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Quality account 24-25 final

Description: QUALITY ACCOUNT 2024/25 QUALITY ACCOUNT Contents Part 1: Statement on quality from the chief executive 1.1 Chief executive’s
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Annual-reports-and-quality-accounts/quality-account-24-25-final1.pdf

Papers CoG 29.04.2025 v2

Description: Date Time Location Chair Agenda Council of Governors 29/04/2025 14:00 - 15:45 Conference Room, Heartbeat/Microsoft Teams Jenni
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Governors/Papers-CoG-29.04.2025-v2.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, HHFT/Microsoft Teams Jenni Douglas-Todd Diana Eccles 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 Minutes of Previous Meeting held on 10 September 2024 Approve the minutes of the previous meeting held on 10 September 2024 3 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. 4 QUALITY, PERFORMANCE and FINANCE 9:10 Quality includes: clinical effectiveness, patient safety, and patient experience 4.1 Briefing from the Chair of the Audit and Risk Committee Keith Evans, Chair 4.2 Briefing from the Chair of the Finance and Investment Committee Dave Bennett, Chair 4.3 Briefing from the Chair of the People and Organisational Development Committee Jane Harwood, Chair 4.4 Briefing from the Chair of the Quality Committee Tim Peachey, Chair 4.5 Chief Executive Officer's Report 9:25 Receive and note the report Sponsor: David French, Chief Executive Officer 4.6 Performance KPI Report for Month 6 9:35 Review and discuss the report Sponsor: David French, Chief Executive Officer 4.7 Finance Report for Month 6 9:55 Review and discuss the report Sponsor: Ian Howard, Chief Financial Officer 4.8 ICB Finance Report for Month 6 10:10 Receive and discuss the report Sponsor: Ian Howard, Chief Financial Officer 4.9 Recovery Support Programme (RSP) Undertakings - Self Assessment 10:20 Review and discuss the self-assessment Sponsor: David French, Chief Executive Officer 4.10 10:30 People Report for Month 6 Review and discuss the report Sponsor: Steve Harris, Chief People Officer 4.11 Cancer Patient Experience Survey Results 2023 10:45 To receive and discuss the results Sponsor: Gail Byrne, Chief Nursing Officer Attendee: Ali Keen, Head of Cancer Nursing 5 STRATEGY and BUSINESS PLANNING 5.1 Corporate Objectives 2024-25 Quarter 2 Review 11:00 Review and feedback on the corporate objectives Sponsor: David French, Chief Executive Officer Attendees: Martin De Sousa, Director of Strategy and Partnerships/Kelly Kent, Head of Strategy and Partnerships 5.2 Board Assurance Framework (BAF) Update 11:10 Review and discuss the update Sponsor: Gail Byrne, Chief Nursing Officer Attendee: Craig Machell, Associate Director of Corporate Affairs and Company Secretary 6 CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 6.1 Feedback from the Council of Governors' (CoG) Meeting 23 October 2024 11:15 (Oral) Sponsor: Jenni Douglas-Todd, Trust Chair 6.2 Register of Seals and Chair's Actions Report 11:20 Receive and ratify In compliance with the Trust Standing Orders, Financial Instructions, and the Scheme of Reservation and Delegation. Sponsor: Jenni Douglas-Todd, Trust Chair 7 Any other business 11:25 Raise any relevant or urgent matters that are not on the agenda Page 2 8 Note the date of the next meeting: 7 January 2025 9 Items circulated to the Board for reading 9.1 CRN: Wessex 2024-25 Q2 Performance Report Note the report Sponsor: Paul Grundy, Chief Medical Officer 10 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. Page 3 Agenda links to the Board Assurance Framework (BAF) 5 November 2024 – 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. Appetite (Category) Minimal (Safety) Cautious (Experience) Minimal (Safety) Open (Technology & Innovation) Open (workforce) Open (workforce) Open (workforce) Cautious (Effectiveness) Cautious (Finance) Cautious (Effectiveness) Open (Technology & Innovation) Open (Technology & Innovation) Current risk rating 4x5 20 3x3 9 4x4 16 3x3 9 4x5 20 4 x3 12 4x3 12 3x3 9 3x5 15 4x5 20 3x4 12 2x3 6 Target risk rating 4 x 2 Apr 6 27 3 x 2 Mar 6 26 2 x 3 Apr 6 27 3 x 2 Mar 6 25 4 x 3 Mar 12 26 4 x 2 Mar 8 27 3 x 2 Mar 6 25 3 x 2 Apr 6 25 3 x 3 Apr 9 25 4 x 2 Apr 8 27 3 x 2 Apr 6 27 2 x 2 Dec 4 24 Agenda links to the BAF No Item 4.6 Performance KPI Report for Month 6 4.7 Finance Report for Month 6 4.8 ICB Finance Report for Month 6 4.9 Recovery Support Programme (RSP) Undertakings – Self Assessment 4.10 People Report for Month 6 4.11 Cancer Patient Experience Survey Results 5.1 Corporate Objectives 2024-25 Quarter 2 Review Linked BAF risk(s) 1a, 1b, 1c 5a 5a 5a 3a, 3b, 3c 1b All 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 Minutes Trust Board – Open Session Date Time 10/09/2024 9:00 – 13:00 Location Conference Room, Heartbeat/Microsoft Teams Chair Jenni Douglas-Todd (JD-T) Present Dave Bennett, NED (DB) Gail Byrne, Chief Nursing Officer (GB) Jenni Douglas-Todd, Chair (JD-T) Diana Eccles, NED (DE) (9:00-10:00 and 12:00-13:00) 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) Tim Peachey, NED (TP) Joe Teape, Chief Operating Officer (JT) Alison Tattersall, NED (AT) In attendance Martin De Sousa, Director of Strategy and Partnerships (MDeS) Craig Machell, Associate Director of Corporate Affairs and Company Secretary (CM) Lauren Anderson, Corporate Governance and Risk Manager (LA) (item 6.1) Jane Fisher, Head of Health and Safety Services (JF) (item 7.2) Danielle Honey, Named Nurse for Safeguarding Children (DH) (item 5.13) Diana Hulbert, Guardian of Safe Working Hours and Emergency Department Consultant (DHu) (item 5.10) Duncan Linning-Karp, Deputy Chief Operating Officer (DLK) (item 5.5) Corinne Miller, Named Nurse for Safeguarding Adults (CMi) (item 5.13) Jenny Milner, Associate Director of Patient Experience (JM) (item 5.11) Jessica Bown, Midwifery Quality Assurance and Safety Matron (shadowing Gail Byrne) 1 member of the public (item 2) 5 governors (observing) 1 members of staff (observing) 2 members of the public (observing) Apologies Diana Eccles, NED (DE) (from 10:00-12:00) 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. 2. Patient Story Allan Peters was invited to relate his experience as a cancer patient, who had been diagnosed with stage 4 lymphoma, and, in particular, his experience of CAR-T cell therapy, which had been successful, with no reappearance of the cancer for more than a year. It was noted that the patient had had a positive experience with staff, and, when he collapsed, had been impressed by the reaction of a student nurse. Page 1 3. Minutes of the Previous Meeting held on 25 July 2024 The draft minutes tabled to the meeting were agreed to be an accurate record of the meeting held on 25 July 2024. 4. Matters Arising and Summary of Agreed Actions It was noted that action 1165 could be closed, and the relevant paper had been updated with the correct information. There were no other matters arising or actions overdue. 5. QUALITY, PERFORMANCE and FINANCE 5.1 Briefing from the Chair of the Finance and Investment Committee The chair of the Finance and Investment Committee was invited to provide an overview of the meeting held on 19 August 2024. It was noted that: • The committee had reviewed the Finance Report for Month 4 (item 5.7), noting that whilst the Trust was slightly off-plan, it was maintaining its trajectory in terms of an improved position. • The Trust was making progress in terms of its Always Improving programme with some reduction in length of stay. • There were a number of risks to the Trust’s achievement of its 2024/25 plan, including costs incurred from industrial action, insufficient funding for the pay award, and non-delivery of system transformation programmes. The Trust was also delivering £10m of unpaid activity. • The committee received a report from Estates, noting that there had been an improvement in the Trust’s ability to recruit staff. 5.2 Briefing from the Chair of the People and Organisational Development Committee The chair of the People and Organisational Development Committee was invited to provide an overview of the meeting held on 21 August 2024. It was noted that: • The committee had reviewed the People Report for Month 4 (item 5.9), noting that the Trust was below its target workforce level, although there had been an increase in use of bank staff due to the holiday period. The Trust was benefitting by £1.5m a month from these savings in staff numbers. • It was expected that the Trust would go above its planned staff numbers in September 2024 due to factors such as higher than assumed numbers of patients having no criteria to reside. • The committee received an update on violence and aggression in the context of the recent riots. 5.3 Briefing from the Chair of the Quality Committee The chair of the Quality Committee was invited to provide an overview of the meeting held on 19 August 2024. It was noted that: • The committee reviewed the Trust’s main quality indicators and noted that the indicators in respect of infection prevention were of concern. However, there had been a reduction in Emergency Department waiting times. • The Trust’s progress in implementing the measures under ‘Martha’s Rule’ was noted. • The committee received the annual medical safety report and reviewed consultant job planning. • There had been difficulties with porting over documents to a new IT system in Ophthalmology. Page 2 5.4 Chief Executive Officer’s Report David French was invited to present the Chief Executive Officer’s Report, the content of which was noted. It was further noted that: • The 2024/25 pay award for Agenda for Change staff was due to be paid in October. In addition, the Government had made an offer to junior doctors, which appeared likely to be acceptable. There were concerns about the extent to which these pay awards would be fully funded. • The Trust had been formally notified of a collective pay grievance for healthcare support workers, which potentially impacted over 1,000 staff and was for up to six years of back pay. • The civil unrest in late July 2024 had had a significant impact on staff, especially from those from black and minority ethnic communities. • The New Hospitals programme had been paused, and the situation regarding the proposed new hospital near Basingstoke was unclear. Separately, the ‘Save Winchester Action Group’ had written to board members of the Hampshire and Isle of Wight Integrated Care Board (HIOW ICB) expressing concerns about the proposed downgrade of Winchester hospital. • The Care Quality Commission had published its adult inpatient survey for 2023, which showed a deterioration in people’s experiences since 2020. • The Trust’s aseptic unit had received a positive audit report and had been assessed as being ‘low risk’. • An inspection of the Trust’s mortuary arrangements had been carried out by the Human Tissue Authority in August 2024. The outcome was awaited. • The NHS’s long-term plan process had commenced, with an expected emphasis on digital and moving away from hospitals to focus on the community and prevention. • The report by Lord Darzi on the NHS had been published. This indicated a variation in both quality of and access to NHS services across the country. • A workshop was scheduled in October 2024 regarding violence and aggression, with the focus now being on there needing to be a limit on what the Trust will tolerate and there being consequences, including exclusion of individuals. 