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Papers Trust Board - 13 January 2026

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

Temporary changes to outpatient pharmacy

Description: The outpatient pharmacy at Southampton General Hospital is undergoing a redesign, with work starting on Saturday, 17 August. This essential work will improve efficiency of our pharmacy and the experience our patients receive.
Url: /AboutTheTrust/Newsandpublications/Latestnews/2019/August/Temporary-changes-to-outpatient-pharmacy.aspx

Papers Trust Board - 15 July 2025

Description: Agenda Trust Board – Open Session Date 15/07/2025 Time 9:00 - 13:00 Location Conference Room, Heartbeat Education Centre Chair Jenni Douglas-Todd Apologies Alison Tattersall In attendance Lauren Anderson, Corporate Governance and Risk Manager (from 9:30) (shadowing Craig Machell) 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 13 May 2025 9:15 Approve the minutes of the previous meeting held on 13 May 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 Audit and Risk Committee 9:20 Keith Evans, Chair 5.2 Briefing from the Chair of the Finance and Investment Committee 9:25 Dave Bennett, Chair 5.3 Briefing from the Chair of the People and Organisational Development 9:30 Committee Jane Harwood, Chair 5.4 Briefing from the Chair of the Quality Committee 9:35 Tim Peachey, Chair including Maternity and Neonatal Safety 2024-25 Quarter 4 Report and Maternity and Neonatal Workforce Report 5.5 Chief Executive Officer's Report 9:40 Receive and note the report Sponsor: David French, Chief Executive Officer 5.6 Performance KPI Report for Month 2 10:10 Review and discuss the report Sponsor: David French, Chief Executive Officer 5.7 Break 10:40 5.8 Finance Report for Month 2 10:55 Review and discuss the report Sponsor: Ian Howard, Chief Financial Officer 5.9 ICS Operational Delivery Report for Month 2 11:05 Receive and discuss the report Sponsor: Ian Howard, Chief Financial Officer 5.10 People Report for Month 2 11:10 Review and discuss the report Sponsor: Steve Harris, Chief People Officer 5.11 Freedom to Speak Up Report 11:20 Review and discuss the report Sponsor: Gail Byrne, Chief Nursing Officer Attendee: Christine Mbabazi, Equality & Inclusion Adviser/Freedom to Speak Up Guardian 5.12 Infection Prevention and Control 2024-25 Annual Report 11:30 Receive and discuss Sponsor: Gail Byrne, Chief Nursing Officer Attendees: Julian Sutton, Clinical Lead, Department of Infection/Julie Brooks, Deputy Director of Infection Prevention and Control 5.13 Guardian of Safe Working Hours Quarterly Report 11:40 Receive and discuss the report Sponsor: Paul Grundy, Chief Medical Officer 6 STRATEGY and BUSINESS PLANNING 6.1 Corporate Objectives 2025-26 Quarter 1 Review 11:50 Review and feedback on the corporate objectives Sponsor: David French, Chief Executive Officer Attendee: Martin De Sousa, Director of Strategy and Partnerships 6.2 Research and Development Plan 2025-26 12:00 Discuss and approve the plan Sponsor: Paul Grundy, Chief Medical Officer Attendees: Christopher Kipps, Clinical Director of R&D/Karen Underwood, Director of R&D/Laura Purandare, Deputy Director of R&D Page 2 6.3 Board Assurance Framework (BAF) Update and Risk Appetite Statement 12:10 Review and discuss the update. Review and ratify the risk appetite statement. Sponsor: Gail Byrne, Chief Nursing Officer Attendees: Craig Machell, Associate Director of Corporate Affairs and Company Secretary/Lauren Anderson, Corporate Governance and Risk Manager 7 CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Register of Seals and Chair's Actions Report 12:30 Receive and ratify In compliance with the Trust Standing Orders, Financial Instructions, and the Scheme of Reservation and Delegation. Sponsor: Jenni Douglas-Todd, Trust Chair 7.2 Review of Standing Financial Instructions 2025 12:35 Review and approve the SFIs Sponsor: Ian Howard, Chief Financial Officer Attendee: Phil Bunting, Director of Operational Finance 8 Any other business 12:40 Raise any relevant or urgent matters that are not on the agenda 9 Note the date of the next meeting: 9 September 2025 10 Resolution regarding the Press, Public and Others Sponsor: Jenni Douglas-Todd, Trust Chair To agree, as permitted by the National Health Service Act 2006 (as amended), the Trust's Constitution and the Standing Orders of the Board of Directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. 11 Follow-up discussion with governors 12:45 Page 3 Agenda links to the Board Assurance Framework (BAF) 15 July 2025 – Open Session Overview of the BAF Risk 1a: Lack of capacity to appropriately respond to emergency demand, manage the increasing waiting lists for elective demand, and provide timely diagnostics, that results in avoidable harm to patients. 1b: Due to the current challenges, we fail to provide patients and their families / carers with a high-quality experience of care and positive patient outcomes. 1c: We do not effectively plan for and implement infection prevention and control measures that reduce the number of hospital-acquired infections and limit the number of nosocomial outbreaks of infection. 2a: We do not take full advantage of our position as a leading University teaching hospital with a growing, reputable, and innovative research and development portfolio, attracting the best staff and efficiently delivering the best possible treatments and care for our patients. 3a: We are unable to meet current and planned service requirements due to the unavailability of staff to fulfil key roles. 3b: We fail to develop a diverse, compassionate, and inclusive workforce, providing a more positive staff experience for all staff. 3c: We fail to create a sustainable and innovative education and development response to meet the current and future workforce needs identified in the Trust’s longer-term workforce plan. 4a: We do not implement effective models to deliver integrated and networked care, resulting in sub-optimal patient experience and outcomes, increased numbers of admissions and increases in patients’ length of stay. 5a: We are unable to deliver a financial breakeven position, resulting in: inability to move out of the NHS England Recovery Support Programme, NHS England imposing additional controls/undertakings, and a reducing cash balance impacting the Trust’s ability to invest in line with its capital plan, estates/digital strategies, and in transformation initiatives. 5b: We do not adequately maintain, improve and develop our estate to deliver our clinical services and increase capacity. 5c: Our digital technology or infrastructure fails to the extent that it impacts our ability to deliver care effectively and safely within the organisation, 5d: We fail to prioritise green initiatives to deliver a trajectory that will reduce our direct and indirect carbon footprint by 80% by 2028-2032 (compared with a 1990 baseline) and reach net zero direct carbon emissions by 2040 and net zero indirect carbon emissions by 2045. Agenda links to the BAF No Item Linked BAF risk(s) 5.6 Performance KPI Report for Month 2 5.8 Finance Report for Month 2 5.9 ICS Finance Report for Month 2 5.10 People Report for Month 2 5.11 Freedom to Speak Up Report 5.12 Infection Prevention and Control 2024-25 Annual Report 5.13 Guardian of Safe Working Hours Quarterly Report 6.1 Corporate Objectives 2025-26 Quarter 1 Review 6.2 Research and Development Plan 2025-26 1a, 1b, 1c 5a 5a 3a, 3b, 3c 3b 1c 3b All 2a 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) 4x5 20 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 13/05/2025 Time 9:00 – 13:00 Location Conference Room, Heartbeat/Microsoft Teams Chair Jenni Douglas-Todd (JD-T) Present Dave Bennett, NED (DB) Gail Byrne, Chief Nursing Officer (GB) Jenni Douglas-Todd, Chair (JD-T) Diana Eccles, NED (DE) David French, Chief Executive Officer (DAF) Paul Grundy, Chief Medical Officer (PG) Steve Harris, Chief People Officer (SH) Jane Harwood, NED/Senior Independent Director (JH) Ian Howard, Chief Financial Officer (IH) Duncan Linning-Karp, Interim Chief Operating Officer (DL-K) David Liverseidge, NED (DL) Tim Peachey, NED (TP) In attendance Martin De Sousa, Director of Strategy and Partnerships (MDeS) Craig Machell, Associate Director of Corporate Affairs and Company Secretary (CM) Ceri Connor, Director of OD and Inclusion (CC) (item 5.11) Lauren Anderson, Corporate Governance and Risk Manager (LA) (item 6.2) Diana Hulbert, Guardian of Safe working Hours and Emergency Department Consultant (DH) (item 5.12) Kelly Kent, Head of Strategy and Partnerships (KK) (item 6.1) Jenny Milner, Associate Director of Patient Experience (JM) (item 5.13) Natasha Watts, Deputy Chief Nursing Officer (NW) (item 5.13) Helena Blake, Head of Clinical Quality Assurance (shadowing G Byrne) Raquel Domene Luque, Interim Lead Matron, Ophthalmology (shadowing G Byrne) 1 governor (observing) 6 members of staff (observing) 3 members of the public (observing) Apologies Keith Evans, Deputy Chair and NED (KE) Alison Tattersall, NED (AT) 1. Chair’s Welcome, Apologies and Declarations of Interest The Chair welcomed attendees to the meeting. There were no interests to declare in the business to be transacted at the meeting. It was noted that apologies had been received from Keith Evans and Alison Tattersall. 2. Patient Story Item postponed to the next meeting. 3. Minutes of the Previous Meeting held on 11 March 2025 The draft minutes tabled to the meeting were agreed to be an accurate record of the meeting held on 11 March 2025. Page 1 4. Matters Arising and Summary of Agreed Actions The matters arising and actions were noted. It was noted that action 1218 could be closed. 5. QUALITY, PERFORMANCE and FINANCE 5.1 Briefing from the Chair of the Audit and Risk Committee Ian Howard was invited to present the Committee Chair’s Report in respect of the meeting held on 17 March 2025, the content of which was noted. It was further noted that: • The committee considered the going concern assessment in respect of the 2024/25 annual accounts and agreed that it was appropriate that the accounts be prepared on a going concern basis. • The committee additionally noted that there had been no significant issues raised by the Trust’s external auditors. • The committee received a report on losses and special payments during 2024/25, noting that these payments generally related to lost patient property. • An update was received in respect of Information Governance. The Trust – in common with most others – was not expected to meet the standards set out in the Data Security and Protection Toolkit due to the introduction of the Cyber Assurance Framework as part of the Toolkit requirements. 5.2 Briefing from the Chair of the Finance and Investment Committee The chair of the Finance and Investment Committee was invited to present the Committee Chair’s Reports in respect of the meetings held on 24 March and 28 April 2025, the content of which was noted. It was further noted that: • The committee reviewed the Finance Report for Month 12 (item 5.8), noting that the Trust had achieved its forecast deficit of £7m for 2024/25 following the receipt of revenue support. Furthermore, the Trust had achieved £85.3m of Cost Improvement Programme delivery and Elective Recovery performance of 127%. Nonetheless, the Trust’s underlying deficit was circa £75m. • The Trust’s cash position remained challenging with the Trust likely to require revenue support during either the first or second quarters of 2025/26. • The committee reviewed the Trust’s proposed 2025/26 plan during March 2025 and noted that there were no material changes between the draft reviewed and that submitted on 23 April 2025. • The committee supported a proposal for the Trust to participate in the elective hub at Winchester. 5.3 Briefing from the Chair of the People and Organisational Development Committee The chair of the People and Organisational Development Committee was invited to present the Committee Chair’s Reports in respect of the meetings held on 24 March and 25 April 2025, the content of which was noted. It was further noted that: • The committee received a briefing in respect of the Staff Survey 2024 (item 5.11). • The committee reviewed the People Report for Month 12 (item 5.10), noting that the Trust had ended the year 373 whole-time-equivalents (WTE) above plan. This was largely due to the reductions in patients having no criteria to reside and mental health patients not materialising. In addition, there had been higher than normal use of bank staff in March 2025 and lower than anticipated staff turnover. Page 2 • An update in respect of the planned organisational restructuring, including regarding the Equality and Quality Impact Assessment process being developed. • It was considered likely that the delivery of the Trust’s 2025/26 workforce plan would necessitate additional workforce controls. It would be important to ensure that appropriate support was provided to staff in managing at a time of increased demand, financial pressures, and a reducing workforce. 5.4 Briefing from the Chair of the Quality Committee The chair of the Quality Committee was invited to present the Committee Chair’s Report in respect of the meeting held on 17 March 2025, the content of which was noted. It was further noted that: • The committee reviewed the Trust’s quality indicators, which continued to indicate that the organisation was under pressure. • Following an incident at Derriford Hospital in Plymouth on 4 March 2022 whereby a member of the public had suffered fatal injuries due to the downwash from a landing helicopter, the Trust had commissioned a review of its own safety arrangements. It was noted that some additional safety measures would be required. • A visit by NHS South East Region to the Princess Anne Hospital in February 2025 had provided some positive feedback about the service. The Maternity and Neonatal Safety 2024/25 Quarter 3 Report was noted. It was further noted that: • The report had been reviewed by the Quality Committee at its meeting held on 17 March 2025. • The proportion of births via caesarean section remained high at over 40%, with late requests in particular placing additional pressure on theatre capacity. • Following successful recruitment of additional staff in late 2024, operational pressures had reduced substantially compared with the previous situation. • A never event relating to a missing swab was under investigation. • The Trust was currently over establishment in terms of its number of midwives and expected to be staffed above the requirement indicated by the anticipated birthrate for the area by the end of 2025/26. 