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Having an x-ray guided lumbar puncture - patient information

Description: This factsheet contains information about having an x-ray guided lumbar puncture.
Url: /Media/UHS-website-2019/Patientinformation/Scansandx-rays/Having-an-x-ray-guided-lumbar-puncture-2063-PIL.pdf

Papers Trust Board - 11 November 2025

Description: Date Time Location Chair Agenda Trust Board – Open Session 11/11/2025 9:00 - 13:00 Conference Room, Heartbeat Education Centre
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Trust-governance-and-corporate-docs/2025-Trust-documents/Papers-Trust-Board-11-November-2025.pdf

Papers Trust Board - 29 November 2022

Description: Date Time Location Chair Agenda Trust Board – Open Session 29/11/2022 9:00 - 13:20 Conference Room, Heartbeat/Microsoft Teams
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Trust-governance-and-corporate-docs/2022-Trust-documents/Papers-Trust-Board-29-November-2022.pdf

Papers Trust Board - 13 January 2026

Description: Date Time Location Chair Apologies Agenda Trust Board – Open Session 13/01/2026 9:00 - 13:00 Conference Room, Heartbeat Education
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Trust-governance-and-corporate-docs/2026-Trust-documents/Papers-Trust-Board-13-January-2026.pdf

Papers Trust Board - 9 September 2025

Description: Date Time Location Chair Apologies Agenda Trust Board – Open Session 09/09/2025 9:00 - 13:00 Conference Room, Heartbeat Education Centre Jenni Douglas-Todd David French, Tim Peachey 1 Chair’s Welcome, Apologies and Declarations of Interest 9:00 Note apologies for absence, and to hear any declarations of interest relating to any item on the Agenda. 2 Patient Story The patient story provides an opportunity for the Board to reflect on the experiences of patients and staff within the Trust and understand what the Trust could do better. 3 Minutes of Previous Meeting held on 15 July 2025 9:15 Approve the minutes of the previous meeting held on 15 July 2025 4 Matters Arising and Summary of Agreed Actions To discuss any matters arising from the minutes, and to agree on the status of any actions assigned at the previous meeting. 5 QUALITY, PERFORMANCE and FINANCE Quality includes: clinical effectiveness, patient safety, and patient experience 5.1 Briefing from the Chair of the Finance and Investment Committee 9:20 David Liverseidge, Chair 5.2 Briefing from the Chair of the People and Organisational Development 9:25 Committee Jane Harwood, Chair 5.3 Briefing from the Chair of the Quality Committee 9:30 including Maternity and Neonatal Safety 2025-26 Quarter 1 Report Tim Peachey, Chair 5.4 Chief Executive Officer's Report 9:35 Receive and note the report Sponsor: David French, Chief Executive Officer 5.5 Performance KPI Report for Month 4 10:00 Review and discuss the report Sponsor: David French, Chief Executive Officer 5.6 UHS Operating Plan 2025-26 and Board Assurance Statement 10:30 Receive and approve the Plan Sponsor: Andy Hyett, Chief Operating Officer Attendee: Duncan Linning-Karp, Deputy Chief Operating Officer 5.7 Break 10:40 5.8 Finance Report for Month 4 10:55 Review and discuss the report Sponsor: Ian Howard, Chief Financial Officer 5.9 ICS Operational Delivery Report for Month 4 11:05 Receive and discuss the report Sponsor: Ian Howard, Chief Financial Officer 5.10 11:10 People Report for Month 4 Review and discuss the report Sponsor: Steve Harris, Chief People Officer 5.11 Learning from Deaths 2025-26 Quarter 1 Report 11:20 Review and discuss the report Sponsor: Paul Grundy, Chief Medical Officer Attendee: Jenny Milner, Associate Director of Patient Experience 5.12 Annual Complaints Report 2024-25 11:30 Receive and discuss the report Sponsor: Gail Byrne, Chief Nursing Officer Attendee: Jenny Milner, Associate Director of Patient Experience 5.13 11:40 Medical Appraisal and Revalidation Annual Report including Board Statement of Compliance Receive and note the Annual Report. Approve the Statement of Compliance. Sponsor: Paul Grundy, Chief Medical Officer 5.14 Safeguarding Annual Report 2024-25 and Strategy 2025-26 11:50 Receive and discuss the report and strategy Sponsor: Gail Byrne, Chief Nursing Officer Attendees: Corinne Miller, Named Nurse for Safeguarding Adults/ Dannielle Honey, Named Nurse for Safeguarding Children 6 STRATEGY and BUSINESS PLANNING 6.1 Board Assurance Framework (BAF) Update 12:05 Review and discuss the update Sponsor: Gail Byrne, Chief Nursing Officer Attendees: Craig Machell, Associate Director of Corporate Affairs and Company Secretary/Lauren Anderson, Corporate Governance and Risk Manager Page 2 7 CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Feedback from the Council of Governors' (CoG) Meeting 16 July 2025 12:20 (Oral) Sponsor: Jenni Douglas-Todd, Trust Chair 7.2 People and Organisational Development Committee Terms of Reference 12:30 Review and approve Sponsor: Steve Harris, Chief People Officer 8 Any other business 12:35 Raise any relevant or urgent matters that are not on the agenda 9 Note the date of the next meeting: 11 November 2025 10 Items circulated to the Board for reading 10.1 South Central Regional Research Delivery Network (SC RRDN) 2025-26 Quarter 1 Performance Report Note the report Sponsor: Paul Grundy, Chief Medical Officer 11 Resolution regarding the Press, Public and Others Sponsor: Jenni Douglas-Todd, Trust Chair To agree, as permitted by the National Health Service Act 2006 (as amended), the Trust's Constitution and the Standing Orders of the Board of Directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. 12 Follow-up discussion with governors 12:45 Page 3 Agenda links to the Board Assurance Framework (BAF) 9 September 2025 – Open Session Overview of the BAF Risk 1a: Lack of capacity to appropriately respond to emergency demand, manage the increasing waiting lists for elective demand, and provide timely diagnostics, that results in avoidable harm to patients. 1b: Due to the current challenges, we fail to provide patients and their families / carers with a high-quality experience of care and positive patient outcomes. 1c: We do not effectively plan for and implement infection prevention and control measures that reduce the number of hospital-acquired infections and limit the number of nosocomial outbreaks of infection. 2a: We do not take full advantage of our position as a leading University teaching hospital with a growing, reputable, and innovative research and development portfolio, attracting the best staff and efficiently delivering the best possible treatments and care for our patients. 3a: We are unable to meet current and planned service requirements due to the unavailability of staff to fulfil key roles. 3b: We fail to develop a diverse, compassionate, and inclusive workforce, providing a more positive staff experience for all staff. 3c: We fail to create a sustainable and innovative education and development response to meet the current and future workforce needs identified in the Trust’s longer-term workforce plan. 4a: We do not implement effective models to deliver integrated and networked care, resulting in sub-optimal patient experience and outcomes, increased numbers of admissions and increases in patients’ length of stay. 5a: We are unable to deliver a financial breakeven position, resulting in: inability to move out of the NHS England Recovery Support Programme, NHS England imposing additional controls/undertakings, and a reducing cash balance impacting the Trust’s ability to invest in line with its capital plan, estates/digital strategies, and in transformation initiatives. 5b: We do not adequately maintain, improve and develop our estate to deliver our clinical services and increase capacity. 5c: Our digital technology or infrastructure fails to the extent that it impacts our ability to deliver care effectively and safely within the organisation, 5d: We fail to prioritise green initiatives to deliver a trajectory that will reduce our direct and indirect carbon footprint by 80% by 2028-2032 (compared with a 1990 baseline) and reach net zero direct carbon emissions by 2040 and net zero indirect carbon emissions by 2045. Agenda links to the BAF No Item Linked BAF risk(s) 5.5 Performance KPI Report for Month 4 5.6 Operating Plan October 2025 – September 2026 5.8 Finance Report for Month 4 5.9 ICS Operational Delivery Report for Month 4 5.10 People Report for Month 4 5.11 Learning from Deaths 2025-26 Quarter 1 Report 5.12 Annual Complaints Report 2024-25 5.13 Medical Appraisal and Revalidation Annual Report including Board Statement of Compliance 5.14 Safeguarding Annual Report 2024-25 and Strategy 2025-26 1a, 1b, 1c 1a, 1b, 1c 5a 5a 3a, 3b, 3c 1b, 3b 1b, 3b 3b, 3c 1b Appetite (Category) Minimal (Safety) Current risk rating 4x5 20 Cautious (Experience) Minimal (Safety) 4x4 16 4x4 16 Open (Technology & Innovation) 3x4 12 Open (workforce) Open (workforce) Open (workforce) 4x5 20 4x3 12 4x4 16 Cautious (Effectiveness) 3x3 9 Cautious (Finance) 5x5 25 Target risk rating 4 x 2 Apr 6 27 3 x 2 Apr 6 27 2 x 3 Apr 6 27 3 x 2 Mar 6 27 4 x 3 Mar 12 30 4 x 2 Mar 8 30 3 x 2 Mar 6 29 3 x 2 Dec 6 25 3 x 3 Apr 9 30 Cautious (Effectiveness) Open (Technology & Innovation) Open (Technology & Innovation) 4x5 20 3x4 12 2x4 8 4 x 2 Apr 8 30 3 x 2 Apr 6 27 2 x 2 Dec 4 27 Does this item facilitate movement towards or away from the intended target risk score and appetite? Towards Away Neither x x x x x x x x x Minutes Trust Board – Open Session Date Time 15/07/2025 9:00 – 13:00 Location Chair Conference Room, Heartbeat/Microsoft Teams Jenni Douglas-Todd (JD-T) Present Gail Byrne, Chief Nursing Officer (GB) Keith Evans, Deputy Chair and NED (KE) David French, Chief Executive Officer (DAF) Paul Grundy, Chief Medical Officer (PG) Steve Harris, Chief People Officer (SH) Jane Harwood, NED/Senior Independent Director (JH) Ian Howard, Chief Financial Officer (IH) Duncan Linning-Karp, Interim Chief Operating Officer (DL-K) David Liverseidge, NED (DL) Tim Peachey, NED (TP) Alison Tattersall, NED (AT) In attendance Craig Machell, Associate Director of Corporate Affairs and Company Secretary (CM) Lauren Anderson, Corporate Governance and Risk Manager (LA) (shadowing CM) Julie Brooks, Deputy Director of Infection Prevention and Control) (JB) (item 5.12) Phil Bunting, Director of Operational Finance (PB) (item 7.2) Martin De Sousa, Director of Strategy and Partnerships (MDeS) (item 6.1) Christopher Kipps, Clinical Director of R&D (CK) (item 6.2) Christine Mbabazi, Equality & Inclusion Adviser/Freedom to Speak Up Guardian (CMb) (item 5.11) Laura Purandare, Deputy Director of R&D (LP) (item 6.2) Julian Sutton, Clinical Lead, Department of Infection (JS) (item 5.12) Karen Underwood, Director of R&D (KU) (item 6.2) 1 members of the public (item 2) 4 governors (observing) 3 members of staff (observing) 1 members of the public (observing) Apologies Diana Eccles, NED (DE) 1. Chair’s Welcome, Apologies and Declarations of Interest The Chair welcomed attendees to the meeting. There were no interests to declare in the business to be transacted at the meeting. It was noted that apologies had been received from Diana Eccles. 2. Patient Story Verity Elbro-White was invited to present her experience of the birth of her second child at Princess Anne Hospital. The mother was diabetic, and the pregnancy was complex. It was noted that: Page 1 • Both the community midwife and diabetic team had been excellent. The midwife had advised that the patient go to hospital because she was feeling unwell, following which she underwent a caesarean section. • The patient felt valued and listened to, with the care patient-centred. • The surgical and neonatal intensive care teams were also excellent and compassionate. • Attention was also paid to family members. 3. Minutes of the Previous Meeting held on 13 May 2025 The draft minutes tabled to the meeting were agreed to be an accurate record of the meeting held on 13 May 2025. 4. Matters Arising and Summary of Agreed Actions The matters arising and actions were noted. It was noted that action 1247 could be closed. 5. QUALITY, PERFORMANCE and FINANCE 5.1 Briefing from the Chair of the Audit and Risk Committee Keith Evans was invited to present the Committee Chair’s Report in respect of the meeting held on 9 June 2025, the content of which was noted. It was further noted that: • There had been a delay in the production of the Trust’s Annual Report and Accounts due to issues with reconciling information from the Trust’s ledgers into the accounts. NHS England had been notified, and it had been agreed that the Trust would submit its accounts by 21 July 2025. • The committee had reviewed the internal auditor’s report for 2024/25 and noted that out of the six reviews undertaken during the year, the results were good overall. • The committee received an update from the Trust’s external auditor and noted that it was necessary for the Trust to simplify its processes in order to prevent a repeat of the delay in producing end-of-year accounts. 5.2 Briefing from the Chair of the Finance and Investment Committee David Liverseidge was invited to present the Committee Chair’s Reports in respect of the meetings held on 2 June 2025 and 23 June 2025, the content of which was noted. It was further noted that: • The committee reviewed the Finance Reports for Month 1 and Month 2 (item 5.8), noting that the Trust’s reported deficit remained in line with its plan. • The Trust’s underlying deficit remained at c.£7m per month. • The committee reviewed the Trust’s Cost Improvement Programme, noting that the Trust was targeting £110m of savings for 2025/26. It was further noted that even with full delivery of the Trust’s workforce plans, there would still be a shortfall. • The committee received an update on the contracting process for 2025/26, noting that there was a risk that there would be £20-30m of unfunded activity during the year based on the current position. • The committee also continued to monitor the Trust’s cash position. Page 2 5.3 Briefing from the Chair of the People and Organisational Development Committee Jane Harwood was invited to present the Committee Chair’s Report in respect of the meeting held on 25 June 2025, the content of which was noted. It was further noted that: • The committee reviewed the People Report for Month 2 (item 5.10), noting that the Trust was on track in terms of its plan to reduce its workforce by c.700 and had received more than 220 applications under the Mutually Agreed Resignation Scheme. • The committee received an update on organisational change and the support being given to staff on managing change. • An update was provided in respect of the Trust’s education programmes, noting that there was a risk due to a lack of resource. • The committee would be reviewing the recently published 10-Year Plan in detail, particularly in terms of the organisational development elements and the plan’s implications for the Trust. 