5.5 Patient Safety and Quality of Care in Pressured Services Joe Teape was invited to present the paper ‘Patient Safety and Quality of Care in Pressured Services’, the content of which was noted. It was further noted that: • NHS England had sent all integrated care boards, integrated care partnerships, regional directors and NHS trusts and foundation trusts a letter on 26 June 2024 regarding urgent and emergency care, and requiring boards to assure themselves that the Trust is doing all it can to provide alternatives to Emergency Department attendance and admission, and to maximise in- hospital flow. • The Trust chose to queue patients in the Emergency Department, rather than in ambulances in order to be able to release ambulances. It was considered that this approach was safer than having patients remain in ambulances. • The Trust was able to provide good assurance based on its performance against the standards. • The HIOW ICB was proposing to introduce an initiative to reduce ambulance delays whereby patients would be released to the Emergency Department after 45 minutes. Page 3 5.6 Performance KPI Report for Month 4 Joe Teape was invited to present the Performance KPI Report for Month 4, the content of which was noted. It was further noted that: • The Trust was in the top quartile for seven out of nine measures. Of those where the Trust was below top quartile, one was 78-week waits due to the shortage of corneal transplant material, and the other was the 31-day standard, although improvement was expected. • The Trust was aiming to reduce its 65-week waiters to single digits by the end of September 2024. • There had been an increase in the relative mortality rate, the causes of which were being investigated. • The Trust had not had to open surge capacity. • Ward D4 had been closed for deep-cleaning to tackle candida auris. In terms of the spotlight on waiting lists, it was noted that: • The Trust’s waiting list had increased slightly in year by c.1,500, although the growth was in outpatients waits, not patients waiting for a procedure. • There was an opportunity to triage referrals, with use of advice and guidance for General Practitioners in particular. However, it was noted that GPs were not obliged to accept advice and guidance as an alternative to a referral, and the expected industrial action by GPs was seen as a risk. • The Trust had been successful in stabilising its waiting list, it would now be necessary to reduce it from c.60k to c.40k in order to meet the 18-week Referral To Treatment standard. Action: Gail Byrne agreed to look into the increase in ‘red flag’ staffing incidents in July 2024. 5.7 Finance Report for Month 4 Ian Howard was invited to present the Finance Report for Month 4, the content of which was noted. It was further noted that: • The Trust had recorded an in-month deficit of £3.9m and £16.9m year-to-date. The monthly position continued to improve month-on-month, and the Trust’s cost base remained relatively stable. • The Trust’s Elective Recovery performance would be key to achievement of its 2024/25 plan. There remained significant uncertainties in respect of the costs of industrial action, pay award funding, payments for 2023/24 Elective Recovery Funding (ERF), and 2024/25 ERF. • The reasons for the Trust’s variance to plan were largely driven by costs of industrial action, pay awards, unidentified Cost Improvement Programme (CIP), and non-delivery of system mental health and non-criteria to reside programmes. • Identification of CIP and pay controls were working well, and the Trust had delivered 126% ERF performance. • The Trust was anticipating a deficit of £3.8m and 128.5% ERF performance in Month 5. 5.8 Break 5.9 People Report for Month 4 Steve Harris was invited to present the People Report for Month 4, the content of which was noted. It was further noted that: Page 4 • At the end of July 2024, the Trust was 288 Whole Time Equivalents (WTE) below its overall workforce plan. However, over the following months a significant increase in workforce numbers was expected due, largely, to the onboarding of newly-qualified nurses. • The Trust’s plan was predicated on the delivery of system programmes to reduce the number of patients having no criteria to reside and mental health patients. The assumed improvements in mental health patient numbers represented approximately 160 WTE. • There was a dispute with the Trust’s porters, with Unite threatening industrial action. 5.10 Guardian of Safe Working Hours Quarterly Report Diana Hulbert was invited to present the Guardian of Safe Working Hours Quarterly Report, the content of which was noted. It was further noted that: • The previous year had been a difficult one for foundation year doctors due to the industrial action and associated press around this. • Changes in the structure of doctors’ postings and training had resulted in a loss of the previously firm structure and had generated uncertainty for those impacted. It was necessary to ensure that F1 and F2 doctors felt part of the UHS family. • Improvements in the induction process for F1 doctors were required. A twoweek shadowing period had been received positively. 5.11 Learning from Deaths 2024-25 Quarter 1 Report Jenny Milner was invited to present the Learning from Deaths report for Quarter 1 of 2024/25, the content of which was noted. It was further noted that: • Nationally, the Trust continues to benchmark lower than the expected death rates. • The morbidity and mortality reviews process required refining, as sharing of learning could be inconsistent as was the quality of reviews. A mobile application was being developed to help share learnings. • A recurrent theme had emerged via incident reporting in respect of out-ofhours paediatric palliative care advice and support, as no out-of-hours service had been commissioned. • There had been an increase in the number of complaints relating to the location of the death due to a lack of side rooms. Similarly, there was a lack of private spaces to have sensitive conversations. • A palliative care box had been trialled on Ward D3. Use of charity funding was being considered to enable this to be rolled out elsewhere. 5.12 Medical Appraisal and Revalidation Annual Report including Board Statement of Compliance Paul Grundy was invited to present the Medical Appraisal and Revalidation Annual Report, the content of which was noted. It was further noted that: • The report was intended to enable the Trust to provide assurance that its professional standards processes meet the requirements of the Medical Profession (Responsible Officers) Regulations 2010 and related guidance. Page 5 • This was the second year of using a portal as part of the appraisals process, which had resulted in an improved user experience. • Compliance rates had continued to improve, and there was a good process in place to remind individuals to complete their appraisals. • There had been an increase in the number of appraisers and these were wellrated. Decision: Having reviewed the Annual Report, the Board approved the Statement of Compliance tabled to the meeting, and authorised either the Chair or Chief Executive Officer to sign the Statement on behalf of the Trust. 5.13 Safeguarding Annual Report 2023-24 Corinne Miller and Danielle Honey were invited to present the Safeguarding Annual Report for 2023/24, the content of which was noted. It was further noted that: • There had been a continued increase in activity across most services, and there had been a sustained increase in the number of Deprivation of Liberty Safeguards (DoLS) applications across the Trust along with requests for support with complex Mental Capacity Act case management. • The year had been challenging due to a loss of key staff. • The Trust had undertaken work to update its policies and Level 3 Safeguarding Adult Training had been rolled out via the Virtual Learning Environment (VLE). • A key area of work had been to review the pathway for adults with local authorities. The response from local partners remained challenging due, largely, to budgetary constraints at these other organisations. • The Trust’s children’s safeguarding team had carried out the self-assessment audit required by section 11 of the Children Act 2004, which highlighted no areas of specific concern or gaps. There had been an 28% increase in referrals as well as an increase in the level of complexity. • The adult safeguarding team had won the ‘UHS Champions Team of the Year’ award. 6. STRATEGY and BUSINESS PLANNING 6.1 Board Assurance Framework (BAF) Update Lauren Anderson was invited to present the Board Assurance Framework, the content of which was noted. It was further noted that: • All risks had been reviewed by the relevant Executive Director(s) since the BAF was last presented to the Board, with an extensive review having been carried out in December 2023 and in April 2024. • Following review by the Finance and Investment Committee in August 2024, risk 5c had been modified to better reflect the Trust’s estates-related risks. • The NHS was designing a dynamic risk assessment framework. • Work was ongoing to compare the Care Quality Commission’s Well-Led framework with the Trust’s BAF, and to identify any gaps. Page 6 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. 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 Health and Safety Annual Report 2023-24 Jane Fisher was invited to present the Health and Safety Annual Report for 2023/24, the content of which was noted. It was further noted that: • There continued to be a number of incidents of late reporting of work-related absence, although steps were being taken to streamline the process and to make reporting easier. • There had been a number of losses in staff over the year, which had impacted the FFP3 mask-fitting team in particular. • Improved training had been made available through the Virtual Learning Environment, and health and safety training received was now listed as a skill on staff members’ HealthRoster profile. • Thirty-nine incidents had been reported under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR). • The main causes of injuries were as a result of collisions, slips, trips and falls, sharps, and incidents of violence and aggression. With the exception of the latter, these incidents were generally accidents or a result of human error, with nursing and healthcare assistants being the most likely groups to be injured. 7.3 People and Organisational Development Committee Terms of Reference It was noted that the People and Organisational Development Committee had reviewed its terms of reference at its meeting held on 21 August 2024. Decision: Following discussion, it was further noted that whilst the committee had proposed no changes to the terms of reference, it was agreed that the terms of reference should include specific reference to the CQC’s quality statements given the emphasis within the CQC’s latest framework on equality, diversity and inclusion related matters. 8. Any other business There was no other business. 9. Note the date of the next meeting: 5 November 2024 10. Items circulated to the Board for reading The item circulated to the Board for reading was noted. There being no further business, the meeting concluded. Page 7 11. 