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Best interests in the absence of suffering

Description: A court decides whether prolonging the life of a child who is unlikely to recover from catastrophic brain damage is in her best interests.
Url: /HealthProfessionals/Clinical-law-updates/Best-interests-in-the-absence-of-suffering.aspx

Lynch syndrome - patient information

Description: This leaflet contains information about Lynch syndrome.
Url: /Media/UHS-website-2019/Patientinformation/Genetics/Lynch-syndrome-1431-PIL.pdf

Von Hippel-Lindau disease (VHL) - patient information

Description: Information about von Hippel-Lindau (VHL) disease.
Url: /Media/UHS-website-2019/Patientinformation/Genetics/Von-Hippel-Lindau-disease-VHL-1438-PIL.pdf

Gross negligence manslaughter: what does 'gross' entail?

Description: If a clinician is suspected by the police of gross negligence manslaughter the point will be reached where, in England and Wales, the Crown Prosecution Service (CPS) must make a decision as to whether the clinician should be charged with this crime.
Url: /HealthProfessionals/Clinical-law-updates/Gross-negligence-manslaughter-what-does-gross-entail.aspx

Testing for gene variants in inherited breast, ovarian and prostate cancers - patient information

Description: Information about testing for gene variants in inherited breast, ovarian and prostate cancers.
Url: /Media/UHS-website-2019/Patientinformation/Genetics/Testing-for-gene-variants-in-inherited-breast-ovarian-and-prostate-cancers-1980-PIL.pdf

What to expect in the last days and weeks of life: When your loved one is staying in hospital - patient information

Description: This booklet provides information for family, friends and carers who will be supporting a loved one in hospital during their last days and weeks.
Url: /Media/UHS-website-2019/Patientinformation/Bereavement-and-end-of-life/What-to-expect-in-the-last-days-and-weeks-of-life-When-your-loved-one-is-staying-in-hospital-3684-PIL.pdf

What to expect in the last days and weeks of life: When your loved one has been discharged from hospital - patient information

Description: This booklet provides information for family, friends and carers who will be supporting a loved one during their last days and weeks after they are discharged from hospital.
Url: /Media/UHS-website-2019/Patientinformation/Bereavement-and-end-of-life/What-to-expect-in-the-last-days-and-weeks-of-life-When-your-loved-one-has-been-discharged-from-hospital-3685-PIL.pdf

