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New volunteer initiative launched to clean up the area around University Hospital Southampton

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 pursuant to Schedule 7, paragraph 25(4)(a) of the National Health Service Act 2006 © 2021 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 29 Directors’ report 30 Remuneration report 53 Staff report 65 NHS Foundation Trust Code of Governance 81 NHS Oversight Framework 81 Annual governance statement 84 Quality report 95 Statement on quality from the chief executive 96 Priorities for improvement and statements of assurance from the board 99 Other information 153 Annual accounts 180 Statement from the chief financial officer 181 Auditor’s report 182 Foreword to the accounts 188 Statement of Comprehensive Income 189 Statement of Financial Position 190 Statement of Changes in Taxpayers’ Equity 191 Statement of Cash Flows 192 Notes to the accounts 193 5 Welcome from our chair and chief executive 2020/21 was undoubtedly the most challenging year in the history of the NHS, and we have felt the impact of the COVID-19 pandemic here at University Hospital Southampton NHS Foundation Trust (UHS) in full. Responding to this has meant there isn’t a single part of our organisation that hasn’t changed in some way over the last year and we have all had to adapt to a rapidly changing environment. Our staff have been unwavering in their dedication, hard work and commitment to keeping our hospitals running, our patients cared for, and their colleagues supported. Every single member of the UHS family has played their part. The loss of life from COVID-19 has been devastating, and at UHS we stand shoulder-to-shoulder with everyone affected by this tragedy, including the families of staff members whom we lost. We must recognise the incredible work of Southampton Hospital Charity, which has funded boost boxes, wellness rooms, a helpline and so much more to support staff at a time when their wellbeing is more important than ever. As the nationwide vaccination programme continues to offer hope of life more like pre-pandemic times, we are proud to have been at the forefront of these efforts - from being part of early research for the Oxford-AstraZeneca vaccine, to the opening of one of the largest vaccination hubs in the region on our site in December 2020. We will continue to play a key role in vaccination development by leading the world’s first clinical trial into the effectiveness of COVID-19 booster vaccines, as well as taking part in a study involving pregnant people. Our response to COVID-19 has prompted innovation and new ways of working across the Trust, to the benefit of patient experience. At the start of the pandemic we faced real challenges of capacity and increases in waiting times, which led to us working with Spire Southampton so cancer treatment and surgery could continue for patients at highest risk. We also increased the number of outpatient attendances which took place by telephone or video call, and our patient support hub was set up to provide a single point of support for patients who had been advised to shield. We are immensely proud of the record of the Trust during the pandemic, exemplified by the number of patients we were able to take into our care from well outside the local area. The Trust is in a strong financial position as a result of careful spending and efficiencies, which has allowed us to invest significantly in upgrading our estate. These improvements have seen the opening of the general intensive care unit, and the new cancer ward, which was built in just six months. These formed part of overall capital expenditure of £80 million during the year. The last year has seen us say goodbye to two members of our executive leadership team. Paula Head left the chief executive officer role in November to join the national response to COVID-19, before becoming a senior fellow at The King’s Fund. Derek Sandeman moved on from being our chief medical officer to take the same position at the Hampshire and Isle of Wight Integrated Care System. We are grateful to both for their efforts on the Trust leadership team during the most challenging of years. One of our non-executive directors, Jenni Douglas-Todd, also left the Trust to take on the important role of director of equality and inclusion with NHS England and NHS Improvement. 6 Looking ahead to the future, UHS will play a key role in the Hampshire and Isle of Wight Integrated Care System. Our commitment is to deliver services with partners through clinical networks, collaboration and integration across geographical and organisational boundaries for seamless patient care. We as a Trust board are looking forward to implementing our own five year strategy, which sets out ambitions for what we want the hospital to be in 2025, for both patients and staff. Our focus will always be on enabling world class people to deliver world class care. Peter Hollins David French Chair Chief Executive Officer 7 OVERVIEW AND PERFORMANCE Performance report Introduction from our chief executive Over the last year, the way in which the Trust has worked and performance it has achieved, has been transformed by the COVID-19 pandemic. • UHS saw a number of large surges in demand for inpatient care, and for intensive respiratory support in particular, due to COVID-19 infection rates. Our capacity to deliver intensive care had to be increased, and many of our staff moved from other services such as our elective theatres in order to meet this need for care. • We have introduced and continue to maintain a number of changes to reduce the risk of COVID-19 being transmitted, or adversely affecting patient outcomes, within the Trust. Changes have included the wearing of additional personal protective equipment by our staff (especially when caring for patients who might have COVID-19 or undertaking higher risk procedures), reducing the number of patients coming to our outpatient departments and increasing the number of telephone and video consultations, separating elective and emergency patients within our departments and regular testing of our staff and all patients on or prior to their admission to hospital for treatment. • Public concerns about safety, government restrictions and the efforts of community services actually contributed to reductions in the total number of patients who sought hospital care this year. • Treatment plans have been modified by a number of services, in partnership with patients, to reduce the risk posed by COVID-19 to those patients. This was often appropriate in those circumstances in which the normal treatment would significantly reduce the patient’s own resistance to infections. Our performance has, in many cases, been strongly influenced by these profound changes. We have responded well to the need to provide the most urgent care, and the adverse impacts on elective care have been slightly less than the average across the NHS. However, we remain very concerned by the significant increase in the numbers of patients waiting longer than they should for elective care. It will take concerted and sustained action within both the Trust and the wider NHS in order to return elective performance to levels achieved before the pandemic whilst also continuing to meet urgent care needs as the restrictions that have been implemented within our society are progressively relaxed. 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 2020/21. 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 Research (NIHR), Wellcome Trust and Cancer Research UK. UHS is consistently one of the UK’s highest recruiting trusts of patients to clinical trials and in the top ten nationally for research study volume 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 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. Over 50% of UHS services are paid for by CCGs and approximately 48% 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 diagram below provides an overview of the overall organisational structure of the Trust. Public and foundation trust members Council of Governors Board of Directors Executive Directors Division A Surgery Critical Care Opthalmology Theatres and Anaesthetics Division B Division C 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 Division D Trust Headquarters Division Cardiovascular and Thoracic Neurosciences Trauma and Orthopaedics Radiology Corporate Affairs Communications Estates, Facilities and Capital Development Finance Human Resources Informatics Patient Support Services Procurement and Supply Transformation and Improvement (‘Always Improving’) Research and Development Strategy and Business Development 11 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 2020/2021 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 describes a number 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 and innovation in 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 will set out a more detailed series of objectives to achieve and progress towards the delivery of its ambitions. In 2020/21 these objectives included: • Recovery, restoration and improvement of clinical services • Implementing the ‘Always Improving’ strategy • Restoring a full research portfolio • Continuing our focus on staff wellbeing including the long-term effects of coronavirus (long COVID) • Working in partnership with the newly established integrated care system • 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, including an estates masterplan. 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 2020/21 were that: • it would be unable to form effective partnerships that achieve networked care for patients; • it could not develop the estate in line with the ambitions set out in the strategy; • it would fail to restore and increase capacity following the COVID-19 pandemic to meet waiting times for elective care and cancer care needs; • it would fail to introduce and implement new technology for the transformation of care; • it would be unable to retain, recruit, develop and train a diverse and inclusive workforce necessary to meet the strategic goals; • it could not develop a sustainable model within the new financial regime that preserves quality care; • it would fail to provide vulnerable service users with timely and high quality and appropriate care; • it would not reach the ambition of outstanding compliance and quality standards; • it could not sufficiently engage with key stakeholders and system partners to support effective interventions and maintain the health of the local population; • it would be unable to respond to the needs of the NHS in order to deliver our strategy; • it would fail to capitalise on its relationship with the universities in Southampton and other health education providers in line with our strategy; • it would not develop innovative education and training approaches. 14 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, added to the risks facing the Trust. 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 and 78 weeks has increased significantly. While the Trust was able to recover capacity quickly between waves of the pandemic, 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 the reduction in the number of referrals from GPs during the pandemic, leading to a potential future increase in the number of patients being referred as people visit their GPs for the first time with more advanced disease. During the pandemic the Trust utilised the support available from the independent sector to continue cancer treatment and surgery for those patients at highest risk. 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 2020/21 (described in the Estates section below), the Trust also committed expenditure and commenced construction works in 2020/21 in order to be in a position to open an additional endoscopy room and four further operating theatres during 2021/22 and prepared plans for a significant expansion in ophthalmology outpatient capacity. These initiatives will contribute to improvements in elective waiting times that needed following the pandemic. Quality and compliance – The Trust continued to monitor the quality of care delivered throughout 2020/21. During the COVID-19 pandemic the primary focus became infection prevention and control, with the launch of a successful COVID ZERO campaign that saw the Trust reduce the transmission of the virus in hospital (nosocomial transmission). The Trust also achieved its annual target for reduction in Clostridium Difficile infections, however, there was one MRSA Bacteraemia during March 2021, the only such event in 2020/21. The Trust continued to develop its proactive patient safety culture during 2020/21 with changes to the way in which patient safety incidents are investigated and the approval of its Always Improving strategy, which will be launched in 2021. Reporting and investigation of incidents continued during 2020/21. Partnerships – During 2020/21, the Trust and its partners worked together very effectively to discharge patients safely and provide ongoing support to patients who had tested positive for COVID-19, to ensure patients requiring urgent cancer treatment and surgery were able to continue their treatment in the independent sector and to develop a COVID-19 saliva testing pilot with the University of Southampton and local authorities. Work to respond to the COVID-19 pandemic, however, meant that as a system we were unable to progress the Hampshire and Isle of Wight strategic plan delivery at the pace we would have wanted or had set out to achieve, particularly the development of networks. Nonetheless the application for Hampshire and Isle of Wight to become an integrated care system was approved with effect from 1 April 2021. 15 Existing networks continued to develop and improve. The Trust also became the Wessex Cancer Surgical Hub during 2020 as a result of a national initiative with the aim of maximising the number of patients receiving curative surgery. Both the Wessex Cancer Alliance and the Trust ended the year as the second highest performing among their respective peers for cancer treatment. Workforce – While additional staff were recruited to specifically assist the Trust during the pandemic, the Trust continued to recruit nurses from overseas during 2020/21 meaning that the number of vacancies has reduced compared to the position prior to the pandemic. Changes to recruitment processes were approved in 2020/21 to improve the fairness, transparency and quality of these. The Trust also continued to work with its staff networks and specific focus groups to increase diversity in leadership roles. While workforce capacity continues to be one of the biggest challenges faced by the Trust, during 2020/21 our main focus has been on supporting our staff to respond to the COVID-19 pandemic and 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 2020/21 including the opening a new general intensive care unit (GICU), a new operating theatre and a new cancer care ward, built in just six months. These were part of £80 million of capital expenditure in 2020/21. The Trust has also established a programme to reduce backlog maintenance in addition to continuing to add to and improve the environment in which services are provided to patients and the working environment for staff. 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 from page 167 of the quality report. The board of directors 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. Sustainable financial model – The Trust achieved its forecast breakeven position in 2020/21. Income was more predictable in 2020/21 as block contract arrangements were put in place in response to the COVID-19 pandemic and ensured that costs were covered. 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. 16 Summary of performance COVID-19 bed occupancy UHS has experienced two distinct peaks in inpatient care for patients with COVID-19 infection, with smaller numbers of patients continuing to receive care outside these peak times. Bed occupancy reached a maximum of 173 in the first peak in April 2020, and 322 in the second peak in January 2021. All bed types Intensive care/higher care beds 17 Emergency access through our emergency and eye casualty departments Public concerns about safety, government restrictions on the activities people were able to do, and the efforts of community services contributed to significant reductions in the total number of patients who presented to our departments. All patients presenting to the emergency department Many changes were introduced within our departments in the course of the year to ensure that emergency assessment and treatment could be provided safely, including wearing of protective equipment by staff and patients, providing care in separate areas for patients suspected or known to have COVID-19, and using rapid laboratory tests to identify infection and confirm/exclude COVID-19 as a cause. Emergency access performance (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) improved significantly in 2020/21 compared to previous years. The national target of 95% was not achieved, however, the performance of our departments compared favourably with the average for acute trusts in England. 18 Emergency access four hour performance 19 Elective Waiting times Demand We saw a significant reduction in the number of elective referrals to hospital in the early part 2020/21, though they had returned close to pre-pandemic levels by the end of the year. It is likely that this pattern relates to a range of factors including reluctance from members of the public to attend healthcare facilities at that time, changes to the ways in which primary care was accessed, and efforts made within primary and community to avoid hospital referrals needing to be made. Accepted referrals The number of patients referred to hospital with suspected cancer also reduced during 2020/21; 7% fewer patients were seen across the year as a whole, though referrals returned to pre-pandemic levels or higher from July 2020 onwards. Patients seen following ‘Two week wait’ urgent referral for suspected cancer 20 Activity UHS hospital appointments, diagnostic tests and elective admissions were all significantly reduced during 2020/21 due to the impact of COVID-19. • During periods of higher bed occupancy with COVID-19 it was necessary to significantly reduce the number of elective admissions undertaken in order that additional staff could work in intensive care. Less clinically urgent and therefore longer waiting patients were primarily those affected. • Throughout the year, additional infection prevention measures have reduced the number of patients that can be seen in each session, particularly when higher risk ‘aerosol generating’ procedures are planned, but also as a result of additional PPE being worn or to enable greater distancing of patients attending outpatient departments. UHS was offered additional capacity at local independent sector hospitals and used this effectively to minimise these adverse impacts. Approximately 30% of outpatient appointments are now undertaken by telephone or video, helping to maintain the capacity for patient care whilst reducing the infection risk for those patients and helping to maintain distancing measures for those patients still attending our outpatient departments. The graphs below show 2020/21 activity levels as a percentage of those achieved in the previous year. Elective admissions (including daycase) 21 Outpatient attendances Performance The average waiting time for first outpatient appointments has remained close to nine weeks for the majority of the year. UHS has however experienced very significant deteriorations in the waiting times our patients experience for diagnostic tests to be undertaken and elective treatment to be provided. The reduced number of new patients referred to hospital early in 2020/21 has moderated the extent of the growth in the total numbers of patients waiting, and the greatest rate of growth has unfortunately been amongst those groups of patients already waiting longest. 