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 8 List of action items Agenda item Assigned to Deadline Status Trust Board – Open Session 06/06/2024 5.6 Performance KPI Report for Month 1 1152. Digital Teape, Joe Explanation action item JT agreed to include Digital as an agenda item at a future Trust Board Study Session. 27/02/2025 Pending Update: Item tentatively scheduled for TBSS on 27/02/2025. Trust Board – Open Session 25/07/2024 5.4 Briefing from the Chair of the Quality Committee (Oral) 1163. Impact of technology Machell, Craig 27/02/2025 Pending Explanation action item Craig Machell agreed to add an item covering the impact of technology over the next 5-10 years to a future Trust Board Study Session agenda. Update: Item tentatively scheduled for 27/02/25 Study Session. Trust Board – Open Session 10/09/2024 5.6 Performance KPI Report for Month 4 1175. 'Red flag' staffing incidents Byrne, Gail Explanation action item Gail Byrne agreed to look into the increase in ‘red flag’ staffing incidents in July 2024. 05/11/2024 Pending Page 1 of 1 Agenda item 4.1 Committee Chair’s Report to the Trust Board of Directors 5 November 2024 Committee: Audit and Risk Committee Meeting Date: 14 October 2024 Key Messages: Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) Any Other Matters: • The committee reviewed the year end process for 2023/24, and associated ‘lessons learned’. Many of the issues encountered ought to be mitigated by the introduction of a new finance system, together with a ‘rehearsal’ of the year end accounts process to be carried out early in 2025. • The Trust’s National Cost Collection submission for 2024 went well with no validation errors requiring re-submission and data quality was good. Whilst the output will be presented to the Finance and Investment Committee, initial indications were that the Trust was more efficient than the average. • The committee received an update on the Procurement Act 2023 and the potential impact on the Trust. It was noted that the additional reporting requirements had been delayed until February 2025 due to issues with the digital reporting platform development. • The committee received updates in respect of Information Governance and Legal. • The committee received an update on Data Quality, including work ongoing to review cancer waiting times data. • A report on a local proactive exercise in respect of Bank/Agency staff identity fraud showed that whilst the Trust was following the majority of the recommendations to reduce the risk of this type of fraud, current practice could be improved. The committee agreed with the report. 6.2 Board Assurance Framework (BAF) Level of Assurance: Substantial • All risks had been reviewed with the relevant executive director(s). • It is intended that agenda items at Board meetings will be more clearly linked to the BAF risks. • In addition, division-level ‘BAFs’ are under consideration to provide a clearer idea of overall risk at the divisional level to bridge the gap between the operational risk register and Board-level BAF. • 90% of operational risks had been reviewed, an indicator of wellembedded risk management within the organisation. The Trust’s Fraud, Bribery & Corruption Annual Report 2023/24 highlighted no particular areas of concern. The committee reviewed the performance of the Trust’s internal and external auditors. In addition, the committee held a discussion with the external auditors without management present. Substantial Assurance Reasonable Assurance There is a robust series of suitably designed internal controls in place upon 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. There is a series of controls in place, however there are potential risks that may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. 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. Page 2 of 2 Agenda item 4.2 Committee Chair’s Report to the Trust Board of Directors 5 November 2024 Committee: Finance and Investment Committee Meeting Date: 21 October 2024 Key Messages: • • • • • • The Trust has received significant additional cash in October 2024 through deficit support funding and additional payments for 2023/24 ERF performance. The Trust’s financial position remains challenging with a year-to-date deficit of £8m. The Always Improving programme continues to make progress, but will need to go further and faster. The Trust’s data centre arrangements remain a risk and design work is ongoing in respect of a solution. The risk associated with cyber incidents also remains high. The committee supported a business case for possible expansion of UHS Pharmacy Limited and recommends it to the Board. The committee reviewed the proposed financial recovery plan and recommends to the Board its submission to the ICB. The main risk to the achievement of the Trust’s 2024/25 plan remains the need for the ICS transformation programmes to deliver. Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) 5.8 Finance Report for Month 6 Level of Assurance: Substantial • The Trust has received £11.2m of deficit support funding as well as £6.5m of additional funding in respect of 2023/24 Elective Recovery performance. • The year-to-date deficit is c.£8m, with an underlying deficit of c.£6m per month. • The Trust’s monthly income remains strong and ERF performance in September 2024 was 130%. However, costs are gradually increasing, and further investigation is required into pay expenditure. • The full amount of 2024/25 CIP has now been identified. • The most significant risk to the Trust’s achievement of its 2024/25 plan remains delivery of the system transformation programmes. 6.2 Board Assurance Framework Level of Assurance: Reasonable • Risks 5a, 5b and 5c have been updated, following discussions with the respective Executive Directors. • Risk 5a will be reassessed following the Trust’s self-assessment against the Recovery Support Programme undertakings to ensure that the risk rating and target are appropriate. • A new scoring framework is being developed to improve consistency in the rating of risks. Any Other Matters: The additional cash received in October 2024 means that it is now likely that the Trust will not need additional cash until February 2025, whereas this was previously expected to be the case in November 2024. The Trust has in place effective controls to monitor its cash position, and a regular report on cash will be provided to the Finance and Investment Committee. Page 1 of 2 Substantial Assurance Reasonable Assurance Limited Assurance No Assurance Not Applicable There is a robust series of suitably designed internal controls in place upon 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. There is a series of controls in place, however there are potential risks that may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Where assurance is not required and/or relevant. Page 2 of 2 Agenda item 4.3 Committee Chair’s Report to the Trust Board of Directors 5 November 2024 Committee: People and Organisational Development Committee Meeting Date: 21 October 2024 Key Messages: Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) Any Other Matters: • The Trust remains below its plan in terms of workforce numbers. However, from October 2024 onward, this position is expected to change. • The risk of non-delivery of ICS transformation programmes is significant. The Trust has assumed a significant reduction in workforce based on delivery of these schemes. • The committee examined the progress against actions designed to improve the lives of resident doctors. It was noted in particular that there was an issue with a lack of availability of office/desk space. • The Trust had been notified that Unite was commencing a ballot of its members commencing on 21 October 2024 as part of the ongoing dispute with porters. 5.11 People Report for Month 6 Level of Assurance: Substantial • The Trust was 249 WTE below its plan. However, this position was expected to change significantly with the onboarding of newly qualified nurses etc. in the autumn. • In addition, the Trust’s plan assumed that the ICS transformation programmes would begin to deliver significant reductions from October 2024 onward. • Turnover and sickness remain below target at 11.1% and 3.6% respectively. Bank and agency rates also remain low. • Appraisal rates remain low at 73%. The Trust was considering a move away from the current ESR system in order to make the appraisal process easier. The Trust had held constructive discussions with Unison as part of the Band 2/3 pay dispute. Substantial Assurance Reasonable Assurance Limited Assurance No Assurance Not Applicable There is a robust series of suitably designed internal controls in place upon 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. There is a series of controls in place, however there are potential risks that may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Where assurance is not required and/or relevant. Page 1 of 1 Agenda item 4.4 Committee Chair’s Report to the Trust Board of Directors 5 November 2024 Committee: Quality Committee Meeting Date: 14 October 2024 Key Messages: Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) Any Other Matters: • The Trust was making good progress against its 2024/25 Quality Priorities. • There were concerns regarding the consistency of approach to infection prevention and control in the Trust. Action plans were being produced and the ‘Fundamentals of Care’ programme is also intended to address many of these concerns. • A never event due to wrong site surgery had been recorded. This is the fifth never event reported during 2024. • The closure of Ward D4 had not been effective in eradicating the candida auris infection with four new cases reported. • There was insufficient resource to roll out National Safety Standard for Invasive Procedures (NatSSIPS) 2 in a comprehensive and systematic manner. • In its review of mental health work, the committee noted the following top three risks: lengths of wait for onward care; parity of esteem for patients; and the level of support from local mental health trusts. 