Papers-CoG-24.07.2024

Description: Date Time Location Chair Agenda Council of Governors 24/07/2024 14:00 - 16:00 Conference Room, Heartbeat/Microsoft Teams Jenni Douglas-Todd 1 Chair’s Welcome and Opening Comments 14:00 2 Declarations of Interest 14:02 3 Minutes of Previous Meeting 14:03 Approve the minutes of the previous meeting held on 1 May 2024 4 Matters Arising/Summary of Agreed Actions 14:05 5 Strategy, Quality and Performance 5.1 Chief Executive Officer's Performance Report 14:08 Receive and note the report Sponsor: David French, Chief Executive Officer 5.2 Operating Plan 14:28 Receive and note the report Sponsor: Ian Howard, Chief Financial Officer 5.3 Annual Report Update - Oral 14:48 Sponsor: David French, Chief Executive Officer Attendee: Craig Machell, Associate Director of Corporate Affairs and Company Secretary 14:53 Break 6 Governance 6.1 Appointment of Lead Governor 15:03 Note the appointment of the new lead governor Sponsor: Jenni Douglas-Todd, Trust Chair Attendee: Karen Russell, Council of Governors' Business Manager 6.2 Confirmation of Election of the Membership and Engagement Working 15:05 Group Chair Confirm the appointment of the new Membership and Engagement Working Group Chair Sponsor: Jenni Douglas-Todd, Trust Chair Attendee: Karen Russell, Council of Governors' Business Manager 6.3 Governors' Nomination Committee Terms of Reference 15:07 Approve the proposed changes to the Governors' Nomination Committee Terms of Reference Sponsor: Jenni Douglas-Todd, Trust Chair Attendees: Craig Machell, Associate Director of Corporate Affairs and Company Secretary and Karen Russell, Council of Governors' Business Manager 7 Membership Engagement and Governor Activity 7.1 Membership Engagement 15:17 Receive the report Sponsor: Jenni Douglas-Todd, Trust Chair Attendee: Sam Dolton, Events and Membership Officer 7.2 Annual Members' Meeting Update - Oral 15:27 Receive the update Sponsor: David French, Chief Executive Officer Attendee: Sam Dolton, Events and Membership Officer 7.3 Governors' Nomination Committee Feedback 15:32 Chair: Jenni Douglas-Todd, Trust Chair 7.4 Feedback from Strategy and Finance Working Group 15:34 Chair: Mandy Fader 7.5 Feedback from Patient and Staff Experience Working Group 15:39 Chair: Sandra Gidley 7.6 Feedback from Membership and Engagement Working Group 15:44 Chair: TBC 8 Review of Meeting 15:49 Review and feedback on the content of this meeting Sponsor: Jenni Douglas-Todd, Trust Chair 9 Any Other Business 15:54 Raise any relevant or urgent matters that are not on the agenda 10 Date of Next Meeting: 23 October 2024 15:59 Note the date of the next meeting Page 2 Minutes - Council of Governors (CoG) Open Session Date Time Location Chair Present In attendance Apologies 1 May 2024 14.35-16:30 Conference Room, Heartbeat Education Centre and Microsoft Teams Jenni Douglas-Todd, Trust Chair Jenni Douglas-Todd, Trust Chair Shirley Anderson, Elected, New Forest, Eastleigh and Test Valley Katherine Barbour, Elected, Southampton City Patricia Crates, Elected, New Forest, Eastleigh and Test Valley Helen Eggleton, Hampshire and Isle of Wight Integrated Care Board (ICB) Professor Mandy Fader, Appointed, University of Southampton Lesley Gilder, Elected, Southampton City Sathish Harinarayanan, Elected, Medical Practitioners and Dental Staff Sandra Gidley, Elected, New Forest, Eastleigh and Test Valley Jenny Lawrie, Elected, Southampton City Kelly Lloyd, Elected, Health Professional and Health Scientist Staff and Lead Governor Brian Lovell, Elected, Rest of England and Wales Esther O’Sullivan, Elected, New Forest, Eastleigh and Test Valley Catherine Rushworth, Elected, Isle of Wight Liz Taylor, Elected, Non-Clinical and Support Staff Councillor Victoria Ugwoeme, Appointed, Southampton City Council Professor Emma Wadsworth, Appointed, Solent University Mike Williams, Elected, New Forest, Eastleigh and Test Valley Peter Baker, Commercial and Enterprise Director (for item 6.3) Jessica Burnett, Associate Governor Tracey Burt, Minutes Martin De Sousa, Director of Strategy and Partnerships (for item 5.2) Sam Dolton, Events and Membership Officer Craig Machell, Associate Director of Corporate Affairs and Company Secretary Neylia Mustafapour, Associate Governor Karen Russell, Council of Governors’ Business Manager Joe Teape, Chief Operating Officer (for item 5.1) Theresa Airiemiokhale, Elected, Southampton City Linda Hebdige, Elected, Southampton City Councillor Edward Heron, Appointed, Hampshire County Council Jake Smokcum, Elected, Nursing and Midwifery Staff Quintin van Wyk, Elected, Rest of England and Wales JDT SA KB PC HE MF LG SH SG JL KL BL EO CR LT VU EW MW PB JB TB MDeS SD CM NM KR JT TA LH EH JS QvW 1 1 Chair’s Welcome and Opening Comments The Chair welcomed everyone to the meeting. 2 Declarations of Interest There were no new declarations of interest related to matters on the agenda. 3 Minutes of Previous Meeting The minutes of the meeting held on 31 January 2024 were approved as an accurate record, after the 4th bullet point of item 5.1 was amended to read: • CR said that many families from the Isle of Wight (IoW) travelled to the mainland to use maternity services and she was extremely concerned that the facilities at PAH were already stretched, without additional patients being sent from Winchester. She felt strongly that it would be inappropriate to send IoW patients to maternity units that were even further away from the island and she said that PAH staff were already fearful of the pressures to come. She queried whether additional staff were being recruited and whether the facilities would be improved to accommodate more patients. 4 Matters Arising/Summary of Agreed Actions The updates on the summary of actions in the paper were noted. 5 Strategy, Quality and Performance 5.1 Chief Executive Officer’s Performance Report JDT welcomed JT to present the performance report on behalf of David French, CEO, who was attending a meeting in London. He highlighted that: • NHSE had granted UHS a one-off cash payment of £24.6m (due partly to the successful delivery of the improvement in its forecast position), which meant that the forecast deficit of £27m for 2023/24 had reduced to £4.5m. • cost savings of £63m had been achieved in 2023/24. • the Trust had delivered £75m of capital development during the year, which had included the opening of new wards and the building of the sky bridge. • 118% of 2019/20 levels of elective, day case and outpatient first attendances had been delivered in 2023/24, against a target of 113%. • UHS should be proud of its performance against other university teaching hospitals. The Emergency Department’s performance had remained in the top quartile for the whole year and significant progress had also been made in treating those who had waited the longest for treatment. • one of the Trust’s biggest risks during 2024/25 was the lack of funding for social care within the community and he noted that there were currently 238 beds occupied by those waiting to be discharged. JT advised that the Trust was looking for more strategic solutions and was working with its partners across the integrated care system, to improve the position. The following comments/queries were raised by governors: • it was encouraging to see the number of performance targets showing as green in the report. • it was interesting to hear that UHS was in the top quartile for many performance targets, even when they showed as red in the report and it gave an indication of the significant challenges all Trusts were facing. JT advised that the Trust had a strong focus on prioritising patients based on clinical need. He also noted that there was a weekly meeting to review those patients who had been on waiting lists the longest. • how staff remained motivated when it felt as though they were treading water? JT advised that staff delivered amazing results, against all the odds and he hoped that motivated them. 2 • what was being done to reduce the number of patients who did not meet the criteria to reside? JT advised that there were improvements that could be made, such as ensuring that patients were on the right clinical pathway and that the number of failed discharges reduced (e.g. transport not booked, medication delays). • SH asked what had been included in the £63m Cost Improvement Programme. JT advised that it had included additional income earned, vacancies held and a series of recurrent savings (e.g. length of stay, outpatient improvements, procurement savings and improved theatre productivity). • EW noted that the report referenced the challenging work environment and she asked whether staff were involved in putting together measures to address the concerns. JT advised that there had been a discussion at Trust Board regarding staff morale and that lots of things had been tried to provide improved support, e.g. the Wellbeing Hub, the PAH roof garden and staffroom refurbishments. He said that the Trust was keen to encourage a long-term, ground up, philosophy and wanted to create an environment in which its staff could thrive. • that many staff were tired and run down, following the pandemic and had not had a chance to recover. Whilst facilities like the Wellbeing Hub were good, staff needed to be allowed time (during the working day) to access them. • many staff believed that they were identifiable through bar codes/reference numbers on staff survey forms, which were meant to be anonymous. It was suggested that the response rate would improve, if they were removed. • KB asked whether governors were aware that there was an issue regarding Band 2 staff, who were seeking to be regraded to Band 3. JT advised that it was a national issue in respect of Band 2 Health Care Assistants who were working at a Band 3 level. He said that UHS wanted people to be paid the right amount for the work they did and Steve Harris, Chief People Officer, was involved in discussions across HIOW, to reach a unified position. • KB noted the importance of people connecting with nature and the positive effect that being able to see greenery from a hospital bed, could have on patients. She queried whether it would be possible to have TV screens on wards, showing scenes of the countryside. • KB advised that the Catholic Home Care service (which had supported many people across the city) was to close, increasing pressure on other services. Actions: • the governors were keen to express their thanks to the staff for the sterling work they did and JT was asked to consider how that message could be shared across the organisation. • JDT agreed to ask Steve Harris, Chief People Officer, to provide governors with an update regarding the situation with Band 2 staff. 5.2 Corporate Objectives 2024/25 JDT welcomed Martin De Sousa (MDeS), Director of Strategy and Partnerships, to the meeting. He advised that there had been a lot of discussion regarding the corporate objectives for 2024/25 as the Trust wanted them to be ambitious but realistic. They were also keen for them to reflect the challenges in the system, whilst recognising the pressure that teams were already under. The report set out the 14 corporate objectives that had been proposed and MDeS advised that they had been structured around the five domains of the UHS 5 Year Strategy. 3 The following comments were made: • KL said that, as a member of staff, she appreciated the fact that the objectives clearly linked to the vision and values of the Trust. • MDeS confirmed that UHS continued to work closely with acute Trusts outside the HIOW ICS, e.g. Salisbury NHS FT and University Hospital Dorset. • MDeS confirmed that the corporate objectives would be included in the Trust Board papers that were available to the public and in the hospital’s annual report. • measures were in place to ensure that progress against the corporate objectives could be monitored. 