22 Diagnostics Our performance measures for diagnostics report on a total of 15 different frequently used tests. The waiting list is approximately 50% bigger than it was before the pandemic and stable through the second half of the year. At the end of the year 28% of patients were waiting more than six weeks to receive their investigation compared to the national target of 1%. The tests with the largest numbers of longer waiting patients include non-obstetric ultrasound, MRI and endoscopies, and further recovery will be driven through a combination of recruitment, independent sector capacity and an additional endoscopy room which opened at the start of April 2021. 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 23 Referral to Treatment Our waiting list from referral to treatment increased in size by 6% (2,220 patients) during 2020/21, rising when the recovery in referral numbers exceeded the recovery in clinical activity, the total increase in waiting list size would have been significantly higher had it not been for the significant reduction in the referrals received by the hospital especially during the early months of the pandemic. Looking forward, we anticipate referrals numbers returning to pre-pandemic levels, and being able to maintain the total size of our waiting list by delivering an equivalent number of treatments each month. 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 against this measure is now 12% worse than one year ago, at 66%. 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 24 Unfortunately, the number of patients waiting significantly longer than the 18 week target has increased at a faster rate than the size of the waiting list as a whole. The graph below shows how the percentage of patients who have waited more 52 weeks increased. The number of patients who have waited more 52 weeks increased from 40 in March 2020 to 3,419 by March 2021 (of these 445 patients had waited more than 78 weeks). Such patients often require surgical treatment, particularly in the orthopaedic, ear nose and throat and oral surgery specialities. The impact on surgical care has been greater than that in outpatients during the pandemic, and it is also more challenging to increase capacity due to the need for additional operating theatres and a combination of different healthcare professionals to work within them. UHS opened an additional operating theatre in 2020/21, and has a further four theatres scheduled to open during 2021/22, which will make a significant contribution to our capacity to treat more patients. Unfortunately, the number of patients waiting significantly longer than the 18 week target is likely to continue to grow further in the short term, due to diagnostic investigations having been progressed less quickly than usual during the pandemic, the need to prioritise our increased treatment capacity according to the clinical urgency of conditions and because our scheduled capacity increases will not be completed before the autumn of 2021. Percentage of patients waiting more than 52 weeks, between referral and commencement of a treatment for their condition 25 Cancer Waiting Times UHS has been mostly successful in maintaining the timeliness of urgent services for patients with suspected cancer through the pandemic, and our performance has been amongst the best in both the south-east and nationally. UHS prioritised the theatre and intensive care capacity we were able to provide during the pandemic in order to meet the needs of those patients with the greatest clinical urgency, used capacity offered by independent sector hospitals to supplement that available within NHS, and operated a hub through which hospitals in Wessex were able to collaborate to continue critical cancer surgery during periods of peak COVID-19 demand. 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. Whilst UHS performance remained below this level in the majority of months, our performance has been significantly better than the national average, and has improved relative to other trusts. Treatment for Cancer within 62 days of an urgent GP referral to hospital 26 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; both for the first and any subsequent treatments for cancer. UHS achieved this level on average across the year, and in the majority of months. The treatments provided are typically by means of surgery, chemotherapy/immunotherapy or radiotherapy. The most significant performance challenge this year has been in radiotherapy, where more sophisticated treatment plans improve patient outcomes but take longer to prepare, and there was also reduced treatment capacity whilst we replaced one of our ‘Linear Accelerator’ treatment machines with a new model. First definitive treatment for cancer within 31 days of a decision to treat Equality in service delivery Identifying and addressing health inequalities have been the central part of the Trust’s approach to improving the experience of care for our patients, families and carers. Over the past year, new initiatives have augmented progress on existing work to ensure there is appropriate support, due regard and recognition of those patients and their families and carers who are most at risk of poor experiences, outcomes and access to services. In 2020 we added two questions to our patient surveys, asking first if patients felt themselves to have a disability or require a reasonable adjustment, and, if yes, whether the Trust met this need. In 2020/21, the results were: TOTAL Had a disability / required a reasonable adjustment 27% Had this need met by the Trust (positive response) 95% This question was added to our major Friends and Family Test surveys as well as our local service-specific patient surveys. In June 2020 the Trust launched the sunflower lanyard scheme for hidden disabilities, participating in the national initiative to ensure that people whose disabilities are not visible are able to access further support and reasonable adjustments by means of a nationally recognised indicator (the sunflower). In 2020/21, 618 lanyards were issued with those needs recorded to ensure future reasonable adjustments are made for those individuals. 27 Carers have always been essential partners in the care that we provide, and having introduced a new post at the end of 2019 to focus solely on carer experience, this work has culminated in a Trust strategy for improving the involvement, support and experience carers have of our services. We have, over the past year, introduced carers cards, virtual peer support and carer-specific information about services while actively participating in local and regional work on carers. In January 2021 we realised our ambition of becoming an accredited ‘Veterans Aware’ hospital, with our submission of evidence being recognised as ‘strong’ and indicative of an organisation that has made great progress in helping to provide enhanced support for the armed forces community. Towards the end of 2019 we worked with the disability organisation AccessAble to produce accessibility guides for all of our services and estate. These online guides allow patients and visitors with disabilities to plan their journey and identify potential challenges to the environment. In 2020/21 our guides had 5,000 unique visits per month. One of our COVID-19 initiatives, a patient support hub, was set up in May 2020 to provide a single point of support for our patients who had been advised to shield. The service has grown and now offers support to patients and carers who are vulnerable, disabled or with additional needs. This includes coordinating community transport, arranging companions to assist with attending appointments, hosting a technology library to support those who are digitally excluded in accessing virtual appointments and information, and most recently receiving funding to pilot volunteer-led support for diabetes patients. Across the Trust, we continue to actively promote the importance of asking patients and carers about disabilities and reasonable adjustments, flagging needs on our patient administrative system to prompt our services to take proactive steps to ensure that any needs or adjustments are met on each and every visit. This has been of vital importance for meeting accessible information and communication needs. We are currently one of first trusts to pilot a new translation app that provides immediate interpretation into different languages, and we have worked closely with our communication support partners to ensure that where virtual appointments are needed, people with communication needs (BSL, foreign language) are supported to access care virtually. Our specialist nursing liaison teams continued to support access to services throughout the pandemic, ensuring that patients with dementia, with learning disabilities and autism, were supported to attend hospital where necessary. Further information about the Trust’s work in relation to equality, diversity and inclusion can be found on page 69 and pages 106 and 160 in the quality report. Going concern After making enquiries, the directors have a reasonable expectation that the services provided by the Trust will continue to be provided by the public sector for the foreseeable future. For this reason, the directors have adopted the going concern basis in preparing the accounts, following the definition of going concern in the public sector adopted by HM Treasury’s Financial Reporting Manual. David French Chief Executive Officer 28 June 2021 28 Accountability report Directors’ report Board of directors The board of directors is usually made up of six executive directors and seven non-executive directors, including the chair. Since 1 January 2021 the number of non-executive directors has been reduced by one as Jane Bailey’s reappointment as a non-executive director was deferred to allow her to lead the Hampshire and Isle of Wight saliva mass testing programme. Jane is expected to return to the board of directors in her non-executive director role by 1 July 2021. Paragraph B.1.2 of the NHS foundation trust code of governance provides that at least half the board of directors, excluding the chair, should comprise non-executive directors determined by the board to be independent. Pending the reappointment of Jane Bailey as a non-executive director, the Trust has been operating with one fewer non-executive directors than is required by the Trust’s constitution and the Trust has been non-compliant with this paragraph of the code. During this period the provisions of the Trust’s constitution that a quorum for meetings of the board of directors requires at least one non-executive director and one executive director to be present and for the chair to have a second and casting vote in the case of an equal vote continued to apply. The board of directors has given careful consideration to the range of skills and experience it requires to run the Trust. Together the members of the board of directors bring a wide range of skills and experience to the Trust, such that the Board achieves balance and completeness at the highest level. The chair was determined to be independent on his appointment and the other non-executive directors have been determined to be independent in both character and judgement. This included specific consideration of Jane Bailey’s continued independence following her role leading the Hampshire and Isle of Wight saliva mass testing programme. The chair, executive directors and non-executive directors have declared any business interests that they have. Each director has declared their interests at public meetings of the board of directors. The register of interests is available on the Trust’s website. 30 The current members of the board of directors are: Non-executive directors Peter Hollins Chair Peter graduated in chemistry from Hertford College, Oxford. Joining Imperial Chemical Industries in 1973, he undertook a series of increasingly senior roles in marketing and then general management. Following three years in the Netherlands as general manager of ICI Resins BV, in 1992 he was appointed as chief operating officer of EVC in Brussels – a joint venture between ICI and Enichem of Italy. He played a key role in the flotation of the company in 1994, before returning in 1998 to the UK as chief executive officer of British Energy where he remained until 2001. From 2001, he held various chairmanships and non-executive directorships. In 2003, he decided to return to an executive role as chief executive of the British Heart Foundation in which post he remained until retirement in March 2013. He joined Southampton University Hospital Trust as a non-executive director in 2010, became senior independent director and deputy chairman of UHS in 2014 and was appointed chair in April 2016. Trust roles: • Chair of remuneration and appointment committee • Chair of governors’ nomination committee Jane Bailey Non-executive director In 1985, Jane joined the pharmaceutical company Glaxo as a management trainee, having graduated from London University with a degree in environmental science and pharmacology. Here she rose to senior commercial vice-president, gaining experience of a broad range of disease areas across different regions of the world. She specialised in leading global research and development teams in the formation of strategies to bring new medicines to patients. She also worked to ensure that the medicines developed were supported by robust evidence demonstrating their clinical and cost-effectiveness. In delivering this she gained extensive experience of leading large diverse teams across a complex global organisation. For five years, Jane ran her own strategy development consultancy, working across a breadth of healthcare organisations. In 2017 Jane gained an MSc in public health, with distinction, at King’s College, London University. Her studies focused on how to ensure the public are engaged in development of healthcare services and how social theories can help inform effective disease prevention and management. Jane is a director of Wessex NHS Procurement Limited, a joint venture between the Trust and Hampshire Hospitals NHS Foundation Trust and a director of Healthwatch Portsmouth. Trust roles: • Deputy chair and senior independent director • Chair of finance and investment committee • Audit and risk committee member • Charitable funds committee member • People and organisational development committee member • Remuneration and appointment committee member • Wellbeing Guardian 31 Non-executive directors Dave Bennett Non-executive director Dave graduated in chemistry from the University of Southampton before entering management consulting, becoming a partner in Accenture’s strategy practice. In 2003 he joined Exel Logistics (later acquired by DHL), managing the company’s healthcare business across Europe and the Middle East. During this time, he established NHS Supply Chain, a UK organisation responsible for procuring and delivering medical consumables for the NHS in England, as well as sourcing capital equipment. Dave joined the board of Cable & Wireless as sales director in 2008. He later set up his own strategy consulting practice serving the healthcare sector, completing numerous projects in the UK and the US. Dave has also served as a non-executive director at The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust between 2009 and 2016, where he chaired the Trust’s quality committee. Dave is a non-executive director at the Faculty of Leadership and Medical Management and a director of Royal College of General Practitioners (RCGP) Enterprises Ltd and RCGP Conferences Ltd. Trust roles: • Chair of charitable funds committee • Chair of finance and investment committee (from 1 January 2021) • Audit and risk committee member (from 9 February 2021) • Quality committee member • Remuneration and appointment committee member • Chair of Trust’s organ donation committee 32 Non-executive directors Cyrus Cooper Non-executive director Cyrus Cooper is professor of rheumatology and director of the MRC Lifecourse Epidemiology Unit. He is also vice-dean of the faculty of medicine at the University of Southampton and professor of epidemiology at the Nuffield Department of Orthopaedics (rheumatology and musculoskeletal sciences, University of Oxford). He leads an internationally competitive programme of research into the epidemiology of musculoskeletal disorders, most notably osteoporosis. His key research contributions have been: • discovery of the developmental influences which contribute to the risk of osteoporosis and hip fracture in late adulthood • demonstration that maternal vitamin D insufficiency is associated with sub-optimal bone mineral accrual in childhood • characterisation of the definition and incidence rates of vertebral fractures • leadership of large pragmatic randomised controlled trials of calcium and vitamin D supplementation in the elderly as immediate preventative strategies against hip fracture. He is president of the International Osteoporosis Foundation, chair of the BHF Project Grants Committee, an emeritus NIHR senior investigator, a director of The Rank Prize Funds and associate editor of Osteoporosis International. He has previously served as chairman of the Scientific Advisors Committee (International Osteoporosis Foundation), the MRC Population Health Sciences Research Network and the National Osteoporosis Society of Great Britain. He has also been president of the Bone Research Society of Great Britain and has worked on numerous Department of Health, European Community and World Health Organisation committees and working groups. Cyrus has published extensively on osteoporosis and rheumatic disorders and pioneered clinical studies on the developmental origins of peak bone mass. In 2015, he was awarded an OBE for services to medical research. Trust roles: • Quality committee member • Remunerati
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Annual-report-24-25-final

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

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
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Annual-reports-and-quality-accounts/UHS-AR-23-24-Final.pdf

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
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Annual-reports-and-quality-accounts/Annual-report-2021-2022.pdf

UHS AR 22-23-6

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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Press release: Bowel cancer and emergency surgery survival in Southampton among best in country

Description: The rate of survival for patients undergoing bowel cancer surgery in Southampton is four times better than the national average.
