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Papers CoG - 29.01.2025

Description: Date Time Location Chair Agenda Council of Governors 29/01/2025 14:00 - 15:30 Conference Room, Heartbeat/Microsoft Teams Jenni Douglas-Todd 1 Chair’s Welcome and Opening Comments 14:00 2 Declarations of Interest 14:03 3 Minutes of Previous Meeting 14:04 Approve the minutes of the previous meeting held on 23 October 2024 4 Matters Arising/Summary of Agreed Actions 14:05 There are no outstanding actions 5 Strategy, Quality and Performance 5.1 Chief Executive Officer's Performance Report 14:06 Receive and note the report Sponsor: David French, Chief Executive Officer 6 Governance 6.1 Chair and Non-Executive Director Appraisal Process 14:26 Approve the Chair and Non-Executive Director Appraisal Process Sponsor: Jenni Douglas-Todd, Trust Chair Attendee: Steve Harris, Chief People Officer 6.2 Audit and Risk Committee Terms of Reference 14:41 Provide feedback on the proposed changes before presentation to the Board of Directors Sponsor: Keith Evans, Audit and Risk Committee Chair Attendee: Craig Machell, Associate Director of Corporate Affairs and Company Secretary 6.3 Governors' Nomination Committee Terms of Reference 14:46 Approve the proposed changes to the Governors' Nomination Committee Terms of Reference Sponsor: Jenni Douglas-Todd, Trust Chair Attendee: Craig Machell, Associate Director of Corporate Affairs and Company Secretary and Karen Russell, Council of Governors' Business Manager 6.4 Annual Business Plan 14:49 Approve the Annual Business Plan for 2025/26 Sponsor: Jenni Douglas-Todd, Trust Chair Attendee: Karen Russell, Council of Governors' Business Manager 6.5 Non-Executive Director Appointment 14:52 Note the commencement of appointment of David Liverseidge Sponsor: Jenni Douglas-Todd, Trust Chair Attendee: Craig Machell, Associate Director of Corporate Affairs and Company Secretary and Karen Russell, Council of Governors' Business Manager 6.6 Governor Attendance at Council of Governors’ Meetings 14:57 Review governor attendance at Council of Governors' meetings Sponsor: Jenni Douglas-Todd, Trust Chair Attendee: Karen Russell, Council of Governors' Business Manager 6.7 Break 15:00 7 Membership Engagement and Governor Activity 7.1 Membership Engagement 15:10 Receive the report Sponsor: Jenni Douglas-Todd, Trust Chair Attendee: Sam Dolton, Events and Membership Officer 7.2 Governors' Nomination Committee Feedback 15:20 Chair: Jenni Douglas-Todd, Trust Chair 8 Review of Meeting 15:25 Review and feedback on the content of this meeting Sponsor: Jenni Douglas-Todd, Trust Chair 9 Any Other Business 15:27 Raise any relevant or urgent matters that are not on the agenda 10 Date of Next Meeting: 29 April 2025 15:29 Note the date of the next meeting Page 2 Minutes - Council of Governors (CoG) Open Session Date Time Location Chair Present 23 October 2024 14.35-15.45 Conference Room, Heartbeat Education Centre and Microsoft Teams Jenni Douglas-Todd, Trust Chair Jenni Douglas-Todd, Trust Chair JDT Shirley Anderson, Elected, New Forest, Eastleigh and Test Valley SA Katherine Barbour, Elected, Southampton City KB Lesley Gilder, Elected, Southampton City LG Sathish Harinarayanan, Elected, Medical Practitioners and Dental SH Staff Councillor Pam Kenny, Appointed, Southampton City Council PK Jenny Lawrie, Elected, Southampton City JL Brian Lovell, Elected, Rest of England and Wales BL Esther O’Sullivan, Elected, New Forest, Eastleigh and Test Valley EO Councillor Louise Parker-Jones, Appointed, Hampshire County LPJ Council Karen Smith, Elected, Health Professional and Health Scientist KS Staff Jake Smokcum, Elected, Nursing and Midwifery Staff JS Professor Emma Wadsworth, Appointed, Solent University EW Mike Williams, Elected, New Forest, Eastleigh and Test Valley MW In attendance Tracey Burt, Minutes TB Sam Dolton, Events and Membership Officer SD David French, Chief Executive Officer (for item 5.1) DF Craig Machell, Associate Director of Corporate Affairs and CM Company Secretary Farhanah Miah, Associate Governor FM Neylia Mustafapour, Associate Governor NM Karen Russell, Council of Governors’ Business Manager KR Apologies Patricia Crates, Elected, New Forest, Eastleigh and Test Valley PC Helen Eggleton, Hampshire and Isle of Wight Integrated Care HE Board (ICB) Professor Mandy Fader, Appointed, University of Southampton MF Ben Grassby, Elected, New Forest, Eastleigh and Test Valley BG Linda Hebdige, Elected, Southampton City LH 1 Chair’s Welcome and Opening Comments The Chair welcomed everyone to the meeting. In particular, the new governors and young Associate Governors. 1 2 Declarations of Interest There were no new declarations of interest relating to matters on the agenda. 3 Minutes of Previous Meeting The minutes of the meeting held on 24 July 2024 were approved as an accurate record of the meeting. 4 Matters Arising/Summary of Agreed Actions All actions had been completed. 5 Strategy, Quality and Performance 5.1 Chief Executive Officer’s Performance Report JDT welcomed DF, Chief Executive, to the meeting. For the benefit of the new governors, he advised that he had joined the Trust in 2016 as its Chief Financial Officer and had then become CEO four years ago. He highlighted the following: • new theatres had recently been opened on F Level which would allow for greater activity. • the waiting list was now stable at around 60,000 having previously been increasing at approximately 1,000 patients per month. He acknowledged the significant effort of staff in reducing the figure. • the Trust had delivered elective activity at 126% of pre-pandemic levels (2019/20), which placed it in the top quartile of peer teaching hospitals across the country. • over the last year, the volume of first time Outpatient appointments had increased by 9%, whilst follow up appointments had reduced by 9%. The challenge was to ensure that every follow up appointment added value. • in September 2024, the hospital’s ED performance had ranked 4th when compared to 20 peer teaching hospitals across the UK. • UHS had been asked to send its financial recovery plan to NHS England (NHSE). • the hospital was constantly looking for ways to stretch itself to do even better (e.g. theatre utilisation, Outpatients and length of stay) but that was a particular challenge, when UHS was already in the top quartile of peer teaching hospitals in the UK. • UHS was working with its local system partners to reduce the number of mental health patients admitted to the hospital, when they should be seen in more appropriate settings. • each day there were around 200/250 frail, elderly patients at UHS who did not meet the criteria to reside (nCTR). On a more positive note, DF advised that: • the new system to log and communicate pathology results (LIMS) had gone live in July 2024. The previous system had been approximately 25 years old and whilst there had been some initial issues externally, the new system was now more stable. • an event ‘We are UHS’ had taken place last week in the Trust. It had provided an opportunity for staff to recognise and celebrate the work done in the hospital. The highlight had been a UHS Staff Awards night at the Hilton Hotel in West End, sponsored by Southampton Hospital Charity and hosted by DF and Gail Byrne, Chief Nursing Officer. Around 400 staff had attended the event. In response to various questions from governors, DF advised that: 2 • the Trust did not always receive extra funding for doing additional activity. The government’s view was that the NHS was still not as productive as it had been prior to the pandemic and that it should be doing more, with fewer resources. DF did not consider that staff should be asked to work any harder and instead, ways needed to be found to ensure that processes were less labour intensive. • the number of Southampton City Council (SCC) and Hampshire County Council (HCC) residents, in the hospital, who did nCTR was very similar. Both councils had been subject to significant cuts in funding and were unable to fund sufficient care home places/domiciliary packages, which would enable those patients to leave the hospital. • the investigation regarding the Never Event that had occurred in September was still underway. KS said that she had been encouraged to hear DF talk about the LIMS project and the incredible work done by the Pathology Team, which she would feedback to the wider pathology community. DF advised that the Trust had commissioned an external review, which would be shared internally and externally. It was hoped that the review would help other hospitals who would, in the future, implement LIMS. 6 Governance 6.1 Governor Attendance at Council of Governors’ Meetings KR advised that under the Trust’s constitution, if a governor failed to attend two successive meetings of the CoG, without good reason, their tenure of office would be terminated. At the time of review, one governor had missed two successive meetings but this had been discussed and was with good cause. Decision: The CoG confirmed that it was satisfied that the failure of the governor to attend two successive meetings of the CoG had been due to reasonable cause and that they would attend future meetings within a reasonable period. No termination of office was therefore required. 6.2 Appointment to the Governors’ Nomination Committee KR advised that a vacancy had arisen on the Governors’ Nomination Committee (GNC) when Kelly Lloyd had left the Trust on 30 June 2024. Governors had been asked to express an interest in joining the GNC, which JL had done. The CoG had decided by unanimous vote to approve her appointment to the GNC. 6.3 Meeting with the Hampshire and IoW ICB - Chair Appointments JDT advised governors that Hampshire and IoW Integrated Care Board (ICB) would be meeting with them on 31 October 2024 at 4 p.m. The intention of the meeting was for the ICB to set out its aspirations for the future of healthcare within Hampshire and the IoW. The ICB had already begun talks with UHS about it working more closely with Hampshire Hospitals NHS Foundation Trust and they also planned for Portsmouth and Isle of Wight hospitals to work together more closely. KR advised that she would circulate the finalised agenda to governors in due course. 