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: • Significant reorganisations of NHS England and integrated care boards (ICBs) had been announced. NHS England was to be abolished, and certain functions merged into the Department of Health and Social Care. Integrated care boards were expected to have to reduce their costs by 50%. • A ‘model’ integrated care board blueprint had been published, which appeared to imply that a significant proportion of ICB functions could be redistributed to providers. • It was expected that the number of ICBs would reduce to 25-30, with each serving populations of c.2m. In Hampshire, ICB and local authority boundaries were expected to align, which was considered to be beneficial. • The British Social Attitudes Survey 2024 showed the lowest satisfaction rating for the NHS since the survey began. • The Spring Statement and subsequent messaging indicated that there would not be additional funding during 2025/26. • The Trust continued to face significant pressure due to patients having no criteria to reside. Historically, there were typically around 100 such patients at Page 3 any one time, whereas 281 had been reported on 13 May 2025. This was the equivalent of six wards. • The Trust faced significant financial pressure during 2025/26 with a lower financial settlement than expected. In order to meet its plans, the Trust would be required to deliver c.£110m of Cost Improvement Programmes, reductions of 5% in divisions and 10% in Trust Headquarters, coupled with clinical and non-clinical recruitment controls. The Trust continued to experience high demand for services, especially in the Emergency Department. • It was important to protect the frontline and assist the organisation with managing at such a time. 5.6 Performance KPI Report for Month 12 Duncan Linning-Karp was invited to present the Performance KPI Report for Month 12, the content of which was noted. It was further noted that: • The Trust continued to face significant challenges in terms of its Emergency Department performance, with only 57.2% of patients spending less than four hours in the main Emergency Department. An external review was to take place. • There had been a four-month trajectory of increasing numbers of falls. Whether there was any correlation between the increasing number of falls and number of patients having no criteria to reside was being investigated. • The Trust continued to report strong Elective Recovery performance, although the size of the Trust’s waiting list continued to increase. There was some concern as to whether the financial pressures were impacting elective performance and waiting times. • There had been a decrease in the number of virtual outpatient appointments. • Ten never events had been reported as of the end of March 2025. The Trust expected regulatory scrutiny as a result. • The metrics reported in respect of research and development were being reevaluated. Duncan Linning-Karp was invited to present the spotlight on the Mental Health Patient Cohort, the content of which was noted. It was further noted that: • Regular reports on mental health patients were provided to the Quality Committee. • During 2024, there were 347 patients with a decision to admit to a mental health bed whilst at UHS (2023: 303), of these only 13.2% were transferred within the expected 12 hours (2023: 18.5%). During the first quarter of 2025, there had been 92 such patients. If the numbers remained consistent for the rest of 2025, a growth rate of 6% was expected. • In terms of patients brought to the Emergency Department as a hospital-based place of safety detained under section 136 of the Mental Health Act 1983, only 22% of patients brought to the Trust had a physical need, whereas the remaining patients were brought to the Emergency Department due to the lack of an available facility. • There were insufficient beds available at mental health providers, who were also impacted by delayed discharges. • The enhanced care required by mental health patients placed significant demand on the Trust’s resources. The situation appeared to be worsening with around 100 patients at any one time, of which around 10 were acute. • The Trust has met with the Integrated Care Board and mental health provider to push for a working group to address the issue that care for mental health patients at the Trust cost significantly more than the cost for looking after Page 4 patients at a dedicated facility due to the need to engage specialist agency staff. Actions Duncan Linning-Karp agreed to investigate why the number of virtual outpatients appointments had reduced. Gail Byrne agreed to examine the trend in respect of the friends and family test negative score for inpatients. 5.7 Break 5.8 Finance Report for Month 12 Ian Howard was invited to present the Finance Report for Month 12, the content of which was noted. It was further noted that: • The Trust had delivered its forecast £7m deficit at year end. This had been achieved through a combination of additional Cost Improvement Programme (CIP) delivery and additional revenue support • Whilst the Trust had delivered £85.3m of CIP, a significant proportion of this was non-recurrent. The Trust continued to record an underlying deficit of £6- 7m per month. • The Trust had £17m in cash, below its usual minimum holding of £30m. The Trust continued to closely monitor and manage its cash position, but it was likely that support would be required in the first quarter. • During 2024/25, the Trust had carried out £34m of unpaid for activity, particularly in terms of Emergency Department, non-elective and outpatient follow ups. There were, however, limited opportunities to reduce this activity due to quality impacts . 5.9 ICB Finance Report for Month 12 Ian Howard was invited the present the ICB Finance Report for Month 12, the content of which was noted. It was further noted that: • The Hampshire and Isle of Wight Integrated Care System had achieved a breakeven position for 2024/25. It was noted that this represented a significant achievement given that the system was reporting a cumulative deficit of £80m at Month 5. • The system-wide transformation programmes had had a lower-than-expected impact on the Trust. 5.10 People Report for Month 12 Steve Harris was invited to present the People Report for Month 12, the content of which was noted. It was further noted that: • At year end the Trust was 373 WTE above its 2024/25 plan. There had been a significant increase in use of bank staff in March 2025 due to annual leave and the number of mental health patients. The size of the substantive workforce had, however, reduced, albeit at a lower level than expected. • The formal consultation in respect of the organisational changes had been commenced with the unions. The Trust would be moving from four to three divisions and reducing its workforce. • The Trust had announced its intention to reduce the size of its workforce by 780 WTE (c.6%). This was to be achieved via a combination of natural Page 5 attrition and vacancy control and through a Mutually Agreed Resignation Scheme. • There were a number of risks to achievement of the Trust’s 2025/26 workforce plan, including: quality and safety risks (mitigated through Equality and Quality Impact Assessment); a lower-than-expected turnover rate due to a lack of opportunities elsewhere; the Trust’s cash position; and delivery of non-criteria to reside and mental health patient reductions. • The Trust had released a statement to staff and was awaiting guidance in respect of the recent Supreme Court ruling regarding the definition of a woman under the Equality Act 2010. 5.11 UHS Staff Survey Results 2024 Report Steve Harris was invited to present the UHS Staff Survey Results 2024 Report, the content of which was noted. It was further noted that: • The results of the Staff Survey had been discussed in detail by the People and Organisational Development Committee on 24 March 2025 and at a Trust Board Study Session held on 1 April 2025. • The Trust benchmarked well in certain areas, such as recommendation as a place to work and in terms of views of line management. However, the response rate was lower than in previous years and violence and aggression and civility and dignity scores remained areas of concern. The Board discussed the results of the Staff Survey and agreed that the Trust should focus its efforts on violence and aggression and on helping staff to manage change. It was noted that there was a strong correlation between line manager engagement and the survey response rate. 5.12 Guardian of Safe Working Hours Quarterly Report Diana Hulbert was invited to present the Guardian of Safe Working Hours Quarterly Report, the content of which was noted. It was further noted that: • There was to be a change in the exception reporting process from September 2025. The Trust was considering how best to manage these changes. • The financial constraints during 2025/26 would potentially impact the locum fill rate. • The Trust’s estate remained an issue, but work was ongoing, including consideration of re-purposing existing spaces. • Concerns had been expressed from some seeking consultant posts about the impact of the organisational changes on these opportunities. • The duration of handovers continued to result in breaches of working hour limits. 5.13 Learning from Deaths 2024-25 Quarter 3 and 4 Reports Jenny Milner was invited to present the Learning from Deaths Report, the content of which was noted. It was further noted that: • The Trust’s expected death rate remained lower than the national average, with the Trust ranked 12 out of 119. Page 6 • Further improvements in terms of the sharing of learning from Mortality and Morbidity meetings were required. Consideration was been given to using the Ulysses tool. • The Trust’s medical examiner service had reviewed more than 1,000 deaths since inception. 6. STRATEGY and BUSINESS PLANNING 6.1 Corporate Objectives 2024-25 Quarter 4 Review Martin de Sousa and Kelly Kent were invited to present the Corporate Objectives 2024/25 Quarter 4 Review, the content of which was noted. It was further noted that: • The Trust had delivered 50% of its annual objectives for 2024/25 and 37.5% of objectives had been partially achieved or had incurred minor delays. Two objectives remained ‘red’. • Particular areas to highlight included progress on long-waiters, patient experience, turnover/sickness of staff, and capital scheme delivery. The Trust had also been successful in slowing the rate by which the waiting list grew and in delivering Cost Improvement Programmes. • Areas of concern included the financial position, patients with no criteria to reside, and staff experience. • The Trust was in control of the delivery of some of the objectives, but full delivery of others was outside of the Trust’s control. 6.2 Board Assurance Framework (BAF) Update Lauren Anderson was invited to present the Board Assurance Framework (BAF) Update, the content of which was noted. It was further noted that: • The BAF had been previously reviewed by the Board in March 2025, following which it had been reviewed by the relevant executive directors and committees. • None of the ratings of the risks had been amended. However, the target dates for three risks had been extended to reflect the challenges in achieving the target rating. • The Trust was holding a higher overall level of risk than had previously been the case. It was considered important to ensure that risks were managed across domains and not in silos. • The Trust was using its risk appetite to support decision-making such as in capital prioritisation and in terms of the decisions required to deliver its 2025/26 plans. • A risk appetite review had been scheduled at a future Trust Board Study Session on the basis that the current situation potentially necessitated changes in terms of the Trust’s stated risk appetite. Action The review of risk appetite was to be scheduled to take place at the Trust Board Study Session on 3 June 2025. Page 7 6.3 South Central Regional Research Delivery Network (SC RRDN) 2024-25 Annual Performance Review and 2025-26 Annual Plan Paul Grundy and Clare Rook were invited to present the South Central Regional and Research Delivery Network (SC RRDN) 2024/25 Annual Performance Review and the SC RRDN 2025/26 Annual Plan, the content of which was noted. It was further noted that: • During the year the organisation transitioned from the Clinical Research Network Wessex to the South Central Regional Research Delivery Network, whereby the Wessex and Thames Valley and Midlands Clinical Research Networks were integrated into a single entity. • In the Wessex region, 33,000 participants were recruited to over 500 studies during the first half of the year. A further 35,000 participants were recruited to over 800 studies during the second half of the year in the South Central region. • Commercial research remained a priority, with the South Central region benchmarking well in terms of recruitment. • In terms of the 2025/26 plan, the NHS 10-year plan was awaited, as this would likely impact the plan. It was currently intended that the network would focus on the National Institute for Health Research’s seven priorities. A stakeholder group was being convened to inform the SC RRDN’s direction of travel. 7. CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Feedback from the Council of Governos’ (CoG) meeting 29 April 2025 The Chair presented a summary of the Council of Governors’ meeting held on 29 April 2025. It was noted that the meeting had considered the following matters: • Chief Executive Officer’s Performance Report • Annual Report and Quality Account Timetable 2024/25 • Draft Quality Account • Corporate Objectives • Non-NHS Activity • Governor Attendance at Council of Governor meetings • Council of Governors’ Elections 2025 • Appointment to the Governors’ Nomination Committee • Membership Engagement and Governor activity • Chair’s and Non-Executive Directors’ appraisal outcomes 7.2 Register of Seals and Chair’s Actions Report The paper ‘Register of Seals and Chair’s Actions Report’ was presented to the meeting, the content of which was noted. It was further noted that, due to an issue with the electronic signature platform, a number of items were included in the report, which should have been included in previous reports. 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’. Page 8 8. Any other business Gail Byrne informed the Board that a joint targeted area inspection of the Trust’s Emergency Department and Maternity service by the Care Quality Commission (CQC), social services and the police was scheduled to take place on 20 May 2025, which would focus in particular on safeguarding of children. In addition, a routine Ionising Radiation (Medical Exposure) Regulations inspection was due to take place in June 2025. It was noted that the CQC had recently carried out unannounced inspections at Portsmouth Hospitals University NHS Trust and at South Central Ambulance Service NHS Foundation Trust. Accordingly, it appeared likely that the Trust should also expect an unannounced CQC visit, followed by a Well-Led review. It was noted that this was Dave Bennett’s last formal scheduled Board meeting, as his second three-year term was due to expire on 14 July 2025. The Board expressed its thanks to Dave Bennett. 9. Note the date of the next meeting: 15 July 2025 10. Resolution regarding the Press, Public and Others Decision: The Board resolved that, as permitted by the National Health Service Act 2006 (as amended), the Trust’s Constitution and the Standing Orders of the board of directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. The meeting was adjourned. Page 9 List of action items Agenda item Assigned to Deadline Trust Board – Open Session 13/05/2025 - 5.6 Performance KPI Report for Month 12 1246. Virtual outpatients appointments Linning-Karp, Duncan 15/07/2025 Explanation action item Duncan Linning-Karp agreed to investigate why the number of virtual outpatients appointments had reduced. 1247. Friends and family test Byrne, Gail 15/07/2025 Explanation action item Gail Byrne agreed to examine the trend in respect of the friends and family test negative score for inpatients. Trust Board – Open Session 13/05/2025 - 6.2 Board Assurance Framework (BAF) Update 1248. Risk appetite Byrne, Gail 03/06/2025 Explanation action item The review of risk appetite was to be scheduled to take place at the Trust Board Study Session on 3 June 2025. Status Pending Pending Completed Page 1 of 1 Agenda Item 5.1 Committee Chair’s Report to the Trust Board of Directors 15 July 2025 Committee: Audit & Risk Committee Meeting Date: 9 June 2025 Key Messages: • • • • • The committee considered the results of a review of historical private activity (pre-2022/23) which had not been invoiced by the Trust. It was noted that, of the £2.5m total, £1.6m had since been paid, but that £0.9m should be written off. It was further noted that this issue should not arise in future due to changes in contracting arrangements and improvements in processes. The committee noted an update in respect of the Trust’s submission as part of the annual National Cost Collection exercise. The committee received a report on waivers of competitive tendering between October 2024 and March 2025, noting that these represented c.£11m of activity over the period. The committee reviewed a draft of the Annual Report and Accounts for 2024/25. The committee noted that the external audit had not progressed as planned. The committee received the Quarter 4 Fraud, Bribery and Corruption Work Plan Update Report, noting that under the Counter-Fraud Functional Return that the Trust was green-rated. Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) 6.3 Board Assurance Framework (BAF) Update Assurance Rating: Risk Rating: Substantial N/A • There had been an increase in the number of critical risks recorded from 30-35 to c.50. Many of these risks related to staffing or capacity. • It was noted that some of this increase was driven by new risks being identified (or existing risks worsening), but that existing critical risks were not being closed due to insufficient resources. • In addition, following the Six Facet survey, there had been an improvement in the articulation of Estates-related risks, which was now reflected in the total number of operational risks. • The committee reviewed the Board Assurance Framework, noting that all risks had been reviewed by the relevant executive(s). 7.2 Review of Standing Assurance Rating: Risk Rating: Financial Instructions 2025-26 Substantial N/A • The committee reviewed the Trust’s Standing Financial Instructions, noting that changes were proposed to two areas: employee expenses and non-pay requisition limits. Any Other Matters: • The committee reviewed the Trust’s internal audit plan and agreed that a cyber security audit should be included as part of the plan. 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 5.2 i) Committee Chair’s Report to the Trust Board of Directors 15 July 2025 Committee: Finance and Investment Committee Meeting Date: 2 June 2025 Key Messages: Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) • The committee reviewed the Finance Report for Month 1. The Trust had reported a deficit of £4.4m in line with its plan whereby the Trust would move from a deficit to breakeven to surplus over the course of the year thereby achieving an overall breakeven position at year end. • The Trust’s underlying deficit was £7.2m in month. This was driven by patients having no criteria to reside, activity above block contract levels, and mental health patients. Use of bank staff had normalised when compared to Month 12, but there had been high drugs spend and lower than expected income which was under investigation. • The Trust was on track in terms of its Cost Improvement Programme (CIP). • The committee received an update in respect of the Trust’s cash position, noting that the Integrated Care Board had agreed to move scheduled payments to aid the Trust’s position. The Trust was forecasting a £7m negative balance in March 2026. • The committee reviewed the ‘Acute Drivers of Deficit’ report prepared by Deloitte, noting that many of the identified areas were long-term and/or structural issues. • The committee received an update on the Trust’s financial improvement programmes, noting that although c.£80m of the £110m CIP was currently viewed as ‘high risk’, this was expected to improve as schemes became more mature. • The committee noted the Trust’s response to a request to consider proposed workforce targets based on removing 50% of reported increases in corporate services expenditure since 2018/19. It was noted that the Trust expected to deliver this target through its existing plans. • The committee received an update in respect of the national and local contracting process, noting that most areas had now been agreed. The potential changes in Elective Recovery Funding posed a risk to the Trust. In addition, it was likely that £20-30m of activity would remain unfunded. N/A Any Other Matters: The committee received the Always Improving – Transformation End of Year Report, noting progress made. 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 5.2 ii) Committee Chair’s Report to the Trust Board of Directors 15 July 2025 Committee: Finance and Investment Committee Meeting Date: 23 June 2025 Key Messages: • • • • • The committee reviewed the Finance Report for Month 2 (see below). The committee received an update in respect of the Trust’s cash position, noting that the position continued to deteriorate. It was further noted that discussions were underway with local providers, as some providers have cash whilst at the same time others risked running out. The committee received an update on the Urgent and Emergency Care Transformation Programme, noting that the Trust was targeting a reduction in length of stay by a further 5%. The committee noted an update from UHS Estates Limited and progress on a number of programmes. The committee considered a summary of the Spending Review presented by the Chancellor of the Exchequer on 11 June 2025. Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) 5.8 Finance Report for Month 2 Assurance Rating: Risk Rating: Substantial High • The Trust had recorded an in-month deficit of £3.8m, which was in line with its plan to reach a breakeven position by year end. • The Trust had achieved its planned Cost Improvement Programme delivery level, although much of this was due to non-recurrent savings, which creates a challenge later in the year. • The Trust’s underlying deficit remained at £7.2m, consistent with Month 1. • Income had been lower than expected with reductions in income from pathology and the Channel Islands. Non-pay costs for drugs and clinical supplies also remained a challenge. • The committee reviewed the Trust’s workforce trajectory for 2025/26, noting that even if all ‘red’ CIP schemes were to deliver, this would still result in a shortfall. 6.2 Board Assurance Framework (BAF) Update Assurance Rating: Risk Rating: Substantial N/A • Risks 5a, 5b and 5c have been updated, following discussions with the respective Executive Director(s). Any Other N/A Matters: 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 5.3 Committee Chair’s Report to the Trust Board of Directors 15 July 2025 Committee: People and Organisational Development Committee Meeting Date: 25 June 2025 Key Messages: • The committee reviewed the People Report for Month 2 including progress on the Workforce Plan for 2025/26 (see below). • The committee noted that the plans for the Divisional restructure are now underway with the intention of implementing these on 01 July 2025. It is understood that whilst not all people plans have been finalised at a granular level, it is anticipated that most issues will be resolved through natural attrition and through the Mutually Agreed Resignation Scheme (MARS). • The MARS application window has now closed and there has been significant interest with 220+ applications submitted. These are currently being assessed for suitability and it is planned that the outcomes will be shared with applicants by 04 July 2025. Not all applications will be accepted as some posts cannot be surrendered, and the organisation cannot afford to accept them all. Whilst each resignation will represent a long-term saving there is a very real risk to in year cost pressures as all successful MARS applications will need to be funded locally, as there is no national funding to support this. • Additional recruitment controls also remain in place including a freeze on non-clinical recruitment, and a hold on 30% of clinical recruitment. • The committee noted that the scale of organisational change is significant and this is likely to be unsettling for staff. A number of support mechanisms have been implemented focussed on wellbeing, and this includes specific organisational change workshops targeted at leaders across the Trust to support them in supporting the wider workforce. The committee reflected that this is a positive step and that once the organisational restructure has completed, this should be used as a foundation for implementing change and leadership training as business as usual. • The committee received an update on the organisation’s education position and the current challenges and opportunities related to this. The committee acknowledged the significant risk to future workforce as a result of the current challenges across the NHS, in combination with the restricted and reduced funding streams which facilitate staff access to education and development. The committee noted the need to review education capacity again at UHS once the long-term workforce plan is published later in the year. Page 1 of 2 Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) Any Other Matters: 5.10 People Report for Month 12 Assurance Rating: Risk Rating: Substantial High • The Trust’s overall workforce grew by 19 WTE in May 2025 however it is still below the NHSE plan by 107 WTE. It was noted that turnover remains lower than average and it is suspected that this will be due to system wide recruitment controls limiting roles UHS staff may move into, in addition to a wider lack of opportunity in the jobs market as general employer confidence reduces. • Additionally, whilst both remain below plan, there has been an increase in temporary staffing bank and agency usage noting that April was a very low month. • The committee noted that the workforce plan is ambitious and sets out a reduction in headcount of c.750. All schemes to deliver this have been assessed for maturity and continue to be worked up, although even if it were to be assumed that all are followed through to completion, there is still a shortfall which needs to be addressed. Significant work has been undertaken to forward plan the trajectory. • It was noted that consideration had been given to the recruitment controls and whether these needed to be taken further, however as it will take several months to fully implement and see the benefit of those in place currently, this was decided against. The improvements in forecasting, and monthly review, will support this decision so that it can be reviewed again later in the year, probably September. • The committee discussed the need to track indicators related to people, money, performance and quality and consideration will be given to a balanced scorecard. • The committee received a further update in respect of the Band 2/3 pay dispute and in respect of the portering department. • The committee also received a series of updates on recent national letters to Trusts including a required review of job evaluation processes and analysis work on non-frontline nursing roles. Page 2 of 2 Agenda Item 5.4 Committee Chair’s Report to the Trust Board of Directors 15 July 2025 Committee: Quality Committee Meeting Date: 2 June 2025 Key Messages: Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) Any Other Matters: • It was n