Url: /AboutTheTrust/Newsandpublications/Latestnews/2019/December/Press-release-Bowel-cancer-and-emergency-surgery-survival-in-Southampton-among-best-in-country.aspx

Handling concerns and complaints policy

Description: Handling Complaints Policy, Version 13.0 Trust reference PET003 Version number 13.0 Description Policy to explain how University Hospital Southampton implements the framework for the NHS Complaints (England) Regulations 2009. It clarifies what people should expect when then complain, in accordance with Parliamentary and Health Service Ombudsman’s complaint standards. Level and type of document Target audience Trust-wide corporate policy – controlled document. Staff, patients, relatives, and carers. Author(s) (names and job titles) Policy sponsor Shona Small, Complaints Manager Jenny Milner, Associate Director of Patient Experience This is a controlled document. Whilst this document may be printed, the electronic version posted on Staffnet is the controlled copy. Any printed copies of this document are not controlled. As a controlled document, this document should not be saved onto local or network drives but should always be accessed from Staffnet. All documents must remain watermarked as ‘draft’ until they have been approved by the Expert Group. 1 Date Version control Author(s) Version Approval created committee 6.9.2024 Shona Small 6.9.2024 Experience of care committee Date of approval 10/7/24 Date next review due 10/7/27 Key changes made to document To bring in line with Ombudsman’s new complaint standard terminology. PET003 Handling Complaints Policy version 13. Issued 10.7.24 Page 1 2 Index 1 Version control ............................................................................................................... 1 2 Index.............................................................................................................................. 2 3 Introduction .................................................................................................................... 2 4 Quick References .......................................................................................................... 3 5 Scope and purpose ........................................................................................................ 3 6 Definitions ...................................................................................................................... 4 7 Details of policy.............................................................................................................. 5 8 Roles and responsibilities ............................................................................................ 15 9 Communication and training plans ............................................................................... 15 11 Document review...................................................................................................... 16 12 Process for monitoring compliance ........................................................................... 16 13 Appendices .............................................................................................................. 17 • Appendix A ................................................................................................................. 17 • Appendix B................................................................................................................. 18 • Appendix C................................................................................................................. 18 • Appendix D................................................................................................................. 21 • Appendix E ................................................................................................................. 22 • Appendix F ................................................................................................................. 23 • Appendix G................................................................................................................. 24 • Appendix H................................................................................................................. 31 • Appendix I .................................................................................................................. 33 • Appendix J ................................................................................................................. 34 • Appendix K - Audit tool to monitor policy compliance ............................................. 35 • Appendix L ................................................................................................................. 36 14 References ............................................................................................................... 36 3 Introduction The purpose of this policy is to explain how University Hospital Southampton NHS Foundation Trust (UHS) implements the statutory legal framework for the local authority, social services and National Health Service Complaints (England) Regulations 2009, and how the Trust meets the requirements of the NHS Constitution. The policy makes clear what people should expect when they complain (NHS Constitution) and supports a culture of openness, honesty and transparency (duty of candour). Trust practice is informed by the Parliamentary and Health Services Ombudsman (PHSO) Complaint Standards and Principles of Remedy, including the Scale of Injustice. The policy deals with the handling of concerns and complaints (regarding Trust services, buildings or the environment) received from patients, patient’s relatives, carers, visitors and other service users. In most circumstances the quickest and most effective way of resolving a concern or complaint is to deal with the issues when they arise or as soon as possible after this (early resolution). PET003 Handling Complaints Policy version 13. Issued 10.7.24 Page 2 In circumstances where early resolution is not possible, this policy describes the processes in place to ensure that complaints are handled efficiently and investigated thoroughly. Patient and Family Relations (P&FR) are responsible for the overall management of complaints. P&FR combines the patient advice and liaison service (PALS) and the complaint handling functions, to provide a flexible approach to resolving complaints. The policy promotes the use of people’s experience of care to improve quality. By listening to people about their experience of healthcare, the Trust can resolve mistakes faster, learn new ways to improve the quality and safety of services, and prevent the same problem from happening again in the future. The reporting and monitoring of trends, themes and lessons learnt is undertaken through divisional governance structures, quality committee and the quality governance steering group and is used to ensure compliance with commissioner, regulatory and good practice requirements. The Trust is committed to providing safe, effective and high-quality services. However, it is recognised that things can occasionally go wrong. When complaints are raised, the Trust has a responsibility to acknowledge the complaint, put things right as quickly as possible, prevent reoccurrence and identify service improvements. Written information regarding how the Trust deals with complaints will be made available in all departments, the main reception, patient support services, the Trust website and through the local Integrated Care Bureau (ICB), The Advocacy People and other patient forums. 4 Quick References None 5 Scope and purpose The purpose of the policy is to: • Outline the Trust policy on handling complaints • Describe the procedure followed to respond to complaints • Confirm the roles and responsibility associated with this process • Provide staff with guidance on how to respond to a complaint • Describe how this policy links to the National Complaint Handling Framework o Promotes a learning and improvement culture o Positively seeks feedback o Is thorough and fair o Gives a fair and accountable decision The aim is to explain how UHS implements the statutory legal framework for the local authority social services and NHS Complaints (England) Regulations 2009, meets the requirements of the NHS Constitution and duty of candour, and ensures compliance with commissioners, regulatory and good practice requirements. The aims and outcomes of this policy promote early, local and prompt resolution involving the complainant in deciding how their complaints are handled. Likewise, good complaint handling and continuous learning is endorsed throughout the policy, promoting improvements in the quality and safety of services at UHS and facilitating positive patient experiences. PET003 Handling Complaints Policy version 13. Issued 10.7.24 Page 3 Aims • To listen, to acknowledge mistakes, explain what went wrong and to consider prompt, appropriate and proportionate remedy to put things right. • To provide a consistent approach to the timely and efficient handling of complaints and establish an agreed plan with the complainant with an emphasis on early resolution, sharing learning and improving our services. • To ensure organisational openness and an approach that is conciliatory and fair to people both using and delivering services. • To respect the individual’s right to confidentiality and treat all users of this policy with respect and courtesy. Outcomes • The policy and procedure will, as far as is reasonably practical, be easy to understand, accessible, publicised in ways that will reach all service users and include information about support and advocacy services, if relevant. • All staff will receive an appropriate level of training to enable them to respond positively to complaints, and endeavour to resolve issues quickly. • The Trust will ensure that service users and carers can raise a complaint without their care, treatment or relationship with staff being compromised. • Investigations will be thorough, fair, responsive and appropriate to the seriousness of the complaint. They will also be conducted within the timescales agreed with the complainant. • The format of the response to the complaint will be agreed with the complainant. This may be verbal, by phone or at a meeting, or written, by email or letter. • The Trust will strive to resolve all complaints locally, while reminding people of their right to take the matter to the Parliamentary and Health Service Ombudsman if they are not satisfied. • Within divisions and care groups, local leadership and accountability will facilitate early resolution and ensure complaints are responded to promptly and used to initiate actions and opportunities for service and staff improvement. • Divisional governance structures will be used to ensure organisational learning from complaints and the sharing of best practice. 6 Definitions Please see Appendix A for flow chart. For the purpose of this policy, the following definition will apply: Term Everyday Conversations Early Resolution Definition Defined as every-day issues that with help can be resolved there and then (within 24 hours), without the person becoming dissatisfied and wanting to make a complaint. Defined as a more straightforward complaint that can be resolved fairly quickly (within 10 days), e.g., appointment issues, staff attitude, services not provided to expected standards. PET003 Handling Complaints Policy version 13. Issued 10.7.24 Page 4 Closer Look Defined as an expression of dissatisfaction, or a perceived grievance or injustice, that needs a closer look. Timescale for resolution is agreed with the complainant. 7 Details of policy 7.0 Details of complaints process – refer to Appendix B for process overview. 7.1 Making a complaint Service users and the public who contact P&FR to make a complaint will receive appropriate assistance from the Trust to enable them to understand the procedure and, if required, will be signposted to complaint advocacy. 7.1.1 How to make a complaint – Stage 1 Information on how to raise a concern or make a complaint can be found on both our internal and external webpages. Complaints may be made about any matter reasonably connected with the exercise of the functions of the Trust, both clinical and non-clinical. They can be made verbally, in person or via telephone, or in writing either in a letter or electronically. A complaint may be raised with any member of Trust staff, P&FR (PALS or complaints team) or the chief executive. Alternatively, the complainant may choose to address their complaint to their local commissioner, NHS England, a member of parliament or another third party, such a health advocate. 7.1.2 Who may make a complaint – Stage 1 Complaints may be made by a patient, their representative, or any persons who are affected by or likely to be affected by the action, omission or decision of the Trust. This includes family, carers, advocates, care home/nursing homes, MPs, Integrated Care Bureau (ICB) and NHS England. When complaints are made by persons other than the complainant, the need for consent will be assessed. In the above circumstances where the Trust does not intend to consider a complaint, the complainant will be notified of the reasons for this decision in writing. Complainants will be made aware of independent complaints advocacy for help and support to make a complaint. Other specialist advocacy agencies covering areas such as mental health, learning disabilities, elderly or disadvantaged groups, and independent mental capacity advocacy (IMCA) are also available for general support. Details are available from PALS and the complaints team. 7.1.3 Consent if the complainant is not the patient – Stage 1 In cases where a patient’s representative makes a complaint, consent will be obtained from the patient, or person legally responsible for the patient, for permission to access their health records for the purpose of the investigation, where required, and to release the details of the investigation to the representative. If the patient is unable to act for themselves, the nominated first contact, or an individual who holds Power of Attorney (POA) for Health and Welfare can make a complaint on the patient’s behalf and will be able to provide consent for this to be investigated and the details released PET003 Handling Complaints Policy version 13. Issued 10.7.24 Page 5 to them. If the complainant is not the patient’s nominated first contact or does not hold POA, we will inform the complainant that the nominated first contact, or POA holder needs to confirm they are happy for the outcome of the investigation to be shared with another party. If the patient has died, the Trust will respect any known wishes that had been expressed by the patient. This includes sharing the outcome of an investigation with parties who are not the nominated first contact or POA holder, but in these circumstances, we will contact the nominated first contact, or POA holder to ensure they are happy for the details to be shared. In circumstances where a complaint is made by a third party when the patient has not authorised the complainant to act on their behalf, this does not preclude the Trust from undertaking a full and thorough investigation into the concerns raised. Specifically, if the complaint raises concerns about patient safety or the conduct of staff, the relevant Trust policies will be evoked. Without consent, a response to the third party will be limited and the reasons for this explained to the complainant. 7.1.4 Complaints relating to Private Patient Services For complaints relating to private patient services at UHS, the patient should refer to the private patient policy, which includes the private patient complaint’s procedure for patients wishing to raise a concern regarding their private treatment at the Trust. 7.1.5 Complaints excluded from the scope of this policy The Trust is not required to consider the complaint in the following circumstances. However, the Trust will consider each case individually and, as soon as reasonably practicable, notify the complainant in writing of its decision and the reason for the decision. a) A complaint made by a responsible body (local authority, NHS body, primary care provider or independent provider who provides care under arrangements made with an NHS body). b) A complaint by an employee of a local authority or NHS body about any matter relating to that employment. c) A complaint which has been investigated previously or either has been or is currently being investigated by the Parliamentary and Health Service Ombudsman. d) A complaint arising out of the alleged failure to comply with a request for information under the Data Protection Act 2018, or a request for information under the Freedom of Information Act 2000. Please refer to the UHS information governance policy. e) Complaints about private treatment provided in the Trust. However, any complaint made about the Trust’s staff or facilities relating to care in their private bed will be investigated under this policy. f) Lost property claims, which are investigated and handled directly by the care group manager. However, any claim for lost property made as part of a complaint will be dealt with under this policy. g) Complaints concerning incidents or events which occurred over 12 months from the date the complaint is submitted. These are seen as out of time in the NHS complaints process – see 3.2.8. PET003 Handling Complaints Policy version 13. Issued 10.7.24 Page 6 7.2 Specific considerations when dealing with complaints 7.2.1 Complaints involving a vulnerable adult or child protection Where it is known that the complaint involves a vulnerable adult or child, the executive lead for child protection or vulnerable adults will be informed. The name nurse for safeguarding children or adults (as appropriate) will be consulted and contribute to the decision as to the most appropriate route of investigation agreed. This may not be the complaints procedure. The named nurse will support with advice on additional notifications and communication with the complainant. 7.2.2 Complaints that include a Patient Safety Incident Investigation (PSII) If the content of the complaint is only about the ‘event’, the patient safety team (PST) will lead and co-ordinate the PSIRF investigation, explain duty of candour and respond to the complainant. If there are matters that need to be investigated outside of PSIRF, agreement will be made between the PST and the complaints team about which elements of the investigation will not be covered by PSIRF and will need to be investigated through the complaints process. In these circumstances, the PST will notify P&FR of appropriate timescales for completion and release of their investigation. P&FR will then agree the timescale for the final complaint response with the complainant and will usually continue to be the main point of contact for the complainant. This is dependent on the nature of the incident and sometimes different arrangements are agreed at the patient safety case review meeting. If there is a need for a dual approach to the investigation, this will be explained to the complainant. Usually, a written response to the whole complaint (i.e., including both investigations) will be offered, explaining the extended period of time required for the Trust to respond. Where a written response is required, this will be produced by the P&FR with support from the PST. Where the investigation has uncovered significant failings in care and treatment, oversight of this process will be provided by the head of P&FR working in partnership with legal services, head of patient safety and Trust medical lead for complaints as appropriate. The complainant will also be offered the opportunity to meet with Trust staff to discuss the findings of the PSII and provide opportunity for Trust staff to respond to any outstanding queries. Alternatively, the complainant may choose to receive the outcome of the two investigations in separate written responses. 7.2.3 Complaints that are relating to Overseas Visitors If a patient considers that they have been charged incorrectly, they should raise this with the Overseas Visitor Manager (OVM) in the first instance to discuss on what basis they have been found to be chargeable and whether the provision of further documentary evidence is required. Where there continues to be a disagreement about how the Charging Regulations have been applied to a particular patient, the patient may want to seek the services of PALS. Where a patient is unhappy with the healthcare they have received, they or someone on their behalf and with their consent, can use the NHS complaints procedure as set out in this policy. The OVMs will ensure that the chargeable patients are aware of the complaint’s procedure. Complaints regarding charging will be fairly heard by an impartial person who is independent of the overseas visitors charging operation within the Trust. 