6.2 Board Assurance Framework Level of Assurance: Reasonable • Risks 1a, 1b, 1c and 4a have been updated, following discussions with the respective Executive Directors. • It was agreed that the likelihood of achieving the target risk level for risk 1c (infection prevention and control) by April 2025 should be reviewed. • Staffing remains the main concern for the Trust’s Maternity services. • The possibility of support from Salisbury NHS FT to manage the increasing number of caesarean sections was being explored. Substantial Assurance Reasonable Assurance Limited Assurance No Assurance Not Applicable There is a robust series of suitably designed internal controls in place upon 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. There is a series of controls in place, however there are potential risks that may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Where assurance is not required and/or relevant. Page 1 of 1 Agenda item 4.5 Report to the Trust Board of Directors, 5 November 2024 Title: Sponsor: Author: Purpose Chief Executive Officer’s Report David French, Chief Executive Officer Craig Machell, Associate Director of Corporate Affairs (Re)Assurance Approval Ratification Information x Strategic Theme Outstanding patient outcomes, safety and experience Pioneering research and innovation World class people Integrated networks and collaboration Foundations for the future x x x x Executive Summary: The CEO’s Report this month covers the following matters: • Autumn Statement • Portering Dispute • BAM Dispute • Change NHS • Review into the Operational Effectiveness of the Care Quality Commission • Proposed Legislative Changes • New Hospital Programme – Hampshire Together • Hampshire and Isle of Wight Healthcare • Charity Priorities • Staff Survey • National Patient Safety Award Contents: Chief Executive Officer’s Report Risk(s): N/A Equality Impact Consideration: YES / NO / N/A Chief Executive Officer’s Report Autumn Statement On 30 October 2024, the Chancellor of the Exchequer presented her Autumn Statement. The statement was said to be based on the principles of restoring economic stability and increasing investment. A summary can be found from NHS Providers website: autumn-budget-2024-on-the-day-briefing.pdf The statement set out measures to raise an additional £40bn in taxation. This includes an increase in employer’s national insurance contributions by 1.2% to 15% from April 2025, increases in the rates of capital gains tax, changes to inheritance tax, abolition of the nondomicile tax regime, increased stamp duty on second homes, an increase in the rate of the windfall tax on energy companies, and removal of the VAT exemption for private schools. The Chancellor said that she would reduce wasteful spending and has set a 2% productivity savings target for all departments. The Government will publish its ten-year plan for the NHS in Spring 2025 and re-committed to reducing waiting times to 18 weeks by delivering on its manifesto commitment for 40,000 extra hospital appointments each week. The key announcements for health and care include: • Day-to-day spending for the Department of Health and Social Care will increase by £22.6bn from 2023/24 to 2025/26. This is a two-year average real terms NHS growth rate of 4% – the highest since 2010 (excluding the years affected by the COVID-19 pandemic). • Capital spending will increase by £3.1bn in 2025/26 (compared to 2023/24 outturn) – rising to £13.6bn. This is a two-year average real terms growth rate of 10.9%, although it is still lower than the overall value of the maintenance backlog (£13.8bn). This includes £1.5bn for new surgical hubs and diagnostics scanners, and £1bn towards backlog maintenance. There remains some uncertainty regarding the implications of the additional revenue funding and whether any of the funding announced will provide in-year relief in addition to values already confirmed as part of pay award and Elective Recovery Framework funding. Overall, the commitment to additional capital and revenue investment to the NHS is extremely welcome. We will assess the implications for HIOW ICS and to UHS over the coming weeks and months. The national proposed rise in the minimum wage to £12.21 in April 2025 will exceed the current lowest level within the NHS of £12.08. The national staff council will be working with NHS unions to review the implication of this and how it is addressed at a national level. Portering Dispute The Trust has been formally notified by UNITE the union that it has initiated a strike ballot of its members employed within the portering department at University Hospital Southampton. The ballot commenced on 21 October and will run until 11 November 2024. UNITE is balloting members on a range of issues including conduct, culture and working conditions. Prior to the ballot, and having been made aware of staff concerns, the Trust commissioned an independent external review, seeking views of all the portering department. The ballot has attracted media coverage from the BBC and some other local sources, and the Trust provided a response to the issues raised. The Trust is in active discussions with UNITE and local portering representatives to address the issues being raised and will continue to work constructively to resolve the dispute. Page 2 of 6 Meanwhile, the Trust is actively considering plans to ensure patient services and safety are maintained in the event a strike takes place. This will include enacting the Trust’s business continuity processes through the hospital incident management structure. The Board will be kept informed as plans are finalised and on conclusion of the ballot. BAM Dispute While the Trust was proceeding with the development of the east wing annex, concerns were raised by external structural engineers over the capacity of the existing building to cope with the expected additional weight the development would put on the existing structure. In 2022, the Trust raised a formal issue with BAM, the principal contractor of the existing east wing annex building. Over the last two years the Trust, with the support of DAC Beachcroft, has been trying to get BAM’s representatives to the mediation table to resolve the issues raised on the building. In September 2024, the decision was taken to commence arbitration proceedings against BAM Construction over the inability to agree to a mediator or mediation date. The Trust continues to work closely with DAC Beachcroft during this process, aiming for completion in early 2025. Change NHS On 21 October 2024, the Department for Health and Social Care launched an online portal for individuals to share their views, experiences and ideas to assist in the development of the Government’s 10 Year Health Plan. Staff and members of the public have been asked to: • Give their views on the NHS and health and care. • Tell the Government what they feel is working well and what needs improving. • Share their experiences. • Post their ideas for improving health and care in the future. More information can be found at: Change NHS: help build a health service fit for the future GOV.UK Review into the Operational Effectiveness of the Care Quality Commission On 15 October 2024, the Government published an independent report by Dr Penny Dash, who had been commissioned in May 2024 to review the operational effectiveness of the Care Quality Commission (CQC). The review heard from over 300 people from across the health and care sectors and within the CQC, and analysed the CQC’s performance data. The review found significant failings in the internal workings of the CQC, which have led to a substantial loss of credibility, a deterioration in the CQC’s ability to identify poor performance and support a drive to improve quality. The review summarised these failings as follows: • Poor operational performance – there has been a stark reduction in activity compared with 2019. • Significant challenges with the provider portal and regulatory platform. • Delays in producing reports and poor-quality reports. • Loss of credibility within the health and care sectors due to the loss of sector expertise and wider restructuring, resulting in lost opportunities for improvement. • Concerns around the single assessment framework and its application. • Lack of clarity regarding how ratings are calculated and concerning use of the outcome of previous inspections to calculate a current rating. • There are opportunities to improve the CQC’s assessment of local authority Health and Care Act 2022 duties. • ICS assessments are in early stages of development with a number of concerns shared. • The CQC could do more to support improvements in quality across the health and care sector. • There are opportunities to improve the sponsorship relationship between the CQC and the Department of Health and Social Care. Page 3 of 6 The full report can be read at: Review into the operational effectiveness of the Care Quality Commission: full report - GOV.UK Proposed Legislative Changes The Government has proposed a number of significant reforms to employment legislation through its Employment Rights Bill. These changes include: • From 2026, employees will have immediate entitlement to paternity leave, unpaid parental leave, and bereavement leave from the first day of employment. Protections for pregnant women and mothers will also be strengthened. • ‘Exploitative’ zero-hours contracts will be banned, giving workers the right to move to guaranteed hours contracts after a 12-week reference period.
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Papers Trust Board 6 June 2024

Description: Date Time Location Chair Apologies Agenda Trust Board – Open Session 06/06/2024 9:00 - 13:00 Conference Room, Heartbeat/Microsoft
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Papers Trust Board 27 May 2021

Description: Date Time Location Chair Agenda Trust Board – Open Session 27/05/2021 9:00 - 13:00 Microsoft Teams Peter Hollins 1 Chair’s Welcome, Apologies and Declarations of Interest 9:00 To note apologies for absence, and to hear any declarations of interest relating to any item on the Agenda. 2 Staff Story The patient or staff 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 30 March 2021 9:15 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 Charitable Funds Committee (Oral) 9:25 Dave Bennett, Chair 5.2 Briefing from the Chair of the Finance and Investment Committee (Oral) 9:30 Dave Bennett, Chair 5.3 Briefing from the Chair of the Quality Committee (Oral) 9:35 Tim Peachey, Chair 5.4 Chief Executive Officer's Update (Oral) 9:40 Sponsor: David French, Chief Executive Officer 5.5 Integrated Performance Report for Month 1 10:00 To review the Trust's performance as reported in the Integrated Performance Report Sponsor: David French, Chief Executive Officer 5.6 Equality and Diversity Update (WRES and WDES) 10:45 Sponsor: Steve Harris, Chief People Officer Attendee: Gemma Genco, Head of Equality, Diversity & Inclusivity 5.7 Gender Pay Gap Reporting 2020 11:05 Sponsor: Steve Harris, Chief People Officer Attendee: Kirsty Durrant, Strategic HR Projects Manager 5.8 Freedom to Speak Up Report 11:25 Sponsor: Gail Byrne, Chief Nursing Officer Attendee: Christine Mbabazi, Equality & Inclusion Adviser/Freedom to Speak Up Guardian 5.9 Finance Report for Month 1 11:45 Sponsor: Ian Howard, Interim Chief Financial Officer 6 STRATEGY and BUSINESS PLANNING 6.1 CRN: Wessex 2020/21 Annual Report and 2021/22 Annual Plan 11:55 Sponsor: Paul Grundy, Chief Medical Officer Attendees: Rebecca McKay, Chief Operating Officer, CRN: Wessex/Clare Rook, Deputy COO, CRN: Wessex 7 CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Register of Seals and Chair's Actions 12:15 In compliance with the Trust Standing Orders, Standing Financial Instructions, and the Scheme of Reservation and Delegation. Sponsor: Peter Hollins, Trust Chair 7.2 Emergency Planning and Business Continuity Annual Report 2020/21 12:20 Sponsor: Joe Teape, Chief Operating Officer 7.3 Charitable Funds Committee Terms of Reference 12:30 Sponsor: Peter Hollins, Trust Chair Attendee: Karen Flaherty, Associate Director of Corporate Affairs and Company Secretary 7.4 Trust Executive Committee Terms of Reference 12:35 Sponsor: David French, Chief Executive Officer Attendee: Karen Flaherty, Associate Director of Corporate Affairs and Company Secretary 8 Any Other Business 12:40 To raise any relevant or urgent matters that are not on the agenda 9 To note the date of the next meeting: 29 July 2021 Page 2 10 Resolution regarding the Press, Public and Others Sponsor: Peter Hollins, 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. 