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Papers Trust Board - 7 January 2025

Description: Date Time Location Chair Observing Agenda Trust Board – Open Session 07/01/2025 9:00 - 13:00 Conference Room, Heartbeat/Microsoft Teams Jenni Douglas-Todd Fatemeh Jenabi, Specialty Registrar (shadowing Joe Teape) 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 5 November 2024 9:15 Approve the minutes of the previous meeting held on 5 November 2024 4 Matters Arising and Summary of Agreed Actions To discuss any matters arising from the minutes, and to agree on the status of any actions assigned at the previous meeting. 5 QUALITY, PERFORMANCE and FINANCE Quality includes: clinical effectiveness, patient safety, and patient experience 5.1 Briefing from the Chair of the Finance and Investment Committee 9:20 Dave Bennett, Chair 5.2 Briefing from the Chair of the People and Organisational Development 9:25 Committee Jane Harwood, Chair 5.3 Briefing from the Chair of the Quality Committee 9:30 Tim Peachey, Chair including Maternity and Neonatal Safety 2024-25 Quarter 2 Report 5.4 Chief Executive Officer's Report 9:40 Receive and note the report Sponsor: David French, Chief Executive Officer 5.5 Performance KPI Report for Month 8 10:00 Review and discuss the report Sponsor: David French, Chief Executive Officer 5.6 Break 10:35 5.7 Finance Report for Month 8 10:45 Review and discuss the report Sponsor: Ian Howard, Chief Financial Officer 5.8 ICB Finance Report for Month 8 10:55 Receive and discuss the report Sponsor: David French, Chief Executive Officer 5.9 People Report for Month 8 11:05 Review and discuss the report Sponsor: Steve Harris, Chief People Officer 5.10 Freedom to Speak Up Report 11:15 Review and discuss the report Sponsor: Gail Byrne, Chief Nursing Officer Attendee: Christine Mbabazi, Equality & Inclusion Adviser/Freedom to Speak Up Guardian 5.11 Guardian of Safe Working Hours Quarterly Report 11:25 Receive and discuss the report Sponsor: Paul Grundy, Chief Medical Officer Attendee: Diana Hulbert, Guardian of Safe Working Hours and Emergency Department Consultant 5.12 Learning from Deaths 2024-25 Quarter 2 Report 11:35 Review and discuss the report Sponsor: Paul Grundy, Chief Medical Officer Attendees: Natasha Watts, Deputy Chief Nursing Officer/Jenny Milner, Associate Director of Patient Experience 5.13 Infection Prevention and Control 2024-25 Quarter 2 Report 11:45 Review and discuss the report Sponsor: Gail Byrne, Chief Nursing Officer Attendees: Julian Sutton, Lead Infection Control Director/Julie Brooks, Deputy Director of Infection Prevention & Control 5.14 Annual Medicines Management 2023-24 Report 11:55 Receive and discuss the report Sponsor: Paul Grundy, Chief Medical Officer Attendee: James Allen, Chief Pharmacist 5.15 Annual Ward Staffing Nursing Establishment Review 2024 12:05 Discuss and approve the review Sponsor: Gail Byrne, Chief Nursing Officer Attendee: Rosemary Chable, Head of Nursing for Education, Practice and Staffing Page 2 6 STRATEGY and BUSINESS PLANNING 6.1 Board Assurance Framework (BAF) Update 12:15 Review and discuss the update Sponsor: Gail Byrne, Chief Nursing Officer Attendees: Craig Machell, Associate Director of Corporate Affairs and Company Secretary/Lauren Anderson, Corporate Governance and Risk Manager 7 CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Annual Assurance for the NHS England Core Standards for Emergency 12:25 Preparedness, Resilience and Response (EPRR) Review and discuss the report Sponsor: Joe Teape, Chief Operating Officer Attendees: John Mcgonigle, Emergency Planning & Resilience Manager/ Danielle Sinclair, Deputy Emergency Planner 7.2 Register of Seals and Chair's Actions Report 12:30 Receive and ratify In compliance with the Trust Standing Orders, Financial Instructions, and the Scheme of Reservation and Delegation. Sponsor: Jenni Douglas-Todd, Trust Chair 8 Any other business 12:35 Raise any relevant or urgent matters that are not on the agenda 9 Note the date of the next meeting: 11 March 2025 10 Resolution regarding the Press, Public and Others Sponsor: Jenni Douglas-Todd, Trust Chair To agree, as permitted by the National Health Service Act 2006 (as amended), the Trust's Constitution and the Standing Orders of the Board of Directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. 11 Follow-up discussion with governors 12:45 Page 3 Agenda links to the Board Assurance Framework (BAF) 7 January 2025 – Open Session Overview of the BAF Risk 1a: Lack of capacity to appropriately respond to emergency demand, manage the increasing waiting lists for elective demand, and provide timely diagnostics, that results in avoidable harm to patients. 1b: Due to the current challenges, we fail to provide patients and their families / carers with a high-quality experience of care and positive patient outcomes. 1c: We do not effectively plan for and implement infection prevention and control measures that reduce the number of hospital-acquired infections and limit the number of nosocomial outbreaks of infection. 2a: We do not take full advantage of our position as a leading University teaching hospital with a growing, reputable, and innovative research and development portfolio, attracting the best staff and efficiently delivering the best possible treatments and care for our patients. 3a: We are unable to meet current and planned service requirements due to the unavailability of staff to fulfil key roles. 3b: We fail to develop a diverse, compassionate, and inclusive workforce, providing a more positive staff experience for all staff. 3c: We fail to create a sustainable and innovative education and development response to meet the current and future workforce needs identified in the Trust’s longer-term workforce plan. 4a: We do not implement effective models to deliver integrated and networked care, resulting in sub-optimal patient experience and outcomes, increased numbers of admissions and increases in patients’ length of stay. 5a: We are unable to deliver a financial breakeven position, resulting in: inability to move out of the NHS England Recovery Support Programme, NHS England imposing additional controls/undertakings, and a reducing cash balance impacting the Trust’s ability to invest in line with its capital plan, estates/digital strategies, and in transformation initiatives. 5b: We do not adequately maintain, improve and develop our estate to deliver our clinical services and increase capacity. 5c: Our digital technology or infrastructure fails to the extent that it impacts our ability to deliver care effectively and safely within the organisation, 5d: We fail to prioritise green initiatives to deliver a trajectory that will reduce our direct and indirect carbon footprint by 80% by 2028-2032 (compared with a 1990 baseline) and reach net zero direct carbon emissions by 2040 and net zero indirect carbon emissions by 2045. Agenda links to the BAF No Item Linked BAF risk(s) 5.5 Performance KPI Report for Month 8 5.7 Finance Report for Month 8 5.8 ICB Finance Report for Month 8 5.9 People Report for Month 8 5.10 Freedom to Speak Up Report 5.11 Guardian of Safe Working Hours Quarterly Report 5.12 Learning from Deaths 2024-25 Quarter 2 Report 5.13 Infection Prevention Control 2024-25 Quarter 2 Report 5.14 Annual Medicines Management 2023-24 Report 5.15 Annual Ward Staffing Nursing Establishment Review 2024 7.1 Annual Assurance for the NHS England Core Standards for Emergency Preparedness, Resilience and Response (EPPR) 1a, 1b, 1c 5a 5a 3a, 3b, 3c 3b 3a, 3b 1b 1c All 1b, 3a 1a, 3a, 5b, 5c Appetite (Category) Minimal (Safety) Current risk rating 4x5 20 Cautious (Experience) Minimal (Safety) 3x3 9 4x4 16 Open (Technology & Innovation) 3x3 9 Open (workforce) Open (workforce) Open (workforce) 4x5 20 4 x3 12 4x3 12 Cautious (Effectiveness) 3x3 9 Cautious (Finance) 3x5 15 Target risk rating 4 x 2 Apr 6 27 3 x 2 Mar 6 26 2 x 3 Apr 6 27 3 x 2 Mar 6 25 4 x 3 Mar 12 26 4 x 2 Mar 8 27 3 x 2 Mar 6 25 3 x 2 Apr 6 25 3 x 3 Apr 9 25 Cautious (Effectiveness) Open (Technology & Innovation) Open (Technology & Innovation) 4x5 20 3x4 12 2x3 6 4 x 2 Apr 8 27 3 x 2 Apr 6 27 2 x 2 Dec 4 24 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 x x Minutes Trust Board – Open Session Date 05/11/2024 Time 9:00 – 11:30 Location The Ark Conference Centre, HHFT/Microsoft Teams Chair Jenni Douglas-Todd (JD-T) Present Dave Bennett, NED (DB) Gail Byrne, Chief Nursing Officer (GB) Keith Evans, Deputy Chair and NED (KE) David French, Chief Executive Officer (DAF) Paul Grundy, Chief Medical Officer (PG) Steve Harris, Chief People Officer (SH) Jane Harwood, NED/Senior Independent Director (JH) Ian Howard, Chief Financial Officer (IH) Tim Peachey, NED (TP) Joe Teape, Chief Operating Officer (JT) Alison Tattersall, NED (AT) In attendance Martin De Sousa, Director of Strategy and Partnerships (MDeS) (item 5.1) Craig Machell, Associate Director of Corporate Affairs and Company Secretary (CM) Ali Keen, Head of Cancer Nursing (AK) (item 4.11) Kelly Kent, Head of Strategy and Partnerships (KK) (item 5.1) 4 governors (observing) 2 members of staff (observing) 2 members of the public (observing) Apologies Diana Eccles, NED (DE) 1. Chair’s Welcome, Apologies and Declarations of Interest The Chair welcomed attendees to the meeting. There were no interests to declare in the business to be transacted at the meeting. It was noted that apologies had been received from Diana Eccles. The Chair provided an overview of her activities since September 2024, including visits to hospital departments, meetings with peers and other key stakeholders. 2. Minutes of the Previous Meeting held on 10 September 2024 The draft minutes tabled to the meeting were agreed to be an accurate record of the meeting held on 10 September 2024. 3. Matters Arising and Summary of Agreed Actions In respect of action 1175, it was noted that there had been an increase in the number of incidents of delays in giving of medication or pain relief, missed symptoms, and insufficient staffing numbers. However, in part the increase in numbers of incidents was considered to be due to efforts to encourage reporting of such incidents, and the situation had improved more recently. It was agreed to close this action. Page 1 It was noted that there were no other matters arising or overdue actions. 4. QUALITY, PERFORMANCE and FINANCE 4.1 Briefing from the Chair of the Audit and Risk Committee The chair of the Audit and Risk Committee was invited to present the Committee Chair’s Report in respect of the meeting held on 14 October 2024, the content of which was noted. It was further noted that: • The committee reviewed the lessons learned from the 2023/24 annual accounts, and noted that the issues encountered should be resolved in time for the 2024/25 accounts due, largely, to the implementation of a new finance system. • The committee also received a report in respect of the risk of impersonation fraud for bank/agency staff and the procedures that had been put in place to mitigate this risk. 4.2 Briefing from the Chair of the Finance and Investment Committee The chair of the Finance and Investment Committee was invited to present the Committee Chair’s Report in respect of the meeting held on 21 October 2024, the content of which was noted. It was further noted that: • The committee had reviewed the Finance Report for Month 6 (item 4.7) and discussed the Trust’s re-commitment to its 2024/25 plan in support of its request for deficit support funding from NHS England. • The position in respect of cash was challenging and the committee discussed what the Trust should do in the final quarter of 2024/25. It was noted that the rules on when and how much cash support could be requested were somewhat unclear. • The committee discussed a potential expansion of the activities of UHS Pharmacy Limited, although it was subsequently noted that the specific potential opportunity had since failed to materialise. • The committee also discussed the Trust’s financial recovery programme. 4.3 Briefing from the Chair of the People and Organisational Development Committee The chair of the People and Organisational Development Committee was invited to present the Committee Chair’s Report in respect of the meeting held on 21 October 2024, the content of which was noted. It was further noted that: • The Trust had been below its plan in terms of whole-time-equivalent (WTE) numbers, although this position would change from October 2024 onward due to the onboarding of newly qualified nurses and the failure of the Integrated Care System transformation plans to deliver in terms of reduction in patients having no criteria to reside and mental health support. • The committee noted the cumulative impact on staff of having to balance staff numbers, performance, and patient experience. • Whilst noting that the annual appraisal rate remained low, it was suspected that more appraisals than recorded had taken place, but that these had not been recorded on the Electronic Staff Record. 