7.2.4 Clinical negligence, personal injury or another claim. PET003 Handling Complaints Policy version 13. Issued 10.7.24 Page 7 If the complainant indicates a clear intention to bring legal proceedings for clinical negligence, personal injury or other claim, the use of the complaint’s procedure is not necessarily precluded. The complaints team will discuss the nature of the complaint with the litigation and insurance services department or Trust solicitor, if required), to determine whether the progression of the complaint might prejudice subsequent legal or judicial action. If there is no legal reason why the complaint should not be investigated, the complaints team will continue to investigate the complaint in accordance with Trust policy. In cases where there are legal reasons why a complaint should not be dealt with under this policy, the complaint investigation will cease. The complainant will be advised of this fact and requested to ask their legal representative to contact the claims department. The complaints team can continue to investigate any issues raised within the complaint that are not part of the claim. 7.2.5 Disciplinary or professional investigation or investigation of a criminal offence Cases regarding professional conduct where a complaint is found to be justified may require an internal disciplinary investigation to be undertaken. Such an investigation may result in the involvement of one of the professional regulatory bodies and/or police/counter fraud team depending on the nature of the allegations. Appropriate action will be taken in accordance with the Trust disciplinary procedure. In such circumstances, the complainant will be informed that a disciplinary investigation will be undertaken but that they have no right to be informed of the outcome of the investigation. Any other issues raised in the complaint which do not form part of the disciplinary or criminal investigation may continue to be dealt with under the complaints policy. 7.2.6 Coroner’s inquest In complaints involving a death that is referred to the coroner, the PST will lead and co-ordinate the investigation. This ensures clear lines of communication and investigation for clinicians and families. The complaints team will advise the family that their concerns will be investigated by the PST in preparation for the inquest hearing and that HM coroner’s office (HMCO) will endeavour to include all concerns raised. Any separate issues can be investigated by the complaints team under the NHS complaint regulations. 7.2.7 Allegations of fraud or corruption Any complaint concerning possible allegations of fraud and corruption is passed immediately to the NHS counter fraud service for action. 7.2.8 Media interest In cases where a complainant has contacted, or expresses their intention to contact, the media, the head of communications will be informed and will take appropriate action regarding Trust communication and media management. 7.2.9 Time limit for making a complaint Normally a complaint should be made within 12 months of the date on which the matter occurred, or 12 months of the date on which the matter came to the notice of the complainant. PET003 Handling Complaints Policy version 13. Issued 10.7.24 Page 8 Where a complaint is made after this time, the complaint may be investigated if the complainant had good reasons for not making the complaint within the above time limits and where, given the time lapse, it is still possible to investigate the complaint effectively and efficiently. In circumstances when a complaint is not being investigated on this basis, the complainant will be informed of the reason for that decision and advised that they may still ask the Parliamentary and Health Service Ombudsman to consider their complaint. 7.2.10 Handling of joint complaints between organisations In cases where a complaint involves more than one NHS provider, commissioner, local authority or third-party independent provider, and the complainant so wishes, the Trust will work with the other relevant organisations in seeking resolution. There is a jointly agreed protocol for the ‘Handling of NHS Inter-organisational Complaints in Hampshire and the Isle of Wight’, (Appendix C). This provides a framework for the handling of joint complaints between organisations, clarifies roles and responsibilities of organisations, enhances inter-organisation co-operation and reduces confusion for service users. The lead organisation will provide a single response on behalf of all organisations involved, ensuring that the complainant receives a seamless, effective service. The procedure for dealing with multi-agency complaints involving third party independent providers can be found at Appendix D. 7.3.11 Complaints received from nursing and care homes on behalf of their residents See Appendix E 7.3.12 Harassment and vexatious/intractable complainants Harassment Violence, racial, sexual or verbal harassment towards staff will not be tolerated; neither will language that is of a personal, abusive or threatening nature, either written or verbal. If staff should encounter this behaviour, they should seek support from their line manager and complete an adverse event form (AER). Where appropriate, the complainant will be informed in writing that their behaviour is unacceptable. Please see the UHS eliminating bullying and harassment policy. Abuse will be reported to the police. In the event that the complainant has harassed or threatened staff dealing with their complaint, all personal contact with the complainant will be discontinued. The complaint thereafter can only be pursued through written communication. Vexatious or intractable complainants In a minority of cases, people pursue their complaints in a way that can either impede the investigation of their complaint or can have a significant resource issue for the Trust and cause undue stress for staff. Unfortunately, despite patience and sympathy there are times when there is nothing further that can reasonably be done to assist them to rectify a real or perceived problem. PET003 Handling Complaints Policy version 13. Issued 10.7.24 Page 9 Judgement and discretion must be used when considering potential persistent, habitual or vexatious complainants. The criteria and procedure can be found at Appendix F and authorisation of vexatious status will be made by the head of P&FR. 7.3 Responding to complaints of patients, their relatives or carers 7.3.1 Local resolution Early resolution is the first line of investigation and response to a complaint and is undertaken within the Trust. Local resolution enables the Trust to provide the quickest opportunity for a full and thorough investigation and respond with the emphasis on a positive outcome rather than the process. The local resolution response will: • Acknowledge failures. • Apologise. • Quickly put things right when they have gone wrong. • Use the opportunity to improve services. Complaints are often raised directly to the staff involved. This is often frontline staff in wards, clinics or reception. All Trust staff, as a means of improving service provision, will welcome the complainant’s concerns or complaint positively. In most circumstances, the quickest and most effective way of resolving a complaint is to deal with the issues when they arise or as soon as possible after this (early local resolution). Upon raising a complaint, the complainant will be listened to, treated courteously and have their confidentiality assured. Discussions should include seeking an understanding of how they would like their complaint managed and what outcomes they are seeking. Every opportunity should be taken to resolve complaints at the outset and deescalate the complaint. If the staff member approached is unable to deal with the issue, they will refer the matter to a more senior member of staff on duty at the time, such as ward sister, matron, head of department or site manager. A complainant may simply require an apology, explanation, clarification of a misunderstanding or remedial action to be taken and therefore should not be automatically referred to P&FR, unless this is the complainant’s wish. 7.3.2 Early resolution All complaints are first assessed by our PALS team. If possible, they will agree with the complainant to investigate to achieve early resolution, in a sooner timescale. The PALS team will investigate via the NHS complaints process and provide a written response. 7.3.3 Taking a closer look If it is not possible to achieve early resolution, the complaint is passed to the complaints team to take a closer look. PET003 Handling Complaints Policy version 13. Issued 10.7.24 Page 10 • 7.3.3 Complaint assessment and acknowledgement On receipt of a complaint in the PALS or complaints team the first responsibility is to ensure that the patient’s immediate health needs are being met; ideally this will occur within 24 hours. In cases where a complaint that is being investigated under the NHS Complaint Regulations is received verbally, a transcript of the concerns should be made and sent to the complainant for agreement before the start of the investigation. The nature, complexity and seriousness of the complaint are assessed and graded using the complaint assessment tool (Appendix G). Any immediate actions are undertaken which may include, but are not restricted to, contact with Trust directors or divisional leads, PST, claims, communications, child protection, vulnerable adults, infection prevention and human resources. An assessment will also be made as to the requirement for consent to be sought before any investigation can proceed. Complaints are acknowledged within three working days, and this includes details of advocacy services and ‘Raising a concern or complaint’ (previously ‘Have your say’) leaflet detailing the Trust’s complaint process. Complaints received via email out of hours will receive an automated acknowledgement of receipt of email. The complaint handler will establish a relationship, offer an apology or empathy, clarify issues for investigation and seek to understand what resolution looks like for the complainant. They will also discuss and agree the management of the complaint, including any opportunity for early resolution, the timescales and the method of response. 7.3.4 Complaint investigation planning The nature and grade of the complaint will influence the level of investigation and the level of notification or cascade throughout the organisation. This is based on the complexity and severity score of the complaint (minimum, minor, moderate, major or severe) and the primary focus or professional group who are the subject of the complaint (medical, nursing, allied professionals, managerial or administrative). Higher graded complaints require prompt action, more robust investigations and may require the involvement of investigation contributors: • external to the division but internal to the organisation • external to the organisation The complaint handler will assess the complaint and plan the scope and approach to the investigation. This includes identifying the key staff required to contribute to the investigation (complaint investigation contributors). Where the contributors are adversely commented upon in the complaint, care is taken to ensure they are informed of the complaint by the complaint lead or line manager to ensure they receive support throughout the process. The complaint lead (CL) can add an additional level of scrutiny and modify or validate the complaint investigation plan prior to the start of the investigation, usually within three days. Staff directly involved in the complaint will not be allocated the role of complaint lead. 7.3.5 Complaint investigation Complaints will be thoroughly investigated in a manner appropriate to resolving the issues speedily and efficiently within the agreed timeframe. The complaint handler remains responsible for keeping the complainant up to date with the progress of the investigation and negotiates any necessary extensions to the agreed timeframe. PET003 Handling Complaints Policy version 13. Issued 10.7.24 Page 11 For all complaints assessed as ‘severe’, if appropriate, and where possible a scoping meeting will be held by the PST to identify any immediate actions and to support investigation planning. This meeting may be virtual or face-to-face, involving the complaint lead, complaint handler and care group clinical lead or matron. The complaint lead will oversee the quality and timeliness of the investigation and validate the conclusions, outcome and actions agreed for inclusion in the complaint response. On completion of the investigation the complaint handler will review the complaint investigation to ensure that it has been thorough and addresses all the issues raised by the complainant. The complaint lead will support the complaint handler to scrutinise the findings, draw conclusions, agree the complaint outcome and consider whether there is evidence of service failure or maladministration. The compliant lead will also ensure that a robust action plan is formulated to cover all upheld elements of the complaint. 7.3.6 Complaint Response When responding to a complaint staff will give a clear, balanced account of what happened based on the established facts. Staff will be open and honest when things have gone wrong and where improvements can be made. All complaints will receive a fair and honest response. The complainant may prefer to receive this via letter, email, at a meeting or as a telephone call. The latter will usually be followed up in writing or via email. The response will address all issues raised, provide a full explanation, an apology as appropriate, any decisions regarding remedy and any actions that have or are planned to be undertaken to put the matter right. Details will also be given of what actions should be taken should the complainant believe the response has not adequately answered the issues raised. Where possible, the response will be in a format suitable for the complainant, such as large font or translation into another language. The complaint handler is responsible for producing a draft response for validation by the complaint lead once all contributors have had the opportunity to comment. The written response may take the form of a complaint response letter or a letter of apology, together with a separate investigation report or recorded audio disc. A final internal quality assurance check is undertaken before sending the response letter to the CEO or delegated deputy for signing and sending out by registered mail or secure email. A main complaint category is identified with the complainant, and this is used to determine the status of the complaint on closure by the complaint handler. Where the main category is found to be upheld, the complaint is recorded as upheld. If the main category is not upheld but some or all of the remaining categories are upheld, the complaint is closed as partially upheld. 7.3.7 Remedy If a complaint is upheld or partially upheld, the Trust will decide whether the maladministration or service failure has caused an injustice (Health Service Ombudsman’s Principles of Remedy). The Trust should, as far as is possible, put the individual back into the position they would have been in if the maladministration or service failure had not occurred. If that is not possible, the Trust should compensate appropriately. PET003 Handling Complaints Policy version 13. Issued 10.7.24 Page 12 The Trust will consider suitable and proportionate financial and non-financial remedies for the complainant and, where appropriate, for others who have suffered the same injustice. An appropriate remedy may be an apology, an explanation or remedial action. Financial compensation will not be appropriate in every case but should be considered. Appropriate and proportionate financial remedy will be considered by the CGM (budget holder for the service complained about) and complaint handler in the first instance. If an agreement cannot be reached, the head of P&FR will review, make comparisons to similar cases and reach agreement for any financial remedy with the director of nursing and, where appropriate, the key internal stakeholders involved. This provides consistency in evaluating the amount of financial remedy that is fair, reasonable and proportionate to the injustice suffered. On agreement with the CGM, any financial remedy is then offered to the complainant explaining the amount, why this has been offered and who to contact to accept the offer. The governance framework includes monitoring of the decision-making processes and recording payments of financial remedy offered to complainants. This will be reported quarterly to the patient experience and engagement steering group. This policy does not relate to medico-legal claims for compensation which will be dealt with through the legal services department in conjunction with the NHSLA. 7.3.8 Re-investigation of a complaint – Stage 2 In cases where the complainant is not satisfied with the Trust response, the complaint will be re-opened, also called Stage 2. This may be because the complainant considers the initial investigation to be inadequate, incomplete or unsatisfactory, or the complainant believes that their issues have not been addressed, fully understood or new questions have been raised. The complaint will be reassessed and the issues that remain unresolved for the complainant will need to be clarified and a new complaint investigation plan agreed. The same investigative procedure will be followed. However, the Trust can decline a Stage 2 investigation if the team feel that there is nothing more to investigate, add or clarify, and believe that the Stage 1 investigation is complete. Independent advice or a second opinion may be considered on the element of the complaint that has been re-opened for investigation. Meeting with the complainant is encouraged to aid resolution of the complaint. In some circumstances, and in agreement with all parties, conciliation or mediation could also be considered. If early resolution has been completely exhausted and the complainant still remains dissatisfied, the complainant is informed of their right to go to the PHSO. 7.3.9 Stage 3: Parliamentary and Health Service Ombudsman (PHSO) & The Independent Sector Adjudication Service (ISCAS) PHSO: In cases where the Trust has been unable to resolve a complaint to the complainant’s satisfaction, the complainant has the right to refer their complaint to the PHSO for independent review. The PHSO is independent of the NHS and is appointed by the government and will undertake an independent investigation into complaints where it is considered that the Trust has not acted properly, fairly or has provided a poor service. PET003 Handling Complaints Policy version 13. Issued 10.7.24 Page 13 The Trust will fully comply with all PHSO requests for information. As appropriate, divisional management teams and directors will be notified by P&FR of any complaint that is being investigated by the PHSO, or any recommendations made by them. The PHSO can be contacted at: www.ombudsman.org.uk Parliamentary and Health Service Ombudsman Millbank Tower 30 Millbank Westminster London SE1P 4QP Telephone: 0345 015 4033 ISCAS: Is a scheme that provides independent adjudication on complaints about independent healthcare providers. ISCAS CEDR, 3rd Floor 100 St Paul’s Churchyard London EC4M 8BU www.iscas.cedr.com Telephone: 0207 7536 6091 7.4 Confidentiality and record keeping 7.4.1 Confidentiality and ensuring patients, their relatives and carers are not treated differently as a result of raising a concern or complaint Information about complaints and all the people involved is strictly confidential, in accordance with Caldicott principles. Information is only disclosed to those with a demonstrable need to know or a legal right to access those records under the Data Protection Act 2018. All data will be processed in accordance with Trust policy. Complaints will not be filed on health records but maintained in a separate case file subject to the need to record any information that is strictly relevant to their health record. Complaints must not affect the patient’s/complainant’s treatment and the complainant must not be discriminated against. Any identified discrimination will be reported to HR and managed as per Trust policies. 7.4.2 Record keeping A complete documentary record will be maintained for each complaint on the Ulysses database. This will include all written or verbal contacts with the complainant, staff involved in the investigative process and all actions taken in investigating the complaint. The complaint file is a confidential record. It will be stored securely and should be easily retrieved and understood in the event of further enquiry. In accordance with the UHS records management policy 2010, complaint files are kept and disposed of confidentially. Complaint files are retained for eight years. 7.5 Support for complainant and staff See Appendix H describing roles and responsibility of staff who can provide support. 