3 6.4 Strategy Session Planning KR advised that there would be a Strategy Session for the CoG on Wednesday 11 December 2024 in the Conference Room, Heartbeat Suite. She asked governors to suggest topics for the session and the following were mentioned: • Prof. Chris Kipps, Clinical Director of Research and Development, the Wessex secure data environment and public engagement. • the management of infection prevention within the hospital (e.g. C. difficile) and keeping staff and patients safe. It was suggested that Julie Brooks, Head of Infection Prevention, was invited to the session. • making boards of governors more effective/looking at case studies. SA and JL mentioned an excellent presentation they had heard by NHS Providers. KR said that Martin De Sousa, Director of Strategy and Partnerships, was already booked to attend the session. KR advised that she would circulate further details regarding the Strategy Session in due course. 7 Membership Engagement and Governor Activity 7.1 Membership Engagement SD introduced the Membership Engagement report. He advised that the Communications Team had been involved in organising the recent UHS Staff Awards night and he said that there had been good engagement on social channels and from the Daily Echo. The event would also be featured in the quarterly Connect digital magazine to be published in November. The team was now focussed on the Annual Members’ Meeting and Open Evening to be held on 21 November 2024 in the Heartbeat Lecture Theatre and Conference Room. Around 50 members had already signed up to attend and he was hoping that would rise to 80. He encouraged governors (6 had already signed up) to attend, as it would provide them with a good opportunity to engage with the membership. He advised that in December the virtual event research series would continue with an event on healthy ageing. The following comments were made: • JDT said that the data on emails sent out and the number of bounces was interesting. It suggested that there was some merit in a more focussed/targeted approach. • JDT noted the low engagement with the appeal for second hand clothing for patients to go home in. Governors wondered whether it was due to it being an appeal that had been done before, rather than one that was new. 7.2 Feedback from Strategy and Finance Working Group EO advised that Jake Wilkins, Associate Director, Always Improving, had given an interesting talk to the group on how the Trust’s strategy, transformation plans and improvement goals were delivered. KR noted that he had emailed a copy of his presentation direct to governors. 4 7.3 Feedback from Patient and Staff Experience Working Group KR advised that Shona Small, Complaints Manager and Debbie Watson, Head of Patient and Family Relations, had attended the group to discuss the annual complaints report, which they had circulated prior to the meeting. They had highlighted the nature and complexity of complaints and the challenges of dealing with people who could be difficult to help. The team had been struggling with a lack of resources but that was beginning to ease and they had been positive above the support they received from senior leadership and from one another. The team did also receive positive feedback but governors noted that there was no regulatory requirement for that to be recorded. 7.4 Feedback from Membership and Engagement Working Group SD advised that there had been a discussion about the Annual Members’ Meeting and the role of governors, on the evening. It had been decided that governors could choose whether they roamed, chatting to attendees, or manned the stand that would be in the Conference Room. JDT encouraged all governors to interact with members both at the event and, more generally, in their constituencies. 8 Review of Meeting Governors felt that the sound quality had improved, both in the room and for those who had joined via Teams. It was, however, noted that some attendees still spoke too quietly. FM said that she had been encouraged that governors’ views were valued and listened to. There was a suggestion that governors should bring their own cups for drinks and they asked to be reminded prior to the meetings. 9 Any Other Business There was no other business. 10 Date of Next Meeting The next meeting of the CoG would be held on 29 January 2025. 5 Item 5.1 Report to the Council of Governors - 29 January 2025 Title: Chief Executive Officer’s Performance Report Sponsor: David French, Chief Executive Officer Author: Sam Dale, Associate Director of Data and Analytics Purpose (type an ‘x’ in the appropriate box(es)) (Re)Assurance Approval Ratification Information Y Strategic Theme (type an ‘x’ in the appropriate box(es)) Outstanding patient Pioneering research World class people outcomes, safety and innovation and experience Integrated networks and collaboration Foundations for the future N/A N/A N/A Executive Summary: Information about Trust performance supports the Council of Governors in their role. This report is intended to inform the Council of Governors about aspects of the Trust’s performance. Contents: The Chief Executive Officer’s Performance Report is attached. Risk(s): N/A Equality Impact Consideration: N/A UHS Council of Governors January 2025 Chief Executive’s Performance Report 1. Purpose and Context The purpose of this report is to summarise the Trust’s performance against a range of key indicators. Where available, this report covers data from the period October 2024 to December 2024, noting that some quarterly performance data is reported further in arrears. Notable features of the last quarter include: • A significantly high volume of attendances to our Emergency Department in the period, averaging 448 patients per day. A reflection of a challenging national position which has significantly impacted four-hour performance. • An extremely challenging number of patients not meeting the criteria to reside with volumes peaking above 250 in recent weeks. These patients continue to occupy hospital beds, restricting flexibility in our elective programmes, and impacting flow through the hospital. • Whilst the waiting list has stabilised across the quarter, volumes continue to be above 60,000 with pressure predominantly in referral cohort. However, good progress has been made in reducing the longest waiting patients at both 78+ and 65+ weeks. • The organisation continues to benchmark well for cancer services, ranking in 1st place compared to peer teaching hospitals for two of the three standard waiting time metrics • The financial environment remains extremely challenging and is being monitored closely. UHS reported an £18.2m deficit after eight months which is £14.8m behind plan. This is predominantly due to savings targets not being fully achieved particularly those related to system transformation. • The trust remains on target to spend its full capital allocation for 2024/25 and has delivered elective recovery fund activity (ERF) at 128% of 2019/20 levels which is 15% above the trust’s target. 2. Safety Infection Control MRSA Bacterium infection Clostridium Difficile infection Target 0 78.0% Oct 2024 Nov 2024 Dec 2024 66.6% 59.4% 57.7% Attendances to the Emergency Department (ED) increased further in quarter three, averaging 448 per day across October, November and December in 2024. This represents an increase of 6.6% compared to the previous quarter and a 5.8% increase compared to the same period last year. The pressure on the emergency department across the festive period presented significant challenges on hospital flow and bed state - the four hour performance position reducing to 57.7% in December 2024. This position places the hospital in the third quartile when compared to twenty peer teaching hospitals for Type 1 attendances. Referral to Treatment (RTT) % incomplete pathways within 18 weeks in month Total patients on a waiting list Target => 92% Oct 2024 63.41% 60,879 Nov 2024 62.44% 60,338 Dec 2024 62.04% 60,387 Despite a small decrease in December, the trust’s RTT waiting list remained above 60,000 in every month within quarter three. The main pressure continues to be the referral element of the pathway with the number of patients waiting for surgery reducing. 62% of patients on the waiting list have been waiting less than 18 weeks - the organisation has consistently benchmarked in the top quartile when compared to peer teaching organisations for this metric. UHS continues to make good progress in reducing the longest waiting patients. UHS reported zero patients waiting over 78 weeks in December 2024 and 22 patients waiting over 65 weeks. The majority of these patients remain those impacted by the national shortage of corneal tissue. The organisation’s focus for the remainder of the year continues to be patients waiting over 52 weeks. Cancer Target Faster Diagnosis - within 28 days > =77% 31 Day target - decision to treat to first definitive treatment 62 day target - urgent referral to first definitive treatment => 96% => 70% Sep 2024 82.4% 93.1% 78.1% Oct 2024 84.8% 94.2% 77.5% Nov 2024 86.2% 94.4% 78.9% The organisation has made positive progress in improving cancer waiting times in quarter three. Delivery against the 28 day faster diagnosis has remained above the national target and seen month on month improvement achieving 86.2% for November. This places the organisation in first place compared to 20 peer teaching hospitals across the country. The hospital also ranks in first place for the 62day target. Page 4 of 6 The organisation continues to prioritise cancer patients and their treatments for all tumour sites and cancer types. Pathway efficiencies particularly around pathology and diagnostics are constantly being explored as well as regular dialogue with Wessex Cancer Alliance and the ICB on improvements and innovative techniques to ensure referrals are appropriate and timely. 