior managers in NHS trusts and foundation trusts Page 5 of 8 Appendix A Executive Director Pay Principles 1. The importance of executive director pay The delivery of the forward vision and our annual Trust objectives is predicated on ensuring talent is available at all levels of the Trust. Good senior leadership is vital, and therefore a key strategy for UHS must be to recruit and retain the best executive director talent into the Trust. This will be from a combination of both good internal succession planning, bringing top talent from the NHS and also seeking high calibre individuals from other sectors. 2. Determination of pay levels of posts Pay for executive director posts will be determined by: • Use of NHS Improvement (NHSI) data on pay for executive director positions in comparable trusts (Figure 1). • Use of other salary benchmarking exercises. • Job evaluation as required. • The conditions required to attract suitably qualified individuals, particularly where commercial, financial or other niche business skills are required. Pay levels will be reviewed not less frequently than annually by the Committee in accordance with the Trust’s pay review cycle to ensure that salary levels are both appropriate and provide value for money. 3. Setting salary of executive directors The following principles will apply: • UHS will aim to pay at around mid-point of NHSI levels for trusts of a comparable nature and scale. • UHS will review pay based on performance, changes in the NHSI framework levels and, in particular, the need to retain key individuals likely to be of interest to other trusts. • UHS will not recognise relevant changes of NHSI framework levels in respect of individuals where this is not justified by individual performance. • UHS will be mindful of equality, particularly in relation to gender and ethnicity in pay levels. • UHS will ensure all cost of living increases nationally awarded are reflected in executive director pay each year, as decided by the Committee, unless performance of an individual is unsatisfactory. • Any decision to introduce performance-related pay, or bonuses, will be subject to decision by the Committee based on a sound business case and adherence to NHSI guidance on executive pay. 4. Approval process All decisions on pay for executive directors will be managed in line with the terms of reference for the Committee. The Committee, supported by the Chief People Officer, will also ensure that the NHSI prevailing guidance on setting executive director pay, including any required approval process, will be followed as appropriate. Page 6 of 8 Figure 1 – NHS Improvement Pay Thresholds Supra large acute NHS trusts and foundation trusts (£750m+) Chief executive Deputy chief executive Director of finance/Chief finance officer Director of workforce Medical director/Chief medical officer Director of nursing/Chief nursing officer Chief operating officer Director of corporate affairs/governance Director of strategy/planning Director of estates and facilities Lower quartile £236,000 £185,500 £166,000 £142,500 £205,000 £150,000 £143,500 £113,000 £135,000 £129,500 Median £250,000 £188,000 £172,500 £155,000 £214,000 £163,500 £162,500 £117,500 £144,000 £137,000 Upper quartile £265,000 £195,500 £190,500 £165,500 £233,500 £168,000 £174,500 £134,000 £152,500 £146,500 Page 7 of 8 Remuneration and Appointment Committee Terms of Reference Version: 5 Document Monitoring Information Approval Committee: Date of Approval: Responsible Committee: Board of Directors 28 February 2023 Remuneration and Appointment Committee Monitoring (Section 9) for Completion and Presentation to Approval Committee: Target audience: Key words: Main areas affected: February 2024 Board of Directors, Remuneration and Appointment Committee, NHS Regulators, Staff and Public Remuneration, Appointment, Nomination, Committee, Board, Terms of Reference Trust-wide Summary of most recent changes if applicable: Consultation: No changes. Remuneration and Appointment Committee Number of pages: 8 Type of document: Committee Terms of Reference Does this document replace or Yes revise an existing document? Should this document be made Yes available on the public website? Is this document to be published in No any other format? Page 8 of 8
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Trust-governance-and-corporate-docs/2023-Trust-documents/Remuneration-and-Appointment-Committee-ToR-Feb-2023.pdf

Remuneration and Appointment Committee ToR May 2022

Description: Remuneration and Appointment Committee Terms of Reference Date Issued: 26 May 2022 Review Date: November 2022 Document Type: Committee Terms of Reference Version: 4 Contents Paragraph 1 2 3 4 5 6 7 8 9 10 Role and Purpose Constitution Membership Attendance and Quorum Frequency of Meetings Conduct and Administration of Meetings Duties and Responsibilities Accountability and Reporting Review of Terms of Reference and Performance and Effectiveness References Appendices Appendix A Executive Director Pay Principles Page 2 2 2 3 3 3 3 5 5 5 Page 6 Document Status This is a controlled document. Whilst this document may be printed, the electronic version posted on the intranet is the controlled copy. Any printed copies of this document are not controlled. As a controlled document, this document should not be saved onto local or network drives but should always be accessed from the intranet. Page 1 of 8 1. Role and Purpose 1.1 The Remuneration and Appointment Committee (the Committee) is responsible for identifying and appointing candidates to fill all the executive director positions on the board of directors (the Board) of University Hospital Southampton NHS Foundation Trust (UHS or the Trust) and for determining their remuneration and other conditions of service. 1.2 The Committee provides the board of directors of the Trust (the Board) with a means of independent and objective review of remuneration and executive director appointments in accordance with relevant laws, regulations and Trust policies. 1.3 The duties and responsibilities of the Committee are more fully described in paragraph 7 below. 2. Constitution 2.1 The Committee has been established by the Board. The Committee has no executive powers other than those set out in these terms of reference. 2.2 The Committee is authorised by the Board to investigate any activity within its terms of reference. It is authorised to seek any information it requires from any member of staff and all members of staff are directed to cooperate with any request made by the Committee. 2.3 The Committee is authorised to seek reports and assurance from executive directors and managers and will maintain effective relationships with the chairs of other Board committees to understand their processes of assurance and links with the work of the Committee. 2.4 The Committee is authorised to obtain external legal or other independent professional advice if it considers this necessary, taking into consideration any issues of confidentiality and the Trust’s standing financial instructions. 3. Membership 3.1 The members of the Committee will be appointed by the Board and will be the non- executive directors of the Trust except as provided in paragraph 3.2 below. 3.2 For any decisions relating to the appointment or removal of the executive directors, membership of the Committee will include the Chief Executive Officer, as required under Schedule 7 of the National Health Service Act 2006, who will count in the quorum for the meeting. The Chief Executive Officer will not be present when the Committee is dealing with matters concerning their appointment or removal, remuneration or terms of service. 3.3 The chair of the Board will chair the Committee (the Committee Chair). In the absence of the Committee Chair and/or an appointed deputy, the remaining non-executive directors present will elect one of themselves to chair the meeting. 3.4 Only members of the Committee have the right to attend and vote at Committee meetings. However, the following will be invited to attend meetings of the Committee on a regular basis: 3.4.1 Chief People Officer; and 3.4.2 Associate Director of Corporate Affairs/Company Secretary. 3.5 Other individuals may be invited to attend for all or part of any meeting, as and when appropriate and necessary, particularly when the Committee is considering areas that are the responsibility of a particular executive director or manager. Any attendee will be Page 2 of 8 asked to leave the meeting when the Committee is dealing with matters concerning their appointment or removal, remuneration or terms of service. 4. Attendance and Quorum 4.1 Members should aim to attend every meeting and should attend a minimum of 75% of meetings held in each financial year. Where a member is unable to attend a meeting they should notify the Committee Chair or Company Secretary in advance. 4.2 The quorum for a meeting will be four members, including the chair of the Board (or the Deputy Chair in their absence). A duly convened meeting of the Committee at which a quorum is present will be competent to exercise all or any of the authorities, powers and discretions vested in or exercisable by the Committee. 5. Frequency of Meetings 5.1 The Committee will meet as required, which will usually be four times each year. 5.2 The Committee may establish a sub-committee for a specific purpose where it would be impractical for the Committee to be involved, for example the appointment of an executive director following agreement by the Committee of the process, job description and person specification. 6. Conduct and Administration of Meetings 6.1 Meetings of the Committee will be convened by the Company Secretary at the request of the Committee Chair or any of its members. 6.2 The agenda of items to be discussed at the meeting will be agreed by the Committee Chair with support from the Chief People Officer and the Company Secretary. The agenda and supporting papers will be distributed to each member of the Committee and the regular attendees no later than three working days before the date of the meeting. Distribution of any papers after this deadline will require the agreement of the Committee Chair. 6.3 The Company Secretary will minute the proceedings of all meetings of the Committee, including recording the names of those present and in attendance and any declarations of interest. 6.4 Draft minutes of Committee meetings and a separate record of the actions to be taken forward will be circulated promptly to all members of the Committee. Once approved by the Committee, minutes will be circulated to all other members of the Board unless it would be inappropriate to do so in the opinion of the Committee Chair. 