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Press release: Hospital trust develops 'WhatsApp-style' flu alert for smartphones

Description: Clinicians at Southampton's teaching hospitals now receive instant alerts to inform them if a patient has tested positive for flu and which strain they have via a new 'WhatsApp-style' messaging app.
Url: /AboutTheTrust/Newsandpublications/Latestnews/2019/January/Press-release-Hospital-trust-develops-'WhatsApp-style'-flu-alert-for-smartphones.aspx

Papers CoG 28.10.2025

Description: Date Time Location Chair Agenda - Council of Governors 28/10/2025 14:00 - 15:30 Heartbeat Conference Room/Microsoft Teams Jenni Douglas-Todd 1 Chair’s Welcome and Opening Comments 14:00 2 Declarations of Interest 14:05 3 Minutes of Previous Meeting 14:06 Approve the minutes of the previous meeting held on 16 July 2025. 4 Matters Arising/Summary of Agreed Actions 14:08 5 Strategy, Quality and Performance 5.1 Chief Executive Officer's Performance Report 14:09 Receive and note the report Sponsor: David French, Chief Executive Officer 6 Governance 6.1 Governor Attendance at Council of Governors' Meetings 14:29 Review governor attendance at Council of Governors' meetings Sponsor: Jenni Douglas-Todd, Trust Chair Attendees: Craig Machell: Associate Director of Corporate Affairs and Company Secretary and Karen Russell, Council of Governors' Business Manager 6.2 Review of Council of Governors' Expenses Reimbursement Protocol 14:34 Review the proposed changes to the Council of Governors' expenses reimbursement protocol Sponsor: Jenni Douglas-Todd, Trust Chair Attendees: Craig Machell, Associate Director of Corporate Affairs and Company Secretary and Karen Russell, Council of Governors' Business Manager 6.3 Appointment of Deputy Chair 14:39 Approve the appointment of Jane Harwood as Deputy Chair Sponsor: Jenni Douglas-Todd, Trust Chair 14:49 Break 7 Membership Engagement and Governor Activity 7.1 Membership Engagement 14:59 Receive the report Sponsor: Jenni Douglas-Todd, Trust Chair Attendee: Sam Dolton, Events and Membership Officer 7.2 Governors' Nomination Committee Feedback 15:09 Chair: Jenni Douglas-Todd, Trust Chair 8 Review of Meeting 15:14 Review and feedback on the content of this meeting Sponsor: Jenni Douglas-Todd, Trust Chair 9 Any Other Business 15:24 Raise any relevant or urgent matters that are not on the agenda 10 Date of Next Meeting: 29 January 2026 15:29 Note the date of the next meeting Page 2 Minutes - Council of Governors (CoG) Open Session Date Time Location Chair Present 16 July 2025 14.00-15.45 Conference Room, Heartbeat Education Centre and Microsoft Teams Jenni Douglas-Todd, Trust Chair Jenni Douglas-Todd, Trust Chair Theresa Airiemiokhale, Elected, Southampton City Shirley Anderson, Elected, New Forest, Eastleigh and Test Valley Patricia Crates, Elected, New Forest, Eastleigh and Test Valley Sandra Gidley, Elected, New Forest, Eastleigh and Test Valley Lesley Gilder, Elected, Southampton City Ben Grassby, Elected, Rest of England and Wales Professor Sue Latter, Appointed, University of Southampton Jenny Lawrie, Elected, Southampton City Brian Lovell, Elected, Rest of England and Wales Councillor Louise Parker-Jones, Appointed, Hampshire County Council Cat Rushworth, Elected, Isle of Wight Karen Smith-Baker, Elected, Health Professional and Health Scientist Staff Jake Smokcum, Elected, Nursing and Midwifery Staff Liz Taylor, Elected, Non-Clinical and Support Staff JDT TA SA PC SG LG BG SL JL BL LPJ CR KSB JS LT In attendance Andrew Asquith, Director of Planning and Productivity (for Item 5.2) AA Tracey Burt, Minutes TB Keith Evans, NED, Chair Audit and Risk Commitee KE Steve Harris, Chief People Officer (for Item 5.1) SHa 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 David Watts, Corporate Affairs DW Apologies Professor Cathy Barnes, Appointed, Solent University CB Sathish Harinarayanan, Elected, Medical Practitioners and Dental SH Staff Linda Hebdige, Elected, Southampton City LH Councillor Pam Kenny, Appointed, Southampton City Council PK Esther O’Sullivan, Elected, New Forest, Eastleigh and Test Valley EO Mike Williams, Elected, New Forest, Eastleigh and Test Valley MW 1 Chair’s Welcome and Opening Comments JDT welcomed everyone to the meeting. She noted that several governors were coming to the end of their term of office and said that she would return to the matter later in the meeting. 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 29 April 2025 were approved as an accurate record of the meeting. 4 Matters Arising/Summary of Agreed Actions There were two items arising from the previous meeting on 29 April 2025: • the poor acoustics in the Heartbeat Suite conference room. JDT advised that she would update governors during Any Other Business. • JDT welcomed KE to the meeting to provide an update regarding the Annual Report and accounts. He advised that it contained three parts, the Annual Report, the Quality Account and detailed annual financial statements and he encouraged governors to read it. External auditors had been going through the document for quality control purposes but he did not expect any issues to be raised. CM advised that he hoped to issue the Annual Report and accounts by Friday 18 July. The final version, however, was now unlikely to be published until September, as it still had to be laid before Parliament, whose summer recess commenced on 21 July 2025. 5 Strategy, Quality and Performance 5.1 Chief Executive Officer’s Performance Report JDT welcomed SHa to the meeting, who said that he was attending on behalf of David French, CEO. He advised that the organisation was under a significant level of duress and he said that he had never known so many competing challenges. Much time was currently occupied by managing organisational change and the need to deliver the financial plan, whilst treating more patients than ever before, with a reduced workforce. At the end of Month 2 (May 2025) the Trust had been in line with the financial plan, with a deficit of £8m and the delivery of £12.5m of savings. Whilst the Trust benchmarked well across many areas, the Emergency Department (ED) continued to be a challenge, with more patients than ever attending. An external review of the department had been undertaken in June but it was proving difficult to move forward. The non-criteria to reside (NCTR) numbers had increased to peaks of 270 from an average of 220 and continued to have a negative impact on expenditure and patient flow across the organisation. Waiting lists were growing and SHa suggested that public patience was wearing thin, which meant that an increase in complaints was being seen. The hospital mortality rate, however, continued to show better than expected survival rates. SH advised that the Trust had one of the most challenging workforce plans it had ever had. It was looking to reduce the workforce by 6% and had set out a number of ways to achieve that goal, including some challenging recruitment controls. The divisional structure, which had been in place for around 15 years had now been changed to align more closely to national NHS priorities and to yield savings. The new structure, with three divisions instead of four, had gone live on 1st July 2025 and had mostly been achieved through natural attrition. Divisions had been asked to look for a 5% reduction in their pay costs and a 10% target 2 had been set for the Trust HQ function. Work was also being undertaken to reduce spending on bank staff. A Mutually Agreed Resignation Scheme (MARS), which was unique to UHS, had been launched and 222 applications had been received. Scrutiny of those applications was ongoing but it had been decided that 95 could not be allowed to resign and 14 were not eligible. Resident doctors, nationally, had turned down a 5.5% pay deal and had issued 14 days’ notice of industrial action, starting on 25 July 2025. Consultants and senior colleagues would, therefore, be required to provide cover by acting down. The Royal College of Nursing was also currently campaigning heavily regarding their pay and industrial action was possible. JDT thanked SHa for his report. 5.2 Operating Plan 2025 JDT welcomed AA, Director of Planning and Productivity, who said that he was attending on behalf of Ian Howard, Chief Financial Officer. He referred to the 2025-26 Annual Plan Summary presentation that had been circulated to governors and said that it was a difficult national landscape. He highlighted the following: • page 3 - when producing its annual plan, the Trust did not have an entirely free hand but had to work within the national NHS planning guidance/financial framework for 2025/26. That framework stated that: o all organisations must live within their means. o there was to be a significant reduction in staff numbers, particularly within corporate roles, bank and agency. o there must be a target to improve waiting times, e.g. a 5% improvement in the percentage of patients waiting more than 18 weeks from their referral to starting treatment. o there would be a new limit on the income available to support elective appointments and treatment. Money would no longer follow the patient and Trusts would receive no extra income if they treated/saw additional patients. • page 19 - despite all the adversity, reductions and cut-backs, the annual plan outlined a significant number of service developments/investments that were planned at UHS. These included the opening of an Urgent Treatment Centre at UHS. The following comments were made/questions raised: • given the current financial climate, whether there was likely to be any increase in research activity. AA advised that the Trust had a strong history of supporting research and he said that much of the treatment patients received had been informed by consultants leading research at UHS. • UHS was nowhere near the 5% improvement target that had been set by the NHS in relation to 18-week performance. BL queried whether the target was wrong or whether the Trust’s ambitions were too soft. AA acknowledged that it was a highly ambitious target but said that UHS was making improvements and it was right that Trusts should be striving to achieve it. • whether the Trust had to bid for national government money. AA advised that the money the organisation received for its annual running costs was set at the beginning of each financial year and there was very little (or no) opportunity to increase it during the year. SHa noted, however, that AA and his colleagues were adept at moving quickly to submit appropriate, high 3 quality bids, whenever national funding for specific service developments became available. • SA noted that there was an unprecedented challenge in relation to the people agenda, which was likely to impact staff survey results. SHa acknowledged that there was likely to be a deterioration in the results across the NHS and UHS would be looking to see whether its results were in line with that. He said that the Trust had always tried to be as transparent as possible with its staff and every two weeks there were Talk to David sessions that were open to all staff, to ask any questions they wanted to. • SA queried whether there was appropriate support for the most senior staff in the organisation. SHa advised that the executive team were very supportive of one another and that they were also well supported by the NEDs. • PC asked whether the Did Not Attend (DNA) rate impacted waiting lists. AA advised that it was around 6% but was reducing and varied between services. Also, clinics were often over-booked, so the time was generally used effectively. JDT thanked AA for attending. 6 Governance 6.1 Review Terms of Reference - Council of Governors JDT advised that the Terms of Reference had been reviewed and a small number of minor amendments proposed. It was noted that working groups had been removed but it was agreed that they could be re-instated in the future, if appropriate. The CoG approved the revised Terms of Reference. 7 Membership Engagement and Governor Activity 7.1 Membership Engagement JDT advised that Sam Dolton (SD), Events and Membership Officer, would no longer attend CoG in person but would still provide a report for the meetings. This was due to changes in the organisation, a reduction in Communication Team staff due to the MARS programme and a significant increase in SD’s workload. The following comments were made: • whether SD could, in future, attend to give his report as other staff did. • members who preferred to be contacted by post had received a written letter asking if they still wanted to be a postal member. If no response had been received, they had been removed from that list. • JDT expressed surprise that there were no members from the gypsy/traveller community and would discuss with SD. 7.2 Governors’ Nomination Committee Feedback JDT advised that the Governors’ Nomination Committee had met, informally, prior to the CoG meeting, so they could be updated regarding the NED vacancy. She advised that whilst it had been decided not to replace the NED who was leaving, the Trust had planned to recruit a replacement for Tim Peachey (TP), who had already been a NED for six years. However, at the stakeholder panel last week, it had been agreed that there was no one suitable to appoint, so the interviews had been stood down. The Trust had now engaged with the NHS regional team to try to extend TP’s term for another 12 months. If approved, at the start of the next calendar year the Trust would try again to recruit a suitable replacement. It was, however, well 4 known nationally that clinical NEDs were difficult to find, so it was possible that headhunters would be used. KE’s tenure as NED and Chair of the Audit and Risk Committee, would come to an end in January 2026 and it was hoped that the process to replace him would commence in September 2025. 8 Review of Meeting The following comments were made: • it had been an informative meeting and the NEDs had provided thorough answers to questions. • sound in the conference room continued to be poor. • several governors raised a concern regarding the incorrect pronunciation of BAME used by KE. JDT apologised to the governors and said that she would speak to KE. 9 Any Other Business • JDT noted that: o TA had reached the end of her second term as a governor. JDT thanked her for her contributions and wished her well for the future. o LH and EO had both come to the end of their first term and had decided not to stand again. JDT thanked them for their contributions to the CoG. o after two years as an Associate Governor, NM, was leaving and hoped to attend Reading University to study pharmacy. JDT wished her all the best with her exam results and future career. o PC, SG, LG, JL, CR, JS and LT were all reaching the end of their first term as governors and had the opportunity to stand again. Nominations would close at 5 p.m. on 30th July. • CR had offered to replace Katherine Barbour as the CoG representative on the Trust’s Sustainability Board. The CoG accepted her offer. • Southampton Pride would take place on 23/24 August and JDT thanked those governors who had already said they would attend. LT asked any other governors who were interested in attending, to let her know. • JDT advised that the cost of upgrading the sound equipment in the conference room had been considered but, in the current climate, was too high (around £5k). Other solutions therefore needed to be considered and she mentioned that a different seating arrangement at the last Trust Board had helped. • SL, who had joined the CoG meeting online, advised that volume had not been a problem but she had experienced some broadband issues. • JDT advised that in light of the financial challenges, the Trust had taken the decision not to provide refreshments for meetings, across the organisation. The CoG was keen to support the decision and agreed that they would, in future, bring their own lunch to meetings. They wanted, however, to retain the same timetable of sessions, as they valued the time together. • SG queried whether the CoG could have a briefing on the new NHS Plan and its implications for UHS. JDT advised that the detail of the plan was still being worked out but she was aware that all Trusts were to become Foundation Trusts by 2035 and there would no longer be a requirement to have a CoG. Given NHSE was hoping to develop an implementation plan by the autumn, she was hopeful governors would be able to have a fuller discussion at the next CoG. 10 Date of Next Meeting The next meeting of the CoG would be held on 28 October 2025. 