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Procedure for BIA using SFB7

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NIHR Southampton Biomedical Research Centre The NIHR Southampton Biomedical Research Centre (BRC) has a tight quality assurance system for the writing
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/Media/Southampton-Clinical-Research/Procedures/BRCProcedures/Procedure-for-BIA-using-SFB7.pdf

Procedure for MIE pinch-grip analyser

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NIHR Southampton Biomedical Research Centre The NIHR Southampton Biomedical Research Centre (BRC) has a tight quality assurance system for the writing
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/Media/Southampton-Clinical-Research/Procedures/BRCProcedures/Procedure-for-MIE-pinch-grip-analyser.pdf

Annual report 2021-2022

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2021/22 Incorporating the quality report University Hospital Southampton NHS Foundation Trust Annual Report and Accounts 2021/22 Presented to Parliament
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/Media/UHS-website-2019/Docs/About-the-Trust/Annual-reports-and-quality-accounts/Annual-report-2021-2022.pdf

UHS AR 21-22 Quality Account

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

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2022/23 Incorporating the quality account University Hospital Southampton NHS Foundation Trust Annual Report and Accounts 2022/23 Presented to Parliament pursuant to Schedule 7, paragraph 25(4)(a) of the National Health Service Act 2006 © 2023 University Hospital Southampton NHS Foundation Trust Contents Welcome from our chair and chief executive 6 Overview and performance 8 Performance report 9 Overview 10 Accountability report 33 Directors’ report 34 Remuneration report 57 Staff report 71 Annual governance statement 91 Quality account 106 Statement on quality from the chief executive 107 Priorities for improvement and statements of assurance from the board 110 Other information 188 Annual accounts 222 Statement from the chief financial officer 223 Auditor’s report 224 Foreword to the accounts 230 Statement of Comprehensive Income 231 Statement of Financial Position 232 Statement of Changes in Taxpayers’ Equity 233 Statement of Cash Flows 234 Notes to the accounts 235 5 Welcome from the Chair and Chief Executive Officer University Hospital Southampton NHS Foundation Trust (‘UHS’ or the ‘Trust’) experienced another challenging year during 2022/23. Nonetheless, the Trust and its staff have continued to deliver for patients and the wider system in which it operates. Trust highlights from 2022/23 include: • Delivering an 8% increase in activity (compared to 2019/20) under the elective recovery programme, which places us as one of the top performing trusts in England. • Being recognised in the NHS staff survey as the seventh highest trust for recommendation as a place to work nationally and the best performing trust in opportunities for career development. • Celebrating 50 years as a medical school with the University of Southampton and continuing to pioneer UK and world-first research studies. • Enhancing the reputation of our specialist care – for example our bone marrow transplant team at UHS have the best patient outcomes in Europe. However, as was the picture across the country, UHS had an extremely challenging winter with attendances at our emergency department often in excess of 400 a day. This was driven in part by high prevalence of streptococcus A (strep A) in the community along with other seasonal illnesses such as influenza and high incidences of COVID-19 at times. Moreover, the lack of availability of care home beds and other care packages in the community has resulted in challenges in discharging patients who are ready to leave hospital and therefore we have been operating at or near to capacity throughout the year. At the time of writing, there continues to be operational pressures due to industrial action by the Royal College of Nursing and British Medical Association. Throughout the disputes, we have attempted to balance the right of our staff to strike with the need to minimise the impact on the Trust’s operations and patients and ensure that safety was not compromised. Our leadership team has engaged proactively with the unions to agree, where possible, derogations (i.e. services that will continue to be staffed during strikes) to ensure that the running of our hospitals can continue and that patients remain safe. We would like to express our thanks to all staff who have gone over and above during these periods of industrial action by being willing to do different work to usual, often at anti-social times of the day. While we cannot influence national negotiations, we are focusing on what we can control within UHS. Our people strategy published last year sets out how we will grow and deploy our workforce of today and the future as part of a thriving community to deliver world-class patient care. Building on this, we have recently launched our inclusion and belonging strategy so that as a leadership team we can deliver what is required for all our workforce to feel they can belong and thrive at UHS. The Trust achieved its Cost Improvement Plan (CIP) target of £45.6m for 2022/23, the highest in our history but despite this, ended the year with a deficit of £11m. The deficit was driven by a combination of factors including a substantial increase in energy prices, higher costs of medicines and equipment and temporary staffing costs as well as changes in recent years in respect of the NHS funding infrastructure, which adversely impacted the Trust relative to others during the year. In terms of the broader context, the Hampshire and Isle of Wight Integrated Care System, in which the Trust operates, reported an overall deficit for 2022/23 driven in part by a significant increase in staffing numbers when compared to 2019/20 as well as structural factors. 6 We have continued to make progress on our estates strategy, building new theatres and carrying out improvements to existing facilities, as well as opening a new park and ride for staff at Adanac Park and progressing plans for a new innovation campus there. During 2022/23 we invested over £88m of capital expenditure to meet our ambition of increasing capacity and improving services in order to manage the increasing demand. All development is underpinned by our green plan, which sets out areas of focus for decarbonising UHS and achieving the net zero target set by the NHS. The Trust has continued to support the Hampshire and Isle of Wight Integrated Care System, which was formed on 1 July 2022 to facilitate integration and collaboration across health and social care partners in the region. In particular, UHS has worked closely with the Integrated Care Board and other providers in the development of the operating plan for 2023/24. We have also continued to work with other partners in the region, including local authorities and the University of Southampton. The 13,000 staff of UHS are our greatest asset and we would like to express our gratitude to them for continuing to go above and beyond to put patients first under very challenging circumstances. Without our staff, we would be unable to fulfil our ambition to be a world-class organisation with world-class people delivering world-class care. Jenni Douglas-Todd Chair 26 June 2023 David French Chief Executive Officer 26 June 2023 7 PERFORMANCE REPORT Performance report Introduction from the Chief Executive Officer The Trust experienced another challenging year with the need to balance the delivery of quality patient care with a significant increase in demand for the Trust’s resources and the need to do so whilst maintaining a sustainable financial position. The Trust saw the number of patients on a waiting list under the 18-week referral to treatment pathway increase to just over 55,000 patients at the end of the year. Despite this, however, the Trust was successful in reducing the number of patients waiting more than 104 weeks to nil and in reducing the number of patients waiting more than 78 weeks to 14 by the end of the year. In addition, the Trust’s performance under the elective recovery programme placed it as one of the topperforming trusts in the country. Demand for non-elective care also significantly increased during the year with the emergency department seeing more than 400 attendances per day at some points, especially during the winter months. The industrial action seen in the latter part of 2022/23 placed further pressure on the Trust and resulted in a need to cancel elective procedures and outpatients appointments. However, on balance, the Trust was able to manage these events through effective planning and the engagement and support of its staff. Although the Trust was successful in recruiting to substantive roles, especially in terms of reducing the number of Health Care Assistant vacancies, the anticipated reduction in use of bank and agency staff was not seen. This, among other factors, such as the substantial increase in energy costs and the rate of inflation, posed a significant challenge in terms of the Trust’s financial position. Despite achieving savings of £45.6m, the Trust reported a deficit of £11m for 2022/23. 9 Overview About the Trust Our services University Hospital Southampton NHS Foundation Trust is one of the largest acute teaching trusts in England with a turnover of more than £1 billion in 2022/23. It is based on the coast in southeast England and provides services to over 1.9 million people living in Southampton and south Hampshire and specialist services, including neurosciences, respiratory medicine, cancer care, cardiovascular, obstetrics and specialist children’s services, to more than 3.7 million people in central southern England and the Channel Islands. The Trust is also a designated major trauma centre, one of only two places in the south of England to offer adults and children full major trauma care provision. As a leading centre for teaching and research, the Trust has close working relationships with the University of Southampton, the Medical Research Council, National Institute for Health and Care Research (NIHR), Wellcome Trust and Cancer Research UK. The Trust is consistently one of the UK’s highest recruiting trusts of patients to clinical trials and one of the top nationally for research study volumes as ranked by the NIHR Clinical Research Network. Every year the Trust: treats around 160,000 inpatients and day patients, including about 75,000 emergency admissions sees over 650,000 people at outpatient appointments deals with around 150,000 cases in our emergency department delivers more than 100 outpatient clinics across the south of England, keeping services local for patients The Trust provides most of its services from the following locations: • Southampton General Hospital – the Trust’s largest location, where a great number of specialist services are based alongside emergency and critical care and which includes Southampton Children’s Hospital. • Princess Anne Hospital – located across the road from Southampton General Hospital and providing maternity care and specialist care for women with medical problems during pregnancy and babies who need extra care around birth across the region. • Royal South Hants Hospital – although the Trust does not operate this site near the centre of Southampton it provides a smaller number of services from this location. • New Forest Birth Centre – located at Ashurst on the edge of the New Forest and run by experienced midwives and support staff it acts as a community midwifery hub. The services provided by the Trust are commissioned and paid for by the Hampshire and Isle of Wight Integrated Care System (ICS) and, in the case of more specialised services (such as treatments for rare conditions), by NHS England. Trust services are supported by clinical income, of which 55% is paid for by NHS England and 43% by the Hampshire and Isle of Wight Integrated Care Board. These are provided under a standard NHS contract, which incorporates ongoing monitoring of the Trust and the quality of the services provided. 10 Our structure UHS gained foundation trust status on 1 October 2011. A foundation trust is a public benefit corporation providing NHS services in line with the core NHS principles: that care should be universal, comprehensive and free at the point of need. The Trust is licensed as a foundation trust to provide these services by NHS England and the healthcare services we provide are regulated by the Care Quality Commission. Since 1 July 2022, the Trust has been part of the Hampshire and Isle of Wight Integrated Care System (ICS) when this was established through the Health and Social Care Act 2022. Each ICS has two statutory elements: an integrated care partnership (ICP) and an integrated care board (ICB). The ICP is a statutory committee jointly formed between the NHS integrated care board and all uppertier local authorities that fall within the ICS area. The ICP will bring together a broad alliance of partners concerned with improving the care, health and wellbeing of the population, with membership determined locally. The ICP is responsible for producing an integrated care strategy on how to meet the health and wellbeing needs of the population in the ICS area. The ICB is a statutory NHS organisation responsible for developing a plan for meeting the health needs of the population, managing the NHS budget and arranging for the provision of health services in the ICS area. The establishment of ICBs resulted in clinical commissioning groups (CCGs) being closed down. The Trust has been a university teaching hospital since 1971. The diagram below provides an overview of the overall organisational structure of the Trust. Division A Surgery Critical Care Opthalmology Theatres and Anaesthetics Public and foundation trust members Council of Governors Board of Directors Executive Directors Division B Division C Division D Cancer Care Emergency Medicine Helicopter Emergency Medical Services Medicine and Medicine for Older People Pathology Specialist Medicine Women and Newborn Maternity Child Health Clinical Support Cardiovascular and Thoracic Neurosciences Trauma and Orthopaedics Radiology Trust Headquarters Division 11 Our values Our values describe how we do things at UHS and act as a guide to all staff working with colleagues to deliver high quality patient care and a great patient experience every day. Our values are: Patients, their families and carers are at the heart of what we do. Their experience of our services will be our measure of success. Partnership between clinicians, patients and carers is critical to achieving our vision, both within hospital teams and extending across organisational boundaries in the NHS, social care and the third sector. We will ensure we are always improving services for patients through research, education, clinical effectiveness and quality improvement. We will continue to incorporate new ideas, technologies and create greater efficiencies in the services we provide. 