5.4 Briefing from the Chair of the Quality Committee Tim Peachey was invited to present the Committee Chair’s Report in respect of the meeting held on 2 June 2025 and to provide an update following the meeting held on 14 July 2025, the content of which was noted. It was further noted that: • There had been a further never event, although no harm had resulted. • The committee received a report on pressure ulcers and noted some concerns with respect to the regular turning of patients. • An update on the Fundamentals of Care programme was received and it was noted that improvement in general standards was limited in the absence of sufficient staff. • The committee noted an update in respect of job planning and that this provided good assurance of the process. • The committee reviewed the Maternity and Neonatal Safety Report for Quarter 4 and confirmed that there was nothing requiring escalation to the Board. Tim Peachey was invited to present the Maternity and Neonatal Workforce Report, the content of which was noted. It was further noted that: • The Trust expected to be compliant with the requirements of the NHS Resolution Maternity Incentive Scheme for 2025/26. • Although the Birthrate Plus assessment indicated a reduction in the birth rate, the acuity was, however, higher. • According to assessment, the Trust was approximately nine midwives below the required level. However, there was a plan in place to address this shortfall using the existing workforce. • There was a national shortage of neonatal nurses, although the Trust was attempting to address this issue through its in-house training programme. • In terms of the obstetrics workforce, there remained an issue with the number of trainees. 5.5 Chief Executive Officer’s Report David French was invited to present the Chief Executive Officer’s Report, the content of which was noted. It was further noted that: • The Trust had opened a new Neonatal ICU facility on 11 July 2025 as part of its work to improve the quality of the environment in the department. • The Government had published its 10-Year Health Plan for the NHS in England, which was based on reforming the NHS through three shifts: hospitals to community; analogue to digital; and sickness to prevention. Page 3 • NHS England had published the NHS Oversight Framework for 2025/26 under which organisations would be segmented based on their performance against a range of metrics. Whilst the Trust was one of the best performing trusts, the impact of a financial override and being in the Recovery Support Programme meant that the Trust would be placed in segment 5, the lowest category of performance. • Whilst the NHS waiting list nationally had fallen, the Trust’s waiting list has continued to grow. This was partially due to the impact of the cap on elective funding which had caused the Trust to cease outsourcing some procedures on the basis that it was not financially viable. • Notification had been received from the British Medical Association that resident doctors would embark on a five-day strike commencing on 25 July 2025. There was a risk of industrial action by other staffing groups, as both the Royal College of Nursing and Unite were conducting consultative ballots in respect of the 2025/26 pay award and other matters. 5.6 Performance KPI Report for Month 2 Duncan Linning-Karp was invited to present the Performance KPI Report for Month 2, the content of which was noted. It was further noted that: • In the spotlight on Referral To Treatment, despite the Trust treating more patients, its waiting list had grown by 1%. Certain services accounted for much of this growth, with other services seeing flat or reducing waiting lists. The increase had also been driven by the decision to cease outsourcing some specialities due to the impact of the elective recovery funding cap. • There were three ways to address the increasing size of the waiting list: refusing referrals, validation, and treating more. The ‘patient choice’ agenda made refusing out-of-area referrals difficult. • The Trust’s performance across the constitutional standards indicated that the Trust was operating in a challenging environment and was delivering at activity levels far in excess of pre-COVID-19 levels. • Attendances at the Emergency Department remained high, averaging 433 attendances per day across March, April and May 2025. The Trust’s performance against the four-hour standard was 56.2%, a reduction of 4.5% compared to April 2025. • There had also been a reported increase in the number of Category 2 Pressure Ulcers (per 1,000 bed days) to 0.37 in May 2025, above the target of 0.3. • The Trust continued to benchmark in the top quartile when compared to peer teaching organisations against the national cancer performance targets. • Pressure on flow had caused an increase in overnight ward moves. 5.7 Break 5.8 Finance Report for Month 2 Ian Howard was invited to present the Finance Report for Month 2, the content of which was noted. It was further noted that: • The Trust had reported an in-month deficit of £3.8m, which was consistent with the Trust’s annual plan. The underlying monthly deficit remained at £7.2m. • There had been a number of ‘one-offs’ during the month which had reduced the underlying deficit to meet the planned level of deficit. The Trust continued to target recurrent savings. • Whilst the Trust remained on an improving trajectory, there was some concern regarding the pace of improvement. Page 4 • The Trust was involved in a number of contractual disputes in respect of currently unfunded or insufficiently funded services. • The Trust’s cash position remained an area of concern and continued to be closely monitored. The Trust had five operating days of expenditure, although this was supported in month by holding c.£13m of payments. There remained a significant risk that the Trust’s cash balance would reduce to close to zero in the first half of 2025/26. 5.9 ICS Operational Delivery Report for Month 2 Ian Howard was invited the present the ICS Operational Delivery Report for Month 2, the content of which was noted. It was further noted that: • The previous ICB Finance Report had been expanded to now include operational and performance information across the system. • The Hampshire and Isle of Wight Integrated Care System had reported that it was on plan for Month 2 with a reported deficit year-to-date of £18.25m against a planned deficit of £18.3m. • All organisations in the system would receive deficit support funding for Quarter 1 and Quarter 2. Whilst there was no clear national picture, it was believed that other organisations were in a similar position. • The South East region’s plan for 2025/26 was for a deficit of £95m at Month 2. 5.10 People Report for Month 2 Steve Harris was invited to present the People Report for Month 2, the content of which was noted. It was further noted that: • In May 2025, the workforce grew by 19 whole-time-equivalents (WTE), although was still below plan by 107 WTE. In addition, in June 2025, there had been a reduction in the overall workforce size of 99 WTE driven by the closure of surge capacity and higher turnover during the month. • There had been a freeze on hiring for administrative and clerical roles since March 2025 and only 70% of clinical leavers were being replaced. However, patient demand was not reducing. • The Trust had carried out a divisional restructure, reducing its clinical divisions from four to three. • Even full delivery of the Trust’s Cost Improvement Programme workforce reduction schemes would still produce a shortfall in terms of the Trust’s achievement of its 2025/26 plan. Whilst the Trust was currently on plan in terms of its workforce numbers, it was expected that it would deviate from this later in the year. • The Trust had accepted 42 applications under the Mutually Agreed Resignation Scheme and a number of others were under consideration. The majority of accepted applicants were from clinical administration teams, • The Trust was carrying out work to benchmark its temporary pay rates against others. • Transparency about the changes was key to mitigate against the anxiety in the workforce. A number of engagement activities were taking place, including regular ‘Talk To David’ sessions. • An Equality and Quality Impact Assessment process was in place and was undertaken in respect of decisions. The impact of decisions would be monitored through the Quality Governance Steering Group. It was also Page 5 necessary to ensure that there was a strategic view of decisions rather than just individual cases. The Board discussed the controls on recruitment. The content of the discussion is summarised below: • It was questioned whether a complete freeze on non-clinical recruitment could be sustained for the full year, and that shortages in administrative staff were already having an impact. It was noted that there had already been restrictions on recruitment for these staff groups during the previous year. • It was noted that decisions made by providers in isolation could impact other providers. However, chief medical officers across the system had agreed to discuss plans collectively. 5.11 Freedom to Speak Up Report Christine Mbabazi was invited to present the Freedom to Speak Up Report, the content of which was noted. It was further noted that: • The Trust had received 37 Freedom to Speak Up cases between December 2024 and June 2025, compared to 64 cases during the same period in 2023/24. There had also been a lower number of patient safety and health and safety reports. • Although there had been fewer reports via Freedom To Speak Up, there were other routes for raising concerns and Freedom To Speak Up was meant to provide a route where other options were unavailable or not possible. • It had been reported that the National Guardian Office function was to be abolished. The Board discussed the report, the key points from which are summarised below: • The Freedom to Speak Up framework was designed to facilitate reporting of patient safety related concerns. However, there had been few such reports through this route, with the mechanism being used more as a conventional ‘speak up’ method to report matters such as bullying and harassment. • Moreover, it was not clear whether the lack of such reports via Freedom to Speak Up was an indicator whether the more conventional reporting mechanisms were working effectively and hence there was no requirement to use Freedom to Speak Up. • It was agreed that it would be helpful to have data from the other means of reporting patient safety concerns included in the report in order to provide greater assurance. Action Christine Mbabazi to include data from other mechanisms for reporting concerns in future Freedom to Speak Up reports. 5.12 Infection Prevention and Control 2024-25 Annual Report Julian Sutton and Julie Brooks were invited to present the Infection Prevention and Control 2024/25 Annual Report, the content of which was noted. It was further noted that: Page 6 • The Trust had exceeded the threshold for Clostridioides Difficile and Methicillin-resistant Staphylococcus aureus (MRSA) cases during the year. However, the Trust had been successful in improving antimicrobial stewardship by 1%. • There had been a surge in respiratory infections in early 2025, which the Trust had managed well due to the use of its rapid testing diagnostic tool. The Trust had also successfully mitigated outbreaks of norovirus. • The measures taken to prevent the spread of Candida auris had been successful with only four acquisitions since September 2024. • Only 59% of areas had achieved the accreditation scheme standard, but there were actions in place to address this and improve standards as well as support through the Fundamentals of Care programme. 5.13 Guardian of Safe Working Hours Quarterly Report Paul Grundy was invited to present the Guardian of Safe Working Hours Quarterly Report, the content of which was noted. It was further noted that: • There was a resident doctor vacancy rate of 8%, which was good compared with others. • Exception reports had decreased since the winter months. 711 exception reports had been received over the past 12 months, an average of 59 per month. • The People and Organisational Development Committee would continue to receive updates in respect of work being carried out to improve the lives of resident doctors. • The main challenge in terms of steps required to improve working conditions remained the Trust’s estate and the limited options for providing office space. 6. STRATEGY and BUSINESS PLANNING 6.1 Corporate Objectives 2025-26 Quarter 1 Review Martin de Sousa and Kelly Kent were invited to present the Corporate Objectives 2025/26 Quarter 1 Review, the content of which was noted. It was further noted that: • Twelve objectives had been agreed for 2025/26. • The Trust was on track with 75% of objectives recorded as ‘green’ and the balance being ‘amber’. • The main risks to achieving the Trust’s objectives related to availability of people and financial constraints. 6.2 Research and Development Plan 2025-26 Karen Underwood and Chris Kipps were invited to present the Research and Development Plan 2025/26, the content of which was noted. It was further noted that: • 2024/25 had been a challenging year, but despite this there had been a number of significant successes. These included an award to host a new Commercial Research Delivery Centre, launch of the South Central Regional Page 7 Research Delivery Network, and securing funding for a secure data environment. • There remained challenges in terms of available capacity to set up and deliver studies. • Key Performance Indicators were to be focused on national priorities. • The plan for 2025/26 would focus on efficiency and working regionally. • The Trust had increased the size of its commercial portfolio. However, there needed to be a balance with non-commercial studies to support the Trust’s wider strategy. Decision Having considered the proposed Research and Development Plan for 2025/26, the Board approved the plan. 6.3 Board Assurance Framework (BAF) Update and Risk Appetite Statement Lauren Anderson was invited to present the Board Assurance Framework (BAF) Update, the content of which was noted. It was further noted that: • All risks had been reviewed by the relevant executive(s) and by the Board’s committees since the Board Assurance Framework was last presented to the Board. • The risk ratings had been increased for three risks. This was broadly due to the tension between the Trust’s finances and increasing demand. As a result, 60% of BAF risks were now at the ‘critical’ level. • The risk descriptions indicated crossover in terms of mitigations, demonstrating a holistic approach to risk management. Lauren Anderson was invited to present the Trust’s Risk Appetite Statement, the content of which was noted. It was further noted that: • The Trust’s Risk Appetite Statement had been updated following the Trust Board Study Session held on 3 June 2025. • Due to the current environment, the Trust was required to tolerate a higher level of risk. • The main changes in terms of risk appetite were to reflect the need to make decisions that might adversely impact patient experience and a lower appetite for financial risk. Decision: The Board agreed the Risk Appetite Statement tabled to the meeting. 7. CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Register of Seals and Chair’s Actions Report The paper ‘Register of Seals and Chair’s Actions Report’ was presented to the meeting, the content of which was noted. Page 8 Decision: The Board agreed to ratify the application of the Trust Seal to the documents listed in the ‘Register of Seals and Chair’s Actions Report’. 7.2 Review of Standing Financial Instructions 2025 Ian Howard was invited to present the review of the Standing Financial Instructions, the content of which was noted. It was further noted that: • There were two main changes proposed: an additional section on employee expenses and reducing non-pay approval limits for certain bands. • The Standing Financial Instructions had been benchmarked against others to address differences of approach. • The proposed changes had been reviewed and supported by the Audit and Risk Committee at its meeting held on 9 June 2025. Decision: The Board approved the proposed changes to the Standing Financial Instructions tabled to the meeting. 8. Any other business There was no other business. 9. Note the date of the next meeting: 9 September 2025 10. Resolution regarding the Press, Public and Others Decision: The Board resolved that, as permitted by the National Health Service Act 2006 (as amended), the Trust’s Constitution and the Standing Orders of the board of directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. The meeting was adjourned. Page 9 List of action items Agenda item Assigned to Deadline Status Trust Board – Open Session 13/05/2025 - 5.6 Performance KPI Report for Month 12 1246. Virtual outpatients appointments Linning-Karp, Duncan 09/09/2025 Pending Explanation action item Duncan Linning-Karp agreed to investigate why the number of virtual outpatients appointments had reduced. Trust Board – Open Session 15/07/2025 - 5.11 Freedom to Speak Up Report 1267. Data Mbabazi, Christine 13/01/2026 Pending Explanation action item Christine Mbabazi to include data from other mechanisms for reporting concerns in future Freedom to Speak Up reports. Page 1 of 1 Agenda Item 5.1 i) Committee Chair’s Report to the Trust Board of Directors 9 September 2025 Committee: Finance and Investment Committee Meeting Date: 21 July 2025 Key Messages: • • • • • • • • • The committee reviewed the Finance Report for Month 3, noting that the Trust had reported a £4.5m in-month deficit. This was £1.1m above the plan submitted to NHS England. The Trust’s underlying deficit was £6.5m in month and income had been lower than expected. Whilst the Trust’s financial trajectory was improving, it was not improving at the rate required to deliver the plan. The committee received an update in respect of the Trust’s cash position, noting that the Trust had received additional cash from the ICB during the month. However, the Trust expected to record a negative cash balance in December 2025. Accordingly, the Trust was investigating further measures to manage its cash position. There was also a risk due to any unfunded elements of the pay award and additional costs due to industrial action. The committee reviewed the Trust’s CIP performance, noting that whilst the Trust was close to full achievement, there had been fewer recurrent schemes delivered than anticipated with a greater proportion of savings being delivered through non-recurrent savings. The committee received an update in respect of the Trust’s productivity, noting that this would be one of the metrics to be included in the new NHS Oversight Framework. The committee received an update regarding the Outpatient Transformation Programme. The committee reviewed Wessex NHS Procurement Limited’s performance, including its delivery of CIP. The committee received the quarterly UHS Digital report. The committee received an update on the proposed Hampshire and Isle of Wight elective hub and on a possible Urgent Treatment Centre at Southampton General Hospital. Assurance: N/A (Reports/Papers reviewed by the Committee also appearing on the Board agenda) Any Other N/A Matters: Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Page 1 of 2 Limited Assurance No Assurance Not Applicable Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Where assurance is not required and/or relevant. Risk Rating: Low Medium High Not Applicable Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda Item 5.1 ii) Committee Chair’s Report to the Trust Board of Directors 9 September 2025 Committee: Finance and Investment Committee Meeting Date: 2 September 2025 Key Messages: • • • • • • The committee reviewed the Finance Report for Month 4 (see below). The committee reviewed and discussed a draft of the Trust’s Financial Recovery Plan, which was to be reviewed by the Board on 9 September 2025. The committee requested some clarifications and proposed some additions to ensure that long-term implications were understood. These changes would be incorporated into the paper to go to the Board. Suggestions for further action were also raised, but some of these had been discounted due to the impact on operations and detriment to the short-term position. The committee received an update in respect of the Trust’s cash position, noting that the Trust had received cash advances in June and July and that the ICB had agreed to provide additional cash in August and September. In addition, the process for requesting cash support from NHS England had now been published, although this would likely require some adjustments to the Trust’s governance to establish a ‘cash committee’ – it was considered appropriate to review the terms of reference for the Finance and Investment Committee and possibly to separate out the cash monitoring activities. It was further noted that NHS England had published guidance which suggested that trusts should have a minimum of four days’ operating expenditure in cash. The committee supported the submission of a request for cash support from NHS England, noting that the consequences of not receiving such support would be extremely serious (see also BAF review below). The committee received an update in respect of ongoing and recent contracting disputes, noting that a number of significant disputes had been closed and two remain in dispute and have been escalated. Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) 5.8 Finance Report for Month 4 Assurance Rating: Risk Rating: Substantial High • The Trust had recorded a year-to-date deficit of £19.5m, which was £5.8m above its 2025/26 plan. • There had not been the one-off benefits seen in previous months during Month 4, which meant that the Trust’s position had worsened. However, its underlying month-on-month deficit was improving with £6.5m being recorded in month (previous months had been c.£7m). • The Trust had also received less income than anticipated from areas such as the Channel Islands, genomics, pathology, and CAR(T). There was also a risk that the Trust would not be fully paid for its over performance in terms of elective work, but this was being pursued with the relevant commissioners. • The Trust was also above its workforce plan by 55 whole-timeequivalents and the unfunded element of the pay award amounted to £2.4m per annum, of which £1.4m related to the training and Page 1 of 2 Any Other Matters: education contract and the balance being as a result of the settlement not accurately reflecting the Trust’s staffing mix. • However, the Trust was on track in terms of its CIP delivery, albeit there had been higher non-recurrent delivery than expected. 6.1 Board Assurance Framework (BAF) Update Assurance Rating: Risk Rating: Substantial N/A • Risks 5a, 5b and 5c have been updated, following discussions with the respective Executive Director(s). • It had been agreed to increase the rating of risk 5a from 20 to 25 on the basis that the Trust did not, currently, have an agreement for the provision of cash support, and that the Trust was reliant on third parties to resolve many of the underlying issues. It was also noted that the need to reduce activity and spending now would likely require increased expenditure in future years in order to recover the Trust’s position. • It was agreed that the target risk ratings should be amended to show a rating of 20 at April 2026 and 15 at April 2027. The committee noted new guidance in respect of strengthening financial management and supporting delivery in 2025/26. Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Limited Assurance Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. No Assurance There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Not Applicable Where assurance is not required and/or relevant. Risk Rating: Low Medium High Not Applicable Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda Item 5.2 i) Committee Chair’s Report to the Trust Board of Directors 9 September 2025 Committee: People and Organisational Development Committee Meeting Date: 21 July 2025 Key Messages: • • • • • • • The committee reviewed the People Report for Month 3 and noted that the size of the workforce had reduced during June 2025. There had been 110 whole-time-equivalent (WTE) staff who left during the month and the Trust was phasing new starters. In addition, the Trust had been able to close surge capacity and was closing wards, which had led to a reduction in bank staff use. Based on the forecast, the Trust expected to be c.350 WTE short of its 2025/26 plan based on the delivery of the ‘green’ and ‘amber’ rated CIP programmes. The Trust continued to experience increased demand and there had been an increase in the number of patients having no criteria to reside. In addition, new resident doctors and newly qualified nurses would impact the Trust’s workforce numbers and the forecast made no assumptions regarding industrial action. The committee noted that administrative and clerical staff had been hardest hit by the recruitment restrictions over the past two years, which was causing difficulties in some areas. The committee discussed the potential intake of newly qualified nurses, noting the difficulty of balancing the Trust’s short-term concerns of needing to reduce its workforce with the longer term need for qualified staff. The committee received an update on the organisational change activities underway, including the proposed divisional restructure and MARS programme. The committee received an update in respect of the planned industrial action by resident doctors. The committee reviewed the National Education and Training Survey for 2024, which covered all staff in training posts in the NHS. Assurance: N/A (Reports/Papers reviewed by the Committee also appearing on the Board agenda) Any Other Matters: • The committee reviewed five draft Equality and Quality Impact Assessments relating to the measures required to deliver the Trust’s 2025/26 plan. Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Page 1 of 2 Limited Assurance No Assurance Not Applicable Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Where assurance is not required and/or relevant. Risk Rating: Low Medium High Not Applicable Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda Item 5.2 ii) Committee Chair’s Report to the Trust Board of Directors 9 September 2025 Committee: People and Organisational Development Committee Meeting Date: 1 September 2025 Key Messages: • • • • • • The committee reviewed the People Report for Month 4 (see below). The committee noted the recent announcement by the Government of a ‘graduate guarantee’ for nurses. It was noted that, prior to this announcement, the Trust had decided to increase the level of offers to newly qualified nurses, but to phase start dates in line with predicted turnover and anticipated vacancies in nursing posts. The committee noted that there were significant challenges across the organisation with staff impacted by multiple factors, including: increased car parking rates, building work requiring temporary relocation of 300-400 car park users to Adanac (Park and Ride), a reduction in enhanced bank rates back to standard Agenda for Change levels, and a decision to no longer offer free tea and coffee in theatres for staff (in line with other areas of the Trust). This coupled with the ongoing financial environment and workforce controls would impact staff engagement and satisfaction with the Staff Survey due to launch at the end of September 2025. The committee also expressed its concern for staff – particularly those from overseas – in view of the recent political climate regarding immigration. The committee reviewed the workforce related elements of the Trust’s proposed recovery plan, noting that the Trust was dependent on a number of material assumptions in order to be able to meet its 2025/26 plan. These included: availability of funding for further restructuring, reductions in mental health and no criteria to reside numbers, and reduction in overall activity levels. The committee received an update in respect of the industrial action undertaken by resident doctors in July 2025 and noted that about one third of staff eligible took part in the strike and that most clinical activity continued. It was also noted that F1 doctors were to be balloted separately by the BMA with the focus more on pay and availability of training places. The Trust has been required to produce a selfassessment of ten actions relating to doctors’ working conditions and to determine how to achieve these actions which will be presented to committee and to Board through the update by the Guardian of Safe Working at UHS. Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) 5.10 People Report for Month 4 Assurance Rating: Risk Rating: Substantial High • The overall workforce had increased by 10 whole-time-equivalents (WTE) in July 2025. Whilst the substantive workforce had decreased by 18 WTE, increased numbers of mental health cases, coupled with industrial action, had led to an increase in use of temporary staff. • Accordingly, the Trust was above the NHSE 2025/26 workforce plan by 55 WTE. • 65 applications under the Mutual Agreed Resignation Scheme (MARS) had been approved with all successful applicants due to leave Page 1 of 2 Any Other Matters: by the end of November 2025. This would deliver a recurrent saving of £2.2m based on the whole-year saving, albeit at a one-off cost of £1.1m, which meant that it was broadly cost neutral for 2025/26. • The Trust completed its divisional restructure on 1 July 2025, which was expected to deliver a saving of £700k and 12 WTE 7.2 People and Organisational Assurance Rating: Risk Rating: Development Committee Terms N/A N/A of Reference • The committee reviewed its terms of reference and recommended that the Board approve the updated terms of reference. • Only one minor change was proposed – to remove reference to the Charitable Funds Committee on the basis that this committee no longer existed. N/A Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Limited Assurance Controls in place are not sufficient to ensure that
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Annual report 2021-2022