7.3.6 Process by which the organisation aims to improve as a result of concerns and complaints being raised PET003 Handling Complaints Policy version 13. Issued 10.7.24 Page 14 Every complaint received should be regarded as an opportunity to learn and improve services. 7.6.1 Development of action plans P&FR will request a completed action report (Appendix I) from the complaint investigation contributors involved in all complaints that are upheld or partially upheld. In some cases, the actions required may already be completed and documented within the complaint response. In this situation the complaint lead should inform P&FR that a separate plan is not required, and this should be recorded on the complaints database. The complaint lead or divisional governance team is responsible for validating the action plan identified within the report. The divisional director of operations (DDO), or delegated person, is responsible for ensuring the action plans arising from concerns and complaints are completed within the agreed timescales and processes are in place for the action plan to be reviewed and monitored by the local governance groups. The DDO, or delegated, is supported by the divisional governance manager (DGM). 7.6.2 P&FR - support of learning The P&FR team will support divisional complaint information hubs, allowing real time information to be accessed by divisions and care groups as to number of complaints for each clinical area and identified key themes. Each division will have an identified lead within P&FR to support development of their individual approaches to learning and they will attend divisional and care group governance with the division. See Action Plan (Appendix I). 7.6.3 Complainant feedback The P&FR will ensure every complaint response is sent out with a patient satisfaction survey and the results are monitored, reported annually to QGSG and used to consider quality improvements. 8 Roles and responsibilities Roles and responsibilities See Appendix H describing roles and responsibilities of staff involved in resolving complaints. 9 Communication and training plans Communication plan This policy will be displayed on the Trust website and Staffnet and sent to divisional management teams to ensure dissemination throughout each division to all staff groups. An introduction to complaints is provided within the staff induction programme and further training is available via the Trust VLE portal in electronic format. Bespoke face-to-face training will be provided by the P&FR team on request to all staff groups. Monitoring of this policy by P&FR team will be used to identify areas where further training may be required. 10 Equality impact assessment (for all policies only) See Appendix L and J Equality and diversity are at the heart of our Trust values. Throughout the development of the policy, we give regard to the need to eliminate discrimination, harassment and victimisation, PET003 Handling Complaints Policy version 13. Issued 10.7.24 Page 15 to advance equality or opportunity, and to foster good relations between people who share a relevant protected characteristic (as cited in under the Equality Act 2010) and those who do not share it. As part of its development this Complaints policy and its impact on equality has been analysed and approved as being appropriate. The Policy & Guidance Team hold all equality impact assessments centrally. These are available upon request from Policy&Guidance@uhs.nhs.uk 11 Document review All Trust policies will be subject to a specific minimum review period of one year; we do not expect policies to be reviewed more frequently than annually unless changes in legislation occur or new evidence becomes available. The maximum review period for policies is every three years. The author of the policy will decide an appropriate frequency of review between these boundaries. Where a policy becomes subject to a partial review due to legislative or national guidance, but the majority of the content remains unchanged, the whole document will still need to be taken through the agreed process as described in this policy with highlighted changes. This Complaints policy will be reviewed in three years’ time in 2027. This policy will be reviewed every three years or earlier if any amendments to the NHS complaints regulations are made, or if any aspect of the policy is found to be inadequate. 12 Process for monitoring compliance The purpose of monitoring is to provide assurance that the agreed approach is being followed. This ensures that we get things right for patients, use resources well and protect our reputation. Our monitoring will therefore be proportionate, achievable and deal with specifics that can be assessed or measured. Key aspects of this policy will be monitored: Element to be monitored Lead (name/job title) Tool Frequency Reporting arrangements Compliance to NHS Complaints (England) Regulation 2009 and Parliamentary and Health Service Ombudsman’s Complaints Standards. Shona Small Measure against policies Every three years Reporting to Jenny Milner Where monitoring identifies deficiencies actions plans will be developed to address them. PET003 Handling Complaints Policy version 13. Issued 10.7.24 Page 16 13 Appendices • Appendix A Managing complaints Processing complaints in the PALS and complaints team. Complaint received into PALS & complaints team. The role of patient support officers (PSOs) and the complaint coordinator is to listen, understand concerns and risk assess situation. PSOs and/or administrator to register issue on Ulysses, consider whether consent is required, categorise concern and discuss with complainant how they would like the matter resolved. Low level to medium level of seriousness and can be resolved in 24 hours or up to 10 days Categorise as a COMPLAINT (Early Resolution) Managed by PALS manager and Patient Support Officers (PSO). • Identify actions needed. Provide feedback to care group if issues are for feedback only • Escalate any concerns to B6/B7/Matron/Consultant • Signpost to other teams/bodies where relevant, such as The Advocacy People • Investigate • Find resolution • Respond to complainant at the earliest opportunity and within 10 working days • Identify learning and share with care group Resolved – Yes • Record outcome and close case Resolved – No • Review whether complaint needs to be passed to the complaints team to take a closer look. Medium to high level of seriousness and requires investigation via the NHS complaints process. Categorise as a COMPLAINT (Taking a Closer Look) Managed by complaints team • Further risk assessment such as PST or safeguarding • Investigate in accordance with the complaints policy • Respond within agreed timescale with a Trust letter or hold complaint resolution meeting to share outcome of investigation • Identify learning and share with care group and divisional governance Resolved – Yes • Record outcome and close case on Ulysses. Resolved – No • Re-open case on Ulysses • Discuss and agree further actions or investigation plan with complainant • Respond within agreed timescale with a Trust letter or share outcome with complainant at resolution meeting Resolved – Yes • Record outcome and close case on Ulysses Resolved – No • Direct complainant to the Parliamentary and Health Service Ombudsman (PHSO) or litigation PET003 Handling Complaints Policy version 13. Issued 10.7.24 Page 17 • Appendix B Making a Complaint process There are different ways to make a complaint. It is usually easier to resolve concerns close to the time they occur by talking to the staff who are looking after you. This may be the ward manager, or matron for the department. They can discuss the things you are not happy with and will try to resolve them for you. If your concerns have not been resolved by talking to the department, you can contact the Patient Advice and Liaison Service (PALS). Their contact details are: Telephone: 023
Url: /Media/UHS-website-2019/Docs/Policies/Handling-concerns-and-complaints-policy.pdf

Annual-report-and-quality-account-2019-20

Description: ANNUAL REPORT AND ACCOUNTS 2019/20 Incorporating the quality account 2019/20 Page 2 University Hospital Southampton NHS Foundation Trust Annual report and accounts 2019/20 incorporating the quality account 2019/20 Presented to Parliament pursuant to Schedule 7, paragraph 25 (4) (a) of the National Health Service Act 2006 Page 4 ©2020 University Hospital Southampton NHS Foundation Trust Page 5 TABLE OF CONTENTS Overview and performance report Welcome from our chair A word from the chief executive Overview of the Trust Statement of purpose and activities History of UHS Our executive team structure Structure of our services Our vision and values Our priorities, key issues and risks Voluntary disclosures Equality, diversity and inclusion 92 8 9 Environmental sustainability and climate chan ge 95 Quality account 10 Chief executive welcome 101 10 11 Annual accounts 12 Statement from the Chief financial officer 183 13 Independent Auditors report 185 14 Foreword to accounts 192 Performance report Going concern disclosure 16 Reporting structure 16 Key performance indicators 18 How we monitor performance 19 Overview of performance of UHS 18 Regulatory body ratings 19 Environmental matters 23 Social, community, anti-bribery and human rights issues 23 Accountability report Members of the Trust Board 25 Trust Board purpose and structure 30 Board meeting attendance record 2018/19 31 Well-led framework 32 Finance and investment committee 34 Quality committee 33 Audit and risk committee 35 External auditors 36 Governance code 36 Performance evaluation of Trust Board and its committees 36 Remuneration 36 Countering fraud and corruption 37 Independence of external auditor 37 Internal audit service 37 Better payment practice code 37 Statement as to the disclosures to auditors 38 Disclosures 38 Income disclosures 38 Governance disclosures 38 Approach to quality governance 38 Council of Governors 41 Annual remuneration statement 51 Remuneration and appointments committee 54 Governors’ nomination committee 57 Staffing report 61 Staff survey results 65 Trade union facility time 68 Statement of chief executive’s responsibilities as the accounting officer 72 Annual governance statement 73 Page 6 OVERVIEW AND PERFORMANCE REPORT Page 7 OVERVIEW AND PERFORMANCE REPORT Welcome from our chair 2019/20 was another challenging year for University Hospital Southampton NHS Foundation Trust (UHS). Demand for our services continued to rise rapidly, partly because of the ageing of the population we are here to serve and partly because of challenges in the external environment, but also because of our ability to offer exciting innovations for a range of conditions. As a result, we were not always able to offer treatment as rapidly as we wished. A major challenge towards the end of the year was the need to prepare the Trust for the COVID-19 pandemic, resulting in the need to re-engineer services on an unprecedented scale. The response of UHS staff to these challenges has, from start to finish, been magnificent. We saw major innovation in improved patient pathways to accommodate rising demand, and the creativity of colleagues in readying the Trust for COVID-19 was truly breath-taking in its scope and energy. UHS has had a long record of effective financial management. By constantly seeking operational innovation and better value for money in procurement, the Trust has been able to generate the funds necessary to make a number of capital investments which will provide huge patient benefit in future. There has been rapid progress in our major project to refurbish and extend our general intensive care unit. Our £2.2m investment in our new urology unit was completed this year; it will transform our patients’ experiences. We have continued wherever possible to work with partners and we are delighted that work on the £5m Maggie’s Centre has started. Quite apart from the need to navigate our way through the COVID-19 crisis and into the world beyond it, the Trust needs to prepare to play its full role in the Hampshire and Isle of Wight healthcare system as it develops in a way consistent with the NHS Long Term Plan. The responsibility for this falls of course to the Trust Board and I believe that even after having had more change on the Board this year than for some time, we continue to have a strong and committed leadership team. Following the retirement of Caroline Marshall, our long-serving chief operating officer, in September 2019 we welcomed Joe Teape into the position. Joe had not been at the Trust long before we were thrust into the COVID-19 pandemic and got to grips with it impressively rapidly. During the year we said farewell to three non-executive directors (NEDs); Catherine Mason who left us to become chair of Solent Healthcare, Mike Sadler our clinical NED and Simon Porter. After a series of rigorous selection processes, we were delighted to welcome Dave Bennett, Dr Tim Peachey and Keith Evans as replacements. Simon had been both deputy chair and senior independent director (SID) and on his departure Jenni Douglas-Todd succeeded him in both roles. The work of the Board is supported, stimulated and, quite correctly, challenged by the Council of Governors (COG) whose enthusiasm is of huge value to the proper governance of UHS. All of the elections to the COG were competitive, in some cases by a multiplicity of candidates. Unfortunately, one of those vacancies resulted from the death of Edward Osmond. Although Edward had only recently been elected as a governor, he had shown huge commitment to the role and I am sure would have gone on to make a major contribution to UHS. We welcomed nine new governors and one new young governor. I look forward to working with them and all the other governors as we move through and beyond the COVID-19 world. Peter Hollins Chair Page 8 OVERVIEW AND PERFORMANCE REPORT A word from the chief executive My first full year as chief executive officer of UHS has been exciting, inspiring, and extremely rewarding but not, as you would expect, without a considerable degree of challenge! The pressures on the NHS have been well publicised as we strive to provide the highest possible standard of care at a time when demand for our services escalates rapidly. At the same time, at UHS we need to play our full part in working out how we shape and deliver the health and care provision for our community into the future. During the year we have done a great deal of work on how we turn our vision for the Trust, world-class care for everyone, into what happens on the front line every day. While the vision may be new it is built firmly on our long-standing values; patients first, working together, and always improving, which together describe who we are as an organisation. These values were central to the development of our new clinical and corporate strategy which sets out an exciting future for UHS over the coming decade. It includes how we will deliver the safest care, delivering the best outcomes, as well as how we will focus on improving the health of our population, supporting both health and wellbeing. The values also provided the basis for our CQC rating of ‘Good’ awarded during the year as were some other fantastic accolades. These included a prestigious British Medical Journal award for improving care for older patients with the development of our frailty unit and activity hub. Our women’s and maternity care at the Princess Anne Hospital was named as being among the best in the world. In addition, we adopted prehabilitation for cancer patients, a pioneering service. There are countless other examples of innovation which have sprung from the creativity and innovative spirit at UHS. Some of these have involved better outcomes for patients, some an improved patient experience and others simply lower the cost of doing things, liberating money which we can then invest in improving other services. I’d like to thank every one of our staff for creating the spirit of UHS which means that the extraordinary happens every day. The world of health and social care is changing dramatically and we continue to be integral to the Hampshire and Isle of Wight Sustainability and Transformation Partnership (STP). UHS will have a leading part to play in ensuring that, with our partners, we forge a pattern for the provision of healthcare across the local system and beyond, delivering the highest possible standards of care on an enduring basis. As we entered 2020, we began preparing to face COVID-19, the largest pandemic we have seen. Some areas of the hospital are truly unrecognisable as we have adapted to the fight against this virus. The loss of life as a result of COVID-19 has been utterly devastating and it has, I am sure, touched us all personally. It has also challenged the health and wellbeing of all our staff, but particularly our frontline staff, in a unique way. I am not sure whether I am prouder of the spirit with which our staff have responded to the challenge or of the fact that they made us by common consent one of the best prepared trusts in the country. Finally, I’d like to recognise the acts of kindness I see throughout the Trust on a daily basis. It is one of the things that has struck me the most as I have got to know this organisation and the people within it. I watch how they support one another through challenging times, how they support patients and visitors in their own time and in work time, and how they go above and beyond every day for the people they’re caring for. Every day they make me hugely privileged to lead this amazing organisation. Paula Head Chief executive officer Page 9 OVERVIEW AND PERFORMANCE REPORT Overview of the Trust Statement of purpose and activities UHS is a large teaching hospital located on the south coast of England. We have a tripartite mission to provide clinical care, educate current and future healthcare professionals, and undertake research to improve healthcare for the future. Our clinical care encompasses local acute and elective care for 680,000 people who live in Southampton, the New Forest, Eastleigh and Test Valley. We also provide care for the residents of the Isle of Wight for many services. As the major university hospital on the south coast, UHS provides the full range of tertiary medical and surgical specialities (with the exception of transplantation, renal services and burns) to over 3.7 million people in central southern England and the Channel Islands. UHS is a centre of excellence for training the doctors, nurses and other healthcare professionals of the future. We work with the University of Southampton and Solent University to educate and develop staff at all levels, including a large apprenticeship programme, undergraduate and postgraduate education. Our role in research, developed in active partnership with the University of Southampton, is to contribute to the development of treatments for tomorrow’s patients. This work distinguishes us as a hospital that works at the leading edge of healthcare developments in the NHS and internationally. In particular we have nationally-leading research into cancer, respiratory disease, nutrition, cardiovascular disease, bone and joint conditions and complex immune system problems. We are one of the largest recruiters of patients into clinical trials in the country. Over 12,000 people work at the Trust, making it one of the area’s biggest employers. We also benefit from the contributions of over 1,000 volunteers. Our turnover in 2019/20 was £912m. History of UHS The Trust has its origins in the 1900s when the Shirley Warren Poor Law Infirmary was built on the site of what is now Southampton General Hospital. In the early half of the century, the site began to expand, including the opening of the school of nursing and the creation of the Wessex Neurological Unit. In 1971 a new medical school was opened in Southampton and the 1970s and 1980s saw a significant building programme encompassing the current footprint of Southampton General Hospital, Princess Anne Hospital and Countess Mountbatten House. During the 1990s, services were increasingly centralised at the general hospital, with the eye hospital and cancer services being relocated from elsewhere in the city. The Wellcome Trust funded a clinical research facility at the hospital in 2001 and this unit remains the foundation for much of the Trust’s groundbreaking medical research. In the last decade, development has continued with the opening of the North Wing Cardiac Centre in 2006, the creation of a major trauma centre with on-site helipad and the opening in 2014 of Ronald McDonald House for the relatives of sick children. Organisationally, Southampton University Hospitals Trust was formed in 1993, creating a single management board for acute services in Southampton. Eighteen years later, University Hospital Southampton NHS Foundation Trust (UHS) was formed (1 October 2011) when Southampton University Hospitals NHS Trust was licensed as a foundation trust by the then regulator, Monitor (now known as NHS