5. Finance The financial environment remains extremely challenging as we head into the final quarter of 2024/25. The annual plan for 2024/25 was originally approved as a £14.5m deficit which was reduced to £3.3m following central support funding being issued for organisations in deficit. UHS is currently reporting an £18.2m deficit after eight months which is £14.8m behind plan. This is predominantly due to savings targets not being fully achieved particularly those related to system transformation not yet yielding financial benefits. These were always known to have greater risk attached due to the scale of change required. Of note both non criteria to reside and mental health schemes are challenged with patient numbers remaining at similar levels to 2023/24. Both these areas were targeted for significant reduction with the aim of delivering both quality and financial savings. The non delivery of system transformation schemes YTD means £9m of planned savings have not been achieved. Other challenges around industrial action and pay disputes have in many areas now been resolved although there are several areas still under discussion with unions. It should also be noted that UHS continues to deliver activity over and above its funded block contract levels which is valued at £20m YTD. This mainly relates to Emergency Department and Non Elective activity. The YTD deficit and underlying deficit run rate means there is now a significant challenge in delivering the financial plan for the year that would require a surplus to be delivered across the remaining four months and over delivery on efficiency savings targets within the plan. In response to this challenge UHS continues to work with both internal and external stakeholders on how improvements can be achieved. Despite this challenge the organisation has made significant efforts in making sure workforce growth is controlled and agency costs minimised. Agency expenditure is below 1% of total pay expenditure and continues to benchmark favourably when compared to similar organisations. Surge capacity (beds not normally commissioned) have also remained much lower levels than the previous year although has known peaks and troughs with the winter period often more challenging. The trust has also delivered elective recovery fund activity (ERF) at 128% of 2019/20 levels which is 15% above the trust’s target. iThis has helped deliver additional revenues of £20m across the first half of 2023/24 and helping to reduce long waiting patient numbers. Internal transformation initiatives also continue to drive incremental improvement in theatres productivity, outpatient productivity and length of stay with the former two workstreams showing noticeable improvements across the first half of 2024/25. Due to the scale of risk around financial delivery however, for both UHS and the HIOW system, the trusts financial recovery journey continues to be monitored closely as continuing to run in a deficit is not sustainable for the trusts cash or capital position. The trust however remains positive that in working with system partners, improvements can be achieved in time returning the trust to a breakeven footing. Further to this the trust remains on target to spend its full capital allocation for 2024/25 totalling £86m. This includes £1.75m funding (awaiting approval) towards Same Day Emergency Care (SDEC), £18m related to continued investment in decarbonisation funded via a Salix grant, and £7m related to the completion of the Southampton Community Diagnostics Centre planned for the Royal South Hants hospital (centrally funded). This continued investment in capacity, digital and estates infrastructure helps support continued efficiency improvement that provide foundations for the future. Page 5 of 6 6. Human Resources Indicator Staff recommend UHS as a place to work % Staff survey engagement score (out of 10) Q2 24/25 64.1% 6.84 Q3 24/25 Results under national embargo Results under national embargo The annual staff survey takes place throughout September to November. The survey has now closed and we have started to receive the initial results from our supplier, Picker. The HR and OD teams are analysing the initial results and will continue to do so as we receive further results. The participation rate decreased this year, from the previous year, and we will be sharing the results over the coming months as per the national embargo timeline, which is expected to lift February-March 2025. Following this we will be sharing the results trust-wide and supporting teams to receive and respond to the feedback. Indicator Staff Turnover (internal target; rolling 12 month) Sickness absence 12 month rolling (internal target) Target <=13.6% <=3.9% Oct 2024 10.8% 3.87% Nov 2024 10.6% 3.9% Dec 2024 10.7% 3.92% Turnover: In December 2024, there was a total of 99.5 WTE leavers, 22.5 WTE more than November 2024 (77 WTE). The highest since September 2024. Division C recorded the highest number of leavers (28 WTE). Within Division C, Allied Health Professionals staff group had the highest number of leavers (7 WTE), followed by the Nursing and Midwifery Registered staff group at 6 WTE. Divisions B and D had the second and third highest number of leavers (22 and 22 WTE respectively); with the largest numbers being Administrative and Clerical staff group for Div B (8 WTE), and Nursing and Midwifery Registered staff group for Div D (9 WTE). Sickness: In December 2024, the Trusts rolling 12-month sickness absence rate increased to 3.92% (0.02% above target). While the in-month sickness absence reduced from 4.2% in November 2024 to 4.1% in December 2024. Over November and December 2024, anxiety, stress and depression remained at 1% while cold, cough and flu – influenza increased from 0.7% in November to 0.9% in December. Page 6 of 6 Item 6.1 Report to the Council of Governors - 29 January 2025 Title: Chair and Non-Executive Director Appraisal Process 2024/25 Sponsor: Jenni Douglas-Todd, Trust Chair Author: Steve Harris, Chief People Officer and Karen Russell, Council of Governors Business Manager Purpose (type an ‘x’ in the appropriate box(es)) (Re)Assurance Approval Ratification Information Y Strategic Theme (type an ‘x’ in the appropriate box(es)) Outstanding patient Pioneering research World class people outcomes, safety and innovation and experience Integrated networks and collaboration Foundations for the future N/A N/A N/A N/A N/A Executive Summary: The NHS Foundation Trust Code of Governance requires that the Council of Governors (CoG) should take the lead on agreeing a process for the evaluation of the chair and the non-executive directors (NEDs). The Governors’ Nomination Committee (GNC) advises the CoG on that process. The appraisal process supports the board of directors (Board) in ensuring its overall effectiveness by making sure that any individual or collective development needs are identified and that the chair and non-executive directors continue to have capacity to meet the time commitment required for the role. The outcome of appraisal will also be relevant to any decision by the CoG to reappoint a non-executive director. Following recommendation by the GNC at its meeting on 15 January 2025, the CoG is asked to approve the Chair and NED appraisal process for 2024/25. Contents: The attached paper sets out the proposed appraisal process for 2024/25. Risk(s): N/A Equality Impact Consideration: N/A Chair and Non-Executive Director (NED) Appraisal Process for 2024/25 1. Introduction and purpose 1.1 The NHS Foundation Trust Code of Governance requires that the Council of Governors (CoG) should take the lead on agreeing a process for the evaluation of the chair and the non-executive directors (NEDs). The Governors’ Nomination Committee (GNC) advises the CoG on that process. The results of the appraisals are shared with the GNC and the CoG. 1.2 The Trust normally aims to complete the process by 31 March each year. 1.3 The new NHS England (NHSE) Fit and Proper Person Framework for boards was introduced with effect from 30 September 2023. NHSE are expected to launch new appraisals processes for all board members as part of a revised national framework for the management of senior leaders. A refreshed appraisal process for chairs was released in 2024, however the remaining board member processes are still outstanding with no clear date yet for implementation. 1.4 It is recommended therefore the Trust proceeds with the use of the existing NED appraisal framework and uses the new framework provided for the Chair appraisal. 1.5 This paper sets out the proposed process and timescales for the Chair and NED appraisals for 2024/25. 2. Overview of the process 2.1 The Chair of the Trust has responsibility for undertaking the appraisals for NEDs. The Chair’s appraisal process is conducted by the Senior Independent Director (SID). 2.2 Jenni Douglas-Todd, as Trust Chair, will undertake the NED appraisals. Jane Harwood, in her role as SID, will undertake the Chair’s appraisal. 2.3 The process will aim to: • Provide a structured review of performance against personal and organisational objectives set, and the performance of the Trust. • Reflect on demonstration of the Trust values. • Review attendance at key Trust meetings. • Plan for the future, including objective setting for the next year and the identification of a personal development plan. • Provide overall reporting and assurance to the GNC and CoG. Self evaluation Monitoring and reporting to GNC Seeking structured feedback from others Appraisal meeting and personal development plan Evaluation against organisational and personal objectives Appraisal of living the Trust values 2.4 The Trust will use the guidance forms provided by NHSE for NED appraisal. The Trust’s NED appraisal process is in line with guidance published by NHS England (NHSE). 