12 Our strategy 2021-25 The Trust’s strategy was updated during 2020/21 to take account of everything our staff had experienced during the COVID-19 pandemic and what we had learnt from this. The vision for UHS is to become an organisation of world class people delivering world class care. Our strategy is organised around five themes and for each of these it describes a number of ambitions we aim to achieve by 2025. Theme Ambitions Outstanding patient outcomes, • We will monitor clinical outcomes, safety and experience of our experience and safety patients regularly to ensure they are amongst the best in the UK By 2025 we will strengthen our and the world. national reputation for outstanding • We will reduce harm, learning from all incidents through our patient outcomes, experience and proactive patient safety culture. safety, providing high quality care • We will ensure all patients and relatives have a positive experience and treatment across an extensive of our care, as a result of the environment created by our people range of services from foetal and our facilities. medicine, through all life stages and conditions, to end-of-life care Pioneering research • We will recruit and enable people to deliver pioneering research in and innovation Southampton. We will continue to be a leading teaching hospital with a growing, reputable and innovative research and development portfolio • We will optimise access to clinical research studies for our patients. • We will enable innovation in everything we do, and ensure that ‘cutting edge’ investigations and treatments are delivered in Southampton. that attracts the best staff and efficiently delivers the best possible treatments and care for our patients. World class people • We will recruit and develop enough people with the right Supporting and nurturing our knowledge and skills to meet the needs of our patients. people through a culture that values • We will provide satisfying and fulfilling roles, growing our talent diversity and builds knowledge and through development and opportunity for progression. skills to ensure everyone reaches • We will empower our people, embracing diversity and embedding their full potential. We must provide compassion, inclusion and equity of opportunity. rewarding career paths within empowered, compassionate, and motivated teams. Integrated networks and collaboration We will deliver our services with partners through clinical networks, collaboration and integration across geographical and organisational boundaries. • We will work in partnership with key stakeholders across the Hampshire and Isle of Wight integrated care system. • We will strengthen our acute clinical networks across the region, centralising when necessary and supporting local care when appropriate. • We will foster local integration with primary and community care as well as mental health and social care services for seamless delivery across boundaries. • We will build on our successful partnership with University of Southampton (UoS), growing our reputation as a national leading university teaching hospital. 13 Theme Foundations for the future Making our enabling infrastructure (finance, digital, estate) fit for the future to support a leading university teaching hospital in the 21st century and recognising our responsibility as a major employer in the community of Southampton and our role in broader environmental sustainability. Ambitions • We will deliver best value to the taxpayer as a financially efficient and sustainable organisation. • We will support patient self-management and seamless care across organisational boundaries through our ambitious digital programme, including real time data reporting, to inform our care. • We will expand and improve our estate, increasing capacity where needed and providing modern facilities for our patients and our people. • We will strengthen our role in the community as an employer of choice, a partner in delivery of services to our population and by leading the Greener NHS agenda locally. During each year of the strategy the Trust sets out a more detailed series of objectives to achieve and progress towards the delivery of its ambitions. In 2022/23 these objectives included: Outstanding patient outcomes, experience and safety Pioneering research and innovation World class people Integrated networks and collaboration Foundations for the future • Recovery, restoration and improvement of clinical services • Introducing a robust and proactive safety culture • Empowering and developing staff to improve services for patients • Always Improving strategy • Delivering a high-quality experience of care for all • Delivery of year two of the research and innovation investment plan • Strategy and partnership working • Growing, developing and innovating our workforce • A great place to work, develop and achieve • Compassionate and inclusive workplace for all • We Work in partnership with Integrated Care System and Primary Care Networks • Integrated Networks and Collaborations • Establishing Southern Counties Pathology Network • Establishing the Wessex Imaging Network • Develop Collaborations strategy • Creating a sustainable financial infrastructure • Making our corporate infrastructure fit for the future to support a leading university teaching hospital in the 21st century • Recognising our responsibility as a major employer in the community of Southampton and our role in delivering a greener NHS Performance against these objectives will be monitored and reported to the Trust’s Board on a quarterly basis. 14 Principal risks to our strategy and objectives The Board has identified and manages the principal risks to the delivery of its strategy and objectives through its board assurance framework. The principal risks to the delivery of its strategy and objectives identified by the Trust during 2022/23 were that: • There would be a lack of capacity to appropriately respond to emergency demand, manage the increasing waiting lists for elective demand, and provide timely diagnostics, that results in avoidable harm to patients. • Due to the current challenges, the Trust fails to provide patients and their families with a high-quality experience of care and positive patient outcomes. • The Trust would not effectively plan for and implement infection prevention and control measures that reduce the number of hospital-acquired infections and limit the number of nosocomial outbreaks of infection. • The Trust is unable to meet current and planned service requirements due to unavailability of qualified staff to fulfil key roles. • The Trust fails to develop a diverse, compassionate and inclusive workforce, providing a more positive experience for all staff. • The Trust fails to create a sustainable and innovative education and development response to meet the current and future workforce needs identified in the Trust’s longer-term workforce plan. • The Trust does not implement effective models to deliver integrated and networked care, resulting in sub-optimal patient experience and outcomes, increased numbers of admissions and increases in patients’ length of stay. • The Trust is unable to deliver a financial breakeven position and support prioritised investment as identified in the Trust’s capital plan within locally available limits (capital departmental expenditure limit (CDEL)). • The Trust does not adequately maintain, improve and develop its estate to deliver its clinical services and increase capacity. • The Trust fails to introduce and implement new technology and expand the use of existing technology to transform its delivery of care through the funding and delivery of the digital strategy. • The Trust fails to prioritise green initiatives to deliver a trajectory that will reduce its direct and indirect carbon footprint by 80% by 2028-2032 (compared with a 1990 baseline) and reach net zero direct carbon emissions by 2040 and net zero indirect carbon emissions by 2045. During 2022/23, the Trust continued to experience the impact of the COVID-19 pandemic. The need to ensure a safe environment for patients through stringent infection control processes impacted the Trust’s capacity due to the need to isolate patients with COVID-19 in separate areas of the hospital. In addition, outbreaks of norovirus during the winter months placed further pressure on hospital capacity. The impact of the pandemic continued to be felt in terms of staff absence due to becoming infected with COVID-19 as well as the significant impact on staff mental health. The higher than normal (i.e. pre-COVID) levels of staff absence placed additional strain on the Trust’s operations and led to increased expenditure due to the requirement to enlist bank and/or agency staff to maintain safe staffing levels. 15 Performance overview The Trust monitors a broad range of key performance indicators within its departments, divisions, directorates and through Trust executive committees. On a monthly basis, the Board and executive committee receives a performance report containing a variety of indicators intended to provide assurance in respect of the Trust’s strategy and that the care provided is safe, caring, effective, responsive and well-led. This report also includes the Trust’s performance against the national targets set by NHS England. The performance reports include a ‘spotlight’ section, which provides more detailed analysis of a particular area. Typically, this is one of either the national targets or the Trust’s performance against the expectations set out in the NHS Constitution. The monthly performance report is also published on the Trust’s website. The Chief Executive Officer provides a regular report on performance to the Council of Governors, which includes a range of non-financial and financial performance information. Capacity The pressures of the COVID-19 pandemic led to increases in the waiting times for patients and the number of patients waiting for more than a year increased significantly. During the year, the Trust achieved its goal of no patients waiting more than 104 weeks by July 2022 and finished the year with only 14 patients waiting for more than 78 weeks. However, the length of time patients are waiting for treatment remains one of the key risks for the Trust. This situation was compounded by the sustained demand for non-elective activity, which saw attendances at the emergency department rise to over 400 patients per day during some periods of 2022/23 and was consistently higher than previously was the case. The significant increase in referrals, often requiring more complex treatment, has seen the number of patients on a waiting list under the 18-week referral to treatment pathway increase to just over 55,000 patients at the end of the year. In addition, the industrial action during the year placed further strain on the Trust’s ability to both provide urgent care and manage its elective recovery programme. Quality and compliance Furthermore, difficulties in obtaining care home beds and other care packages in the community has resulted in challenges in discharging patients who are ready to leave hospital and therefore the Trust has been operating at or near to capacity throughout the year. The Trust continued to monitor the quality of care delivered throughout 2022/23. The Trust continued its focus on infection prevention and control, which had proven successful during the COVID-19 pandemic. The Trust progressed its Always Improving strategy and successfully supported the identification and implementation of 84 quality improvement projects. In addition, the Trust continued to implement the patient safety incident response framework as well as taking other steps to drive a safety culture within the organisation. Furthermore, the Trust conducted further trials of shared decision making between clinicians and patients and is a leading site nationally for shared decision-making principles. Further information can be found in the Quality Account. 