5.3 Non-NHS Activity JDT welcomed Peter Baker (PB), Commercial & Enterprise Director, to the meeting and he acknowledged that one of the responsibilities of governors was to provide a level of assurance that the Trust was predominantly focussed on NHS activity. He noted that private patients and overseas visitors continued to bring income into the Trust and that in 2023 a new company, UHS International Development Centre (IDC) had been set up to support the funding and development of innovative products. The IDC would enable staff to bring forward innovations for consideration and to present them to a professional team, who could then take them forward and look for investors. Many staff had innovative ideas and the IDC provided an exciting opportunity for them. PB advised that the IDC worked closely with the University of Southampton and also that it generated income from contracts with independent hospitals (Spire and Nuffield), the Ministry of Defence and the cruise line industry. The following comments were made: • staff were already under a lot of pressure, caring for NHS patients, so how did the Trust ensure that any additional work was monitored in terms of hours worked, well being and guarding against burnout. PB advised that if a consultant wanted to do private work in NHS time, they had to obtain sign off at a senior level. Generally, however, they would undertake any additional work at weekends or in the evenings. • the IDC was seen as a good recruitment and retention tool and the Trust had a generous intellectual property policy. • EW advised that Solent University would be keen to support the IDC with knowledge exchange and PB agreed to pursue the opportunity. Action: EW and PB to discuss the potential for knowledge exchange between the IDC and Solent University. 5.4 Annual Report and Quality Accounts Timetable 2023/24 CM presented the paper and highlighted the timetable provided. He advised that the Quality Account had to be published by 30 June 2024 and that the Annual Report and Accounts 2023/24, could not be published until after they had been laid before Parliament. It was noted that Parliament’s summer recess would commence on 23 July 2024. The first draft of the annual report and accounts was about to be circulated to the governors for a one-month consultation period and final sign off was scheduled for 17 June 2024, with submission by 28 June 2024. 4 6 Governance 6.1 Review Terms of Reference - Council of Governors and Working Groups CM advised that there had been no significant changes to the Terms of Reference for the Council of Governors and its working groups. A couple of minor changes had been proposed to reflect the current composition of the CoG and compliance arrangements, together with a small number of grammatical changes. Decision: The CoG approved the revised Terms of Reference for the Council of Governors and its working groups. 6.2 Vacancy for the Health Professional and Health Scientist Staff Governor KR advised that KL would be standing down as a governor on 28 June 2024 as she would be leaving UHS. Generally, there would be three options for filling a vacancy for any reason other than the expiry of the term of office but Option 2 did not apply, as there had only been one candidate at the last election. The CoG was therefore asked to approve Option 1, by calling an election to coincide with the scheduled governor elections in 2024. Decision: The CoG approved the use of Option 1 to fill the vacant seat for the health professional and health scientist staff group, by calling an election to coincide with the scheduled governor elections in 2024. 6.3 Council of Governors’ Elections 2024 KR advised that two vacancies would arise within the Rest of England and Wales public constituency of the CoG on 1 October 2024, when the current governors reached the end of their term of office. The proposed timetable and arrangements for the elections to the CoG in 2024, were noted. 7 Membership Engagement and Governor Activity 7.1 Membership Engagement SD introduced the membership engagement report and advised that the Communication Team was in a transition phase, which meant that it was having to look at what events it could coordinate and support. Consequently, he had not yet circulated a list of events to governors, for them to indicate their availability. He highlighted the following: • with reduced staff available, the Trust’s attendance at larger community events, would be the priority (e.g. the Mela Festival). Working in partnership with other teams was also being considered. • there was a particular focus on existing members, to ensure they were kept up-to-date with news/events and a monthly email was sent out. The digital magazine, Connect, was sent out quarterly. • there had been lots of questions from members at the virtual event held in February on dementia. A second virtual event in the series ‘Transforming lives and healthcare through research’, was being arranged. • there would be a virtual event w/c 6 May 2024 on choosing the right healthcare for your child. The head of the 111 service from South Central Ambulance and David Jones, Consultant Paediatrician at UHS, were both due to speak. The following comments were made: • it was unfortunate that the number of events to be attended, was having to be reduced. 5 • whether the ‘open’ rate for emails sent to members, suggested that it was not their preferred means of receiving updates. SD advised that it was typical of the ‘open’ rate experienced by other organisations. • it was suggested that key points should be included in the body of any email sent out, rather than as an attachment, which members may not open. • that any material sent out needed to be as engaging as possible. Action: SD agreed to provide a list of events (for KR to circulate) so that governors could indicate their availability. 7.2 Membership Strategy - Review of the Trust’s Public Membership SD advised that many of the Trust’s public members had been recruited when the Foundation Trust was formed in 2011 but that a large proportion of the database was now out of date, due to members moving or being deceased. A data cleansing programme was used but was only around 80% accurate. Public members with an email address were contacted regularly. However, those for whom the Trust only held a postal address, were only contacted when there was an election to the CoG in their constituency. The Trust was therefore keen that members for whom it did not hold an email address, were asked to opt in, if they wished to continue as a Trust member. The following comments were made: • it was suggested that members might be encouraged to opt in, if the Trust made them aware of the overall cost of communicating by post and how, for example, that might equate to employing an additional nurse. • the Trust should be careful not to make members feel guilty, as they may decide to opt out and then receive nothing. SD assured the CoG that UHS would use the experience of the database company to ensure that any wording used was appropriate. Decision: The CoG approved Option 1, which had also been the preferred option of the governors who had attended the Membership and Engagement Working Group on 11 January 2024. 7.3 Governors’ Nomination Committee Feedback JDT advised that the NED appraisals had been conducted and the relevant documents were complete. She had provided a report to the Governors’ Nomination Committee and had attended their recent meeting. 7.4 Feedback from Strategy and Finance Working Group MF advised that the Strategy and Finance Working Group had met on the 29 April 2024. There had been a discussion about health inequalities and Paul Grundy, Chief Medical Officer and Luci Hood, Head of Medical Directorate had been invited to talk about what actions the Trust was taking. MF said that it had been well attended, there had been good presentations and lots of questions raised. 7.5 Feedback from Patient and Staff Experience Working Group SG advised that Serena Gaukroger-Woods, Head of Clinical Quality Assurance, had attended the working group. She had discussed the draft Quality Account priorities for 2024/25 and had given an overview of how the process worked. Those attending had been able to ask questions and had inputted into the draft plan. 6 SG mentioned that governors had been surprised to learn that a behaviour framework, initiated by staff, was being produced and that post Covid-19 there had been a need to go back to some of the more traditional values. 7.6 Feedback from Membership and Engagement Working Group KL advised that Arabella Roderick, the Trust’s Gypsy, Roma and Traveller (GRT) Liaison Lead, had attended the working group. She had been in post for 18 months and had been working with the GRT community to build better links and to try to make UHS a more welcoming environment for them to seek help and treatment. KL said that it had been a very engaging conversation, that it was a community who experienced significant health inequalities and that there was a lot more work to be done. 8 Review of Meeting JDT asked governors for their feedback regarding the meeting and the following comments were made: • that the informal session with the NEDs had been valuable and their detailed answers had been appreciated. • that more time with the NEDs would have been useful. • that a more “punchy”, top line account of the finances, with visual aids and without acronyms, would have been welcomed. 9 Any Other Business JDT noted that it was KL’s last meeting and she thanked her for stepping into the Lead Governor role, when she had still been a relatively new governor. She thanked her for all her work and wished her well for the future. KL responded by saying that she had enjoyed the role and she thanked the governors for being relatable and approachable. 10 Date of Next Meeting The next meeting of the CoG would be held on 24 July 2024. 7 18 July 2024 Agenda item Assigned to Deadline Status Council of Governors 31/01/2024 7.1 Membership Engagement 1114 . Membership Events 2024/25 Sam Dolton 01/05/2024 Completed Explanation It was agreed that SD would circulate a list of all events (once available) to governors, so that they could indicate their availability. Update SD provided a further update at the meeting on 1 May 2024 regarding the reduced number of community events which the Trust would be attend in 2024. Following his update, a new action item was created regarding this (see action item 1131). Council of Governors 31/01/2024 7.3 Feedback from Strategy and Finance Working Group 1115 . Trust's Inequalities Strategy Mandy Fader and Karen Russell 01/05/2024 Completed Explanation It was suggested that MF/KR obtain more information from Paul Grundy (Chief Medical Officer) about the new health inequalities group at UHS. Update Paul Grundy and Luci Hood (Head of Medical Directorate) attended the Strategy and Finance Working Group meeting on Monday, 29 April 2024 to provide a presentation regarding the Trust's Health Inequalities Strategy. Council of Governors 31/01/2024 7.4 Feedback from Patient and Staff Experience Working Group 1116 . Security at the Princess Anne Hospital Sandra Gidley and Karen Russell 24/07/2024 Completed Explanation It was agreed that SG would seek clarification regarding the specific issues picked up in the CQC report around security and the actions that had been taken and that governors consider joining a matrons’ walkabout at the PAH, so they could see the current security system that was in place. 18 July 2024 12:48 Update An update was provided by Tim Peachey at the governors' and non-executive directors' discussion meeting on 1 May 2024. A further update on the progress of the new security arrangements will be provided at the governors' and non-executive directors' discussion meeting on 24 July 2024. Arrangements for governor walkabouts within the hospital are currently being reviewed on a broader basis. Council of Governors 01/05/2024 5.1 Chief Executive Officer's Performance Report 1128 Thank you to UHS staff . Joe Teape 24/07/2024 Completed Explanation The governors were keen to express their thanks to the staff for the sterling work they did and JT was asked to consider how that message could be shared across the organisation. Update An infographic has been shared across staff briefing and social channels. David French (Chief Executive Officer) has also arranged to prepare a video which will include this message. 