4.4 Briefing from the Chair of the Quality Committee The chair of the Quality Committee was invited to present the Committee Chair’s Report in respect of the meeting held on 14 October 2024, the content of which was noted. It was further noted that: Page 2 • Patients’ access to a rehabilitation and recovery service during and after intensive care unit (ICU) admission was limited due to a lack of service provision. The Trust was non-compliant with national guidance in this area. • Due to resource constraints the Trust was unable to systematically roll out the National Safety Standards for Invasive Procedures (NatSSIPS) 2. However, it was noted that a solution to this issue was being considered. • There had been no significant improvement in terms of the Trust’s system partners in respect of supporting the Trust with mental health admissions. • The committee also reviewed the Maternity and Neonatal Safety Report, based on data available at September 2024, and including the NHS Resolution Maternity Incentive Scheme Year 6 progress update, the local response to the Care Quality Commission’s National Report Review of Maternity Services in England 2022-2024, and the Antenatal and Newborn Screening Annual Report 2023/24. 4.5 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: • Whilst the commitment in the Autumn Statement to additional funding for the NHS was welcomed, it was unclear at this stage what this additional funding will mean in practice and how it would be allocated. • There had been recent media coverage of the Trust’s ongoing dispute with its porters following a press release by the UNITE union. • Arbitration proceedings were expected to commence in respect of a long- running dispute with BAM Construction relating to the construction of the east wing annex building. • Significant changes in employment legislation were anticipated between now and 2026, although, due to the nature of employment conditions in the NHS, it was not anticipated that these changes would have a significant impact on the Trust. • The new combined community provider, Hampshire and Isle of Wight Healthcare NHS Foundation Trust was launched on 1 October 2024. • A meeting had been held with the now independent hospital charity to discuss priorities over the medium term. • The national NHS staff survey had launched on 20 September 2024 and would run until 28 November 2024. It was noted that the participation rate thus far had been below that seen in previous years. • The Trust’s quality and patient safety partners programme had won the ‘Patient Involvement in Safety’ award at the Health Service Journal’s Patient Safety Awards on 16 September 2024. • There was a concern that the Government’s intended 10-Year Plan for the NHS, which was expected to redirect focus on prevention and community healthcare, could result in an immediate loss of funding for acute providers, i.e. before the longer-term preventative measures had had an opportunity to take effect. 4.6 Performance KPI Report for Month 6 Joe Teape 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 overall performance was good compared to other teaching hospitals. In August 2024, the Trust was first for its 65-week wait performance, and second for the 60-day cancer metric. Page 3 • The month of October was proving to be challenging with increased bed occupancy and surge capacity having to be opened. Type 1 Emergency Department attendance was over 400 per day. • Whilst there had been improvements in the length of stay, the impact of this had largely been negated by the high demand being experienced. • The ‘W-45’ initiative was to be implemented at the end of November 2024, whereby ambulances would automatically hand over patients to emergency departments after 45 minutes. It was noted that this policy would potentially put strain the relationship between the Emergency Department and the South Central Ambulance Service (SCAS). • It was noted that there were potential issues with the data presented in terms of the number of virtual appointments and use of MyMedicalRecord. The Board discussed the high levels of attendance in the Emergency Department. It was noted that: • The Trust’s winter plans did not assume 400 attendances per day. • Attendances were typically of higher acuity, and did not appear to be as a result of patients being unable to access GP services. • The Trust had a number of projects underway in order to direct patients to alternative routes into the hospital, such as through the Same-Day Emergency Care service. • The importance of ensuring the wellbeing of staff during such a period of sustained demand was also noted. • In addition, the Trust had requested funding for GPs in the Emergency Department as had occurred in previous years as a means of reducing demand on the Emergency Department. Action: Joe Teape agreed to investigate the data in respect of virtual appointment and MyMedicalRecord numbers presented for Month 6. 4.7 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 received additional funding in respect of 2023/24 Elective Recovery Fund (ERF) performance, funding for industrial action costs, and deficit support funding from NHS England. As a result, the Trust had recorded a year-to-date deficit of £8m, a variance of -£4.7m against plan. • The Trust’s underlying deficit continued to be £5-6m per month. • The Trust had 200-220 patients with no criteria to reside at any one time, and expected reductions in mental health demand had not been realised due to non-delivery of system programmes. • The Trust had also undertaken £17m of unpaid activity in the first half of 2024/25. • The Trust had recorded 130% ERF performance in month and 128% year-to- date. It also continued to maintain low bank and agency use, and had delivered £32m of Cost Improvement Programme benefits. • There was significant financial pressure throughout the NHS in England. 4.8 ICB Finance Report for Month 6 Ian Howard was invited to present the ICB Finance Report for Month 6, the content of which was noted. It was further noted that: • The report tabled to the meeting had been prepared by the Hampshire and Isle of Wight Integrated Care Board (ICB) for all providers in the system. Page 4 • The system’s 2024/25 plan targeted a deficit of £70m. • During the first half of 2024/25, the system had received £55m in deficit support funding from NHS England and a surplus of £20m would be required during the second half of the year in order to be able to meet its 2024/25 target. • Meeting the 2024/25 target would likely be challenging. • The system had yet to see any significant benefit from the six transformation programmes. • It was noted that the ICB report would benefit from additional information in respect of workforce and equality, diversity and inclusion. 4.9 Recovery Support Programme (RSP) Undertakings – Self Assessment Ian Howard was invited to present the paper ‘Recovery Support Programme (RSP) Undertakings – Self-Assessment’, the content of which was noted. It was further noted that: • In June 2024, the Trust, along with all other organisations in the Hampshire and Isle of Wight Integrated Care System (ICS) under the Recovery Support Programme had submitted a self-assessment in respect of the undertakings entered into in 2023. NHS England had provided feedback in respect of these self-assessments in August 2024. • All providers had been asked to provide a further self-assessment, which would then be incorporated into a system-wide response in January 2025. • The evidence supplied by the Trust in support of its self-assessment indicated significant engagement by the Trust’s Board with the organisation’s undertakings under the RSP as well as progress against these undertakings since the previous submission. • Factors such as the number of patients having no criteria to reside and other matters beyond the Trust’s control remained a concern in terms of the Trust’s ability to fully meet the undertakings. • The action plans for the ICS transformation programmes should be included as part of the Trust’s response to the request for a self-assessment. Decision Having discussed the proposed response by the Trust, the Board agreed the proposed self-assessment, and authorised David French and Ian Howard to submit it to the Hampshire and Isle of Wight Integrated Care Board, subject to there being no material changes prior to submission. 4.10 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 Trust was currently under its 2024/25 plan by 249 whole-time-equivalents (WTE). However, this situation was expected to change in October 2024 due to the impact of onboarding of newly qualified nurses and midwives, and also due to non-delivery of ICS transformation programmes in non-criteria to reside and mental health, which assumed a reduction of 167 WTE. • The Trust benchmarked well in terms of its sickness absence rate and turnover. • The Trust had plans to transfer recording of appraisals from the Electronic Staff Record to the Visual Learning Environment platform, which was considered to be more ‘user friendly’ and was therefore expected to improve recorded appraisal numbers. Page 5 • The Trust was in active negotiations with Unison in respect of the Band 2/3 pay dispute. • The People and Organisational Development Committee was to examine the overall workforce picture in more detail. 4.11 Cancer Patient Experience Survey Results 2023 Ali Keen was invited to present the Cancer Patient Experience Survey Results 2023, the content of which was noted. It was further noted that: • The survey involved 132 trusts, and had a 58% response rate at UHS (1,064 patients). • At the Trust 15 out of 59 questions scored above the expected range, which indicated that the Trust was a positive outlier when compared to trusts of a similar size and demographic. • Patients with longer-term health conditions and women tended to have worse experiences than other groups. • The care by and quality of staff at the Trust were rated highly. • There were opportunities for improvement in some areas such as administration and communication around appointments. 5. STRATEGY and BUSINESS PLANNING 5.1 Corporate Objectives 2024-25 Quarter 2 Review Martin De Sousa and Kelly Kent were invited to present the Corporate Objectives 2024/25 Quarter 2 review, the content of which was noted. It was further noted that: • The report now incorporated a forecast for the end of year. • The overall picture was positive with 12 objectives shown as ‘green’, two as ‘amber’, and two as ‘red’. • The main areas of risk in terms of the objectives concerned the deliverability of a stretching financial plan. • The completion of year two of the Public Sector Decarbonisation Scheme was also at risk due to the state of steam duct tunnels, which required substantial remediation ahead of work commencing on the low temperature hot water system. 5.2 Board Assurance Framework (BAF) Update Craig Machell was invited to present the Board Assurance Framework Update, the content of which was noted. It was further noted that: • In September and October 2024, the Board’s committees had reviewed the BAF risks assigned to them, and the Audit and Risk Committee had reviewed the entire BAF. • As a result of these reviews, it had been agreed to increase the risk rating for Risk 1c (Infection Prevention Control) and to extend the target date. In addition, the target dates for all risks were to be reviewed to ensure that they were realistic. • The Board agenda now included an annex, which indicated where papers were linked to a BAF risk and the impact of any decision by the Board on the Trust’s achievement of its target risk rating. Furthermore, Board papers now Page 6 had a clear link to any relevant BAF risk included as part of the new cover sheet. 6. CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 6.1 Feedback from the Council of Governors’ (CoG) Meeting 23 October 2024 The Chair provided an overview of the meeting of the Council of Governors held on 23 October 2024. It was noted that the meeting had addressed the following matters: • Attendance at Council of Governors meetings • Appointment of a member of the Governors’ Nomination Committee • Planning for the Governors’ strategy session in December 2024 • Membership engagement • Feedback from the Working Groups • The external auditor’s report on the Annual Accounts In addition, on 31 October 2024, the Council of Governors had met with the Hampshire and Isle of Wight ICB to discuss future plans for the system and opportunities for collaboration between providers. 6.2 Register of Seals and Chair’s Actions Report The paper ‘Register of Seals and Chair’s Actions Report’ was presented to the meeting, the content of which was noted. Decision: The Board agreed to ratify the application of the Trust Seal to the documents listed in the ‘Register of Seals and Chair’s Actions Report’. 7. Any other business There was no other business. 8. Note the date of the next meeting: 7 January 2025 9. 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. 10. Resolution regarding the Press, Public and Others Decision: The Board resolved that, as permitted by the National Health Service Act 2006 (as amended), the Trust’s Constitution and the Standing Orders of the board of directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. The meeting was adjourned. Page 7 List of action items Agenda item Assigned to Deadline Status Trust Board – Open Session 06/06/2024 5.6 Performance KPI Report for Month 1 1152. Digital Teape, Joe Explanation action item JT agreed to include Digital as an agenda item at a future Trust Board Study Session. 