Improvement (NHSI)). Page 10 OVERVIEW AND PERFORMANCE REPORT Our executive team structure Executive team structure as at 31/03/2020 Page 11 OVERVIEW AND PERFORMANCE REPORT Structure of our services Our organisation is split into five areas, with our clinical services grouped into four divisions. Within each division there are care groups. Each division, with the exception of Trust headquarters, is led by a divisional management team consisting of: • divisional clinical director (DCD) • divisional director of operations (DDO) • divisional head of nursing/professions (DHN) • divisional research and development lead • divisional finance manager • divisional planning and business development (or strategy) manager • divisional education lead • division HR business partner • divisional governance manager (DGM) The diagram below outlines the five divisions and care groups/services within each. Each care group has a clinical lead, care group manager and matron/s for specific services as a minimum. Page 12 OVERVIEW AND PERFORMANCE REPORT Our vision and values Our vision outlines who we are and what we stand for, as well as describing the current challenges we face and our priorities for the future. It also provides an in-depth review of our three Trust values, which are summarised below: Patients first Patients and families will be at the heart of what we do and their experience within the hospital, and their perception of the Trust, will be our measure of success. Working together Our clinical teams will provide services to patients and are crucial to our success. We have launched a leadership strategy that ensures our clinical management teams are engaged in the day-today management and governance of the Trust. Always improving Our growing reputation in research and development and our approach to education and training will continue to incorporate new ideas, technologies and greater efficiencies in the services we provide Page 13 OVERVIEW AND PERFORMANCE REPORT Our priorities, key issues and risks Our goals 1. Improving patient journeys (system focus, integration) We will: • Write a strategic plan for integrated ‘front door; services to address capacity and demand mismatch and enable flow • Secure influence in primary care by establishing the hospital’s role in supporting primary care networks • Promote value-based healthcare, particularly: Introduce ‘advanced decision making’ • Redesign services to provide timely safe care and meet constitutional access trajectories • Deliver priorities relevant to UHS in the first year of the long-term plan including commissioning and long-term changes 2. Delivering value-based health and care We will: • Deliver the Trust financial plan and maximise any national funding • Prepare UHS for the new NHS financial regime • Deliver the Trust Quality Improvement plan to improve safety/experience and outcomes • Build capability for change by embedding quality improvement, innovation and transformation at a leadership level • Deliver the Cost Improvement Plan (CIP) without compromising on quality 3. Supporting health lives (prevention, wellbeing inequalities, outcomes and experience) We will: • Improve staff health and wellbeing • Improve population health, maximising the impact of UHS touch points • Develop an early warning tool to identify any deterioration in quality 4. Building an expert and inclusive workforce (diversity, engagement, leadership) We will: • Close the staffing supply gap in priority groups/services to provide high quality and timely care • Manage overall workforce cost to meet CIP challenge • Measure improvement in staff engagement by increasing participation in staff survey • Increase representation of diverse groups in leadership and decision making • Improve the staff engagement score 5. Being agile in meeting people’s needs (organisational elegance/design/flexibility) We will: • Reset organisational structure as necessary, responding to changes outlined in the NHS long-term plan • Leverage digital capability to support patient empowerment and self-care • Measure staff user satisfaction with the Trust IT systems and use this to support the digital strategy • Be agile in flexing resources, responding to fluctuating demand • Secure strategic influence by establishing UHS role in the transition from STP to ICS 6. Leading edge research, education and innovation (research and outcomes) We will: • Identify the capacity constraints to expand research and plan to address • Identify priority areas without a research base and set strategy • Improve quality and breadth of education and training programme Page 14 OVERVIEW AND PERFORMANCE REPORT The novel coronavirus (COVID-19) will continue to have a significant impact on public health, morbidity and mortality if adequate prevention and control is not in place. The Trust put rapid and robust arrangements in place early on to prepare for the potential surge in COVID-19 patients. As the government now announces the easing of the lockdown restrictions, the COVID-19 challenge continues to unfold and still represents a very significant future risk to the organization. Our response and mitigations will continue to evolve through 2020/21. Further details on our response to the COVID-19 challenge are in included in the Annual Governance Statement on page 73.. Key issues and risks 1. Inability to develop partnerships and redesign services innovatively renders the Trust unable to meet the expectations of the NHS long-term plan, our strategic plan, and sustainable elective and non-elective pathways. UHS continues to actively develop partnerships across the region and work within the Integrated Care System whilst promoting value-based healthcare and delivering priorities relevant to UHS in the first year of the longterm plan. 2. Failure to deliver regulatory requirements results in license breach and loss of local control with an enforced change in leadership, impacting on Goals 1 to 6. UHS continues to monitor progress against NHSI Performance framework at committee and Board level and build capability for change by embedding quality improvement, innovation and transformation at a leadership level. 3. Failure to achieve financial targets results in a shortfall in cash required to deliver the capital programme. A robust cost improvement programme is in place, continuously monitored through governance processes with a focus on delivery of the Trust’s financial plan. 4. Reduced access to resources compromises the quality of services. We will implement the Trust Quality Improvement plan to improve safety/ experience and outcomes. 5. Capacity and capability gaps in the workforce lead to an inability to provide safe and timely care. To mitigate this risk, we will continue to develop initiatives to improve staff health and wellbeing with proactive recruitment and retention initiatives in place. Staff engagement is monitored through staff survey and leadership and development training in place. 6. Lack of inclusion and diversity results in the failure to get the best from every individual. UHS has an equality, diversity and inclusion strategy, with established Trust networks and inclusive talent management programmes. Page 15 OVERVIEW AND PERFORMANCE REPORT Performance report Going concern disclosure After making enquiries, the directors have a reasonable expectation that the Trust has adequate resources to continue in operational existence for the foreseeable future. For this reason, they continue to adopt the going concern basis in preparing the accounts. Reporting structure As a large NHS university hospital foundation trust, UHS monitors performance within individual teams throughout the year with feedback processes in place to escalate issues to more senior management teams. At a corporate level we have an established executive reporting structure. Page 16 OVERVIEW AND PERFORMANCE REPORT Monthly Trust Board Public meeting where executive directors present high level summary to chairman and non-executive directors. Audit andrisk committee Finance and Investment committee Quality Committee People & Organisational Development Committee Trust executive committee (TEC) Review performance/issues/risks in greater depth For further detail on role of these committees please refer to the annual governance statement section. Trust Board study sessions Trust Board members meet to focus on a specific issue. Performance meetings Operational management team (led by chief operating officer) and division and care group management teams focus on individual patient and service pathways to develop improvement plans. Page 17 OVERVIEW AND PERFORMANCE REPORT Key performance indicators (KPIs) The Trust publishes a monthly integrated KPI Board report on our website which provides both the Board and the public with an overview of our performance. This report is constantly evolving as new areas of monitoring are developed and new areas of national focus become apparent. The format of the monthly report follows our six strategic goals: • Improve patient journeys • Value-based health and care • Healthy lives • An expert and inclusive workforce • Being agile in meeting people’s needs • Leading edge research, education and innovation The monthly report features the following sections: • Overview – Aggregation of commentary supporting all sections of the report • Safe • Effective • Caring • Activity • Emergency access • Referral to treatment and diagnostics • Cancer waiting times • Flow • Staffing • Research and development • Estates • Digital This report also includes summary versions of quarterly reports submitted to the Trust executive committee, which go into greater detail about patient experience, patient safety, clinical effectiveness outcomes, and infection prevention. In addition, a separate finance Board report is submitted to Trust Board on a monthly basis. The Emergency Access, Activity and Flow section has several KPIs that are relevant to the key risk of delivering the national access target. Some of the KPIs are: • Number of attendances • Time to initial assessment • Delayed transfers of care • Non-elective length of stay The Activity and Flow sections have several KPIs that are relevant to the key risk of capacity and occupancy. Some of the KPIs are: • Length of stay • New referrals • Number of attendances • Bed occupancy The Staffing (HR) section has several KPIs that are relevant to the key risk of Staffing. Some of the KPIs are: • Staff turnover • Nursing vacancies • Friends and Family Test – percentage of staff who recommend UHS as a place to work You can see full copies of the monthly report by visiting www.uhs.nhs.uk Page 18 OVERVIEW AND PERFORMANCE REPORT How we monitor performance In addition to reviewing the data submitted to the Trust Board in these papers, we have a suite of tools available to compare UHS performance to that of comparable trusts around the country. Depending on the measures being monitored, UHS has a number of peer groups to benchmark against, including other local providers, major trauma centres and university hospital teaching trusts. Each NHS trust will service a different size and type of population and will offer a slightly different range of services so it is important to understand that this benchmarking provides an initial indication of performance rather than an absolute guide to our position nationally. In 2020/21 we continue to review the National Model Hospital data as it is published from NHS Improvement. The data and ability to compare our performance has helped to highlight areas of excellent practice and areas where there is potential to improve. The Trust is engaging with the model hospital team and has a member of staff on the ‘model hospital ambassador program’, as well as reviewing areas highlighted as having potential opportunities alongside finance and operational teams. Overview of performance Improving patient journeys 2019/20 was a challenging year in which we made only modest progress against some objectives to ‘Improve Patient Journeys’, and deteriorated in performance against others. • Inpatient length of stay remained stable but didn’t reduce as significantly as we had intended. The percentage of bed days used due to ‘Delayed Transfers of Care’ to other settings increased to nearly twice the national target. This, combined with growth in non-elective admissions (2.8% YTD excluding M12), resulted in occupancy rates which often exceeded our target, and an increase in patients cared for as ‘outliers’ away from their own speciality wards. • Emergency Access Performance (patients spending less than four hours in the emergency department) remained below both the national and local targets, though performance did show modest improvement during the year. There has been a further substantial increase in the volume of emergency department attendances. • The number of ‘elective’ patients waiting for treatment, the percentage of patients waiting within 18 weeks, and also the waiting time for first outpatient appointments, deteriorated significantly during the year. This has, in part, been impacted upon by reduced availability of clinical capacity due to staff concerns about the impact of new pension/tax regulations. There are, however, good indications that service changes are being implemented to increase consultation capacity in an efficient way as we had aimed to. There has been a substantial increase in consultations provided through ‘non-face-to-face’ routes, and a small decrease in the number of more traditional face-to-face consultations. • Urgent GP referrals for suspected cancer seen within two weeks saw a substantial and sustained improvement compared to the previous year, exceeding that target. • Performance against treatment within 62 days measures also demonstrated modest improvement during the year. Significant improvement in cancer performance continues to be required in order for UHS to deliver the national targets for timeliness of treatment. Page 19 OVERVIEW AND PERFORMANCE REPORT Delivering value-based healthcare • Complaints about UHS care have remained low, with the percentage of complaints ‘closed’ within 35 days above target for the first 11 months of 2019/2020. • Pleasingly, the availability of nursing care to our inpatients (expressed as care hours per patient per day) has increased progressively through the year from 8.6 to 8.9. An active overseas nursing recruitment and induction process has supplemented domestic recruitment and training. • The Trust has formed a 50/50 joint venture company with Hampshire Hospitals NHS Foundation Trust called Wessex NHS Procurement Limited (WPL). From 1 December 2019, WPL is providing procurement, supply chain and materials management services to the Trust. The objectives of this innovative partnership include the consolidation of supplies purchases for both Trusts (combined revenue £1.4bn) to leverage better prices from suppliers and increased productivity through the elimination of previously duplicated procurement activity. Supporting healthy lives • There was very good performance on the Hospital Standardised Mortality Ratio. The standard is 100 and we are consistently below this (83 in December, results are reported nationally retrospectively). This measure includes all patients in England with the same condition and compares those who have died with those that have survived. Being below 100 is a strong indicator of good care. • We continue to receive feedback, which is largely positive, through the national ‘Friends and Family’ survey for both our inpatient and maternity care. • The Board monitors a range of quality indicators. Of these, exceeding the target number of patients infected with clostridium difficile by six is of some concern, we are pleased that the number of severe/moderate medication errors has been maintained well below our target level, and following an increase in the number of Serious Incidents Requiring Investigation (SIRI) that were reported to Board in the early part of the year both the number of SIRIs has reduced and the timeliness of investigation has significantly improved. • Staff sickness levels were on target through the summer months, but significantly in excess of this through the winter months. As a whole, this is a cause for some concern. Building an expert and inclusive workforce • Very pleasingly, nursing vacancies were reduced significantly during the year, from 18% to 15%. Though still a challenge, this supports increases in the treatment capacity we can make available in the Trust, in our ability to open additional bed capacity to reduce our inpatient occupancy rates, and increases the care hours provided per patient per day. • Turnover rates have been in excess of our target throughout the year and there has also been a reduction in the percentage of staff who would recommend UHS as a place to work, though we remain above our target of 76%. The percentage of non-medical appraisals taking place within 12 months remains below target and is declining. • We have made steady progress this year towards our target of 15% of staff at Band 7 and above being from Black and Minority Ethnic backgrounds by 2023 (above 9% in March 2020). Being agile in meeting people’s needs • 2019/2020 has seen further progress in the implementation of digital tools that enable patients and clinicians to review and discuss patient specific clinical information in new ways, for example, large increases in usage of ‘My Medical Record’ and ‘digi-rounds’, modest further progress in electronic requesting and acknowledgement of tests, and stable usage of other tools. Page 20 OVERVIEW AND PERFORMANCE REPORT Leading edge research, education and innovation • The majority of recruitment targets have been achieved during 2019/20. • In Q4 UHS ranked 13th for contract commercial study recruitment, which is the same position achieved in the previous year and thus did not achieve our target of Top 10, with a constraint on pharmacy research capacity being a contributing factor. • The proportion of commercial studies closing in the 2019/20 financial year on time and to recruitment target ended the year below the 80% target at 68%, though the year-end target for the proportion of non-commercial studies closing on time and to recruitment target was exceeded at 88% compared to 80% target. Details of UHS performance can be found in the Integrated Performance report which is available in the Trust Board papers section of our website www.uhs.nhs.uk. UHS performance is scrutinised by the Board on a monthly basis. Paula Head, chief executive officer 22 June 2020 Regulatory body ratings Single Oversight Framework NHS Improvement’s Single Oversight Framework provides the framework for overseeing providers and identifying potential support needs. The framework looks at five themes: 1. Quality of care 2. Finance and use of resources 3. Operational performance 4. Strategic change 5. Leadership and improvement capability (well-led) Based on information from these themes, providers are segmented from one to four where ‘4’ reflects providers receiving the most support, and ‘1’ reflects providers with maximum autonomy. A foundation trust will only be in segments three or four where it has been found to be in breach or suspected breach of its licence. Segmentation During 2019/20 the Trust was confirmed as being placed within segment ‘2’. This segmentation information is the Trust’s position as at 31 March 2020. Current segmentation information for NHS trusts and foundation trusts is published on the NHS Improvement website. Finance and use of resources The finance and use of resources theme is based on the scoring of five measures from ‘1’ to ‘4’, where ‘1’ reflects the strongest performance. These scores are then weighted to give an overall score. Given that finance and use of resources is only one of the five themes feeding into the Single Oversight Framework, the segmentation of the Trust disclosed above might not be the same as the overall finance score here. The Trust was on track to deliver a use of resources score of ‘2’. However, as a direct result of COVID-19 our staff were unable to take their full complement of annual leave. The Trust was required Page 21 OVERVIEW AND PERFORMANCE REPORT to allow for this additional cost, which was an unfunded cost pressure allowable by NHS Improvement. This had the impact of moving the distance from financial plan score to a ‘4’ and subsequently the overall use of resources score to a ‘3’. Area Financial sustainability Financial sustainability Financial sustainability Overall scoring Metric Capital service cover Liquidity Income and expenditure margin Distance from financial plan Agency spend Q1 Q2 Q3 Q4 Year 3 3 2 2 2 1 1 1 1 1 3 1 1 1 1 1 1 2 4 4 1 1 1 1 1 2 1 2 3 3 Care Quality Commission ratings: Overall rating for this trust Are services at this trust safe? Are services at this trust effective? Are services at this trust caring? Are services at this trust responsive? Are services at this trust well-led? Good Requires improvement Outstanding Good Requires