16 Partnerships The new arrangements for integrated care systems were implemented in July 2022 with the Trust becoming part of the Hampshire and Isle of Wight Integrated Care System. As such, the Trust’s senior management frequently meets with peers from across the system to consider and agree matters of wider concern across the system. In addition, the Trust worked with the Integrated Care Board in order to develop its financial and capital plans for 2023/24 and beyond. The Trust also attends the Southampton Health and Wellbeing Board at Southampton City Council and in the Hampshire and Isle of Wight Acute Provider Partnership Board. During 2022/23, the Trust continued to progress research activities and opportunities with the University of Southampton and Wessex Health Partners. Workforce In addition, work continued in the development of an elective hub at Winchester with Hampshire Hospitals NHS Foundation Trust, which will provide the Trust with additional capacity to carry out its elective programme. The Trust’s key areas of focus during 2022/23 were in respect of increasing the substantive workforce and reducing staff turnover. Although the Trust was successful in recruiting to substantive posts, the expected reduction in reliance on bank and agency staff did not materialise, which meant that the Trust was 1,068 whole-time equivalents above its plan for 2022/23. Included in this figure is the TUPE transfer of genomics staff from Salisbury. A particular area of focus was the recruitment of Health Care Assistants where the Trust was successful in reducing the number of vacancies from 27% to 18%. Whilst the Trust was successful in reducing staff turnover from 14.9% in 2021/22 to 13.5%, it remained above the 12% target. However, the Trust did experience a reduction in staff absence from 4.7% in April 2022 to 4.3% in March 2023, and initiatives to improve staff wellbeing were an area of focus during the year. Estate Innovation and technology The industrial action in late 2022 and early 2023 posed significant challenges for the Trust, including in terms of the need to engage additional temporary staff to ensure patient safety. The Trust continued to invest in and develop its estate during 2022/23 including successful completion of the Paediatric Intensive Care Unit project, which delivered single rooms and specialist accent lighting alongside delivery of a ‘twin care’ room. There were a number of other significant projects during the year, including refurbishments of wards and work on creating new theatres as well as projects to improve staff wellbeing. These were part of over £88m of capital expenditure in 2022/23 that also included equipment, digital and the backlog maintenance programme. The Trust continued to promote research and development during 2022/23, including through partnerships with the University of Southampton and Wessex Health Partners. Furthermore, the Trust continued to examine ways to make use of technology to improve its service delivery. In particular, the Trust has promoted the use of MyMedicalRecord, which gives patients the ability to co-manage their healthcare online and through an app. 17 Sustainable financial model The Trust did not achieve breakeven status at the end of 2022/23 and reported a deficit of £11.037m at year-end. This was due to a number of factors, including the Trust’s underlying deficit as well as the increase in energy prices. The Trust was more exposed than most to fluctuations in the wholesale price of gas due to its reliance on a gas-powered energy supply. In addition, the Trust’s 8% uplift in elective activity when compared to 2019/20 was not fullyfunded, which placed further pressure on the Trust’s existing financial resources, which had been used to ensure a breakeven position in 2021/22. The continued use of bank and agency staff as well as the costs of industrial action in late 2022 and early 2023 further eroded the Trust’s financial position. Notwithstanding the above, the Trust did succeed in obtaining a number of sources of nonrecurrent funding during the year, including a successful bid for £29.4m of funding through the Public Sector De-Carbonisation Fund, which will be used to fund green initiatives as part of the Trust’s capital programme. The financial outlook across the NHS continues to appear very challenging during 2023/24 and the Hampshire and Isle of Wight Integrated Care System is forecasting one of the highest deficits in England. 18 Performance analysis COVID-19 Impacts Although the pandemic has ended and serious cases of COVID-19 have reduced significantly, the Trust continued to be impacted by COVID-19 during 2022/23. Heightened infection prevention control measures in respect of patients with COVID-19 placed additional stress on the Trust’s capacity due to the need to isolate those patients and there was a consequential reduction in the Trust’s ability to make most efficient use of its available spaces. Furthermore, the ongoing impact on the Trust’s staff has led to higher staff absence than was the case prior to the pandemic, particularly due anxiety, infectious diseases and colds and flu. • The Trust experienced an average number of 98.7 patients per day who tested positive for COVID-19. During the winter months, this number increased substantially to nearly 200. • During the year, an average of 3.6 intensive care/high-dependency beds per day were occupied by COVID-19 patients. However, at times this increased to as much as ten. • Although staff sickness rates remained higher than pre-pandemic, the Trust saw a decrease in the absence rate from 4.7% at the beginning of 2022/23 to 4.3% by the end of the period. COVID-19 Cases UHS average number of confirmed COVID-19 patients in bed (08:00 census) 250 200 150 100 50 0 4/1/20225/1/2022 6/1/20227/1/2022 8/1/2022 9/1/202210/1/202211/1/202212/1/2022 1/1/2023 2/1/20233/1/2023 Intensive care/higher care beds UHS average number of confirmed COVID-19 patients in an ICU/HDU bed (08:00 census) 12 10 8 6 4 2 0 4/1/20225/1/2022 6/1/20227/1/2022 8/1/2022 9/1/202210/1/202211/1/202212/1/2022 1/1/2023 2/1/20233/1/2023 19 Number of patients Emergency access through the emergency department The Trust continued to experience high demand from patients presenting to receive care in the emergency department throughout the year above that seen prior to the COVID-19 pandemic. In particular, during the period between January and March 2023, the Trust averaged 352 attendances per day compared to 301 during the same period in 2019/20, an increase of 17%. The Trust also saw a significant increase in attendances during December due to both seasonal illnesses, but also due to the prevalence of streptococcus A in the community with attendances sometimes over 400 per day. Furthermore, the industrial action during the latter part of 2022 and early 2023 placed further pressure on the Trust’s ability to deliver services. In addition, the difficulties in discharging patients in need of care either at home or in another setting resulted in reduced flow from the emergency department to the relevant ward(s), which placed further strain on the Trust’s performance. During the year, in order to reduce emergency department attendances, the Trust trialled using General Practitioners to triage and see more straightforward patients who would otherwise have presented to the emergency department. Although this trial did result in a slight reduction in terms of number of patients and waiting times in ambulatory majors and majors, the affordability and value for money of this scheme is under review. Number of patients presenting to the emergency department 16,000 14,000 12,000 10,000 8,000 6,000 4,000 2,000 0 Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 Mar-23 As a result of the increase in demand upon the emergency department, there continued to be a significant adverse impact on timeliness of care. The Trust failed to meet the national target of 95% of main emergency department/type 1 attendances seen within four hours, achieving 64.5% in March 2023, although this performance was above average in England. 20 % standard met Emergency access 4hr standard UHS vs NHSE average Type 1 performance 70% 0 10 60% 20 50% 30 40 40% 50 Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-2 2 Oct-22 Nov-22 Dec-22 Jan-23 Feb-2 3 Mar-23 UH S NHSE average UHS rank amongst NHSE trusts Rank Ambulance handovers are an area of focus for NHS England, with a target of all handovers having to take place within 15 minutes and none waiting more than 30 minutes. The Trust performed well in this area with an average handover time of 17 minutes, having made the conscious decision to ensure that patients did not queue in ambulances at the expense of patients being queued within emergency department majors – thus impacting the Trust’s four-hour target, but meaning that ambulances were not queued outside the hospital as was seen in other areas of the country. Elective Waiting times Demand The year saw a continuation of the trend of increasing elective referrals experienced in 2021/22 following the pandemic, and referral rates continued to be above those seen prior to the pandemic. UHS Accepted Referrals 30,000 25,000 20,000 15,000 10,000 5,000 0 Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-2 2 Oct-22 Nov-22 Dec-22 Jan-23 Feb-2 3 Mar-23 Number of accepted referrals 21 Activity The Trust experienced significant increases in terms of the number of hospital appointments, diagnostic tests and elective admissions during the year, exceeding levels in previous years. The Trust was one of the top performing trusts in terms of its elective recovery programme, achieving an 8% increase in its elective activity during the year when compared to 2019/20. However, performance in this area and in terms of outpatients appointments was negatively affected by the industrial action by nurses, junior doctors and other members of staff, which took place in late 2022 and early 2023 due to the need to cancel non-urgent procedures and appointments in favour of maintaining safe staffing levels in areas such as the emergency department. In addition, the continued presence of COVID-19 as well as other illnesses such as influenza and norovirus placed significant pressure at times on the Trust’s capacity due to the need to implement appropriate infection prevention control measures. Furthermore, difficulties in discharging patients fit to be discharged, but in need of a care package, placed additional strain on the Trust’s capacity. Elective admissions (including day case) Post-COVID-19 pandemic Elective (including day case) recovery (% of same month compared between March 2019 – February 2020) 105% 100% 95% 90% 85% 80% 75% Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 % recovery Outpatient attendances Post-COVID-19 pandemic outpatient seen recovery (% of same month compared between March 2019 – February 2020) 140% 0 90% 10 20 40% 30 Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 UH S UHS rank amongst NHSE trusts % recovery Rank 22 Diagnostics The Trust measures performance on a total of 15 frequently used diagnostic tests. In March 2023, 22% of patients were waiting more than six weeks for diagnostics compared with the national target of less than 1%. Patients waiting for a diagnostic test to be performed (sum of 15 different frequently used tests) UHS diagnostic waiting list volume 12,000 11,500 11,000 10,500 10,000 9,500 Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-2 2 Oct-22 Nov-22 Dec-22 Jan-23 Feb-2 3 Mar-23 Diagnostic waiting list volume Percentage of patients waiting over 6 weeks for a diagnostic test to be performed Diagnostic 6 week wait performance UHS vs. NHSE average 35% 30% 25% 20% 15% 10% 5% 0% Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 Mar-23 UH S NHSE average % standard met 23 Referral to Treatment The Trust continued to see an increase in the number of patients being referred for treatment during 2022/23 with just over 55,000 patients on a waiting list under the 18-week referral to treatment pathway at the end of the year. Averaged across the year, the volume of referrals exceeded the Trust’s theoretical capacity by around 3.5%. Due to this significant demand, the Trust only achieved 63.2% of patients being treated within 18 weeks of referral in March 2023 compared with the monthly target of more than 92%. However, despite this, the Trust remained in the top quartile when compared to other teaching hospitals, reflecting that this growth in demand continues to be a national challenge. During 2022/23, the national target was to ensure that there were no patients waiting over two years for treatment by July 2022, and that there were no patients waiting more than 78 weeks by the end of March 2023. Long-waiting patients were an area of particular focus for the Trust during the year with no reported two-year waits since November 2022 and only two between the period June-November due to patients choosing to delay their treatment. This was a significant improvement compared to the peak of 171 patients reported in December 2021. Similarly, the Trust made progress in reducing the number of patients waiting over 78 weeks for treatment. In February 2023, the Trust reported 84 patients in this category compared to the peak of over 900 patients in September 2021. By the end of March 2023, the Trust had managed to further reduce this number of patients to 14, with those in breach of the target all due to the complexity of the cases. UHS referral to treatment waiting list 56,000 54,000 52,000 50,000 48,000 46,000 44,000 Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 Mar-23 24 Number on waiting list % standard met Percentage of patients waiting up to 18 weeks between referral and treatment RTT 18 week performance UHS vs. NHSE average 70% 65% 60% 55% 50% Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 Mar-23 UH S NHSE average Percentage of patients waiting more than 52 weeks between referral and commencement of a treatment for their condition Number of patients Rank UHS Referral to treatment patients waiting more than 52 weeks 3,000 0 2,500 10 2,000 20 1,500 30 1,000 40 500 50 0 60 Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 Mar-23 UH S UHS rank amongst NHSE trusts % of RTT patients RTT % of patients waiting more than 52 weeks UHS vs. NHSE average 5.0% 0 4.5% 20 40 4.0% 60 3.5% 80 Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 Mar-23 UH S UHS rank amongst NHSE trusts Rank 25 % standard met Cancer Waiting Times The Trust is one of 12 regional cancer centres in the UK offering treatment for rare and complex cancers as well as cancer in children and brain cancer. The Trust has historically been in the upper quartile, relative to teaching hospital peers. Due to loss of key members of staff and industrial action, the Trust’s performance has slipped over the year with 72.5% of patients seen within two weeks in March 2023 following referral by a General Practitioner for suspected cancer (national target: > 93% per month). Cancer waiting times - 2 week wait performance UHS vs NHSE average 100% 0 80% 50 60% 100 40% 150 Apr-22May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23Mar-23 UH S NHSE average UHS rank amongst NHSE trusts Rank Referrals for January to March 2023 were at the highest for that month for the past five years and overall referral volumes in 2022/23 averaged 2,049 patients per month, 8% higher than in 2021/22 and 28% higher than in 2019/20. The national target was for 96% of patients to commence treatment within 31 days of diagnosis. However, in March 2023, the Trust only achieved 87.9%, but this figure hides considerable variation dependent on the tumour site and type of cancer with a range of 100% for haematology and children’s cancers to 71% for skin. The high rate of referrals led to a significant backlog in terms of patients waiting longer than 62 days for treatment. However, the Trust took steps to reduce this backlog by more than 50% through a dedicated recovery programme. In March 2023, the Trust treated 54.8% of patients within 62 days of referral compared to the target of more than 85%. Treatment for Cancer within 62 days of an urgent GP referral to hospital Cancer waiting times 62 day RTT performance UHS vs. NHSE average 80% 60% 40% 20% 0% Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 Mar-23 UH S NHSE average % standard met 26 First definitive treatment for cancer within 31 days of a decision to treat % standard met Cancer waiting times 31 day RTT performance UHS vs. NHSE average 95% 90% 85% 80% 75% Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 Mar-23 UH S NHSE average Quality priorities The Trust set eight quality