5 List of action items Agenda item Assigned to Deadline Status Council of Governors 16/07/2025 7.1 Membership Engagement 1277 Presentation of the Membership Report at Council of Governors' Meetings Karen Russell 28/10/2025 Completed Explanation action item Due to a lack of resource in the Communications Team, Sam Dolton was no longer able to attend CoG on a regular basis. SG asked if it was possible for Sam to continue to attend just to present the quarterly membership report. Outcome Sam has kindly agreed to attend (either in person or via MS Teams) for the presentation of the membership report and to answer any questions which may arise. 1278 Trust Membership - Gypsy, Roma and Traveller (GRT) Community Jenni Douglas-Todd Karen Russell 28/10/2025 Completed Explanation action item JDT noted in the membership report that there were currently no members from the GRT community and advised that she would discuss with Sam Dolton. Outcome Sam has been reviewing the position regarding GRT members at other foundations trusts and will provide an update at the CoG meeting on 28 October 2025. Item 5.1 Report to the Council of Governors - 28 October 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 x 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 x x x 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 October 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 June to August 2025, noting that some performance data is reported further in arrears and therefore unavailable. Notable features of the quarter include: • The trust’s financial plan for 25/26 was breakeven including a savings target of £110m. In August, the trust reported a deficit of £25m which is £10m behind plan. The organisation has now submitted a financial recovery plan to NHS England to minimise the deficit through schemes of greater scale and pace. • The trust remains on target to spend its full capital allocation for 2025/26 ensuring continued investment in capacity, digital and infrastructure. • The trust’s overall waiting list has been increasing since the start of the financial year with several services impacted by increased demand. However, the waiting list remained stable between July and August (63,018 patients). • The percentage of patients waiting less than 18 weeks decreased to 62.0% for August 2025. The organisation is reporting an increase in the volume of long waiting patients (over 65 and 78 weeks) in certain surgical specialties but is exploring options to bring this back in line with national ambitions. • In August 2025 the ED department delivered a much improved four hour performance position of 68.7% and a reduction in average time in the department for admitted and nonadmitted patients. • The trust reported one never event across the reported period and five PSSIs (Patient Safety Incident Investigations). • The HSMR statistics have been refreshed for the July 2025 position and continue to reflect better than expected survival. • Despite the challenging environment facing all NHS staff, the latest pulse survey illustrates a 5.5% improvement for staff who recommend UHS as a place to work. 2. Safety Infection Control Clostridium Difficile infection MRSA Bacterium infection E.coli Target 78.0% June 2025 60.8% July 2025 61.0% August 2025 68.7% In August 2025 the ED department delivered a much improved four hour performance position of 68.7% and a reduction in average time in the department for admitted and non-admitted patients. The stronger August position reflects both a reduction in attendances in the month but also the early focus on action plans agreed internally and with the support of ECIST (Emergency Care Improvement Support Team) following a recent visit. The hospital continues to perform well against the 12 hour target averaging 2.1% of patients across this financial year. The hospital successfully transitioned to a new emergency department system (Miya) on 13 October. Whilst the implementation of a new digital system requires significant training and some disruption, Page 3 of 6 the rollout has been well managed and we look forward to the long term benefits for patient management and flow throughout the organisation. Referral to Treatment (RTT) % incomplete pathways within 18 weeks in month Total patients on a waiting list Target => 92% June 2025 64.1% 62,644 July 2025 63.4% 63,007 August 2025 62.0% 63,018 The overall waiting list across the trust remained steady at 63,018 patients for August 2025 which is an increase of just eleven patients since July 2025. However 18 week performance for August was 61.8% which is a reduction since July 2025 (63.4%). The trust reported thirty patients waiting over 78 weeks by the end of August 2025. The pressure area continues to be patients within the hospital’s skin service waiting for low priority surgery for benign conditions. Discussions are ongoing with the ICB and other trusts about pathway options for this cohort of long waiting patients. There were 188 patients waiting over 65 weeks predominantly within the surgery caregroup, but also within trauma and orthopaedics and gynaecology, where capacity has outstripped demand. The trust is meeting the regional team fortnightly to discuss action plans to address the waiting list position including providing speciality level support and expert insight for the most challenged areas. 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% May 2025 78.0% 96.0% 77.5% June 2025 73.1% 96.0% 70.4% July 2025 80.0% 95.3% 78.0% The trust reported an improvement in July for performance against both national cancer metrics. 28 day faster diagnosis performance significantly increased to 80.0% for July (73.1% in June) moving the trust back in the top quartile compared to peer teaching hospitals. Similarly, performance for the 62 day standard improved to 78% for July 2025 ranking UHS 2nd against peer teaching hospitals. 5. Finance The financial environment remains extremely challenging for UHS. Our plan submission for 2025/26 targets breakeven delivery which is predicated on the achievement of £110m of savings. This represents 8% of turnover and would be a record achievement for UHS if delivered. The shape of the financial plan is one that requires month on month improvement with a deficit plan of £17m in the first half of the year offset by an equivalent surplus plan of £17m in the second half of the year. The financial architecture in 2025/26 also means a greater majority of the trust’s income is fixed (or capped) therefore savings are required to be achieved mainly via cost out schemes covering both pay and non pay. All areas were asked to explore workforce reductions (5% for clinical divisions and 10% for corporate areas) and a financial improvement group was established, chaired by the CEO, to help drive the pace of efficiency improvement in a mindful way. As at August (month 5) the trust is reporting a deficit of £25m which is £10m behind plan. The key deficit drivers are as follows: Page 4 of 6 1. The trust continues to ‘overtrade’ on block contracts with activity exceeding funded levels. Demand management continues to be a focus for the trust engaging with system partners to ensure only the most appropriate patients are admitted to UHS. 2. Non-criteria to reside numbers have increased to peaks of over 275 from an average of 215 in 2024/25. This is over 20% of the trust’s bed base and has a significant cost in addition to clinical risks of patient deconditioning and infection. This remains a focus of the inpatient flow programme. 3. Mental health patient demand has grown from previous years with patients often requiring enhanced levels of support at a premium cost to the trust. UHS continues to work with system providers on improvements for this patient group. Despite these pressures however the trust has continued to ensure value for money remains an organisational priority and is focused on transforming services under the three workstreams of theatre optimisation, outpatients and inpatient flow. There are positive signs of month-on-month improvement, but this has not been at the required pace to deliver the year-to-date plan. At the current run rate the scale of deficit would not be sustainable for the trust, or affordable for the NHS, and for this reason a financial recovery plan has been developed, signed off by the Trust Board, and submitted to NHS England. This targets greater scale and pace of financial improvement to try and minimise the deficit. Further to this the trust remains on target to spend its full capital allocation for 2025/26 totalling over £74m for which £44m is externally funded following successful grant/business case applications. This includes further investment in the emergency department of £8m. This continued investment in capacity, digital and infrastructure helps support continued ongoing financial sustainability and efficiency improvements. 6. Human Resources Indicator Staff recommend UHS as a place to work % Staff survey engagement score (out of 10) Q1 25/26 47.7% 6.39 Q2 25/26 53.2% 6.60 The Q2 trust survey results reflect the staff Pulse survey completed in July. The organisation is now focussed on the national NHS staff survey which continues until November. The pulse survey indicates improvements since quarter one in both the survey engagement scores and recommendation as a place to work since. Given the financial and operational pressures within the organisation, the trust has increased the number of platforms for senior leaders to engage with staff ensuring feedback is heard and changes well communicated. The trust is also providing additional support services for those managing change within their teams. Indicator Target Staff Turnover (internal target; rolling 12 month) <=13.6% June 2025 10.4% July 2025 10.9% August 2025 10.1% Sickness absence 12 month rolling (internal target) <=3.7% 3.9% 3.9% 3.8% Turnover: In August 2025, there was a total of 122 WTE leavers, 35 WTE more than July 2025 (87 WTE). Division A recorded the highest number of leavers (37 WTE). Within Division A, Nursing and Midwifery Registered Page 5 of 6 staff group had the highest number of leavers (16 WTE). Divisions C and B had the second and third highest number of leavers (35 and 28 WTE respectively); with the largest number of leavers for Division C being the Additional Clinical Services staff group (12 WTE), while in Division B Nursing and Midwifery Registered staff group accounted for 11 WTE leavers. Sickness: The current rolling sickness rate is 3.8% (as of August 2025), this is 0.1% above the 25/26 target (3.7%) and a reduction of 0.1% compared with both July 25 and June 2025 (both 3.9%). In-month sickness for August 2025 was 3.3%, a reduction of 0.22% from July 2025. Year-to-date sickness is 3.4% as of August 2025. Page 6 of 6 Item 6.1 Report to the Council of Governors - 28 October 2025 Title: Governor Attendance at Council of Governors’ Meetings Sponsor: Jenni Douglas-Todd, Trust Chair Author: Karen Russell, Council of Governors’ Business Manager Purpose (type an ‘x’ in the appropriate box(es)) (Re)Assurance Approval Ratification Information x 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: Under the Trust’s constitution (paragraph 2.1 of Annex 5) if a governor fails to attend two successive meetings of the council of governors, his or her tenure of office is to be immediately terminated by the council of governors (CoG) unless the CoG is satisfied that: • the absences were due to reasonable cause; and • he/she will be able to attend meetings of the CoG within such a period as the CoG considers reasonable. Following the recent review, there was one governor who had failed to attend two successive ordinary meetings of the CoG. Reasons for non-attendance were provided and were due to reasonable causes. In order to ensure that the CoG considers the situation when a governor fails to attend two successive ordinary meetings of the CoG, the process is for the Chair or Company Secretary contact the governor to understand the reasons for this if these have not already been provided. The Chair or Company Secretary would then provide confirmation to the CoG as to whether this was due to reasonable causes and the governor’s ability to attend future meetings. This would also help to identify any steps that the Trust could take to facilitate attendance. The CoG is asked to confirm that it is satisfied that the process has been followed correctly to confirm that the failure of one current governor to attend two successive meetings of the CoG was due to reasonable causes and that they would be able to attend future meetings within a reasonable period. Contents: N/A Risk(s): N/A Equality Impact Consideration: N/A Item 6.2 Report to the Council of Governors - 28 October 2025 Title: Review of Council of Governors’ Expenses Reimbursement Protocol Sponsor: Jenni Douglas-Todd, Trust Chair Author: Craig Machell, Associate Director of Corporate Affairs and Company Secretary and Karen Russell, Council of Governors’ Business Manager Purpose (type an ‘x’ in the appropriate box(es)) (Re)Assurance Approval Ratification Information x 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 Council of Governors’ Expenses Reimbursement Protocol is required to be reviewed regularly and at least once every three years. Following review, the rates at which travelling and other expenses are paid to governors remain consistent with HM Revenue and Customs (HMRC) ‘approved amounts’ therefore no changes are required. However, a minor change to some of the wording which was unnecessary was identified. The Council of Governors is asked to approve the proposed changes to the Council of Governors expenses reimbursement protocol which are shown as tracked changes on the attached document. Contents: N/A Risk(s): N/A Equality Impact Consideration: N/A Council of Governors expenses reimbursement protocol, Trust reference Description Level and type of document Target audience List related documents/policies (do not include those listed as appendices) Author(s) (names and job titles) Document sponsor Version number 34 This document sets out the policy and procedure for the payment of travelling and other expenses to governors and the rates at which these will be paid Level 1: applicable across the Trust Standard operating procedure – controlled document Governors, Corporate affairs team Constitution Karen FlahertyCraig Machell, Associate Director of Corporate Affairs Trust Chair This is a controlled document. Whilst this document may be printed, the electronic version posted on Staffnet 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 Staffnet. 