11 Follow-up discussion with governors 12:45 Page 3 3 Minutes of Previous Meeting held on 30 March 2021 1 Minutes TB 30 March 2021 OS Minutes Trust Board – Open Session Date Time Location Chair Present 30/03/2021 9:00 - 12:05 Microsoft Teams Peter Hollins (PH) Dave Bennett (DB), Non-Executive Director (NED) Gail Byrne (GB), Chief Nursing Officer Cyrus Cooper (CC), NED Keith Evans (KE), NED David French (DAF), Interim Chief Executive Officer Paul Grundy (PG), Interim Chief Medical Officer Steve Harris (SH), Chief People Officer Jane Harwood (JH), NED (until item 5.10) Ian Howard (IH), Interim Chief Financial Officer Tim Peachey (TP), NED and Senior Independent Director/Deputy Chair Joe Teape (JT), Chief Operating Officer In attendance Brenda Carter (BC), Assistant Director of People (for item 5.8) Ellen Copson (EC), Associate Professor of Medical Oncology, University of Southampton and Honorary Medical Oncology Consultant (for item 2) Kirsty Durrant (KD), Strategic HR Projects Manager (for item 5.8) Karen Flaherty (KF), Associate Director or Corporate Affairs and Company Secretary Sarah Herbert (SHe), Divisional Head of Nursing and Professions, Division B (for item 5.9) Sandra Hodgkyns (SHo), Head of Emergency Planning Response and Resilience/Security (for item 5.9) Stephanie Ramsey (SR), Director of Quality and Integration (Chief Quality Officer and Chief Nurse), NHS Southampton City CCG (for item 5.6) 3 governors (observing) 3 members of the public (observing) 5 members of staff (observing) 1 member of the public (for item 2) 1 Chair’s Welcome, Apologies and Declarations of Interest The Chairman welcomed all those attending to the meeting. The following declaration of interests for GB were reported to the Board: • Chair of the Directors of Nursing Group, University Hospital Association; • Chair of the Wessex Patient Safety Collaborative; and • Member of the Policy Board, NHS Employers. The Board also noted that DB was no longer a director of Davox Consulting Limited. 2 Patient Story The patient story was told by the husband of a patient who sadly died in early 2020 following treatment for cancer at the Trust. As a result of the treatment she had received at the Trust following a diagnosis in April 2017, her life had been extended by over three years. In terms of areas for improvement, better communication of his wife’s initial diagnosis would have helped her and her family to come to terms with the diagnosis more quickly. Following their arrival at hospital, they were being asked lots of questions and his wife was being sent for tests and scans without being given information about what concerns the clinicians had or potential diagnoses. The diagnosis was also delivered on the ward just prior to a visit from a relative and with better planning this could have been done more sensitively by providing a better environment in which to have the conversation and more time for his wife to absorb the information. Once his wife met the specialist team, including the specialist nurse, she felt more reassured and was given hope by the availability of different treatment options. The Trust’s appointment of a dedicated specialist nurse for his wife’s particular cancer shortly after her diagnosis made a huge difference. The specialist nurse was always present when his wife met the consultants and would check if there was anything he or his wife needed and provided practical advice and support, which meant that he and his wife were able to spend more time together. GB reiterated the importance of specialist nurses across different patient pathways and the Trust continued to invest in more specialist nurses. While acknowledging that there was a shortage of private spaces to speak with patients and their families, through its End of Life Care Steering Group the Trust had identified a number of rooms across the hospitals to enable clinicians to go somewhere private in situations like these. The cancer service also continued to adapt to changes in cancer care and the needs of patients, with patients now living longer. Maggie’s Southampton had recently opened at the Southampton General Hospital site to provide help and support for those living with cancer, although the services it offered were currently reduced as a result of the Covid-19 pandemic. The Board expressed its gratitude for sharing the story with such strength and dignity. 3 Minutes of Previous Meeting held on 28 January 2021 The minutes of the meeting held on 28 January 2021 were approved as an accurate record of that meeting. 4 Matters Arising and Summary of Agreed Actions The updates on the actions were noted. The action relating to cancelled appointments in ophthalmology (reference 354) had been followed up and could be closed, as could the actions relating to patients medically optimised for discharge (reference 351 and 393) and the Ockenden report (reference 395), which were included as items on the agenda later in the meeting. The action relating to patient nutrition (reference 394) would be reviewed at the next meeting of the Quality Committee, which would then report to the Board. The Board agreed that the actions relating to specialty outcomes (reference 350 and reference 326) should be combined, with the paper due to be presented to the Board at its meeting in April 2021. Page 2 5 QUALITY, PERFORMANCE and FINANCE 5.1 Briefing from the Chair of the Audit and Risk Committee KE updated the Board on the meeting of the Audit and Risk Committee held on 15 March 2021: • the external audit work had commenced and there were no issues to report at this early stage; • the internal auditors had reviewed referral to treatment (RTT) data quality and while data inaccuracies had been identified in the sample testing, these had not impacted on patients clinical treatment or on Trust’s the overall performance against the RTT target, and in most instances had resulted in the Trust overreporting on pathways; and • updates had been provided on progress against the recommendations in the board governance review and the ongoing review of the data security and protection toolkit. 5.2 Briefing from the Chair of the Finance and Investment Committee DB provided an overview of the Finance and Investment Committee meeting the previous day, highlighting: • that funding for the loss of other income and additional accruals of annual leave that staff had been unable to take due to the Covid-19 pandemic had been received; • the update on the planning process for 2021/22 following the publication of new national guidance that sought to achieve a balance between restoring services and reducing backlogs while supporting staff recovery; • the review of the most recent operational productivity dashboard, from which it had been difficult to draw any meaningful conclusions given the impact of the Trust’s response to the most recent wave of the Covid-19 pandemic in the previous months; and • the business case for the expansion of the outpatients area in ophthalmology, which would be considered by the Board later in the meeting. 5.3 Briefing from the Chair of the Quality Committee TP provided an update on the meeting of the Quality Committee held on 15 March 2021 focusing on the following areas: • the increase in waiting times for diagnostics and plans to recover performance, with a review of patient harm to be completed once patients who had waited longer than six weeks had been seen; • the review of a ‘never event’ relating to a retained swab including the recommendations for a number of sensible actions that had already been implemented; • the latest update on experience of care including the Trust’s accreditation as a Veteran Aware NHS trust; • the recommendations for reporting on maternity safety following the Ockenden review of maternity services at Shrewsbury and Telford Hospital NHS Trust, which would be considered by the Board later in the meeting; • the urgent investigation of aspergillus infections in the intensive care unit to establish whether there was a link to an earlier leak in a pipe above the ceiling in that area; • the latest report on clinical outcomes, with the Board to receive a full Page 3 report at its meeting in April 2021; and • the review of the committee’s effectiveness. 5.4 Chief Executive Officer’s Update The Trust had taken part in the national day of reflection and one minute’s silence on 23 March 2021 to commemorate the anniversary of the first national lockdown due to the Covid-19 pandemic. This had given staff an opportunity to pause and reflect on the loss of life over the previous year, including patients and staff. There were currently 20 patients in the hospital who had tested positive for Covid-19, three of which were in intensive care. An average of three or four patients with Covid-19 were being admitted daily, which highlighted the importance of continuing to follow the rules as lockdown measures were eased. Staff were being encouraged to take annual leave and wellbeing conversations were taking place with every member of staff. Second doses of the Covid-19 vaccine were being administered to Trust staff and staff at health and social care partners. 92% of frontline staff and 90% of all staff had received at least one dose of the vaccine, including 88% of BAME (Black and Minority Ethnic) staff. Staff who had not yet received the vaccination were being contacted individually to understand the reasons for this and provide additional information where appropriate. As well as planning for the recovery of services in the short term, the Trust was carrying out long-term modelling of future demand and capacity supported by external consultants and architects, which would form the basis of the Trust’s estates masterplan for the main hospital site. In advance of this work, the corporate objectives for 2021/22 would be presented to the Board at its meeting in April 2021. The Trust had performed exceptionally well in its recent external accreditation of endoscopy by the Joint Advisory Group on GI Endoscopy (JAG), providing one of the best submissions reviewed by JAG. Each of the executive directors provided an update in turn, covering the following areas: • reopening of theatres in Southampton General and Princess Anne Hospitals, replacing the current additional capacity in the independent sector from 1 April 2021; • four ‘Always Improving’ quality improvement projects relating to the emergency department (ED), discharge of patients medically optimised for discharge (MOFD), theatres and outpatients; • the launch of the ‘Always Improving’ strategy with staff in June 2021; • the review of patients who had been waiting for surgery, in particular those in priority level 2 (surgery that can be deferred for up to four weeks); • modelling of the potential impact on the waiting list of GP referrals returning to more normal levels and patients potentially presenting with more advanced disease than if they had seen their GP earlier; • the business intelligence programme to improve prospective as well as retrospective reporting; • allowing time for teams to readjust to working together as part of the recovery process with additional support from the Trust for those teams experiencing challenges; • plans to safely reopen the hospitals to visitors, particularly while the Page 4 Trust continued to admit patients with Covid-19; • re-energising the COVID ZERO campaign to ensure that the infection control measures continued to be followed rigorously even as the number of cases reduced, with a nosocomial infection the previous week acting as a timely reminder of the risk; • the successful renegotiation of the limit on expenditure (CDEL) for 2020/21 through which the Trust had been able to access additional capital and the negotiation of the allocation of CDEL across the integrated care system (ICS) for 2021/22; and • the current projects in development including theatres, the private patient unit, ophthalmology and the pathology laboratory information system. The Board noted that that the Trust would need to establish how it would balance the needs of those patients who had been waiting longest for treatment with the clinical prioritisation process already in place as it planned for the recovery of activity. 