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

Description: Report to the Trust Board of Directors Title: Agenda item: Sponsor: Author: Date: Purpose Issue to be addressed: Finance Report 2021-22 Month 4 11.3 Ian Howard – Interim Chief Financial Officer Philip Bunting – Interim Deputy Director of Finance 26 August 2021 Assurance Approval or reassurance Ratification Information X The finance report provides a monthly summary of the key financial information for the Trust. Response to the issue: The Trust continues to report an on plan financial position of breakeven. In month £1.3m of non-recurrent benefits have however helped support breakeven achievement with ERF income significantly lower than expected. Elective Recovery Framework (ERF): • Elective Recovery Framework achievement of £0.35m is estimated in month, based on activity of circa 97% of pre-Covid levels of activity for Elective and Outpatients. This compares to a baseline expectation of 95%. (M3 achievement of 94% vs. 80% baseline target). Although this has marginally improved from June this is significantly lower than the anticipated forecast of £3m achievement (108%). The drivers behind this are as follows: o Increased levels of annual leave and staff isolating. Rates of self-isolation increased from 0.5% of workforce in April to June to 2.5% of workforce in July. This has had a significant impact on the availability of staffing and therefore activity. o Continued non-elective pressure (spells increasing 3% from M3 and reaching 99% of production plan levels) and ED activity (also 3% increase from M3). Operational bed pressures are particularly acute within critical care. o Increasing numbers of Covid-19 patients on wards which ended July with 48 Covid positive inpatients reported. This number remains above 40 in mid-August having started July at below 10 patients. • ERF achievement is below the 110% target for elective and outpatient activity by July as per the accelerator programme ambitions. M4 Forecast Review: • We undertake a quarterly review of the Trust forecast position. • Operational pressures in July and August have significantly dampened the trusts ERF forecast for H1 which has been revised down by £6.6m from £23.8m to £17.2m as a result. This poses a significant risk to financial performance over the remainder of H1 however the trust remains in a strong position to Page 1 of 17 manage this risk making an underlying margin on ERF in Q1. • Overall, given the stability of the year-to-date position and balance sheet, the Trust are in a strong position to manage the risks of quarter 2 and achieve a break-even plan position for H1. • The forecast for H2 will be reviewed as part of the H2 planning process. Capital: • CDEL reported spend is £1.5m behind plan YTD with spend in month £1.3m below plan. The trust remains confident however that the annual CDEL allocation of £49.8m will be spent in full. ICS finance position: • All organisations at month 3 were reporting a break-even position. A verbal update will be provided to the Committee on the underlying position within the ICS. An ICS finance report will be made available to the Committee but is not ready for UHS paper deadlines. Other financial issues: • The finance team continue to undertake investigations with Pharmacy regarding use of drugs that are included within block contracts. The value has reduced from previous months but is still £2m ahead of plan YTD. • Specialist commissioning have started informal consultation around the transfer of a proportion of activity to ICS level which will be funded on a population needs basis. The exact quantum of activity, funding envelope and scope of services is currently undecided. This is likely to be in shadow format in 22/23 and then permanently embedded in 23/24. UHS intends to work closely with NHS England and the provider network throughout the consultation period. Implications: (Clinical, Organisational, Governance, Legal?) • Financial implications of availability of funding to cover growth, cost pressures and new activity. • Organisational implications of remaining within statutory duties. Risks: (Top 3) of carrying out the change / or not: • Financial risk mainly linked to the uncertainty of H2 21/22 funding arrangements and ability to support long term decision making. • Cash risk linked to volatility above • Inability to maximise CDEL (which cannot be carried forward) if mitigations are not put into place Summary: Conclusion Trust Board is asked to note this report. and/or recommendation Page 2 of 17 2021/22 Finance Report - Month 4 Report to: Board of Directors and Finance & Investment Committee July 2021 Title: Finance Report for Period ending 31/07/2021 Author: Philip Bunting, Interim Deputy Director of Finance Sponsoring Ian Howard, Interim Chief Director: Financial Officer Purpose: Standing Item The Board is asked to note the report Executive Summary: In Month and Year to date Highlights: 1. In July 2021, the Trust reported a breakeven position as planned. 2. Elective Recovery Framework (ERF) income is estimated at £0.35m for July; however this has not yet been confirmed and is dependent on wider system achievement and NHSI validation. This was down from £3.1m the previous month and reflects the revised activity achievement target of 95% now in place for Q2. Significant operational pressures have also dampened ERF achievement and forecast. 3. In month, £3.6m (£2.5m pay and £1.1m non pay) was incurred on additional expenditure relating to Covid-19. This was £0.6m lower than in June mainly due to lower Covid vaccination costs (down £0.5m). Within the trusts block funding is a non-recurrent fixed element for Covid costs which will continue throughout H1. Covid inpatient volumes increased in month to 48 diverting resources away from elective. 4. The main underlying themes seen in M4 were : – Elective activity in July represents 94% of planned income levels, up slightly from 93% in June. – Non Elective activity levels in July was at 99% of planned levels, down from 103% in June. A&E attendances continue to be high, back to pre-Covid levels. – Outpatient activity in July was at 107% of planned levels, down slightly from 108% in June. – Drugs and devices expenditure was high in month with £4.6m over performance reported on pass through items, higher than the £2.2m over performance in M3. This is mirrored by additional income. – Trust underlying performance deteriorated slightly although remains at close to breakeven levels after adjusting for one off items. 1 Page 3 of 17 2021/22 Finance Report - Month 4 Finance: I&E Summary The financial position for M4 was breakeven as per plan. This position does however include £1.3m in non recurrent income. The Saliva testing finances are significantly distorting variances within income and expenditure categories as testing activity is not yet fully mobilised. Pay costs are £1.7m below plan in month and now £9.5m behind plan YTD. In addition to Saliva testing this is further driven by elective recovery costs that have not increased pay to the originally anticipated level. This is however offset by reduced ERF income. Agency costs spiked in month due partly to increased staff sickness due to covid self isolation notifications dramatically increasing. Block drugs costs were £0.2m above plan in M4 and remain under investigation as this remains an in year pressure having previously been pass through costs. Energy cost increases and overseas recruitment expenditure are the key areas of overspend within ‘other non pay’. NHS Income: Clinical Pass-through Drugs & Devices Other income Other Income excl. PSF Top Up Income Total income Costs Pay-Substantive Pay-Bank Pay-Agency Drugs Pass-through Drugs & Devices Clinical supplies Other non pay Total expenditure EBITDA EBITDA % Depreciation / Non Operating Expenditure Surplus / (Deficit) Less Donated income Add Back Donated depreciation Net Surplus / (Deficit) 2 Page 4 of 17 Current Month Cumulative H1 Plan Plan Actual Variance Plan Actual Variance Plan Forecast Variance £m £m £m £m £m £m £m £m £m 69.1 65.4 3.8 275.1 266.4 8.6 412.8 406.4 6.4 8.5 13.1 (4.6) 33.9 44.0 (10.1) 50.9 61.6 (10.7) 15.2 13.2 2.0 60.6 52.1 8.6 90.9 77.8 13.1 0.8 1.1 (0.3) 3.1 4.6 (1.4) 4.7 6.9 (2.2) 93.6 92.7 0.8 372.8 367.1 5.7 561.4 552.7 6.7 46.9 45.4 (1.6) 187.7 180.9 (6.8) 281.5 273.0 (8.5) 4.0 3.5 (0.4) 15.8 14.0 (1.9) 23.7 21.8 (1.9) 1.2 1.6 0.3 5.0 4.2 (0.8) 7.5 5.2 (2.3) 4.3 4.5 0.2 17.4 19.4 2.0 26.0 30.4 4.4 8.5 13.1 4.6 33.9 44.0 10.1 50.9 61.6 10.7 11.2 6.4 (4.8) 43.2 31.9 (11.3) 65.1 51.9 (13.2) 14.2 15.2 0.9 56.9 60.6 3.7 85.4 90.9 5.5 90.4 89.7 (0.7) 360.0 354.9 (5.0) 542.2 534.9 (5.3) 3.2 3.0 0.2 12.8 12.1 0.7 19.2 17.8 1.4 3.4% 3.3% 0.1% 3.4% 3.3% 0.1% 3.4% 3.2% 0.2% 3.2 3.1 (0.1) 12.9 12.4 (0.4) 19.3 18.6 (0.6) (0.0) (0.1) 0.1 (0.0) (0.3) 0.2 (0.1) (0.8) 0.8 0.1 0.0 0.1 0.4 0.0 0.3 0.5 0.0 0.5 0.1 0.1 0.0 0.4 0.6 0.2 0.6 0.9 0.3 (0.0) 0.0 (0.0) (0.0) 0.3 (0.3) (0.0) 0.0 (0.0) 2021/22 Finance Report - Month 4 Monthly Underlying Position The graph shows the underlying position for the Trust from 2019/20 to present. This position is however heavily linked to the numbers of Covid positive patients the Trust is managing. We are now operating at a position where we would be earning marginally more under PbR than the current block. However, we are also earning ERF, which would not be payable under PbR for activity below 100% of contract. After adjusting the income position to be reflective of what would prevail under PbR it is clear that the underlying position is close to breakeven and has been throughout Q1. This has slightly deteriorated in July as staffing pressures together with non elective and covid pressures have suppressed elective activity and PbR equivalent income. 