7. Duties and Responsibilities 7.1 The Committee will carry out the duties below for the Trust. Remuneration Role 7.2 The Committee will: 7.2.1 establish and keep under review a remuneration policy in respect of executive directors (as set out in Appendix A); 7.2.2 consult the Chief Executive Officer about proposals relating to the remuneration of the other executive directors; 7.2.3 in accordance with relevant laws, regulations and Trust policies, decide and keep under review the terms and conditions of office of the Trust’s executive directors, including salary, any performance-related pay or bonus, provisions for other benefits, Page 3 of 8 including pensions and cars, allowances, payable expenses and compensation payments; 7.2.4 adhering to all relevant laws, regulations and Trust policies: 7.2.4.1 establish levels of remuneration that are sufficient to attract, retain and motivate executive directors of the quality and with the skills and experience required to lead the Trust successfully, without paying more than is necessary for this purpose, and at a level that is affordable to the Trust; 7.2.4.2 decide whether a proportion of executive director remuneration should be structured so as to link reward to corporate and individual performance; 7.2.4.3 make sure that any performance-related elements of executive remuneration are stretching and promote the long-term sustainability of the Trust, and take as a baseline for performance any competencies required and specified in the job description for the post; 7.2.4.4 consider all relevant and current directors relating to contractual benefits such as pay and redundancy entitlements; 7.2.4.5 use national guidance and market benchmarking analysis in the annual determination of remuneration of executive directors while ensuring that increases are not made where Trust or individual performance do not justify them; 7.2.4.6 be sensitive to pay and employment conditions elsewhere in the Trust; 7.2.5 monitor and assess the output of the evaluation of the performance of individual executive directors, and consider this output when reviewing changes to remuneration levels; 7.2.6 on an annual basis monitor the remuneration of non-clinical senior leadership roles remunerated at levels above those specified in the NHS agenda for change terms and conditions; 7.2.7 approve the level of remuneration or any proposed change to remuneration for a senior leadership role referred to in 7.2.6 where the proposed remuneration for the role would exceed that of any executive director; and 7.2.8 consider issues of equality and diversity when evaluating and setting remuneration. Appointment Role 7.3 The Committee will: 7.3.1 regularly review the structure, size and composition (including the skills, knowledge, experience and diversity) of the Board, making use of the output of the Board evaluation process as appropriate, and make recommendations to the Board and the Governors’ Nomination Committee, as applicable, with regard to any changes; 7.3.2 give full consideration to and make plans for succession planning for the executive directors, taking into account the challenges and opportunities facing the Trust and the skills and expertise needed on the Board in the future; 7.3.3 keep the leadership needs of the Trust under review at executive director level to ensure the continued ability of the Trust to operate effectively in the health economy; 7.3.4 be responsible for identifying the and appointing candidates to fill posts within its remit as and when they arise; 7.3.5 when a vacancy is identified, evaluate the balance of skills, knowledge and experience of the Board, and its diversity, and in the light of this evaluation, prepare a description of the role and capabilities required for the particular appointment. In Page 4 of 8 identifying suitable candidates the Committee will use open advertising or the services of external advisers to facilitate the search, consider candidates from a wide range of backgrounds and consider candidates on merit against objective criteria; 7.3.6 ensure that a proposed executive director is a ‘fit and proper’ person as defined in law and regulation and monitor procedures to ensure that executive directors remain ‘fit and proper’ persons; 7.3.7 ensure that a proposed executive director’s other significant commitments (if applicable) are disclosed before appointment and that any changes to their commitments are reported to the Board as they arise; 7.3.8 ensure that proposed appointees disclose any business interests that may result in a conflict of interest prior to appointment and that any future business interests that could result in a conflict of interest are reported; 7.3.9 carefully consider what compensation commitments (including pension contributions) the executive directors’ terms of office would give rise to in the event of early termination to avoid rewarding poor performance. Contracts should allow for compensation to be reduced to reflect a departing executive director’s obligation to mitigate loss. Appropriate clawback provisions should be considered in the case of an executive director returning to the NHS within the period of putative notice; and 7.3.10 consider any matter relating to the continuation in office of any executive director, including the suspension or termination of service of an individual as an employee of the Trust, subject to the provisions of the law and their service contract. 8. Accountability and Reporting 8.1 The Committee Chair will report to the Board following each meeting, drawing the Board’s attention to any matters of significance or where actions or improvements are needed. 8.2 The Trust’s annual report will include sections describing the work of the Committee including its remuneration policies, details of the remuneration paid to executive directors and the process it has used in relation to the appointment of executive directors. 9. Review of Terms of Reference and Performance and Effectiveness 9.1 At least once a year the Committee will review its collective performance and its terms of reference. Any proposed changes to the terms of reference will be recommended to the Board for approval. 10. References 10.1National Health Service Act 2006 10.2NHS Foundation Trust Code of Governance 10.3NHS Improvement Guidance on pay for very senior managers in NHS trusts and foundation trusts Page 5 of 8 Appendix A Executive Director Pay Principles 1. The importance of executive director pay The delivery of the forward vision and our annual Trust objectives is predicated on ensuring talent is available at all levels of the Trust. Good senior leadership is vital, and therefore a key strategy for UHS must be to recruit and retain the best executive director talent into the Trust. This will be from a combination of both good internal succession planning, bringing top talent from the NHS and also seeking high calibre individuals from other sectors. 2. Determination of pay levels of posts Pay for executive director posts will be determined by: • Use of NHS Improvement (NHSI) data on pay for executive director positions in comparable trusts (Figure 1). • Use of other salary benchmarking exercises. • Job evaluation as required. • The conditions required to attract suitably qualified individuals, particularly where commercial, financial or other niche business skills are required. Pay levels will be reviewed not less frequently than annually by the Committee in accordance with the Trust’s pay review cycle to ensure that salary levels are both appropriate and provide value for money. 3. Setting salary of executive directors The following principles will apply: • UHS will aim to pay at around mid-point of NHSI levels for trusts of a comparable nature and scale. • UHS will review pay based on performance, changes in the NHSI framework levels and, in particular, the need to retain key individuals likely to be of interest to other trusts. • UHS will not recognise relevant changes of NHSI framework levels in respect of individuals where this is not justified by individual performance. • UHS will be mindful of equality, particularly in relation to gender and ethnicity in pay levels. • UHS will ensure all cost of living increases nationally awarded are reflected in executive director pay each year, as decided by the Committee, unless performance of an individual is unsatisfactory. • Any decision to introduce performance-related pay, or bonuses, will be subject to decision by the Committee based on a sound business case and adherence to NHSI guidance on executive pay. 4. Approval process All decisions on pay for executive directors will be managed in line with the terms of reference for the Committee. The Committee, supported by the Chief People Officer, will also ensure that the NHSI prevailing guidance on setting executive director pay, including any required approval process, will be followed as appropriate. Page 6 of 8 Figure 1 – NHS Improvement Pay Thresholds Supra large acute NHS trusts and foundation trusts (£750m+) Chief executive Deputy chief executive Director of finance/Chief finance officer Director of workforce Medical director/Chief medical officer Director of nursing/Chief nursing officer Chief operating officer Director of corporate affairs/governance Director of strategy/planning Director of estates and facilities Lower quartile £236,000 £185,500 £166,000 £142,500 £205,000 £150,000 £143,500 £113,000 £135,000 £129,500 Median £250,000 £188,000 £172,500 £155,000 £214,000 £163,500 £162,500 £117,500 £144,000 £137,000 Upper quartile £265,000 £195,500 £190,500 £165,500 £233,500 £168,000 £174,500 £134,000 £152,500 £146,500 Page 7 of 8 Remuneration and Appointment Committee Terms of Reference Version: 4 Document Monitoring Information Approval Committee: Date of Approval: Responsible Committee: Board of Directors 26 May 2022 Remuneration and Appointment Committee Monitoring (Section 9) for Completion and Presentation to Approval Committee: Target audience: Key words: Main areas affected: November 2022 Board of Directors, Remuneration and Appointment Committee, NHS Regulators, Staff and Public Remuneration, Appointment, Nomination, Committee, Board, Terms of Reference Trust-wide Summary of most recent changes if applicable: Consultation: Addition of a description of the role of the committee in respect of the remuneration of senior management other than executive directors and the replacement of the remuneration table in appendix A with that applicable to supra large acute NHS trusts Remuneration and Appointment Committee Number of pages: 8 Type of document: Committee Terms of Reference Does this document replace or Yes revise an existing document? Should this document be made Yes available on the public website? Is this document to be published in No any other format? Page 8 of 8
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Trust-governance-and-corporate-docs/2022-Trust-documents/Remuneration-and-Appointment-Committee-ToR-May-2022.pdf