3. NHSE Framework for Chair’s appraisal 3.1 NHSE have a national framework for appraisals of Chairs of provider organisations which was refreshed in 2024. This requests that Trusts ensure a robust multi-source feedback process is conducted. In the refreshed process this is now to be undertaken with consideration given to the NHSE new leadership framework. A summary of these 6 areas can be found in appendix A. The full framework can be found here. 3.2 A summary of the Chair’s appraisal is also required to be provided to the NHSE Regional Director. 3.3 It is intended that UHS use the templates provided for the Chair’s appraisal, and also include our own local values. Multi-source feedback will continue to be requested from Trust Board members and the CoG. Feedback will also be sought from the ICS. 4. Scope of Appraisal 4.1 Appraisals will cover all non-executive directors. This includes: • Jenni Douglas-Todd (Trust Chair) • Keith Evans (Deputy Chair) • Jane Harwood (Senior Independent Director) • Dave Bennett • Professor Diana Eccles • Dr Tim Peachey • Alison Tattersall An objective setting process will take place with David Liverseidge as very recent new starter. 5. Proposed process 5.1 The following is proposed as the process for the 2024/25 round of appraisals: • Use of the standard NED NHSE appraisal template. • Use a system of gaining qualitative feedback on each NED to be appraised from both the CoG and from the Board. • The Chair will meet with each NED to conduct the appraisal once feedback has been collated. • The SID will conduct the appraisal for the Chair. 5.2 To ensure meaningful views can be obtained, it is suggested that the CoG will be asked to provide positive feedback and areas of development in respect of the NEDs as individuals, and as a group. The Lead Governor (Shirley Anderson) will be asked to seek feedback from the council members. 6. Timetable of events Action Agree process and timescales with GNC Details GNC briefed on process and timescales. Who JDT and SH To be completed by 15 January 2025 Booking appraisal Appraisal meetings to be booked by KB meetings JDT (KB) 31 January 2025 Sending out forms All feedback forms to be sent out to SH appraisees and to Governors by close of play on 1 February 2024. Feedback forms to be sent to: • Governors (Via Lead Governor) • All Executives • All NEDs 1 February 2025 Seeking feedback Feedback to be provided to the Chief SA People Officer, who will collate it. SH 21 February 2025 Booking appraisal Appraisal meetings to be booked by KB meetings JDT (KB) 31 January 2025 Appraisal meetings held JDT to hold appraisal meetings with: JDT • Dave Bennett • Professor Diana Eccles • Keith Evans • Jane Harwood 31 March 2025 • Dr Tim Peachey • Alison Tattersall Objective setting meeting to be held with David Liverseidge as a new NED JH to hold appraisal meeting with JDT JH Summary reporting to GNC SH, JDT and JH to draft a summary report to be shared with GNC covering: • Feedback • Areas for development • Objectives going forward SH, JDT and JH Report to be provided to the GNC by SH, JDT and JH. Reporting to COG GNC, supported by Chief People Officer and Chair, to provide a summary report and assurance to the CoG. SH, JDT and JH Reporting to NHSE Summary report to be provided to SH NHSE in line with framework process. 31 March 2025 22 April 2025 29 April 2025 30 April 2025 7. The role of the GNC in assurance and scrutiny 7.1 The GNC will be provided with an annual report written by the Chair, supported by the Chief People Officer, which will provide an overview of the appraisals undertaken, including an overall performance summary and objectives. 7.2 The GNC will have a direct role in endorsing the appraisal process for the Chair. The SID will undertake the appraisal and provide a key summary to the GNC who will be asked to endorse the outcome. 7.3 The CoG will receive assurance from the GNC that appropriate performance appraisal of the Chair and NEDs has taken place. 8. Recommended next steps 8.1 Following recommendation by the GNC at its meeting on 15 January 2025, the CoG is asked to approve the Chair and NED appraisal process for 2024/25. Steve Harris Chief People Officer January 2025 Appendix A – Refreshed leadership framework competencies for the Chair Appraisal Driving high-quality and sustainable outcomes The skills, knowledge and behaviours needed to deliver and bring about high quality and safe care and lasting change and improvement - from ensuring all staff are trained and well led, to fostering improvement and innovation which leads to better health and care outcomes. Setting strategy and delivering long-term transformation The skills that need to be employed in strategy development and planning, and ensuring a system wide view, along with using intelligence from quality, performance, finance and workforce measures to feed into strategy development. Promoting equality and inclusion, and reducing health and workforce inequalities The importance of continually reviewing plans and strategies to ensure their delivery leads to improved services and outcomes for all communities, narrows health and workforce inequalities, and promotes inclusion. Providing robust governance and assurance The system of leadership accountability and the behaviours, values and standards that underpin our work as leaders. This domain also covers the principles of evaluation, the significance of evidence and assurance in decision making and ensuring patient safety, and the vital importance of collaboration on the board to drive delivery and improvement. Creating a compassionate, just and positive culture The skills and behaviours needed to develop great team and organisation cultures. This includes ensuring all staff and service users are listened to and heard, being respectful and challenging inappropriate behaviours. Building a trusted relationship with partners and communities The need to collaborate, consult and co-produce with colleagues in neighbouring teams, providers and systems, people using services, our communities, and our workforce. Strengthening relationships and developing Agenda item 6.2 Report to the Council of Governors - 29 January 2025 Title: Audit and Risk Committee Terms of Reference Sponsor: Keith Evans, Chair Author: Craig Machell, Associate Director of Corporate Affairs Purpose (Re)Assurance Approval Ratification Information x Strategic Theme Outstanding patient outcomes, safety and experience Pioneering research and innovation World class people Integrated networks and collaboration Foundations for the future x Executive Summary: The terms of reference for all Board committees should be reviewed regularly, and at least once annually, to ensure that these reflect the purpose and activities of each committee. The Code of Governance for NHS Provider Trusts requires that Council of Governors is consulted on the terms of reference. The terms of reference are approved by the Board of Directors. It is proposed to amend 10.2 to Code of Governance for NHS Provider Trusts and remove Charitable Funds Committee from Appendix A. No other changes are proposed. The Council of Governors is requested to provide any feedback on the proposed changes to the terms of reference prior to their submission to the Board of Directors for approval. Contents: Audit and Risk Committee Terms of Reference Risk(s): N/A Equality Impact Consideration: N/A Audit and Risk Committee Terms of Reference Version: 67 Date Issued: Review Date: Document Type: 29 February 2024 11 March 2025 30 January 2025 January 2026 Committee Terms of Reference Contents Paragraph 1 2 3 4 5 6 7 8 9 10 Role and Purpose Constitution Membership Attendance and Quorum Frequency of Meetings Conduct and Administration of Meetings Duties and Responsibilities Accountability and Reporting Review of Terms of Reference and Performance and Effectiveness References Appendices Appendix A Committee and Reporting Structure Page 2 2 2 3 3 3 4 6 6 6 Page 7 Document Status This is a controlled document. Whilst this document may be printed, the electronic version posted on the intranet is the controlled copy. Any printed copies of this document are not controlled. As a controlled document, this document should not be saved onto local or network drives but should always be accessed from the intranet. Page 1 of 8 1. Role and Purpose 1.1 The Audit and Risk Committee (the Committee) is responsible for overseeing, monitoring and reviewing corporate reporting, the adequacy and effectiveness of the governance, risk management and internal control framework and systems and areas of legal and regulatory compliance at University Hospital Southampton NHS Foundation Trust (UHS or the Trust) and the external and internal audit functions. 1.2 The Committee provides the board of directors of the Trust (the Board) with a means of independent and objective review of financial and corporate governance, assurance processes and risk management across the whole of the Trust’s activities both generally and in support of the annual governance statement. 1.3 The duties and responsibilities of the Committee are more fully described in paragraph 7 below. 2. Constitution 2.1 The Committee has been established by the Board. The Committee has no executive powers other than those set out in these terms of reference. It is supported in its work by other committees established by the Board as shown in Appendix A. 2.2 The Committee is authorised by the Board to investigate any activity within its terms of reference. It is authorised to seek any information it requires from any member of staff and all members of staff are directed to cooperate with any request made by the Committee. 2.3 In carrying out its role the Committee will primarily utilise the work of internal audit, external audit and other assurance functions. It is also authorised to seek reports and assurance from executive directors and managers and will maintain effective relationships with the chairs of other Board committees to understand their processes of assurance and links with the work of the Committee. 