5.00 - -5.00 -10.00 -15.00 -20.00 -25.00 -30.00 With future funding arrangements unclear due to non recurrent ERF and additional Covid-19 funding, we exercise caution over the Trust’s underlying position going forwards. Monthly Underlying Position 2020/21 & 2021/22 Budget 2019/20 Underlying Actuals 2020/21 & 2021/22 Underlying Actuals 3 Page 5 of 17 2021/22 Finance Report - Month 4 Clinical Income Clinical income for the month of July was £0.9m favourable to plan and including Non NHS income was £0.7m favourable to plan. Most of the Trust's income remains fixed with confirmed block contract funding in place for at least the first half of the financial year. July has seen a small increase in activity from June. Plans for 21/22 have been phased to account for the variation in calendar and working days in relevant POD Groups. Elective income increased to 94% of planned levels although this follows a dip in June having been over 100% in May. Overall non elective activity increased but against the working day adjusted plan reduced to 99% of planned level. A&E attendances continue to be high, back to pre-Covid levels having shown a downward trend for much of the previous financial year. Outpatient income remains strong at over 100% of planned levels although not as high against plan as in May. The graphs overleaf show trends over the last 16 months and the impact of Covid-19 as well as the recovery to pre Covid levels of activity in many areas. (Fav Variance) / Adv Variance POD GROUP NHS Clinical Income Elective Inpatients Non-Elective Inpatients Outpatients Other Activity Blocks & Financial Adjustments Other Exclusions Pass-through Exclusions Subtotal NHS Clinical Income Additional funding Covid block adjustments Total NHS Clinical Income Non NHS Clinical Income Private Patients CRU Overseas Chargeable Patients Total Non NHS Clinical Income In Month In Month Plan £000s Estimate £000s In Month Variance £000s 2021/22 YTD Plan £000s YTD Estimate £000s YTD Variance £000s £13,159 £19,474 £7,718 £11,864 £5,590 £8,003 £8,485 £74,292 £5,848 (£2,535) £77,605 £12,413 £20,140 £8,249 £11,571 £1,872 £5,648 £13,100 £72,993 £5,848 (£368) £78,473 £745 (£666) (£531) £294 £3,718 £2,355 (£4,616) £1,299 £0 (£2,167) (£868) £49,645 £76,638 £29,119 £46,239 £20,449 £31,543 £33,938 £287,571 £23,392 (£1,952) £309,011 £47,675 £78,250 £32,081 £45,770 £8,530 £31,105 £44,025 £287,438 £23,392 (£368) £310,462 £1,969 (£1,612) (£2,962) £469 £11,919 £438 (£10,087) £133 £0 (£1,584) (£1,450) £368 £235 £134 £208 £186 £23 £66 £64 £2 £643 £484 £158 £1,504 £833 £264 £2,601 £2,023 £683 £158 £2,864 (£519) £150 £106 (£263) 2019/20 YTD Actuals £000s £47,966 £71,796 £28,339 £42,701 £1,475 £1,260 £38,725 £232,262 £232,262 £1,394 £840 £651 £2,885 Grand Total £78,248 £78,958 (£710) £311,612 £313,325 (£1,713) £235,147 Income (£m) NHS Clinical Income £100 £80 £60 £40 £20 £0 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 2020/21 2021/22 Plan - Income Actual - Income 4 Page 6 of 17 2021/22 Finance Report - Month 4 Clinical Income Activity ('000) Income (£m) Elective spells £16 8 £14 7 £12 2% 6 £10 5 £8 4 £6 3 £4 2 £2 1 £0 0 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 2020/21 2021/22 Plan - Activity Actual - Activity Plan - Income Actual - Income Activity ('000) Income (£m) Non elective spells £25 7 £20 3% 6 5 £15 4 £10 3 2 £5 1 £0 0 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 2020/21 2021/22 Plan - Activity Actual - Activity Plan - Income Actual - Income Outpatients £10 70 £8 -1% 60 50 £6 40 £4 30 20 £2 10 £0 0 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 2020/21 2021/22 Plan - Activity Actual - Activity Plan - Income Actual - Income Activity ('000) Income (£m) A&E £3 14 £2 3% 12 10 £2 8 £1 6 4 £1 2 £0 0 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 2020/21 2021/22 Plan - Activity Actual - Activity Plan - Income Actual - Income 5 Page 7 of 17 Activity ('000) Income (£m) 2021/22 Finance Report - Month 4 Clinical Income Activity ('000) Income (£m) Adult critical care £6 4 £5 3 £4 2% £3 2 £2 1 £1 £0 0 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 2020/21 2021/22 Plan - Activity Actual - Activity Plan - Income Actual - Income Activity ('000) Income (£m) Neonatal & paediatric critical care £3 3 £3 5% £2 2 £2 £1 1 £1 £0 0 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 2020/21 2021/22 Plan - Activity Actual - Activity Plan - Income Actual - Income Tariff excluded drugs £14 1 £12 -8% £10 £8 £6 £4 £2 £0 0 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 2020/21 2021/22 Plan - Activity Actual - Activity Plan - Income Actual - Income Activity ('000) Income (£m) Tariff excluded devices £3 2 £3 -14% £2 £2 1 £1 £1 £0 0 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 2020/21 2021/22 Plan - Activity Actual - Activity Plan - Income Actual - Income 6 Page 8 of 17 Activity ('000) Income (£m) 2021/22 Finance Report - Month 4 Income and Activity The tables shown illustrate by division and care group the % of the activity and income plan being achieved across the first month of 2021/22 for Elective, Non Elective and Outpatient Activity. The plan for 2021/22 has been phased to reflect working day differences for Elective and Outpatient and calendar days for Non Elective. Elective activity in July represents 94% of planned income levels, up slightly from 93% in June. Recovery planning is targeting improvement in all areas but will be governed by clinical priority. Non Elective activity levels in July was at 99% of planned levels, down from 103% in June. It should be noted that non elective spells actually increased 3% month on month but due to July being a day longer the % of production plan delivered actually reduced slightly. Page 79 of 17 2021/22 Finance Report - Month 4 Income and Activity Outpatient activity in July was at 107% of planned levels, down slightly from 108% in June. Page 180 of 17 2021/22 Finance Report - Month 4 Elective Recovery Fund 21/22 The Elective Recovery Fund has been launched as part of the 21/22 planning guidance as a mechanism for distributing £1bn of national recovery funds for Elective and Outpatient activity. Providers are targeted with achieving threshold equivalent PbR income levels set at a % of pre-Covid income levels (Price x Activity). The graph shows both the trends through 20/21 and estimated performance for July. This indicates performance of 97% of baseline activity which is 2% over the revised target threshold of 95% in July. This would yield an estimate of £0.35m additional income if paid at tariff. It should be noted that this is an early estimate of this data and has dependencies on the performance of others from within the ICS. The 20% premium has already been agreed with ICS partners will be centrally pooled rather than allocated directly to providers. Elective Recovery Framework Performance 20-21-22 % 120% 100% Actual Activity 80% (OP & EL) 70% Threshold 60% (April-21) 85% Threshold 40% 20% 0% Month Apr-21 May-21 Jun-21 Jul-21 YTD Total ERF Achievement - Elective/Daycase/Outpatients (£'000) Baseline Actuals Variance % £ 18,770 £ 18,575 -£ 195 99% £ 18,276 £ 19,673 £ 1,398 108% £ 21,464 £ 20,274 -£ 1,189 94% £ 20,780 £ 20,091 -£ 688 97% £ 37,046 £ 38,249 £ 1,203 103% ERF Top-up 100% Top Up 20% Top Up Total £ 5,436 £ 524 £ 5,960 £ 5,967 £ 828 £ 6,794 £ 3,104 £ 406 £ 3,510 £ 351 £ -£ 351 £ 14,506 £ 1,758 £ 16,264 9 Page 11 of 17 2021/22 Finance Report - Month 4 ICS Elective Recovery Fund 21/22 ICS current estimated performance and forecast is shown for the four main Providers for the Elective Recovery Framework (ERF). April – July numbers are all currently based on local assessment and awaiting national finalisation. It should be noted that the Q2 forecast reflects the recent increase to the baseline for Q2 moving from 85% to 95% hence the trajectory indicating below plan performance for these months. At M4 the ICS has collectively reported £38.9m in ERF income vs an original (unadjusted) plan of £35.1m. The H1 forecast is now £46.3m dropping from £55.3m last month, this is against an original (unadjusted) plan of £50.4m. This includes circa £3.4m estimated impact of accelerator programmes on ERF income. 16000 14000 12000 10000 8000 6000 4000 2000 ICS ERF - All Organisations Plan vs Estimates(M1-4) vs Forecast (M5-6) 0 Apr May Jun Jul Aug Sep Plan Estimates/Forecast 10 Page 12 of 17 2021/22 Finance Report - Month 4 Substantive Pay Costs Total pay expenditure in July was £50.5m. This was higher than in June (up by £0.9m). The main increase was nursing agency staff (£0.7m) due mainly to staff sickness backfill and increased staffing requirements due to non elective pressures and covid. There was also a small increase in substantive medical staff costs. Pay costs remain in excess of that seen last year prior to the second covid wave as the organisation continues to drive recovery. Substantive recruitment has been challenging however with workforce numbers remaining broadly flat since April 21. These will be monitored closely going forward as costs are expected to increase as new theatre capacity comes on board this summer, in addition to investment in recovery plans and accelerator programme initiatives which are fully funded. £m £m £m 53.0 51.0 49.0 47.0 45.0 43.0 41.0 39.0 37.0 35.0 Total Pay Jul-20 Aug-20 Sep-20 Oct-20 Nov-20 Dec-20 Jan-21 Feb-21 Mar-21 Apr-21 May-21 Jun-21 Jul-21 18.0 Substantive Pay 16.0 14.0 12.0 10.0 Covid Agency Bank Substantive Plan Total Medical Nursing Other 48.0 Substantive Pay 46.0 44.0 42.0 40.0 Start Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Substantive Plan 21/22 Substantive Actual 21/22 Substantive Actual 20/21 11 Page 13 of 17 2021/22 Finance Report - Month 4 Temporary Staff Costs Agency spend has increased sharply month on month by £0.7m. All staff groups increased spend but the majority was in nursing (£0.5m) which was driven by increased short notice sickness (covid self isolation) plus bed pressures due to non elective and covid forcing ward costs higher. Expenditure on bank staff has fallen slightly month on month (£0.2m) with the largest fall in nursing. The plan adjustment within the bank graph relates to staffing requirements to deliver elective recovery that were forecast to increase the need for bank staffing. 