1129 . Band 2 staff Jenni Douglas-Todd 24/07/2024 Completed Explanation JDT agreed to ask Steve Harris, Chief People Officer, to provide governors with an update regarding the situation with Band 2 staff. Update Steve Harris has provided the following update: UNISON (an NHS trade union) is leading a national campaign for healthcare assistants (HCAs) in Trusts. This is in relation to levels of pay for these roles, which are typically paid at band 2. UNISON's campaign pushes for a recognition that many HCAs have actually undertaken band 3 duties over a number of years. The claim pushes for an entitlement to a rectification of their banding and appropriate back pay to reflect this. A small number of Trusts have seen industrial action and have reached a settlement. UNISON has been conducting campaigning activity at UHS over the last few months. UHS is currently evaluating the potential impact of a claim being lodged here and simultaneously pushing for a national solution to the issue, as it is likely to affect nearly all NHS organisations. Page 2 18 July 2024 12:48 Council of Governors 01/05/2024 5.3 Non-NHS Activity 1130 Knowledge exchange between the IDC and Solent . University Emma Wadsworth and Pete Baker 24/07/2024 Completed Explanation EW and PB to discuss the potential for knowledge exchange between the IDC and Solent University. Update EW has advised that her colleagues Katarzyna Gleadell (Head of Knowledge Exchange) and Mike Toy (Senior Communities Development Manager) met with PB and Martin Gossling (Head of Commercial Innovation) on 12 June 2024. They discussed the UHS Innovation Centre and any collaborative support Solent University might be able to offer. Following the meeting, Katarzyna and Mike shared Solent’s Business Solution information and details of their current Innovation Voucher scheme. They also extended an invitation to Martin and Peter to visit the University for a tour of their facilities and discussion with some of their Research Leads. It is hoped to arrange this visit over the summer. Council of Governors 01/05/2024 7.1 Membership Engagement 1131 . UHS attendance at community events in 2024 Sam Dolton and Karen Russell 24/07/2024 Completed Explanation SD agreed to provide details of any events which the Trust is planning attend, for KR to circulate), so that governors could indicate their availability. Update SD confirmed that the Trust's research communications team would be attending the Southampton Mela Festival on Saturday, 13 July 2024 and governors were invited to support the event. Details of the event were circulated to governors on 26 June 2024. Governors were also invited to support a dual stand between Diabetes UK and the Digital team at HIOW ICB at Eastleigh Mela on Sunday, 21 July. Details of the event were circulated to governors on 9 July 2024. The Trust will be attending Southampton Pride during the weekend of 24/25 August 2024 and governors are invited to support this event. Details were circulated to governors on 18 July 2024. There is currently no other planned attendance at community events in 2024 but governors will be advised if this changes. Page 3 Report to the Council of Governors Title: Agenda item: Sponsor: Author: Date: Purpose Chief Executive Officer’s Performance Report 5.1 David French, Chief Executive Officer Sam Dale, Associate Director of Data and Analytics 24 July 2024 Assurance Approval or reassurance Ratification Information Y Issue to be addressed: Information about Trust performance supports the Council of Governors in their role. Response to the issue: This report is intended to inform the Council of Governors about aspects of the Trust’s performance. Implications: This report provides performance information relating to a broad range of Trust services and activities. There are no specific implications. Risks: This report is provided for the purpose of information. Summary: This report is provided for the purpose of information. UHS Council of Governors July 2024 Chief Executive’s Performance Report 1. Purpose and Context The purpose of this report is to summarise the Trust’s performance against a range of key indicators. Where available, this report covers data from the period April 2024 to June 2024, noting that some performance data in relation to some of the targets is reported further in arrears. Notable features of the last quarter include: • The trust set a £14.5m deficit plan for 2024/25 which includes incremental monthly improvements and a break even position for the second half of the year. The plan includes an £85m savings target underpinned by internal productivity and efficiency schemes alongside system wide transformation. • The trust reported an £8.4m deficit after two months, which is £2m behind the financial plan. However significant progress has been through new recruitment controls and the trust continues to increase clinical revenue as elective activity levels reached 123% of 19/20 levels. • Patient flow challenges remain as the volume of patients attending the emergency department grew by 2% in quarter two and the volume of patients in the hospital not meeting the criteria to reside (nCTR) remains above 200 each day. • Despite the operational challenges, the hospital is benchmarking well on performance targets for elective waiting lists, emergency waiting times and cancer pathways despite a recent increase in referrals. UHS is consistently in the top quarter for most key metrics when compared to peer teaching hospitals across the UK. • The organisation continued to prioritise clinically urgent and long waiting patients during the latest period of industrial action. The hospital is in a positive position as we target the national ambition of zero patients waiting over 65 weeks by the end of September 2024. 2. Safety Infection Control Clostridium Difficile infection MRSA Bacterium infection Target 78.0% EDs (Types 1 & 2) (Mar’25) Apr 2024 May 2024 Jun 2024 69.1% 71.3% 69.7% Attendances to the Emergency Department (ED) have continued to increase, averaging 435 per day across April, May and June in 2024. This represents a 2% increase on volumes reported in the previous quarter and a 5% increase against the equivalent period last year. Whilst this generates flow challenges for the organisation, UHS has maintained a four hour performance position close to 70% for all months in quarter one. The hospital’s ED performance continues to compare strongly, ranking 2nd for May 2024 and 4th for June 2024 when compared to 20 peer teaching hospitals across the UK (for Type 1 attendances). Referral to Treatment (RTT) % incomplete pathways within 18 weeks in month Total patients on a waiting list Target => 92% Apr 2024 62.74% 59,485 Page 3 of 5 May 2024 63.89% 59,812 Jun 2024 TBC TBC The trust has seen a 2% increase in the number of patients on the RTT waiting list since the final quarter of the 2023/24 financial year. This increase is within the referral element of patient pathways, whereas the volume of patients waiting for a planned admission or diagnostics have both reduced. A significant proportion of the referral growth sits within specialties impacted by seasonal conditions. Overall, the hospital continues to benchmark well for the proportion of patients who have been waiting over 18 weeks for treatment, with UHS ranking in fourth place for each of the last six months when compared to 20 peer teaching hospitals. The organisation continues to report zero patients waiting over two years and the only cohort of patients now waiting over 78 weeks (14 in May 2024) remains those impacted by the national shortage of corneal tissue which is managed nationally. In May 2024, the trust reported less than 50 patients waiting over 65 weeks and is fully focussed on the national ambition to achieve zero by September 2024. Outside of the corneal patients, the remaining 65 week waiters are complex cases in a small number of specialties. The organisation continues to rank in the top quartile for this metric when compared to peer teaching hospitals. Cancer Faster Diagnosis - within 28 days 31 Day target - decision to treat to first definitive treatment 62 day target - urgent referral to first definitive treatment Target > =77% => 96% => 70% Mar 2024 87.2% 92.3% 77.3% Apr 2024 85.7% 90.8% 76.5% May 2024 85.9% 88.7% 69.7% Over the last six months, the organisation implemented multiple steps to streamline patient pathways, increase capacity and balance staffing levels with the demand for cancer services. These action plans have proved successful as our waiting times and breach cohorts improved. The trust benchmark wells for both 28 day and 62 days metrics, consistently ranking first for 28 day faster diagnosis against peer teaching hospitals. Alongside a difficult financial and recruitment position, the organisation has faced challenges to maintain these levels of performance in the last two months as urgent referrals continue to increase in 2024. The organisation continued to prioritise cancer patients and their treatments through all periods of industrial action and the organisation is in constant dialogue with primary care to explore innovative pathways and share referral outcomes. 5. Finance The financial environment remains extremely challenging as the organisation commences a new financial year. The annual plan for 2024/25 is a £14.5m deficit with incremental improvement needed to take the organisation from a deficit in the first half of the year to breakeven in the second half of the year. The plan is predicated on the delivery of an £85m savings programme that not only needs a step change improvement in productivity and efficiency but system wide transformation particularly across schemes helping accelerate discharge and reducing the numbers of patients within the hospital who don’t meet the criteria to reside or who have mental health rather than physical health needs. Further to this the plan assumes no industrial action which carries an immediate risk for June. UHS is currently reporting an £8.4m deficit after two months (April and May) which is £2m behind plan. This is predominantly due to savings targets not being achieved fully in early months coupled with an estimated gap in consultant pay award funding of £0.2m per month. Mobilising the delivery of efficiency plans to keep pace with required efficiency savings was a known risk through the planning process and progress continues to be made in making sustainable financial improvements. Page 4 of 5 The organisation has made great strides in making sure workforce growth is controlled and agency costs minimised. Agency expenditure is below 1% of total pay expenditure and continues to benchmark favourably when compared to similar organisations. Surge capacity has also reduced in usage across April and May with the organisation delivering activity predominantly from within its funded bed base. The trust has also delivered elective activity at 123% of 2019/20 levels which is 10% above the trusts target. This has helped deliver additional revenues of £3m across April and May. Non criteria to reside numbers however remain flat from 2023/24 at between 200 and 250 in any day. Similarly mental health patient volumes also remain broadly similar to 2023/24. Both these two factors pose significant risk to the delivery of the financial plan. Risks will continue to be monitored closely in year as continuing to run in a deficit is not sustainable for the trust’s cash or capital position. The trust however remains positive that in working with system partners, improvements can be achieved and therefore continues to forecast plan delivery. Further to this the trust remains on target to spend its full capital allocation for 2024/25 totalling £86m. This includes £5.5m (£3.5m subject to business case approval) recently awarded for the emergency department, £18m related to continued investment in decarbonisation funded via a Salix grant, and £7m related to the completion of the Southampton Community Diagnostics Centre planned for the Royal South Hants hospital (centrally funded). This investment in capacity, digital and estates infrastructure helps support continued ongoing financial sustainability and efficiency improvements that provide foundations for the future. 