improvement Good In December 2018, the CQC inspected four core services; urgent and emergency care, medicine, maternity and outpatients. It also looked at management and leadership, and effective and efficient use of resources. The CQC report (published on the 17 April 2019) rated the Trust as ‘good’ overall and ‘outstanding’ for providing effective services. All sites and services across the organisation are now rated as ‘good’ in the effective and caring domains, with Southampton General Hospital rated as ‘outstanding’ in these areas. The Well-Led section of this report provides further details of the inspectors’ findings. “Our inspectors found a strong patient-centred culture with staff committed to keeping their people safe, and encouraging them to be independent. Patients’ needs came first and staff worked hard to deliver the best possible care with compassion and respect. Inspectors saw many areas of outstanding practice, with care delivered by compassionate and knowledgeable staff. Several teams led by example with a continuous focus on quality improvement. The Trust did face some challenges especially with the ageing estates. Some patient environments were showing significant signs of wear and tear – but again staff were doing their utmost to deliver compassionate care”. Dr Nigel Acheson Deputy chief inspector of hospitals (South) Page 22 OVERVIEW AND PERFORMANCE REPORT Environmental matters We recognise that the Trust’s business has an impact on the environment. As a large hospital, we undertake a wide range of activities and use a large amount of resources. We are committed to environmental sustainability and consider it as part of the business culture. We continue to invest in energy saving initiatives and staff awareness campaigns that focus on promoting sustainability. We acknowledge that reducing waste and minimising the consumption of scarce resources is consistent with financial sustainability. Our sustainability disclosure section on pages 86 and 95 provides greater detail on the steps we are taking to reduce our activities’ impact on the environment. Social, community, anti-bribery and human rights issues We recognise our responsibilities under the European Convention on Human Rights (included in the Human Rights Act 1998 in the UK), which are relevant to health and social care. These rights include the: • right to life • right not to be subjected to torture, inhuman or degrading treatment or punishment • right to liberty • right to respect for private and family life The Trust is committed to ensuring it fully takes into account all aspects of human rights in our work. At University Hospital Southampton we value our reputation for top quality care and financial probity and conduct our business in an ethical manner. The Bribery Act 2010 was introduced to make it easier to tackle the issue of bribery which is a damaging practice. Bribery can be defined as ‘giving someone a financial or other advantage to encourage them to perform their duties improperly or reward them for having done so’. To limit our exposure to bribery we have in place an Anti-Fraud, Bribery and Corruption Policy, a Standards of Business Conduct Policy and a Freedom to Speak Up (formerly Raising Concerns) Policy. These apply to all staff and to individuals and organisations who act on behalf of UHS. We also employ a local counter-fraud specialist who will investigate, as appropriate, any allegations of fraud, bribery or corruption. The success of our anti-bribery approach depends on our staff playing their part in helping to detect and eradicate bribery. Therefore, we encourage staff, service users and others associated with UHS to report any suspicions of bribery and we will rigorously investigate any allegations. In addition, we hold a register of interest for directors, staff, and governors, and ask staff not to accept gifts or hospitality that will compromise them or the Trust. The Board of Directors carries out its business in an open and transparent way. We are committed to the prevention of bribery as well as to combating fraud, and expect the organisations we work with to do the same. Doing business in this way enables us to reassure our patients, members and stakeholders that public funds are properly safeguarded. There are no important events since the year end affecting the Foundation Trust. No political donations have been made. The Trust has no overseas branches. Page 23 OVERVIEW AND PERFORMANCE REPORT Page 24 ACCOUNTABILITY REPORT Members of the Trust Board Board member Name Title Paula Head Chief executive officer David French Deputy chief executive officer and chief financial officer Gail Byrne Director of nursing and organisational development Biography Paula joined the Trust as chief executive in September 2018, having been chief executive at the Royal Surrey County NHS Foundation Trust in Guildford and before that at Sussex Community NHS Foundation Trust. She began her career as a pharmacist working in the community, in hospitals and at health authorities before moving into general management and her first board position at Kingston Hospital. Since then she has spent time on the boards of commissioners and providers, including director of transformation at Frimley Park Hospital NHS FT. Paula lives in Hampshire and has a daughter studying medicine at the University of Southampton. David joined the Trust in February 2016 and served as interim chief executive officer from April to September 2018. He read Economics and Social Policy at the University of London before joining ICI plc, where he qualified as a chartered management accountant. David has extensive healthcare experience from the pharmaceutical industry, mostly Eli Lilly and Company where he held many commercial and financial roles in the UK and overseas. He joined the NHS in 2010 as chief financial officer of Hampshire Hospitals NHS Foundation Trust. He also serves as a non-executive director for Vivid Housing Limited, a social housing provider across Hampshire and the Solent. Gail joined the Trust in 2010 as deputy director of nursing and head of patient safety. Prior to this, she has worked at the Strategic Health Authority as head of patient safety, and director of clinical services at Portsmouth Hospital. Gail has also worked in Brisbane, Australia as a hospital Macmillan nurse, and as general manager of a special purpose vehicle company for the private finance initiative at South Manchester Hospitals. Declarations Daughter is a medical student at University of Southampton; Member of Hampshire & Isle of Wight Sustainability and Transformation Partnership Executive Delivery Group Non-executive director and chair of audit and risk committee, Vivid Housing Limited; Director, UHS Estates Limited, a wholly-owned subsidiary of UHSFT; Director, Southampton Commercial Estates Development Partnership (CEDP) Project Company Limited, a joint-venture company owned 50/50 by UHSFT and Prime plc; Member of Hampshire & Isle of Wight Counter Fraud Board; Member of Hampshire & Isle of Wight Sustainability and Transformation Partnership Capital Planning Panel; Director of Wessex NHS Procurement Limited (WPL), a joint venture company owned 50/50 by UHSFT and Hampshire Hospitals NHS Foundation Trust (from December 2019) Husband is a consultant surgeon at UHS; Daughter is a midwife at UHS (from March 2019) Dr Derek Sandeman Joe Teape Medical director Chief operating officer Derek was appointed to the Trust as a consultant physician in 1993 and went on to develop a regional Director of UHS Pharmacy Limited, endocrine service. Throughout his career he has had a wholly-owned subsidiary of extensive clinical leadership experience, most recently serving eight years as clinical director. Derek’s leadership roles have also included programme director for postgraduate education and the Wessex Endocrine Royal College representative. He has a strong history of wider system engagement, working collaboratively with partners to improve systems resilience and pathways. UHSFT; Member of Hampshire & Isle of Wight Sustainability and Transformation Partnership Clinical Executive Group Joe joined the Trust as chief operating officer in December Nil 2019. Previously he was deputy chief executive and director of operations of a large health board in Wales which managed integrated services across three counties including four district general hospitals as well as mental health, learning disability and community services. Prior to this, Joe worked in director roles across finance and strategy within provider acute trusts across the south west of England. Joe is passionate about providing leadership and support for all staff, whatever their profession, and contributing to excellent patient care. He is committed to open and ongoing engagement with the general public and often uses social media to engage with colleagues and with those who have an interest in healthcare. Page 25 ACCOUNTABILITY REPORT Non-executive directors Name Title Peter Hollins Chair Dr Tim Peachey Non-executive director David Bennett Non-executive director Biography Declarations Peter graduated in chemistry from Hertford College, Chair of CLIC Sargent Cancer Care Oxford. Joining Imperial Chemical Industries in 1973, for Children (a company limited by he undertook a series of increasingly senior roles in guarantee) (until December 2019); marketing and then general management. Following Council member of University of three years in the Netherlands as general manager of Southampton ICI Resins BV, he was appointed in 1992 as chief operating officer of EVC in Brussels – a joint venture between ICI and Enichem of Italy. He played a key role in the flotation of the company in 1994, returning in 1998 to the UK as chief executive officer of British Energy where he remained until 2001. From 2001, he held various chairmanships and non- executive directorships. In 2003, he decided to return to an executive role as chief executive of the British Heart Foundation in which post he remained until retirement in March 2013. He joined Southampton University Hospital Trust as a non- executive director in 2010, became senior independent director and deputy chairman of UHS in 2014, and was appointed chair in April 2016. Tim qualified as a doctor from Kings College Hospital Director, TP Medcon Ltd; Clinical School of Medicine in 1983. For nearly 20 years, he Safety Officer, Block Solutions Ltd; worked as a consultant anaesthetist at the Royal Free Non-executive director and Quality Hospital in London, specialising in pancreatic cancer Committee chair, Isle of Wight NHS surgery, liver surgery and liver transplantation. He also Trust developed an interest in medical leadership and management and has held positions such as clinical director, divisional director and medical director at the Royal Free. In 2012, Tim moved into full-time management as chief executive of Barnet and Chase Farm Hospitals NHS Trust until its acquisition by the Royal Free. He then worked as the London associate medical director at the NHS Trust Development Authority before moving to Barts Health NHS Trust as improvement director and subsequently became deputy chief executive. Tim now holds two NHS non-executive posts. In addition to his role at University Hospital Southampton, Tim also serves on the board for Isle of Wight NHS Trust as deputy chair. He is a practicing mediator specialising in the healthcare sector. He also consults for companies in the medical information technology industry. Dave graduated in chemistry from the University of Director, Davox Consulting Limited; Southampton before entering management consulting, Non-executive director, Faculty of becoming a partner in Accenture’s strategy practice. Leadership and Medical In 2003 he joined Exel Logistics (later bought by DHL), Management (from November managing the company’s healthcare business across 2019); Director Royal College of Europe and the Middle East. During this time, he General Practitioners (RCGP) established NHS Supply Chain, a UK organisation Enterprises Ltd and RGCP responsible for procuring and delivering medical Conferences Ltd (from November consumables for the NHS in England, as well as sourcing 2019) capital equipment. Dave joined the board of Cable & Wireless as sales director in 2008. He later set up his own strategy consulting practice serving the healthcare sector, completing numerous projects in the UK and the US. Dave has also served as a non-executive director at The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust between 2009 and 2016. He chaired the Trust’s quality committee. Page 26 ACCOUNTABILITY REPORT Board member Name Title Jenni DouglasTodd Senior independent director/deputy chair (from 01/02/2020) Biography Jenni is a former chief executive of Hampshire Police Authority and the office of the Hampshire police and crime commissioner. After beginning her career in the probation service, she was headhunted into the civil service, at the Home Office, where she spent four years before becoming director of policy and research for the Independent Police Complaints Commission. In the latter role she was responsible for establishing governance of the new police complaints system. She then spent two and a half years as a resident twinning adviser for the UK, based in Turkey to help set up a law enforcement complaints system before taking up the role of chief executive of the county’s police authority. During her three years in the post, she supported the authority in developing effective governance processes to increase accountability and transparency. She also helped the organisation deliver cost-savings whilst still improving performance and developing closer working relations with neighbouring forces. Declarations Independent chair, Dorset Integrated Care System. Managing director, Diversa Consultancy Limited; Member of the Judicial Conduct Investigative Office; Nonexecutive director, Hampshire Cricket Board; Trustee, NACRO; Member of English Cricket Board’s Regulatory Committee. Professor Non-executive Cyrus director Cooper In 2012, she became chief executive and monitoring officer for the Hampshire police and crime commissioner, where she led the development of the office’s vision, mission, values and organisational strategy. She took on the role of investigating committee chair for the General Dental Council in 2014 and, in April that year, founded the Diversa Consultancy, which supports organisations with changes in business, culture and behaviour. She is also a member of the Judicial Conduct Investigating Office, a public appointment. Cyrus Cooper is professor of rheumatology and director of the MRC Lifecourse Epidemiology Unit. He’s also vicedean of the faculty of medicine at the University of Southampton and professor of epidemiology at the Nuffield Department of Orthopaedics (rheumatology and musculoskeletal sciences, University of Oxford). He leads an internationally competitive programme of research into the epidemiology of musculoskeletal disorders, most notably osteoporosis. His key research contributions have been: • discovery of the developmental influences which contribute to the risk of osteoporosis and hip fracture in late adulthood • demonstration that maternal vitamin D insufficiency is associated with sub-optimal bone mineral accrual in childhood • characterisation of the definition and incidence rates of vertebral fractures • leadership of large pragmatic randomised controlled trials of calcium and vitamin D supplementation in the elderly as immediate preventative strategies against hip fracture. Director and professor of rheumatology, Medical Research Council (MRC) Lifecourse Epidemiology Unit; Vice-D
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UHS Our People Strategy 2022 - 2026

Description: OUR PEOPLE STRATEGY 2022 to 2026 CONTENTS 05 Foreword by Steve Harris – chief people officer 06 Our strategic framework 07 Always Improving 08 Insights from the UHS family 10 The National NHS People Agenda 12 Our key strategy goals 14 The collaboration between our strategic pillars 18 What are we aiming for? 22 How will we do this? 24 Time horizon 26 Measuring success 30 Governance and oversight 32 Appendix 1 – Insight work 35 “HEALTH, SAFETY AND WELLBEING, COMPASSION AND INCLUSION HAS NEVER BEEN MORE IMPORTANT. THE PANDEMIC HAS LEFT THE NHS WITH CRITICAL CHALLENGES IN EMERGENCY AND ELECTIVE DEMAND” 06 FOREWORD BY STEVE HARRIS – CHIEF PEOPLE OFFICER The Coronavirus pandemic has fundamentally shifted the way people across the world think, act and what they value. Our people at UHS have worked relentlessly through challenging conditions over this time. They are our greatest asset and, as we move into our new future, their health, safety and wellbeing, compassion and inclusion has never been more important. The days of competition for resources, for patients, and for people are over as the new world of healthcare places collaboration at its core. Working as part of the Integrated Care System (ICS) will shape and determine our future workforce planning and success. As one of England’s largest acute teaching trusts our ongoing partnership with the University of Southampton will also be a key component to recruitment and ongoing education opportunities. We will also be driven more from the central NHS approach to people leadership. With a regularly evolving national People Plan, and a new blueprint for how the Human Resources (HR) and Organisational Development (OD) profession will operate over the next 10 years. In this context the Trust developed its 5 Year Strategy – World Class People delivering World Class Care – guided by the principles of our Trust Values: Patients First, Always Improving and Working Together. One of its pillars is ‘World Class People’, our strategy for our UHS family for the next 5 years. Its success is interwoven with the wider ambitions for research and development (R&D), patient outcomes and experience, creating sustainable foundations for our future and delivering on the integrated networks agenda. A strategy for our 13,000 people in the UHS family is a big challenge. We face national and international shortages of talented people, the conditions under which our people work in are not always ideal, and people have lacked time and space to develop and grow. Our people strategy is designed to give us light, give us hope, and provide a roadmap for achieving our World Class People ambition. Steve Harris Chief People Officer 05 OUR STRATEGIC FRAMEWORK Collectively, our Vision, our Mission, our strategic themes and our Values form our strategic framework. UHS Strategy 2021-2025 World class people delivering world class care Together, we care, innovate and inspire Our vision: What we want our organisation to become by 2025; the tomorrow we are all working for Our mission: Who we are and what we do, shaping our culture and informing our objectives Outstanding patient outcomes, safety and experience Pioneering research and innovation World class people Integrated networks and collaboration Foundations for the future Our strategic themes: Our key themes for the next 5 years to deliver our vision PATIENTS FIRST WORKING TOGETHER ALWAYS IMPROVING Our values: The DNA of who we are Our approach is underpinned by our systematic approach to quality improvement at every level, facilitated by the implementation of our always improving strategy. Our vision of ‘World Class People, delivering World Class Care’ is underpinned by our constant commitment to making ourselves even prouder tomorrow than we are today of the outstanding patient care, inclusive culture, spirit of teamwork and collaboration (both within and outside our organisation). That commitment is embodied in our determination to always improve which directs how we do things at UHS. We call it THE UHS WAY. The thread that brings everything together and provides a unifying measure of our progress towards achieving our corporate vision. The people strategy will deliver its part by enabling our people to thrive, excel and belong. 