2.4 The Committee is authorised to obtain external legal or other independent professional advice if it considers this necessary, taking into consideration any issues of confidentiality and the Trust’s standing financial instructions. 3. Membership 3.1 The members of the Committee will be appointed by the Board and will be independent non-executive directors of the Trust (other than the chair of the Board). The Committee will consist of not less than three members, at least one of whom will have recent and relevant financial experience, ideally with a qualification from one of the professional accountancy bodies. 3.2 The Board will appoint the chair of the Committee from among its members (the Committee Chair).The Committee Chair may be the deputy chair of the Board. However, in the event that the deputy chair must act as chair of the Board for an extended period of time, the deputy chair will resign as Committee Chair. In the absence of the Committee Chair and/or an appointed deputy, the remaining members present will elect one of themselves to chair the meeting. 3.3 Only members of the Committee have the right to attend and vote at Committee meetings. However, the following will be invited to attend meetings of the Committee on a regular basis: 3.3.1 representative(s) from the external auditor; 3.3.2 representative(s) from the internal auditor; Page 2 of 8 3.3.3 representative(s) from the local counter fraud service; 3.3.4 Chief Financial Officer; 3.3.5 Chief Nursing Officer; and 3.3.6 Associate Director of Corporate Affairs/Company Secretary. 3.4 The Chief Executive Officer will be invited to attend meetings of the Committee, at least annually, to discuss with the Committee the process for assurance that supports the annual governance statement. 3.5 Other individuals may be invited to attend for all or part of any meeting, as and when appropriate and necessary, particularly when the Committee is considering areas of risk or operation that are the responsibility of a particular executive director or manager. 3.6 Governors may be invited to attend meetings of the Committee. 4. Attendance and Quorum 4.1 Members should aim to attend every meeting and should attend a minimum of 75% of meetings held in each financial year. Where a member is unable to attend a meeting they should notify the Committee Chair or Company Secretary in advance. 4.2 The quorum for a meeting will be two members. A duly convened meeting of the Committee at which a quorum is present will be competent to exercise all or any of the authorities, powers and discretions vested in or exercisable by the Committee. 4.3 When an executive director or manager is unable to attend a meeting they should appoint a deputy to attend on their behalf. 5. Frequency of Meetings 5.1 The Committee will meet at least four times each year and otherwise as required. 5.2 At least once each financial year the Committee will meet with representatives of the external and internal auditors without management being present to discuss their remit and any issues arising from their audits. 5.3 Outside of the formal meeting programme, the Committee Chair will maintain a dialogue with key individuals involved in the Trust’s governance, including the chair of the Board, the Chief Executive Officer, the Chief Financial Officer, the Chief Nursing Officer, the external audit lead partner and the head of internal audit. 6. Conduct and Administration of Meetings 6.1 Meetings of the Committee will be convened by the secretary of the Committee at the request of the Committee Chair or any of its members, or at the request of external or internal auditors if they consider it necessary. 6.2 The agenda of items to be discussed at the meeting will be agreed by the Committee Chair with support from the Chief Financial Officer and the Company Secretary. The agenda and supporting papers will be distributed to each member of the Committee and the regular attendees no later than five working days before the date of the meeting. Distribution of any papers after this deadline will require the agreement of the Committee Chair. 6.3 The secretary of the Committee will minute the proceedings of all meetings of the Committee, including recording the names of those present and in attendance and any declarations of interest. 6.4 Draft minutes of Committee meetings and a separate record of the actions to be taken forward will be circulated promptly to all members of the Committee. Once approved by Page 3 of 8 the Committee, minutes will be circulated to all other members of the Board unless it would be inappropriate to do so in the opinion of the Committee Chair. 7. Duties and Responsibilities The Committee will carry out the duties below for the Trust. 7.1 Integrated Governance, Risk Management and Internal Control 7.1.1 The Committee will review the establishment and maintenance of an effective system of integrated governance, risk management and internal control across the whole of the Trust’s activities (clinical and non-clinical), that supports the achievement of the Trust’s objectives. In particular, the Committee will review the adequacy and effectiveness of: 7.1.1.1 all risk and control related disclosure statements (in particular the annual governance statement), together with the head of internal audit opinion, external audit opinion or other appropriate independent assurances, prior to submission to the Board; 7.1.1.2 the underlying assurance processes that indicate the degree of achievement of the Trust’s objectives, the effectiveness of the management of principal risks and the appropriateness of annual disclosure statements; and 7.1.1.3 the policies and arrangements for ensuring compliance with relevant regulatory, legal and code of conduct requirements and any related reviews, reporting and selfcertifications, including the NHS Constitution, the Trust’s NHS provider licence, registration with the Care Quality Commission and the Trust’s constitution, standing orders and standing financial instructions and management of conflicts of interest. 7.2 Internal Audit 7.2.1 The Committee will ensure that there is an effective internal audit function that meets the Public Sector Internal Audit Standards and provides appropriate independent assurance to the Committee, Accounting Officer and Board. This will be achieved by: 7.2.1.1 considering the provision of the internal audit service and the costs involved; 7.2.1.2 reviewing and approving the annual internal audit plan and more detailed programme of work, ensuring that this is consistent with the audit needs of the Trust as identified in any risk assessment; 7.2.1.3 considering the major findings of internal audit work (and the appropriateness and implementation of management responses) and ensuring coordination between the internal and external auditors to optimise audit resources; 7.2.1.4 ensuring the internal audit function is adequately resourced and has appropriate standing within the Trust; and 7.2.1.5 monitoring the effectiveness of internal audit and carrying out an annual review. 7.3 External Audit 7.3.1 The Committee will review and monitor the external auditors’ integrity, independence and objectivity and the effectiveness of the external audit process. In particular, the Committee will review the work and findings of the external auditors and consider the implications and management’s response to their work. This will be achieved by: 7.3.1.1 considering the appointment and performance of the external auditors, including providing information and recommendations to the council of governors in connection with the appointment, reappointment and removal of the external auditors in line with criteria agreed by the council of governors and the Committee; Page 4 of 8 7.3.1.2 discussing and agreeing with the external auditors, before the external audit commences, the nature and scope of the audit as set out in the annual external audit plan; 7.3.1.3 discussing with the external auditors their evaluation of audit risks and assessment of the Trust and the impact on the audit fee; 7.3.1.4 reviewing all external audit reports, including reports addressed to the Board and the council of governors, and any work undertaken outside the annual external audit plan, together with any significant findings and the appropriateness and implementation of management responses; and 7.3.1.5 ensuring that there is in place a clear policy for the engagement of external auditors to supply non-audit services taking into account relevant ethical guidance. 7.4 Financial Reporting 7.4.1 The Committee will monitor the integrity of the financial statements of the Trust and any formal announcements relating to the Trust’s financial performance. 7.4.2 The Committee will ensure that the systems for financial reporting to the Board, including those of budgetary control, are subject to review as to the completeness and accuracy of the information provided to the Board. 7.4.3 The Committee will review the annual report and financial statements before these are presented to the Board in order to determine their completeness, objectivity, integrity and accuracy and the letter of representation addressed to the external auditors from the Board. This review will cover but is not limited to: 7.4.3.1 the annual governance statement and other disclosures relevant to the work of the Committee; 7.4.3.2 areas where judgment has been exercised; 7.4.3.3 appropriateness and adherence to accounting policies and practices; 7.4.3.4 explanation of estimates or provisions having material effect and significant variances; 7.4.3.5 the schedule of losses and special payments, which will also be reported on separately during the financial year; 7.4.3.6 any significant adjustments resulting from the audit and unadjusted audit differences; and 7.4.3.7 any reservations and disagreements between the
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Governors/Papers-CoG-29.01.2025.pdf