Annual report 2021-2022

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

Annual report 15-16

Description: University Hospital Southampton NHS Foundation Trust Annual report and accounts 2015/16 incorporating the quality account 2015/16 Presented to Parliament pursuant to Schedule 7, paragraph 25 (4) (a) of the National Health Service Act 2006 3 ©2016 University Hospital Southampton NHS Foundation Trust TABLE OF CONTENTS Performance report Statement from the chief executive 7 Statement of purpose and activities 8 History of UHS 8 Key issues and risks 9 Going concern disclosure 9 Performance reporting 10 Regulatory body ratings 14 Environmental matters 14 Social, community and human rights issues 15 Accountability report Directors’ report 17 Introducing the Board of Directors 20 The people 21 Audit and assurance committee 25 Disclosures 28 Council of Governors 33 Annual remuneration statement 40 Appointment and remuneration committee 43 Governors’ nomination committee 45 Staffing data 50 Regulatory ratings 57 Statement of chief executive’s responsibilities as the accounting officer 59 Annual governance statement 60 Voluntary disclosures 69 Quality account and report 2015/16 Chief executive’s welcome 121 Overview of University Hospital Southampton NHS Foundation Trust 122 Activity levels during 2015/16 122 Our 2015/16 priorities for improving quality 123 Our 2015/16 priorities for outcomes and clinical effectiveness 124 Our 2015/16 priorities for patient experience 126 Our 2015/16 priorities for patient safety 129 Never events 130 Our quality priorities for 2016/17 130 Participation in national clinical audits and confidential enquiries 131 Participation in clinical research 133 Data quality 133 Review of services 134 Registration with the Care Quality Commission (CQC) 136 Our standard core indicators of quality 139 Overview of performance 146 Further information about our Trust 150 Conclusion 153 Responses to our quality account 154 Statement of directors’ responsibilities 160 Independent auditor’s report 161 Annual accounts Statement from the chief financial officer 79 Foreward to the accounts 81 Independent auditor’s report 82 Financial statements 87 FTC summarisation schedules for UHS NHS Foundation Trust 118 Appendix Appendix A – pulse KPI’s 165 Appendix B – national clinical audit activity 166 Appendix C – local clinical audit activity 167 Appendix D – patient improvement framework 2016/17 175 Appendix E – glossary of acronyms 176 5 Statement from the chief executive 2015/16 has been a challenging year for University Hospital Southampton (UHS) but we are proud of the achievements we have made. In order to meet the needs of the population, we have seen 706,931 patients (total inpatients and outpatients), which is over 25,000 more patients than in the previous year. You’ll find a more detailed breakdown of activity on page 11. Overall, patients were happy with the care that we gave them, with 96%* likely to recommend UHS. We have worked hard to maintain and improve the quality of our services. In particular, we are pleased that our Hospital Standardised Mortality Rate (HSMR) is now below nationally expected levels. You can find more detail on this within the quality account section of this report. We are very aware that healthcare is a ‘risky business’ and that, internationally, healthcare is not as safe as it could be. In order to address this it is crucial that we encourage a safety conscious culture, including the reporting and analysis of all incidents and untoward events. In February 2016 the NHS published a ‘transparency league’ designed to assess how open and transparent NHS organisations are with regards to errors. We were pleased to be ranked as ‘good’ in this assessment. Patient waiting times is another important aspect of quality – whether that be waiting at home for a cancer diagnosis or elective surgery, or waiting in the emergency department for treatment or an inpatient bed. Throughout the year we met the national standards for cancer treatment, diagnostics and elective care, but we did not meet the four hour emergency access standard. We have, however, improved our performance compared to 2014/15, and we are committed to improving this performance in 2016/17. Feedback from our staff is important to us and is another important indicator of quality. The most recent staff Friends and Family Test indicated that 90% of our staff would recommend us as a place to be treated, and 76% as a place to work. Whilst we still have work to do, these figures are significantly better than the national average, and the highest that we have ever achieved. Other highlights of the year include being selected for two national initiatives: 1. to be one of the early implementers for the seven day service standards for emergency and inpatient services, and 2. to be one of the pilots for supporting staff health and wellbeing. Both of these initiatives are an important part of our journey towards becoming a higher quality provider of healthcare and an exemplary employer. Following extensive consultation, we also launched our new vision ‘Forward’ which can be found at www.uhs.nhs.uk/AboutTheTrust/Ourvision. Our Trust chair, John Trewby, left the Trust at the end of March 2016 when his second term of office came to an end. John has been an exceptional leader and over the last eight years he has steered UHS to achieve great things in some truly difficult circumstances. Under his leadership we achieved foundation status in 2011, developed as a clinical academic centre with a growing reputation for research, and have gained an outstanding reputation for the excellence and outcomes of our clinical services. I would like to take this opportunity to thank him for his commitment to UHS and welcome his successor, Peter Hollins, to the role. Finally, we continued to invest in our buildings and equipment. This included the creation of a new main entrance opened in May 2016, and ongoing major investment into radiological equipment. We also expanded our emergency department to create an ambulance assessment area and, in March 2016, chancellor George Osborne announced that the government will invest £2m in a new £4.8m children’s emergency and trauma department for our Southampton Children’s Hospital. Fiona Dalton Chief executive *figure based on April 2016 survey 7 Statement of purpose and activities UHS is a large teaching hospital located on the south coast of England. We have a tripartite mission to provide clinical care, educate current and future healthcare professionals, and undertake research to improve healthcare for the future. Our clinical care encompasses local acute and elective care for 650,000 people who live in Southampton, the New Forest, Eastleigh and Test Valley. We also provide care for the residents of the Isle of Wight for many services. As the major university hospital on the south coast, UHS provides the full range of tertiary medical and surgical specialities (with the exception of transplantation, renal services and burns) to more than three million people in central southern England and the Channel Islands. UHS is a centre of excellence for training the doctors, nurses and other healthcare professionals of the future. We work with the University of Southampton and Solent University to educate and develop staff at all levels, including a large apprenticeship programme, undergraduate and post-graduate education. Our role in research, developed in active partnership with the University of Southampton, is to contribute to the development of treatments for tomorrow’s patients. This work distinguishes us as a hospital that works at the leading edge of healthcare developments in the NHS and internationally. In particular we have nationally-leading research into cancer, respiratory disease, nutrition, cardiovascular disease, bone and joint conditions and complex immune system problems. We are one of the largest recruiters of patients into clinical trials in the country. Over 10,500 people work at the Trust, making it one of the area’s biggest employers. We also benefit from the time of over 1,000 volunteers. Our turnover in 2015/16 was £693m. History of UHS The Trust has its origins in the 1900s when the Shirley Warren Poor Law Infirmary was built on the site of what is now Southampton General Hospital. In the early half of the century, the site began to expand, including the opening of the school of nursing and the creation of the Wessex Neurological Unit. In 1971 a new medical school was opened in Southampton and the 1970s and 1980s saw a significant building programme encompassing the current footprint of Southampton General Hospital, Princess Anne Hospital and Countess Mountbatten House. During the 1990s, services were increasingly centralised at the general hospital, with the eye hospital and cancer services being relocated from elsewhere in the city. The Wellcome Trust funded a clinical research facility at the hospital in 2001 and this unit remains the foundation for much of the Trust’s groundbreaking medical research. In the last decade, development has continued with the opening of the North Wing Cardiac Centre in 2006, the creation of a major trauma centre with on-site helipad and the opening in 2014 of Ronald McDonald House for the relatives of sick children. Organisationally, Southampton University Hospitals Trust was formed in 1993, creating a single management board for acute services in Southampton. Fourteen years later, University Hospital Southampton NHS Foundation Trust (UHS) was formed (1 October 2011) when Southampton University Hospitals NHS Trust was licensed as a foundation trust by the regulator, Monitor. 8 Key issues and risks that could affect achievement of our objectives There are three key issues that could affect our ability to achieve our objectives, these are: 1. Failure to deliver the four hour emergency department target, which impacts both patient experience and safety. There is a recovery action plan in place which has been formally reviewed by our commissioners. The main focus for 2016/17 is working with partners to reduce delayed transfers in care, improving the numbers of discharges that occur before midday and improving processes for emergency patients between the ED and inpatient teams. 2. Capacity and occupancy, which impacts on patient flow and timeliness of care. Increased risk in 2016/17 through unplanned transfers in service by other local providers and support for emergency flows. We have mitigated this by minimising the bed closures refurbishment programme, focusing on seven day service, improving patient flow (such as home before lunch), developing a hospital without walls, investing in a capital programme to improve capacity (surgical robot, hybrid theatres and minor ops rooms) and reducing length of stay. 3. Staffing, plans are in place for both recruitment and retention. To mitigate this risk we will continue to focus on making UHS an attractive employer by: - continuing to recruit from overseas - working with universities to increase student nurses - developing band 4 posts and apprentices - rolling out a new, consistently branded, ‘Think UHS’ recruitment campaign - enhancing overseas fellows posts - reviewing all junior rotas in light of the new contract - using flexible and temporary staff when needed - creating different roles linked to our research agenda - reviewing training and education to enhance retention Going concern disclosure After making enquiries, the directors have a reasonable expectation that the Trust has adequate resources to continue in operational existence for the foreseeable future. For this reason, they continue to adopt the going concern basis in preparing the accounts. 9 Performance reporting Reporting structure As a large NHS university hospital foundation trust, UHS monitors performance within individual teams throughout the year with feedback processes in place to escalate issues to more senior management teams. At a corporate level we have an established executive reporting structure. This begins with the monthly Trust Board meeting where the executive directors of the Trust will present a high level summary to the chairman and non-executive directors, as well as providing greater detail on key performance changes, risks and issues. Below this are a number of executive sub-committees attended by a subset of executive and non-executive directors. These are the audit and assurance committee, the strategy and finance committee and the quality and performance committee. These committees will review performance and issues in greater depth, feeding back to Trust Board as appropriate. In addition, there are regular Trust Board study sessions which focus on specific individual issues with the entire Board present. The Trust executive committee (TEC) meets monthly and is made up of the executive board members and the divisional management teams. Performance and service issues are discussed with greater granularity at this meeting. Finally, there are regular performance meetings between the operational management team, led by the chief operating officer, and the division and care group management teams. These meetings focus on the individual patient and service pathways and developing the detailed plans for improvement. Key performance indicators (KPIs) The Trust publishes a monthly Integrated KPI Board Report on its website which provides both the Board and the public with an overview of performance within the Trust. This report is constantly evolving as new areas of monitoring are developed and new areas of national focus become apparent. The monthly report features the following sections: • Executive digest – a textual update on the previous month’s performance across the Trust written by the director of transformation and improvement • Pulse KPIs – the top KPIs identified by Trust Board, RAG-rates for the previous 13 months (see appendix A) • Performance • Activity • Capacity • Emergency department (ED) • Referral to Treatment (RTT, or 18 Weeks) • Cancer waiting times • Finance • Patient experience • Patient safety • Outcomes • Staffing (HR) and estates • Education and training • Research and development This report also includes summary versions of quarterly reports submitted to TEC which go into greater detail about patient experience, patient safety, clinical effectiveness and outcomes, and infection prevention In addition, a separate Finance Board Report is submitted to Trust Board on a monthly basis. 10 How we monitor performance In addition to reviewing the data submitted to the Trust Board in these papers, we have a suite of tools available to compare UHS performance to that of comparable trusts around the country. Depending on the measures being monitored, UHS has a number of peer groups to benchmark against including other local providers, major trauma centres and university hospital teaching trusts. Each NHS trust will serve a different size and type of population and will offer a slightly different range of services so it is important to understand that this benchmarking provides an initial indication of performance rather than an absolute guide to our position nationally. We will build on this knowledge by meeting and working with other trusts around the country and the world in order to share learning and build the best patient pathways and most efficient uses of resources possible. Detailed analysis and explanation of the development and performance of UHS Over the past four years we have seen significant increases in all types of activity. Some of this is due to an increase in the range of specialist services we offer, becoming a major trauma centre and the building of the helipad, but much of it is due to the increased and aging population in Southampton and the surrounding area. The graphs below demonstrate this increase in activity. UHS Growth in Activity - 2012/13 to 2015/16 600000 500000 400000 300000 200000 100000 2012/13 2013/14 2014/15 2015/16 0 Inpatient Spells (inc day cases) Outpatient Appointments ED Attendances (type 1) Referrals 2012/13 Inpatient spells (inc day cases 133,712 Outpatient appointments 447,122 ED attendance (type 1 & 2) 115,917 Referrals 165,597 2013/14 138,868 493,471 115,660 181,761 2014/15 144,934 536,949 111,297 182,402 2015/16 145,524 561,407 113,569 190,170 Increase 2012/13 to 2015/16 8.8% 25.6% -2.0& 14.8% In order to manage these increasing pressures we have focused our attention on the flow through the hospital. Our adult midday bed occupancy decreased by 4.3% in 2015/16 (to the end of February) compared to the same period in 2014/15, allowing the Trust greater flexibility when dealing with periods of high demand. This is reflected in the reduction in the number of red and black alerts issued in 2015/16. 