1 Date 28/04/22 Version control Author(s) Version created 3 Approval committee Board of Directors 28/10/2025 4 ? Date of Date next approval review due 28/04/2022 April 2025 28/10/2025 April 2028 Key changes made to document Updated rates at which travel expenses are paid and clarified policy in a number of areas. Minor changes to wording [Reference number]. Council of Governors expenses reimbursement protocol. Issued April 2022 Page 1 of 6 2 Index 1 Version control............................................................................................................................1 2 Index ...........................................................................................................................................2 3 Introduction .................................................................................................................................3 4 Scope..........................................................................................................................................3 5 Aim/purpose................................................................................................................................3 6 Training.......................................................................................................................................3 7 Travel..........................................................................................................................................3 8 Parking........................................................................................................................................4 9 Subsistence ................................................................................................................................4 10 Carers’ costs ...........................................................................................................................4 11 Completing expenses claim forms ..........................................................................................4 12 Roles and responsibilities .......................................................................................................5 13 Document review.....................................................................................................................5 14 Process for monitoring compliance .........................................................................................5 15 Appendices .............................................................................................................................6 16 References..............................................................................................................................6 [Reference number]. Council of Governors expenses reimbursement protocol. Issued April 2022 Page 2 of 6 3 Introduction The role of governor of a foundation trust is voluntary, and governors do not receive payment for this role. In accordance with paragraph 20 of the constitution of University Hospital Southampton NHS Foundation Trust (the Trust), the Trust should determine the rates at which travelling and other expenses are paid to governors. This document sets out the circumstances in which governors may be reimbursed for legitimate and necessary expenses incurred in the course of their duties as governors of the Trust. 4 Scope This policy and procedure applies to all governors. Where governors have been appointed by a partner organisation, in some cases that organisation may pay the expenses incurred by the appointed governor in performing the governor role in accordance with its own policies and procedures. 5 Aim/purpose Governors may incur expenses in carrying out their role. The expenses incurred will depend on each governor’s personal circumstances. All expenditure must be actually and necessarily incurred in carrying out the role and responsibilities of a governor. This will include travelling and other expenses for governors to attend council of governors’ meetings, board of directors’ meetings and committee or working group meetings as well as to any training or member events that the Trust requests governors to attend. The payment of expenses ensures that the Trust provides financial support to governors and they do not incur additional personal expenditure when performing their role. 6 Training The Trust has a duty to take steps to ensure that governors are equipped with the skills and knowledge they need to discharge their duties appropriately. Where training is not provided by the Trust, the Trust will be responsible for booking places on training courses, seminars and similar events for governors, therefore no Governor need incur any personal expense. Places at many external governor events are limited, so not all governors wishing to attend may be able to do so. Governors may identify and propose any suitable training opportunities they would like to attend to the Trust prior to such events taking place. Where approved by the Trust, the Trust will book places on these events. Any training, or similar events, booked directly by governors may not be funded by the Trust. 6 Travel Travel expenses will be paid at the rates set out below, which are the HM Revenue and Customs (HMRC) ‘approved amounts’, which do not require reporting or deductions for tax purposes. Governors should only claim for the return distance between their home and the Trust site or other venue or the distance travelled where this is less. When their journey starts from a location other than their home address and is further away than their home then this should be agreed with the Council of Governors’ Business Manager in advance. Public transport Cars and vans Paid on a like for like basis. Any claim must be supported by a valid ticket. Rail fares reimbursed at standard class only for advance purchase tickets. 45p per mile up to 10,000 miles and then 25p per mile thereafter. Governors are responsible for ensuring their private vehicles are appropriately insured. [Reference number]. Council of Governors expenses reimbursement protocol. Issued April 2022 Page 3 of 6 Passenger allowance Motorcycles Bikes Taxi Toll charges 5p per mile. This applies where a governor carries another governor in their own car or van. 24p per mile 20p per mile Taxis should only be used in exceptional circumstances where no other reasonable transport method is available or possible. Any claim must be supported by a valid taxi receipt issued by the driver. Any toll charges must be supported by a valid ticket/receipt. No driving penalties or fines will be reimbursed by the Trust. The Trust will not be responsible for any loss or damage to private vehicles or property or possessions. 7 Parking Redeemable tickets will be issued for you to use car park facilities at the Trust’s sites. Parking expenses incurred when attending meetings or events not held at Trust sites must be supported by a valid ticket/receipt. No traffic or parking fines will be reimbursed by the Trust. 8 Subsistence When away from the Trust sites and attending meetings that last more than five hours when meals are not provided, the Trust will reimburse governors subsistence claims in line with current staff allowances. The cost of any alcohol consumed, with or without meals, will not be reimbursed by the Trust and should not be claimed. Receipts for any expenditure will be required. Any potential claims for subsistence should be discussed with the Council of Governors’ Business Manager in advance. 9 Carers’ costs Governors may claim for reasonable carers’ costs for children under 16 and dependents, where there is medical or social services evidence that care is required and not already in place in order to attend meetings. Any potential claim for carers’ costs should be discussed with the Council of Governors’ Business Manager in advance. A receipt for the carers’ costs should be attached to the claim form. Expenses for carers’ costs will not be liable to deductions for tax and national insurance. I There is also some wording in brackets at the end of the carers costs section that should be removed as the actual costs would be paid provided that are not being paid/reimbursed by someone else. 10 Completing expenses claim forms The Trust will provide governors with an expenses claims form on request. Claim forms should be completed and returned to the Council of Governors’ Business Manager for authorisation as soon as possible after the expense has been incurred and no later than one month after the date on which the expenses were incurred. All claims (except mileage costs) should be supported by an itemised invoice or receipt. Claims, including invoices and receipts, received more than one month after the expenses were incurred could result in the claim not being paid depending on the reasons for this. In signing and dating the claim form, you are confirming: • that you actually and necessarily incurred the expense while carrying out your role as a governor; [Reference number]. Council of Governors expenses reimbursement protocol. Issued April 2022 Page 4 of 6 • that the journeys made were required for you to fulfil your duties and responsibilities as a governor; and • that you have not received any reimbursement from any other source for the expenses claimed. Claims will normally be reimbursed direct to the nominated bank or building society account by bank transfer. In order to ensure efficient reimbursement, the expenses claim form requests your bank details. This information will be held in the strictest confidence. 11 Roles and responsibilities Governors will be responsible for accurately completing expenses claims forms, retaining receipts and tickets to support any claim and submitting these to the Trust as soon as possible after the expense has been incurred and no later than one month of the date on which the expenses were incurred. The Council of Governors’ Business Manager will be responsible for making expenses claims forms available to governors, verifying that the claim relates to a meeting or event that governors were required or requested to attend and keeping accurate records of all claims submitted. The Associate Director of Corporate Affairs and Company Secretary will be responsible for making the final decision as to whether any claim should be accepted or accepted later than one month after the expenses were incurred. 12 Document review All Trust policies will be subject to a specific minimum review period of one year; we do not expect policies to be reviewed more frequently than annually unless changes in legislation occur or new evidence becomes available. The maximum review period for policies is every three years. The author of the policy will decide an appropriate frequency of review between these boundaries. Where a policy becomes subject to a partial review due to legislative or national guidance, but the majority of the content remains unchanged, the whole document will still need to be taken through the agreed process as described in this policy with highlighted changes. This Council of Governors reimbursement protocol will be reviewed every three years. 13 Process for monitoring compliance The purpose of monitoring is to provide assurance that the agreed approach is being followed. This ensures that we get things right for patients, use resources well and protect our reputation. Our monitoring will therefore be proportionate, achievable and deal with specifics that can be assessed or measured. Key aspects of this policy will be monitored: Element to be Total expenses incurred by all governors in each financial year as an monitored aggregate figure and comparative information from the previous year Lead (name/job title) Council of Governors’ Business Manager Tool Expenses claim forms and cost centre breakdown Frequency Annually Reporting This information is included in the Trust’s annual report and accounts arrangements Where monitoring identifies deficiencies actions plans will be developed to address them. [Reference number]. Council of Governors expenses reimbursement protocol. Issued April 2022 Page 5 of 6 14 Appendices Expenses claim form 15 References National Health Service Act 2006 [Reference number]. Council of Governors expenses reimbursement protocol. Issued April 2022 Page 6 of 6 Item 6.3 Report to the Council of Governors - 28 October 2025 Title: Appointment of Deputy Chair Sponsor: Jenni Douglas-Todd, Trust Chair Author: Karen Russell, Council of Governors’ Business Manager Purpose (type an ‘x’ in the appropriate box(es)) (Re)Assurance Approval Ratification Information x 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: In accordance with the paragraph 26.1 of the Trust’s constitution, the council of governors (CoG) is responsible for appointing the deputy chair. The current deputy chair, Keith Evans, will come to the end of his second term of office on 31 January 2026 therefore a new deputy chair needs to be appointed. It is usual practice for the Trust’s Chair to make a recommendation to the CoG as to who should be appointed to the role. Following discussion with non-executive directors, the Trust’s Chair would like to recommend to the CoG that Jane Harwood, non-executive director and senior independent director (SID), be appointed to the role of Deputy Chair. The NHS Code of Governance permits the same individual to serve as both the Deputy Chair and SID. The CoG is asked to approve the appointment of Jane Harwood as Deputy Chair with effect from 1 October 2025. Contents: N/A Risk(s): N/A Equality Impact Consideration: N/A 7.1 Report to the Council of Governors - 28 October 2025 Title: Membership Engagement Sponsor: Jenni Douglas-Todd, Trust Chair Author: Sam Dolton, events and membership officer Purpose (type an ‘x’ in the appropriate box(es)) (Re)Assurance Approval Ratification Information x 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 Executive Summary: This report aims to update the council on Trust membership and recent and planned engagement activities. Contents: Membership engagement report. Risk(s): This report is provided for the purpose of information. Equality Impact Consideration: N/A Overview of engagement Over the last three months we have continued to engage with our members. * All open rates as of 20 October 2025 Membership updates Our routine membership updates are split into two different formats: • A monthly newsletter to keep public members updated on what’s happening across the Trust and the ways they can get involved in various projects, with an edition produced in September. • A quarterly Connect digital magazine which mainly focuses on patient stories, UHS successes and individual/team achievements, with the autumn 2025 edition going out later in October. Update Type September 2025 Monthly update Date sent Sent to 17/09/2025 3,022 Bounces 64 Opens* 53% Other emails To mark Organ Donation Week in September we invited our public members to register their decision on the organ donation register. A link to the annual report and accounts 2024/25 was also sent to members in September. Email Register organ donation decision Annual report and accounts 2024/25 Date sent 22/09/2025 24/09/2025 Sent to 3,003 2,984 Bounces 65 65 Opens* 50% 47% Annual members’ meeting We held our annual members’ meeting in person on 8 October 2025. It included highlights of 2024/25 from the executive team, as well as a look at our current priorities, and a membership update from the lead governor. Following the presentation, there was a Q&A session with our executives covering a range of topics. Teams from across UHS took part in an exhibition showcasing their patient services and projects. In total 42 people attended the meeting (26 public members, 16 staff members), up from 17 last year. We have received 13 feedback forms: • 8 rating the event excellent • 4 good • 1 fair • 0 poor Positive feedback included: • “I thought David’s presentation was excellent. Pitched to the “layman” - not too medical, not too accounting.” • “It was a clear insight to both successes and challenges within the UHS. Very open and honest.” • “An excellent opportunity to understand the problems and to look at the possible solutions, given that there is an imbalance between supply and demand.” Suggestions for improvement: • “Microphones would have made hearing a lot easier.” • “Allow more time to be given to questions and to visit the range of stalls and the excellent We Are UHS display.” Public engagement on social Impressions = number of times a post has been displayed Engagement = number of likes, shares, comments We have been active across our social media channels, content with high engagement included: RSV protection for premature babies Earlier in October BBC News reported on the nationwide roll out of a new drug to protect premature babies from RSV this winter, following a successful trial at UHS. 124,076 impressions 9,378 en
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Governors/Papers-CoG-28.10.2025.pdf