1,700,000 1,600,000 1,500,000 1,400,000 1,300,000 1,200,000 1,100,000 1,000,000 900,000 800,000 700,000 600,000 500,000 400,000 300,000 200,000 100,000 0 5,000,000 4,500,000 4,000,000 3,500,000 3,000,000 2,500,000 2,000,000 1,500,000 1,000,000 500,000 0 2021/22 Agency Total Spend 2021/22 Bank Total Spend Page1142of 17 Total Agency Nursing Medics Scient & Tech Admin & Estates NHSI Plan Nursing Medics Scient & Tech Admin & Estates Total Bank 2021/22 Finance Report - Month 4 Cash The cash balance decreased slightly in July to £117.3m. This continues the marginal downward trend as cash reserves are used to deliver capital expansions. There are no foreseen material movements forecast now the cash regime has adjusted back to pre-covid levels with block income paid in the month for which it is due. We may however see some in-month volatility as we move to a more “normal” period and the working capital position stabilises. A gradual reduction is expected over the next two years as capital expenditure plans exceed depreciation. 180.0 160.0 140.0 120.0 100.0 80.0 60.0 40.0 20.0 - Cash Position Actual Minimum Cash Holding 13 Page 15 of 17 2021/22 Finance Report - Month 4 Capital Expenditure Expenditure on internally funded capital schemes YTD is £14.6m against budget of £16,2m. Total expenditure including externally funded schemes is £16m against budget of £17,4m, £1.4m behind plan. Significant expenditure in M4 included the vertical extension theatres scheme, which is nearing completion, the ED expansion scheme, where phase 1b of the works has commenced and the Ophthalmology Outpatients scheme where significant expenditure was incurred this month. The Trust continues to forecast to spend all of the Capital Departmental Expenditure Limit (CDEL) funding. The forecast shows expenditure of £2.46m over plan based on the expectation of receiving £2m of external funding for community diagnostic hubs and an allowable overspend of £0.46m on medical equipment as part of the accelerator funding scheme . Forecast variances on individual schemes include the vertical extension theatres scheme (-£1m), the ED expansion scheme where unforeseen generator and VAT costs were incurred (+£0.7m), IISS leases (£2.5m slippage) and equipment leases, where additional leases have been authorised. (Fav Variance) / Adv Variance Month Year to Date Full Year (Forecast) Plan Actual Var Plan Actual Var Plan Actual Var Scheme £000's £000's £000's £000's £000's £000's £000's £000's £000's Fit out of E level. Vertical Extension - Theatres 2,460 1,056 1,404 9,463 7,174 2,289 11,941 10,950 991 Strategic Maintenance 258 242 16 1,032 1,087 (55) 6,183 6,183 0 ED Expansion and Refurbishment 827 428 399 2,908 1,642 1,266 5,791 6,489 (698) Wards 0 17 (17) 0 17 (17) 4,000 4,000 0 Ophthalmology OPD 737 718 19 787 937 (150) 3,303 3,098 205 Maternity Induction Suite 0 0 0 0 (0) 0 2,000 2,000 0 NICU Pendants 0 0 (0) 0 0 (0) 896 355 541 Oncology Ward 0 2 (2) 861 430 431 861 751 110 Decorative / Environment Improvements 21 0 21 84 0 84 500 500 0 Side Rooms 0 5 (5) 490 517 (27) 490 537 (47) Information Technology Programme 250 137 113 1,000 810 190 5,000 5,000 0 Other Projects 175 374 (199) 1,208 1,073 135 3,060 2,803 257 Pathology Digitisation 59 5 54 236 22 214 1,171 1,171 0 Medical Equipment 42 64 (22) 168 476 (308) 1,000 2,016 (1,016) Accelerator Funded Equipment 0 0 0 0 0 0 0 460 (460) Slippage (516) 0 (516) (2,464) 0 (2,464) (5,035) (3,143) (1,892) Total Trust Funded Capital excl Finance Leases 4,313 3,049 1,264 15,773 14,185 1,588 41,161 43,170 (2,009) Finance Leases - IISS 0 0 0 0 32 (32) 5,230 2,765 2,465 Finance Leases - MEP 92 0 92 368 179 189 2,200 1,183 1,017 Finance Leases - Other Equipment 75 104 (29) 300 159 141 1,500 3,083 (1,583) Finance Leases - Opthalmology OPD 0 0 0 0 0 0 1,166 1,166 0 Finance Leases - Divisonal Equipment 25 (25) 50 75 82 (7) 475 500 (25) Donated Income (88) (32) (56) (352) (49) (303) (1,921) (1,596) (325) Total Trust Funded Capital Expenditure 4,417 3,096 1,321 16,164 14,588 1,576 49,811 50,271 (460) Fit out of E level. Vertical Extension - Theatres 140 140 0 538 538 0 700 700 0 Maternity Care System (Wave 3 STP) 96 243 (147) 384 753 (369) 1,917 1,776 141 Digital Outpatients (Wave 3 STP) 41 47 (6) 164 72 92 814 955 (141) LIMS Digital Enhancement 38 (0) 38 152 (0) 152 455 455 0 Community Diagnostic Hub 0 0 0 0 0 0 0 2,000 (2,000) Total CDEL Expenditure 4,732 3,526 1,206 17,402 15,950 1,452 53,697 56,157 (2,460) Page 16 of1147 2021/22 Finance Report - Month 4 Statement of Financial Position The July statement of financial position illustrates net assets of £443.6m which has decreased £7.6m compared to June 2021. This is however within the bounds of normal month on month volatility. The downward movement on inventories is driven by a reduction in Pharmacy stock (£2m). The Payables reduction of £5.3m was primarily due to the clearing of aged trade payables and also a reduction in capital creditors. Payables is becoming a greater focus area for the NHS and an improvement plan is being developed to help tackle this down to Better Payment Practice Code (BPPC) compliant levels. The Receivables increase of £4.6m was due to Chilworth invoicing. Statement of Financial Position Fixed Assets Inventories Receivables Cash Payables Current Loan Current PFI and Leases Net Assets Non Current Liabilities Non Current Loan Non Current PFI and Leases Total Assets Employed Public Dividend Capital Retained Earnings Revaluation Reserve Other Reserves Total Taxpayers' Equity 15 Page 17 of 17 2020/21 YE Actuals £m 415.4 14.7 71.3 129.0 (171.5) (2.8) (9.0) 447.1 (18.3) (8.5) (36.3) 384.0 246.0 114.0 24.0 0.0 384.0 (Fav Variance) / Adv Variance M3 Act £m 425.6 15.9 77.9 123.6 (180.2) (2.7) (8.8) 451.3 (17.5) (7.8) (34.7) 391.3 246.0 121.3 24.0 0.0 391.3 2021/22 M4 Act £m 426.9 13.8 82.5 117.3 (185.5) (2.7) (8.6) 443.6 (18.1) (7.5) (34.3) 383.7 246.0 113.7 24.0 0.0 383.7 MoM Movement £m 1.3 (2.0) 4.6 (6.4) (5.3) 0.0 0.2 (7.6) (0.6) 0.3 0.4 (7.6) 0.0 (7.6) 0.0 0.0 (7.6) Report to the Trust Board of Directors Title: Agenda item: Sponsor: Date: Purpose Integrated Performance Report 2021/22 Month 4 11.2 Chief Executive 26 August 2021 Assurance Approval or reassurance Y Ratification Information Issue to be addressed: The report aims to provide assurance: • Regarding the successful implementation of our strategy • That the care we provide is safe, caring, effective, responsive, and well led Response to the issue: The Integrated Performance Report reflects the current operating environment and is aligned with our strategy. Implications: This report covers a broad range of trust services and activities. It is (Clinical, Organisational, intended to assist the Board in assuring that the Trust meets regulatory Governance, Legal?) requirements and corporate objectives. Risks: (Top 3) of carrying out the change / or not: Summary: Conclusion and/or recommendation This report is provided for the purpose of assurance. This report is provided for the purpose of assurance. Page 1 of 29 Integrated KPI Board Report covering up to July 2021 Sponsor - Andrew Asquith, Director of Planning, Performance and Productivity, andrew.asquith@uhs.nhs.uk Page 2 of 29 Chart Type Cumulative Column Example Cumulative Column Year on Year Line Benchmarked Line & bar Benchmarked Control Chart 100% 0% 49.0% Variance from Target Report Guide Explanation A cumulative column chart is used to represent a total count of the variable and shows how the total count increases over time. This example shows quarterly updates. A cumulative year on year column chart is used to represent a total count of the variable throughout the year. The variable value is reset to zero at the start of the year because the target for the metric is yearly. The line benchmarked chart shows our performance compared to the average performance of a peer group. The number at the bottom of the chart shows where we are ranked in the group (1 would mean ranked 1st that month). 72.09% The line shows our performance and the bar underneath represents the range of 0.72 performance of benchmarked trusts (bottom = lowest performance, top = highest performance) A control chart shows movement of a variable in relation to its control limits (the 3 lines = Upper control limit, Mean and Lower control limit). When the value shows special variation (not expected) then it is highlighted green (leading to a good outcome) or red (leading to a bad outcome). Values are considered to show special variation if they -Go outside control limits -Have 6 points in a row above or below the mean, -Trend for 6 points, -Have 2 out of 3 points past 2/3 of the control limit, -Show a significant movement (greater than the average moving range). Variance from target charts are used to show how far away a variable is from its target each month. Green bars represent the value the metric is achieving better than target and the red bars represent the distance a metric is away from achieving its target. 2 Page 3 of 29 Report to Trust Board in August 2021 Introduction The Integrated Performance Report is presented to the Trust Board each month. The report aims to provide assurance: • Regarding the successful implementation of our strategy • That the care we provide is safe, caring, effective, responsive, and well led The content of the report includes the following: • The ‘Spotlight’ section, to enable more detailed consideration of any topics that are of particular interest or concern. The selection of topics is informed by a rolling schedule, performance concerns, and requests from the Board • An ‘NHS Constitution Standards’ section, summarising the standards and performance in relation to service waiting times • An ‘Appendix’, with indicators presented monthly, aligned with the five themes within our strategy This month, several of the new indicators have commenced reporting and further development is also taking place. Our indicators and this report structure will continue to be regularly reviewed, and feedback would be welcome. 3 Page 4 of 29 Report to Trust Board in August 2021 Summary This month the ‘Spotlight’ section features: 1. Clostridium Difficile Infection (C. diff) There have been 25 infections compared to a ‘target’ limit of 20 year to date, whilst in 2020/21 there were 63 infections compared to a limit of 64. UHS performance remains good compared to peer hospitals. The spotlight discusses variability in infection rates, the link to antibiotic prescribing, and actions being taken to further reduce the number of C. diff infections. 