27/02/2025 Pending Update: Item tentatively scheduled for TBSS on 27/02/2025 Trust Board – Open Session 25/07/2024 5.4 Briefing from the Chair of the Quality Committee (Oral) 1163. Impact of technology Machell, Craig 27/02/2025 Pending Explanation action item Craig Machell agreed to add an item covering the impact of technology over the next 5-10 years to a future Trust Board Study Session agenda. Update: Item tentatively scheduled for 27/02/25 Study Session. Trust Board – Open Session 05/11/2024 4.6 Performance KPI Report for Month 6 1181. MyMedicalRecord (MMR) Teape, Joe 07/01/2025 Completed Explanation action item Joe Teape agreed to investigate the data in respect of virtual appointment and MyMedicalRecord numbers presented for Month 6. Update: The issue was related to the MMR – drop-in logins in month and the increase in the previous month which was noted in the Month 6 report, as oncology had been added to the system and all patients notified in that month driving a surge in logins. Page 1 of 1 Agenda Item 5.1 i) Committee Chair’s Report to the Trust Board of Directors 7 January 2025 Committee: Finance & Investment Committee Meeting Date: 25 November 2024 Key Messages: • • • • • • • • For month 7, the Trust had reported an in-month deficit of £4.5m and a £12.5m year-to-date deficit. The Trust was £9.2m behind plan. The non-delivery of system-wide transformation programmes represented approximately half of the overall deficit. The recent pay awards resulted in an additional £2m cost pressure. Elective Recovery performance was 125%, which was lower than previously due to operational challenges in October 2024, high levels of annual leave, and the performance achieved in October 2019 on which in-month performance was based. The Trust’s workforce numbers were beginning to increase as anticipated as newly qualified staff members were onboarded. The ongoing discussions with Unison in respect of the Band 2/3 pay dispute would likely lead to additional one-off costs as well as recurring costs if any pay increase were agreed. It was expected that the Trust would be below the NHS England minimum cash holding during Quarter 4. It was forecast that the Trust would deliver £67.7m of CIP for 2024/25 against £84.9m of identified schemes. The Trust’s Always Improving programme had succeeded in delivering a 3.6% reduction in length of stay. Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) Not applicable. Any Other Matters: • The committee received a quarterly update from Estates, Facilities and Capital Development. • The committee supported the Trust’s bid for external funding in support of the Southampton Elective Hub. 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 5.1 ii) Committee Chair’s Report to the Trust Board of Directors 7 January 2025 Committee: Finance & Investment Committee Meeting Date: 16 December 2024 Key Messages: • • • • The Trust’s financial position remains difficult despite significant levels of savings being delivered in areas such as patient flow, theatres, and outpatients. The main contributor to the Trust’s deficit continues to be non-delivery of system-wide transformation programmes, especially those concerning patients having no criteria to reside. The Trust was forecasting to achieve c.£67m of its cost improvement programme target for 2024/25, a shortfall of £17m against the identified opportunities. However, much of the unachieved amount assumed delivery of system transformation programmes. The Trust’s cash balance was initially expected to fall below the NHS England minimum holding level during Quarter 4. However, the Trust has received £12m of additional cash, which now means that the Trust’s cash balance should not fall below minimum required levels until Quarter 1 of 2025/26. 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’s in-month deficit was £5.7m and a year-to-date deficit of £18.2m, £14.8m behind plan year-to-date. • The Trust has carried out £21m of unfunded activity during the year. • The Trust continues to benchmark well in terms of value for money, and continues to apply measures to ensure financial grip and governance with strong controls in place. 6.1 Board Assurance Framework (BAF) Update Assurance Rating: Risk Rating: Substantial N/A • Risks 5a, 5b and 5c have been updated, following discussions with the respective Executive Director(s). • The risk rating for Risk 5a has been increased from 15 to 20 due to the deteriorating cash balance and the ongoing financial pressures. Any Other Matters: • The committee reviewed the outputs of the review of non-pay expenditure carried out by Deloitte. • The committee supported the outline strategy for a possible private patient unit. • The committee gave its support in principle for the Trust to bid for £1.75m of funding in support of the Trust’s Same-Day Emergency Care service. Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Page 1 of 2 Limited Assurance No Assurance Not Applicable Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Where assurance is not required and/or relevant. Risk Rating: Low Medium High Not Applicable Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda item 5.2 Committee Chair’s Report to the Trust Board of Directors 7 January 2025 Committee: People & Organisational Development Committee Meeting Date: 13 December 2024 Key Messages: • • • • • The Trust’s substantive workforce grew by 7 whole-time-equivalents (WTE) during November 2024 in line with forecast. However, an adjustment has also been made to the substantive numbers being reported due to the status of a hosted network (the CRN), which expanded following a TUPE transfer of staff. The rate of bank staff usage had increased in November 2024 due to the need to open surge capacity. This was expected to continue during the remainder of the year. Reduction in bank benefit has been assumed though, commencing in January linked to NQNs exiting supernumerary periods. The non-delivery of system-wide transformation programmes continues to pose a significant risk to the Trust’s delivery of its 2024/25 workforce plan. A Mutually Agreed Resignation Scheme (MARS) has been approved by NHS England, which was expected to deliver a reduction in workforce of c.20 WTE by March 2025. The Trust was forecasting a total workforce of 13,464 WTE at the end of the year – broadly flat compared with the end of 2023/24. Increases in substantive workforce has been forecasted during December and January. Due to the volatility of predicting start dates during the Christmas period, a reforecast may take place in January. Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) 5.9 People Report for Month 8 Assurance Rating: Risk Rating: Substantial High • The Trust is above its 2024/25 workforce plan by 77 WTE due to a combination of the planned increases in substantive staff as newly qualified employees are onboarded, and the assumed reduction in workforce requirements due to delivery of system-wide transformation programmes. • The system-wide transformation programmes assumed a reduction in workforce of 218 WTE. Non-delivery of these programmes therefore poses a significant risk to the Trust’s achievement of its overall 2024/25 workforce plan. • The Trust’s sickness absence rate was 3.3% against the target of 3.9%, and turnover was lower than expected. • The response rate to the Staff Survey was low compared to the national average. 6.1 Board Assurance Framework (BAF) Update Assurance Rating: Risk Rating: Substantial N/A • Risks 3a, 3b and 3c have been updated, following discussions with the respective Executive Director(s). • The financial situation and uncertainty in respect of the NHS long-term workforce plan poses a significant underlying risk, and it was suggested that increasing the rating of risk 3c should be considered to reflect this. Any Other Matters: • A detailed update was provided in respect of the ongoing industrial dispute with the porters and in respect of the Band 2/3 pay dispute. Page 1 of 2 • The need to manage ongoing industrial disputes was impacting the Trust’s People team’s capacity to make progress on other areas, such as those relating to transformation. 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 5.3 Committee Chair’s Report to the Trust Board of Directors 7 January 2025 Committee: Quality Committee Meeting Date: 25 November 2024 Key Messages: • • • • • • • There had been seven never events reported during 2024/25. There had been a decrease in the number of category 2 pressure ulcers, which was possibly due to increased training rates. Three prostate patients had been lost to follow up, and there were concerns in respect of capacity within the prostate service. Overall, the Quality Indicators show a system under pressure. There were also concerns in respect of cardiac surgery services due to staffing levels and culture within the team, which had led to cancellations and increased waiting lists. The PALS/complaints service had had 2,135 interactions during Quarter 2. The top themes related to clinical treatment, patient care, and communication. The number of Inquests was increasing, which was putting pressure on services. Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) 5.12 Learning from Deaths 2024-25 Quarter 2 Report Assurance Rating: Risk Rating: Substantial Medium • Whilst the overall death rate had increased, this was in line with national trends. The Trust was performing well, and was one of 13 trusts scoring below the expected figure. • A mobile application to share the outputs of mortality and morbidity meetings was being reviewed. • The lack of available side rooms was leading to an increasing number of patients dying on wards rather than in a private environment. 5.13 Infection Prevention and Control 2024-25 Quarter 2 Report Assurance Rating: Risk Rating: Substantial High • The Trust was expected to miss most bacteraemia targets for 2024/25. • The Trust was mid-table compared with other teaching hospitals. • The rate of MRSA had increased to 4-5 cases per annum from 2020 onwards, compared with 0-2 per annum between 2015 and 2020. • An audit of hand washing had raised concerns about the compliance rate. • The loss of experienced staff since the COVID-19 pandemic was considered to be a significant contributor to the decline in performance. Any Other Matters: The committee reviewed the Maternity and Neonatal Safety 2024-25 Quarter 2 Report and noted the following: • Caesarean section rates remained high. • The Trust’s post-partum haemorrhage rate remained above the national expectations, but no key themes had been identified following review of this matter. • In a review of third- and fourth-degree tears, no key themes had been identified. • One maternal death was under investigation. Page 1 of 43 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 43 Agenda Item 4.6 Report to the Quality Committee, 25 November 2024 Title: Sponsor: Author: Purpose Maternity and Neonatal Safety 2024-25 Quarter 2 Report Gail Byrne, Chief Nursing Officer Alison Millman, Quality Assurance and Safety Midwifery Matron Jessica Bown, Quality Assurance and Safety Midwifery Matron Hannah Mallon, Quality Assurance and Safety Neonatal Matron Marie Cann, Maternity and Neonatal Safety Lead Emma Northover, Director of Midwifery (Re)Assurance Approval Ratification Information x x x Strategic Theme Outstanding patient outcomes, safety and experience Pioneering research and innovation World class people Integrated networks Foundations for the and collaboration future x Executive Summary: NHS Resolution (NHSR) requires that the Maternity & Neonatal (MatNeo) service reports to our Trust Quality Committee each time it meets. This Quarter 2 (Q2) 24-25 MatNeo services safety report will continue to be adapted and responsive to safety concerns or issues within our service providing assurance around safety improvements impacting our families, services, and staff. The information provided is for assurance and reassurance, whilst meeting the requirements of NHSR Maternity Incentive Scheme (MIS)Year 6 and highlights the safety improvement work and learning from all aspects of the services. We ask members to continue to support the MatNeo Services and provide monitoring and scrutiny as required. Contents: This report provides an update in relation to the following areas for Quarter 2 2024/25: 1. Perinatal Quality Surveillance – Maternity & Neonatal Dashboard (Appendix 1) 1.1. Scheduled Caesarean Section Capacity 1.2. Post Partum Haemorrhage (PPHs) 1.3. Episiotomy 1.4. 3rd and 4th degree tears 1.5. ITU transfers 1.6. Apgars 500ms (43.58%) NMPA target is 1500mls (5.8%) NMPA target is 35% Global majority booked CoC Model – Q2 compliance 19.5%, National target is > 35% The most vulnerable families are still supported by our Needing Extra Support Teams (NEST) and as we progress workstreams around future workforce plans, the service aspires to develop new and more sustainable CoC models of care. To give assurance we monitor and audit outcomes to ensure that groups most likely to be offered a CoC model are not showing as exceptions in our data or when clinically reviewing adverse outcomes. 1.9 FFT recommenders as % of responders Current compliance: 83.9% of responders would recommend our service. This has fallen slightly from Q1 (87.4%). As mentioned in the previous Committee report, the % of responders who would recommend our postnatal ward dropped to 67% in September 2024. This was escalated to the inpatient matrons and an improvement plan focusing on two areas has been developed (Appendix 2). These areas are: • Partner or someone else involved in service users care being allowed to stay with them as much as the service user wanted during their stay in hospital. • After the birth, ensure that women and birthing people are given the opportunity to ask any questions they may have about their labour and birth. 1.10 Maternity Opel 4 Diverts There has been an increase in the number of occasions when the Maternity Service has moved through escalation and ultimately declared OPEL 4. There are escalation processes and policies in place that aim to ensure appropriate decision making and the safety of our families and workforce. This issue has been widely monitored through Birthrate Plus reporting and reviewed within safety incident investigations and is on our Risk Register (Risk 259 High Red). As per the Trust’s PSIRF plan, harm tools are completed for each Opel 4 exceeding 24 hours to review the wider impact and harm associated with the service being on