5.5 Integrated Performance Report for Month 11 The integrated performance report (IPR) for month 11 was noted. During February 2021 the direct impact of Covid-19 infections upon the Trust continued to be significant. There were 263 patients in the hospital with Covid19 at the start of February and 129 at the end of the month. The number of patients in intensive care reduced from 67 at the beginning of the month to 39 by the end of February. This compared to the first wave of Covid-19 pandemic, when the number of patients with Covid-19 in the hospital peaked at 173 and 38 in intensive care. This also had an impact on elective activity within the Trust, which was 42% of the level in February 2020. The Board discussed the following areas: Responsive • while the Trust’s ED was performing well comparatively, it was not meeting the performance target on the length of time patients spent in ED, despite attendances at 71% of the normal level; • this was principally due to patients presenting with mental health conditions and surges of high acuity patients, however, new junior doctors had also joined ED in February who were not used to the level of attendances; • leadership in ED was central to managing the department in these situations particularly the effective operation of the consultant of the day model to ensure that decisions regarding patients were made in a timely manner; • performance in ED had improved overall as 87% of patients were currently seen within four hours with an average daily attendance of 345 patients compared to 78% of patients two years ago when the average daily attendance was 350 patients; • to continue to improve performance and the flow of patients through ED the Trust was ensuring that specialties adhered to the one hour standard for referrals; • infection control measures remained in place, including respiratory assessment and rapid testing in ED and the acute medical unit, although it was difficult to establish whether this had a material impact on performance as ED had performed consistently well during the Page 5 period of the pandemic; • activity in ED had increased in March 2021 as lockdown restrictions had eased; • while the number of non-face-to-face outpatient appointments had increased following the first wave of the pandemic, some of these had not been full appointments but rather an opportunity to check in with patients; • the use of non-face-to face outpatient appointments varied by condition and specialty and was more appropriate for some of these than others, however, the Trust was seeking to learn from those clinicians who had used these types of appointment successfully as part of its quality improvement work in outpatients; • feedback from patients non-face-to face appointments had been positive on the basis that their care was continuing, however, limited work had been done to assess effectiveness in terms of the experience and outcome of these appointments; and • although cancer performance measures remained stable, both the Trust and the Wessex Cancer Alliance had performed well comparatively and ranked as second highest performing in their respective peer groups. Safe • • the unusually high number of medication incidents reported with moderate or severe harm in February and the actions taken in response to these; and ensuring that staff continued to report incidents, particularly as they returned to their normal areas of work following the pandemic. Caring • the number of overnight ward moves for non-clinical reasons given that most patient moves during this period would be related to patients admitted with Covid-19; • the percentage of patients with a disability or additional needs reporting that those needs were met had reduced and there were resource challenges in this area currently with a vacancy in one of the two adult learning disabilities nursing roles, although the recruitment process was underway; and • increasing the number of vulnerable women on a continuity of carer pathway given the benefit to all these women in terms of the quality of oversight in maternity. ACTIONS: (1) GB would review the non-clinical reasons for overnight ward moves and provide an overview to the Quality Committee. (2) The Quality Committee would review the resourcing required to increase the percentage of vulnerable women on a continuity of carer pathway and update the Board. Well-led • the impact of research activity on outcomes, more detail of which would be provided in the report on clinical outcomes at the meeting of the Board in April 2021. The Board’s review of the IPR, led by TP, would report to the Board in May 2021 with a candidate IPR. Page 6 5.6 Inpatient Flow - Medically Optimised for Discharge Update SR joined the meeting for this item. The Board noted the current performance against the process improvement trajectories and key performance indicators agreed by the system, system plans in the light of current performance and the Trust’s internal work programme for MOFD. The Board was interested to learn what the Trust could be doing differently or better in order to help improve performance as a system. The work to date had made a significant impact as the system responded to discharge an increased number of patients with more complex needs such as stroke patients, patients with challenging behaviours, patients requiring more intensive therapy and homeless patients. There was a specific issue with discharging to care homes at weekends and providing the necessary clinical support to these care homes to enable discharge. The main areas of focus for the Trust were to speed up processes and ensure patients MOFD were ready to be discharged earlier in the day as this would make it easier for services in the community to respond. While there was a target to get to 40-60 patients MOFD in hospital, no specific timescales had been set. ACTION: JT agreed to include a trajectory for MOFD patients in the regular reports to the Finance and Investment Committee. Funding was also likely to be an issue in the future as additional national funding provided during the Covid-19 pandemic to support the discharge of patients would be withdrawn at the end of June 2021. The Board recognised that system partners were aligned in their aim to address the delays in discharging patients MOFD and prevent potential patient harm as a result. However, the Board suggested a more holistic view of the issue would be beneficial when reviewing future resourcing, taking into account the revenue and capital implications and the consequences in terms of hospital capacity and addressing the current backlog of patients waiting for treatment. This analysis may identify where investment was needed to support discharge, including additional capacity, albeit that the ambition remained ‘home first’ when discharging patients in order to assess ongoing needs more accurately and reduce dependency. The meeting was adjourned briefly to allow for a break. 5.7 Ockenden Review of Maternity Services The Board noted the update on progress on the emerging findings and recommendations of the independent review of maternity services at the Shrewsbury and Telford Hospital NHS Trust released on 10 December 2020. The Trust had rated its progress against two of the recommendations as red, with no actions currently in place, and nine of the recommendations as amber, where actions were still in progress. Completion of these recommendations was dependent the Trust’s submission to NHS Resolution’s maternity incentive scheme which would be made by mid-July 2021 and therefore other trusts would be in a similar position. The Trust had received feedback on the information submitted to NHS England and NHS Improvement, which had been positive overall. A template had been designed to report to the Board and the local maternity Page 7 service (LMS) on maternity safety, which would incorporate a summary of serious incidents (SIs) and moderate harm incidents. This report would be submitted to the Board maternity safety champions and LMS on a monthly basis. The Board maternity safety champions would also meet with complainants before the referral of a complaint to the Parliamentary and Health Service Ombudsman. It was proposed that reporting to the Board on maternity safety issues including SIs and moderate harm incidents, the perinatal mortality report tool, early notification scheme, red flag incidents, staff concerns and evidence of listening to families including complaints would take place quarterly following review of the information by the Quality Committee. The frequency of reporting to the Board was in line with the recommendations in the Ockenden review although not with the guidance issued subsequently. The Board was keen to ensure it maintained a good understanding of the culture and patient experience in the maternity service given the impact of each on the quality of the service. Proposals to regularly survey staff would be considered later in the meeting. In addition the Board requested that the regular patient story should include maternity at least once annually. ACTION: KF to arrange a patient story from a patient using the maternity service at least once annually. DECISION: The Board agreed: • to receive a quarterly report on maternity safety issues; and • that all SIs and moderate harm incidents would be provided to the Board maternity safety champions and LMS. 5.8 UHS Staff Survey Results 2020 Report BC and KD joined the meeting for this item. The results of the NHS staff survey 2020 were noted by the Board. The survey had been completed by staff between September and November 2020. Overall the Trust’s results were at or above the acute trust average in nine out of ten themes. 77% of staff would recommend the Trust as a place to work and 87% of staff agreed that care of patients was the top priority for the Trust. Performance on health and wellbeing had significantly increased compared to 2019. However, the survey had also identified some areas for improvement. The areas with statistically significant decreases in performance compared to the 2019 staff survey results were: • Equality, diversity and inclusion; • Immediate managers; • Violence; and • Team working. In response to a question from a NED, it was clarified that only a small number of incidents of violence against staff from managers and colleagues reflected in the staff survey results were reported leading to an investigation. The reporting through the Trust’s Freedom to Speak Up processes had identified incidents involving microaggressions rather than acts of violence. Work was also ongoing to improve leadership skills within the organisation, which would set out expectations regarding values and behaviours. Over 1,000 free text comments had been submitted from staff as part of the survey and a national analysis of themes was being prepared, which would Page 8 provide further insight into how staff were feeling following the first wave of the pandemic. The Board supported more regular surveying of staff, particularly around the areas of improvement identified, recognising that things had changed since the survey was carried out six months ago and would continue to change. 