NIHR RTB_IBHO_PIS-ICF_v1.4_12SEP2024_Localised

Description: PARTICIPANT INFORMATION SHEET Improving Black Health Outcomes (IBHO) NIHR BioResource Version 1.4, 12 Sep 2024 Reading time: 20 minutes This is a detailed document outlining why we are inviting you to join the National Institute for Health and Care Research (NIHR) BioResource through a research project called Improving Black Health Outcomes (IBHO), known as the IBHO BioResource. We understand your time is valuable, however, we would encourage you to take the time to read all the information before deciding whether you would like to get involved. Please feel free to ask if you have questions or would like more information. You can also visit: www.bioresource.nihr.ac.uk/ibho Taking part in research is completely voluntary and your decision will not in any way affect your healthcare. You can also withdraw from taking part at any time. More information on this can be found in this document in Section 1 & 2. Contents: Section 1: Why we are asking you to join this research project Section 2: Who manages and funds the project Section 3: What to expect from taking part Section 4: Consent form *If you need this information to be translated into another language or in a different format, please speak to a member of the NIHR BioResource team. Website: https://bioresource.nihr.ac.uk/ Email: ibho@bioresource.nihr.ac.uk Page 1 of 13 IRAS ID: 313104 NIHR RTB IBHO PIS-ICF v1.4, 12/SEP/2024 Section 1 Why am I being asked to join the IBHO BioResource? We are inviting people from Black communities, with and without health conditions, to join the IBHO BioResource. For the IBHO BioResource, Black communities refers to individuals who are from the following ethnic backgrounds: Black African, Black Caribbean, Black African-Caribbean, Black British, Black Welsh, Black Irish, Black Scottish, Dual or Mixed Black heritage, and/or Black ‘other’. We recognise that individuals who are not from Black communities may also live with a health condition of interest to the IBHO BioResource, such as Sickle Cell. To help us better understand these conditions, we are inviting patients of any ethnicity with certain health conditions to join our programme. Your contribution will help us improve understanding, treatment and ultimately outcomes for all individuals affected. What is the aim of the IBHO BioResource? Health research studies have rarely focused on the specific health needs and experiences of people from Black communities. This can be problematic since the findings might not always apply to everyone equally. As a result, people from Black communities have often not benefitted from advances in health research. By creating the IBHO BioResource we hope to change this, so that in future, when researchers find something important, for example, a gene that relates to a health condition, we can be sure that this is true for Black communities too. The IBHO BioResource will be a resource to support health research. We will create this resource by collecting information from your sample (e.g., genetic data), information from health records (e.g., use of medication), personal information (e.g., age, gender), and lifestyle (e.g., diet, smoking), and social factors (e.g., housing, employment). Why is the IBHO BioResource important? The IBHO BioResource will enable research into a range of health conditions. These include: • conditions that are common in UK-based Black communities such as diabetes, • conditions that almost exclusively affect Black people such as sickle cell disorder, • conditions that are not well researched in UK-based Black communities such as anxiety, depression, and skin problems. We aim to improve our understanding of: a) how and why some health conditions occur in Black communities, Website: https://bioresource.nihr.ac.uk/ Email: ibho@bioresource.nihr.ac.uk Page 2 of 13 IRAS ID: 313104 NIHR RTB IBHO PIS-ICF v1.4, 12/SEP/2024 b) what are the best assessments to accurately identify these conditions in Black people, and, most importantly, c) how we can use the research findings to improve and/or develop interventions and treatments that are tailored to the specific needs and health experiences of Black communities. Do I have to join the IBHO BioResource? No. Your decision is voluntary, and it is completely up to you to decide whether you wish to take part. If you decide not to join, your decision will not affect the healthcare you receive in any way. If you join, you will be free to withdraw at any time, without having to give a reason. Section 2 Who manages and funds the IBHO BioResource? The IBHO BioResource forms part of the NIHR BioResource Research Tissue Bank. The IBHO BioResource is a collaboration between the NIHR Maudsley BioResource Centre at King’s College London, led by Professor Gerome Breen and Dr Juliana Onwumere (IBHO project Co-Principal Investigators), the NIHR BioResource, which is led by Professor John Bradley (Chief Investigator) and Dr Nathalie Kingston (Director), and Genomics England, led by Professor Matt Brown (Chief Scientific Officer) and Dr Sara Trompeter (Clinical lead for Sickle Cell, Diverse Data). The NIHR BioResource and NIHR Maudsley BioResource Centre is funded by the National Institute for Health and Care Research (NIHR). Genomics England is funded by the Department of Health and Social Care (DHSC). Research such as this must be approved by a research ethics committee. The NIHR BioResource has been approved by Cambridge Central Research Ethics Committee. What is the NIHR BioResource Research Tissue Bank? The NIHR BioResource is a panel of hundreds of thousands of volunteers, with and without health conditions, who wish to participate in health research. Volunteers joining the BioResource are asked to donate a small blood or saliva sample and give consent to be invited to participate in health-related research studies. Invitations are based on data gathered from samples and information volunteers have provided. Information and samples that the BioResource holds may also be made available to researchers working in biomedical and healthcare research. Website: https://bioresource.nihr.ac.uk/ Email: ibho@bioresource.nihr.ac.uk Page 3 of 13 IRAS ID: 313104 NIHR RTB IBHO PIS-ICF v1.4, 12/SEP/2024 What is Genomics England’s National Genomic Research Library? The National Genomic Research Library (the ‘Library’) is a secure national database of deidentified genetic and health data from people in the UK, managed by Genomics England. We are inviting you to join the ‘Library’, to help us learn more about genes and health, so we can improve healthcare for everyone in the future. You can choose not to join the ‘Library’ and still join the IBHO BioResource. If you choose to opt-in, the IBHO team may share your sample and data with Genomics England depending on the analysis that will be done (e.g., whole genome sequencing). The NIHR BioResource will also share a copy of your signed consent form with Genomics England. Section 3 What will happen if I agree to take part in the IBHO BioResource? 1. If you are interested in participating, you will be asked to read and sign the consent form at the end of this document, and you will be given a copy to keep. 2. After providing your written permission to take part, you will be asked to complete a questionnaire that will ask some questions about yourself and your health experiences. You can choose to complete it either by yourself or with a member of the healthcare or research team using a paper format or online. This will take approximately 20 minutes. 3. To facilitate this important health research, we also request consent to link to your health and social care records. Using these linkages, we can investigate how health experiences and treatment can affect your healthcare and other areas of your life, such as education and employment. You will be asked to provide a blood or saliva sample, depending on your preference. This will involve taking blood from you via a needle in your arm like during a blood test or swabbing the inside of your cheek/spitting into a tube. 4. We will offer you a £15 voucher and cover travel costs incurred outside of routine clinical appointments up to the value of £22.50 for joining the IBHO BioResource. 5. As a participant of the IBHO BioResource, and based on the information you provide, you may receive invitations to other studies you can take part in, and you can decide whether to do so. You will be invited to a maximum of eight studies per year (four face-to-face and four online). Participation in further studies will always be optional and voluntary. If applicable, we can contribute towards your travel costs to take part in further studies. Website: https://bioresource.nihr.ac.uk/ Email: ibho@bioresource.nihr.ac.uk Page 4 of 13 IRAS ID: 313104 NIHR RTB IBHO PIS-ICF v1.4, 12/SEP/2024 Some studies may not require any further input from you as the data or samples you provided previously will be enough. What are the potential benefits of taking part in IBHO? There are no immediate benefits to taking part in the IBHO BioResource. However, some people welcome the opportunity to be involved in a new project and contributing to new knowledge that might lead to better future healthcare for individuals. We will keep participants who opt in on the Data Collection Sheet up to date with progress via a yearly newsletter. What are the potential disadvantages/risks? Some of the study questionnaires include sensitive questions about health conditions, experiences of using health services, and other topics. You do not have to complete any questions that you do not wish to answer, and you can always approach a member of the clinical or IBHO BioResource team for further clarification if anything is unclear. Providing a saliva sample involves spitting into a tube that some people find unpleasant. Giving a blood sample can sometimes cause discomfort, and a small bruise may develop. Only trained staff will collect samples and will be happy to answer any questions, respond to any concerns you might have and provide reassurance. What will happen to the samples I give? We will extract DNA (deoxyribonucleic acid) from your blood or saliva sample in various ways to study your genetic makeup. This can include methods such as whole genome sequencing of your DNA. For specific projects, we will also test other parts of your blood, such as cells, RNA (ribonucleic acid), proteins and metabolites. Your samples will be labelled with a unique number before being transferred to the laboratory for testing, so that laboratory staff will not know your name or any personal information. Your samples will be kept in a secure location. Why are you collecting my genetic data (DNA)? Genes are made up of DNA. The genetic code of your DNA can provide a picture about risks of disease development, and can, together with lifestyle data, help us research and understand potential changes that affect health risks. Can I know the results obtained from my samples? The BioResource does not provide a report or feedback on any genetic or laboratory results obtained from your sample, as it is taken for research purposes only. Website: https://bioresource.nihr.ac.uk/ Email: ibho@bioresource.nihr.ac.uk Page 5 of 13 IRAS ID: 313104 NIHR RTB IBHO PIS-ICF v1.4, 12/SEP/2024 Will any of the results obtained with my sample predict the risk of disease? The BioResource supports studies that may discover genetic links to certain diseases. While it is unlikely that the sample of a single person can predict disease risk, looking at data and samples in large numbers helps us find patterns and trends. It may be years before these discoveries can be used to predict the risk of disease or the risk of a complication from a known disease. If you are contacted to take part in a future study, this does not mean that your health is at risk. Genetic differences between individuals can either protect against or increase the risk of developing a disease. We are a long way from fully understanding the complete picture of how genes and environmental factors (e.g., lifestyle) affect the risk of disease. Some of the studies the IBHO BioResource may invite you to take part in could reveal unexpected/previously unknown health conditions or future health risks. You will be able to decide if you want to be invited to these types of studies. What happens if an invention is made using my sample? Your samples and related information are donated as a gift for research. If an invention is made from the research undertaken with your sample or data, you will not receive any compensation, recognition or payment for your valuable contribution. Any researchers who publish studies that use IBHO BioResource and/or ‘Library’ data are required to thank IBHO participants for their contribution. The BioResource and/or the ‘Library’ will not share your sample to make a profit. Will my details be kept confidential and secure? Yes. Best ethical and legal practices will be followed to ensure that all information collected about you will be handled safely and securely. Data about you (e.g., personal details and health information) will be stored in secure electronic databases. Any information from genetic and other tests will be stored separately from your personal details. Only authorised members of the NIHR BioResource or Genomics England can access your personal details (for example, to invite you to take part in other research studies). Information about you will not be used or shared for any purpose other than for research. We do not share any data with insurance companies. We also do not share data with governmental organisations, unless they have a research purpose. An explanation of how the BioResource complies with the Data Protection Act 2018 and UK General Data Protection Regulation (UK GDPR) can be found at the end of this document. Website: https://bioresource.nihr.ac.uk/ Email: ibho@bioresource.nihr.ac.uk Page 6 of 13 IRAS ID: 313104 NIHR RTB IBHO PIS-ICF v1.4, 12/SEP/2024 Data linkage for health and social care records For data linkage for important information about your health, and where necessary education and social records, the IBHO BioResource or ‘Library’ team will securely link your data directly with the database managers at, for example, the NHS or Office for National Statistics. Only individuals with approved qualifications, including on data security can do this linkage. This will be via secure transfer that meets NHS and/or Government data security standards. How will researchers use data within the IBHO BioResource and/or the ‘Library’? IBHO BioResource Researchers must apply, and receive approval, to access your samples or data. Researchers can only request data that is relevant and specific to their project. Research applications are discussed by our Data Access Committee or Steering Committee, who use a set of principles to decide whether the application is acceptable. This is referred to as ‘managed access’. Requests could come from researchers from the public and charitable sector (Universities, Research Institutes), or from commercial and pharmaceutical companies. These can be based either in the UK or overseas. Data may be accessed in several ways, for example, by logging in to secure data analysis environments or by downloading it from the BioResource. Researchers are legally bound to keep your data secure by accepting the terms of an agreement, this includes not attempting to identify you. Researchers can publish the results of their studies in reports or publications which are available on the internet and in journal articles. Under no circumstances will information that identifies you or any other participant be disclosed. Published studies are available to view on the NIHR BioResource website https://bioresource.nihr.ac.uk/studies/. National Genomic Research Library As in the BioResource, researchers can apply to use samples and data from the ‘Library’ in a format that does not identify you, to study diseases and look for new treatments. Researchers may come from all over the world, and they may work for not-for-profit organisations, such as research charities, universities, or hospitals, and commercial companies such as drug or technology companies. They will only have access to your deidentified (pseudonymised) data in the National Genomic Research Library, and only if their application to access your data is approved by Genomics England. Your samples and data will be kept securely. Your data cannot be taken out of the ‘Library’ and any results of research cannot be used to re-identify you. Website: https://bioresource.nihr.ac.uk/ Email: ibho@bioresource.nihr.ac.uk Page 7 of 13 IRAS ID: 313104 NIHR RTB IBHO PIS-ICF v1.4, 12/SEP/2024 What if I no longer wish to be a member of the IBHO BioResource and/or the National Genomic Research Library? You are free to withdraw from the IBHO BioResource and/or the National Genomic Research Library at any time, without giving a reason. If you would like to withdraw, simply contact the IBHO BioResource team by email or phone. If you choose to withdraw, there are two options: 1. Full withdrawal: You can ask us to stop further use of your data and to destroy your remaining samples. Any research that has used your data or sample(s) cannot be undone. 2. Partial withdrawal: You can allow us to continue accessing your healthcare records (and any required social and educational records) from central NHS records, your hospital, your GP, school and/or research done with your sample, but we will not contact you about future research. Your personal information will be retained in an archive so that a record remains of your initial consent and the withdrawal process. If the BioResource is unable to confirm your decision, your sample(s) and data will be retained for future use, and you will not be contacted again. Contact information If you require further information before deciding to join the IBHO BioResource, or have any queries, please feel free to contact the BioResource team on 0800 090 2233 or email us on ibho@bioresource.nihr.ac.uk. General Data Protection Regulation (UK GDPR) Here, we explain how we comply with the Data protection Act 2018 and UK General Data Protection Regulation (UK GDPR). Please also read our Privacy Notice: https://bioresource.nihr.ac.uk/media/04nhduml/privacy-notice-v2.pdf, which explains what we do with the information we hold about you, how you can request access to this personal data, and your other data rights. Cambridge University Hospitals NHS Foundation Trust (CUH) is the organisation responsible for managing the NIHR BioResource Research Tissue Bank, including the IBHO BioResource. We will be using information from you, and your healthcare, social care and education (if required) records in order to support research studies, and CUH will act as the data controller for the information we hold. We are responsible for looking after your information and using it properly. Website: https://bioresource.nihr.ac.uk/ Email: ibho@bioresource.nihr.ac.uk Page 8 of 13 IRAS ID: 313104 NIHR RTB IBHO PIS-ICF v1.4, 12/SEP/2024 We will keep identifiable information about you for 10 years after the programme has finished, and we may approach you to extend this. How will we use information about you? The IBHO BioResource and/or Genomics England asks to use information from you, from your medical records, including from your GP, hospital records and other health-related central records. The NIHR BioResource will also ask to access your social care and, if required, your education records. This information will include your: • Full name; • NHS/CHI number; • Date of birth; • Contact details, including address, phone number and email address; • Name and contact details of your GP; • Health-related information, e.g., on your lifestyle, medical history, medication etc; • Social care and education information, e.g., level of education; • Genetic information that will be generated from your blood or saliva samples or provided by, for example, NHS health-related central records, disease registries etc. • Electronic copies of all your past and future records from the NHS, your GP and other organisations (such as NHS England and other Public Health bodies); • Information about any illnesses or stays in an NHS hospital; • Copies of hospital or clinic records, medical notes, social care, and other local or national disease registries; • Relevant images from your NHS or other records, such as MRI scans, X-rays, or medical photographs; • Data from other research registries and studies that may be relevant (but only where you have given them your permission to share that information). Information about you, but not your personal identifiable information, will be sent to approved researchers in other countries worldwide. They will not be able to see your name, NHS/CHI number, date of birth or contact details (which are your “personal identifiable information”). Your data will be de-identified and have a code number instead. They must follow our rules about keeping your information safe (see the section about ‘Managed access’). If and when the IBHO BioResource finishes, we will keep some of the data so we can check the results. We will write our reports in a way that ensures no-one can work out that you took part in the study. Website: https://bioresource.nihr.ac.uk/ Email: ibho@bioresource.nihr.ac.uk Page 9 of 13 IRAS ID: 313104 NIHR RTB IBHO PIS-ICF v1.4, 12/SEP/2024 What are your choices about how your information is used? • You can stop being part of the study at any time, without giving a reason as explained in the 'Withdrawal process’ section above. • You may request a copy of the information we hold about you; • You can request changes in some of the information we hold about you (for example, your contact details and contact preferences); however, we won’t be able to change other data we hold about you (such as your genetic information). Where can you find out more about how your information is used? You can find out more about how we use your information • On the Health Research Authority website www.hra.nhs.uk/information-aboutpatients/ • The NIHR BioResource privacy notice, available from https://bioresource.nihr.ac.uk/media/04nhduml/privacy-notice-v2.pdf which includes the contact details of the Data Protection Officer at CUH; • Genomics England’s privacy notice available from https://www.genomicsengland.co.uk/privacy-policy • By asking one of the IBHO BioResource research team; • By sending us an email at ibho@bioresource.nihr.ac.uk; • By calling us on Freephone 0800 090 2233. Thank you for reading this information sheet and for considering joining the IBHO BioResource If you would like independent advice please contact: Patient Support Services, C Level Centre Block, Mailpoint 81, Southampton General Hospital, Tremona Road, Southampton, SO16 6YD. Telephone on 023 8120 6325 or Email at patientsupportservices@uhs.nhs.uk Principal Investigator Prof Saul Faust, National Institute of Health Clinical Research Facility Director, University Hospital Southampton NHS Foundation Trust, MP 218, Level C, West Wing, Tremona Road, Southampton, SO16 6YD. Telephone: 023 8120 4989. Southampton BioResource Centre Coordinating Team NIHR Southampton Clinical Research Facility (CRF) study team, University Hospital Southampton NHS Foundation Trust, MP 218, Level C, West Wing, Tremona Road, Southampton, SO16 6YD. Telephone: 023 8120 4989. Website: https://bioresource.nihr.ac.uk/ Email: ibho@bioresource.nihr.ac.uk Page 10 of 13 IRAS ID: 313104 NIHR RTB IBHO PIS-ICF v1.4, 12/SEP/2024 Attach barcode here PARTICIPANT CONSENT FORM The IBHO BioResource, part of the NIHR BioResource Research Tissue Bank Please initial box 1. I confirm that I have read (or had read to me) the information sheet version 1.4, dated 12/SEP/2024. I have had the opportunity to consider the information, ask questions and have these answered satisfactorily. 2. I understand that my participation is voluntary and that I am free to withdraw at any time, without giving any reason, and without my medical care or legal rights being affected. 3. I agree that the IBHO BioResource may access my medical, health, social care, and educational (if required) records held by public bodies, and to analyse and store this information long-term. I understand that this may include the provision of information about my health status. I understand that in order to access these records, identifiable personal details – like name, NHS number, date of birth will be sent to these public bodies. 4. I agree to give blood or saliva for health-related research. I understand that my samples and data may be shared to support future research, including commercial studies. I understand my samples will be tested, and that this may include the reading of my entire genetic code. I understand my samples will be stored long-term. 5. I agree to provide personal and contact details. I agree to provide information for example, through the completion of questionnaires. I agree to be contacted by the BioResource to invite me to participate in other research studies. 6. I understand that relevant sections of my medical/health related, social care and education (if required) records and data collected during the study may be looked at by approved individuals for auditing and monitoring purposes. I give permission for this. 7. I understand my samples and de-personalised data may be shared with researchers through a ‘managed access’ process. 8. I understand that my samples are taken for research, and the BioResource will not feed back any genetic or other test results. Website: https://bioresource.nihr.ac.uk/ Email: ibho@bioresource.nihr.ac.uk Page 11 of 13 IRAS ID: 313104 NIHR RTB IBHO PIS-ICF V 1.4, 12 SEP 2024 When completed: 1 for participant; 1 (original) for researcher site file; [1 to be kept in medical notes (optional – delete as required)]. 9. I agree to join the IBHO BioResource, which is part of the NIHR BioResource Research Tissue Bank. OPTIONAL CONSENT TO THE NATIONAL GENOMIC RESEARCH LIBRARY Please put your initials in the box This section gives you the choice to opt-in to the National Genomic Research Library. Please initial box 10. I understand that my sample and data may be held in the National Genomic Research Library, managed by Genomics England. I am happy for Genomics England to obtain additional data from the NHS and other public registries. I give my permission for approved researchers to access my data for research. I understand I can withdraw from the National Genomic Research Library at any time. I agree for my sample and data to be held by the National Genomic Research Library. ……………………………………………. Participant: First Name and Surname (BLOCK CAPITALS) ……………… ……………………… …………….. Date of Birth Signature Date ……………………………………………………………… Person receiving consent: First Name and Surname (BLOCK CAPITALS) ……………………… ……………... Signature Date Website: https://bioresource.nihr.ac.uk/ Email: ibho@bioresource.nihr.ac.uk Page 12 of 13 IRAS ID: 313104 NIHR RTB IBHO PIS-ICF V 1.4, 12 SEP 2024 When completed: 1 for participant; 1 (original) for researcher site file; [1 to be kept in medical notes (optional – delete as required)]. WITNESS/TRANSLATOR STATEMENT: If participant is not able to read the text and/or sign for themselves but has capacity to give consent OR if the Participant Information Sheet and Consent Form has been translated. Witness/translator [to delete either as appropriate]: I witnessed accurate reading of the consent form to the potential participant, who could ask any questions and received satisfactory answers or I was present during the meeting between [insert name] and the participant. I translated for the participant the Participant Information Sheet and the Consent Form. I confirm that they gave their consent freely. ……………………………………………………. Witness/translator: First Name and Surname (BLOCK CAPITALS) ……………………… …………….. Signature Date FOR WITNESS AND/OR TRANSLATOR USE ONLY Website: https://bioresource.nihr.ac.uk/ Email: ibho@bioresource.nihr.ac.uk Page 13 of 13 IRAS ID: 313104 NIHR RTB IBHO PIS-ICF V 1.4, 12 SEP 2024 When completed: 1 for participant; 1 (original) for researcher site file; [1 to be kept in medical notes (optional – delete as required)].
Url: /Media/Southampton-Clinical-Research/Downloads/NIHR-RTB-IBHO-PIS-ICF-v1.4-12SEP2024-Localised.pdf