2. Diagnostic waiting time target Diagnostic waiting times have experienced major impacts during the pandemic, and 17% of patients are currently waiting longer than the national 6-week target. Trends at UHS are similar to those at peer hospitals. The spotlight discusses current performance and forecast recovery timescales for different test types, alongside strategic issues, and opportunities for diagnostics. Highlights to note in the appendix containing indicators by strategic theme include: • A further decline in Emergency Department performance to 78.4% and an increase in attendances to a new maximum • An increase to 129 inpatients who had been medically optimised for discharge but were waiting for care at home / in the community • Staff sick absence remains close to target (although COVID-19 absence including isolation of COVID-19 ‘contacts’ reached a peak of 2.5% during July) • Excellent research performance across a range of measures. 4 Page 5 of 29 Report to Trust Board in August 2021 Spotlight Spotlight Subject - Clostridium Difficile Infection (C. diff) C. diff infections are caused by an imbalance of gut microbiota. The person must have been exposed to C. diff spores either from food or from acquisition from the healthcare environment. The toxigenic C. diff spores reside in the large intestine for months to years. In the case of exposure to a broad-spectrum antibiotic, or cancer chemotherapy, the toxigenic spores start to produce toxins causing clinical disease manifesting with diarrhoea. In 2020/21 UHS reported 63 infections compared to a limit of 64. In 2021/22 to date, the monthly limits have been exceeded. The graph below shows the most recent 12 month period in blue, and prior 12 months in yellow. UHS ranks 3rd out of 16 self-selected peer acute trusts, with a rate of 16.2 cases/ 100,000 bed days. Reporting criteria are standardised across trusts. 5 Page 6 of 29 Report to Trust Board in August 2021 In 2021/22 there were 19 Community Onset – Hospital Attributable (COHA), 44 Hospital Onset – Hospital Attributable (HOHA) cases. The total number of infections has varied significantly in the past 18 months. The reasons for peaks are unclear but a possible reason might relate to the pandemic, C. diff infections appear to have peaked three months after both the first and second waves. Spotlight It is likely that C. diff rates relate to rates of antibiotic use, possibly in the community as well as hospital; hospital antibiotic usage has been at higher levels during COVID-19 peaks. Underlying trends are of stable / reducing antibiotic use, and the use of ‘broad-spectrum’ antibiotics is particularly closely managed. The average length of an antibiotic course at UHS has also reduced from 7.5 days in 2018/19 to 6.7 in 2020/21. 6 Page 7 of 29 Report to Trust Board in August 2021 Spotlight A wide range of other potential influences upon C. diff infection have been examined including: Infection control – most cases are not part of a cluster or outbreak Infection control – infections in chemotherapy patients appear to relate to their treatment, not an association between the patients themselves or the care environment Cleaning – Audited and generally found to be of a high standard; some opportunities for improvement identified with those items that are to be cleaned by clinical staff Hand hygiene – Improved during the pandemic, and is audited, though a minority of areas still require improvements Physical environment – UHS has relatively few individual rooms, which risks delay in isolation in patients with symptoms which might indicate an infection i.e. loose stools A range of measures are in place, and further actions have been taken, which are expected to impact upon C. diff infection rates and maintain them within acceptable levels: All inpatient cases are reviewed by the infection prevention team to ensure all elements of the care bundle were followed. All hospital acquired cases are reviewed by a Consultant microbiologist/Infection control doctor. The Antimicrobial Review Group reviews cases for appropriate antibiotic use and duration. An updated C. diff policy was approved in July, including changes to the required prevention, treatment and infection control measures. The care plan documentation was expanded. Additional individual rooms have been built in 2020 and 2021, within adult and paediatric wards, and the new Cancer Care ward (C2). This need will remain an important focus for the Trust. Improvements in the turnaround time for stool samples has helped to achieve appropriate isolation of infected patients / closure of bays, whilst making effective use of available bed capacity. Further innovation in point of care testing and rapid laboratory testing are expected to deliver additional improvement in 2021/22. Investment in equipment, and 24/7 operation of the microbiology laboratory, have significantly improved the turnaround time for blood cultures for patients with bacteraemia, and enabled earlier implementation of more specific antibiotics which are less likely to promote C. diff infection. The ongoing review of anti-microbial guidelines and high-risk broad-spectrum antibiotics had been disrupted by the pandemic, and by the resource requirements of the COVID-19 vaccination programme. This is expected to be addressed during the remainder of 2021/22. 7 Page 8 of 29 Report to Trust Board in August 2021 Spotlight Spotlight Subject - Diagnostic waiting time target The national target is that at least 99% of the patients waiting for an elective diagnostic test will have waited less than 6 weeks / no more than 1% will have waited more than 6 weeks. 15 different tests are reported at the end of each month, although Trust performance is normally assessed for the group of tests as a total. UHS is not currently achieving the target, largely due to the impact of COVID-19. During the pandemic, diagnostic services have experienced postponement of nonurgent patients, staff shortages, and reduced productivity due to enhanced infection control measures. Performance is gradually improving, although 17% patients currently waiting have still waited more than 6 weeks. UHS performance is typical of the NHS, UHS is currently 7th best amongst a peer group of large teaching hospitals. As referral volumes recovered following a steep drop when the pandemic started (referrals come from both primary and secondary care clinicians, dependent upon the test), the total number of patients on the waiting list increased beyond pre-pandemic levels (Feb 2020 = 7907), but this is currently relatively stable. 8 Page 9 of 29 Report to Trust Board in August 2021 Spotlight Diagnostic activity levels, as a whole, have recovered and are now above pre-pandemic levels. 20000 15000 10000 5000 0 Diagnostic activity per month The following table show the position at end July, ordered by the number of patients waiting over 6 weeks. There are significant differences between the size and duration of the waiting lists for each of the tests. Tests also require different professions and equipment to perform them (although there are some resources in common e.g. Radiographers and Radiologists shared between MRI and CT, Endoscopy rooms shared between Colonoscopy, Gastroscopy and Flexible Sigmoidoscopy). Diagnostic Area NEUROPHYSIOLOGY - PERIPHERAL NEUROPHYSIOLOGY MAGNETIC RESONANCE IMAGING NON-OBSTETRIC ULTRASOUND GASTROSCOPY CARDIOLOGY - ECHOCARDIOGRAPHY CYSTOSCOPY COLONOSCOPY RESPIRATORY PHYSIOLOGY - SLEEP STUDIES FLEXI SIGMOIDOSCOPY COMPUTED TOMOGRAPHY URODYNAMICS - PRESSURES & FLOWS DEXA SCAN CARDIOLOGY - ELECTROPHYSIOLOGY AUDIOLOGY - AUDIOLOGY ASSESSMENTS BARIUM ENEMA Breach 6 Week Target Within 6 Week Target Grand Total % achieved within 6 weeks 499 629 1128 55.76 425 1583 2008 78.83 175 2779 2954 94.08 150 233 383 60.84 84 370 454 81.5 69 145 214 67.76 44 292 336 86.9 40 89 129 68.99 22 90 112 80.36 18 937 955 98.12 13 27 40 67.5 9 311 320 97.19 9 4 13 30.77 1 110 111 99.1 1 65 66 98.48 9 Page 10 of 29 Report to Trust Board in August 2021 Spotlight All services are forecasting recovery of their pre-pandemic performance by the end of October 2021, with the exception of Neurophysiology and Magnetic Resonance Imaging (MRI). Neurophysiology waiting times were substantially impacted by a two month cessation of most investigations at the start of the pandemic in order to reduce the risk of COVID-19 transmission, and also by subsequent staff shortages - due to vacancies and role changes to protect staff at high risk from COVID-19, and reductions in productivity in outpatients as a result of additional infection control measures. The service is now fully staffed, but capacity to increase activity is constrained by physical space, ability to recruit further, and limited capacity amongst staff to undertake further overtime / additional sessions. Further opportunities to improve productivity, and test new working practices, continue to be investigated. MRI waiting times are at risk because our scanners are already operated for extended hours each day, both Radiographers and Radiologists are difficult to recruit in sufficient numbers, and capacity is currently being supported by scanner time contracted from Independent Sector suppliers which is not secure in the long term. A business case is being prepared which will propose an option to replace existing older scanners without the loss of capacity that would normally be experienced during decommissioning / commissioning, and to upgrade an existing scanner to extend its life and increase the number of UHS operated scanners by one. Strategic issues and opportunities related to diagnostic services include: Community Diagnostic Hub (CDH) - The NHS Long Term Plan recognised a need for radical investment and reform, and an Independent Review of Diagnostic Services* in Oct 2020 recommended ‘Community Diagnostic Hubs’ be established away from Acute Hospital Sites. UHS is currently part of a collaborative bid which, if successful, would provide an additional NHS CT scanner and Ultrasound room in Southampton. Further NHS CDH investment is likely, and UHS will consider this as part of the Estate Strategy. Growth in Demand – Significant (national) growth rates include CT (6.8%), MRI (5.6%), Colonoscopy (5.3%) and Flexible Sigmoidoscopy (8.4%). Diagnostic activity rates are also often