5.9 Plan to Address Violence and Aggression against Staff SHe and SHo joined the meeting for this item. The Board noted the update on the progress made since the previous update in September 2020. This included closer working with Hampshire Constabulary, proposed changes to security arrangements, staff training and staff support. These plans aimed to reduce incidents of violence and aggression against staff and provide support to staff in the management of violence and aggression and following any incidents. The Board recognised that violence and aggression against staff would never be eliminated entirely as the Trust provided care to individuals with mental health issues, brain injuries, dementia and who lacked capacity who may find it difficult to control their behaviour. It was important, however, that violent and aggressive behaviour was challenged consistently when appropriate. The Board supported the approach to exclude violent and aggressive individuals from the Trust when they repeatedly displayed unacceptable behaviour that it was not possible to manage through de-escalation, anticipatory care planning and the challenging behaviour protocol. While not formally approving the funding for the plans set out in the paper, the Board noted the importance of investment in this area in order to support staff. A further update on progress would be provided in December 2021. 5.10 Finance Report for Month 11 The finance report for month 11 was noted. The following areas were highlighted: • the Trust has received the payments for the loss of other income, additional accruals of annual leave that staff had been unable to take due to the Covid-19 pandemic and the elective incentive scheme; • the Trust remained on track to achieve a breakeven position for 2020/21 as did the other trusts in the Hampshire and Isle of Wight ICS; and • the Trust’s balance sheet position remained strong, which placed the Trust in a good position to address likely pressures in 2021/22. 6 CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 6.1 Register of Seals and Chair's Actions for ratification DECISION: The Board ratified the application of the Trust seal and the Chair’s actions set out in the report. ACTION: IH would follow up on the Wessex Clinical Research Network and the assisted conception service items in the paper as these were not single tender actions required to be reported in accordance with the Trust’s Standing Financial Instructions. 6.2 Amendment to Constitution for CCG Merger With effect from 1 April 2021, the individual Clinical Commissioning Groups Page 9 (CCGs) within Hampshire and the Isle of Wight were to merge to create a new NHS Hampshire, Southampton and Isle of Wight CCG. The Council of Governors (CoG) included an appointed governor from each of NHS Southampton City CCG and NHS West Hampshire CCG and as a result of the merger these two organisations would cease to exist. It was proposed that the Trust should reflect the merger in the composition of the CoG, by amending the composition of the CoG in Annex 3 of the Trust’s constitution to remove the Appointed Governor from each of NHS Southampton City CCG and NHS West Hampshire CCG and include an Appointed Governor from NHS Hampshire, Southampton and Isle of Wight CCG in their place. A separate review of the composition of the CoG would be undertaken as part of the annual review of the Trust’s constitution to ensure that the overall composition of the CoG remains representative and reflected the changes to NHS governance structures. DECISION: The Board approved the amendment to the Trust’s constitution with effect from 1 April 2021, subject to the approval of the CoG at its meeting on 31 March 2021. 7 Any Other Business There was no other business. 8 To note the date of the next meeting: 27 May 2021 9 Resolution regarding the Press, Public and Others DECISION: The Board resolved that, as permitted by the National Health Service Act 2006 (as amended), the Trust's Constitution and the Standing Orders for the Practice and Procedure of the Board of Directors, 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 10 4 Matters Arising and Summary of Agreed Actions 1 List of Action Items List of action items Agenda item Assigned to Deadline Status Trust Board – Open Session 30/03/2021 5.5 Integrated Performance Report for Month 11 426. Caring - overnight ward moves Byrne, Gail Peachey, Tim 27/05/2021 Pending Explanation action item GB would review the non-clinical reasons for overnight ward moves and provide an overview to the Quality Committee. 427. Caring - vulnerable women Byrne, Gail Peachey, Tim 27/05/2021 Pending Explanation action item The Quality Committee would review the resourcing required to increase the percentage of vulnerable women on a continuity of carer pathway and update the Board. Trust Board – Open Session 30/03/2021 5.6 Inpatient Flow - Medically Optimised for Discharge Update 428. Trajectory for MOFD patients Teape, Joe 27/05/2021 Pending Explanation action item JT agreed to include a trajectory for MOFD patients in the regular reports to the Finance and Investment Committee. Trust Board – Open Session 30/03/2021 5.7 Ockenden Review of Maternity Services 429. Patient story Flaherty, Karen 31/03/2022 Pending Explanation action item KF to arrange a patient story from a patient using the maternity service at least once annually. Page 1 of 2 Agenda item Assigned to Deadline Status Trust Board – Open Session 30/03/2021 6.1 Register of Seals and Chair's Actions for ratification 430. Follow up Howard, Ian 27/05/2021 Pending Explanation action item IH would follow up on the Wessex Clinical Research Network and the assisted conception service items in the paper as these were not single tender actions required to be reported in accordance with the Trust’s Standing Financial Instructions. Page 2 of 2 Report to the Trust Board of Directors Title: Agenda item: Sponsor: Date: Purpose Issue to be addressed: Integrated Performance Report 2021/22 Month 1 5.5 David French, Chief Executive Officer 27 May 2021 Assurance Approval or reassurance Y Ratification Information This report is intended to support the Trust Board in assuring that: • the care we provide is safe, caring, effective, responsive and well led in the context of the COVID-19 pandemic • at the same time we continue our journey toward our vision of World Class Care for Everyone. Response to the issue: The Integrated Performance Report reflects the current operating environment and is aligned with the Care Quality Commission Key Lines of Enquiry. 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 This report is provided for the purpose of assurance. out the change / or not: Summary: Conclusion This report is provided for the purpose of assurance. and/or recommendation Page 1 of 1 Integrated KPI Board Report covering up to April 2021 Sponsor - Andrew Asquith, Director of Planning, Performance and Productivity, andrew.asquith@uhs.nhs.uk Chart Type Cumulative Column Example Cumulative Column Year on Year Line Benchmarked Line & bar Benchmarked Control Chart 100% 0% 66.8% 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). 66.49% The line shows our performance and the bar underneath represents the range of 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 Report to Trust Board in May 2021 Introduction The Integrated Performance Report is presented to the Trust Board each month. The report aims to: • Provide assurance that the care we provide is safe, caring, effective, responsive and well led in the context of the COVID-19 pandemic • Ensure that at the same time we continue our journey toward our vision of World Class Care for Everyone. We adjust / add to these indicators – informing the Board and keeping a comparative narrative – as the situation changes as we work through these unusual circumstances. The structure of the report is currently being reviewed in order that it can better reflect the ambitions within ‘Our Strategy 2025’, and to support the strategic discussions of the Board. April 2021 Summary During April the direct impact of COVID-19 infections upon the Trust reduced further. Patients with a confirmed COVID-19 diagnosis during their admission: • Started the month at 48 (11 of which were in intensive care / high care) • Finished the month at 24 (5 of which were in intensive care / high care) The phased resumption of the elective admissions continued within NHS facilities, and the additional access to independent sector theatres and beds that had been secured by NHS England during the pandemic terminated at the end March. 3 Report to Trust Board in May 2021 Key aspects of performance for consideration this month include: • The total number of patients on the RTT waiting list increased by over 1,000 patients to 37,613 in April. There are over 3,000 patients waiting over 52 weeks for treatment and over 500 patients waiting over 78 weeks. Our benchmarking confirms that we are continuing to perform well in comparison to our peer group. • The crude mortality rate and Hospital Standardised Mortality Ratio (HSMR) both increased significantly in January (though HSMR remained significantly better than would be expected on average in the NHS). Patient details have been requested in order that the recorded diagnosis can be checked as a first step in investigation. It may be relevant that January saw a peak in COVID-19 occupancy. • UHS 62 day performance (RE 23) improved to 86.5% (better than our local target and the national target applying to the majority of 62 day pathways). UHS was the best performing trust amongst our 10 ‘peer’ teaching hospitals in March. 4 Report to Trust Board in May 2021 RESPONSIVE • Emergency Department timeliness deteriorated slightly to 87% (RE 9) whilst remaining 3rd best amongst 8 benchmark trusts. Attendance numbers increased further to the highest levels since the COVID-19 pandemic started (RE 8). • Elective spell volumes (excluding daycases, at SGH/PAH only) (RE 13) recovered further, yet remained below those in Autumn 2020. Two SGH theatres are currently closed due to building works and are due to reopen in June. • The total number of patients on the RTT waiting list increased by over 1,000 patients this month. The cohort of patients who have waited over 52 weeks (RE 16) reduced by over 300 patients, whilst those waiting over 78 weeks (RE 17) increased by over 100 patients. We remain concerned by this situation and are focussed on improving the situation as soon as possible for our patients. Our benchmarking (in a group of 20 Teaching hospitals) confirms that we are continuing to perform well in comparison to our peer group. • Cancer performance measures for March indicate continued improvement in performance: o UHS 62 day performance (RE 23) improved to 86.5% (better than our local target and the national target applying to the majority of 62 day pathways). UHS was the best performing trust amongst our 10 ‘peer’ teaching hospitals again this month. o 31 day performance (RE 24) was maintained above the target at 97.6%. 