Customised swim moulds - patient information

Description: This factsheet explains what customised swim moulds are and how to use them.
Url: /Media/UHS-website-2019/Patientinformation/Audiology/Customised-swim-moulds-2641-PIL.pdf

Children's renal service contacts: open access - patient information

Description: This factsheet contains important contact information for parents and carers of children with a kidney condition.
Url: /Media/UHS-website-2019/Patientinformation/Childhealth/Childrens-renal-service-contacts-open-access-2123-PIL.pdf

Papers Council of Governors - 27 April 2022

Description: Date Time Location Chair Agenda Council of Governors 27/04/2022 14:00 - 16:00 Microsoft Teams Jane Bailey 1 Chair’s Welcome and Opening Comments 14:00 2 Declarations of Interest 14:01 3 Minutes of Previous Meeting 14:02 To approve the minutes of the previous meeting held on 26 January 2022 4 Matters Arising/Summary of Agreed Actions 14:03 5 Strategy, Quality and Performance 5.1 Operational Plan 2022/23 14:05 Sponsor: Ian Howard, Chief Financial Officer 5.2 Non-NHS Activity 14:20 Sponsor: Ian Howard, Chief Financial Officer Attendees: Na'el Clarke, Commercial Director 5.3 Chief Executive Officer's Performance Report 14:35 Sponsor: David French, Chief Executive Officer 5.4 Draft Quality Report and Annual Report Timetable 14:55 Sponsor: David French, Chief Executive Officer Attendee: Karen Flaherty, Associate Director of Corporate Affairs and Company Secretary 6 Governance 6.1 Non-Executive Director Reappointment 15:00 Sponsor: Jane Bailey, Interim Chair Attendee: Karen Flaherty, Associate Director of Corporate Affairs and Company Secretary 6.2 Review Terms of Reference - Council of Governors and Working Groups 15:10 Sponsor: Jane Bailey, Interim Chair Attendee: Karen Flaherty, Associate Director of Corporate Affairs and Company Secretary 6.3 Council of Governors' Election 2022 15:15 Sponsor: Jane Bailey, Interim Chair Attendee: Karen Russell, Council of Governors' Business Manager 6.4 Council of Governors' Expenses Reimbursement Protocol 15:19 Sponsor: Jane Bailey, Interim Chair Attendee: Karen Flaherty, Associate Director of Corporate Affairs and Company Secretary 6.5 Consultation Regarding Timings of Council of Governors' Meetings 15:24 Sponsor: Jane Bailey, Interim Chair Attendee: Karen Flaherty, Associate Director of Corporate Affairs and Company Secretary 7 Membership Engagement and Governor Activity 7.1 Membership Engagement 15:29 Sponsor: David French, Chief Executive Officer Attendee: Sam Dolton, Events and Membership Officer 7.2 Governors' Nomination Committee Feedback 15:39 Chair: Jane Bailey 7.3 Feedback from Strategy and Finance Working Group 15:43 Chair: Tim Waldron 7.4 Feedback from Patient and Staff Experience Working Group 15:47 Chair: Forkanul Quader 7.5 Feedback from Membership and Engagement Working Group 15:51 Chair: Bob Purkiss 8 Any other business 15:55 To raise any relevant or urgent matters that are not on the agenda 9 Date of next meeting: 19 July 2022 15:59 To note the date of the next meeting Page 2 Minutes - Council of Governors (CoG) Date Time Location Chair Present In attendance Apologies 26 January 2022 14.00-15.40 Microsoft Teams Peter Hollins Peter Hollins, Chair Theresa Airiemiokhale, Elected, Southampton City (until item 7.1) Katherine Barbour, Elected, Southampton City (until item 7.1) Colin Bulpett, Elected, Rest of England and Wales Dr Nigel Dickson, Elected, New Forest, Eastleigh and Test Valley Professor Mandy Fader, Appointed, University of Southampton (for items 6.2 to 6.4) Harry Hellier, Elected, New Forest, Eastleigh and Test Valley Kelly Lloyd, Elected, Health Professional and Health Scientist Staff Councillor Alexis McEvoy, Appointed, Hampshire County Council Robert Purkiss, Elected, Rest of England and Wales (until item 6.4) Forkanul Quader, Elected, Southampton City Catherine Rushworth, Elected, Isle of Wight Quintin van Wyk, Elected, Rest of England and Wales Tim Waldron, Elected, Southampton City (until item 7.1) Jane Bailey, Non-Executive Director (NED), Deputy Chair and Senior Independent Director Sam Dolton, Events and Membership Officer Karen Flaherty, Associate Director of Corporate Affairs David French, Chief Executive Officer (for item 5.1) Steve Harris, Chief People Officer (for item 6.2) Femi Macaulay, Associate NED Karen Russell, Council of Governors’ Business Manager James Woodward, Student Governor Representative (until item 4) Dr Diane Bray, Appointed, Solent University Helen Eggleton, Appointed, NHS Hampshire, Southampton and Isle of Wight CCG Rebecca Reynolds, Elected, Nursing and Midwifery Staff Councillor Rob Stead, Appointed, Southampton City Council Amanda Turner, Elected, Non-Clinical and Support Staff PTH TA KBa CB ND MF HH KL AM RP FQ CR QvW TW JB SD KF DAF SH FM KR JW DB HE RR RS AT 1 Chair’s Welcome and Opening Comments The Chair welcomed everyone to the meeting and in particular CR and FM who were attending a meeting of the CoG for the first time. DB and RR, who had recently joined the CoG, were also welcomed to the CoG, although they had sent apologies for the meeting. 2 Declarations of Interest There were no new declarations of interest relating to matters on the agenda. 1 3 Minutes of Previous Meeting The minutes of the meeting held on 27 October 2021 were approved as an accurate record of the meeting. 4 Matters Arising/Summary of Agreed Actions The updates on the actions in the paper were noted and further updates were provided on the following actions: • Review of the Council of Governors’ Composition This had been considered by the CoG Membership and Engagement Working Group and a progress update with proposals would be presented to the CoG later in the meeting. • Governor Forum The guidance had been shared with governors on 17 November 2021 and the Governor Forum was available for use. 5 Strategy, Quality and Performance 5.1 Chief Executive Officer’s Performance Report PTH welcomed DAF, who was attending to present the performance report. The report was noted and DAF provided an update since the period of September to November 2021 covered by the report. He highlighted that: • although the COVID-19 Omicron variant had proved to be much more transmissible than the Delta variant, its symptoms appeared to be less severe; • there were approximately 50 patients in the hospitals who had tested positive for COVID-19, two of whom were in critical care being treated for other medical conditions; • the number of patients with COVID-19 had been relatively stable over the previous two weeks and it was anticipated that numbers would steadily decline over the next few months; • there were 220 patients in the hospitals who were medically optimised for discharge (MOFD), however, levels of staff sickness absence in community care, domiciliary care and care homes were leading to delays in discharge where patients needed further support following discharge or had longerterm care needs; • the number of patients MOFD in hospital was impacting on the Trust’s capacity, particularly elective capacity as beds in surgical wards were being used to accommodate these patients; • sickness absence in the Trust, normally in the region of 3% of staff, had increased to 6% as staff were absent due to COVID-19; • University Hospitals Sussex NHS Foundation Trust and Oxford University Hospitals NHS Foundation Trust were assisting the Trust to reduce the number of patients awaiting cardiac surgery, which had arisen due to a shortage of specialist critical care capacity as the Trust had provided additional surge capacity in previous waves of the COVID-19 pandemic; • the Trust was continuing work to reinstate its full programme of elective activity as the number of patients with COVID-19 in the hospitals reduced; • the Trust was working to increase theatre and bed capacity for elective activity and submitting bids for external funding to support this, including a joint bid with the other acute trusts in Hampshire and the Isle of Wight for an elective hub at Winchester Hospital; • the number of staff at the Trust who were fully vaccinated against COVID-19 was more than 96%, one of the highest levels in the country; • the Trust was continuing to prioritise recruitment and retention of staff, including recruitment in areas where there were staff shortages such as critical care; 2 • Saul Faust, a consultant at the Trust, had led the COV-BOOST vaccine trial, which had been instrumental in informing national policy through identifying the level of protection offered by the booster vaccination; • work was commencing on the rooftop garden at the Princess Anne Hospital for use by staff, which was funded by Southampton Hospital Charity from the proceeds of the auction of the ‘Game Changer’ artwork by Banksy, and there were also plans for a wellbeing centre for staff and to upgrade staff rooms and changing areas across the Trust reflecting the donor’s wishes for a lasting legacy to support the wellbeing of staff; • the implementation of changes to the structure of integrated care systems, which were being introduced to improve coordination of health and social care services at a local level, had been delayed until 1 July 2022; • the Trust was expected to deliver its financial forecast and breakeven in 2021/22 due to additional elective recovery fund income, however, the position for 2022/23 was still uncertain as guidance continued to be released and a reduction in funding was expected; and • the Trust was also on track to deliver its capital programme for 2021/22, having spent £33.2 million up to the end of November 2021, including investment in four new theatres within the vertical extension building and an expanded ophthalmology outpatient facility. In response to a query raised by RP, DAF explained that where a complainant was not satisfied with the Trust’s response (identified as complaints returned dissatisfied in the report), the complaint would be reopened and issues that remain unresolved for the complainant would be investigated again. If the complainant remained dissatisfied following this they could contact the Parliamentary and Health Service Ombudsman. Following a question from FQ about whether other hospitals could assist in reducing waiting lists for elective activity in other areas, DAF explained that capacity and the length of waiting lists were a challenge throughout the NHS due to the COVID-19 pandemic and the Trust was focusing on increasing its capacity. AM queried whether the incidence of COVID-19 transmission within the hospital related to more vulnerable patients and if those who had antibodies due to previously contracting COVID-19 could still transmit the infection to others despite having some degree of protection themselves. DAF advised that the mortality rate for patients who contracted COVID-19 in hospital earlier in the pandemic had been approximately 40-50%, however, strict infection control procedures in place at the Trust had kept the rates of transmission in hospital (nosocomial transmission) low. Currently transmission to patients was tending to occur when patients were visiting non-clinical areas within the hospitals and from visitors. Actions: • DAF would provide a response to a query regarding one of the cookers in the Trust’s Feast restaurant which was reported to have been out of order for some time. • PTH would provide a more detailed response about the ability of those who had previously been infected with COVID-19 to transmit the virus. 6 Governance 6.1 Annual Business Plan 2022/23 KF presented the annual business plan for CoG for 2022/23, which would be reviewed and updated during the year as required. Action: It was requested that the annual CoG strategy event was added to the plan 3 for information. Decision: The CoG approved the Annual Business Plan for 2022/23. 6.2 Chair and Non-Executive Director Appraisal Process PTH advised that the contribution of the CoG to the NED appraisal process was critical as one of the key roles of governors was to hold the NEDs to account for the performance of the board of directors (Board). The NHS Foundation Trust Code of Governance required that the CoG should take the lead on agreeing the process for appraisal. The timeline for the appraisal process would ensure its completion before the tenure of the current Chair ended on 31 March 2022. The GNC had reviewed the proposed process at its meeting on 7 January 2022 and recommended that it should be approved by the CoG. Governors were encouraged to participate in the appraisal process by providing feedback to the Lead Governor by 4 February 2022. Although there had been fewer opportunities for governors to interact in person with NEDs due to restrictions on visiting the hospitals and meeting in person as a result of the COVID-19 pandemic, governors were invited to observe the NEDs at Board meetings and Board committee meetings, which were chaired and attended by NEDs, and to participate in the question and answer sessions with NEDs prior to the CoG meetings and in the discussions with governors following the open session of the Board meeting. Decision: The CoG approved the appraisal process as recommended by the GNC. 6.3 Governor attendance at Council of Governors’ Meetings Under the Trust’s constitution if a governor failed to attend two successive meetings of the CoG, his or her tenure of office was to be immediately terminated by the CoG unless the CoG was satisfied that: • the absences were due to reasonable cause; and • he/she would be able to attend meetings of the CoG within such a period as the CoG considers reasonable. Whilst it was recognised that governors may not be able to attend every meeting the expectation was that they would make every effort to attend meetings regularly. There were five governors who had failed to attend two successive meetings of the CoG, however, for three of these governors this had included the extraordinary meeting of the CoG held in December 2021. There were two governors who had failed to attend two consecutive ordinary meetings of the CoG, both of whom were clinical NHS staff who had not been able to attend due to work commitments. While the CoG was likely to consider that their absence was due to reasonable causes, the two governors concerned had subsequently resigned as they did not feel that they would be able to attend meetings regularly in the future due to work commitments and the timing of CoG meetings. Decision: The CoG confirmed that it was satisfied that the failure of the remaining three governors to attend two successive meetings of the CoG was due to reasonable causes and that they would be able to attend future meetings within a reasonable period so that no termination of a current governor’s tenure of office is required or occurs. 4 6.4 Composition of the Council of Governors At its meeting in July 2021 the CoG reviewed its current composition. The consideration of the composition of the CoG had subsequently been referred to the CoG Membership and Engagement Working Group for further review. The CoG Membership and Engagement Working Group commenced this review at its meeting in November 2021 and considered updated proposals at its meeting in January 2022. Following its review, the CoG Membership and Engagement Working Group recommended the following proposals: • to reduce the number of governors in the Rest of England and Wales public constituency by one governor and increase the number of governors in the New Forest, Eastleigh and Test Valley public constituency by one governor to ensure that the number of governors representing the public constituencies was more representative of the number of patients seen by the Trust from those areas; and • to include a student representative as a full member of the CoG as an appointed governor. The Trust’s constitution would need to be amended to reflect these changes and would require approval by the CoG and the Board. Decision: The CoG noted the progress of the review to date and supported the proposals recommended by the CoG Membership and Engagement Working Group. 6.5 Audit and Risk Committee Terms of Reference The terms of reference for all Board committees should be reviewed regularly, and at least once annually, to ensure that they reflected the purpose and activities of each committee. The NHS Foundation Trust Code of Governance required that the CoG was consulted on changes to the terms of reference for any audit committee given the CoG’s role in appointing, reappointing and removing external auditors, prior to their submission to the Board for approval. Only minor changes of a typographical nature were proposed to the terms of reference following a comprehensive review and update in 2021. Decision: The CoG agreed the proposed changes to the Audit and Risk Committee terms of reference. 