11 The hospital alert status is decided by the operations centre after assessing the bed and staffing position, and is recorded twice daily at the Trust bed meetings (though the status may change at any time). Black alert is the highest level of alert and is issued when there are no empty beds available across the Trust with no expected discharges, the emergency department is full, and several ambulances are likely to be delayed for long periods of time, stopping them from responding to 999 calls. In 2014/15 a black alert was recorded 91 times at the twice daily bed meetings. In 2015/16 this was reduced to seven. A central pillar of this change has been the stabilisation of Length of Stay (LoS) despite the increased number of patients requiring a complex package of care after their discharge. These patients can often have their discharges delayed while beds in community care homes are found and supporting community care packages are arranged. The chart below demonstrates the change in LoS for elective and non-elective (emergency) patients over the past four years. Rolling 12-Month Average Length of Stay - Elective and Non-Elective 6.50 6.00 5.50 5.00 4.50 4.00 3.50 R-12 Non-Elective LoS R-12 Elective LoS 3.00 2015/16 saw an increased focus on discharging patients earlier in the day and at the weekend. This will remain a major focus for the Trust in 2016/17. Each of the above metrics will have an impact on the Trust’s performance against the three primary nationally reported targets for Referral to Treatment (RTT, or 18 Weeks) performance, emergency department performance and cancer waiting times performance. Referral to Treatment (18 Weeks) performance At the start of 2015/16 there were three targets the Trust was responsible for delivering: 1. Incomplete Pathways – 92% of all patients on an 18 week pathway and not yet treated should have waited 18 weeks or less at the end of the month. 2. Admitted Stops – 90% of all patients requiring an inpatient treatment should receive this treatment within 18 weeks of referral. 3. Non-Admitted Stops – 95% of all patients either receiving treatment in an outpatient setting or discharged without requiring treatment should have their pathway stopped within 18 weeks of referral. The government announced that, from July 2015 onwards, only the achievement of the Incomplete Pathways target would be required. This change allowed trusts to treat greater numbers of long-waiting patients each month. UHS met all three targets in quarter 1 of 2015/16 and continued to meet the Incomplete Pathways target throughout the rest of the year. 12 This continuing good performance should be set against the aforementioned rise in patient referrals, which highlights the increased demands being placed on the Trust. It is only due to the increased efficiency shown by the Trust’s inpatient and outpatient services that it has been possible to meet these targets on an ongoing basis. Emergency department (ED) performance We have failed to meet the national target of 95% of all ED attendances being treated and either admitted or discharged within four hours of arrival in any month in 2015/16. However, this has been a challenging target nationwide with the winter period providing the worst performance the NHS in England has ever recorded. Against this, the year on year improvement seen at UHS is good progress. There are three types of ED that can be included in these figures: Type 1 A consultant led 24-hour service with full resuscitation facilities and designated accommodation for the reception of accident and emergency patients. Type 2 A consultant led single specialty accident and emergency service (e.g. ophthalmology, dental) with designated accommodation for the reception of patients. Type 3 Other type of A&E/minor injury units (MIUs)/Walk-in Centres, primarily designed for the receiving of accident and emergency patients. A type 3 department may be doctor led or nurse led. It may be co-located with a major ED or sited in the community. A defining characteristic of a service qualifying as a type 3 department is that it treats at least minor injuries and illnesses (sprains for example) and can be routinely accessed without appointment. UHS has a type 1 and a type 2 (ophthalmology) department. The Trust also had a type 3 (MIU) department until July 2014. Due to the nature of the activity at the MIU, the transfer of this department to another provider reduced UHS performance against the four hour target by approximately 3%. When comparing performance over the long term, it is important to factor this change in. ED performance reduced fractionally in quarters 1 and 2 of 2015/16 compared to 2014/15, despite the loss of the MIU activity. In quarter 3, when the comparative activity was the same, performance improved by 4.7%. This was due in part to the improvements in hospital flow outlined earlier, and also linked to improvements in the operational performance of the department itself. While performance fell by 1.2% in quarter 4 of 2015/16 compared to the same time the previous year, this must be set against an increase in activity of over 3,000 additional ED attendances (12.1%). The graph below shows UHS performance against the four hour target over the past four years. Year-On-Year ED Performance by Quarter 98.00% 96.00% 94.00% 92.00% 90.00% 88.00% 86.00% 84.00% Cancer waiting times 82.00% 80.00% 78.00% 76.00% Q1 Q2 Q3 Q4 2012/13 2013/14 2014/15 2015/16 13 There are 10 separate cancer waiting times measures that the Trust reports to the Department of Health on a monthly basis, each of which can then be split into tumour site specific performance groups. In 2015/16 (to the end of February) the Trust met all 10 of these measures, an improvement on 2014/15 when one target was failed. This performance against the targets should be set against the significant rise in activity seen on the cancer pathways. The three central targets are the percentage of two week wait urgent suspected cancer patients seen within two weeks of their referral, which saw a rise in demand of 13% in 2015/16, the percentage of these patients diagnosed with cancer treated within 62-days of their referral (for which demand increased by 20.1%) and the number of all patients treated within 31 days of an agreed treatment plan being put in place (for which demand rose by 14.2%). The chart below shows the rise in demand for UHS cancer services over the past five years. 18,000 16,000 14,000 12,000 10,000 8,000 6,000 4,000 2,000 - UHS Growth in Activity - 2012/13 to 2015/16 Two Week Waits 62-Day Target Patients 31-Day Target Patients 2011/12 2012/13 2013/14 2014/15 2015/16* * 2015/16 data covers April to February only These targets are a leading priority for the Trust and will be the focus of in depth work in 2016/17, especially given the ongoing increases in demand for these services. Regulatory body ratings In the last quarter of 2015/16 Monitor rated UHS ‘2’ for our financial sustainability risk rating (1 being the most serious risk and 4 the lowest risk) and ‘green’ for our governance risk rating, which means that no governance concern is evident and no formal investigation is being undertaken. More details can be found on page 57. The Care Quality Commission (CQC) gave us an overall rating of ‘requires improvement’ as at December 2014. You can see the full report by visiting www.uhs.nhs.uk or www.cqc.org.uk. Environmental matters A number of projects were undertaken in 2015/16 to reduce our impact on the environment. We installed a large anaerobic digester which will provide renewable energy by naturally breaking down waste and turning it into fuel. We have also replaced one of our combined heat and power engines so that we can generate more of our own electricity on site and get the benefit of free heating that is a by-product of running a large gas engine. 14 In conjunction with these two developments we have implemented a range of measures to ensure that we are using energy more efficiently. For example, we are now ensuring that large water pumps are only running when needed and we are in the process of replacing old fluorescent lighting with more efficient LED systems. More information can be found within the environmental sustainability and climate change section of this report. Social, community and human rights issues We recognise our responsibilities under the European Convention on Human Rights (included in the Human Rights Act 1998 in the UK), which are relevant to health and social care. These rights include the: • right to life • right not to be subjected to torture, inhuman or degrading treatment or punishment • right to liberty • right to respect for private and family life The Trust is committed to ensuring it fully takes into account all aspects of human rights in our work. 15 Directors’ report Composition of the Board The Board is currently comprised as follows: Non-executive directors: Peter Hollins, chair Simon Porter, senior independent director Professor Iain Cameron Lynne Lockyer Dr David Price Dr Mike Sadler Jenni Douglas Todd Executive directors: Fiona Dalton, chief executive Gail Byrne, director of nursing and organisational development Jane Hayward, director of transformation and improvement Dr Derek Sandeman, medical director Dr Caroline Marshall, chief operating officer David French, chief financial officer Name John Trewby Lena Samuels Judy Gillow Dr Michael Marsh Mike Murphy Alastair Matthews Gail Byrne Dr Derek Sandeman Position Chairman Non-executive director Director of nursing and organisational development Medical director Director of strategy Director of finance and deputy chief executive Director of nursing and organisational development Medical director Paul Goddard Acting director of finance David French Chief financial officer Note Left the organisation on 31 March 2016 Left the organisation on 29 February 2016 Left the organisation on 30 September 2015 Left the organisation on 31 May 2015 Left the organisation on 31 December 2015 Left the organisation on 1 November 2015 Commenced from within the organisation on 1 October 2015 Commenced from within the organisation on 1 June 2015 Acting director from 23 October 2015 to 2 February 2016 Joined the organisation on 3 February 2016 It should be noted that the size of the Board has been reduced to seven non-executive directors (including the chair) and six executive directors. This decision was agreed by our appointments and remuneration committee on 25 August 2015. Each director confirms that at the time the annual report and accounts is approved: • so far as the director is aware, there is no relevant audit information of which the NHS foundation trust’s auditor is unaware • the director has taken all the steps they ought to have taken as director in order to make themselves aware of any relevant audit information and to establish that the NHS foundation trust’s auditor is aware of that information. 17 There are no important events since the year end affecting the foundation trust. No political donations have been made. The Trust has no overseas branches. Trust Board declarations of interest John Trewby Council member University of Southampton; chair Exelis Defence Ltd; associate of Group 4 Securicor. Peter Hollins Partner in the Jubilee Film Partnership; chair of CLIC Sargent Cancer Care for Children (a company limited by guarantee). Lena Samuels Shareholder and director, 37 Patshull Road NW5 Limited; magistrate of Southampton Bench; member of staff at BBC; shareholder and director of Wessex Creative Media Ltd; chair of Pylewell Park Cricket Club; trustee Cultural Development Trust; prospective Labour Party parliamentary candidate for the New Forest West constituency (until 7 May 2015); communications and development specialist advisor for the Hampshire Cultural Trust (from 4 May 2015) Iain Cameron Dean of Faculty of Medicine and Member of University Executive Board, University of Southampton; board member of Wessex Academic Health Science Network; director (chair) of Medical Schools Council; director of Medical Schools Council Assessment; director of UK Clinical Aptitude Test; trustee of Wessex Medical Trust; joint chair of University Hospital Southampton/University of Southampton Joint Research Strategy Board; joint chair, National Institute for Health Research (NIHR) Biomedical Research Centre (BRC) Southampton Executive Board. Simon Porter Independent member of audit committee Amicus Horizon (until 21 October 2015); Former partner in Ernst & Young LLP; non-executive director and chair of audit committee, Radian Group; non-executive director and chair of audit committee, Octavia Housing. Lynne Lockyer Board member/trustee of the Brendoncare Foundation. David Price Public member of Network Rail Ltd (until 30 June 2015); chair of RTL Materials Ltd; chair of Telesoft Technologies Ltd; chair of Optitune Plc; chair of Symetrica Ltd; member of Advisory Board, Silverstream Technologies BV; treasurer, University of Southampton. Michael Sadler GP specialist advisor for the Care Quality Commission; external clinical associate for PricewaterhouseCoopers. Fiona Dalton Trustee of Gingerbread, the national charity for one-parent families (until 31 December 2015). Judy Gillow Trustee of Naomi House Children’s Hospice, Winchester (until 31 August 2015); trustee of Enham House Disability Charity, Andover. Gail Byrne Husband is a consultant surgeon in the Trust; trustee of Naomi House Children’s Hospice (from 1 January 2016). 18 Caroline Marshall Nothing to declare Jane Hayward Father is mental health act manager, Southern Foundation Trust (voluntary position), member of Mental Health Act Committee, Southern Foundation Trust (voluntary position), member of Assessment Committee for Clinical Excellence Awards (lay member), a UHS Simulated Patient (voluntary position), Lay member on Medical School undergraduate interview panels (until 31 December 2015); Mother is a UHS Simulated Patient (voluntary position). Michael Marsh Married to Sarah Marsh, who works within Specialised Commissioning of NHS Commissioning Board; selfemployed Medico Legal Expert on ad hoc basis independently to solicitors, Medical Defence Union (MDU) and NHS Litigation Authority. Derek Sandeman Nothing to declare. Alastair Matthews Non-executive director of NHS Innovations South East Ltd. Paul Goddard Partner works for the Trust as projects officer within the contracting department and previously PA to the director of research and development. David French Non-executive director and chair of audit and risk committee, Sentinel Housing Association; governor and chair of audit committee, South Wilts Grammar School for Girls; chair of Hampshire & Isle of Wight NHS Counter Fraud Board. Mike Murphy Parent governor, Mountbatten School, Romsey. 19 Introducing the Board of Directors Trust Board The Board is made up of the chair, six non-executive directors and six executive directors including the chief executive. Together they bring a wide range of skills and experience to the Trust, such that the board achieves balance and completeness at the highest level. The non-executive directors, including the chair, are people who live or work in the local area and have shown a genuine interest in helping to improve the health of local people. The non-executive directors are determined by the Board to be independent in both character and judgement. The chair, executive directors and non-executive directors have declared any business interests that they have. The Board is satisfied that no conflicts of interest are indicated in any external involvement. The register of Board members’ interests is updated at least annually and is maintained by the company secretary and associate director of corporate affairs. It is available for public inspection from the company secretary and associate director of corporate affairs. The ‘reservation of powers to the Board and delegation of powers policy’ sets out the business to be conducted by the Board, or by one of its committees. Any enquiries should be made to: company secretary and associate director of corporate affairs, Trust Headquarters, Mailpoint 18, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, SO16 6YD or telephone 023 8120 6829. Senior independent director The role of senior independent director has been established and, until 31 March 2016, was held by Peter Hollins, a non-executive director. The senior independent director role provides a channel through which foundation trust members and governors are able to express concerns, other than the normal route of the chair or chief executive. Appointments Non-executive directors are appointed via open advertisement in accordance with the ‘Appointment of a foundation trust non-executive director good practice guide’ procedure adopted by the Trust. The process is managed through the governors’ nomination committee, a sub-committee of the Council of Governors. This committee also determines the remuneration and terms and conditions of the non-executive directors. For further details on the appointment of non-executive directors please see page 45. Development of the Board The Board held monthly study sessions during 2015/16 where strategic issues, along with emerging issues, were discussed. Meetings of the Board The Board meets once a month in public. Additional private meetings with only the board, and associated employees of the Trust making presentations to the board in attendance, are held as required. Other committees of the Board include: appointment and remuneration committee; audit and assurance committee, strategy and finance committee; quality and performance committee and charitable funds committee. Generally the other committees of the board meet monthly with the exception of the audit and assurance committee, which meets five times a year and the appointments and remuneration committee which meets every other month. The frequency of the meetings is set out in each committee’s terms of reference. These terms of reference are reviewed at least annually. 