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Trust-governance-and-corporate-docs/2025-Trust-documents/Papers-Trust-Board-7-January-2025.pdf

Hydrocephalus - patient information

Description: Information about hydrocephalus (excess fluid in the brain) in children
Url: /Media/UHS-website-2019/Patientinformation/Childhealth/Hydrocephalus-715-PIL.pdf

Papers Trust Board - 10 September 2024

Description: Agenda Trust Board – Open Session Date 10/09/2024 Time 9:00 - 13:00 Location Conference Room, Heartbeat/Microsoft Teams Chair Jenni Douglas-Todd Apologies Diana Eccles (10:00-12:00) In attendance Jessica Bown, Midwifery Quality Assurance and Safety Matron (shadowing Gail Byrne) 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 25 July 2024 9:15 Approve the minutes of the previous meeting held on 25 July 2024 4 Matters Arising and Summary of Agreed Actions To discuss any matters arising from the minutes, and to agree on the status of any actions assigned at the previous meeting. 5 QUALITY, PERFORMANCE and FINANCE Quality includes: clinical effectiveness, patient safety, and patient experience 5.1 Briefing from the Chair of the Finance and Investment Committee (Oral) 9:20 Dave Bennett, Chair 5.2 Briefing from the Chair of the People and Organisational Development 9:25 Committee (Oral) Jane Harwood, Chair 5.3 Briefing from the Chair of the Quality Committee (Oral) 9:30 Tim Peachey, Chair 5.4 Chief Executive Officer's Report 9:35 Receive and note the report Sponsor: David French, Chief Executive Officer 5.5 Patient Safety and Quality of Care in Pressurised Services 9:55 Review and discuss the report Sponsor: Joe Teape, Chief Operating Officer Attendee: Duncan Linning-Karp, Deputy Chief Operating Officer 5.6 Performance KPI Report for Month 4 10:05 Review and discuss the report Sponsor: David French, Chief Executive Officer 5.7 Finance Report for Month 4 10:30 Review and discuss the report Sponsor: Ian Howard, Chief Financial Officer 5.8 Break 10:40 5.9 People Report for Month 4 10:55 Review and discuss the report Sponsor: Steve Harris, Chief People Officer 5.10 Guardian of Safe Working Hours Quarterly Report 11:10 Receive and discuss the report Sponsor: Paul Grundy, Chief Medical Officer Attendee: Diana Hulbert, Emergency Medicine Consultant and Guardian of Safe Working Hours 5.11 Learning from Deaths 2024-25 Quarter 1 Report 11:25 Review and discuss the report Sponsor: Paul Grundy, Chief Medical Officer Attendee: Jenny Milner, Associate Director of Patient Experience 5.12 Medical Appraisal and Revalidation Annual Report including Board 11:40 Statement of Compliance Receive and note the Annual Report. Approve the Statement of Compliance. Sponsor: Paul Grundy, Chief Medical Officer 5.13 Safeguarding Annual Report 2023-24 11:55 Receive and discuss Sponsor: Gail Byrne, Chief Nursing Officer Attendees: Corinne Miller, Named Nurse for Safeguarding Adults/ Danielle Honey, Named Nurse for Safeguarding Children 6 STRATEGY and BUSINESS PLANNING 6.1 Board Assurance Framework (BAF) Update 12:10 Review and discuss the update Sponsor: Gail Byrne, Chief Nursing Officer Attendees: Craig Machell, Associate Director of Corporate Affairs and Company Secretary/Lauren Anderson, Corporate Governance and Risk Manager Page 2 7 CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Register of Seals and Chair's Actions Report 12:20 Receive and ratify In compliance with the Trust Standing Orders, Financial Instructions, and the Scheme of Reservation and Delegation. Sponsor: Jenni Douglas-Todd, Trust Chair 7.2 Health and Safety Annual Report 2023-24 12:25 Receive and discuss Sponsor: Gail Byrne, Chief Nursing Officer Attendee: Jane Fisher, Head of Health and Safety Services 7.3 People and Organisational Development Committee Terms of Reference 12:35 Review and approve Sponsor: Steve Harris, Chief People Officer 8 Any other business 12:40 Raise any relevant or urgent matters that are not on the agenda 9 Note the date of the next meeting: 5 November 2024 10 Items circulated to the Board for reading 10.1 CRN: Wessex 2024-25 Q1 Performance Report Note the report Sponsor: Paul Grundy, Chief Medical Officer 11 Resolution regarding the Press, Public and Others Sponsor: Jenni Douglas-Todd, Trust Chair To agree, as permitted by the National Health Service Act 2006 (as amended), the Trust's Constitution and the Standing Orders of the Board of Directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. 12 Follow-up discussion with governors 12:45 Page 3 Minutes Trust Board – Open Session Date Time 25/07/2024 9:00 – 13:00 Location Anaesthetic Seminar Room (CE95/99)/Microsoft Teams Chair Jenni Douglas-Todd (JD-T) Present Dave Bennett, NED (DB) Jenni Douglas-Todd, Chair (JD-T) 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) Tim Peachey, NED (TP) (until 12:00) Joe Teape, Chief Operating Officer (JT) Alison Tattersall, NED (AT) Natasha Watts, Interim Deputy Chief Nursing Officer (NW) (for G Byrne) In attendance Martin De Sousa, Director of Strategy and Partnerships (MDeS) Craig Machell, Associate Director of Corporate Affairs and Company Secretary (CM) Lauren Anderson, Corporate Governance and Risk Manager (LA) (item 6.3) Kelly Kent, Head of Strategy and Partnerships (KK) (item 6.1) Marie Nelson, R&D Head of Nursing and Health Professions (MN) (item 6.2) Karen Underwood, Director of R&D (KU) (item 6.2) Kerrie Montoute, Head of Programmes, CDO Directorate at NHSE (shadowing JDT) 1 member of the public (item 2) 3 governors (observing) 3 members of staff (observing) 2 members of the public (observing) Apologies Gail Byrne, Chief Nursing Officer (GB) 1. Chair’s Welcome, Apologies and Declarations of Interest The Chair welcomed attendees to the meeting. There were no interests to declare in the business to be transacted at the meeting. It was noted that apologies had been received from Gail Byrne. The Board welcomed Alison Tattersall, who joined the Board as a non-executive director on 1 June 2024. The Chair provided an overview of her activities since June 2024, including visits to hospital departments, meetings with peers and other key stakeholders. 2. Patient Story Georgia Blackman and her parents were invited to relate their story following Georgia’s admission with serious head and abdominal injuries after a car accident in November 2023. She had not been expected to survive, but had instead made Page 1 a very good recovery and was undergoing rehabilitation and had regained some sight. The family related their experience of being told that their daughter was going to die and the importance of how this message is delivered was highlighted. It was further noted that where a patient is between 16 and 18 years old it was necessary to consider whether they are managed as a child or as an adult in terms of their care. 3. Minutes of the Previous Meeting held on 6 June 2024 The draft minutes tabled to the meeting were agreed to be an accurate record of the meeting held on 6 June 2024. 4. Matters Arising and Summary of Agreed Actions It was noted that there were no matters arising or overdue actions. 5. QUALITY, PERFORMANCE and FINANCE 5.1 Briefing from the Chair of the Audit and Risk Committee The chair of the Audit and Risk Committee was invited to provide an overview of the meeting held on 27 June 2024 and the subsequent meeting of a committee authorised to approve the final annual report and accounts for 2023/24 held on 16 July 2024. It was noted that the annual report and accounts had been submitted to NHS England on 19 July 2024 and that the Trust’s external auditor had provided a ‘clean’ audit opinion. 5.2 Briefing from the Chair of the Finance and Investment Committee The chair of the Finance and Investment Committee was invited to provide an overview of the meeting held on 22 July 2024. It was noted that: • The committee had reviewed the Finance Report for Month 3 (item 5.8). • The committee had examined the Trust’s progress on its transformation programme, and noted in particular the success in reducing length of stay by 5% for P0 patients as part of the discharge programme. • The committee received a report on the Trust’s productivity and noted that the national methodology used created a confusing position and did not incorporate the impacts of certain factors which should be included. • The committee reviewed the Trust’s activities in the digital space and noted that capital in this area was primarily used for maintenance rather than development and that there was a significant infrastructure risk due to the Trust’s current data centre set up. It was further noted that better understanding of the benefits of digital development and timescales was required. • The Trust had agreed to participate in establishing a separate legal entity to seek investment to exploit intellectual property rights jointly developed by the Trust and the University of Southampton. 5.3 Briefing from the Chair of the People and Organisational Development Committee The chair of the People and Organisational Development Committee was invited to provide an overview of the meeting held on 22 July 2024. It was noted that: • The committee reviewed the revised People Report for Month 3 (item 5.9), noting that the workforce plan was at risk if there was no reduction in patients having no criteria to reside and mental health demand. • The committee had reviewed the Trust’s Employee Relations activities and received an update on an investigation into comments made on social media. Page 2 5.4 5.4.1 5.5 • In its review of the Board Assurance Framework (item 6.3), it was agreed that culture also needed to be reflected in the people-related risks. Briefing from the Chair of the Quality Committee The chair of the Quality Committee was invited to provide an overview of the meeting held on 15 July 2024. It was noted that: • In its report from the Quality Governance Steering Group, the committee noted that there were two new never events under investigation. In addition, there were national shortages of certain medicines. The committee also noted an increase in violence and aggression linked to the increasing number of patients with mental health issues. • The committee reviewed the Fundamentals of Care programme and noted that it was very comprehensive. • The committee also received updates following a visit by Southern Health and the impact of demand by patients with mental health issues on the Trust. • The committee also noted a report by the Royal College of Radiologists on the Trust’s radiotherapy department, which provided positive feedback, and noted the expansion in use and scope of the service. • In its review of the Board Assurance Framework (item 6.3), the committee noted that the risk of staff availability could be due to both unaffordability as well as national lack of availability of qualified individuals. Action Craig Machell agreed to add an item covering the impact of technology over the next 5-10 years to a future Trust Board Study Session agenda. Maternity and Neonatal Safety 2024-25 Quarter 1 Report The chair of the Quality Committee was invited to provide an overview of the Maternity and Neonatal Safety 2024/25 report for the first quarter, the content of which was noted. It was further noted that: • Under the terms of the NHS Resolution Maternity Incentive Scheme, the Board had delegated review of the report to the Quality Committee. • There had been sustained improvement in meeting the required timescales for booking of appointments and screening since April 2024. • The continuity of carer need should be focused where it could make the most difference. • Appointment of a community partner by the Integrated Care Board was expected soon. • The Trust was approximately 40 members of staff short. However, plans were in place to address this deficit, including use of newly qualified nurses on rotations and the 36 new entrants expected between November 2024 and March 2025. 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: • David French had met with the new Secretary of State for Health and Social Care on 19 July 2024 where the Secretary of State had outlined his priorities in terms of urgent and emergency care and addressing the backlog in elective care through using private sector capacity. In addition, it was noted that the intention for the longer term was to focus on preventative health and digital. • Following the General Election, there were also a number of new Members of Parliament for the area served by the Trust. Page 3 • On 1 July 2024, the new pathology laboratory information management system had been rolled out across the region. There had been some initial issues with providing information to primary care providers. • David French had been asked and had agreed to remain as the provider representative on the Hampshire and Isle of Wight Integrated Care Board until September 2024. • A new referral system for Ophthalmology had been launched, which would use A/I in supporting the booking process. 5.6 Performance KPI Report for Month 3 Joe Teape was invited to present the Performance KPI Report for Month 3, the content of which was noted. It was further noted that: • The Trust’s performance was in the top quartile for six out of nine measures and the top half for two others. • There had been a fairly stable period with better occupancy levels and improvements in timings of discharges. • There were ~220 patients no longer meeting criteria to reside during June 2024, and the Trust was considering a new plan with local partners for a local system delivery plan. • The Trust’s cancer performance continued to be impacted by the challenge posed by increasing demand. • The Trust’s performance against the 31-day standard had fallen to the third decile, with capacity issues in radiology and prostate services. • Further understanding of who was being referred under cancer pathways was required, as this could identify health inequality concerns in terms of who was accessing the Trust’s services. • Increases in referrals could be due to national campaigns which raise public awareness of certain forms of cancer and the possible symptoms. 