priorities in 2022/23, which were aimed at ensuring it continued to deliver the highest quality of care. The quality priorities were shaped by a range of national and regional factors as well as local and Trust‐wide considerations. The Trust recognised the overriding issues of significant operational pressures being felt right across the health and social care system, including those associated with the previous two years of the COVID-19 pandemic. The challenge was to deliver the best quality care in the context of these operational pressures, and the Trust set its quality priorities accordingly. Out of the eight priories set, the Trust achieved five and partially achieved three. Priority One: Enhancing capability in Quality Improvement (QI) through our Always Improving strategy The transformation team has grown to over thirty team members including project support officers, project managers, benefit realisation managers. This has allowed the Trust to develop that systematic organisational approach to guide and support its staff in their QI projects. The Trust originally set a target of delivering fifty quality improvement projects but have successfully supported a total of 84 (55 local and 29 flow improvements). These are local change projects which were identified, proposed, led, and delivered by the people who do the work. To date over 1500 people have been trained in the Trust’s improvement approach, which exceeds the original target of 500. The Trust also developed a QI project register and held an Always Improving conference. Priority Two: Developing a culture of kindness and compassion to drive a safety culture The Trust only partially achieved this priority as plans to fully deliver training were affected by operational pressures. However, during the year a variety of communication platforms were used to make sure staff understood the Trust’s vision and were kept up to date with plans and progress. The Trust worked to develop and embed a ‘just culture’ allowing staff to speak up and ask, “what happened and how do we learn?” and developed ‘stop for safety’ staff huddles. Priority Three: We will improve mental health care across the Trust including support for staff delivering care The Trust only partially achieved this priority as several key quality improvement projects have not yet been delivered, and the mental health strategy not yet been finalised. However, a training needs analysis was completed and significant staff training and an education scheme were introduced in response to the findings of the analysis. Mental health champion training has been delivered to 153 staff and IT systems have been improved to help capture vital data to help shape the Trust’s service. 27 Priority Four: Recognising and responding to deterioration in patients During 2021/22 the Trust successfully introduced national Paediatric Early Warning System (nPEWS) into its Southampton Children’s Hospital and UHS is now part of the national test and trial of nPEWS which is assessing the usability of the scoring system. The Trust has also explored how nPEWS can be adapted for children with complex medical conditions requiring interventions (including non-invasive ventilation) as part of their normal care. A daily heat map of escalation times over a 24-hour period was piloted in 2022 and will be rolled out across all adult’s inpatient areas during 2023. The Trust has also performed well with its cardiac arrest audits, and training and education programmes have consistently been delivered. September 2022 saw the implementation of a 24-hour paediatric outreach service. There is a deteriorating patient group and several successful QI projects have been introduced. Priority Five: Improving how the organisation learns from deaths The Trust only partially achieved this priority as it has been unable to establish a learning from deaths steering group. The Trust has introduced a mortality governance coordinator/analyst and grown its bereavement care service. Priority Six: Shared Decision Making (SDM) The shared decision models started at UHS in 2021/22 and have continued to grow with investment in pilot roles to expand these models, which include several advanced nurse practitioner roles, models in paediatrics bringing Shared Decision Making to patients who are transitioning from paediatric to adult services, while in maternity we have introduced SDM in birth planning. When assessing delivery of SDM against NICE guidelines, UHS performs well, especially in targets related to Trust buy-in, governance and practices of pilot areas. This year the Trust has implemented training through key platforms and expanded patient involvement in the project. As a leading site nationally for SDM principles, UHS have worked with NHS England on creating materials for others to learn from. Priority Seven: Working with our local community to expose and address health inequalities During the year the Trust refocused its efforts on making sure that its involvement and participation activities support the health inequalities agenda, while also working to deliver responsive information and advice to patients, carers, and families. Priority Eight: Ensure patients are involved, supported, and appropriately communicated with on discharge During the year the Trust has focused on improved patient, carer and family involvement, and improved communication during the discharge process as well as prompting a more collaborative working between social and health care staff. Strong partnership working with external agencies has been developed to support a system approach to hospital discharge, develop digital solutions, develop the patient hub to support discharge and delivered education to UHS staff. More information can be found about how the Trust delivered and measured its quality priorities, including feedback from patients and staff and improvement aims and quality priorities for 2023/24, in the Trust’s Quality Account for 2022/23. 28 Financial performance The Trust delivered a deficit of £11 million from a revenue position of over £1.2 billion, once items deemed as “below the line” by NHS England, such as the financial position of the Southampton Hospitals Charity, were removed. The Trust was unable to deliver the planned breakeven position. Several material cost pressures were incurred, including unfunded high-cost drugs costs and energy prices. These were unable to be off set in full by a savings programme, despite delivery of £45.6m of efficiencies (2021/22: £15m). Trust operating income rose by £64m from the previous financial year, most notably funding the NHS pay award, as well as additional elective recovery funding. Income reduced from the prior year in relation to ending a nationally funded project regarding testing for COVID-19. The Trust has however been successful in increasing funding for research and development. Trust operating expenditure rose by £78m, incorporating funded inflationary costs as well as the cost pressures outlined above. The Trust has also continued its reinvestment of surplus cash into infrastructure for the Trust, with capital investmen
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Papers Trust Board - 10 March 2026

Description
Date Time Location Chair Apologies Agenda Trust Board – Open Session 10/03/2026 9:00 - 13:00 Conference Room, Heartbeat Education Centre Jenni Douglas-Todd Steve Peacock 1 Chair’s Welcome, Apologies and Declarations of Interest 9:00 Note apologies for absence, and to hear any declarations of interest relating to any item on the Agenda. 2 Patient Story The patient story provides an opportunity for the Board to reflect on the experiences of patients and staff within the Trust and understand what the Trust could do better. 3 Minutes of Previous Meeting held on 13 January 2026 9:15 Approve the minutes of the previous meeting held on 13 January 2026 4 Matters Arising and Summary of Agreed Actions To discuss any matters arising from the minutes, and to agree on the status of any actions assigned at the previous meeting. 5 QUALITY, PERFORMANCE and FINANCE Quality includes: clinical effectiveness, patient safety, and patient experience 5.1 Briefing from the Chair of the Audit and Risk Committee 9:20 Ian Howard, Chief Financial Officer, for Chair 5.2 Briefing from the Chair of the Finance, Investment & Cash Committee 9:25 David Liverseidge, Chair 5.3 Briefing from the Chair of the People and Organisational Development 9:30 Committee Jane Harwood, Chair 5.4 Briefing from the Chair of the Quality Committee 9:35 including Interim Maternity and Neonatal Safety Report Tim Peachey, Chair 5.5 Chief Executive Officer's Report 9:40 Receive and note the report Sponsor: David French, Chief Executive Officer 5.6 Performance KPI Report for Month 10 10:10 Review and discuss the report Sponsor: Andy Hyett, Chief Operating Officer 5.7 Break 10:40 5.8 Finance Report for Month 10 10:55 Review and discuss the report Sponsor: Ian Howard, Chief Financial Officer 5.9 ICB System Report for Month 10 11:05 Receive and discuss the report Sponsor: Ian Howard, Chief Financial Officer 5.10 People Report for Month 10 11:10 Review and discuss the report Sponsor: Steve Harris, Chief People Officer 5.11 Freedom to Speak Up Report 11:20 Review and discuss the report Sponsor: Natasha Watts, Acting Chief Nursing Officer Attendee: Christine Mbabazi, Equality & Inclusion Adviser/Freedom to Speak Up Guardian 5.12 11:35 Guardian of Safe Working Hours Quarterly Report and Update on 10-Point Plan Review and discuss the report and update Sponsor: Paul Grundy, Chief Medical Officer Attendee: Diana Hulbert, Guardian of Safe Working Hours and Emergency Department Consultant 6 STRATEGY and BUSINESS PLANNING 6.1 Corporate Objectives 2025-26 Quarter 3 Update 11:50 Review and feedback on the corporate objectives Sponsor: David French, Chief Executive Officer Attendee: Martin de Sousa, Director of Strategy and Partnerships 6.2 Board Assurance Framework (BAF) Update 12:00 Review and discuss the update Sponsor: Natasha Watts, Acting Chief Nursing Officer Attendee: Craig Machell, Associate Director of Corporate Affairs and Company Secretary 7 CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Feedback from the Council of Governors' (CoG) Meeting 29 January 2026 12:15 (Oral) Sponsor: Jenni Douglas-Todd, Trust Chair Page 2 7.2 Register of Seals and Chair's Actions Report 12:20 Receive and ratify the report In compliance with the Trust Standing Orders, Financial Instructions, and the Scheme of Reservation and Delegation. Sponsor: Jenni Douglas-Todd, Trust Chair 7.3 Audit and Risk Committee Terms of Reference 12:25 Review and approve the Terms of Reference Sponsor: Ian Howard, Chief Financial Officer, for Committee Chair Attendee: Craig Machell, Associate Director of Corporate Affairs and Company Secretary 7.4 Quality Committee Terms of Reference 12:30 Review and approve the Terms of Reference Sponsor: Tim Peachey, Committee Chair Attendee: Craig Machell, Associate Director of Corporate Affairs and Company Secretary 7.5 Remuneration and Appointment Committee Terms of Reference 12:35 Review and approve the Terms of Reference Sponsor: Jenni Douglas-Todd, Trust Chair Attendee: Craig Machell, Associate Director of Corporate Affairs and Company Secretary 8 Any other business 12:40 Raise any relevant or urgent matters that are not on the agenda 9 Note the date of the next meeting: 14 May 2026 10 Items circulated to the Board for reading 10.1 South Central Regional Research Delivery Network (SC RRDN) 2025-26 Q3 Performance Report Note the report Sponsor: Paul Grundy, Chief Medical Officer 11 Resolution regarding the Press, Public and Others Sponsor: Jenni Douglas-Todd, Trust Chair To agree, as permitted by the National Health Service Act 2006 (as amended), the Trust's Constitution and the Standing Orders of the Board of Directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. 12 Follow-up discussion with governors 12:45 Page 3 Agenda links to the Board Assurance Framework (BAF) 10 March 2026 – Open Session Overview of the BAF Risk 1a: Lack of capacity to appropriately respond to emergency demand, manage the increasing waiting lists for elective demand, and provide timely diagnostics, that results in avoidable harm to patients. 1b: Due to the current challenges, we fail to provide patients and their families / carers with a high-quality experience of care and positive patient outcomes. 1c: We do not effectively plan for and implement infection prevention and control measures that reduce the number of hospital-acquired infections and limit the number of nosocomial outbreaks of infection. 2a: We do not take full advantage of our position as a leading University teaching hospital with a growing, reputable, and innovative research and development portfolio, attracting the best staff and efficiently delivering the best possible treatments and care for our patients. 3a: We are unable to meet current and planned service requirements due to the unavailability of staff to fulfil key roles. 3b: We fail to develop a diverse, compassionate, and inclusive workforce, providing a more positive staff experience for all staff. 3c: We fail to create a sustainable and innovative education and development response to meet the current and future workforce needs identified in the Trust’s longer-term workforce plan. 4a: We do not implement effective models to deliver integrated and networked care, resulting in sub-optimal patient experience and outcomes, increased numbers of admissions and increases in patients’ length of stay. 5a: We are unable to deliver a financial breakeven position, resulting in: inability to move out of the NHS England Recovery Support Programme, NHS England imposing additional controls/undertakings, and a reducing cash balance impacting the Trust’s ability to invest in line with its capital plan, estates/digital strategies, and in transformation initiatives. 5b: We do not adequately maintain, improve and develop our estate to deliver our clinical services and increase capacity. 