significantly below international comparators. Further growth in demand should be anticipated and planned for, for example recommendations* that CT scanning capacity should be increased by 100% within 5 years, and that at least 200 new endoscopy rooms are required in NHS trusts. Capacity Expansion and Innovation – is supporting the current recovery. For example, national funding supported construction of an additional UHS endoscopy room which opened in April, and the purchase of equipment which enables ‘sleep studies’ to be performed in greater volumes and in a patient’s home rather than in the hospital. * https://www.england.nhs.uk/wp-content/uploads/2020/11/diagnostics-recovery-and-renewal-independent-review-of-diagnostic-services-for-nhs-england2.pdf 10 Page 11 of 29 Report to Trust Board in August 2021 NHS Constitution Standards for Access to services within waiting times The NHS Constitution* and the Handbook to the NHS Constitution** together set out a range of rights to which people are entitled, and pledges that the NHS is committed to achieve, including: The right to access certain services commissioned by NHS bodies within maximum waiting times, or for the NHS to take all reasonable steps to offer you a range of suitable alternative providers if this is not possible o Start your consultant-led treatment within a maximum of 18 weeks from referral for non-urgent conditions o Be seen by a cancer specialist within a maximum of 2 weeks from GP referral for urgent referrals where cancer is suspected The NHS pledges to provide convenient, easy access to services within the waiting times set out in the Handbook to the NHS Constitution o All patients should receive high-quality care without any unnecessary delay o Patients can expect to be treated at the right time and according to their clinical priority. Patients with urgent conditions, such as cancer, will be able to be seen and receive treatment more quickly The handbook lists 11 of the government pledges on waiting times that are relevant to UHS services, such pledges are monitored within the organisation and by NHS commissioners and regulators. Performance against the NHS rights, and a range of the pledges, is summarised below. Further information is available within the Appendix to this report. * https://www.gov.uk/government/publications/the-nhs-constitution-for-england/the-nhs-constitution-for-england ** https://www.gov.uk/government/publications/supplements-to-the-nhs-constitution-for-england/the-handbook-to-the-nhs-constitution-for-england 11 Page 12 of 29 Report to Trust Board in August 2021 NHS Constitution Standards for Access to services within waiting times Monthly May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul target YTD % Patients on an open 18 week 100% 72.1% UT28-N pathway teaching (within 18 weeks ) with hospital min-max range and 49.0% ≥92% rank (of 20) 14 7 6 7 7 10 10 10 9 9 8 7 8 8 30% 100% 96.3% % Patients following a GP referral for - suspected cancer seen by a specialist within 2 weeks 83.8% ≥93% 80% Cancer waiting times 62 day standard - Urgent referral to first definitive 100% 87.8% UT34-N treatment (Latest data held by UHS) ≥85% - with teaching hospital min-max range 73.5% 4 3 1 1 1 9 10 9 3 4 2 1 4 6 and rank (of 20) 30% Patients spending less than 4hrs in ED - 93% 94.1% SGH Main ED (Type 1 and UCH) UT25-N Major Trauma Centres (Type 1) 85% 77% 78.4% ≥95% - Rank of 8-> 5 3 3 4 2 2 1 1 1 2 3 3 3 3 703.28% % of Patients waiting over 6 weeks for 80% 35.4% UT33-N diagnostics with teaching hospital min- 16.9% ≤1% - max range and rank (of 20) 7 7 9 13 14 14 11 12 9 10 10 10 9 7 0% 12 Page 13 of 29 Report to Trust Board in August 2021 Outstanding Patient Outcomes, Safety and Experience Outcomes UT1-N HSMR - UHS HSMR - SGH UT2 HSMR - Crude Mortality Rate May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul 83 77 3.1% 78.3 77.9 2.9% 2.6% 800 597 UT3 Emergency readmissions within 30 days of discharge from hospital 627 200 Monthly target ≤100 - - UT4-L Cumulative Specialities with Outcome Measures Developed 54 56 56 57 61 +1 260 285 305 332 396 100% UT5 Developed Outcomes RAG ratings 81% 75% 79% 77% 76% 80% - 50% Appendix YTD YTD target 13 Page 14 of 29 Report to Trust Board in August 2021 Outstanding Patient Outcomes, Safety and Experience Safety May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Cumulative Clostridium difficile UT6-N This year vs. last year 2732 3039 3543 4250 4852 5455 6057 7063 57 1116 1521 1825 35 Healthcare-acquired COVID infection: UT7 COVID-positive sample taken > 14days 39 after admission (validated) 0 12 1 0 0 0 8 0 10 2 5 0 0 0 3 Probable hospital-associated COVID 80 UT8 infection: COVID-positive sample taken > 7 days and 70.28% 533422111233333 05:00 UT26 Average (Mean) time in Dept - nonadmitted patients 02:14 03:06 - 01:00 05:00 03:17 UT27 Average (Mean) time in Dept - admitted patients 04:13 - 01:00 100% % Patients on an open 18 week pathway 72.1% UT28-N (within 18 weeks ) with teaching 49.0% ≥92% hospital min-max range and rank (of 20) 14 7 6 7 7 10 10 10 9 9 8 7 8 8 30% 42,500 Total number of patients on a waiting 42149 UT29 list (18 week referral to treatment 33401 - pathway) 30,000 21,000 Patients on an open 18 week pathway UT30 (waiting 52 weeks+ ) with teaching 951 2309 - hospital min-max range and rank (of 20) 0 13 11 11 11 10 9 6 6 6 5 4 4 4 6 Appendix YTD YTD target - - - - - - - - - - 17 Page 18 of 29 Report to Trust Board in August 2021 Outstanding Patient Outcomes, Safety and Experience May Jun 1000 UT31 Patients on an open 18 week pathway (waiting 78 weeks+ ) 0 11,000 UT32 Patients waiting for diagnostics Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul 799 7 7875 9223 Monthly target - - 4,000 80% % of Patients waiting over 6 weeks for UT33-N diagnostics with teaching hospital min- max range and rank (of 20) 7 0% Cancer waiting times 62 day standard - Urgent referral to first definitive 100% UT34-N treatment (Latest data held by UHS) with teaching hospital min-max range 4 and rank (of 20) 30% 100% 31 day cancer wait performance - UT35-N decision to treat to first definitive treatment (Latest data held by UHS) 80% 100% 31 day cancer wait performance - UT36-N Subsequent Treatments of Cancer (Latest data held by UHS) 80% 35.4% 7 9 13 14 14 11 12 9 87.8% 3 1 1 1 9 10 9 3 97.6% 98.6% 10 10 10 9 16.9% 7 73.5% 4 2 1 4 6 96.0% 96.2% ≤1% ≥85% ≥96% ≥95.2% Appendix YTD YTD target - - - - - - - - - - 18 Page 19 of 29 Report to Trust Board in August 2021 Pioneering Research and Innovation PN1-L Comparative CRN Recruitment Performance - non-weighted May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul 2 5 9 10 10 9 Monthly target Top 10 PN2-L Comparative CRN Recruitment Performance - weighted 2 2 5 3 7 8 Top 5 PN3-L Comparative CRN Recruitment contract commercial 7 13 17 PN4-L Achievement compared to R+D Income 160% Baseline Monthly income increase % YTD income increase % -50% 2 12 11 Top 10 46.0% 152.0% 55.0% -22.0% 45.0% ≥5% Appendix YTD YTD target 19 Page 20 of 29 Report to Trust Board in August 2021 World Class People Appendix Workforce Capacity May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Monthly target 14% Substantive Staff - Turnover WR1-L -R12M turnover % -Leavers in month (FTE) 10% 12.6% 80 200 12.7% R12M 100 =92.0% 84.5% > =76% 20 Page 21 of 29 Report to Trust Board in August 2021 World Class People Staff survey engagement score WR8-L National NHS Staff Survey May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul 8 7.3 0 WR8-L - Maximum score = 10, Average of “Acute and Acute&Community”, group is 7 Compassion and Inclusion 11% WR9-L % of Band 7+ staff who are Black and Minority Ethnic 9.21% 7% WR10 14% % of Band 7+ Staff who have declared a disability or long term health condition 13.7% WR11 12% Pulse survey % of staff recommend UHS as a place to work- White British staff compared with all other ethnic groups combined Data available from August 2021 - new monthly staff survey 10.19% 13.5% WR12 Pulse survey % of staff recommend UHS as a place to work- Disabled compared with non disabled / prefer not to answer Data available from August 2021 - new monthly staff survey WR13 Pulse survey % of staff recommend UHS as a place to work- Sexuality = Heterosexual compared with all other groups combined Data available from August 2021 - new monthly staff survey Appendix Monthly target YTD YTD target 15% by 2023 - 21 Page 22 of 29 Report to Trust Board in August 2021 Integrated Networks and Collaboration Local Integration Number of inpatients that were NT1 medically optimised for discharge (monthly average) May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Monthly target 150 129 92 ≤80 50 Emergency Department NT2 activity - type 1 This year vs. last year Percentage of virtual appointments as a NT3 proportion of outpatient consultations This year vs. last year 15,000 9,482 9,077 5,000 70.00% 44.40% 15.6% 0.00% 11,722 - 8,456 51.5% - 28.1% Appendix YTD YTD target - - - - - - 22 Page 23 of
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Trust-governance-and-corporate-docs/2021-Trust-document/Finance-and-performance-reports/Finance-and-Performance-Reports-2021-22-Month-4-July-2021.pdf

Finance and Performance Reports 2022-23 Month 2 May 2022

Description: Report to the Trust Board of Directors Title: Agenda item: Sponsor: Author: Date: Purpose Issue to be addressed: Finance
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Trust-governance-and-corporate-docs/2022-Trust-documents/Finance-and-Performance-Reports-2022-23-Month-2-May-2022.pdf

Papers Trust Board - 5 November 2024

Description: Date Time Location Chair Apologies Agenda Trust Board – Open Session 05/11/2024 9:00 - 11:30 The Ark Conference Centre
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Trust-governance-and-corporate-docs/2024-Trust-documents/Papers-Trust-Board-5-November-2024.pdf

Papers Trust Board - 25 July 2024

Description: Agenda Trust Board – Open Session Date 25/07/2024 Time 9:00 - 13:00 Location Anaesthetic Seminar Room (CE95/99), E
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Trust-governance-and-corporate-docs/2024-Trust-documents/Papers-Trust-Board-25-July-2024.pdf

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