6.6 Non-Executive Directors’ Additional Commitments The NHS Foundation Trust Code of Governance required that the CoG was informed of any changes to the significant commitments of NEDs following their appointment by the CoG. The Chair would discuss changes to their commitments with NEDs during their appraisals. There was no potential conflict of interest relating to the new commitments that had been declared. Decision: The CoG noted the additional commitments of the NEDs. 6.7 Decisions in Response to Recent Vacancies on the Council of Governors The CoG had been asked to consider a number of proposals to fill governor vacancies that had arisen in the public and staff constituencies in recent months. In addition, there had been a number of new appointed governors who had joined the CoG during that period. 5 Governors had previously been asked to approve each of the proposals in response to governor vacancies by written resolution. Decision: The CoG ratified and confirmed the decisions taken in response to vacancies on the CoG. 7 Membership Engagement and Governor Activity 7.1 Membership Engagement SD introduced the membership engagement report highlighting that: • engagement with the Trust’s members had continued and included the rebranding of the membership newsletter as Connect, making it more interactive in a page turner format rather than a standard PDF format; • targeted tailored emails had been issued to members including surveys relating to Patient Initiated Follow Up and the UHS discharge process; • in November 2021 members who had stated that they had a disability or were carers were invited to attend a virtual event to launch new access guides for the Trust; • the rescheduled annual members’ meeting took place in November 2021 and included highlights from the annual report and accounts for 2020/21 and the Trust’s five year strategic plan, an update on the membership strategy and an operational update on priorities for managing the surgical waiting list; • a virtual event was held in December 2021, which focused on the next steps for COVID-19 vaccination and included key findings from the Trust led COV-BOOST trial, latest updates on vaccine safety in pregnancy and the vaccination situation in the community from Southampton City Council; • social media activity included an emphasis on encouraging the public to have their COVID-19 booster vaccinations and a message to the community regarding pressures faced by the Trust’s emergency department; • in November 2021 the Trust attended a Health and Home Fair at the University of Southampton, which KBa had kindly supported; • the Trust’s COVID ZERO campaign had been shortlisted in PRWeek’s awards for best crisis communications and results would be announced in February 2022; • governors were thanked for their feedback prior to the issue of a survey to the Trust’s members regarding the membership programme; and • planned future activities included an event about the Trust’s new Green Plan and engagement with students, young people and underrepresented ethnic groups. 7.2 Governors’ Nomination Committee Feedback The GNC had concluded the appointment process for the associate NED role by appointing FM and had reviewed the appraisal process for the Chair and NEDs, approved earlier in the meeting. An update on the recruitment process for a new chair would be provided in the closed session of the meeting. 7.3 Feedback from Strategy and Finance Working Group Due to the operational pressures as a result of COVID-19 in January 2022, it had been agreed with the TW, the chair of the CoG Strategy and Finance Working Group, that the meeting due to have taken place would be rescheduled. 6 7.4 Feedback from Patient and Staff Experience Working Group (including confirmation of election of the Patient and Staff Experience Working Group Chair) A vacancy had arisen for the chair of the CoG Patient and Staff Experience Working Group following the death of Tony Havlin at the end of 2021. FQ had very kindly volunteered to take on the role and was elected as chair at the CoG Patient and Staff Experience Working Group meeting on 24 January 2022. The CoG was asked to confirm the appointment. Decision: The CoG confirmed the appointment of FQ as Chair of the CoG Patient and Staff Experience Working Group. FQ advised that Laura White, the Head of Involvement and Participation, had provided an update on the results of three patient surveys: Adult Inpatients, Children and Young People and Urgent and Emergency Care at the most recent meeting. Following the meeting KR had circulated the full survey results to governors. A question was raised at the meeting relating to the pain scores in the Children and Young People’s survey and the scoring/assessments used and this information would be provided to governors as soon as it was received. Emma Jane Squires had also attended the meeting to provide an update on the Patient Support Hub which had been very informative and well received. FQ was considering including feedback from junior doctors and trainee nurse at a future meeting of the working group. 7.5 Feedback from Membership and Engagement Working Group At the meeting of the CoG Membership and Engagement Working Group on 20 January 2022, the composition of the CoG had been considered followed by an update from SD relating to the membership strategy, feedback on previous events and plans for future events. 8 Any other business Following the discussion with staff governors who had been unable to attend meetings of the CoG, PTH suggested that a consultation exercise was undertaken to ask for governors’ views on varying the timing of CoG meetings to accommodate work schedules of staff and other governors. Action: KR would carry out a consultation to consider the timing of CoG meetings. PTH informed the CoG that this would be his last full meeting as Chair prior to the end of his tenure on 31 March 2022, and thanked governors for their help and support. 9 Date of Next Meeting - 23 February 2022 To note the date of the next meeting. 10 Resolution regarding the press, public and others Decision: The CoG resolved that, as permitted by the National Health Service Act 2006 (as amended), the Trust's Constitution and the Standing Orders for the Practice and Procedure of the CoG, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. 7 List of action items Agenda item Assigned to 14 April 2022 16:00 Deadline Status Council of Governors 31/03/2021 5.5 Amendment to the Trust's Constitution - CCG Merger 444. Review the Council of Governors' Composition Flaherty, Karen Russell, Karen 27/04/2022 Explanation action item A review of the Council of Governors' composition is to be carried out to check that it still remains appropriate. Pending The review was presented to the CoG at the meeting on 21 July 2021. The CoG agreed that volunteers for a task and finish group would be sought to consider the composition of the CoG in more detail. If no volunteers were forthcoming it would be referred to the Membership and Engagement Working Group for further review. Explanation Russell, Karen Following the discussion at the CoG meeting on 26 January 2022, feedback will be provided to the Membership and Engagement Working Group at its meeting on 26 April 2022. Council of Governors 26/01/2022 5.1 Chief Executive’s Performance Report 633. Query regarding a cooker in the Trust's Feast restaurant French, David 27/04/2022 Completed Explanation action item RP raised a concern regarding one of the cookers in the Trust’s Feast restaurant which was reported to have been out of order for some time. DF agreed to investigate. It was confirmed that the cooker had been replaced and was in operation. Governors were advised by email on 2 February 2022. 14 April 2022 16:00 634. COVID-19 transmission Hollins, Peter 27/04/2022 Completed Explanation action item AM queried whether the incidents of COVID-19 transmission within the hospital related to more vulnerable patients and if those who had antibodies due to previously having COVID-19 could still transmit to others despite having some degree of protection themselves. KR consulted Dr Eleri Dr Eleri Wilson-Davies who is the principal investigator for the Sarscov2 Immunity and Reinfection Evaluation (SIREN) study at the Trust. It was confirmed that transmission could still take place. A full explanation was provided to governors on 2 February 2022. Council of Governors 26/01/2022 6.1 Annual Business Plan 2022/23 635. Strategy Day to be added to the Annual Business Plan Flaherty, Karen Russell, Karen 27/04/2022 Completed Explanation action item PTH queried whether the CoG Strategy Day could be added to the Annual Business Plan. KF agreed this could be added. Explanation Russell, Karen Strategy Day has now been added to the Annual Business Plan Council of Governors 26/01/2022 8 Any other business 636. Consultation regarding timings of CoG meetings Russell, Karen 27/04/2022 Completed Explanation action item Two governors had resigned recently and had found difficulty attending CoG meetings due to work commitments. Governors would be consulted as to the most appropriate timings for CoG meetings. Explanation Russell, Karen The consultation has been held and feedback will be provided to the CoG at its meeting on 27 April 2022. Page 2 5.1 Operational Plan 2022/23 1 5.1i Report template UHS COG April 2022 Operating Plan.docx Report to the Council of Governors Title: Agenda item: Sponsor: Author: Date: Purpose Issue to be addressed: 2022/23 Operational Plan 5.1 Ian Howard, Chief Financial Officer Andrew Asquith, Director of Planning, Performance and Productivity 27 April 2022 Assurance Approval or reassurance Ratification Information Y Information about trust planning and budget setting supports the Council of Governors in their role. Response to the issue: This report is intended to inform the Council of Governors about aspects of the Trust’s operating environment and plan for 2022/23. A more detailed report is presented to Trust Board for their consideration and approval. Implications: This report provides information relating to a broad range of trust (Clinical, Organisational, services and activities, there are no specific implications. Governance, Legal?) Risks: (Top 3) of carrying This report is provided for the purpose of information. out the change / or not: Summary: Conclusion This report is provided for the purpose of information. and/or recommendation Page 1 of 1 Council of Governors Meeting April 2022 2022/23 Operational Plan 2022/23 Operational Plan Content of Presentation • Process / Expectations • Summary of plan – finance, workforce, activity and performance • Conclusion • Building on ‘Connect’ (Internal Presentation for Senior Leaders) • Questions Process / Expectations • Final plan submission to NHSE (via ICS) due on 28th April • Trust board briefed on draft submissions and the anticipated final submission • Strong influence from national ‘guidance’ / frameworks, issued between Dec 24th and late February, with subsequent clarifications too… • Planning for a ‘low COVID’ environment Summary of plan (see following slides) Summary of plan - Finance • Income broadly level with 2021/22, additional funding for inflation fully offset by reductions in funding / national efficiency requirements • Expectation that 104% elective activity will be delivered for this level of funding through increased efficiency • Planned UHS operating deficit - £19.5m – Driven by understandable factors where the reality is differing from planning assumptions / factors outside trust control e.g. COVID prevalence, energy prices, general inflation, drug cost increases in block contracts Summary of plan - Finance • Planned efficiency improvement valued at £33m / 2.7% (compared to 2021/22) – 2% / £20m Cost Improvement requirement as part of issued budgets – Further £13m improvement to be delivered centrally including through business cases and management of growth funding – Little opportunity to achieve additional financial contribution through growth in NHS activity due to the financial framework / contractual arrangements (75% of tariff) • Financial challenges in delivering the 22/23 plan are being consistently reported across the country Summary of plan - Workforce • Continued recruitment and retention to increase employed staff by a further 478 wte • Offset by planned reductions in the use of Bank and Agency hours • Minimal net increase in funded posts (establishment) - aligned with funding availability, cost improvements to offset additional investments, and significant increases during COVID-19 to date Summary of plan - Activity and Performance Planning to deliver activity as follows: • 104% of 19/20 levels for elective care • 100% of 19/20 outpatient follow-ups (doesn’t achieve national ambition for reduction, despite good UHS engagement with initiatives) • 100% of 19/20 levels for non-elective admissions • 20/21 numbers of A&E attendances (there are risks here, given the 21/22 growth rate) Summary of plan - Activity and Performance RTT • July 2022 - no patient waiting > 2 years • April 2023 - no patient waiting > 18 months Cancer • March 2023 - patients waiting > 62 days from referral returned to pre-pandemic levels Outpatients • Transform care, greater use of technology, improve both waiting times and experience of waiting Conclusion • Very challenging national expectation, when considering finances, workforce, and patient care in combination • Exacerbated by the current variance between planning assumptions and the real environment e.g. COVID, inflation • UHS is well positioned to respond, and aims to deliver for our patients, and people, operate efficiently, and achieve acceptable financial outcomes relative to the context and to our peers Conclusion – ‘Connect’ Slides Our World with and beyond COVID: •Pause to reflect as we come out of COVID •National messages •Reasons to be proud •Our collective leadership priorities  2025 vision guides us  Unite around the patient  Personal development, wellbeing, inclusion, recruitment  Operational sweet spot  Bringing back the hospital to normal footprint  Maximise elective activity  Transformation projects in theatres, outpatients and flow improvement  Always Improving, pathway/process innovation and squeaking wheels  Confidence in us and in our future Questions / Discussion Report to the Council of Governors Title: Agenda item: Sponsor: Author: Date: Purpose Issue to be addressed: Non-NHS Activity 5.2 Ian Howard, Chief Financial Officer Na’el Clarke, Commercial Director 27 April 2022 Assurance Approval or reassurance Y Ratification Information One of the responsibilities of the Council of Governors is to determine whether the Trust’s non-NHS activity would significantly interfere with its principal purpose, which is to provide goods and services for the health service in England, or the performance of its other functions. Response to the issue: The Council of Governors must then notify the directors of its decision. The Trust’s private patient income for 2021-22 is forecast to be approximately £6.4 million. This represents just under 0.7% of the Trust’s overall income. This year has seen a growth in activity due to the more complex patients being treated, whilst maintaining the prioritisation of clinically urgent procedures, noting the unprecedented pressure that core NHS services have faced. There has been growth in services delivered through an outpatient setting, whilst remaining mindful of the needs and constraints faced by our core services. Over the next six months at least, activity for private patient services is expected to remain at the same level as NHS activity is prioritised. Again, it is expected that only a limited number of patients that are deemed an emergency or clinically urgent will be treated privately as inpatients. Private cancer treatment is expected to continue in the Solent suite, which provides a dedicated nurse-led service. The income forecast for 2022-23 will be in line with the forecast total for 2021-22. There is also a growing income stream linked to the commercialisation of Trust-derived intellectual property, although this is forecast at just under £40,000 for 2021-22, we expect a forecast income of at least £140k in 2022-23. Another core area of non-core income is linked to the co-development of innovative medical technology, again income from this workstream is forecast at £150,000 for 2022-23, having been established through a series of strategic partnerships to co-develop products that meet unmet clinical needs during 2021-22. The range of commercial workstreams that deliver non-core income has been expanded. Implications: Risks: Summary: This ensures that the Trust meets its legal requirements that income received from its principal purpose is greater than its non-NHS income. It also enables the Council of Governors to monitor when it may need to specifically approve an increase in non-NHS income under other provisions of the National Health Service Act 2006. This would apply to proposals to increase by 5% or more the proportion of total income in any financial year attributable to activities other than the provision of goods and services for the purposes of the health service in England (including private work). 