5 Report to Trust Board in May 2021 RESPONSIVE RE1 Non-elective Spells (discharged, including CDU) Non Elective LOS RE2-L Rolling 12 months (Solid) Monthly (Dashed) Number of inpatients that were RE3 medically optimised for discharge (monthly average) Monthly Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr target 6,800 6,292 4,000 7.5 6.0 4,128 6.49 - 5.45 - 4.5 250 76 0 122 - Longer LOS Census average RE4-N (Patients with LOS > =21days) 203.38 160.86 118.33 73 145 - RE5-l RE6 RE7 Adult midday bed occupancy Last minute cancelled operations not readmitted within 28 days Last minute cancelled operations 100% 98.2% 84.6% 71.1% 82.6% 40% 55 40 0 150 5 0 79.0% 90-95% - 6 35 - 6 Report to Trust Board in May 2021 RESPONSIVE Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr QTD 12,000 10663 RE8 Total ED Attendances - 5735 5,000 RE9-N Patients spending less than 4hrs in ED SGH Main ED (Type 1 and UCH) 92% 84% Major Trauma Centres (Type 1) 76% 90.2% 87.2% 81.30% 87.2% Rank of 8-> RE10-N Patients spending less than 4hrs in ED UHS Total (includes SGH all types) - 532533422111233 92.22% 85.5% 78.82% 91.1% 91.1% 88.0% 88.0% Q target - 95% 95% RE11-N Total time Total spent in ED - Percentiles UHS RE12 27,000 Accepted Referrals (excluding -initiated by consultant responsible) 0 RE13 2,000 Elective spells (excluding daycase, onsite SGH/PAH only) 0 90th, 4:00 Mean, 2:45 8,013 446 90th, 4:59 - - Mean, 3:04 19,100 - - 1,438 - - 7 Report to Trust Board in May 2021 RESPONSIVE Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan 100% % Patients on an open 18 week pathway 66.8% RE14-N (within 18 weeks ) with teaching hospital min-max range and rank (of 20) 18 12 14 14 7 6 7 7 10 10 10 9 30% 38,000 Total number of patients on a waiting RE15-N list (18 week referral to treatment 33106 pathway) 30,000 Patients on an open 18 week pathway 9,000 RE16-N (waiting 52 weeks+ ) with teaching hospital min-max range and rank (of 20) 0 15 154 13 13 13 11 11 11 10 9 6 6 6 1000 RE17 Patients on an open 18 week pathway (waiting 78 weeks+ ) 500 0 0 65,000 RE18 Face to face outpatient attendances 40,105 Feb Mar Apr 66.5% 9 8 37613 3108 5 4 553 34,415 Target > =92% - 0 65,000 RE19 Non-face to face outpatient attendances 15,703 0 RE19 - Latest month is awaiting approx ~3k outpatient attendances to be reported 18,748 - RE20-N Average weeks waited for first outpatient appointment 12.00 10.47 8.89 10.3 7.00 7.30 8.5 - 8 Report to Trust Board in May 2021 7.00 7.30 RESPONSIVE Target Patients to Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar /Apr recover target QTD 11,000 9563 RE21-N Patients waiting for diagnostics - 4317 4,000 80% % of Patients waiting over 6 weeks for RE22-N diagnostics with teaching hospital min- 45.2% 27.2% 90% N = 7 L= L=> 0 of 197 80% 85% 69.1% UHS Total ………………….Rank(of 10)-> 6 5 3 1 1 1 1 1 5 7 4 2 1 1 0.5 31 day cancer wait performance RE24-N (Latest data held by UHS, Combined measure – First and Subsequent Treatments of Cancer) 97.1% 93.2% 89.4% 92.2% 97.6% N=> 96% N=0 of 948 97.41% RE25-N Snapshot of waits > 104 days (from referral on a 62 day pathway) 36 27 29 25 11 17 9 11 25 24 17 13 16 22 - - - RE26-N 28 Day Faster Diagnosis 100% 70% 82.7% 87.5% => 75 % - 84.16% 9 Report to Trust Board in May 2021 RESPONSIVE RE27 My Medical Record - UHS patient logins Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr Monthly target 20,000 18,182 10,000 5,566 - 0 2,500 RE28 Number of Estates Help desk requests 900 and percentage completed on time 100% 85% 997 89.6% 1,592 - 84.7% > 85% 50% Elective inpatient activity - % of same month pre COVID-19 100% RE29 UHS Corporate peer average ------------------------------Rank--> 20% Non-elective inpatient activity - % of same month pre COVID-19 100% RE30 UHS Corporate peer average ------------------------------Rank--> 50% 1st outpatient attendances - % of same month pre COVID-19 100% RE31 UHS Corporate peer average ------------------------------Rank--> 30% Follow up outpatient attendances - 110% % of same month pre COVID-19 RE32 UHS Corporate peer average ------------------------------Rank--> 50% RE29-32 corporate peers group size = 7 90.4% 85.1% 35.23% 3 2 2 2 2 2 1 1 4 4 2 95.0% 66.6% 95.42% 534422232254 96.2% 51.7% 93.77% 47.20%2 2 2 2 2 2 2 2 2 2 2 3 70.3% 108.9% 102.8% - 63.6% 6 3 2 2 1 1 2 2 1 1 4 5 QTD - 86.2% - 10 Report to Trust Board in May 2021 SAFE • Only a single case of probable hospital associated COVID-19 acquisition > 7 days occurred in April (SA 6). • Our measure related to pressure ulcers was amended this month to distinguish between category 2 and 3 ulcers, regardless of level of ‘harm’ (SA 7/8). Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr Target YTD SA1-N Cumulative Clostridium difficile 2 SA2 MRSA bacteraemia 0 100 SA3 Clinical cleaning scores for very high risk areas 95 100 SA4 Serco cleaning scores for very high risk areas 95 Healthcare-acquired COVID 35 SA5 infection: COVID-positive sample taken > 14days after admission (validated) 0 Probable hospital-associated 80 SA6 COVID infection: COVID-positive sample taken > 7 days and 95% - 93.4% YTD target 95% 12 Report to Trust Board in May 2021 CARING • Inpatient feedback (CA 1) continues to be good and significantly better than target. • Maternity patient negative feedback (CA 2) continues to be worse than target; 6.6% compared to the target of =70% 41.5% 65.6% 14 Report to Trust Board in May 2021 0% CARING Monthly Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr target Total vulnerable women (living 100% CA8 within 10% most deprived decile) booked onto a continuity of carer 40.0% pathway 0% 100% % Patients reporting being CA9 involved in decisions about care and treatment 50% 86.0% 85.0% > =90% CA10 100% % Patients reporting finding somebody to talk to about worries and fears 50% 97.0% % Patients with a disability/ 100% additional needs reporting those 81.0% CA11 needs/adjustments were met (total number questioned included at chart base) 30 165 39 50% 57 153 215 133 164 174 178 240 77 CA11 - Performance is a scored metric with a "Yes" response scoring 1, "Yes, to some extent" receiving 0.5 score and other responses scoring 0. Overnight ward moves with a 100 CA12 reason marked as non-clinical (excludes moves from admitting 75.58 44.08 10 wards with LOS =90% 89.0% > =90% 63 110 289 29 - 10.8 - 15 Report to Trust Board in May 2021 EFFECTIVE • The crude mortality rate (EF 4) and Hospital Standardised Mortality Ratio (HSMR) (EF 3), both increased significantly in January (though HSMR remained significantly better than would be expected on average in the NHS). More deaths than ‘expected’ are reported in General Medicine, Respiratory Medicine and Medicine for Older People, with a primary diagnosis of ‘viral infection’. Information for 97 patients has been requested in order that the recorded diagnosis can be checked as a first step in investigation. • Measures relating to patients screened for smoking and harmful alcohol consumption (EF 5), with those found to smoke and given brief advice or a medication offer (EF 7), stalled in their recovery following the COVID-19 peak in January and are currently slightly below target. EF1-L Cumulative Specialities with Outcome Measures Developed EF2 Developed Outcomes RAG ratings EF3-N HSMR - UHS HSMR - SGH EF4 HSMR - Crude Mortality Rate Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr 53 54 56 56 57 255 260 285 305 332 100% 75% 80% 81% 79% 77% 76% 50% 85 82.2 81.5 75 3.5% 3.0% 2.5% Monthly target +1 - 80% EF6-N % patients screened & found to 100% have either moderate or high alcohol dependence given advice or referral 80% 96.7% 95.7% > 90% 100% % patients screened & found to EF7-N smoke given brief advice or a medication offer 60% 83.6% 88.9% > 90% 17 Report to Trust Board in May 2021 WELL LED • Non-medical appraisal rates (WL 2) have continued their modest rate of recovery to 81%, but still remain significantly below the target of 92%. • Overall sickness absence (WL 6) reduced to 3%, which is within target, whilst COVID-19 related absence (WL 7) reduced to 1% of employed time during the month of April. WL1-L Substantive Staff - Turnover Monthly Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr Target 13.63% 12.92% 12.22% 13.4% 12.3% 92% 95.0% 3.4% 12.4% =76% WL9-N Response rate of - staff recommend UHS 60% as a place to work: UHS Quarterly staff FFT National NHS Staff Survey 20% 50.0% 30% 11% WL10-L % of Band 7+ staff who are Black and Minority Ethnic 9.2% 10.0% 15% by 2023 7% WL11 14% % of Band 7+ Staff who have declared a disability or long term health condition 13.3% 13.6% - 12% WL12- QI training programme, and reporting, is currently temporarily suspended as team members support urgent change programmes as part of our Covid 19 response and recovery WL12-L Statutory & Mandatory Training Achieving Target 7 7 7 6 6 6 6 6 6 6 6 6 6 6 6 - 5 5 5 6 6 6 6 6 6 6 6 6 6 6 6 100 WL13-L Number of Apprenticeship Starts 44 49 59 23 - 0 19 Report to Trust Board in May 2021 0 WELL LED Monthly Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr target WL14-L Comparative CRN Recruitment Performance by clinical specialty 56% 52% 28% 36% 40% > =70.0% WL15-L Comparative CRN Recruitment Performance - weighted WL16-L Comparative CRN Recruitment - contract commercial WL17-L Proportion of studies closing in FY on time and to recruitment target non-commercial WL18 NIHR CRF & BRC cumulative quarterly publications 2 5 13 88% 13 50% 600 137 120 0 2 17 43% 246 261 7 7 45% 424 329 Top 5 8 2 Top 10 42% 452 562 > =80% 20 Report to Trust Board in May 2021 Changes and Corrections Section Responsive Safe Safe Caring Caring KPI KPI Name Type RE29-32 Activity metrics - % of same month pre COVID-19, UHS and corporate peer average change SA7 Pressure ulcers category 2 per 1000 bed days change SA8 Pressure ulcers category 3 and above per 1000 bed days change CA11 % Patients with a disability/ additional needs reporting those needs/adjustments were met correction (total number questioned included at
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Description: 2024/25 Incorporating the quality account University Hospital Southampton NHS Foundation Trust Annual Report and Accounts 2024/25 Presented to Parliament
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UHS AR 23-24 Final

Description: 2023/24 Incorporating the quality account University Hospital Southampton NHS Foundation Trust Annual Report and Accounts 2023/24 Presented to Parliament
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Description: 2022/23 Incorporating the quality account University Hospital Southampton NHS Foundation Trust Annual Report and Accounts 2022/23 Presented to Parliament
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Annual report 20-21

Description: 2020/21 Incorporating the quality report University Hospital Southampton NHS Foundation Trust Annual Report and Accounts 2020/21 Presented to Parliament
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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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