5c: Our digital technology or infrastructure fails to the extent that it impacts our ability to deliver care effectively and safely within the organisation, 5d: We fail to prioritise green initiatives to deliver a trajectory that will reduce our direct and indirect carbon footprint by 80% by 2028-2032 (compared with a 1990 baseline) and reach net zero direct carbon emissions by 2040 and net zero indirect carbon emissions by 2045. Agenda links to the BAF No Item Linked BAF risk(s) 5.6 Performance KPI Report for Month 10 5.8 Finance Report for Month 10 5.9 ICB System Report for Month 10 5.10 People Report for Month 10 5.11 Freedom to Speak Up Report 5.12 Guardian of Safe Working Hours Quarterly Report and Update on 10-Point Plan 1a, 1b, 1c 5a 5a 3a, 3b, 3c 3b 3b Appetite (Category) Minimal (Safety) Current risk rating 4x5 20 Cautious (Experience) Minimal (Safety) 4x4 16 4x4 16 Open (Technology & Innovation) 3x4 12 Open (workforce) Open (workforce) Open (workforce) 4x5 20 4x3 12 4x4 16 Cautious (Effectiveness) 3x3 9 Cautious (Finance) 5x5 25 Target risk rating 4 x 2 Apr 6 27 3 x 2 Apr 6 27 2 x 3 Apr 6 27 3 x 2 Mar 6 27 4 x 3 Mar 12 30 4 x 2 Mar 8 30 3 x 2 Mar 6 29 3 x 2 Dec 6 25 3 x 3 Apr 9 30 Cautious (Effectiveness) Open (Technology & Innovation) Open (Technology & Innovation) 4x5 20 4x4 16 2x4 8 4 x 2 Apr 8 30 3 x 2 Apr 6 27 2 x 2 Dec 4 27 Does this item facilitate movement towards or away from the intended target risk score and appetite? Towards Away Neither x x x x x x Minutes Trust Board – Open Session Date Time Location Chair 13/01/2026 9:00 – 13:00 Conference Room, Heartbeat Education Centre Jenni Douglas-Todd (JD-T) Present Jenni Douglas-Todd, Chair (JD-T) Keith Evans, Non-Executive Director (NED) (KE) David French, Chief Executive Officer (DAF) Paul Grundy, Chief Medical Officer (PG) Steve Harris, Chief People Officer (SH) Jane Harwood, NED/Senior Independent Director and Deputy Chair (JH) Ian Howard, Chief Financial Officer (IH) Andy Hyett, Chief Operating Officer (AH) David Liverseidge, NED (DL) Tim Peachey, NED (TP) Alison Tattersall, NED (AT) Natasha Watts, Acting Chief Nursing Officer (NW) In attendance Craig Machell, Associate Director of Corporate Affairs and Company Secretary (CM) James Allen, Chief Pharmacist (JA) (item 5.12) Julie Brooks, Deputy Director of Infection Prevention and Control (JB) (item 5.11) Blue Cunningham, Patient Engagement & Involvement Officer (item 2) John Mcgonigle, Emergency Planning & Resilience Manager (JMc) (item 6.1) Jenny Milner, Associate Director of Patient Experience (JM) (item 5.10) Julian Sutton, Clinical Lead, Department of Infection (JS) (item 5.11) 4 governors (observing) 5 members of staff (observing) 2 members of the public (observing) Apologies Diana Eccles, NED (DE) 1. Chair’s Welcome, Apologies and Declarations of Interest The Chair welcomed attendees to the meeting. There were no interests to declare in the business to be transacted at the meeting. It was noted that apologies had been received from Diana Eccles. The Chair provided an overview of meetings she had held and events that she had attended since the previous Board meeting. 2. Patient Story Blue Cunningham was invited to present the Patient Story on behalf of Jade […], whose nine-year-old daughter, Lucy, had had a bowel resection at the Trust. It was noted that: • Lucy was a very structured child, who relied heavily on planning and knowing outcomes as well as having sensitivities to lots of different sensory inputs. Page 1 • In their treatment of Lucy, staff paid particular attention to Lucy’s needs and adapted their behaviour and took the time to make Lucy’s stay in hospital as comfortable as possible. • This Patient Story clearly demonstrated the Trusts’ values and the time taken in the handling of Lucy by staff likely saved time and effort in the long run by not distressing the patient and then having to manage this situation. 3. Minutes of the Previous Meeting held on 11 November 2025 The draft minutes tabled to the meeting were agreed to be an accurate record of the meeting held on 11 November 2025, subject to reassigning action 1296 to James Allen. 4. Matters Arising and Summary of Agreed Actions The matters arising and actions were noted. • Action 1293: work had commenced on a broader MRI strategy. This work would be presented to the Quality Committee in due course – the action remained open. • Action 1294: this formed part of a larger piece of work, which would be addressed through the planning cycle. The action could be closed. • Action 1295: a solution had been developed, but the Trust was waiting on a third party to be able to implement the solution. The action could be closed. • Action 1296 was addressed as part of item 5.12 below. It was explained that the metric was based on day cases and national statistics and was intended to show usage levels of the most critical antibiotics. 5. QUALITY, PERFORMANCE and FINANCE 5.1 Briefing from the Chair of the Finance, Investment & Cash Committee David Liverseidge was invited to present the Committee Chair’s Reports in respect of the meetings held on 24 November and 15 December 2025, the contents of which were noted. It was further noted that: • The Trust had reported an in-month deficit of c.£5m and, at the end of November 2025, had reported a year-to-date deficit of £40m. • The committee had received an update in respect of the Trust’s theatres improvement plans, noting that there had been a 3% increase in utilisation and a 3% reduction in cancellations. • The committee had received a report on the Trust’s productivity based on the national framework and noted that further work was required to understand the metrics behind the national framework. • The committee had reviewed the Trust’s cash position and supported a proposal to request further cash support for January 2026. • The committee noted that whilst the Trust’s transformation plans were ambitious, they were nonetheless grounded in reality. • In its review of the proposed capital plans for 2026/27-2029/30, the committee noted the challenge of having to balance the Trust’s allocation of Capital Departmental Expenditure Limit (CDEL) with the cash available to the Trust. • The committee reviewed the Trust’s medium-term plan ahead of the first submission to NHS England on 17 December 2025. It was noted that the assumed reductions in patients with no criteria to reside and mental health Page 2 patients were those reasonably considered to be within the Trust’s control rather than reductions which were dependent on third parties. • The committee supported a proposal for transforming the Southern Counties Pathology network. 5.2 Briefing from the Chair of the People and Organisational Development Committee Jane Harwood was invited to present the Committee Chair’s Reports in respect of the meetings held on 21 November and 15 December 2025, the contents of which were noted. It was further noted that: • Whilst there had been reductions in the size of the substantive workforce, this had been offset by an increase in temporary staff due to a combination of demand, sickness absence, patients with no criteria to reside, and mental health patients. • The committee noted changes with respect to statutory and mandatory training, which would facilitate ‘passporting’ between NHS organisations. • The committee received an update in respect of the Trust’s Inclusion and Belonging strategy, noting that progress had been slower than anticipated due to available resource. It was further noted that the external political environment had also created additional challenges in this area. • The committee received an update regarding the Trust’s refreshed approach to violence and aggression, noting a greater willingness to take action against violent/abusive patients and members of the public. It was further noted that the communications accompanying the new approach would be key. • The committee reviewed the Trust’s performance against the ten-point plan for resident doctors, noting that the Trust was, subject to a few exceptions, in a good position. • Whilst the results of the Staff Survey were still under an embargo, early indications were that the participation rate was lower than hoped for. • The Trust’s seasonal vaccination campaign had been successful with over 50% of staff having been vaccinated against influenza. 5.3 Briefing from the Chair of the Quality Committee Tim Peachey was invited to present the Committee Chair’s Report in respect of the meeting held on 24 November 2025, the content of which was noted. It was further noted that: • The committee noted that the Trust’s Complaints service, particularly Patient Advice and Liaison Service (PALS), was fragile. There was a backlog of c.500 emails due to resource constraints. • The committee noted that despite the financial pressure the Trust was under, it had sought to maintain staff numbers to ensure patient safety. A significant proportion of the reduction in staff during the year had been from administrative staffing groups. Whilst the Trust had successfully reduced the size of the clinical administrative workforce, it had not been possible to transform how this service was delivered through technical or other means. Therefore, there was a risk of bottlenecks due to insufficient administrative staff with the high level of demand falling on a smaller number of staff. • NHS England had launched changes to maternity care reporting with additional reporting requirements with the aim of developing national standards and approaches. • The committee had reviewed the Trust’s Maternity and Neonatal Safety report for the second quarter and noted that the Trust had demonstrated compliance with the requirements for the NHS Resolution Maternity Incentive Scheme. Page 3 5.4 Chief Executive Officer’s Report David French was invited to present the Chief Executive Officer’s Report, the content of which was noted. It was further noted that: • NHS England had published latest segmentation and league tables under the NHS Oversight Framework for Quarter 2. The Trust had fallen slightly from 48 out of 134 to 51 out of 134. The Trust remained in segment 5 due to being in the Recovery Support Programme. • The number of patients waiting over 65 weeks in October 2025 had resulted in the Trust entering Tier 1 for elective performance. However, since that time, the Trust had successfully reduced the number of patients waiting over 65 weeks to c.80, with a target to reduce this number to nil by the end of March 2026. • The Employment Rights Bill received Royal Assent on 18 December 2025. The Act included a number of changes which would impact the Trust. These changes were to be reviewed in detail by the People and Organisational Development Committee. • During further strike action by resident doctors between 17 December and 22 December 2025, the Trust had met the national target of maintaining 95% of activity. Roughly one-third of resident doctors had taken part in the industrial action, which compared favourably to other trusts – some had reported a participation rate of 80-90%. • University Hospitals Sussex NHS Foundation Trust had been fined in connection with the death of a patient with severe mental health problems who had absconded from a ward at the trust and subsequently committed suicide. This case was pertinent for the Trust given the number of mental health patients currently being cared for at the Trust in the absence of a more appropriate setting. It was noted that the Trust’s policy was clear on the approach to be taken in the event of a similar situation to that faced by University Hospitals Sussex NHS FT. • On 2 January 2026, the Trust had been informed that its endoscopy service had had its accreditation renewed until 1 November 2026 following an annual review by the Royal College of Physicians’ Joint Advisory Group on Gastro- Intestinal Endoscopy. • Alison Tattersall had been appointed as the Trust’s second Nominated Trustee on the board of the Southampton Hospitals Charity. • The Trust’s department of clinical law – a service established to deal with clinical questions relating to regulatory and legal principles within the Trust – had been in existence for 16 years. 5.5 Performance KPI Report for Month 8 Andy Hyett was invited to present the ‘spotlight’ report in respect of Cancer waiting time targets, the content of which was noted. It was further noted that: • There had been an increase in referrals over recent years, but despite this increase, the Trust had maintained performance, particularly in respect of the 28-day faster diagnosis pathway. • Consideration was being given in terms of demographic groups to be targeted in view of the success of the Targeted Lung Health Check programme and its efforts to target particular sections of the population. • The main challenge in terms of improving performance was in terms of diagnostic capacity, including access to magnetic resonance imaging (MRI) and other imaging services. Improving the diagnostics services remained a key priority, including development of a longer-term strategy for imaging. It was noted that MRI and computed tomography (CT) scan capacity in the UK was lower than that in comparable nations such as those in the US and EU. Page 4 • The Trust maintained a good relationship with the Wessex Cancer Alliance, which was an effective route for obtaining additional funding for cancer care. Action Andy Hyett agreed to provide Jane Harwood with further data regarding the stage at which cancer was diagnosed by socio-economic group. Andy Hyett was invited to present the Performance KPI Report for Month 8, the content of which was noted. It was further noted that: • The Trust’s overall Referral To Treatment (RTT) waiting list for November 2025 had decreased by 0.9% and the Trust had made significant progress in reducing the number of patients waiting more than 65 weeks. • The number of patients waiting for diagnostics marginally increased, but the Trust had maintained its previous performance with c.80% of patients waiting under six weeks for the fourth month in a row. • The Trust’s performance against the four-hour emergency department target had improved by 5.8% since October 2025, achieving 60.4% in November 2025, which was above its in-year performance plan submitted at the beginning of 2025/26. The Board discussed the Performance KPI Report for Month 8. This discussion is summarised below: • In terms of the Trust’s RTT waiting list, it was forecast that there would be c.60,000 patients on this list by the end of March 2026 with performance against the 18-week target expected to be c.67%. • The Trust’s performance in respect of the number of mental health patients spending over 12 hours in accident and emergency was considered to be reflective of the need to admit mental health patients where there was no more appropriate venue available. This situation also gave rise to increased use of agency staff. A workshop had been held with Hampshire and Isle of Wight Healthcare NHS Foundation Trust (HIOWH) and an action plan had been agreed. It was noted that HIOWH was also experiencing challenges in terms of its ability to discharge patients. • The reduction in the percentage of virtual appointments as a proportion of all outpatient consultations compared to 2024/25 was being looked at. • As of 13 January 2026, there were 295 patients with no criteria to reside – equivalent to 12 wards – at Southampton General Hospital. Work was ongoing to create wards specifically for this cohort of patients. It was noted that Hampshire and Isle of Wight Integrated Care System was ranked 39 out of 42 in terms of its number of patients with no criteria to reside. 