1. Non-compliance with the provisions of the National Health Service Act 2006 and the Trust’s constitution. 2. Monitoring the performance of the Trust against its principal purpose. 3. Ensuring NHS activity is not negatively impacted by non-NHS activity whilst recognising how income from additional activity supports NHS services and the activity itself supports innovation. Given the current and forecast levels of non-NHS income, the Council of Governors is requested to: • confirm that is satisfied that the Trust’s non-NHS activity would not significantly interfere with its principal purpose, which is to provide goods and services for the health service in England, or the performance of its other functions; and • authorise the Interim Chair or Associate Director of Corporate Affairs and Company Secretary to inform the directors of its decision. Non-Core Income –UHS HIGHLIGHTS: • Non-Core (Commercial Income) forecast at £8.5m for the 22/23 FY • Core areas of commercial activity are : the provision of private patient services, management of overseas visitors, commercialisation of UHS-derived innovations and strategic working with medical technology suppliers to create technology that addresses unmet clinical needs. • Third party commercial contracting with non-NHS bodies is also an important area of commercial activity that brings in around £1.5m of income per annum and which also has reduced third party contractual costs by at least £90k (21/22 FY) and mitigated commercial risks of > £1m • Miscellaneous schemes such as the commercial use of physical and digital space produce a useful income of around £100k p.a. • This income is re-invested back into development projects and core NHS services as part of our CIP PRIVATE PATIENT SERVICES –Summary • Private Patient Income (£6.4m forecast year end position) (21/22) represents a small % of our overall income ( 95.0% ≥ 90.0% Dec 2021 70.1% 79.7% Jan 2022 69.1% 79.5% Feb 2022 65.8% 77.9% A deterioration in UHS timeliness has continued and performance is now a significant distance from the national target, yet remains relatively good in comparison to many other acute trusts. In the period between December 2021 and February 2022 UHS ranked third best amongst eight major trauma centres that we benchmark with (Type 1 attendances). The Trust Board reviews emergency access performance every month and has reviewed the subject in detail at its meetings in September 2021, November 2021 and February 2022. The Trust has continued to invest in both the physical environment and workforce to respond to rapidly increasing levels of attendances. We are also seeking to progress other contributions to improvement including working with partners to improve discharge from hospital beds, an internal focus on improving treatment and reducing patients’ length of stay in hospital, and working with partners to reduce the numbers of patients attending the emergency department where there are alternative ways of meeting their clinical needs. Referral to Treatment (RTT) % incomplete pathways within 18 weeks in month Total patients on a waiting list Target => 92% Dec 2021 67.4% 44,737 Jan 2022 67.2% 44,551 Feb 2022 67.4% 45,857 The number of patients on our waiting lists has increased by approximately 30% compared to January 2020, although the size of the waiting list has been stable in recent months. Page 3 of 5 Many of our patients are also waiting very long periods to start their treatment: • There were 2,032 patients who had waited over 52 weeks at the end of February 2022 (down from a peak in 3,149 in March 2021) • We are confident that by July 2022 no patient (other than those who are choosing to wait longer) will have waited over 104 weeks (there were a total of 171 such patients waiting in December 2021). The Trust has increased its physical capacity and workforce, and is engaging with NHS partners to plan further expansions which would respond to both rising need for the types of treatment UHS can provide and the ‘backlog’ due to COVID-19. Reductions in the number of inpatients with COVID-19 infection, and the number of staff absent with COVID-19 infection, will also be critical to our rate of improvement. The Trust Board reviewed Referral to Treatment performance in detail through spotlight reports at its meetings in October 2021, November 2021 and January 2022. Cancer Urgent GP referrals seen in 2 weeks Breast symptomatic patients’ referral seen in 2 weeks Treatment started within 62 days of urgent GP referral Target => 93% => 93% => 85% Dec 2021 74.5% 7.0% 71.0% Jan 2022 80.4% 33.3% 66.8% Feb 2022 89.6% 36.4% 69.2% Our breast service is in the process of increasing capacity and improving performance following the challenges relating to demand and COVID-19 disruption described in the previous report. These difficulties, and the time required to implement solutions, account for the failure to achieve two week waiting time targets for urgent GP referrals (patients suspected of having cancer, including breast patients), and breast symptomatic patients (symptoms not considered suspicious for cancer). Improving performance trajectories can now be observed, and further improvement is expected. As a result of both referral and treatment challenges across the majority of specialities, our 62 day cancer treatment performance has been adversely impacted. Performance has deteriorated compared to the previous three month period when it ranged between 71.8% and 74.7%. Despite this, UHS performance remains very good compared to other hospitals, in February 2022 UHS was fourth best amongst our peer group of 19 teaching hospitals, and matched the average performance of 17 hospital trusts in the south east region despite the majority of these hospitals offering a significantly less complex range of treatments than UHS. Cancer performance was reviewed by the Trust Board in detail at the December 2021 meeting and a further detailed review is planned for the April 2022 meeting. 5. Finance At the end of March 2022, the Trust reported a breakeven position for the year. This was an improvement on a planned £3.4 million deficit position as a result of receipt of additional national elective recovery funding. Operational pressures related to staffing (COVID-19 related sickness absence), increased emergency demand and increased COVID-19 inpatient numbers have led to a challenging operational position; however the financial pressures have been supported by nonrecurrent national funding. The underlying position of the finances is however more challenging, with inflationary pressures in energy and drugs cost growth within block contracts, meaning the outlook for 2022/23 is one of significant financial as well as operational challenge. Page 4 of 5 The Trust also reported on plan with its capital investment programme for 2021/22 with expenditure of internally funded capital (£50 million) and additional national funding (£15 million). This included investment in four new theatres within the ‘vertical extension’ building, a refurbishment and expansion of emergency department ‘majors’, and an expanded ophthalmology outpatients facility, as well as investment in digital, equipment and backlog maintenance. 6. Human Resources Indicator Target 2020/21 UHS Comparison Q3 2021/22 Staff FFT - % of staff likely or extremely likely to recommend UHS as a place to work Staff recommending UHS as a place to receive care/treatment => 75.5% => 85.0% 77% 86.7% 71.9% 83.1% National Average (Acute/Acute + Community Trusts) 58.4% 66.9% The ‘advocacy’ scores above, measured through the NHS Staff Survey, have declined since the previous year but remain well above the benchmark averages which have declined further. UHS had a survey response rate of 56%, which is an increase of 6% from 2020, and the highest level of participation UHS has achieved since the survey began. The median response rate in our benchmark group was 46%. UHS: • • • rated “the best” for career progression opportunities, and for offering a range of challenging work scored above average on 106 of 126 questions and scored below average on only 7 of 127 questions Indicator Turnover (internal target) Sickness absence 12 month rolling (internal target) Nursing vacancies (registered nurse only in clinical wards) (internal target) Target <=12% <=3.4% <=15% Dec 2021 13.4% 4.1% 15.6% Jan 2022 13.6% 4.1% 14.9% Feb 2022 13.7% 4.2% 15.0% Staff ‘turnover’ continues to be high and is increasing (following a reduction in 2020/21). A wide range of actions are being progressed including to support wellbeing, internal career development, work-life balance, and to focus on specific improvement opportunities such as healthcare assistant roles, recent recruits and staff approaching retirement. Sickness absence has unfortunately increased further, with monthly levels reaching a peak of 5.7% in January 2022 associated with a peak of COVID-19 infection. Page 5 of 5 5.4 Draft Quality Report and Annual Report Timetable 1 5.4a Annual Report and Quality Accounts timetable cover sheet.doc Report to the Council of Governors Title: Agenda item: Sponsor: Author: Date: Purpose Issue to be addressed: Annual Report and Quality Accounts Timetable 5.4 David French, Chief Executive Officer Karen Flaherty, Associate Director of Corporate Affairs and Company Secretary 27 April 2022 Assurance Approval or reassurance Ratification Information Y NHS England and NHS Improvement (NHSE/I) has published the timetable for the 2021-22 annual report and accounts and associated guidance. This removes the requirements to produce a separate quality report, although the quality accounts requirements set out in The National Health Service (Quality Accounts) Regulations 2010 still apply requiring trusts to produce quality accounts, including circulation of the quality accounts to commissioners, local authorities, local Healthwatch and the Council of Governors by the end of April for comment. Some additional quality reporting will be required to be included in the performance report section of the annual report instead. There are also no external audit assurance requirements in respect of the quality accounts as a result of the changes to the NHSE/I guidance. Response to the issue: Implications: The quality accounts are required to be published by 30 June 2022, whereas the annual report and accounts cannot be published until after they have been laid before Parliament. This is expected to occur at the beginning of September 2022 to allow time for the external auditor to complete the value for money external audit work and finalise its audit report and certificate for inclusion in the published version of the annual report and accounts. The external auditor expects to complete this work by the end of July 2022 after Parliament begins its summer recess. The Trust has taken the decision to produce the annual report and accounts and the quality accounts on the same timetable as a single document by the submission deadline of 22 June 2022. However, due the additional work required to complete the value for money external audit, the quality accounts will be published as a separate document by 30 June 2022. The attached timetable sets out the process in greater detail. The Trust meets the requirements of the National Health Service Act 2006, The National Health Service (Quality Accounts) Regulations 2010 and the NHS foundation trust annual reporting manual 2021/22. The timing of the meeting of the Council of Governors at which the final annual report and accounts (including the quality accounts) and the external auditors’ report are presented will be later than usual to allow for these to be laid before Parliament as this would normally take place in July. An update will be provided to the Council of Governors in a closed session of its meeting in July 2022 to mitigate the impact of this Risks: Summary: Conclusion and/or recommendation delay. The date of the annual members’ meeting will be finalised at a later date or delayed slightly to ensure that the annual report and accounts have been laid before Parliament before the annual members’ meeting takes place. 1. Non-compliance with the National Health Service Act 2006, The National Health Service (Quality Accounts) Regulations 2010 and the NHS foundation trust annual reporting manual 2021/22. 2. Ensuring openness, transparency and accountability regarding the performance and activities of the Trust. 3. Pressure on staff to provide information for inclusion in the annual report and accounts and the quality accounts as the Trust emerges from the latest wave of the COVID-19 pandemic, deals with significant emergency pressures and deliver the elective recovery programme. The Council of Governors is asked to note the timetable. Annual Report and Accounts (including the Quality Accounts) 2021-22 Timetable NHS England and NHS Improvement (NHSE/I) has published the timetable for the 2021-22 annual report and accounts and guidance on producing the annual report and accounts. This takes into account the pressures of the latest wave of the COVID-19 pandemic and feedback in earlier years of the COVID-19 pandemic that the process went on too long. NHSE/I have been consulting on changes to the quality reporting requirements over the past year and it is anticipated that changes will be made to the requirements in future years. In 2021-22 the requirements to produce a separate quality report have been removed, although the quality accounts requirements set out in The National Health Service (Quality Accounts) Regulations 2010 still apply requiring trusts to produce quality accounts, including circulation of the quality accounts to commissioners, local authorities, local Healthwatch and the Council of Governors by the end of April for comment. Some additional quality reporting will be required to be included in the performance report section of the annual report instead. There are also no external audit assurance requirements in respect of the quality accounts as a result of the changes to the NHSE/I guidance. As a result the deadline for submission of the annual report and accounts to NHSE/I has been extended to 22 June 2022. Additional time has also been allowed for the completion of the external audit of value for money introduced in 2020-21. The main changes to the requirements this year are: • reintroduction of the requirement for a performance analysis, which includes information on sustainability incorporating progress against the Trust’s Green Plan and information about social, community, anti-bribery and human rights; • removal of the quality report requirements and a requirement to include performance against quality priorities and quality indicators in the performance report in the main body of the annual report instead; and • new and expanded ‘fair pay’ disclosure requirements. The proposed timetable is set out below Action Deadline for draft accounts submission to NHSE/NHSI through NHSI Portal Draft quality accounts circulated to governors and Quality Committee members Issue final draft quality accounts to CCG, Local Healthwatch, Overview and Scrutiny Committee and Council of Governors for one month consultation Early May Bank Holiday Circulation of first draft annual report to external auditor, Board of Directors and Council of Governors Draft annual report and accounts reviewed at Audit and Risk Committee meeting Draft annual report and accounts reviewed at Board of Directors meeting Spring Bank Holiday Platinum Jubilee Bank Holiday Final draft quality accounts reviewed at Quality Committee meeting Date Tuesday, 26 April 2022 (noon) Thursday, 21 April 2022 By Friday, 29 April 2022 Monday, 2 May 2022 w/c Monday, 9 May 2022 Monday, 23 May 2022 Thursday, 26 May 2022 Thursday, 2 June 2022 Friday, 3 June 2022 Monday, 13 June 2022 Page 1 of 2 Action Final draft annual report and accounts including quality accounts reviewed at Audit and Risk Committee meeting Final draft annual report and accounts including the quality accounts approved by Board of Directors Deadline for submission of signed annual report and accounts and supporting documentation to NHS England and NHS Improvement Add quality accounts to Trust website and forward th
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Trust-governance-and-corporate-docs/2022-Trust-documents/Papers-Council-of-Governors-27-April-2022.pdf