20 The performance of individual Board members is reviewed as set out on page 44 of this report. Engagement with Council of Governors The Trust Board engages with the Council of Governors through the chair and senior independent director. Non-executive and executive directors engage with sub-groups of the council where these are related to their portfolios. Board members meet regularly with governors and have an open invitation to attend formal Council of Governor meetings. The people Non-executive directors John Trewby, chair to 31 March 2016 John joined the Trust on 1 April 2008, bringing with him a wealth of leadership experience after a distinguished career in the Navy where he rose to the rank of rear admiral and became the first chief executive of the Naval Bases and Supply Agency. After 36 years in the Navy, John joined the defence company British Aerospace (latterly BAE Systems) where he was their chief naval advisor for eight years. He is an associate of Group4Securicor and chair of Exelis Defence Ltd. He is a fellow of the Royal Academy of Engineering; sitting on its proactive membership committee and in 2009 chaired a study into “ICT for the UK’s Future”. He is currently chairing a study on wind turbines. He is a council member of the University of Southampton. Professor Iain Cameron Iain Cameron is a professor of obstetrics and gynaecology and dean of the Faculty of Medicine at the University of Southampton. After graduating in medicine at the University of Edinburgh, he underwent postgraduate clinical and research training in Edinburgh, Melbourne and Cambridge. He held the regius chair of obstetrics and gynaecology at the University of Glasgow from 1993 and moved to Southampton in 1999. His main clinical and research interests are reproductive endocrinology and investigation of the impact of the maternal environment on early pregnancy. Iain is chair of the Medical Schools Council; a member of the UK Clinical Research Collaboration board; the National Institute for Health Research advisory board; the Health Education England medical advisory group; and the Wessex Academic Health Science Network delivery board. Peter Hollins Peter Hollins graduated in chemistry from Hertford College, Oxford. Joining Imperial Chemical Industries in 1973, he undertook a series of increasingly senior roles in marketing and then general management. Following three years in the Netherlands as general manager of ICI Resins BV, he was appointed in 1992 as chief operating officer of EVC in Brussels – a joint venture between ICI and Enichem of Italy. He played a key role in the flotation of the company in 1994, returning in 1998 to the UK as chief executive officer of British Energy where he remained until 2001. From 2001, he held various chairmanships and non-executive directorships. In 2003, he decided to return to an executive role as chief executive of the British Heart Foundation in which post he remained until retirement in March 2013. Lynne Lockyer Lynne’s background is in human resource management and strategic management. She became a nonexecutive director for Southampton and South West Hampshire in 1996 and the vice chair in 2000. She was chair of Eastleigh and Test Valley South PCT from its inception in 2002 until its disestablishment in 2006. She has taken many roles in the local health economy including being a member of Hampshire’s Local Area Agreement Board and nationally was a member of the NHS Confederation Council and the National NHS Leaders Steering Group. She was until recently a course director at the University of Portsmouth and is now an organisation development consultant. She is a trustee of the Brendoncare Foundation. 21 Simon Porter Simon was born and educated in Southampton and then Oxford, graduating with a degree in modern languages (Italian and French). He is a qualified chartered accountant, having spent most of his career with the London office of Ernst & Young, where he specialised first in audit, then in transactions and finally management. He was a partner with Ernst & Young from 1994 to 2010. He joined the Trust Board on 1 January 2011 as a designate non-executive director and became non-executive director and co-chair of the audit and assurance committee from 1 June 2011. He has chaired the quality and performance committee since it was established in January 2014. He also holds non-executive board positions in the social housing sector. Dr David Price David is a former chief executive of a FTSE-250 company with broad experience within the electronics, chemical, aerospace, defence, marine, and nuclear industries. He has a successful track record of developing highly complex companies in international markets. He is currently non-executive chairman of Symetrica Ltd, Telesoft Technologies Ltd, RTL Materials Ltd and Optitune Plc. He is treasurer of the University of Southampton and a member of the advisory board of Silverstream Technologies BV. David is a chartered engineer and chartered scientist. He has a degree in electronic engineering, a PhD from University College London and, in 2001, he was awarded an honorary doctorate by Cranfield University for his services to science and engineering. David was made a Commander of the Order of the British Empire (CBE) for his services to industry. Dr Mike Sadler Mike joined us as a clinical non-executive director in September 2014, from a similar position at an NHS Foundation Trust providing mental health, learning disability and community services. He works for the CQC as a specialist adviser in primary care and works as an advisor and consultant on health and social care services. Mike was a GP principal in Hampshire before moving into public health medicine. Having achieved an MSc with distinction at the London School of Hygiene and Tropical Medicine, he joined Portsmouth and South East Hampshire Health Authority, holding the joint posts of deputy director of public health and medical adviser. He has since held a series of senior clinical leadership roles in national organisations in both the public and private sector, including as a chief operating officer at NHS Direct and Serco’s health division. His last full time role, up until July 2013 when he commenced his portfolio career, was as director of health and social care at West Sussex County Council. Jenni Douglas Todd – appointed 1 April 2016 Jenni is a former chief executive of Hampshire Police Authority and the office of the Hampshire police and crime commissioner. After beginning her career in the probation service, she was head hunted into the civil service, at the Home Office, where she spent four years before being becoming director of policy and research for the Independent Police Complaints Commission. In the latter role she was responsible for establishing governance of the new police complaints system. She then spent two-and-a-half years as a resident twinning adviser for the UK, based in Turkey to help set-up a law enforcement complaints system before taking up the role of chief executive of the county’s Police Authority. During her three years in the post, she supported the authority in developing effective governance processes to increase accountability and transparency. She also helped the organisation deliver cost-savings whilst still improving performance and developing closer working relations with neighbouring forces. In 2012, she became chief executive and monitoring officer for the Hampshire police and crime commissioner, where she led the development of the office’s vision, mission, values and organisational strategy. She took on the role of investigating committee chair for the general dental council in 2014 and, in April that year, founded the Diversa Consultancy, which supports organisations with changes in business, culture and behaviour. She is also a member of the Judicial Conduct Investigating Office, a public appointment. 22 Executive directors Fiona Dalton, chief executive Fiona was appointed as chief executive in 2013. Prior to re-joining the Trust she held the combined position of deputy chief executive and chief operating officer at Great Ormond Street Hospital for Children. Fiona joined the NHS management training scheme after graduating from Oxford University with a degree in human sciences and began her career in hospital management at Oxford Radcliffe Hospitals NHS Trust in 1996. She then spent four years at UHS as director of strategy and business development before moving to Great Ormond Street Hospital. Gail Byrne, director of nursing and organisational development Gail joined the Trust in 2010 as deputy director of nursing and head of patient safety. Prior to this, she has worked at the Strategic Health Authority as head of patient safety, and director of clinical services at Portsmouth Hospital. Gail has also worked in Brisbane, Australia as a hospital Macmillan nurse, and as general manager of a special purpose vehicle company for the private finance initiative at South Manchester Hospitals. Jane Hayward, director of transformation and improvement Jane joined the Trust in 2000 as a clinical services manager for the cardiothoracic directorate after spending two years in Hertfordshire as director of performance and 11 years at Barts and the London Hospitals in various roles including planning, finance and commissioning. Jane has led on human resources, information management and technology, improvement and modernisation and has been chief operating officer. Jane joined the Trust Board in February 2008 and became director of transformation and improvement in January 2014. Dr Derek Sandeman, medical director Dr Derek Sandeman was appointed to the Trust as a consultant physician in 1993 and went on to develop a regional endocrine service. Throughout his career he has had extensive clinical leadership experience, most recently serving eight years as clinical director. Derek’s leadership roles have also included programme director for postgraduate education and the Wessex Endocrine Royal College representative. He has a strong history of wider system engagement, working collaboratively with partners to improve systems resilience and pathways. Dr Caroline Marshall, chief operating officer Caroline joined the Trust in 1997 as a consultant hepatobiliary and neuroanaesthetist. She has held the posts of college tutor for the Royal College of Anaesthetists and UHS mentoring and coaching lead. In 2008, she became clinical service director for critical care before holding the position of divisional clinical director between 2010 and 2013. Caroline served as interim chief operating officer before being appointed in December 2014. David French, chief financial officer David joined the Trust in February 2016 and leads on finance, estates and commercial development. He read Economics and Social Policy at the University of London before joining ICI plc, where he qualified as a chartered management accountant. David has extensive healthcare experience from the pharmaceutical industry, mostly Eli Lilly and Company where he held many commercial and financial roles in the UK and overseas. He joined the NHS in 2010 as chief financial officer of Hampshire Hospitals NHS Foundation Trust. He also serves as a non-executive director for Sentinel Housing Association, a Hampshire-based social housing provider. Board effectiveness On the basis of the expertise and experience described above, the Trust is confident that the necessary range of knowledge and skills exists within the Board of Directors and that its balance, completeness and appropriateness to the requirements of the NHS Foundation Trust constitutes a high performing and effective Board. The chairman has held no other significant commitments during 2015/16. A register of interests of Board members is outlined within this report and is also available from the associate director 23 of corporate affairs. The effectiveness of the Board of Directors meetings is reviewed at the end of each meeting. Effectiveness of Board sub-committees are monitored through monthly board reports and annual evaluation/review of the terms of reference and work programmes. Schedule of Decisions Reserved to the Board The NHS Foundation Trust Code of Governance requires that there should be a formal schedule of matters specifically reserved for decision by the Board. The Scheme of Delegation shows the ‘top level’ of delegation within the Trust. The Scheme should be read in conjunction with Trust’s Standing Financial Instructions and Standing Orders. A copy of the Schedule of Matters Reserved for the Board can be obtained from the associate director of corporate affairs. Attendance at board meetings in 2015/16 Board Apr member 28 John Trewby chair 3 Peter Hollins SID & 3 deputy chair Iain Cameron NED 5 Lena Samuels NED 3 Simon Porter NED 3 Lynne Lockyer NED 3 David Price NED 3 Mike Sadler NED 3 Fiona Dalton CEO 3 Alastair Matthews finance 3 director and deputy CEO (until 1/11/15) Paul Goddard acting director of finance (from 24/10/15 until 2/2/16) David French chief financial officer (from 3/2/16) Michael Marsh medical 3 director (until 31/5/15) Derek Sandeman medical director (from 8/10/15 previously interim from 1/6/15) Judy Gillow director of 3 nursing and organisational development (until 30/9/15) Gail Byrne director of nursing and organisational development (from 1/10/15) Caroline Marshall chief 3 operating officer Jane Hayward director 3 of transformation and improvement Mike Murphy director 5 of strategy and business development May 26 May Jun Jul Extra 28 30 28 CS only 3 3 3 3 3 3 3 3 Sept Oct Nov Dec 18 Jan 29 29 24 CS only 28 3 3 3 3 3 3 3 3 3 3 3 telecon 3 3 3 3 3 5 3 3 5 3 3 5 3 3 5 5 5 3 telecon 3 3 3 3 3 3 3 3 5 3 3 3 3 3 3 3 3 3 telecon 3 3 3 3 3 3 3 3 3 telecon 3 3 3 3 3 3 3 5 3 3 3 3 3 3 3 3 3 3 3 3 3 3 5 (CS only) n/a 3 3 3 3 n/a n/a 5 5 n/a 5 5 3 3 3 3 3 n/a 3 3 3 3 3 n/a 3 3 3 3 n/a 5 3 3 3 5 3 5 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 5 Feb Mar 23 31 3 3 3 3 3 3 5 n/a 3 5 3 3 3 5 3 3 3 3 n/a 3 3 3 3 3 3 3 3 3 5 n/a 24 Audit and assurance committee attendance 2015/16 Board member Simon Porter NED and co-chair Iain Cameron NED and co-chair Peter Hollins NED senior independent director/ deputy chair Lena Samuels NED Lynne Lockyer NED David Price NED Mike Sadler NED Alastair Matthews finance director and deputy CEO (until 1/11/15) Paul Goddard acting director of finance (from 24/10/15 until 2/2/16) David French chief financial officer (from 3/2/16) Michael Marsh medical director (until 31/5/15) Derek Sandeman medical director (from 8/10/15 previously interim from 1/6/15) Judy Gillow director of nursing and organisational development (until 30/9/15) Gail Byrne director of nursing and organisational development (from 1/10/15) May 18 3 3 3 3 3 3 3 3 3 n/a 5 July 20 3 3 3 3 3 3 3 5 n/a 5 3 n/a Oct 19 3 3 3 3 5 3 3 3 n/a 3 3 Jan 18 3 3 3 Mar 21 3 3 3 3 n/a 3 3 3 3 5 3 n/a 3 n/a 3 n/a 3 3 n/a 3 3 Audit and assurance committee Introduction The audit and assurance committee is a non-executive committee of the Trust Board with delegated authority to review the estab
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Annual-reports-and-quality-accounts/annual-report-15-16.pdf