5.6 Break 5.7 Finance Report for Month 8 Ian Howard was invited to present the Finance Report for Month 8, the content of which was noted. It was further noted that: • The Trust had reported a £4.9m deficit for Month 8 (£40.8m deficit, year-to- date), which was in line with its Financial Recovery Plan. This in-month deficit had also been maintained for Month 9, with the year-to-date deficit increasing to £45.6m. • The Trust’s underlying deficit remained at c.£6m per month with continued high numbers of patients with no criteria to reside and mental health patients coupled with operational pressures. Page 5 • The Trust had carried out between £20m and £30m of unfunded work during the year and had incurred £10m-15m of costs associated with patients with no criteria to reside and mental health patients. • The Trust expected to deliver £90m of savings under its Cost Improvement Programme against its target of £110m. • The Trust had requested £8.4m of additional cash support for January 2026 and expected to require a further £3m of support in March 2026. 5.8 ICS System Report for Month 8 Ian Howard was invited to present the ICS System Report for Month 8, the content of which was noted. It was further noted that: • The Hampshire and Isle of Wight Integrated Care System had reported a year- to-date deficit of £65m, which represented a variance of £36m from plan. It was noted that the Trust was a significant contributor to this variance, but that other organisations were also now reporting variances to plan. • The Trust had achieved the best ambulance handover time performance in the system, but further work was ongoing across the system with South Central Ambulance Service (SCAS) to improve performance. 5.9 People Report for Month 8 Steve Harris was invited to present the People Report for Month 8, the content of which was noted. It was further noted that: • The overall workforce fell marginally during November 2025, with reduction in substantive staff of 52 whole-time-equivalents (WTE) being partially offset by an increase in temporary staff usage due to operational pressures and sickness absence. • The Trust remained above its 2025/26 plan by 214 WTE despite a decrease of nearly 400 WTE since 31 March 2025. In order to meet its Financial Recovery Plan, the Trust’s workforce needed to reduce by a further 137 WTE. • Sickness absence continued to increase with 4.2% being reported during November and 4.8% being reported for December 2025. • The 2025 Staff Survey had closed. It was noted that the results were expected to be challenging. • The Trust had hit its target of 58% of staff having been vaccinated against flu, which placed the Trust in the top 15 nationally and second in the South East. • There was a significant amount of work ongoing to refresh the Trust’s approach and policies in respect of violence and aggression, including policy changes, training and communications. 5.10 Learning from Deaths 2025-26 Quarter 2 Report Jenny Milner was invited to present the Learning from Deaths report for the second quarter, the content of which was noted. It was further noted that: • The Trust continued to benchmark well against other organisations. It was one of only 11 trusts nationally with a lower than anticipated mortality rate based on its summary hospital-level mortality indicator (SHMI) score. • The Medical Examiner Service had reviewed a total of 1,078 deaths, of which 36% had occurred at the Trust’s sites. • Patients with learning disabilities remained an area of concern, although progress was being made in this area. The Trust was one of only a few Page 6 organisations to hold separate meetings to discuss deaths of patients with learning disabilities. • The Trust had procured a system to support organisation-wide learning from Morbidity and Mortality outcomes. 5.11 Infection Prevention and Control 2025-26 Quarter 2 Report Julian Sutton and Julie Brooks were invited to present the Infection Prevention and Control report for the second quarter, the content of which was noted. It was further noted that: • For the period covered by the report (July-September 2025), the Trust had exceeded all measures in terms of the annual limits for incidences of bacteraemia. The Trust was in a similar position to other organisations nationally. • There had been two cases of Methicillin-resistant Staphylococcus aureus (MRSA) and 34 cases of Clostridioides difficile (C-diff) during the period. • There had been a focus on invasive device care management (such as cannulas and catheters) and on hand hygiene. • The Trust had successfully managed the Candidozyma auris outbreak, with only three new cases identified since the beginning of 2025, the last of which was identified in April 2025. 5.12 Medicines Management Annual Report 2024-25 James Allen was invited to present the Medicines Management Annual Report 2024/25, the content of which was noted. It was further noted that: • The Trust’s expenditure on medicines during 2024/25 was £215m, a 2% reduction compared to 2023/24 and was on track to spend only £207m during 2025/26. These reductions indicated that the strategy of using less expensive generic and biosimilar medicines had been effective in reducing costs. • The number of approvals for clinical trials and research activity had continued to improve. • The Trust had completed work to decommission nitrous oxide manifolds, which was expected to reduce the Trust’s nitrous oxide emissions by 600,000 litres per year, equivalent to 354 tonnes of carbon dioxide emissions. • An area of focus was the deployment of digital systems. Action Ian Howard agreed to look at the level of savings achieved in terms of medicines costs and how costs of medicines were budgeted for. 5.13 Ward Staffing Nursing Establishment Review 2025 Natasha Watts was invited to present the Ward Staffing Nursing Establishment Review 2025, the content of which was noted. It was further noted that: • The report set out the results of the ward staffing review undertaken between July and October 2025. • There was a renewed national focus on safe staffing. • Overall, the Trust’s staffing establishments remain appropriate and within recommended guidelines. Page 7 • Continued high levels of enhanced care demand, a significantly more junior workforce, managing additional surge areas, and the impact of financial controls had been highlighted as ongoing challenges. 6. CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 6.1 Annual Assurance for the NHS England Core Standards for Emergency Preparedness, Resilience and Response (EPRR) Jon Mcgonigle was invited to present the Annual Assurance for the NHS England Core Standards for Emergency Preparedness, Resilience and Response, the content of which was noted. It was further noted that: • NHS England required all trusts to complete an annual self-assessment against a number of core standards. In its assessment against 62 applicable core standards, the Trust was fully compliant with 56 and not yet fully compliant with 6 standards. • Of the areas where the Trust was not yet fully compliant, these related primarily to governance maturity, exercising and testing, workforce training consistency, and assurance evidence, rather than the absence of emergency response arrangements. • Since an initial report had been submitted to the Trust Executive Committee in November 2025, the Trust had completed development and approval of the Business Continuity Management System, completed the consultation and adoption of Protective Security and Emergency Lockdown arrangements, and had commenced consultation and system engagement for Evacuation and Shelter. • Training was scheduled to take place between February and May 2026 for on- call staff in charge. It was intended to hold a tabletop exercise during 2027. • It was noted that it had been some time since the Trust had practised a major incident response with other partners. • The Trust was on schedule to embed the ‘protect’ duty under the Terrorism (Protection of Premises) Act 2025 by March 2027. Action John Mcgonigle agreed to look at scheduling a major incident response exercise with other partners involved. 7. Any other business It was noted that the Trust had declared a critical incident on 10/11 December 2025 due to an IT system failure. It was noted that this was Keith Evans’ final formal meeting, as his second threeyear term as a non-executive director was due to expire on 31 January 2026. The Board expressed its thanks to Keith Evans for his service and support. 8. Note the date of the next meeting: 10 March 2026 Page 8 9. Resolution regarding the Press, Public and Others Decision: The Board resolved that, as permitted by the National Health Service Act 2006 (as amended), the Trust’s Constitution and the Standing Orders of the board of directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. The meeting was adjourned. Page 9 List of action items Agenda item Assigned to Deadline Status Trust Board – Open Session 11/11/2025 - 5.6 Performance KPI Report for Month 6 1293. MRI scanners and imaging Hyett, Andy 10/03/2026 Pending Explanation action item Andy Hyett agreed to work on and present at either a future Board meeting or Trust Board Study Session the Trust’s longer-term strategy with respect to MRI scanners and imaging. TB 13/01/26: work had commenced on a broader MRI strategy. This work would be presented to the Quality Committee in due course – the action remained open. Trust Board – Open Session 09/09/2025 - 8 Any other business 1286. Organ donation Machell, Craig Explanation action item Craig Machell agreed to add organ donation to the agenda of a future Trust Board Study Session. 16/04/2026 Pending Update: Item deferred to TBSS on 16/04/26. Trust Board – Open Session 15/07/2025 - 5.11 Freedom to Speak Up Report 1267. Data Mbabazi, Christine 10/03/2026 Pending Explanation action item Christine Mbabazi to include data from other mechanisms for reporting concerns in future Freedom to Speak Up reports. Page 1 of 2 Agenda item Assigned to Deadline Status Trust Board – Open Session 13/01/2026 - 5.5 Performance KPI Report for Month 8 1311. Cancer diagnosis Hyett, Andy 10/03/2026 Pending Explanation action item Andy Hyett agreed to provide Jane Harwood with further data regarding the stage at which cancer was diagnosed by socio-economic group. Trust Board – Open Session 13/01/2026 - 5.12 Medicines Management Annual Report 2024-25 1312. Medicines costs Howard, Ian 10/03/2026 Pending Explanation action item Ian Howard agreed to look at the level of savings achieved in terms of medicines costs and how costs of medicines were budgeted for. Trust Board – Open Session 13/01/2026 - 6.1 Annual Assurance for the NHS England Core Standards for Emergency Preparedness, Resilience and Response (EPRR) 1313. Major incident response exercise Mcgonigle, John Hyett, Andy 10/03/2026 Pending Explanation action item John Mcgonigle agreed to look at scheduling a major incident response exercise with other partners involved. Page 2 of 2 Agenda Item 5.1 Committee Chair’s Report to the Trust Board of Directors 10 March 2026 Committee: Audit & Risk Committee Meeting Date: 27 January 2026 Key Messages: Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) • The committee considered the accounting policies and management judgements in respect of the 2025/26 annual accounts, noting the impact of the review of the Modern Equivalent Asset valuation estimation methodology. This review was to ensure that the valuation reflects specialised assets based on a modern, functionally equivalent facility at an alternative location, rather than simply replicating the current buildings and equipment. • The committee received an update in respect of the work on the Trust’s interim accounts, noting that there had been significant improvements in terms of use and recording of manual adjustments, with an objective of further reducing the use of manual adjustments in future. • The committee noted the work undertaken to address the issues identified in the production of the 2023/24 and 2024/25 accounts. • The committee reviewed the Trust’s compliance with the Code of Governance for NHS Provider Trusts, noting that the Trust was compliant in all areas or had appropriate explanations for areas of non-compliance, of which there were only a few. • The committee received a report on compliance with the Trust’s Standards of Business Conduct Policy, noting that the level of declarations of interest had remained largely static and that further work would be required to review the Trust’s approach in this area. • The committee received updates in respect of the internal audit programme, including the reports in respect of an audit of cyber security and the Trust’s core financial systems. • An update was provided in respect of the work of the counter-fraud team. It was noted that the risk of temporary worker impersonation was a particular area of focus. In addition, the committee noted the work undertaken to review the Trust’s compliance with the Economic Crime and Corporate Transparency Act 2023. 