Welcome to radiotherapy - patient information

Description: This factsheet contains information about your visit to the radiotherapy department at Southampton General Hospital and aims to answer some of the initial questions you are likely to have.
Url: /Media/UHS-website-2019/Patientinformation/Cancercare/Welcome-to-radiotherapy-1330-PIL.pdf

Radiotherapy to the upper abdomen - patient information

Description: This factsheet explains what to expect at your radiotherapy treatment appointments.
Url: /Media/UHS-website-2019/Patientinformation/Cancercare/Radiotherapy-to-the-upper-abdomen-1328-PIL.pdf

Recovering after intensive care - patient information

Description: This factsheet is a guide to your recovery after a stay on one of the intensive care units (ICUs).
Url: /Media/UHS-website-2019/Patientinformation/Visitinghospital/Recovering-after-intensive-care-2684-PIL.pdf

Annual complaints report 2020-21

Description: ANNUAL COMPLAINTS REPORT 2020/21 RETROSPECTIVE PERFORMANCE LOOKING FORWARDS “All patients, from every background and walk of life, will experience the same world-class standard of care at UHS” INTRODUCTION Ellis Banfield Head of Experience & Involvement We often get overly focused on functional responses to learning from complaints by looking for specific actions and improvements we can make. Although this is important, a deeper value of complaints is how we, as an organisation, listen. Sometimes in the attempt to identify actions, improvements, and emerging trends, we risk overlooking what a complaint is – a highly personal and individual expression of feeling. Anger and sadness, yes, but also vulnerability, doubt, and fear. Many complaints are a subjective account of an experience of care that has left the individual feeling that they have no other way to make themselves heard. This is the deeper value of complaints – a measure of how much we, as an organisation, are prepared to properly listen to somebody who wants, quite simply, to be heard. Our complaints process tries to balance the need to identify actions to improve care with the ability to listen, reflect, and recognise that each and every one of us can learn from the experiences of others. The questions we, as an organisation, need to ask are whether we are willing to make ourselves uncomfortable by listening authentically to experiences that aren’t good: are we willing to listen, to hear, and to validate experiences that find us falling short? When I reflect back on our complaints process, on our PALS service, on our patient feedback and involvement channels, I do really think that ‘we’re listening’ in the best possible way. Impact of COVID-19 One of the biggest impacts of the pandemic was on how quickly and effectively we were able to manage and respond to complaints. On the chart below, the improvement made to the complaints process at the beginning of 2019 was maintained consistently until COVID-19 struck and complaints management was paused nationwide in May 2020. Getting back on track took the best part of half a year as the backlog stretched the team’s resources. We have a fantastic complaints team, and we are now ready to build on some of our successes of the past year and work towards delivering a ‘best in the NHS’ complaints service. I’m immensely proud of how the team have responded in 2020/21 and look forward to supporting them through the next year. Please note that due to the impact of the pandemic, there were no upheld Parliamentary & Health Service Ombudsman cases in 2020/21. MEET THE COMPLAINTS TEAM Working together to put patients first Vicki Havercroft-Dixon Head of Patient & Family Relations “I’m responsible for the complaints, PALS, and bereavement teams and this gives me a good view of concerns and complaints to pick out themes and opportunities for learning” Shona Small Complaints Manager “I am the Trust’s complaints manager and my role is to ensure that complaints are managed efficiently, within agreed timescales, and to a high standard” Hayley Yeomans Complaints Coordinator “My role is to act as the main point of contact for both the complainant and staff involved. I listen to the complainant’s concerns and agree with them what needs to be investigated” Clare McCormick Complaints Coordinator “What I enjoy about the role is being able to empathise, and build trust and understanding to support patients, families, and carers in achieving the best chance of resolution” Ellen Millard Complaints Editorial Assistant ”My job involves drafting, editing, and proofreading response letters to ensure that they are easy to understand, contain relevant information, and strike the right balance between fact and empathy” LOOKING BACK AT THE PAST YEAR Although the past year has been challenging, we are really lucky that my team are experienced and extremely good at what we do: each complaint coordinator is a qualified complaints investigator and our editorial assistant is qualified and accredited in her field. This expertise has helped us respond to the consistent challenges of the pandemic. We have worked hard during COVID-19 and we have all adapted to working from home by maintaining good relationships. We pride ourselves on our good communication through Teams, emails, and phone, but also our regular ‘walk and talk’ meetings that we do outside to ensure we are all supported. Shona Small Complaints Manager In numbers We have maintained good productivity levels despite the impact of the pandemic, the loss of onsite office space, and team members being seconded to short-term projects. We are continually reviewing how best to deliver our service, and we’ve managed to get back on track following a significant backlog of complaints due to the pandemic. Key achievement We had the opportunity in 2020 to recruit to a new role – a first in the NHS, to our knowledge – of a complaints editorial assistant. This post brought into the team professional and accredited proofreading, editing, and writing experience that has elevated the quality of our written responses even further. 345 Complaints received Evaluating our service One of the things we’ve done over the past year is to try to get feedback from complainants about the complaints process. In 2019 we ran an extremely valuable patient complaint panel where service users helped us to review our processes and identify improvements. We’ve recently launched a complaints survey that all complainants have the opportunity of completing. Although responses are limited, we have seen that: 32 Working days on average to respond • All respondents reported being given a single point of contact for managing their complaint • 91% of respondents said they felt confident their care would not be affected by making a complaint • 82% said they felt listened to and taken seriously • 27% felt they could have been kept better informed – an impact, perhaps, of the pandemic • 91% said the response they received was personal and specific to their concerns 23 Dissatisfied and reopened complaints I look forward to building on these results in the coming year as we work to get fully back on track and continue to deliver a high-quality complaints service. COMPLAINTS ACTIVITY Complaints received Prior to 2020/21, the Trust received an average of 450 complaints a year. During the pandemic year 345 formal complaints were received – a drop of 105 compared to the previous year. This reflects the response to the pandemic, lower patient numbers due to suspended services, and a national pause on complaints management. The biggest dropoff occurred in the first quarter of the year, before the rate of complaints steadily returned to pre-pandemic numbers. Complaints management The national pause to complaints management had an unavoidable impact on response times. A backlog of complaints, from before the pandemic and during, needed to be cleared and this work is reflected in the drop in the numbers of complaints being closed within 35 working days in the first 6 months of the year, where it took an average of 37 days to close a complaint. In the second half of the year, the team got back within target and averaged 27 days per complaint. Multi-agency complaints Historically, multi-agency complaints (those involving multiple organisations) have always been more challenging to manage as each organisation has different timeframes and priorities. The pandemic has made these even more difficult to complete in a timely manner. In June 2020 we decided to record these complaints separately to better monitor them. From June 2020 to March 2021, we responded to these with an average response time of 57 days – 25 days longer than internal complaints. THEMES AND TRENDS We received 345 formal complaints in 2020/21 and trying to find themes and trends within and across 345 very individual experiences is challenging. We report our complaints data to NHS England every quarter and submit a breakdown of complaint themes according to nationally-defined categories: communication, clinical treatment, access to services, and more. Although the categories help reporting, to understand the concerns being raised, a deeper dive is required. Ellis Banfield Head of Experience & Involvement One of the most prominent things that jumps out of a review of our complaints is how complaints often have multiple themes within them. For example, some of our patients had reason to complain as they felt their diagnosis was delayed and their symptoms not recognised early enough. Woven into these complaints are concerns about communication, both its timeliness and its empathy, as well as other aspects of care, such as pain management. One aspect of a complaint is often the driver behind others: poor communication or pain management often influences how other elements of care are experienced and reported within complaints. It is clear when reading these letters that these different aspects of complaints are often so interlinked and interrelated as to make simple categorisation challenging. Clearly the pandemic was the ever-present backdrop to all our activity over the past year and the complaints we received reflect this vividly. COVID-19 and the response to it put strain on the important partnership between patients, staff, and families and this effect is unmistakable in many of our complaints. The visiting restrictions put greater focus on the need to communicate effectively and clearly with both patients – many deprived of immediate family support during care and treatment – and families, who were at a distance outside the hospital. While we implemented initiatives such as virtual visiting, a messaging service, and a patient drop-off property pod, we did not always get it right and keep patients and families connected in the way they wanted. Our complaints evidence the challenges for families in contacting the ward, being involved in discussions about treatment, and being kept up-to-date about their relative’s care. Our responses from staff document just how challenging it was working in the hospital during the pandemic but testify to their ongoing commitment to getting it right for patients and their families. Respecting religious rites and customs, especially at the end of life, in death, and in bereavement, is immensely important to us, but we also had to learn and adapt our practices in response to COVID-19 and the need to ensure we remained committed to helping our patients of different faiths. Feedback in our complaints have helped us achieve this: for example, in response to a complaint about preparation of bodies for Islamic funerals, Siraj, our spiritual care manager and Muslim chaplain, will now be teaching this at nurse study days. Visiting restrictions proved challenging for patients, families, and staff. The complaints, for example, from adult children about their parents admitted with dementia and other vulnerabilities expressed a clear worry about ensuring the care was appropriate for their parent, but also highlighted feelings of helplessness and detachment. Attempting repeated calls to wards for updates proved frustrating for families and staff alike, and in some instances intensified communication problems. We continued to evolve our visiting policy both on feedback from families and staff, as well as aligning with national policy and guidance. We tried to ensure that compassionate visiting was offered and introduced a range of support for carers to continue to be involved and support the delivery of care. THEMES AND TRENDS Our response to the pandemic also had an impact seen in some of our multi-agency complaints. These complaints highlighted situations in which patients and families were often given different information by different care providers. For example, a relative being told by the GP they would be able to travel in the ambulance with their parent only to be told this wasn’t allowed by the ambulance crew, compounded by no information being provided on admittance about what support was available at hospital. Navigating through each organisations’ processes and policies was clearly challenging for the relative and highlights the importance of thinking about the interconnectivity of organisations through the healthcare system. Some of our most challenging complaints were those involving the end of life, as although all our staff are completely committed to getting it right for patients and families, on the occasions when things do go wrong, the impact can be deep and traumatic. Delayed treatment, the impact of hospital-acquired COVID-19, and unexpected or rapid deterioration leading to death all greatly impacted families and staff involved in care. There were occasions where communication was perceived to fall short, and where families felt outside the decision-making process and not empowered, such as during DNACPR discussions and decisions. In our investigations and responses we were not always able to agree with the complainant’s views, but we recognised the emotional distress bereavement can cause and explained our position clearly, empathetically, and signposted to further support and advice. We’ve taken learning from these complaints and have adjusted our visiting policy, looked at availability and timeliness of anticipatory care plan drug prescriptions, and sought to redouble our efforts to keep families involved. We relaunched our end of life care programme board in late 2020 to provide assurance, oversight, and learning, review complaints and hear directly from families about their experiences. Upheld complaints In every complaint we investigate, we look at whether we can uphold the complaint (agree with the complainant on all points of concern), partially uphold it (agree on aspects of concern), or not uphold it (where we find no failings and cannot agree with the complainant). The chart to the right shows how many complaints were upheld (11%), partially upheld (42%), and not upheld (47%). 2020/21 11% 47% 42% Upheld Partial ly upheld Not upheld WHAT WE ARE DOING NEXT The pandemic has certainly been a challenging period in which to manage complaints, but there are now some real opportunities for us to build on the changes we’ve made to our processes and practices and continue to work towards making complaints count. Vicki Havercroft-Dixon Head of Patient & Family Relations In 2021 a new set of NHS Complaints Standards was developed by the Parliamentary and Health Service Ombudsman to set out a quicker, simpler, and more streamlined complaints handling service. The standards are being piloted across a number of Trusts before being nationally rolled out in 2022. We have applied to be a pilot in the second phase of the rollout. While we believe in our complaints processes and have confidence we handle complaints well, a national agreed standard can only help improve the overall experience of people making complaints to NHS organisations and we are fully supportive of this. Documentation of learning and actions One of our early priorities, identified through our initial gap analysis, is to improve the documentation of our learning from complaints and to make this learning more widely available. Working with divisional teams, our aim is to ensure learning and actions are recorded on the action plan module of our Safeguard system. This will lead to better assurance and oversight that actions are being completed and will allow us to feed back the positive steps we are taking to complainants and the public. Early resolution Resolving complaints early has long been an organisational objective and we do it well. The pandemic introduced new challenges: we found that although complainants were willing to try a resolution meeting, many of them wanted these face-to-face and did not want to do it virtually via Teams or Zoom. As restrictions ease, we want to bring back resolution meetings as an effective way of managing complaints and have applied for funding to put the team on mediation and conflict resolution training to better equip them with the tools to manage these meetings successfully. Complaint ownership Our complaints coordinators Hayley and Clare play a vital role in managing investigations, but there are some complaints that can be answered by one individual, often directly. Ellen, our complaints editor, will start working with clinicians to offer writing support where a direct written response will resolve a complaint quickly and effectively. Making complaints inclusive In 2018 we took steps to ensure that information about how to make complaints was available in accessible formats such as braille, large print, different languages, and audio recordings. A review of our complaints demographics still shows below expected levels of diversity in those who complain. We recognise that we need to give more attention to ensuring that people from different backgrounds have the confidence in the system to speak up and share their experiences. We will be working hard in 2021/22 to ensure that there are no barriers to accessing our complaints service.
Url: /Media/UHS-website-2019/Patientinformation/Contactingus/Annual-complaints-report-2020-21.pdf

