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BRC MRI Pump-priming Research Project application form_v1 2025 FINAL

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NIHR Southampton Biomedical Research Centre (BRC) Imaging Research Panel Application for an MRI Pump-priming Research Project Award The scheme Th
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/Media/Southampton-Clinical-Research/Downloads/BRC-MRI-Pump-priming-Research-Project-application-form-v1-2025-FINAL.docx

BRC_SDE Joint Funding Call CLEAN

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NIHR Southampton BRC and Wessex SDE joint funding call 2025 NIHR Southampton Biomedical Research Centre (BRC) and Wessex Secure Data Environment
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/Media/Southampton-Clinical-Research/Downloads/BRC-SDE-Joint-Funding-Call-CLEAN.pdf

BRC MRI Pump-priming Research Project application form_v1 FINAL 10.12.2024

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NIHR Southampton Biomedical Research Centre (BRC) Imaging Research Panel Application for an MRI Pump-priming Research Project Award The scheme Th
Url
/Media/Southampton-Clinical-Research/Grants/Download/BRC-MRI-Pump-priming-Research-Project-application-form-v1-FINAL-10.12.2024.docx

BRC MRI Pump-priming Research Project application form_v1 FINAL 10.12.2024

Description
NIHR Southampton Biomedical Research Centre (BRC) Imaging Research Panel Application for an MRI Pump-priming Research Project Award The scheme Th
Url
/Media/Southampton-Clinical-Research/Downloads/BRC-MRI-Pump-priming-Research-Project-application-form-v1-FINAL-10.12.2024.docx

BEACON protocol v8.0 07Mar2023 signed

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A randomised phase IIb trial of BE AC v izumab added to Temozolomide O ± Irin tecan for children with N refractory
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/Media/UHS-website-2019/Docs/PaediatricOncology/beacon-protocol-v8.0-07mar2023-signed.pdf

Papers CoG 29.04.2025 v2

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Date Time Location Chair Agenda Council of Governors 29/04/2025 14:00 - 15:45 Conference Room, Heartbeat/Microsoft Teams Jenni
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/Media/UHS-website-2019/Docs/About-the-Trust/Governors/Papers-CoG-29.04.2025-v2.pdf

Annual-report-24-25-final

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2024/25 Incorporating the quality account University Hospital Southampton NHS Foundation Trust Annual Report and Accounts 2024/25 Presented to Parliament
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/Media/UHS-website-2019/Docs/About-the-Trust/Annual-reports-and-quality-accounts/Annual-report-24-25-final.pdf

Quality account 24-25 final

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