EDI Champion role descriptor_final 180924

Description: Job Title: NIHR Southampton BRC Equity Champion Salary: Clinical Academic 2PAs / non-Clinical Academics 0.2 WTE Department: Trust HQ, NIHR
Url: /Media/Southampton-Clinical-Research/Downloads/EDI-Champion-role-descriptor-final-180924.pdf

Cardiac surgery - patient information

Description: The aim of this book is to give you written advice about recovery following cardiac surgery. We know that for many
Url: /Media/UHS-website-2019/Patientinformation/Heartandlungs/Cardiacsurgery-1362-PIL.pdf

Trastuzumab (21 day-Maintenance)

Description: Chemotherapy Protocol BREAST CANCER TRASTUZUMAB (21 day- Maintenance) Regimen • Breast Cancer – Trastuzumab (21 day-Maintenance) Indication • Adjuvant treatment of breast cancer
Url: /Media/UHS-website-2019/Docs/Chemotherapy-SOPs1/Breastcancer/Trastuzumab-21-day-Maintenance.pdf

Trastuzumab (21 day-Load)

Description: Chemotherapy Protocol BREAST CANCER TRASTUZUMAB (21 day-Load) Regimen • Breast Cancer – Trastuzumab (21 day-Load) Indication • Adjuvant treatment of breast cancer
Url: /Media/UHS-website-2019/Docs/Chemotherapy-SOPs1/Breastcancer/Trastuzumab-21-day-Load.pdf

Trastuzumab Main

Description: Chemotherapy Protocol GASTROINTESTINAL (UPPER) CANCER TRASTUZUMAB (21 day-Maintenance) Regimen • GI (upper) – Trastuzumab (21 day-Maintenance) Indication • Trastuzumab, in combination with
Url: /Media/UHS-website-2019/Docs/Chemotherapy-SOPs1/Upper-gastro-intestinal/TrastuzumabMainVer1.2.pdf

Tracheostomy - patient information

Description: A tracheostomy is an opening created at the front of the neck allowing a tube to be inserted into the windpipe
Url: /Media/UHS-website-2019/Patientinformation/Childhealth/Tracheostomy-1139-patientinformation.pdf

Robotic gynaecological surgery - patient information

Description: information about robotic gynaecological surgery to the female pelvic region: the uterus, ovaries, cervix, fallopian tubes, vagina and vulva.
Url: /Media/UHS-website-2019/Patientinformation/Womenshealth/Robotic-gynaecological-surgery-3779-PIL.pdf

Pain relief in labour: epidurals and remifentanil explained - patient information

Description: Pain relief in labour: Epidurals and Remifentanil explained.
Url: /Media/UHS-website-2019/Patientinformation/Pregnancyandbirth/Pain-relief-in-labour-epidurals-and-remifentanil-690-PIL.pdf

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NIHR RTB_IBHO_PIS-ICF_v1.4_12SEP2024_Localised

EDI Champion role descriptor_final 180924

Cardiac surgery - patient information

Trastuzumab (21 day-Maintenance)

Trastuzumab (21 day-Load)

Trastuzumab Main

Tracheostomy - patient information

Robotic gynaecological surgery - patient information

Pain relief in labour: epidurals and remifentanil explained - patient information

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