Rehab pathway for Msk patients 2016

Description: Rehabilitation Pathway for Complex Musculoskeletal Trauma - June 2016 To date, there has been no rehabilitation pathway written for multi-trauma patients with complex musculoskeletal (MSK) injuries in the Wessex Region. In fact, the paucity of services for this particular patient group has been highlighted nationally by the Trauma CRG . These patients often fall into levels 2a or 2b as outlined in the BSRM definitions (2009, 2010) and as such do not qualify for specialist funding. They cannot therefore access specialist rehabilitation services. These patients are a priority in terms of clinical need, cost to the NHS and lost tax to the exchequer if they are not managed well, and do not return to their former vocation. This document has been written in conjunction with local health / social workers, patients and commissioners, and in reference to the evidence base as it exists. The pathway aims at ideal care irrespective of whether it exists currently. (These patients generally have multiple limb fractures - often with significant external fixation - and often requiring plastic surgery input. Many of them have peripheral nerve injuries. Internal injuries and / or minor head injuries increase patients ISS scores. However, the rehabilitation community generally reports ISS scores bear no correlation with rehabilitation needs. These patients cover all age groups.) Pathway Acute Care Patients following a traumatic injury are taken to either: a/ University Hospitals Southampton (UHS) as the Multi-trauma Centre (MTC), or b/ a local Trauma Unit (TU). The patient may then be transferred to the MTC as a secondary transfer, and possibly on to Salisbury District Hospital which leads on Plastic Surgery across the WTN. Patients with these types of injuries are invariably sited in an Intensive Care Unit (ITU) whether at the MTC or TU. This can be as a result of the MSK injury or associated internal injuries to the lungs, spleen etc. A Rehabilitation Prescription, or equivalent document, should be filled in within 72 hours by a Rehabilitation Specialist (either Rehabilitation Consultant or Rehabilitation trained AHP ? Band 7 or upwards) as per national trauma guidelines. If possible / appropriate, an holistic assessment should be undertaken including family members / carers as appropriate. This should include physical, cognitive, communication, psychological and social needs and relevant history. If this is not appropriate at this point, it is expected that this would be done within the first 10 days and patients with, or expected to have, complex needs be identified. The rehabilitation specialist should have access to the full multi-disciplinary team (MDT) for their expertise as needed including nurses, Physiotherapists, Occupational Therapists, Consultants in Rehabilitation Medicine, Orthopaedics and / or Plastics, Psychologist, Psychiatrist, Dietetics, etc. The MDT should meet regularly to discuss the changing needs of patients in the acute setting. Acute rehabilitation should start as soon as clinically safe following medical protocols. Reassessment should occur regularly, at least weekly, as patient status changes quickly at this point in their journey. It is recommended that a Consultant and AHP `injury list' and `management plan' are written within 72 hours of arrival and that excellent communication between both groups occurs concerning them. It is likely that MSK patients will be transferred to a Trauma, Orthopaedic or Plastic ward at an appropriate point. Their acute rehabilitation would continue at this point. When the patient is medically stable, the rehabilitation team should consider onward referral. Services are currently limited at this point (this is the national picture). This pathway recommends that there should be appropriate referral options at this point depending on the patients need: specialist intensive rehabilitation Specialist community and / or outpatient management Referral should occur as early as possible with patient and carer involvement in all decision making. Complex MSK patients should be reviewed within one week of discharge from acute services. Intensive Rehabilitation Input There are currently very few intensive MSK rehabilitation facilities nationally. However, it is generally accepted, both locally and at national level, that complex MSK injuries require more input than most outpatient / community departments can offer. There are already clear guidelines for rehabilitation facilities and many of these are transferable to a MSK centre (See BSRM 2002, 2009, 2012). The armed forces and police / fire services are already employing such centres / services. Services must be patient focused and goal driven. They must have a strong, well trained and full MDT which meets regularly and can demonstrate evidence of regular training / CPD. Rehabilitation centres should be patient friendly in terms of environment, resources and culture. They must have all the resources / equipment requisite for providing appropriate treatment. These should include PT (Physiotherapy), OT (Occupational Therapy), early access to psychology, regular hydrotherapy (i.e. available > once per week), access to pain specialists and vocational rehabilitation facilities. Strong links with local orthotics and prothetics Departments are recommended with lower limb expertise in the team. Similarly, excellent communication with relevant Orthopaedic and / or Plastic Consultants. On arrival at a rehabilitation centre, appropriate, patient driven SMART goals should be set with the patient / carers and the MDT within the first week. These goals should be reviewed on a regular basis ? two to four weekly. The patient / carers should receive regular feedback from these meetings as should the patient's GP and relevant commissioners. The RP, or equivalent, should be repeated at appropriate time frames as part of this process. Nursing care needs vary for MSK patients. Initially, patients may require more intense nursing care but later they may be able to manage with minimal assistance e.g. staying in hostel type accommodation without nursing care. Services should reflect this changing need. MSK patients may also require further follow-up surgery and so move in and out of an intensive centre as their needs change over several years. It is essential that there is flexibility in planning and treatment so that patient programmes can be tailored to individual patient needs rather than service needs. Initial programme planning should be holistic addressing all needs identified on the RP or equivalent. Goals should be both long and short term. Length of stay in the centre should be agreed between the MDT and family at an early point ? although this might be revised later. Vocational goals should be set at an early stage and appropriate communication with employers to facilitate return to normal activities if possible, or plans for alternative employment. Patients may spend time in and out of the service as their rehabilitation progresses. It is recommended that therapy assistants (or fitness instructors / equivalent) are utilised regularly in intensive centres. Specialist community / outpatient services Currently, local outpatient departments and community services are the default referral option for most MSK injuries. It is recommended that complex trauma patients require management by specialists with MSK trauma expertise ? see below. Therapists should use a goal setting approach both with short term and long term goals. Services should be able to see patients as their therapy requires i.e. multiple times in a week if their level of injury requires it. Similarly, hydrotherapy should be available for multiple sessions per week if the patient requires it. Specialists should have access to appropriate rehabilitation equipment e.g. parallel bars, gymnasium equipment, supports, splints etc. There is clear data that the number of frail patients has increased in the recent past. It is also evident that the number varies geographically. It is important that such patients have access to appropriate input to manage co-morbidities. Services managing such patients should have expertise both in frailty and MSK trauma. All services should have access to timely vocational rehabilitation input. General Recommendations It is recommended that all complex MSK patients have a named key worker at all points through the rehabilitation journey. It is recommended that all complex MSK patients are managed by someone with relevant trauma expertise i.e. someone with upper or lower limb expertise (whether in intensive, community or outpatient services). It is recommended that rehabilitation services are within 45 minutes travel time (whether community, outpatient or intensive centres). It is recommended that complex MSK patients meet all relevant surgical teams at one appointment with relevant rehabilitation specialists to discuss / agree plans. Patients have reported at local and national meetings that multiple appointments are not helpful to efficient rehabilitation. In a similar vein, it is recommended that services should provide rehabilitation experts in all relevant limbs at one session rather than requiring patients to attend different appointments for different limbs' management / treatment. It is recommended that rehabilitation specialists use appropriate outcome measures e.g. EQ5D5L (a quality of life measure), LEFS (lower extremity functional scale), QDASH (functional tool for `disability assessment of the shoulder and hand'), etc. to demonstrate effective input to patients, clinicians, family members and commissioners. Appropriate seating should be easily available. Easy access to appropriate transport is essential. Current Services There is currently one intensive MSK service in the area fitting most of the above criteria, namely the Wessex Rehabilitation Centre in Salisbury. The centre treats patients from 9.30 ? 4.45 Monday to Thursday (assessments can be on a Friday). The centre has access to regular hydrotherapy, Physiotherapy in a custom built gymnasium, and Occupational Therapy including an industrial workshop and bungalow. The centre also has regular weekly input from a Specialist Nurse and Pain Consultant. Psychology is standardly included in treatment for appropriate patients and their input guides therapy programmes. There is hostel type accommodation for patients staying mid week. The Trauma Specialist Plastic Surgeons are partly based at Salisbury and therefore accessible. Patients are given a key therapist and are involved in goal setting from first assessment. The service has good links with the Trauma Centre in Southampton. There are agreements with commissioning bodies across the Wessex Network that mean complex trauma patients are able to access the service with a rehab prescription. Patients can be referred by Consultants, GPs or AHPs. Quality Indicators RP or equivalent filled in by Rehab Specialist (Cons or AHP B7), within 72 hrs Holistic r/v ? multiple professionals including psychosocial ax by 10/7 Evidence of reassessment (at least weekly) in acute setting (if appropriate) Y / N / NE Y / N / NE Y / N / NE Evidence of daily rehabilitation (if appropriate) input by MDT: PT, OT, SLT, Psychology etc. ? ---------------------------------- Clear involvement of patient in decision making concerning rehab options? Patient reviewed within one week of discharge from acute service Evidence of goalsetting, with patient involved, at regular time frames Access to psychology available if necessary? Access to vocational rehabilitation services if necessary? Regular access to hydrotherapy available? Service able to see patient multiple times weekly if necessary? Evidence of clearly assigned Key Worker at 1/52, 4/52, 10/52? Could the patient's injuries be rehabilitated in one setting? Did rehabilitation workers have relevant expertise? Evidence of use of relevant clinical and QOL outcome measures Evidence of communication with GP, relevant consultants and local services. Evidence of rehabilitation services being less than 45 minutes away Patient able to see orthoplastic team at one appointment Y / N / NE Y / N / NE Y / N / NE Y / N / NE Y / N / NE Y / N / NE Y / N / NE Y / N / NE Y / N / NE Y / N / NE Y / N / NE Y / N / NE Y / N / NE Y / N / NE NE = no evidence Quality Measures 1. 2. 3. 4. RP or equivalent filled in by Rehab Specialist (Cons or AHP B7), within 72 hrs y / n / NE Holistic r/v ? multiple professionals including psychosocial ax by 10/7 y / n / NE Evidence of reassessment (at least weekly) in acute setting (if appropriate) y / n / NE Evidence of daily rehabilitation (if appropriate) input by MDT PT, OT, SLT, Psychology etc. ? --------------------------------Date of medical stability clearly recorded Re-assessment of RP or equivalent within few days of above date? Evidence of communication to Rehab Centre within 2 days of above date? Evidence of involvement of family / carers in above decision making process concerning rehab centre? 5. Evidence of goal setting in acute setting if not transferred 1. 2. 3. 4. y / n / NE Y / n / NE Y / n / NE Y / n / NE y / n / NE --------------------------------1. 2. 3. 4. 5. Patient accepted at rehab centre within 2/52 of medical stability date Evidence of goal setting with patient / family / carer involvement, in first week Evidence of long term and short term goals Evidence of review of goals and RP within 4/52 and 8/52 Evidence of voc rehab consideration (if appropriate) y / n / NE y / n / NE y / n / NE y / n / NE y / n / NE 6. Evidence of clearly assigned key worker at 1/52, 4/52, 10/52 y / n / NE 7. Evidence of relevant clinical and QOL Outcome measures at rehab centre y / n / NE 8. Evidence of communication with: GP, Social Worker, Voluntary agencies. y / n / NE NE = no evidence
Url: /Media/SUHTExtranet/WessexTraumaNetwork/Rehab-pathway-for-Msk-patients-2016.pdf

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