Annual-report-2017-18

Description: ANNUAL REPORT AND ACCOUNTS 2017/18 incorporating the quality account 2017/18 Presented to Parliament pursuant to Schedule 7, paragraph 25 (4) (a) of the National Health Service Act 2006 University Hospital Southampton NHS Foundation Trust Annual report and accounts 2017/18 incorporating the quality account 2017/18 Presented to Parliament pursuant to Schedule 7, paragraph 25 (4) (a) of the National Health Service Act 2006 3 ©2018 University Hospital Southampton NHS Foundation Trust 4 TABLE OF CONTENTS Overview and performance report Statement from the chairman and chief executive 7 Statement of purpose and activities 8 History of UHS 8 Structure of executive team 9 Structure of our services 10 Our vision and values 11 Priorities, key issues and risks 12 Going concern disclosure 15 Performance report 15 Regulatory body ratings 22 Environmental matters 23 Social, community and human rights issues 24 Accountability report Directors’ report – the Trust Board 26 Well-led framework 32 Audit and risk committee 32 Disclosures 35 Council of Governors 43 Annual remuneration statement 52 Remuneration and appointments committee 55 Governors’ nomination committee 57 Staffing report 61 Responding to the staff annual attitude survey 66 Statement of chief executive’s responsibilities as the accounting officer 71 Annual governance statement 72 Review of economy, efficiency and effectiveness of the use of resources 79 Equality, diversity and inclusion 83 Environmental sustainability and climate change 85 Southampton Hospital Charity 89 Developments in informatics 90 Leading research into better care 90 Investing for the future 91 Quality account and report Chief executive’s welcome 139 Our approach to quality assurance 141 Our commitment to safety 142 Our commitment to staff 143 Our commitment to education and training 145 Our commitment to technology to support quality 146 Our commitment to the Care Quality Commission 147 Review of quality performance 149 Progress against 2017/18 priorities 157 Clinical research 149 Review of services 150 CQUIN payment framework 150 Data quality 151 Clinical audits and confidential enquiries 152 Seven day hospital services 153 Learning from deaths 154 Priorities for improvement 2018/19 175 Conclusion 191 Responses to our quality account 192 Statement of directors’ responsibilities 198 Independent auditor’s report 199 Appendix Appendix one Quality improvement framework 2018/19 203 Appendix two Quality performance data 204 Appendix three CQUIN data 211 Appendix four Clinical audit and confidential enquiries data 214 Appendix five Registration with the Care Quality Commission 216 Appendix six Glossary of acronyms 217 Annual accounts Statement from the chief financial officer 93 Foreward to the accounts 94 Independent auditor’s report 95 Financial statements 101 5 OVERVIEW AND PERFORMANCE REPORT OVERVIEW AND PERFORMANCE REPORT A word from the chairman and chief executive Staff at UHS achieved some amazing things in 2017/18, a year in which the Trust faced the huge challenge of continuing to deal with rapidly rising demand for our services at a time when, like many hospitals, we were already under great pressure. Perhaps the most obvious achievement was that the Care Quality Commission (CQC) rated UHS as good for the quality of care which it provides overall and outstanding for leadership. It is no coincidence that the results from our latest NHS staff survey were so positive. We were particularly pleased that our response rate had increased and that UHS staff rated us the fourth best nationally for staff recommending the hospital as a place to work or receive care. We are also the seventh best nationally for staff engagement and results show that our staff feel able to contribute fully towards improvements. However, it’s truly in times of adversity, such as that we experienced over the winter period, that you see teamwork and commitment shine through. On several occasions we supported our neighbouring hospitals by providing care to their patients. We were also immensely proud of the way our staff pulled together during the days of thick snow with many staying on site overnight to ensure we had enough staff to care for our patients. Others stayed to look after stranded patients who were unable to get home. Staff with 4x4 vehicles collected colleagues for work and drove patients home. It was a monumental and incredibly uplifting effort from all. Our staff have indeed continued to strive tirelessly to provide both the quality of care and the speed of access to treatment to which we aspire. We are confident that we have done the former but the rapid increase in patient numbers has at times made it difficult to achieve the latter. We are determined to improve our performance to achieve the standards our patients expect. We are encouraged by the terrific results we achieve in the NHS Friends and Family test, with patients overwhelmingly recommending UHS as a place to have their hospital care. As the result of achieving our financial target for 2016/17 we became eligible for additional national cash incentive payments, which meant that in 2017/18 we were able to commit to the biggest capital investment programme the Trust has ever seen. As part of this programme we were able to address some of the areas of our estate that were highlighted as requiring improvement in a previous CQC report. We are delighted to say that we have again delivered our financial target for 2017/18 and will as a result be able to sustain a high rate of investment in upgrading our hospitals. We have also recently been able to start work on a £5m project to build a new Children’s Emergency Department as the result of generous support from the public for Southampton Hospital Charity and our partnership with the Murray Parish Trust without which the project would have been impossible. It will transform the environment in which our young patients are treated. Sadly at the end of the year we waved goodbye to Fiona Dalton, our chief executive for the last four years, who took the opportunity of a lifetime to live and work in Vancouver where she will lead a major Canadian healthcare group. Fiona was a remarkable chief executive, both immensely liked and admired throughout UHS and she left with the goodwill and best wishes of everyone. Peter Hollins David French Chairman Interim chief executive officer 7 OVERVIEW AND PERFORMANCE REPORT Overview of the Trust Statement of purpose and activities UHS is a large teaching hospital located on the south coast of England. We have a tripartite mission to provide clinical care, educate current and future healthcare professionals, and undertake research to improve healthcare for the future. Our clinical care encompasses local acute and elective care for 680,000 people who live in Southampton, the New Forest, Eastleigh and Test Valley. We also provide care for the residents of the Isle of Wight for many services. As the major university hospital on the south coast, UHS provides the full range of tertiary medical and surgical specialities (with the exception of transplantation, renal services and burns) to over 3.7 million people in central southern England and the Channel Islands. UHS is a centre of excellence for training the doctors, nurses and other healthcare professionals of the future. We work with the University of Southampton and Solent University to educate and develop staff at all levels, including a large apprenticeship programme, undergraduate and post-graduate education. Our role in research, developed in active partnership with the University of Southampton, is to contribute to the development of treatments for tomorrow’s patients. This work distinguishes us as a hospital that works at the leading edge of healthcare developments in the NHS and internationally. In particular we have nationally-leading research into cancer, respiratory disease, nutrition, cardiovascular disease, bone and joint conditions and complex immune system problems. We are one of the largest recruiters of patients into clinical trials in the country. Over 11,454 people work at the Trust, making it one of the area’s biggest employers. We also benefit from the contributions of over 1,000 volunteers. Our turnover in 2017/18 was more than £810m. History of UHS The Trust has its origins in the 1900s when the Shirley Warren Poor Law Infirmary was built on the site of what is now Southampton General Hospital. In the early half of the century, the site began to expand, including the opening of the school of nursing and the creation of the Wessex Neurological Unit. In 1971 a new medical school was opened in Southampton and the 1970s and 1980s saw a significant building programme encompassing the current footprint of Southampton General Hospital, Princess Anne Hospital and Countess Mountbatten House. During the 1990s, services were increasingly centralised at the general hospital, with the eye hospital and cancer services being relocated from elsewhere in the city. The Wellcome Trust funded a clinical research facility at the hospital in 2001 and this unit remains the foundation for much of the Trust’s groundbreaking medical research. In the last decade, development has continued with the opening of the North Wing Cardiac Centre in 2006, the creation of a major trauma centre with on-site helipad and the opening in 2014 of Ronald McDonald House for the relatives of sick children. Organisationally, Southampton University Hospitals Trust was formed in 1993, creating a single management board for acute services in Southampton. Eighteen years later, University Hospital Southampton NHS Foundation Trust (UHS) was formed (1 October 2011) when Southampton University Hospitals NHS Trust was licensed as a foundation trust by the then regulator, Monitor (now known as NHS Improvement (NHSI)). 8 OVERVIEW AND PERFORMANCE REPORT The way we’re structured Structure of the executive team Associate director of corporate affairs Amanda Lowe Constitution; Council of governors; legal services; insurance; risk management; policy management; freedom of information (FOI) general data protection regulations (GDPR) Chief executive (interim) David French Director of HR Steven Harris Employee relations; pay and reward; resourcing and temporary staffing; staff engagement; staff performance and appraisal; occupational health and wellbeing; childcare services Medical director Dr Derek Sandeman MD for research & development; clinical effectiveness; clinical practices and outcomes; professional regulation & standards; GP relationships Director of nursing & organisational development Gail Byrne Chief financial officer (interim) Paul Goddard Clinical governance & patient safety; education; patient experience; clinical practice & outcomes; professional regulation & standards; complaints/PALS; HR/workforce; voluntary services; fundraising Caldicott Guardian Financial management; financial strategy; investment & ROI; audit; procurement; capital programme management; estates; Commercial development Division A Surgery Cancer care Critical care & theatres Chief operating officer Caroline Marshall Major incident planning; security; communications Division B Division C Emergency medicine Women & newborn Specialist medicine/ ophthalmology Pathology Child health Support services Director of transformation & improvement Jane Hayward Division D Cardiovascular & thoracic Neurosciences Trauma & orthopaedics Cost improvement & transformation; information technology; information governance; core platform systems; informatics development; strategy; commissioning; business & capacity planning Senior Information Risk Owner (SIRO) Radiology 9 OVERVIEW AND PERFORMANCE REPORT Structure of our services Our services are split into five divisions and within each division there are care groups. Each division, with the exception of Trust headquarters, is led by a divisional management team consisting of: • divisional clinical director (DCD) • divisional director of operations (DDO) • divisional head of nursing/professions (DHN) • divisional research and development lead • divisional finance manager • divisional planning and business development (or strategy) manager • divisional education lead • division HR business partner • divisional governance manager (DGM) The diagram below outlines the five divisions and care groups/services within each. Each care group has a clinical lead, care group manager and matron/s for specific services as a minimum. Division A Surgery Cancer care Critical care Theatres Division B Emergency medicine Medicine for older people Pathology Specialist medicine and ophthalmology Genetics Division C Child health Women and newborn Support services Division D Cardiovascular and thoracic Neurosciences Trauma and orthopaedics Major trauma centre Radiology TRUST HQ Corporate affairs Communications Finance Human resources Informatics Patient support services Claims and litigation Cost improvement and transformation Estates and capital developments Research and development 10 OVERVIEW AND PERFORMANCE REPORT Our vision and values Our Forward vision outlines who we are and what we stand for, as well as describing the current challenges we face and our priorities for the future. It also provides an in-depth review of our three Trust values, which are summarised below: putting patien putting patien putting patien putting patien putting patien putting patien putting patien putting patien putting patien king together king together king together king together king together king together king together king together king together ts first ts firwsotr ts firwsotr wor ts first ts firwsotr ts firwsotr wor ts first ts firwsotr ts firwsotr wor always imparlwovaiynsg imparlwovaiynsg improving always imparlwovaiynsg imparlwovaiynsg improving always imparlwovaiynsg imparlwovaiynsg improving ts first ts first ts first wor wor wor putting patien putting patien putting patien king together king together king together always imparlwovaiynsg imparlwovaiynsg improving Patients and families will be at Our clinical teams will provide the heart of what we do and services to patients and are their experience within the crucial to our success. hospital, and their perception We have launched a leadership ofmtheeasTurruensgtop,aftwiesnuitlslcfbcnigreesptsaosti.euntrs fnigrsptatients first clsintrrikacintageltgomgyetahtnherkraianggtteoegmnetsehuernkrrintegstteoogaeumthresr are engaged in the day-to-day management and governance of the Trust. alw alw alw Our growing reputation in research and development and our approach to education and training will continue ays improtvoinagiyns icmoprropvionagrysaitmeprnoveinwg ideas, technologies and greater efficiencies in the services we provide tients first tients first tients first together together together mproving mproving mproving putti putting pa putti putting pa putti putting pa wo working wo working wo working always i always i always i 11 OVERVIEW AND PERFORMANCE REPORT Our priorities, key issues and risks Our top eight priorities 1 Promote and live our values. We will: • be clearer about the behaviours we expect from our staff • recruit, train and promote people who demonstrably share our values in everything they do 2 Improve safety, quality and productivity. We will: • Sign up to safety and deliver on our promises to patients as part of this campaign • Focus on improving outcomes by measuring and publishing clinical outcomes for all specialties • Focus on improving the whole patient experience, so that patients feel treated with compassion by all staff in every contact • Develop the concept of excellent administrative care, organising our services well so that the patient journey runs smoothly • Commit to productivity improvement across all areas • Develop innovative solutions that allow us to deliver services more efficiently while making better use of our capacity 3 Our staff and education mission. We will: • Attract the best staff by offering them a better deal and the best place to work • Continue to invest in education and training opportunities for our staff including leadership development • Ensure that our leaders and staff understand and deliver our equality and diversity agenda • Prioritise excellent communication that allows the voice of our staff to be heard and acted on • Focus on the staff of the future by developing our education and training capability for clinical and non-clinical staff • Work with our local education providers to offer excellent education opportunities and bring high calibre people into healthcare roles in our hospitals 4 Become a hospital without walls. We will: • Increase the number of patients we care for who are not inpatients within the hospital. Some of these will be cared for in another residential location or at home in partnership