6.2 Board Assurance Framework (BAF) Update Assurance Rating: Risk Rating: Substantial N/A • All risks had been reviewed with the relevant executive director(s). • There had been no significant changes in ratings or target dates since the BAF had been last reviewed in October 2025. However, the committee challenged how realistic some of the target dates were on the basis that many of the actions required were reliant on third parties. • The committee suggested that the rating for risk 5c should be reconsidered in view of the increasing cyber risk. • It was noted that the actions from the internal audit on the Trust’s risk management maturity were on track. Page 1 of 2 Any Other Matters: 7.4 Audit and Risk Committee Assurance Rating: Risk Rating: Terms of Reference Substantial N/A • The committee reviewed its Terms of Reference and no changes were proposed. • The committee recommended that the Board approve the revised Terms of Reference. N/A Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Limited Assurance Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. No Assurance There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Not Applicable Where assurance is not required and/or relevant. Risk Rating: Low Medium High Not Applicable Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda Item 5.2 i) Committee Chair’s Report to the Trust Board of Directors 10 March 2026 Committee: Finance, Investment and Cash Committee Meeting Date: 26 January 2026 Key Messages: Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) • The committee received the Finance Report for Month 9. The Trust had reported an in-month deficit of £4.9m and continued to report in line with the Financial Recovery Plan. The Trust had also delivered £10.3m of savings under the Cost Improvement Programme during the month. The modern equivalent assets review had been completed, which delivered £3m of benefit during the month. • The committee carried out a deep-dive into the Trust’s underlying financial position, noting that there had been £15.8m of one-off adjustments and that the underlying deficit was £61.4m year-to-date. The monthly underlying deficit continued to be c.£6m and therefore the 2025/26 exit position was assessed to be £72m. • The committee received an update on the Trust’s medium term planning submission, noting that it was expected that the Trust would submit a non-compliant plan. There remained a significant gap between the level of performance required under the framework and the available funding and an absence of proposals from Specialised Commissioning. It was noted that the assumptions regarding noncriteria to reside numbers were based on factors within the Trust’s control, rather than those dependent on third parties. • The committee received an update on financial improvement, noting that the Trust was £4m behind its CIP plan for 2025/26, expecting to deliver £88m of savings by year end compared to the £110m target. The Trust was targeting £50m of CIP savings for 2026/27. Based on national data, the Trust had the tenth smallest opportunity for productivity savings. • The committee considered the Trust’s cash position as at 31 December 2025 and the forecast cash position for the remainder of the financial year. The Trust expected to require a further £2.9m of cash support in March 2026, which the committee supported. • The committee received an update in respect of the Trust’s outsourced cleaning and catering services contract. N/A Any Other N/A Matters: Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Page 1 of 2 Reasonable Assurance Limited Assurance No Assurance Not Applicable There is a series of controls in place, however there are potential risks that may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Where assurance is not required and/or relevant. Risk Rating: Low Medium High Not Applicable Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda Item 5.2 ii) Committee Chair’s Report to the Trust Board of Directors 10 March 2026 Committee: Finance, Investment and Cash Committee Meeting Date: 23 February 2026 Key Messages: • • • • • • • • • The committee received the Finance Report for Month 10 (see below). The committee received an update in respect of the impact of the fire at Southampton General Hospital on 1 February 2026, including in respect of the actions being taken to restore the lost services and the Trust’s claims under the NHS Resolution Property Expenses Scheme and under its commercial insurance policy. The committee received an update following the submission of the Trust’s medium term plan on 12 February 2026, noting that the Trust’s current proposed deficit made it an outlier. There remained a significant gap between the level of funding available from commissioners and the performance required under the framework. The committee enquired as to the possible route to resolve and supported the view that pricing of activity needed to be set at a level which did not create an increasing deficit as it currently does in critical care areas. Following the external review recommendations, the committee look forward to a deeper dive into the drivers of the increases in the Trust’s cost base over the past 5-6 years as this has increased at a greater rate than activity levels. This is planned for the March 2026 meeting. The committee received an update in respect of the Always Improving programme, noting that the fire had prompted something of a re-think in terms of organisational and system fundamentals. It was noted that there had been changes in the Trust’s risk appetite in terms of management of patients having no criteria to reside and outpatient appointments. Sustaining the improvements in these areas was considered to be a key priority. The committee received a report on the roll out of the MIYA system in the Trust’s emergency department, which went live on 8 October 2025. It was noted that whilst there had been some initial impact on performance during the first weeks, this had been expected, and the issues appeared to have been largely resolved. The system had delivered improvements in clinical management and in terms of data analytics. The committee noted that the Trust had been awarded £39m in capital funding for 2025/26. It was noted that this was a significant amount of funding to be used during the final months of 2025/26 and that work was ongoing to secure this funding through placing of orders and other activity. The committee received an update in respect of the Trust’s proposed tender for car parking services. The committee supported the proposals to obtain mobile endoscopy units to address the loss of the Trust’s endoscopy service in the fire on 1 February 2026. The committee noted proposals in respect of changes to NHS Property Services. Page 1 of 3 Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) Any Other Matters: 5.8 Finance Report for Month 10 Assurance Rating: Risk Rating: Substantial High • The Trust had submitted a revised forecast to NHS England of a deficit of £49.9m following a request for an ‘art of the possible’ reforecast. The Trust had since received additional funding, which reduced the 2025/26 forecast deficit to c.£45m. • The Trust had reported a year-to-date deficit of £44.8m, with the underlying monthly deficit remaining between £5.5-6m. The Trust expected additional one-offs during the final months, but there was significant risk associated with this. • The Trust was forecasting CIP delivery of £94m for 2025/26, with £78m achieved year-to-date. • Whilst there had been some increase in workforce numbers in December 2025 and January 2026, it was considered normal for this to occur during this period, however this was creating a deviation from the planned workforce numbers. This was explained as the result of the decision taken to address 65- and 52-week waits which had therefore impacted staff numbers. The resulting increased income from additional work had yet to register in the Trust's revenue numbers but was expected in February and March.. 6.2 Board Assurance Framework (BAF) Update Assurance Rating: Risk Rating: N/A • Risk 5a remained the Trust’s highest-rated risk at 25 and the target date for reduction had been extended by six months due to continued uncertainty around the funding available during 2026/27 and the impact of the fire on 1 February 2026. • Risk 5b had been assessed following the fire, but it was considered that whilst there had been significant disruption, the event and subsequent activities had been well-managed and demonstrated the effectiveness of the Trust’s evacuation and business continuity plans. Accordingly, no changes were proposed to the rating. • There had been an increase in the rating of risk 5c, largely due to risks surrounding the age of the Trust’s digital infrastructure and uncertainty regarding the OneEPR programme. The committee reviewed the Trust’s cash position and forecast, and the committee supported the additional request to be submitted in February 2026 for cash support up to a maximum of £10m to be received in April 2026. The trajectory for cash support in 2026/27 was to be reviewed at the March 2026 meeting. Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Page 2 of 3 Limited Assurance No Assurance Not Applicable Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Where assurance is not required and/or relevant. Risk Rating: Low Medium High Not Applicable Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trus
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Procedure for USING THE SECA mBCA VALIDATION TEST KIT

Description
NIHR Southampton Biomedical Research Centre The NIHR Southampton Biomedical Research Centre (BRC) has a tight quality assurance system for the writing, reviewing and updating of Standard Operating Procedures. As such, version-controlled and QA authorised Standard Operating Procedures are internal to the BRC. The Standard Operating Procedure from which information in this document has been extracted, is a version controlled document, managed within a Quality Management System. However, extracts that document the technical aspects can be made more widely available. Standard Operating Procedures are more than a set of detailed instructions; they also provide a necessary record of their origination, amendment and usage within the setting in which they are used. They are an important component of any Quality Assurance Framework, but in themselves are insufficient and need to be used and interpreted with care. Alongside the extracts from our Standard Operating Procedures, we have also made available here an example Standard Operating Procedure and a word version of a Standard Operating Procedure template. Using the example and the Standard Operating Procedure template, institutions can generate their own Standard Operating Procedures and customise them, in line with their own institutions. Simply offering a list of instructions to follow does not assure that the user is able to generate a value that is either accurate or precise so here in the BRC we require that Standard Operating Procedures are accompanied by face-to-face training. This is provided by someone with a qualification in the area or by someone with extensive experience in making the measurements. Training is followed by a short competency assessment and performance is monitored and maintained using annual refresher sessions. If you require any extra information, clarification or are interested in attending a training session, please contact Dr Kesta Durkin (k.l.durkin@soton.ac.uk). This document has been prepared from Version 1 of the BRC Standard Operating Procedure for using the Seca medical Body Composition Analyser validation test kit. It was approved in December 2014 and the next review date is set for December 2016. The version number only changes if any amendments are made when the document is reviewed. Page 1 of 8 NIHR Southampton Biomedical Research Centre NIHR Southampton Biomedical Research Centre Procedure for USING THE SECA mBCA VALIDATION TEST KIT BACKGROUND The Seca mBCA (medical Body Composition Analyser) analyses body composition using the Bioelectrical Impedance methodology. Bioelectrical Impedance is a method used to obtain impedance values generated by different components of the body in response to a small electric current. In order to be confident that the Seca mBCA machine is working correctly it must undergo monthly validation checks. A record of which is kept in the Seca mBCA validation folder in the Bod Pod and Body Comp room (WC205A) in the NIHR Wellcome Trust Clinical Research Facility (CRF). PURPOSE To ensure the correct validation procedure for the Seca mBCA machine, within the BRC. SCOPE This procedure applies to any individual performing the monthly validation checks on the Seca mBCA machine, within the BRC RESPONSIBILITIES It is the responsibility of the individual to use this procedure when performing monthly validation checks on the Seca mBCA machine and they will be responsible for reporting and recording the outcome of the validation test in the validation test folder held in the Bod Pod and Body Comp room (WC205A). Page 2 of 8 NIHR Southampton Biomedical Research Centre PROCEDURE 1. Switch the laptop, printer and Seca mBCA machine on at the wall sockets. 2. Get the SECA Wireless Dongle (figure 1) out of the box file and plug into a USB port on the laptop. The box file is on the bottom on the workstation desk next to the printer and is labelled "Seca mBCA". Figure 1. Seca wireless dongle 3. Turn on the Seca mBCA machine by pressing the on/off button on the bottom left corner of the display panel. 4. Do not touch any part of the equipment during this process as you will interfere with internal set-up calibrations. 5. Wait until the start screen is displayed. It should say 0.00 in centre of the screen as it will not be registering any weight. 6. Switch on the laptop and log in with your UHS login details. 7. Click the "SECA medical software" icon on the computer desktop to open the Seca mBCA software program. 8. It will ask for a username and password. This will be supplied to you after training. During the training session the trainer will use their log in details. 9. Enter the user name and password that has been assigned to you. 10. Position the components of the Test kit on the equipment in the following order. a. Position one small cylindrical test weight on each foot electrode (figure 1). It does not matter which one goes on which electrode but the end with the hole in the centre needs to be face-up. Page 3 of 8 NIHR Southampton Biomedical Research Centre Figure 1. b. Clip the red and black clips to contact the hand electrodes on each side of the machine, in the positions shown in figure 2. Make sure the red clips are at the front (figure 2). Figure 2. Page 4 of 8 NIHR Southampton Biomedical Research Centre c. Connect red leads in the "hand leads" bag to the red clips and black leads in the "hand leads" bag to the black clips over the hand electrodes (figure 3). The attachment side of the clips needs to face outwards and the larger pin end of the leads must be pushed through the hole and the screw mechanism used to tighten the lead in place. Leave the other end of the leads to dangle for the moment. Figure 3. d. Make sure the sets of red and black leads and the Reference Unit are out of the case and then place the case on its end on to the machine (figure 4). Double check you are using the Reference Unit do NOT use the Test Unit. Leave all the other components in the box. Figure 4. e. Now use the other set of red and black leads. f. Take two red leads from the "foot leads" bag and connect one to each of the cylindrical weights on the ball of the foot electrodes (figure 5). Page 5 of 8 NIHR Southampton Biomedical Research Centre g. Take two black from the "foot leads" bag and connect one to each of the cylindrical weights on the heel of the foot electrodes (figure 5). h. Place the Reference Unit on top of the case and connect the other end of the two red and two black leads plugged into the weights, into the corresponding coloured positions at the person's foot-end of the image on the Reference Unit (figure 5). Figure 5. i. j. Now take the dangling opposite end of the red leads for the hands that you previously connected to the red clips and connect the dangling free end to the corresponding coloured positions at the person's head-end of the image on the Reference Unit (figure 6). Do the same for the black leads (figure 6). Figure 6. Page 6 of 8 NIHR Southampton Biomedical Research Centre 11. Set-up of the test kit is now complete. Check that your set up matches that shown in figure 6. 