6. Human Resources Indicator Q4 23/24 Staff recommend UHS as a place to work % 63.0% Staff survey engagement score (out of 10) 6.8 Q1 24/25 63.8% 6.85 The most recent quarterly survey results show a slight increase in the percentage of staff who would recommend UHS as a place of work and the overall engagement score, which we hope will continue. It is acknowledged that the response rate for quarterly submissions is significantly below the rate achieved for the annual staff survey. Indicator Staff Turnover (internal target; rolling 12 month) Sickness absence 12 month rolling (internal target) Target <=13.6% <=3.9% Apr 2024 11.0 3.8 May 2024 11.4 3.8 Jun 2024 11.2 3.9 Turnover: In June 2024, UHS had a total of 107.1 WTE leavers. The highest number of leavers was within Trust HQ, with 25.6 WTE leavers. Within Trust HQ, the Admin & Clerical staff group had the most significant turnover, accounting for 13.9 WTE leavers. Division B had the second highest turnover, with 23.9 WTE leavers, which is 1.6 WTE fewer than Trust HQ. In Division B, the largest contributions to turnover came from the Nursing and Midwifery staff group, with 8.7 WTE leavers, and the Additional Clinical Services staff group, with 8.0 WTE leavers. Sickness: The current rolling sickness rate (as of June 2024) is 3.9%, which is the same as the sickness target for 24/25 (<3.9%). In-month sickness for June 2024 was 3.6%. The rolling sickness rate for June 2024 is 0.1% higher than July 2023 figure (3.8%). Page 5 of 5 Report to the Council of Governors Title: Agenda item: Sponsor: Author: Date: Purpose Operating Plan 2024/25 5.2 Ian Howard, Chief Financial Officer Ian Howard, Chief Financial Officer 24 July 2024 Assurance or Approval reassurance Ratification Information Y Issue to be addressed: Information about trust planning and budget setting supports the Council of Governors in their role. This report is intended to inform the Council of Governors about aspects of the Trust’s operating environment and plan for 2024/25. A more detailed report is presented to Trust Board for their consideration and approval. Response to the issue: UHS is entering the financial year with a deficit run rate of between £4m - £4.5m per month (£48m-£54m per year). The financial settlement for 2024/25 remains challenging, with reductions to funding in relation to national convergence to a “fair share” of funding and return of deficit from the prior year, and no growth funding has been offered. We have been in discussions with HIOW ICB and NHSE, noting this position is not affordable nationally, nor do we at UHS have the cash to support this scale of deficit. We have therefore been focussing on stretch improvements we can make within UHS and across the system, as well as identifying some additional funding, in order to deliver an improved financial deficit plan position. UHS has now submitted a revised 2024/25 operational plan that delivers an improved financial deficit of £14.5m, whilst maintaining our commitment to both quality and performance targets. As part of the improved plan we are also anticipating a further £11m of cash support from NHSE. The assumptions within the plan are outlined in Appendix A. This relies upon delivery of a number of system-wide initiatives, including reductions to Non-Criteria to Reside (NCTR) patients, reduced mental health demand and an unidentified system stretch focussed on potential corporate savings through collaboration with partners. The plan also relies upon stretched internal targets relating to our programmes of transformation, including outpatients, theatres and patient flow. This is on top of previous targets, benefits from business cases and “BAU” CIP in divisions. The overall plan is therefore significantly ambitious and stretching, with elements within our control and some elements where we need to work with partners. There is of course significant risk within these plans. However, we have also focussed on areas where we know there are opportunities, and we can improve. Our collective effort needs to focus on delivering the best position we can in these areas, which will support our position across performance, quality and financial metrics. Implications: (Clinical, Organisational, Governance, Legal?) This report provides information relating to a broad range of trust services and activities, there are no specific implications. Risks: (Top 3) of This report is provided for the purpose of information carrying out the change / or not: Summary: Conclusion This report is provided for the purpose of information. and/or recommendation 2024-25 Annual Plan Summary Report to Council of Governors 24 July 2024 UHS Executive Summary This presentation: • Sets out the plans we have submitted to HIOW ICB and NHS England, and that we will be expected to deliver. • Highlights important opportunities and areas that we can focus on within our plan. • Acknowledges the significant level of challenge that we will need to manage, aligned the scale and pace of improvement we seek. In summary, our plan shows: • We are performing well on quality/performance metrics, with specific areas of focus to improve further. • Finances – UHS is planning to deliver a £14.5m deficit in 2024-25. This financial position comes with significant risks. It is expected to be reached through NCTR & Mental Health reductions, confirmed additional funding, increased transformation programme targets, and further CIP stretch. • We require ICS support to reduce NCTR and MH patients by a total of 170 per day. Production of realistic ICB delivery plans is ongoing. • Workforce – our WTE has grown by 18% since April 2020, in line with ERF performance. Our plan includes targeted reductions, alongside planned increases, with a net total reduction of 333 WTE by March 2025 assuming demand initiatives are successful. 2 Finance (Underlying Position 23/24) Key drivers of the underlying position: Underlying pressures have built up over several years. 3 Financial Planning Bridge (24/25) Note: A further £2.9m stretch was applied to System-related CIP, taking the revised deficit plan to £14.5m. 4 ERF Performance In 2024-25 we plan to increase our ERF income to 136% of 2019-20 levels. We expect to deliver 127% through existing levels of activity, approved business cases, and based on the assumption of no Industrial Action in year. A further 9% requires delivery via transformational programmes increasing productivity. 5 Transformation Programme Our plan includes further improvements within our existing Transformation programme. Programme Patient Flow Stretch Value £2.4m Optimising Operating Services £3.3m Outpatients £2.5m Rationale Difference between a 5% length of stay reduction and the existing plan to achieve a 3% improvement compared to 2023/24 Additional 5% ERF income at a 50% margin, related to elective admissions, as a result of additional cases per list / improved capped theatre utilisation %, phased achievement Most likely to be achieved through conversion of PIFU / OPFU demand reduction into additional OPFA or Advice & Guidance Note: The above Transformation programmes are enablers for divisional CIP delivery. 6 Transformation Programme: Patient Flow The patient flow programme is targeting a 5% reduction in length of stay in 24/25 having delivered a 1.6% reduction in 23/24. The initial ambition of a 3% reduction would yield £5m of benefit to UHS. The financial stretch to get to 5% represents an additional £2.4m, this totals £7.4m. Flow Programme - Average LoS against Baseline and LoS Reduction Target 7.50 7.00 6.50 6.00 5.50 5.00 4.50 4.00 02/04/2023 02/05/2023 02/06/2023 02/07/2023 02/08/2023 02/09/2023 02/10/2023 02/11/2023 02/12/2023 02/01/2024 02/02/2024 02/03/2024 02/04/2024 02/05/2024 LoS Average LoS rolling 13 Weeks Baseline LoS Reduction Target 7 Transformation Programme: Outpatients Planning guidance created a new metric looking at the volume of first appointments and procedures as a proportion of overall outpatient appointments, replacing the previous target on outpatient follow-up reduction. Alongside improvements in DNA’s and A&G diversions, UHS will need to hit 55% on this metric to deliver our original programme plus the £2.5m of financial stretch. UHS increased by 5% against this metric in 23/24 from 46% to 51% requiring a further 4% this year. Outpatient Programme - % of New and OPPROC Attendances against Follow ups 56.0% 54.0% 55% 52.0% 50.0% 48.0% 45.9% 46.0% 45.3% 46.0% 46.7% 46.5% 47.4% 48.9% 47.9% 49.0% 48.7% 50.2% 49.9% 50.8% 44.0% 42.0% 40.0% 01/04/2023 01/05/2023 01/06/2023 01/07/2023 01/08/2023 01/09/2023 01/10/2023 01/11/2023 01/12/2023 01/01/2024 01/02/2024 01/03/2024 01/04/2024 % New and OPPROC Target 8 Transformation Programme: Theatres UHS increased its average theatre utilisation performance by 2% in 23/24 to 82.4% ending the year around 85% capped utilisation. Consistent performance above 85% utilisation enabling a further 2,310 cases (at £3,615 average tariff) to be completed is required to deliver £3.3m of financial stretch in addition to the original programme plan. The accuracy of internal theatre utilisation data and correlation to model hospital is currently under review so the chart below is subject to change. Theatre Programme - % Capped Utilisation 90.0% 85.0% 80.0% 75.0% 70.0% 65.0% 60.0% 02/04/21062/034/23002/034/21042/035/22082/035/21012/036/22052/036/20092/037/22032/037/20062/038/22002/038/20032/039/21072/039/20012/130/21052/130/22092/130/21022/131/22062/131/21002/132/22042/132/20072/031/22012/041/20042/042/21082/042/20032/043/21072/043/23012/043/21042/044/22082/044/21022/045/2024 Capped Utilisation % Capped Utilisation Target 9 NCTR Patients A reduction in the number of acute hospital beds inappropriately occupied by NCTR patients is fundamental to the UHS plan. UHS is reliant on system plans to support delivery of reductions in NCTR. UHS Average Daily nCTR Patients (by month) 300 250 200 150 100 50 0 Jan-23 Feb-23 Mar-23 Apr-23May-23 Jun-23 Jul-23 Aug-23 Sep-23 Oct-23 Nov-23 Dec-23 Jan-24 Feb-24 Mar-24 Apr-24May-24 Jun-24 Jul-24 Aug-24 Sep-24 Oct-24 Nov-24 Dec-24 Jan-25 Feb-25 Mar-25 Average Daily nCTR 24/25 Trajectory 10 Mental Health Patients Our plan is predicated on a reduction in the number of mental health patients inappropriately accommodated within UHS’s acute hospital beds. UHS is reliant on system plans to support delivery. 11 Workforce Plan The graph and table summarises the WTE plan and movements in year for 2024/25. This includes system related CIPs of 338 wte that take effect from Q2. Adjusting for these the plan is forecast to be relatively flat over the year with divisions allocated AWL targets. 12 Quality and Performance Targets Area National Target UHS Performance Improvement trajectory in 24/25 year from 70% achievement in March 24 target to achieve 78% in Urgent care and emergency Improve A&E waiting times, minimum of 78% of patients 4 hours in March 2025 with a seen within March 2025. Viewed as a system-wide target and is contingent upon: - inclusion of UEC/UTC activity as per 23/24 approach, and - delivery of ICS-wide transformation including reduction of NCTR patients to improve inpatient flow. Eliminate waits of over 65 weeks for UHS is expecting to meet this target, with zero RTT 65 week waits by September 24. Elective waits elective care by September 2024 (except UHS has profiled zero RTT 52 week waits by March 25. Performance is dependent upon referral where patients choose to wait longer or growth rates and no Industrial Action in specific specialties) Increase the percentage of patients that UHS expects to achieve the national trajectory for diagnostic 6 week waits at trust level overall. Diagnostics receive a diagnostic test within six weeks UHS will struggle to meet the target for both NOUS and CT as individual modalities, where long in line with the March 2025 ambition of term recruitment challenges are impacting activity/capacity, but it aims to continue making some 95% improvements in these modalities. Increase the proportion of outpatient OPFU (without attendances that are either first UHS is already achieving this target in 23/24 and this is expected to continue in 24/25 with some procedures) attendances or attract a procedure tariff improvements expected linked to the Trust's ongoing outpatient transformation programme to 46% across 2024/25 Implementation of a system-wide transformation programme has been agreed with the ICS and Improve community services waiting reflected into UHS projections. The plan targets a reduction in UHS NCTR patients, to 160 patients NCTR times, with a focus on reducing long in Q2 and further reduced to 100 from Q3 to year end. Achievement of this is dependent upon the waits successful delivery of transformation plans by ICS colleague organisations (including local authorities). Improve performance against the 28 day Cancer 28 day Faster Diagnosis Standard to 77% by UHS forecast to achieve this in 24/25, based on assumptions provided by the Wessex Cancer March 2025 towards the 80% ambition byAlliance March 2026 Improve performance against the UHS forecast to achieve this during 24/25, based on assumptions provided by the Wessex Cancer Cancer 62 day headline 62-day standard to 70% by Alliance. March 2025 It should be noted that the
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Governors/Papers-CoG-24.07.2024.pdf