0137 INSIGHTS FROM THE UHS FAMILY Our people strategy is based on feedback and insights. Using a series of techniques and interventions, over 1,500 staff shared their experiences with us. This, coupled with our annual Staff Survey results, pulse surveys, and our social media insights and engagements, gave us a rich picture of what our people feel The UHS Way means to them. OD / Wellbeing initiatives Corporate strategy engagement events Staff networks and staff partnership Insight from digital channels IN SUMMARY THESE THEMES TELL US THAT OUR PEOPLE: • Want the time to ensure they can deliver their best care for our patients. • Are proud to be part of a leading teaching hospital with access to research. • Believe that inclusion and belonging is important. • Want health and wellbeing to always be a key priority. • V alue time for personal and team development and are frustrated they cannot always get this. • Were energised by the creativity and speed of decision making that was unleashed during the first wave of COVID. • Are strong advocates of UHS. • Believe that kindness, civility, and compassion are crucial. • Are concerned about the current and future pressure on UHS and the NHS. • Want better rest facilities, improved digital people systems, and a better work environment. • Want to ensure they have fair and equitable access to development and growth to be their best, whatever their background or stage in life. Insight work in Appendix 1 09 THE NATIONAL NHS PEOPLE AGENDA In 2020, The National NHS People Plan was published. This focused on 4 key areas and was underpinned by the People Promise. Together, the People Plan and People Promise are grounded in inclusion, belonging, growing and developing our people, and embracing new and innovative ways of working. In November 2021, The Future of HR and OD in the NHS was published. Following detailed consultation with stakeholders across the service and acquiring expert advice from the Chartered Institute of Personnel and Development, and Lancaster University, the reports set the blueprint for the delivery of people services in the NHS for the next 10 years. WHAT DOES THIS MEAN FOR UHS? The national direction of travel aligns well with the 5 Year Strategy for UHS. It meets our ambitions, matches the insight from our own people, and provides a platform to continue to transform people practices in our organisation. It aligns to our values, particularly a goal to ensure we are Always Improving through ‘The UHS Way’. It matches our collective ambitions to ensure inclusion, wellbeing, belonging and compassion are at the heart of our people experience. The forward plan of the NHSI People Directorate will mean, over time, our individual approach to strategy will be driven by central NHSI, and our ICS, rather than organisational goals. Our progress against national people priorities will be measured through the ICS, and NHSI regional teams. We will review and refresh our people priorities at UHS as the emergent national review begins to be implemented. The people directorate at UHS will align activities with the emerging national agenda which will include: • Enhancing our digital people offerings to improve experience and increase productivity. • Work with our partners in the ICS to build capacity and capability at scale across NHS. • D eliver the continued development of this in the people profession at UHS, ensuring we continue to recruit, retain, and grow a values-driven, agile and innovative team. • A ligning to national frameworks and policies developed as standardisation increases across the NHS. • Strengthening further our partnership with the University of Southampton (and other education partners) to deliver our shared ambitions in education, workforce development and enhanced career opportunities. 11 OUR KEY STRATEGY GOALS To achieve our ambition of World Class People our strategy sets out 3 key areas of focus. These will inform our intention to grow our UHS family to: 1. T HRIVE by looking to the future to plan, attract and retain great people and to ensure every area is resourced to meet demand. Working with our education partners, we will invest in opportunities for people to nurture and grow their skills, as well as work with them to grow our future workforce. We will offer flexible careers and make the best use of technology to ensure we plan and deploy our people to provide safe, high quality care. 2. E XCEL within an organisation where forward-thinking people practices are delivered at the right time and where team structures, culture and environment are all designed to support wellbeing and develop potential. We will deliver progressive opportunities for individuals to develop their knowledge and skills to become their best selves. We will recognise and reward our people for the great work they do in well-designed roles that provide the freedom to innovate and improve. 3. B ELONG in a compassionate, inclusive and welcoming environment that values and supports every individual, both personally and professionally. We will ensure that every person feels free and comfortable to bring their whole selves to work, safe in the knowledge that they are welcomed, respected and represented. These 3 principles will guide our activities, allocation of resources, and the management of our capacity and capabilities. 15 THE COLLABORATION BETWEEN OUR STRATEGIC PILLARS World Class People is critical to the delivery of the four other strategic pillars in our 5 Year Strategy. Our people, and the innovation, quality, motivation, and care they provide, is critical to driving our strategy forward. The co-dependency and collaboration between pillars is critical to success. • Recruiting, retaining, and developing compassionate, inclusive people. • F air and Just culture – learning from sucesses and improving from errors. • Caring for our people so that they can care for others. • H arnessing the power of our diversity to improve our patient experience. • A ttracting and retaining the best clinical minds to UHS. • Supporting time and space for innovation in all our professions. • Strong partnership with the University of Southampton in the people space. • People agility and flexibility across organisational boundaries. • Seamless movement between Trusts. • B uilding people capacity at scale in the ICS. • S tandardisation of roles, terms, policies across the ICS. • A deeper partnership between the NHS, social care, and third sector to meet people challenges. • Sustainable, fair, flexible employment to grow opportunity. • Building social purpose. • Growing our future workforce. • Improving health and wealth through great employment. • Productivity and value for money through people practices. • A chieving net zero through the engagement, energy, and passion of our people. • P roviding and maintaining a fit-for-purpose estate and environment for our people. 17 “THE WORLD CLASS PEOPLE STRATEGY IS ABOUT GROWING AND DEPLOYING THE WORKFORCE OF TODAY AND THE FUTURE. A THRIVING COMMUNITY, DELIVERING WORLD CLASS PATIENT CARE AND PEOPLE SERVICES” WHAT ARE WE AIMING FOR? AREA OUR GOALS Meeting demands through innovation, focus on people, and development of talent: • P LAN AND INOVATE – Design a workforce plan which aligns to the ambitions in our Digital Strategy and Always Improving Strategy, where we develop roles for the future, aligned to transformation and emerging clinical practice. As key collaborators with our ICS partners we will focus on workforce capacity, growth and sustainability now and in the future at scale. • EDUCATE – Work with the University of Southampton, our wider education partners, and ICS colleagues to grow our future professionally qualified workforce capacity, specifically through more qualified nurses, Allied Healthcare Professionals, scientific and technical roles, and junior doctors. • ATTRACT – Develop a comprehensive inclusive talent attraction plan which will: • Expand our overseas recruitment. • Increase our apprenticeships with an ambition to grow our own. • Offer career pathways and progression routes. • Ensure succession plans for all leadership roles and critical/hard to recruit roles. • Work with people in local communities to attract future talent into UHS and the wider NHS.➢ • E nsure a diverse and representative UHS leadership and workforce community. • Focus on a flexible employment offering to meet diverse needs. • Maximise our opportunities as a university teaching hospital. • INSIGHT – We will develop our people analytics, creating insights and intelligent dashboards to enhance the rigour of decision making. • L EARNING – Transforming professional learning and development to a more inclusive, discovery-based approach, self-driven development of knowledge, skills and experience, supported by leading educational provision. • AGILE DEPLOYMENT – Agile deployment; maximising technology and workforce systems to ensure skills and experience are in the right place at the right time. Greater flexibility to work at UHS and through our partner organisations in the ICS seamlessly. • CONTINGENT WORKFORCE – Ensure maximum value and opportunity from our contingent workforce focusing on agency, bank and our volunteers. AREA OUR GOALS • HEALTH AND WELLBEING – The health and wellbeing of our people is a top priority. We will ensure we consider the impact of wellbeing initiatives and activity to promote and sustain wellbeing and a healthy work environment. We will focus on what really makes a difference in supporting people to stay well and healthy, and strive to achieve these. • T HE UHS CAREER PROMISE – Everyone has a career plan who wants it. We will refresh our appraisal and performance system to ensure continual feedback, and clarity of purpose for all roles, connecting people to The UHS Way. We will link our careers opportunities and support to diversity, including different parts of peoples life experience and expectations. • LISTEN AND ACT – We will listen to our diverse UHS family, integrated team members, partners and communities to develop a deep understanding of how they are treated and what it feels like to work at UHS, and to respond accordingly. We will seek to make year-on-year improvements in the annual NHS Staff Survey and continue to raise participation. • REWARD AND CELEBRATE – We will reward people for the amazing work they do. We will celebrate success and raise the profile of our people and teams regionally and nationally. We will ensure our reward and celebration reflect our amazing diversity with the UHS family. • A WHOLE EMPLOYMENT APPROACH – We will major on the “UHS experience”, we will delight people from our advert, to our induction, and right the way through their UHS journey. If they leave, we will ensure that is positive too. • GREAT JOBS, WELL DESIGNED – We want to get our job design right. We will simplify our processes and structures and ensure our jobs allow innovation and creativity. • N URTURING TALENT – we will grow and nurture diverse talent from all parts of the UHS family. We will enable this talent to flourish at UHS and across our partners in the ICS. • OUR EMPLOYER BRAND – We will generate a compelling offer for potential candidates through investment in our employer value proposition and brand. • OUR ENVIROMENT – We will develop our physical estate to improve the working, learning and rest environments for our people, including meeting diverse needs. • PARTNERSHIPS – We will ensure those we commercially partner with, align with our values and our expectations on the importance of the people agenda. • SAFETY – We will continue to make every effort to ensure our staff are not harmed, injured or become ill whilst at work; we will develop and implement a safety competence framework of knowledge and skills for staff in order to reduce the number of injuries and ill-health that occur as a result of our activities. • RESEARCH AND DEVELOPMENT – We will develop roles across our organisation that support our research for all strategy. 21 AREA OUR GOALS • L IVING OUR VALUES – We will aspire to live our values every day through our interactions and decision making. We will review the behaviours that underpin our values, and ensure they remain true to our strategies and the driving force behind our aspired culture. • LEADING THE UHS WAY – We will continue to invest in our leaders and managers, recognising the impact they have on our people. We will create a variety of leadership programmes, interventions and offerings which will enable leaders to develop their skills for the future and equip them to deal with current challenges. Our leaders will focus on improvement in all that they do. • B EING YOU AT WORK – We will focus on creating the conditions where people can thrive and be their best self at work, where difference is celebrated and respected. We will drive the ethos of inclusion and belonging through all our strategies, and leadership development and culture programmes. We will collaborate with external partners who will assist us in this ambition. • JUST AND LEARNING CULTURE – We will develop our culture of civility where people can confidently speak up, learn from errors and improve services. We will train more people in appreciative inquiry techniques so we can identify what works well and replicate success. • REPRESENTING ALL OUR PEOPLE – We will take positive action to develop people from underrepresented groups with an aim of diversifying leadership at all levels. • OUR NETWORKS GUIDING US – We will support our Staff Networks to grow and thrive, ensuring people can get involved, share their lived experiences, and input in to decision making. • BELONGING FOR ALL – We will tackle inequality in the workforce driven through a progressive and bold Diversity and Inclusion Strategy, and we will not tolerate bullying, harassment and discrimination towards our people. • A FAMILY OF ALLIES AT UHS – We will focus on allyship and offer bystander training for all our leaders and people. 23 HOW WILL WE DO THIS? How we approach the implementation of the people strategy is key. We will deliver our five year strategic goals through: Driven by our values Our approach to delivery will be driven by our 3 Trust values. We will keep Patients First, Working Together, and Always improving at the centre of how we work. We will listen to our people who will help us to refresh and evolve the values underpinning meaning and behaviours to meet our desired culture and strategic aims. Insight led Our approach will be driven by the insight of people, by national and local intelligence, and by industry standard practice on what works. Inside out approach Collaboration at UHS The brand of UHS will be driven by our people; our people are the core focus of our attention. Our communication will be driven by an inside out approach, where our people are the key influences and drivers of our messages, engagement, and involvement. We will aim to break down silos, work flexibly across corporate and clinical teams, and maximise talent and engagement. Our overall strategy at UHS can only be achieved by effective collaboration between all of the 5 pillars. We will proactively partner with our staffside groups, building on our strong relationships. We will continue to develop our Staff Networks to ensure diverse voice is at the heart of our decision making. Collaboration with our partners We will collaborate and share with our NHS and other health and social care partners locally and nationally to collectively address the workforce challenges of today and solutions for tomorrow. We will work to remove organisational boundaries and work together to maximise economies of scale and capitalise on innovation. Sustainability Sustainability is important to our people and it is important to the Trust. We will ensure a sustainability focused approach to our work that: • Reduces environmental impact. • Aims to deliver long term benefits for our people and our communities. • Can demonstrate our social responsibilities. Delivery through the UHS family We have so much talent and enthusiasm across the UHS family. We will deliver our goals where possible through using the creativity, passion, and experience of our people. We will develop communities of practice for OD initiatives, we will offer opportunities for people to engage on key projects and initiatives, and we will provide time, space and resources away from the workplace to do this. 25 TIME HORIZON UHS Digital Inclusion Conference Publish gender equality metrics for 2022 Refreshed our values, our talent management and leadership approach Implemented phase 1 of HR and OD overview 2021 2022 2023 UHS People strategy development Launch of our new employer brand Five year workforce and education plan Establish formal people provider relationship with ICS Completion of Banksy staff wellbeing projects Fully agile digital deployment and level 4 NHSI framework A top employer on WRES, WDES and gender metrics UHS achieving recognised industry standard award for people 2024 8% vacancy on registered nursing 2025 Expanded education 100% of apprentice levy used 2026 A top university teaching hospital in NHS staff survey 27 MEASURING SUCCESS We will measure success through clear key performance indicators (KPIs) based on best in class in the NHS and industry. These will be reported through our Trust governance mechanisms, reported to Trust Board, and through to the ICS and regional oversight groups. Our KPIS are driven by our own peoples experience (inside out), but also our comparison with peers and other industries (outside in). Our KPIs may evolve over time and may be informed by national priorities and standardisation. They will continue to be informed by the priorities at UHS, our strategy, but also the national people agenda. AREA KPI measure Vacancy rate: All staff Vacancy rate: Registered nursing All staff turnover Sickness absence NHS Staff Survey: We work flexibly NHSI levels of attainment (Rostering and deployment maturity) NHS Staff Survey: Recommendation as a place to work NHS Staff Survey: Staff engagement score Trust NHS Rank engagement of official channels on social media % of Appraisals completed NHS Staff Survey: We are always learning Source ESR ESR Current 2024 2026 Target Target 7.0% 6% 5% 13.4% 10% 8% ESR ESR Staff survey theme 13.7% 4.2% 6.4% 12% 3.4% 6.7% 11% 3.2% 7.0% National NHSI team TBA Level 1 Level 4 Annual and pulse staff survey question Annual staff survey theme Social and digital media tracking 72% 7.2% Top 5 76% 80% 7.4% 7.5% Top in all channels ESR Annual staff survey theme 72.6% 5.7% 92% 6.0% 92% 6.5% AREA All AREAS KPI measure Source Current 2024 2026 Target Target Satisfaction with quality of work environment % Apprentice levy utilised each year NHS Staff Survey: Safe environment measure NHS Staff survey: My organisation takes positive action on health and wellbeing External industry accreditation NHS Staff Survey: We are compassionate and inclusive Annual staff survey – local question from 2022 Apprentice Levy TBC Annual staff survey theme Staff survey Question 6.1% 61% Times top 100 Employers Annual staff survey theme 7.6% 60% 70% TBC TBC 6.5% 7.0% 75% 80% Award achieved 7.8% 8.0% Percentage of staff who definitely feel a sense of belonging Percentage of staff employed at Band 7 and above from non-white backgrounds Percentage of staff employed at Band 7 and above with a disability or long term condition Quarterly pulse survey ESR ESR Recommendation as a place to work from our diverse communities Quarterly pulse survey CQC Outstanding for well led CQC 74% 77% 80% 10% 14% 19% – – – Race, gender, LGBTQ+, disability and LID to mirror all staff Good Good Out- standing 29 “ENSURING CONTINUED PROGRESS AGAINST THE STRATEGY IS KEY, INCLUDING VISIBILITY TO THIS VITAL ISSUE AT TRUST BOARD LEVEL” GOVERNANCE AND OVERSIGHT Ensuring continued progress against the strategy is key, including visibility to this vital issue at Trust Board level. The strategy will become our guiding document for all activities in the People Directorate and beyond as appropriate. Each year a set of annual objectives will be set based on the five year milestones. These will be reported through our corporate objectives, through People and OD Committee and through Trust Board. Tactical decision making and governance will take place through our UHS People Board, which reports to Trust Executive Committee (TEC). Matters of inclusion will be addressed through our Equality, Diversity and Inclusion Committee also reporting to TEC. Progress will also be reported through our Always Improving Strategy Board, to ensure collaboration with other key strategic themes. A number of sub-groups will focus core activities, reporting through the UHS People Board. Collaborating with our partners The Hampshire and Isle of Wight (HIOW) People Board will provide oversight and leadership to the system agenda, and UHS will be represented through this forum, in addition to the emerging HIOW Chief People Officer collaborative. UHS People Board Trust Board People and OD Committee Trust Executive Committee HIOW collaborative: • University Hospital Southampton NHS Foundation Trust • Portsmouth Hospitals University NHS Trust • Isle of Wight NHS Trust • Southern Health NHS Foundation Trust • Solent NHS Trust Equality, Diversity and Inclusion Committee Staff Partnership Forum Pay Steering Group HR Performance Board Recruitment and Retention Group Medical Workforce Group Education Quality Group HR Policy Group ER Performance Board Staff Networks 33 APPENDIX 1 – INSIGHT WORK 35 “OUR PLAN WILL SUPPORT OUR GREATEST ASSET – OUR PEOPLE. TO BUILD A FUTURE FOR UHS WHERE WORLD CLASS PEOPLE ARE ABLE TO DELIVER THE WORLD CLASS CARE OUR PATIENTS DESERVE. WE LOOK FORWARD TO WORKING WITH YOU ALL ON THIS JOURNEY” 35 “A WORLD CLASS ORGANISATION IS MADE UP OF WORLD CLASS PEOPLE. THEY ARE OUR GREATEST ASSET” University Hospital Southampton NHS Foundation Trust Trust Management Offices, Mailpoint 18 Tremona Road, Southampton Hampshire SO16 6YD www.uhs.nhs.uk
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