between ourselves and other organisations • Be clear about services where we wish to provide end-to-end integrated care, and those where we wish to work with partners to integrate care across organisations • Work with health and social care partners (public, private and third sector), where necessary using new organisational models, to ensure that patients are always cared for in the right setting • Work more closely with general practices and support innovation being led by primary care 12 OVERVIEW AND PERFORMANCE REPORT 5 Specialised services. We will: • Engage with commissioners to plan changes in service models according to national service specifications • Continue to plan and manage the ongoing drift of sub-specialist work particularly in paediatrics and complex surgical services • Maintain and develop the critical mass that is increasingly required to care for complex and specialist patients • Work with Salisbury NHS Foundation Trust, the University of Southampton and other partners to play our part in the genomic revolution, building on the Genomic Medicine Centre and seeking to become a Genomics Central Laboratory Hub for the region • Develop our clinical informatics ability to ensure that we can take advantage of new information available for the benefit of patients 6 Preventative care. We will: • Continue to expand our screening programmes as national policy and commissioning intentions develop • Take every opportunity to further support and improve the health of our staff • Ensure that our clinical translational research programme, much of which is directly relevant to health promotion, accelerates translation of research into benefit for the local population 7 Discovery. We will: • Develop a detailed plan to continue increasing the number of UHS patients who are offered access to clinical trials and maximise the impact of the research we undertake • Work with the University of Southampton to submit a strong bid for the next round of Biomedical Research Centre / Biomedical Research Unit funding opportunities • Support the University of Southampton to create an international centre for cancer immunology to accelerate the development of new immune therapies to treat cancer 8 All stages of life. We will: • Continue to expand our paediatric services in partnership with community and local acute paediatrics and develop the physical infrastructure of a modern children’s hospital as quickly as finances allow • Continue to improve transition and the care of teenagers and young adults • Develop elderly care services that are integrated across the acute and community sectors • Continue to develop our end of life care 13 OVERVIEW AND PERFORMANCE REPORT Key issues and risks 1 Failure to deliver national access targets, which impacts patient experience and patient safety. Whilst we are meeting some of the national constitutional standards in waiting times, we are not meeting them all. A number of actions have been taken in relation to improving responsiveness and working with local health and social care partners to reduce delayed transfers of care. The Trust will continue to work to reduce delayed transfers of care, as well as reviewing the efficiency of discharge processes during 2018/19. 2 Capacity and occupancy, which impacts on patient flow and the quality and timeliness of care. Operational risks have been identified across a number of services/specialties linking to issues around increasing referrals, system capacity and delayed transfers of care. We have mitigated this by implementing daily reviews to assess system capacity and escalation requirements aligning capacity plans with the wider system, developing plans to reduce length of stay with strong clinical leadership and oversight and working with local health and social care partners to reduce delayed transfers of care. 3 Staffing, both in terms of recruitment and retention. To mitigate this risk we will continue to focus on making UHS an attractive employer by: • developing band four posts and apprentices • leveraging the ‘Think UHS’ recruitment brand • continuing to recruit within Europe and further afield • working with universities to increase student nurses • enhancing medical overseas fellows posts • reviewing all junior doctor rotas in light of the new contract • using flexible and temporary staff when needed • creating different roles linked to our research agenda • reviewing training and education to enhance retention. 14 OVERVIEW AND PERFORMANCE REPORT Performance report Going concern disclosure After making enquiries, the directors have a reasonable expectation that the Trust has adequate resources to continue in operational existence for the foreseeable future. For this reason, they continue to adopt the going concern basis in preparing the accounts. Reporting structure As a large NHS university hospital foundation trust, UHS monitors performance within individual teams throughout the year with feedback processes in place to escalate issues to more senior management teams. At a corporate level we have an established executive reporting structure. Monthly Trust Board Public meeting where executive directors present high level summary to chairman and non-executive directors. For further information see page 30. Audit and risk committee Strategy and finance committee Quality committee Trust executive committee (TEC) Review performance/issues/risks in greater depth For further detail on role of these committees please refer to the annual governance statement section on page 72. Trust Board study sessions Trust Board members meet to focus on a specific issue. Performance meetings Operational management team (led by chief operating officer) and division and care group management teams focus on individual patient and service pathways to develop improvement plans. 15 OVERVIEW AND PERFORMANCE REPORT Key performance indicators (KPIs) The Trust publishes a monthly Integrated KPI Board Report on its website which provides both the Board and the public with an overview of performance within the Trust. This report is constantly evolving as new areas of monitoring are developed and new areas of national focus become apparent. For 2017/18 the format of the monthly report followed the five key Care Quality Commission (CQC) questions: • Are we safe? • Are we effective? • Are we caring? • Are we responsive? • Are we well-led? The monthly report features the following sections: • Executive digest – update on the previous month’s performance written by the director of transformation and improvement. • Trust overview – the top KPIs identified by Trust Board, RAG-rates for the previous 13 months • Safe • Effective • Caring • Activity • Emergency department (ED) • Referral to treatment (RTT/18 weeks) • Cancer waiting times • Flow • Staffing (HR) • Education and training • Research and development • Estates This report also includes summary versions of quarterly reports submitted to TEC which go into greater detail about patient experience, patient safety, clinical effectiveness and outcomes, and infection prevention. In addition, a separate Finance Board Report is submitted to Trust Board on a monthly basis. The emergency department, Activity and Flow section have several KPI’s that are relevant to the key risk of delivering the national access target. Some of the KPI’s are: • Number of attendances • Time to initial assessment • Hospital red/black alerts • Delayed transfers of care • Non-elective length of stay The Activity and Flow section have several KPI’s that are relevant to the key risk of capacity and occupancy. Some of the KPI’s are: • Length of stay • New referrals • Number of attendances • Bed occupancy • Hospital red/black alerts The Staffing (HR) section has several KPI’s that are relevant to the key risk of Staffing. Some of the KPI’s are: • Staff turnover • Nursing vacancies • Friends and Family Test – percentage of staff who recommend UHS as a place to work You can see full copies of the monthly report by visiting www.uhs.nhs.uk 16 OVERVIEW AND PERFORMANCE REPORT How we monitor performance In addition to reviewing the data submitted to the Trust Board in these papers, we have a suite of tools available to compare UHS performance to that of comparable trusts around the country. Depending on the measures being monitored, UHS has a number of peer groups to benchmark against including other local providers, major trauma centres and university hospital teaching trusts. Each NHS Trust will service a different size and type of population and will offer a slightly different range of services so it is important to understand that this benchmarking provides an initial indication of performance rather than an absolute guide to our position nationally. In 2017/18 we continue to review the National Model Hospital data as it is published from NHS Improvement. The data and ability to compare our performance has helped to highlight areas of excellent practice and areas where there is potential to improve. The Trust now has a model hospital steering group which identifies potential improvement projects from the data and reports to transformation board. Detailed analysis and explanation of the development and performance of UHS Activity, capacity and occupancy Over the past three years we have seen significant increases in all types of activity. This is linked to demographic growth, new specialist techniques and services transferring from other providers including vascular services from Portsmouth. In addition, UHS now has responsibility for surgical services at Lymington. The graph and table below demonstrate this increase in activity. UHS growth in activity – 2015/16 to 2017/18 700,000 600,000 500,000 400,000 300,000 200,000 100,000 0 Inpatient spells (inc. day cases Outpatient appointments 2015/16 2016/17 2017/18 ED attendances (type one) Referrals Inpatient spells (inc. day cases Outpatient appointments ED attendances (type one) Referrals 2015/16 146,066 562,972 95,217 191,888 2016/17 155,780 596,621 99,493 204,840 2017/18 154,224 624,083 102,547 208,872 Increase 15/16 to 17/18 5.6% 10.9% 7.7% 8.9% 17 OVERVIEW AND PERFORMANCE REPORT Hospital alert status The hospital alert status is decided by the operations centre after assessing the bed and staffing position, and is recorded twice daily at the Trust bed meetings (though the status may change at any time). Black alert is the highest level of alert and is issued when there are no empty beds available across the Trust with no expected discharges, the emergency department is full, and if actions are not taken several ambulances are likely to be delayed for long periods of time, stopping them from responding to 999 calls (this is based on a national definition of escalation). Red alert is when the majority of the hospital is under significant operational pressure and is likely to include a mismatch between supply and demand of beds and/or there are no beds available, with patients waiting more than three hours in the emergency department, and patients with a clinical decision for admission but no bed identified for them to move to. The Trust will undertake a wide range of actions in response to this, including the opening of additional overnight beds (usually within day wards), the redistribution of staff or bed capacity to support areas under most pressure, Trust-wide communication to request a focus on actions which will enable patients to be discharged or the admission avoided and the potential review of less urgent elective operations to maintain bed availability for patients with more urgent needs. In 2015/16 a black alert was recorded seven times at the twice daily bed meetings. In 2016/17 this was increased to eleven and in 2017/18 this increased again to twenty. The chart below shows red and black alerts logged during 2017/18. 50 Number of AM and PM alerts 40 30 20 10 0 Mar 17 Apr 17 May 17 Jun 17 Jul 17 Aug 17 Sep 17 Oct 17 Nov 17 Dec 17 Jan 18 Feb 18 Mar 18 Red alerts Black alerts Contributing to this change has been an increase in length of stay (LoS) for elective patients linked to a more complex case mix and an increase in day cases. The chart below shows the total bed days attributable to delayed transfers of care at UHS in 2017/18. UHS delayed transfers of care 2017/18 Percentage of bed days lost 3,400 3,200 3,000 2,800 2,600 2,400 2,200 2,000 Mar 2017 April 2017 May 2017 June 2017 July 2017 Aug 2017 Sept 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Mar 2018 18 OVERVIEW AND PERFORMANCE REPORT Referral to treatment (18 weeks) performance National target: 92% of all patients on 18 week pathway and not yet treated should have waited 18 weeks or less at the end of the month (incomplete pathways target). How did we do? UHS met the target in quarter one of 2017/18 but did not meet the target for the rest of the year. Achievement of this target in 2017/18 should be set against a rise in patient referrals, which highlights the increased demands being placed on the Trust. We have identified a reporting issue at our satellite outpatient clinics in Salisbury and are investigating the impact on referral to treatment reporting. Emergency department (ED) performance There are three types of emergency departments: Type Type Type ONE TWO THREE 3 24 hour with full resuscitation facilities 3 Consultant-led 3 Designated accommodation for patients admitted via ED 3 Single specialty emergencies (eye or dental) 3 Consultant-led 3 Designated accommodation 3 Minor injuries/walk-in centres 3 Doctor or nurse-led 3 Can be routinely accessed without appointment 3 May be co-located within an ED or sited in the community We run all three types of departments and, in August 2017 we also took over the operation of Lymington Minor Injuries Unit and opened the Urgent Care Hub at Southampton General in October 2017. All three types are subject to the national target and are therefore reflected in our figures. National target: The constitutional standard remains at 95% but a national recovery trajectory was agreed as: Patients should be treated and either admitted or discharged within four hours of arrival 85% achievement target set for April 17 90% achievement target in or before September 2017 95% achievement target by March 2018. How did we do? December 2017 was an extremely challenging month for emergency patients for the whole Hampshire and Isle of Wight area. UHS saw an increase in patients admitted to the Trust with influenza and, alongside our own bed pressures, we took ambulance diverts from other hospitals in order to maintain patient safety across Hampshire. Our Trust received formal letters of thanks from local commissioners and providers for the part we played during this difficult period. 19 OVERVIEW AND PERFORMANCE REPORT The graph below shows our performance against the four hour target over the last year. National 4 hour access target – UHS performance 100% 95% 89.4% 90% 85% 80% 87.4% 86.7% 91.4% 89.5% 93.3% 91.9% 90.5% 87.1% 83.2% 82.1% 82.5% 75% April 2017 May 2017 June 2017 July 2017 Aug 2017 Sept 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Mar 2018 Cancer waiting times There are ten separate cancer waiting times measures (below) that the Trust reports to the Department of Health on a monthly basis, each of which can then be split into tumour site specific performance groups. In 2017/18 the Trust met six of these measures. Number Measures Achieved 1 a maximum one month (31-day) wait from the date a decision to treat (DTT) is made to the first definitive 8 treatment for all cancers 2 a maximum 31-day wait for subsequent treatment where the treatment is surgery 8 3 a maximum 31-day wait for subsequent treatment where the treatment is a course of radiotherapy 3 4 a maximum 31-day wait for subsequent treatment where the treatment is an anti-cancer drug regimen 3 5 a maximum two month (62-day) wait from urgent referral for suspected cancer to the first definitive 8 treatment for all cancers 6 a maximum 62-day wait from referral from an NHS cancer screening service to the first definitive treatment 3 for cancer 7 a maximum 62-day wait for the first definitive treatment following a consultant’s decision to upgrade the 3 priority of the patient (all cancers) 8 a maximum two-week wait to see a specialist for all patients referred with suspected cancer symptoms 3 9 a maximum two-week wait to see a specialist for all patients referred for investigation of breast symptoms, 8 even if cancer is not initially suspected 10 A maximum 31-day wait (urgent GP referral to treatment) for first treatment for rarer cancers 3 The number of patients referred under the two week wait urgent suspected cancer protocol seen within two weeks of their referral, rose by 5.2% in 2017/18. The chart overleaf shows the rise in demand for UHS cancer services over the past three years. 