Papers Trust Board - 13 January 2026

Description: Date Time Location Chair Apologies Agenda Trust Board – Open Session 13/01/2026 9:00 - 13:00 Conference Room, Heartbeat Education Centre Jenni Douglas-Todd Diana Eccles 1 Chair’s Welcome, Apologies and Declarations of Interest 9:00 Note apologies for absence, and to hear any declarations of interest relating to any item on the Agenda. 2 Patient Story The patient story provides an opportunity for the Board to reflect on the experiences of patients and staff within the Trust and understand what the Trust could do better. 3 Minutes of Previous Meeting held on 11 November 2025 9:15 Approve the minutes of the previous meeting held on 11 November 2025 4 Matters Arising and Summary of Agreed Actions To discuss any matters arising from the minutes, and to agree on the status of any actions assigned at the previous meeting. 5 QUALITY, PERFORMANCE and FINANCE Quality includes: clinical effectiveness, patient safety, and patient experience 5.1 Briefing from the Chair of the Finance, Investment & Cash Committee 9:20 David Liverseidge, Chair 5.2 Briefing from the Chair of the People and Organisational Development 9:30 Committee Jane Harwood, Chair 5.3 Briefing from the Chair of the Quality Committee 9:40 including Maternity and Neonatal Safety 2025-26 Quarter 2 Report Tim Peachey, Chair 5.4 Chief Executive Officer's Report 9:50 Receive and note the report Sponsor: David French, Chief Executive Officer 5.5 Performance KPI Report for Month 8 10:20 Review and discuss the report Sponsor: Andy Hyett, Chief Operating Officer 5.6 11:00 5.7 11:15 5.8 11:25 5.9 11:30 5.10 11:45 5.11 11:55 5.12 12:05 5.13 12:15 6 6.1 12:25 7 12:35 8 Break Finance Report for Month 8 Review and discuss the report Sponsor: Ian Howard, Chief Financial Officer ICB System Report for Month 8 Receive and discuss the report Sponsor: Ian Howard, Chief Financial Officer People Report for Month 8 Review and discuss the report Sponsor: Steve Harris, Chief People Officer Learning from Deaths 2025-26 Quarter 2 Report Review and discuss the report Sponsor: Paul Grundy, Chief Medical Officer Attendee: Jenny Milner, Associate Director of Patient Experience Infection Prevention and Control 2025-26 Quarter 2 Report Review and discuss the report Sponsor: Natasha Watts, Acting Chief Nursing Officer Attendees: Julian Sutton, Clinical Lead, Department of Infection/Julie Brooks, Deputy Director of Infection Prevention and Control Medicines Management Annual Report 2024-25 Receive and discuss the report Sponsor: Paul Grundy, Chief Medical Officer Attendee: James Allen, Chief Pharmacist Annual Ward Staffing Nursing Establishment Review 2025 Discuss and approve the review Sponsor: Natasha Watts, Acting Chief Nursing Officer CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL Annual Assurance for the NHS England Core Standards for Emergency Preparedness, Resilience and Response (EPRR) Review and discuss the report Sponsor: Andy Hyett, Chief Operating Officer Attendee: John Mcgonigle, Emergency Planning & Resilience Manager Any other business Raise any relevant or urgent matters that are not on the agenda Note the date of the next meeting: 10 March 2026 Page 2 9 Resolution regarding the Press, Public and Others Sponsor: Jenni Douglas-Todd, Trust Chair To agree, as permitted by the National Health Service Act 2006 (as amended), the Trust's Constitution and the Standing Orders of the Board of Directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. 10 Follow-up discussion with governors 12:45 Page 3 Agenda links to the Board Assurance Framework (BAF) 13 January 2026 – Open Session Overview of the BAF Risk 1a: Lack of capacity to appropriately respond to emergency demand, manage the increasing waiting lists for elective demand, and provide timely diagnostics, that results in avoidable harm to patients. 1b: Due to the current challenges, we fail to provide patients and their families / carers with a high-quality experience of care and positive patient outcomes. 1c: We do not effectively plan for and implement infection prevention and control measures that reduce the number of hospital-acquired infections and limit the number of nosocomial outbreaks of infection. 2a: We do not take full advantage of our position as a leading University teaching hospital with a growing, reputable, and innovative research and development portfolio, attracting the best staff and efficiently delivering the best possible treatments and care for our patients. 3a: We are unable to meet current and planned service requirements due to the unavailability of staff to fulfil key roles. 3b: We fail to develop a diverse, compassionate, and inclusive workforce, providing a more positive staff experience for all staff. 3c: We fail to create a sustainable and innovative education and development response to meet the current and future workforce needs identified in the Trust’s longer-term workforce plan. 4a: We do not implement effective models to deliver integrated and networked care, resulting in sub-optimal patient experience and outcomes, increased numbers of admissions and increases in patients’ length of stay. 5a: We are unable to deliver a financial breakeven position, resulting in: inability to move out of the NHS England Recovery Support Programme, NHS England imposing additional controls/undertakings, and a reducing cash balance impacting the Trust’s ability to invest in line with its capital plan, estates/digital strategies, and in transformation initiatives. 5b: We do not adequately maintain, improve and develop our estate to deliver our clinical services and increase capacity. 5c: Our digital technology or infrastructure fails to the extent that it impacts our ability to deliver care effectively and safely within the organisation, 5d: We fail to prioritise green initiatives to deliver a trajectory that will reduce our direct and indirect carbon footprint by 80% by 2028-2032 (compared with a 1990 baseline) and reach net zero direct carbon emissions by 2040 and net zero indirect carbon emissions by 2045. Agenda links to the BAF No Item Linked BAF risk(s) 5.5 Performance KPI Report for Month 8 5.7 Finance Report for Month 8 5.8 ICB System Report for Month 8 5.9 People Report for Month 8 5.10 Learning from Deaths 2025-26 Quarter 2 Report 5.11 Infection Prevention and Control 2025-26 Quarter 2 Report 5.12 Medicines Management Annual Report 2024-25 5.13 Annual Ward Staffing Nursing Establishment Review 2025 6.1 Annual Assurance for the NHS England Core Standards for Emergency Preparedness, Resilience and Response (EPRR) 1a, 1b, 1c 5a 5a 3a, 3b, 3c 1b 1c 1b 1b, 3a 1b Appetite (Category) Minimal (Safety) Current risk rating 4x5 20 Cautious (Experience) Minimal (Safety) 4x4 16 4x4 16 Open (Technology & Innovation) 3x4 12 Open (workforce) Open (workforce) Open (workforce) 4x5 20 4x3 12 4x4 16 Cautious (Effectiveness) 3x3 9 Cautious (Finance) 5x5 25 Target risk rating 4 x 2 Apr 6 27 3 x 2 Apr 6 27 2 x 3 Apr 6 27 3 x 2 Mar 6 27 4 x 3 Mar 12 30 4 x 2 Mar 8 30 3 x 2 Mar 6 29 3 x 2 Dec 6 25 3 x 3 Apr 9 30 Cautious (Effectiveness) Open (Technology & Innovation) Open (Technology & Innovation) 4x5 20 3x4 12 2x4 8 4 x 2 Apr 8 30 3 x 2 Apr 6 27 2 x 2 Dec 4 27 Does this item facilitate movement towards or away from the intended target risk score and appetite? Towards Away Neither x x x x x x x x x Minutes Trust Board – Open Session Date 11/11/2025 Time 9:00 – 13:00 Location Conference Room, Heartbeat Education Centre Chair Jenni Douglas-Todd (JD-T) Present Diana Eccles, NED (DE) Keith Evans, Deputy Chair and NED (KE) David French, Chief Executive Officer (DAF) Paul Grundy, Chief Medical Officer (PG) Steve Harris, Chief People Officer (SH) Jane Harwood, NED/Senior Independent Director (JH) Ian Howard, Chief Financial Officer (IH) Andy Hyett, Chief Operating Officer (AH) David Liverseidge, NED (DL) Tim Peachey, NED (TP) Alison Tattersall, NED (AT) Natasha Watts, Acting Chief Nursing Officer (NW) In attendance Craig Machell, Associate Director of Corporate Affairs and Company Secretary (CM) Lauren Anderson, Corporate Governance and Risk Manager (LA) (item 6.2) Martin de Sousa, Director of Strategy and Partnerships (MdS) (item 6.1) Lucinda Hood, Head of Medical Directorate (LH) (item 5.13) Diana Hulbert, Guardian of Safe Working Hours and Emergency Department Consultant (DH) (item 5.12) Vickie Purdie, Head of Patient Safety (VP) (item 7.3) Kate Pryde, Clinical Director for Improvement and Clinical Effectiveness (KP) (item 5.13) Scott Spencer, Health and Safety Advisor (SS) (item 7.3) 4 governors (observing) 2 members of staff (observing) 1. Chair’s Welcome, Apologies and Declarations of Interest The Chair welcomed attendees to the meeting. There were no interests to declare in the business to be transacted at the meeting. It was noted that no apologies had been received. The Chair provided an overview of meetings she had held and events that she had attended since the previous Board meeting. 2. Patient Story Item deferred to the next meeting. 3. Minutes of the Previous Meeting held on 9 September 2025 The draft minutes tabled to the meeting were agreed to be an accurate record of the meeting held on 9 September 2025, subject to a minor correction at 5.10. Page 1 4. Matters Arising and Summary of Agreed Actions The matters arising and actions were noted. • Actions 1281, 1283 and 1284 were closed. • Action 1282 was to be addressed through item 5.6 below. • In respect of action 1285, the Quality Committee would monitor progress on complaints response times. 5. QUALITY, PERFORMANCE and FINANCE 5.1 Briefing from the Chair of the Audit and Risk Committee Keith Evans was invited to present the Committee Chair’s Report in respect of the meeting held on 13 October 2025, the content of which was noted. It was further noted that: • In terms of the internal audit reports, which had been received by the committee, whilst there were a number of points for the Trust to address, no areas of significant concern had been identified. • There was a focus on ‘imposter fraud’ whereby individuals who had turned up to carry out a shift were not who they claimed to be. Whilst there had been no reported incidents at the Trust, the Trust had implemented controls at the ward level, which would be subject to testing during 2025/26. 5.2 Briefing from the Chair of the Finance, Investment & Cash Committee David Liverseidge was invited to present the Committee Chair’s Reports in respect of the meetings held on 22 September and 3 November 2025, the contents of which were noted. It was further noted that: • In September 2025, the Trust had reported that it was in line with its Financial Recovery Plan. Of the £110m Cost Improvement Programme (CIP) target, 76% had been fully developed. • The committee had reviewed the Finance Report for Month 6 (item 5.8), noting that the Trust had reported an in-month deficit of £5.4m, which was in line with the Financial Recovery Plan. • The committee had expressed concern that 17% of the CIP target was not fully developed and that the Trust was £2.5m off-track in terms of delivery of the target at Month 6. • Whilst progress had been made in terms of addressing patients with no criteria to reside and mental health patients, this remained an area of concern. • The committee considered the NHS England Medium Term Planning Framework, noting that the first submission by the Trust was due prior to Christmas 2025. 5.3 Briefing from the Chair of the People and Organisational Development Committee Jane Harwood was invited to present the Committee Chair’s Reports in respect of the meetings held on 22 September and 3 November 2025, the contents of which were noted. It was further noted that: • There continued to be little improvement in terms of the number of patients with no criteria to reside or mental health patients, which impacted staffing numbers. • The Trust was adopting a harder line in respect of its approach to violence and aggression, which included a greater willingness to exclude individuals. • The current participation rate in the Staff Survey was lower than the national average, which was likely indicative of staff morale and engagement. Page 2 • The Trust’s workforce numbers remained above plan, with limited options available to address this issue, especially in the absence of funding for restructuring costs. 5.4 Briefing from the Chair of the Quality Committee Tim Peachey was invited to present the Committee Chair’s Report in respect of the meeting held on 13 October 2025, the content of which was noted. It was further noted that: • The committee received an update in respect of mental health patients, noting that although there were significant issues in the Emergency Department, the whole pathway for these patients remained a problem. • The committee carried out a six-monthly review of the Trust’s progress against its Quality Priorities, noting that good progress had been made on four of the six priorities and two were slightly behind. 