12. Work with the machine now as if you are measuring a participant 13. The weight should read the weight of the test kit (5.8kg). Press hold to fix the weight. 14. Enter a height value of 1 meter and then press the BIA button on the right of the display panel. 15. Carry out the measurement by performing the long (75 second) test. This requires you to make sure that all the boxes are ticked (including the "raw data for impedance" box) when you are viewing the screen shown in figure 7. Do not touch the machine whilst the measurement is in progress. Figure 7. 16. When the measurement is complete, press "continue". 17. When asked to enter "Activity Level" enter the value 1.5 and then press "confirm". 18. On the screen that requests the patient details: For First Name, enter "3" and for Surname enter "VALIDATION" 19. When this has been entered press "search". 20. Enter user PIN when requested. 21. Wait until the machine has completed the patient search and when VALIDATION 3 has been found, press "confirm". 22. Press "save". 23. Open the file on the laptop and obtain navigate to the "Raw Data for Impedance" section. Select "Right Half of Body" and check the results at 5 and 50kHz fit within the required limits. Page 7 of 8 NIHR Southampton Biomedical Research Centre Raw Data Measurements Zre (50kHz) re (50kHz) Rre (50kHz) Xcre (50kHz) Zre (5kHz) re (5kHz) Rre (5kHz) Xcre (5kHz) Target Value 524.9 (+/-1) 0.0? (+/-0.1?) 524.9 (+/-1) 0.0 (+/-1) 524.9 (+/-1) 0.0? (+/-0.1?) 524.9 (+/-1) 0.0 (+/-1) 24. Record the results on the Seca mBCA Validation Record Form in the blue folder labelled Seca mBCA Validations in the Bod Pod and Body Comp room in the CRF (WC205A) 25. If there are any problems and the results are not within the specified limits repeat the test twice more. If the problem persists, please report the problem to the SCBR Operations Manager and clearly mark the machine "Do not use" so that it is not used again before repair/recalibration. 26. Shut down the laptop and the mBCA machine. 27. Completely dismantle the validation kit set-up and return all the components to the box. Page 8 of 8
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Procedure for bioimpedance using the Seca mBCA

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NIHR Southampton Biomedical Research Centre The NIHR Southampton Biomedical Research Centre (BRC) has a tight quality assurance system for the writing
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Papers Trust Board - 29 November 2022

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Date Time Location Chair Agenda Trust Board – Open Session 29/11/2022 9:00 - 13:20 Conference Room, Heartbeat/Microsoft Teams
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Procedure for GEM 1 and 2 calorimeter

Description
NIHR Southampton Biomedical Research Centre The NIHR Southampton Biomedical Research Centre (BRC) has a tight quality assurance system for the writing, reviewing and updating of Standard Operating Procedures. As such, version-controlled and QA authorised Standard Operating Procedures are internal to the BRC. The Standard Operating Procedure from which information in this document has been extracted, is a version controlled document, managed within a Quality Management System. However, extracts that document the technical aspects can be made more widely available. Standard Operating Procedures are more than a set of detailed instructions; they also provide a necessary record of their origination, amendment and usage within the setting in which they are used. They are an important component of any Quality Assurance Framework, but in themselves are insufficient and need to be used and interpreted with care. Alongside the extracts from our Standard Operating Procedures, we have also made available here an example Standard Operating Procedure and a word version of a Standard Operating Procedure template. Using the example and the Standard Operating Procedure template, institutions can generate their own Standard Operating Procedures and customise them, in line with their own institutions. Simply offering a list of instructions to follow does not assure that the user is able to generate a value that is either accurate or precise so here in the BRC we require that Standard Operating Procedures are accompanied by face-to-face training. This is provided by someone with a qualification in the area or by someone with extensive experience in making the measurements. Training is followed by a short competency assessment and performance is monitored and maintained using annual refresher sessions. If you require any extra information, clarification or are interested in attending a training session, please contact Dr Kesta Durkin (k.l.durkin@soton.ac.uk). This document has been prepared from Version 1 of the BRC Standard Operating Procedure for indirect calorimetry using the GEM 1 or GEM 2 analyser. The document was written in October 2014, authorised in April 2015 and the next review date is set for April 2017. The version number only changes if any amendments are made when the document is reviewed. Page 1 of 9 NIHR Southampton Biomedical Research Centre NIHR Southampton Biomedical Research Centre Procedure for INDIRECT CALORIMETRY USING THE GEM 1 or GEM 2 ANALYSER BACKGROUND Energy can be measured from heat. Heat produced can be derived by the amount of oxygen consumed. Energy expenditure can be measured by calorimetry and is based on the law of conservation of energy. There are two types of calorimetry: direct and indirect. The GEM is used for indirect calorimetry. It measures oxygen consumption and carbon dioxide production through assessing expired gases, the results of which are then used to calculate the respiratory quotient and resting energy expenditure. PURPOSE To ensure correct and safe use of the GEM 1 or GEM 2 calorimeter. SCOPE This procedure applies to every staff member required to use the GEM 1 or GEM 2 calorimeter. RESPONSIBILITIES It is the responsibility of staff to ensure they read, understand and use this procedure for measuring calorimetry using the GEM 1 or GEM 2 machine. PROCEDURE The two GEM machines are operated in the same way. Both machines can be used in Consulting Room 15 or the Low Dependency Ward (bed 2) in the CRF. The only difference is where the gas cylinders are located and how to turn the gases on, which is part of the preparation of the GEM 1 or GEM 2 machine being used. Page 2 of 9 NIHR Southampton Biomedical Research Centre TURNING ON THE GASES: FOR CONSULTING ROOM 15 1. 2. 3. 4. 5. Attach a laptop/computer with the GEM software on, to the GEM by plugging in the cables that enable the GEM to communicate with the computer. Turn on the GEM analyser and the GEM laptop. Allow the GEM analyser to warm up for a minimum of 20 minutes before calibrating or making measurements. Prepare the participant by instructing them to lie down on the bed/consultation couch also for a minimum of 15 minutes prior to starting the test. Turn on the Nitrogen (zero) gas cylinder by using the cylinder spindle key (figure 1), (resting on the little wooden mount to which the cylinders are secured, on the wall) to turn to the left approximately 180?. Then open the valve of the 1% CO2, 20% O2, Nitrogen (span) gas cylinder by turning the flat red and black knob on the top of the cylinder, anti-clockwise. You don't need to open it much ? one full turn of the knob will be sufficient. Check that one of the two pressure dials on each cylinder are set at 1 bar. There is a black dot on one of the dials of each cylinder, indicating where the 1 bar needle should sit. 6. Figure 1. Gas cylinder spindle key FOR THE LOW DEPENDENCY WARD AREA (BED 2 ONLY) 1. 2. 3. 4. 5. Attach a laptop/computer with the GEM software on, to the GEM by plugging the cables that enable the GEM to communicate with the computer. Turn on the GEM analyser and the GEM laptop Allow the GEM analyser to warm up for a minimum of 20 minutes before calibrating or making measurements. Prepare the participant by instructing them to lie down on the bed/consultation couch also for a minimum of 15 minutes prior to starting the test. During this time, take the padlock key (in the key box, SCBR/CRF Admin Office behind Reception), go out to the CRF gas cylinder cage and open the valve of the Nitrogen (zero) gas cylinder by using the cylinder spindle key (figure 1), (on shelf in gas cage) to turn to the left approximately 180?. Then open the valve of the 1% CO2, 20% O2, Nitrogen balance (span) gas cylinder by turning the flat Page 3 of 9 NIHR Southampton Biomedical Research Centre red and black knob on the top of the cylinder, anti-clockwise. You don't need to open it much ? one full turn of the knob will be sufficient. 6. Turn on the gas supplies in the low dependency ward area, by the GEM machine using the wall mounted valves. Just loosening by turning to the left will make the needles jump up to the 1 bar level which is correct. USING THE GEM 1 AND GEM 2 ON PARTICIPANTS 1. Click on the computer desktop icon to load the "GEM nutrition" program. The open program is shown in figure 2. Figure 2. GEM Nutrition software start screen 2. 3. Before any involvement with the participant, you must calibrate the equipment. Click on "set up run" (circled red in figure 2). Then click on "calibrate" (circled red in figure 3). Page 4 of 9 NIHR Southampton Biomedical Research Centre Figure 3. Select "calibrate". 4. 5. The calibration process will begin automatically and takes about 3.5 minutes. Complete 3 calibrations, clicking "ok" after each, which allows the machine to accept each calibration. The values from calibrations must fit within these ranges: O2 ZERO SPAN INSPIRED -0.990 to +0.123 +19.587 to +21.110 +20.800 to +21.270 CO2 -0.020 to +0.020 +0.962 to +1.041 +0.047 to +0.139 If your calibration results do not fall within these ranges, you must contact the expert for assistance. 6. 7. Write down the results from each calibration on the calibration log form which is kept by the machine. After each calibration, "OK" in green text will be displayed (circled red in figure 4). Page 5 of 9 NIHR Southampton Biomedical Research Centre Figure 4. Calibration result. 8. When 3 calibrations have been performed, select the "defaults" tab and check that the program is set to discard the first three measurements and that the bin size is 60 seconds, unless otherwise required by the study protocol. Make any appropriate changes but do not alter the values in the calibration settings (the values in these boxes are set according to the percentages of O2 and CO2 in the gas cylinders). All outlined in red in figure 5. Figure 5. Set defaults tab Page 6 of 9 NIHR Southampton Biomedical Research Centre 9. In order to save participant results enter some participant details into the "record number", "name" and "date of birth" boxes (circled red in figure 6). Figure 6. Participant details. 10. 11. Ensure that the participant is comfortably lying on the bed (check with the protocol for details of any study specific resting periods). Place the hood over the participant with the air-intake at the top of the head. Tuck in the sheeting to ensure that there are no leaks. This can be done before the calibration if it is necessary to allow the participant further time to adjust. After the protocol required resting period, go to running screen and start run. Use the slider bar to set the flow rate to the appropriate value. Following the guidelines below will help. 12. 13. You need to adjust the flow rate by moving the sliding bar (outlined in red in figure 6) until the FeCO2 value reads approximately 0.5. For adults 38-45L/m is usually satisfactory. If the FeCO2 value reads higher than 0.5 then the flow rate needs to be INCREASED. If the FeCO2 value reads lower than 0.5 then the flow rate needs to be DECREASED. 14. 15. 16. The results are collected in sections at intervals set by the bin size. After determining the correct flow rate based on the value for FeCO2, continue collecting data for 30 minutes or as otherwise specified in the study protocol. Click "stop" to end run. Page 7 of 9 NIHR Southampton Biomedical Research Centre 17. 18. 19. 20. 21. 22. 23. 24. 25. Remove the hood from the participant Save file as CSV file ? naming it according to your study participant ID. Click "OK". The results file will be given a name identifying the date and run start time. The participant information will be displayed within the file. Copy the file onto a memory stick for analysis elsewhere. Leave the original on the GEM computer. To read the file on another computer, open Excel and import the GEM data file into Excel and then resave/"save as" an Excel file. Turn the gas valves off at the wall in the Low Dependency Ward (GEM 2). Turn off the gas flow at the cylinders in room 15 (GEM 1). REMEMBER TO TURN OFF THE GASES IN THE CRF CAGE OUTSIDE. If you encounter the error message below which says "cannot communicate with bedside unit, running in demo mode!" (figure 7) then it could be that the GEM software was started too soon so that first thing to do is close and re-open the GEM Nutrition software. If this does not solve the problem then you can try the following: a. Check that the instrument is turned on b. Check that the cable connecting the GEM to the laptop/computer is securely connected at each end. c. Go to the "default settings" tab (shown in figure 4) and check under "connection settings" and "serial port name" it says "COM3. Page 8 of 9 NIHR Southampton Biomedical Research Centre Figure 7. "Cannot communicate with bedside unit" Page 9 of 9
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