20 OVERVIEW AND PERFORMANCE REPORT UHS growth in cancer actvity – 2015/16 to 2017/18 20,000 18,000 16,000 14,000 12,000 10,000 8,000 6,000 4,000 2,000 0 Two week waits 62 day target patients 2015/16 2016/17 2017/18 31 day target patients For staffing performance, please refer to page 61. For financial performance please see page 93. David French Interim chief executive officer 24 May 2018 21 OVERVIEW AND PERFORMANCE REPORT Regulatory body ratings Single Oversight Framework NHS Improvement’s Single Oversight Framework provides the framework for overseeing providers and identifying potential support needs. The framework looks at five themes: 1. Quality of care 2. Finance and use of resources 3. Operational performance 4. Strategic change 5. Leadership and improvement capability (well-led) Based on information from these themes, providers are segmented from one to four where ‘4’ reflects providers receiving the most support, and ‘1’ reflects providers with maximum autonomy. A foundation trust will only be in segments three or four where it has been found to be in breach or suspected breach of its licence. Segmentation During 2017/18 the Trust was confirmed as being placed within segment ‘2’. This segmentation information is the Trust’s position as at 31 March 2018. Current segmentation information for NHS trusts and foundation trusts is published on the NHS Improvement website. Finance and use of resources The finance and use of resources theme is based on the scoring of five measures from ‘1’ to ‘4’, where ‘1’ reflects the strongest performance. These scores are then weighted to give an overall score. Given that finance and use of resources is only one of the five themes feeding into the Single Oversight Framework, the segmentation of the Trust disclosed above might not be the same as the overall finance score here. Area Financial sustainability Financial sustainability Financial sustainability Overall scoring Care Quality Commission ratings: Metric Capital service cover Liquidity Income and expenditure margin Distance from financial plan Agency spend Q1 Q2 Q3 Q4 2 2 2 1 2 2 1 1 1 1 1 1 1 1 2 1 1 1 1 1 1 1 1 1 Overall rating for this trust Are services at this trust safe? Are services at this trust effective? Are services at this trust caring? Are services at this trust responsive? Are services at this trust well-led? Good Requires improvement Good Outstanding Requires improvement Outstanding 22 OVERVIEW AND PERFORMANCE REPORT The CQC inspected all key questions in four of the eight core services of surgery, critical care, end of life care and outpatient and diagnostic imaging and noted the Trust had a stable leadership team in place since their last inspection. The previous inspection in 2015 had found safety of medicine and maternity services, along with responsiveness of urgent and emergency care and children’s services ‘required improvement’. At the 2017 inspection the following observation was made: ‘At this inspection we saw significant improvement across the areas we inspected. There were improvements in surgery, critical care, end of life care and outpatients. Critical care is rated overall as ‘Outstanding’, with surgery, end of life care, and outpatients and diagnostic imaging as ‘Good’ overall. These services had been rated requires improvement in 2015. The improvements were in line with the trust’s improvement plan and had been assisted by the trust board and executive leadership team’ Professor Sir Mike Richards Chief Inspector of Hospitals Environmental matters We recognise that the Trust’s business has an impact on the environment. As a large hospital we undertake a wide range of activities and use a large amount of resources, for example: • The Trust generates approximately 3,000 tonnes of waste yearly, half of which is clinical waste. If not properly treated this huge amount of waste can cause soil, water and air pollution depending on the disposal route. • Due to the large number of visitors and deliveries we attract every day, traffic congestion is regularly experienced on and around the site, which impacts the air quality around the hospital. We are committed to environmental sustainability and consider it as part of the business culture. We acknowledge that reducing waste and minimising the consumption of scarce resources is consistent with financial sustainability. Our sustainability disclosure section on page 85 provides greater detail on the steps we are taking to reduce our activities’ impact on the environment. 23 OVERVIEW AND PERFORMANCE REPORT Social, community, anti-bribery and human rights issues We recognise our responsibilities under the European Convention on Human Rights (included in the Human Rights Act 1998 in the UK), which are relevant to health and social care. These rights include the: • right to life • right not to be subjected to torture, inhuman or degrading treatment or punishment • right to liberty • right to respect for private and family life The Trust is committed to ensuring it fully takes into account all aspects of human rights in our work. At University Hospital Southampton we value our reputation for top quality care and financial probity and conduct our business in an ethical manner. The Bribery Act 2010 was introduced to make it easier to tackle the issue of bribery which is a damaging practice. Bribery can be defined as ‘giving someone a financial or other advantage to encourage them to perform their duties improperly or reward them for having done so’. To limit our exposure to bribery we have in place an Anti-Fraud, Bribery and Corruption Policy, a Standards of Business Conduct Policy and a Freedom to Speak Up (formerly Raising Concerns) Policy. These apply to all staff and to individuals and organisations who act on behalf of UHS. We also employ a local counter fraud specialist who will investigate, as appropriate, any allegations of fraud, bribery or corruption. The success of our anti-bribery approach depends on our staff playing their part in helping to detect and eradicate bribery. Therefore, we encourage staff, service users and others associated with UHS to report any suspicions of bribery and we will rigorously investigate any allegations. In addition, we hold a register of interest for directors, staff, and governors and ask staff not to accept gifts or hospitality that will compromise them or the Trust. The Board of Directors carries out its business in an open and transparent way. We are committed to the prevention of bribery as well as to combating fraud and expect the organisations we work with to do the same. Doing business in this way enables us to reassure our patients, members and stakeholders that public funds are properly safeguarded. There are no important events since the year end affecting the foundation trust. No political donations have been made. The Trust has no overseas branches. 24 FR STAND BODY ACCOUNTABILITY REPORT Directors’ report – the Trust Board Board member Name Title Fiona Dalton Chief executive (until March 2018) David French Interim chief executive (chief financial officer until March 2018) Gail Byrne Director of nursing and organisational development Jane Hayward Director of transformation and improvement Biography Declarations Fiona was appointed as chief executive in 2013. Prior to re-joining the Trust she held the combined position of deputy chief executive and chief operating officer at Great Ormond Street Hospital for Children. Fiona joined the NHS management training scheme after graduating from Oxford University with a degree in human sciences and began her career in hospital management at Oxford Radcliffe Hospitals NHS Trust in 1996. She then spent four years at UHS as director of strategy and business development before moving to Great Ormond Street Hospital. NHS representative on Office for the Strategic Co-ordination of Health Research (OSCHR) Board; Director, Southampton Commercial Estates Development Partnership (CEDP) Project Company Limited, a whollyowned subsidiary of UHSFT. David joined the Trust in February 2016 and led on finance, procurement, estates and commercial development until March 2018, when he became interim chief executive officer. He read Economics and Social Policy at the University of London before joining ICI plc, where he qualified as a chartered management accountant. David has extensive healthcare experience from the pharmaceutical industry, mostly Eli Lilly and Company where he held many commercial and financial roles in the UK and overseas. He joined the NHS in 2010 as chief financial officer of Hampshire Hospitals NHS Foundation Trust. He also serves as a non-executive director for Vivid Housing Limited, a social housing provider across Hampshire and the Solent. Non-executive director and chair of audit and risk committee, Vivid Housing Limited; Director, UHS Estates Limited, a wholly-owned subsidiary of UHSFT; Director, Southampton Commercial Estates Development Partnership (CEDP) Project Company Limited, a wholly-owned subsidiary of UHSFT; Member of Solent Acute Alliance Gail joined the Trust in 2010 as deputy director of nursing and head of patient safety. Prior to this, she has worked at the Strategic Health Authority as head of patient safety, and director of clinical services at Portsmouth Hospital. Gail has also worked in Brisbane, Australia as a hospital Macmillan nurse, and as general manager of a special purpose vehicle company for the private finance initiative at South Manchester Hospitals. Husband is a consultant surgeon in the Trust; Trustee of Naomi House Children’s Hospice (until 10 February Jane joined the Trust in 2000 as a clinical services manager for the cardiothoracic directorate after spending two years in Hertfordshire as director of performance and 11 years at Barts and the London Hospitals in various roles including planning, finance and commissioning. Jane has led on human resources, information management and technology, improvement and modernisation and has been chief operating officer. Jane joined the Trust Board in February 2008 and became director of transformation and improvement in January 2014. Director, UHS Estates Limited, a wholly-owned subsidiary of UHSFT; Father is mental health act manager, Southern Foundation Trust (voluntary position) (until 31 August 2017), member of assessment committee for Clinical Excellence Awards South and Public Health England (lay member) (until January 2018), a UHSFT simulated patient (voluntary position); Mother is a UHSFT simulated patient (voluntary position) Dr Derek Medical Sandeman director Dr Caroline Marshall Chief operating officer Derek was appointed to the Trust as a consultant physician in 1993 and went on to develop a regional endocrine service. Throughout his career he has had extensive clinical leadership experience, most recently serving eight years as clinical director. Derek’s leadership roles have also included programme director for postgraduate education and the Wessex Endocrine Royal College representative. He has a strong history of wider system engagement, working collaboratively with partners to improve systems resilience and pathways. Caroline joined the Trust in 1997 as a consultant hepatobiliary and neuroanaesthetist. She has held the posts of college tutor for the Royal College of Anaesthetists and UHS mentoring and coaching lead. In 2008, she became clinical service director for critical care, and then divisional clinical director for division A between 2010 and 2013. Caroline served as interim chief operating officer between January to December 2014, and was then appointed to the substantive post. Her portfolio includes the executive lead for cancer and the executive lead for major trauma. Director of UHS Pharmacy Limited, a wholly-owned subsidiary of UHSFT; Daughter-in-law employed at UHSFT as medical support to department of innovation (from January 2017 – December 2017) Daughter is in an administration role at UHS (from July 2017) 26 ACCOUNTABILITY REPORT Board member Name Title Biography Declarations Paul Goddard Interim chief financial officer (from April 2018) Paul joined the Trust in June 2007 as assistant director of finance and become the deputy director in December 2012. Paul has spent over 25 years in NHS finance having worked in many different organisations. A fellow of the Association of Chartered Certified Accountants, Paul became interim chief financial officer at UHS from April 2018. Serves as a director of the Trust’s wholly owned subsidiary company, UHS Pharmacy Limited. Sits on the Southampton Hospital Charity committee. Non-executive directors Peter Hollins Simon Porter Chair Senior independent director and deputy chair Peter graduated in chemistry from Hertford College, Oxford. Joining Imperial Chemical Industries in 1973, he undertook a series of increasingly senior roles in marketing and then general management. Following three years in the Netherlands as general manager of ICI Resins BV, he was appointed in 1992 as chief operating officer of EVC in Brussels – a joint venture between ICI and Enichem of Italy. He played a key role in the flotation of the company in 1994, returning in 1998 to the UK as chief executive officer of British Energy where he remained until 2001. From 2001, he held various chairmanships and non-executive directorships. In 2003, he decided to return to an executive role as chief executive of the British Heart Foundation in which post he remained until retirement in March 2013. He joined Southampton University Hospital Trust as a nonexecutive director in 2010, became senior independent director and deputy chairman of UHS in 2014, and was appointed chair in April 2016. Partner in the Jubilee Film Partnership; Chair of CLIC Sargent Cancer Care for Children (a company limited by guarantee); Council member of University of Southampton Simon was born and educated in Southampton and then Oxford, graduating with a degree in modern languages (Italian and French). He is a qualified chartered accountant, having spent most of his career with the London office of Ernst & Young, where he specialised first in audit, then in transactions and finally risk management. He was a partner with Ernst & Young from 1994 to 2010. He joined the Trust Board on 1 January 2011 as a designate non-executive director and became non-executive director from 1 June 2011. He is chair of the audit and risk committee and a member of the strategy and finance committee. He also holds non-executive board positions in the social housing sector. Former partner in Ernst & Young LLP; Non-executive director and chair of audit committee, Radian Group; Non-executive director and chair of audit committee, Octavia Housing Dr Mike Sadler Non-executive director Mike joined UHS as a clinical non-executive director in September 2014, from a similar position at an NHS foundation trust providing mental health, learning disability and community services. He has chaired our quality committee since June 2016. He works as an advisor and consultant on health and social care services, recently advising on health reform in the Middle East, and in Ireland. He has been chair and technical adviser to the Diabetes Professional Care Conference since 2015, and also worked for the CQC as a specialist adviser in primary care. External clinical associate for PricewaterhouseCoopers; Member of the Advisory Board for xim (from 1 May) Mike graduated from Nottingham University, and was a GP principal in Hampshire before moving into public health medicine. Having achieved an MSc with distinction at the London School of Hygiene and Tropical Medicine, he joined Portsmouth and South East Hampshire Health Authority, holding the joint posts of deputy director of public health and medical adviser. He has since held a series of senior clinical leadership roles in national organisations in both the public and private sector, including as a chief operating officer at NHS Direct and Serco’s health division. His last full time role, up until July 2013 when he commenced his portfolio career, was as director of health and social care at West Sussex County Council. 27 ACCOUNTABILITY REPORT Board member Name Title Jenni Non-executive Douglas- director Todd Biography
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Annual-reports-and-quality-accounts/annual-report-2017-181.pdf

1 to 10 of 17

Previous 1 2 Next

Browse site A to Z

Search results

Featured research: fighting lung disease

UHS register of interests June 2025

Remuneration & Appointment Committee ToR March 2026

Remuneration and Appointment Committee ToR March 2025

RLP Guidance Notes Cohort 5 Final

Remuneration and Appointment Committee ToR Feb 2023

Remuneration and Appointment Committee ToR May 2022

Annual report 2021-2022

Annual report 15-16

Annual-report-2017-18

Site policies

Contact details

Useful links