5.5 Chief Executive Officer’s Report David French was invited to present the Chief Executive Officer’s Report, the content of which was noted. It was further noted that: • NHS England had published the Medium Term Planning Framework, which was intended to encourage organisations to think beyond a 12-month time horizon and to progress the NHS 10-Year Plan. The Trust was expected to provide its first submission prior to Christmas 2025, but the detailed planning assumptions had yet to be received from NHS England. It was noted that a more detailed report on the Medium Term Planning Framework was to be received as part of the closed session of the meeting. • The Strategic Commissioning Framework had been published by NHS England, which provided welcome clarifications about the future role of integrated care boards. • The Trust had been placed into Tier 1 for both Urgent and Emergency Care and for Elective performance. There was a national expectation that trusts would have no patients waiting over 65 weeks for elective care by 21 December 2025. Where organisations had more than 100 such patients at the end of October 2025, they had been placed into Tier 1. The Trust was taking steps, including mutual aid, to attempt to address the number of long waiters, but there was insufficient capacity in the system. • Resident doctors were due to strike for a further five-day period commencing on 14 November 2025, having rejected the Government’s latest offer to resolve the ongoing dispute with the British Medical Association. • The Hampshire and Isle of Wight Integrated Care Board and NHS England South East Region had carried out a visit to the Trust’s paediatric hearing services in May 2025. The report, received in October 2025, had been positive about the service. • The Trust and the University of Southampton had been awarded £16.3m by the National Institute for Health and Care Research. The Trust was one of only four organisations out of 15 applications to receive an award. • The NHS Business Services Authority had announced the award of a £1.2bn contract to Infosys to deliver a new and enhanced workforce management system for the NHS to replace the existing Electronic Staff Record system. The 2030 target date for implementation was considered ambitious. Further details would be considered by the People and Organisational Development Committee when available. Page 3 5.6 Performance KPI Report for Month 6 Andy Hyett was invited to present the ‘spotlight’ report in respect of Diagnostics, the content of which was noted. It was further noted that: • Diagnostics performance was a key element of the pathway, as delays in diagnosis had a consequential impact on the overall length of pathways such as those for cancer and patients on a Referral To Treatment pathway. • Although there were some concerns with Diagnostics in the Trust, the Trust, generally, performed better than other organisations. The Board discussed the matters raised in the Diagnostics ‘spotlight’. This discussion is summarised below: • There had been a long-standing issue with waiting times for cystoscopy due to insufficient capacity. However, a plan was being developed to improve the situation, although it was considered appropriate that the plan should also address broader issues with urology as a whole. • There was concern regarding the availability of magnetic resonance imaging (MRI) scanners, particularly as two scanners were out-of-action. It was noted that the current set-up in terms of MRI scanners was not fit for the longer term and a strategy for the future needed to be developed. • There was a disparity between capacity and demand in respect of the neurophysiology service, as this service had previously relied on outsourcing. • Generally, activity was increasing, but overall performance appeared to be declining. There was also the additional financial challenge that Diagnostics was funded under a ‘block’ contract arrangement which did not fully take into account the demand for these services. • There were concerns about the electrical supply capacity at the Southampton General Hospital site and the ability of the Trust to expand its Diagnostic capacity with this limitation. It was considered that a better longer-term model would be for scanners at local community diagnostics centres. Actions Andy Hyett agreed to work on and present at either a future Board meeting or Trust Board Study Session the Trust’s longer-term strategy with respect to MRI scanners and imaging. Andy Hyett agreed to develop a longer-term plan for cystoscopy/urology and to report back to the Board during Quarter 4. Andy Hyett agreed to develop a long-term solution to the neurophysiology service. Andy Hyett was invited to present the Performance KPI Report for Month 6, the content of which was noted. It was further noted that: • The Trust’s Emergency Department had recorded performance of 67.6% against the four-hour standard during September 2025. The department remained busy with c.450 patients and 120 ambulance attendances per day. • There had been some initial performance impacts with the roll out of the MIYA system in the Emergency Department, but this appeared to have now been addressed with performance up to previous levels. • A number of initiatives were being introduced into the Emergency Department in order to improve performance. These included the layout of the service, pathway re-designs, having General Practitioners in the department, and arranging with non-urgent patients to attend at a scheduled time rather than waiting in the department. Page 4 • In October 2025, the Trust had recorded 363 patients waiting over 65 weeks on a Referral To Treatment pathway against a national target of no such patients by the end of December 2025. • The Trust was making use of the independent sector, weekend working, and was requesting capacity from other providers to address the number of patients waiting over 65 weeks. • The planned industrial action by resident doctors posed a challenge, noting that the national expectation was that trusts maintain 95% of their capacity during this period. It was noted that, in contrast to previous instances of industrial action, resident doctors were apparently less forthcoming in terms of whether they intended to participate in the industrial action. • The Trust continued to report one of the lowest Hospital Standardised Mortality Rates in England. • The Trust’s cancer performance, based on a BBC article, was 21 out of 121 trusts. It was noted that whilst the number of patients being referred on a cancer pathway had increased significantly, the number of patients diagnosed with cancer had not materially changed. • There appeared to have been an increase in the number of pressure ulcers and ‘red flag’ incidents. Work was ongoing to address the findings of the pressure ulcer audit which had been presented to the Quality Committee on 2 June 2025. • The number of patients having no criteria to reside and mental health patients remained high. Actions Andy Hyett agreed to clarify the basis of the calculation of the ‘Watch & Reserve antibiotics usage per 1,000 adms’ metric. 5.7 Break 5.8 Finance Report for Month 6 Ian Howard was invited to present the Finance Report for Month 6, the content of which was noted. It was further noted that: • The Trust had submitted its Financial Recovery Plan to NHS England in August 2025, which committed to an additional £23m improvement in the Trust’s financial position to deliver a full-year position of a £54.9m deficit. In the absence of these additional improvements, the Trust had been forecasting a year-end position of a £78m deficit. The revised target was subject to a number of assumptions, including the need for demand management and improvements in non-criteria to reside and mental health patient numbers. • There were a number of risks to the achievement of the Financial Recovery Plan, including whether there would be improvements in mental health and non-criteria to reside and/or steps taken to manage demand, high levels of activity, and whether it would be possible to reduce the workforce and close theatres. The need for the Trust to focus on achieving the 65-week wait target in particular could impact the Trust’s ability to close capacity. • The Trust had reported an in-month deficit of £5.4m (£30.8m year-to-date), which was in line with the trajectory set out in the Financial Recovery Plan. The Trust’s underlying deficit had seen some marginal improvement during the period. • The Trust’s cash position remains an area of significant concern. Cash requests had been made to NHS England, but the latest request for November 2025 had been rejected. It was therefore likely that the Trust would need to manage its supplier payments in accordance with its available cash. Page 5 5.9 ICS System Report for Month 6 Ian Howard was invited to present the ICS System Report for Month 6, the content of which was noted. It was further noted that: • The Hampshire and Isle of Wight Integrated Care System had reported a year- to-date deficit of £48m. • A significant improvement in the run-rate would be required for the system to be able to deliver its 2025/26 plan. • The system was one of the worst in England in terms of the number of beds occupied by patients having no criteria to reside with approximately 23% of beds being occupied by such patients compared with a national average of 12%. • The system was also below plan in terms of its targets for access to General Practitioners and targets relating to mental health patients. It was noted that the performance in these areas had a consequential impact on the Trust’s performance in areas such as urgent and emergency care performance. 5.10 People Report for Month 6 Steve Harris was invited to present the People Report for Month 6, the content of which was noted. It was further noted that: • The overall workforce fell by 73 whole-time-equivalents (WTE) during September 2025 and was reported as being 54 WTE above the Trust’s 2025/26 plan. The reduction in workforce had been driven through a combination of the impact of the recruitment controls, mutually agreed resignation scheme (MARS) leavers, and a significant drop in use of temporary staff during the month. • On 15 October 2025, the Trust had heard the collective grievance brought by the Royal College of Nursing in respect of the removal of enhanced NHS Professionals rates. It was decided not to reverse the decision in order to maintain equity with the rest of the workforce and consistency across other local providers. A number of actions had been agreed following the hearing. • Sickness rates had increased to 3.8%, although the Trust still benchmarked well against peers. • There were concerns about the potential impact of influenza during the winter period and therefore the Trust was taking a number of actions to promote vaccination of staff. The Trust was currently third in terms of uptake in the Region. • The level of participation in the national Staff Survey remained a challenge with only 32% of staff having completed the survey compared with a national average of 38%. It was considered likely that the recent difficult decisions taken and the impact on staff was impacting staff experience and engagement. • The People and Organisational Development Committee would be examining statutory and mandatory training levels together with the latest proposed national changes. Page 6 5.11 NHSE Audit and review of 'Developing Workforce Safeguards' including UHS Self-Assessment Return Natasha Watts was invited to present the NHS England audit and review of ‘Developing Workforce Safeguards’ (2018), including the Trust’s Self-Assessment Return, the content of which was noted. It was further noted that: • ‘Developing Workforce Safeguards’ was published in October 2018 and included a range of standards to assure safe staffing across the workforce. NHS England had initiated an audit, review and improvement plan amidst concern about a national reduction in compliance. • The Trust had submitted a self-assessment as part of this NHS England review. This assessment showed that the Trust continued to comply with the majority of the standards. • The audit exercise has been used as an opportunity to identify opportunities for improvement. Twelve recommendations have been developed, of which nine were assessed as ‘green’ and three as ‘amber’. 5.12 Guardian of Safe Working Hours Quarterly Report and Update on 10-Point Plan Diana Hulbert was invited to present the Guardian of Safe Working Hours Quarterly Report and Update on the 10-Point Plan, the content of which was noted. It was further noted that: • Resident doctors were due to strike for five days from 14 November 2025. This would be the thirteenth strike in recent years. It was noted that, in addition to pay, the dispute also concerned working conditions and the shortage of posts and consequent risk to resident doctors of unemployment. • The Trust had performed a self-assessment against the 10-Point Plan and it was noted that the majority of the plan’s contents had been considered by the Trust for some time. There were also a number of dependencies on the part of NHS England in areas such as lead employer models. • A national review of statutory and mandatory training was expected to enable portability of training records to facilitate staff moving between NHS organisations. • There had been significant improvements in respect of gaps in rotas. 5.13 Annual Clinical Outcomes Summary Luci Hood and Kate Pryde were invited to present the Annual Clinical Outcomes Summary Report, the content of which was noted. It was further noted that: • The paper provided an overview of the clinical outcomes reviewed by the Clinical Assurance Meeting for Effectiveness and Outcomes (CAMEO) over the 12-month period to September 2025. • The majority of specialities provide reports to CAMEO, although outcome data can be more difficult in some areas to capture than in others. • The outcomes reviewed by the CAMEO and outputs from this body were also influencing the development of the Trust’s clinical strategy. • The strains on the capacity of services posed a risk to clinical outcomes. Page 7 • There was potential that a ‘quality’ override could form part of the NHS Oversight Framework in the future, operating in a similar manner to the ‘financial’ override by limiting the segmentations available to an organisation. 6. STRATEGY and BUSINESS PLANNING 6.1 Corporate Objectives 2025-26 Quarter 2 Review Martin De Sousa was invited to present the review of Corporate Objectives 2025/26 for the second quarter, the content of which was noted. It was further noted that: • Of the 12 objectives agreed for 2025/26, six were rated ‘green’, four were ‘amber’ and two were ‘red’. • The ‘red’ rated risks were that relating to the Trust’s financial performance and that relating to the Trust’s achievement of its workforce plan for 2025/26. 6.2 Board Assurance Framework (BAF) Update Lauren Anderson was invited to present the Board Assurance Framework update, the content of which was noted. It was further noted that: • BDO had completed its audit of the Trust’s risk maturity and had presented its report to the Audit and Risk Committee on 13 October 2025. The audit had highlighted a number of strengths including the Board Assurance Framework, risk definition, and use of risk in decision-making. In terms of opportunities for improvement, the audit report suggested some improvements in articulation of operational risks and use of ‘SMART’ methodology for actions. • The Board Assurance Framework had been reviewed by relevant executive directors and committees since it was last presented to the Board. There had been no changes to the ratings or target dates. 7. CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Feedback from the Council of Governors’ (COG) Meeting 28 October 2025 The Chair presented a summary of the Council of Governors’ meeting held on 28 October 2025. It was noted that the meeting had considered the following matters: • Chief Executive Officer’s Performance Report • Governor attendance at Council of Governors’ meetings • Review of the Council of Governors’ Expenses Reimbursement Protocol • Appointment of Jane Harwood as Deputy Chair with effect from 1 October 2025 • Membership engagement • Feedback from the Governors’ Nomination Committee It was noted that the Trust’s work on violence and aggression received particular attention from the Governors. 7.2 Register of Seals and Chair’s Action Report The paper ‘Register of Seals and Chair’s Actions Report’ was presented to the meeting, the content of which was noted. Page 8 It was further noted that one further item had been sealed on 7 November: Deed of Guarantee between University Hospital Southampton NHS Foundation Trust (Guarantor) and CHG-Meridian UK Limited (Beneficiary) regarding the payment and due performance obligations of UHS Estates Limited (UEL) under the Guaranteed Contract and specifically the Stryker Power Tools delivered to UEL under the pre-contract open build period with CHG. Seal number 307 on 7 November 2025. Decision: The Board agreed to ratify the application of the Trust Seal to the documents listed in the ‘Register of Seals and Chair’s Actions Report’ and to the additional document referred to above. 7.3 Health and Safety Services Annual Report 2024-25 Spencer Scott was invited to present the Health and Safety Services Annual Report 2024/25, the content of which was noted. It was further noted that: • The number of incidents reportable pursuant to the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) had increased substantially to 68 such incidents compared to 39 in 2023/24. The majority of these incidents related to moving and handling or exposure to infectious diseases. • There was a concern that there had been a reduction in the number of health and safety related reports and escalations whilst at the same time the number of RIDDORs had increased. • Four areas of concern were highlighted: Entonox surveillance of maternity staff, display screen equipment compliance, the Southampton General Hospital loading bay, and workplace temperatures during the summer. 8. Any other business There was no other business. 9. Note the date of the next meeting: 13 January 2026 10. Items circulated to the Board for reading The item circulated to the Board for reading was noted. There being no further business, the meeting concluded. 11. Resolution regarding the Press, Public and Others Decision: The Board resolved that, as permitted by the National Health Service Act 2006 (as amended), the Trust’s Constitution and the Standing Orders of the board of directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. The meeting was adjourned. Page 9 List of action items Agenda item Assigned to Deadline Status Trust Board – Open Session 15/07/2025 - 5.11 Freedom to Speak Up Report 1267. Data Mbabazi, Christine 10/03/2026 Pending Explanation action item Christine Mbabazi to include data from other mechanisms for reporting concerns in future Freedom to Speak Up reports. Trust Board – Open Session 09/09/2025 - 8 Any other business 1286. Organ donation Machell, Craig 03/02/2026 Pending Explanation action item Craig Machell agreed to add organ donation to the agenda of a future Trust Board Study Session. Update: Scheduled for TBSS on 03/02/26. Trust Board – Open Session 11/11/2025 - 5.6 Performance KPI Report for Month 6 1293. MRI scanners and imaging Hyett, Andy 13/01/2026 Pending Explanation action item Andy Hyett agreed to work on and present at either a future Board meeting or Trust Board Study Session the Trust’s longer-term strategy with respect to MRI scanners and imaging. 1294. Cystopscopy/urology Hyett, Andy 13/01/2026 Pending Explanation action item Andy Hyett agreed to develop a longer-term plan for cystoscopy/urology and to report back to the Board during Quarter 4. Page 1 of 2 Agenda item Assigned to Deadline Status Trust Board – Open Session 11/11/2025 - 5.6 Performance KPI Report for Month 6 1295. Neurophysiology Hyett, Andy 13/01/2026 Pending Explanation action item Andy Hyett agreed to develop a long-term solution to the neurophysiology service. 1296. Watch & Reserve antibiotics usage Hyett, Andy 13/01/2026 Pending Explanation action item Andy Hyett agreed to clarify the basis of the calculation of the ‘Watch & Reserve antibiotics usage per 1,000 adms’ metric. Page 2 of 2 Agenda Item 5.1 i) Committee Chair’s Report to the Trust Board of Directors 13 January 2026 Committee: Finance, Investment and Cash Committee Meeting Date: 24 November 2025 Key Messages: Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) Any Other Matters: • The committee received an update in respect of the Trust’s commercial activities, noting that the Trust had robust systems in place to maximise cost recovery for private patient and overseas visitor income. The Trust’s private patient unit project continued to progress. The Trust was also seeking a partner to manage its parking provision. • The committee received the Finance Report for Month 7. The Trust had reported a £5.1m in-month deficit (£35.9m year-to-date), which was in line with the trajectory contained in the Financial Recovery Plan. The underlying deficit remained flat at £6.4m. Whilst there had been a slight reduction in the number of mental health patients, there were c.240 patients having no criteria to reside at any point during the period. There was an increased level of scrutiny in respect of non-pay expenditure. • The committee reviewed an update on the Trust’s measures for financial improvement, noting that the Trust was forecasting achievement of £85-95m against its target of £110m Cost Improvement Programme delivery for 2025/26. • The committee noted the Trust’s approach and the timelines associated with the Medium Term Planning submission. It was noted that the framework set ambitious financial and performance targets. • The committee received an update in respect of the Trust’s Theatre Experience Programme, noting that there had been a 3% increase in utilisation and a 3% reduction in cancellations. • The committee reviewed the Trust’s productivity, noting that the Trust’s productivity had fallen by 3.3% compared to the prior year due to high-cost growth. • The committee received an update in respect of the Trust’s cash position and forecast and supported a proposal to request further cash support for January 2026. • The committee received an update on Capital Planning for 2026/272029/30. It was noted that it was expected that the Trust would be allocated c.£40m per annum, although there were concerns about the impact of the Trust’s cash position and the ability of the Trust to meet this level of expenditure. N/A N/A Page 1 of 2 Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Limited Assurance Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. No Assurance There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Not Applicable Where assurance is not required and/or relevant. Risk Rating: Low Medium High Not Applicable Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda Item 5.1 ii) Committee Chair’s Report to the Trust Board of Directors 13 January 2026 Committee: Finance, Investment and Cash Committee Meeting Date: 15 December 2025 Key Messages: • • • • • • The committee received the Finance Report for Month 8 (see below). The committee discussed the Trust’s future transformation programmes, noting that the areas of focus would be: urgent and emergency care, elective care, and automation of administrative processes. The committee was assured that the programmes were felt to be suitably ‘bold and ambitious’ and were grounded in realistic opportunities, rather than ‘blue sky’ ideas. The committee reviewed the draft capital plan for 2026/27 – 2029/30, noting that the Trust had been allocated c.£40m of capital departmental expenditure limit (CDEL) per year. It was noted that the Trust’s cash position could place constraints on the Trust’s capital programme. The opportunity to secure funding from national programmes outside of CDEL should be pursued vigorously. The plan was to be discussed in a Trust Board Study Session prior to submission in February 2026. The committee reviewed, challenged and discussed the Trust’s medium-term plan ahead of the first submission to NHS England on 17 December 2025. The committee provided feedback in respect of the proposed submission noting that some of the assumptions within the 2025/26 plan had not materialised with regard to matters such as reductions in non-criteria to reside numbers and the committee sought assurance that learnings had been applied to the development of the medium-term plan submission. The committee was assured that such assumed reductions within the 2026/27 plan were based purely on actions which were deemed to be within the Trust’s control. The committee suggested some changes with regard to the plan, particularly around growth assumptions in the cost base, and agreed to recommend the revised plan to the Board for approval. It was noted that more detail and reviews would be required prior to the final submission date in February 2026. The committee received an update in respect of the Trust’s cash position and supported a proposal to make a further request for cash support from NHS England for January 2026. The Trust reviewed and supported a proposal for transforming the Southern Counties Pathology network. Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) 5.7 Finance Report for Month 8 Assurance Rating: Risk Rating: Substantial High • The Trust had reported an in-month deficit of £4.9m (£40m year-todate), which was consistent with the Trust’s Financial Recovery Plan. • November 2025 had been a challenging month due to costs associated with industrial action, patients with no criteria to reside and mental health patients. • The Trust had received c.£3m of income out of £6.1m for elective over-performance. • There had been a slight improvement in the Trust’s underlying deficit. Page 1 of 2 Any Other N/A Matters: Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Limited Assurance Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. No Assurance There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Not Applicable Where assurance is not required and/or relevant. Risk Rating: Low Medium High Not Applicable Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda Item 5.2 i) Committee Chair’s Report to the Trust Board of Directors 13 January 2026 Committee: People & Organisational Development Committee Meeting Date: 21 November 2025 Key Messages: • • • • The committee reviewed the People Report for Month 7 including progress against the workforce plan. During October 2025, the overall workforce grew by 14 whole-time-equivalents (WTE). Although the substantive workforce had reduced by 15 WTE, there had been lowerthan-expected turnover and increased temporary staffing usage due in part to high sickness levels. The Trust remained on track, however, with respect to its Financial Recovery Plan trajectory. There were concerns about the response rate to the Staff Survey, which was below the national average. The Trust’s vaccination campaign for staff had started well with the uptake rate for the flu vaccine amongst staff at 43%. The committee considered the outputs of the review by NHS England of statutory and mandatory training and the implications for UHS. It was noted that a revised framework would facilitate passporting of training between NHS organisations. The Trust was aligned to the Core Skills Training Framework across six out of eleven areas and ten out of eleven areas for the Utilising E-Learning for Health material. The committee received an update in respect of the Trust’s Inclusion and Belonging strategy. It was noted that resource constraints and the impact of the current financial and operational environment on staff morale had impacted progress towards achievement of the objectives set out in the strategy. The committee reviewed the People risks contained within the Trust’s Board Assurance Framework. Assurance: N/A (Reports/Papers reviewed by the Committee also appearing on the Board agenda) Any Other N/A Matters: Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Limited Assurance Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. Page 1 of 2 No Assurance Not Applicable Risk Rating: Low Medium High Not Applicable There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Where assurance is not required and/or relevant. Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda Item 5.2 ii) Committee Chair’s Report to the Trust Board of Directors 13 January 2026 Committee: People & Organisational Development Committee Meeting Date: 15 December 2025 Key Messages: Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) • The committee reviewed the People Report for Month 8 (see below) including progress against the workforce plan and Financial Recovery Plan. • The committee considered the workforce implications of the Trust’s medium term plan submission, noting that there were a number of national expectations and targets, such as those relating to sickness rates and elimination of agency spend. In addition, the committee noted the risks associated with the plan, including those where the Trust was reliant on progress with respect to non-criteria to reside and mental health numbers. • The committee received an update regarding the Trust’s Violence and Aggression workstream, noting that the Trust had adopted a revised approach to violence, aggression and abuse directed at staff with a greater willingness to take action against violent/abusive patients and members of the public. A violence and aggression board had been established to provide executive oversight and leadership, and the Trust’s policy was being revised. This work would be accompanied by a comprehensive communication plan for both staff and members of the public. • The committee reviewed the Trust’s progress against its objectives for Year 4 of its People Strategy. 5.9 People Report for Month 8 Assurance Rating: Risk Rating: Substantial High • The overall workforce fell during November 2025, with substantive numbers falling by 52 whole-time-equivalents (WTE). However, temporary staffing use had increased during the month due to increased sickness and operational pressures, which offset much of the reduction in substantive numbers. • The Trust was over its original plan by 214 WTE despite a decrease of nearly 400 WTE since 31 March 2025. In order to hit the Trust’s Financial Recovery Plan target, the overall workforce would need to fall by a further 137 WTE (including a 72 WTE reduction in temporary staffing) by the end of March 2026. • A forecast based on the previous year’s temporary staffing usage for the remaining months of the year indicated that the Trust would end the year approximately 500 WTE above the Trust’s 2025/26 plan. • The Trust had submitted a baseline assessment against the 10 Point Plan to improve Resident Doctors’ working lives in August 2025, which indicated that the Trust compared favourably against other organisations in the South East. The main issues concerned space available for doctors to work in and timeliness of reimbursement of course-related expenses. • The Trust was expected to meet a target of 95% of job plans having been signed off prior to 31 March 2026. At the start of December 2025, 55% of job plans had been signed off. Page 1 of 2 Any Other Matters: • Sickness absence had increased in November 2025 to 4.2% in month due to seasonal illnesses. • The staff survey closed on 28 November 2025. The completion rate for the staff survey had been lower t
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Papers Trust Board - 13 January 2026

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