5.7 Break 5.8 Finance Report for Month 3 Ian Howard was invited to present the Finance Report for Month 3, the content of which was noted. It was further noted that: • Nationally, the NHS’s deficit was above £1bn, representing 4-5%. The Hampshire and Isle of Wight Integrated Care Board had recorded a £57m deficit (6%) for month 3. The average deficit for university teaching hospitals was 4.1%. • The Trust had recorded a £13m deficit (year-to-date) and an in-month deficit of £4.5m. • There had been some early signs of improvement with the underlying position having improved since month 1. • The Trust’s elective recovery performance was 128% and there had been improvements in length of stay. • The Trust’s workforce numbers and pay costs were below plan, and agency numbers had halved since summer 2023. • The underlying monthly deficit was c.£5m, with approximately £1m of this attributable to unfunded pay awards and costs of industrial action. • Meeting the Trust’s plan for Quarter 2 of 2024/25 was expected to be challenging, as it assumed that the Integrated Care System’s transformation programmes would begin to deliver. • The Trust’s cash reserves were now below £30m, and the Trust might need to consider the need for additional cash from NHS England. • The Trust would continue to focus on its transformation programmes. Page 4 • The level of the anticipated pay award for 2024/25 and a likely shortfall in funding for the award was a risk to the Trust’s financial position. 5.9 People Report for Month 3 Steve Harris was invited to present the People Report for Month 3, the content of which was noted. It was further noted that: • A number of improvements were in the process of being made to the report to incorporate a ‘heat map’ and provide additional focus on culture. • The Trust was under its overall workforce plan by 313 whole-time equivalents (WTE) at the end of June 2024. However, in terms of its overall plan, ~200 WTE were reliant on improvements in the non-criteria to reside and mental health position. • Violence and aggression remained a key concern, with increasing use by the Trust of its warning and exclusion policy. • Work was ongoing to review the number of statutory and mandatory training courses with a view toward rationalising the number. • The ‘We Are UHS’ Champions award ceremony was to be held in October 2024. • The Integrated Care Board recruitment control panel appeared to be limiting the number of requests for recruitment likely due to improved filtering taking place by the individual trusts. 5.10 Annual Complaints Report 2023-24 Natasha Watts was invited to present the Annual Complaints Report for 2023/24, the content of which was noted. It was further noted that: • The number of complaints received had decreased slightly compared to the previous year, and the number of complaints upheld or partially upheld had decreased compared to the previous year and remained lower than the national average. • There had been four cases reviewed by the Parliamentary and Health Service Ombudsman, of which two were closed and two were partially upheld. • The overall quality of responses to complaints had improved. 6. STRATEGY and BUSINESS PLANNING 6.1 Corporate Objectives 2024-25 Quarter 1 Review Martin De Sousa was invited to present the Corporate Objectives 2024/25 Quarter 1 Review, the content of which was noted. It was further noted that: • The Trust’s performance was largely positive with 11 (out of 16) objectives on track to be delivered in full. • The major risks for achievement of the objectives were the Trust’s financial position and the possible impact of this on the workforce, and the Trust’s ability to reduce the number of patients not having criteria to reside. • Inclusion of a predicted future rating for each objective in reports was to be considered. Page 5 6.2 Research and Development Plan 2024-25 Karen Underwood was invited to present the Research and Development Plan for 2024/25, the content of which was noted. It was further noted that: • During 2023/24, the Trust had recruited its 250,000th participant and had launched its Research for Impact strategy. • Income for 2024/25 was predicted to be lower than previously due to the impact of Covid-19-related studies on prior years. • Vacancies and the reliance on clinical support services would be a challenge for 2024/25. Decision Having discussed the proposal, the Board approved the Research and Development Plan for 2024/25. Action Ian Howard agreed to obtain clarification regarding the discrepancy between the Return on Investment table and Appendix 4 in the plan. 6.3 Board Assurance Framework (BAF) Update Lauren Anderson was invited to present the Board Assurance Framework, the content of which was noted. It was further noted that: • All risks had been reviewed by the Executive leads since June 2024. • The recorded gaps and controls were being checked and the BAF would differentiate between actions and aspirations in terms of the Trust’s steps to mitigate or address areas of risk. • It was intended to more closely link the BAF risks to the Board’s agenda. • The maturity assessment undertaken during 2023/24 as part of the audit of risk management carried out by KPMG would be reviewed to determine where the Trust would be against its aspirations by the end of the year. 7. CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Feedback from the Council of Governors’ (CoG) Meeting 24 July 2024 The Chair provided an overview of the meeting of the Council of Governors held on 24 July 2024. It was noted that the meeting had addressed the following matters: • The appointment of Shirley Anderson as the new Lead Governor. • Reports from the Chief Executive Officer and Chief Financial Officer. • The Trust’s annual report and accounts for the year ended 31 March 2024. 7.2 Register of Seals and Chair’s Actions Report The paper ‘Register of Seals and Chair’s Actions Report’ was presented to the meeting, the content of which was noted. Decision: The Board agreed to ratify the application of the Trust Seal to the documents listed in the ‘Register of Seals and Chair’s Actions Report’. 8. Any other business There was no other business. Page 6 9. Note the date of the next meeting: 10 September 2024 10. Resolution regarding the Press, Public and Others Decision: The Board resolved that, as permitted by the National Health Service Act 2006 (as amended), the Trust’s Constitution and the Standing Orders of the board of directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. The meeting was adjourned. Page 7 List of action items Agenda item Assigned to Deadline Status Trust Board – Open Session 28/03/2024 4.14 Guardian of Safe Working Hours Quarterly Report 1127. Junior Doctors Grundy, Paul 24/10/2024 Pending Explanation action item Paul Grundy and Diana Hulbert agreed to include an item regarding junior doctors on a future Trust Board Study Session agenda. Due to industrial action on 27 June, this item has been deferred to the next TBSS on 24/10/2024. Trust Board – Open Session 06/06/2024 5.6 Performance KPI Report for Month 1 1152. Digital Teape, Joe Explanation action item JT agreed to include Digital as an agenda item at a future Trust Board Study Session. 24/10/2024 Pending This item is tentatively scheduled for TBSS on 24/10/2024. Trust Board – Open Session 25/07/2024 5.4 Briefing from the Chair of the Quality Committee (Oral) 1163. Impact of technology Machell, Craig 27/02/2025 Pending Explanation action item Craig Machell agreed to add an item covering the impact of technology over the next 5-10 years to a future Trust Board Study Session agenda. Update: Item tentatively scheduled for 27/02/25 Study Session. Page 1 of 2 Agenda item Assigned to Deadline Status Trust Board – Open Session 25/07/2024 6.2 Research and Development Plan 2024-25 1165. Discrepancy Howard, Ian 10/09/2024 Pending Explanation action item Ian Howard agreed to obtain clarification regarding the discrepancy between the Return on Investment table and Appendix 4 in the plan. Page 2 of 2 Report to the Trust Board of Directors Title: Agenda item: Sponsor: Date: Purpose: Issue to be addressed: Response to the issue: Chief Executive Officer’s Report 5.4 David French, Chief Executive Officer 10 September 2024 Assurance Approval or reassurance Ratification Information X My report this month covers updates on the following items: • NHS Pay Offers • National Unison Campaign – Collective Pay Grievance for Healthcare Support Workers • Civil Unrest • Hampshire Together • Maternity Services and Sustainable Staffing • CQC Annual Hospital Inpatients Survey • Annual Regulation and Oversight Survey • Cass Review Implementation • Aseptic Preparation Audit • Human Tissue Authority inspection The response to each of these issues is covered in the report. Implications: Any implications of these issues are covered in the report. (Clinical, Organisational, Governance, Legal?) Summary: Conclusion The Board is asked to note the report. and/or recommendation Page 1 of 9 NHS Pay Offers On 29 July 2024, the Government announced that it would accept in full pay review body advice on NHS staff salaries and would make a pay offer to junior doctors in an attempt to end the ongoing industrial action. The Government accepted the 2024/25 recommendations of the NHS Pay Review Body for a 5.5% increase, backdated to 1 April 2024, for all Agenda for Change staff. This increase is expected to be reflected in October pay. In addition, intermediate pay bands will be created for Band 8 and 9 staff. In line with national guidance UHS will also offer back pay payments to be spread out over six months if individuals request this to help mitigate any impact on universal credit. The offer made to the junior doctors represents a 22.3% uplift over two years. This comprises an additional average of 4.05% for 2023/24 on top of the existing 8.8% implemented last year, taking the average uplift to 13.2%. In addition, 2024/25 pay would increase by an average of 12.4% against current 2023/24 payscales. The British Medical Association junior doctors committee recommends acceptance of this offer. Voting opened on 19 August and closes on 15 September 2024. The Government has also announced its intention to repeal the Strikes (Minimum Service Levels) Act 2023, which provides a mechanism to require workers in particular sectors, such as health, education, fire and rescue, and transport, to guarantee certain minimum levels of service during periods of industrial action. This will form part of a range of employment law modifications the government is considering, and the Board will be updated with further details once these are finalised. National Unison Campaign – Collective Pay Grievance for Healthcare Support Workers During August, UHS formally received a collective grievance relating to pay for Healthcare Support Workers (HCSWs). This is a national campaign led by UNISON pushing for recognition of duties carried out by these staff, formal re-grading of pay band, and appropriate back pay. UHS has over 1,200 individuals in these roles. The Chief People Officer is formally meeting with UNISON to discuss how the matter can be resolved. Whilst this is a national campaign, we have been told not to expect national resolution and Trusts have been directed to resolve locally as appropriate. Civil Unrest The nation experienced significant violent and racially motivated civil unrest during August. Farright anti-immigration rallies were planned in a number of cities across the UK, including Southampton. Healthcare workers had been directly targeted in some parts of the country by farright groups. This understandably generated fear and concern from our black, minority ethnic communities which was raised through various routes to leaders at the Trust. Communication was sent by the Chief Executive Officer and Chief Nursing Officer to all staff setting out our stance on the situation and proposed practical measures, coupled with local support from managers to those who were concerned. Led by the Chief Nurse through the Trust's incident management process, we rapidly implemented practical measures in addition to wider wellbeing and psychological support. Measures included additional security, additional transport and other local actions to help with people's safe journey to work on the day of planned demonstrations. Friday prayers were also attended by the Chief Medical Officer and the Director of OD and Inclusion to provide support to our Muslim communities. The unsavoury events have also triggered a collective drive to push again to focus on the violence and aggression issues at UHS. Staff still experience unacceptable violence, aggression and hate crimes by patients and service users at UHS and across the whole NHS. A multistakeholder workshop, including police partners, is planned for 2 October 2024 to re-energise Page 2 of 9 delivery of our existing commitments. We also want to use the expertise and advice of a range of people to explore and plan where we can go further and be bolder with this important agenda. At the national level, NHS England wrote to all integrated care boards, NHS trusts and foundation trusts, GP and dental practices, pharmacy contractors, and general ophthalmic service contractors on 12 August 2024 emphasising the NHS position that ‘discrimination is unacceptable, and the NHS should have a zero tolerance of racism towards our patients and colleagues’. NHS England also sets out some guidance in the following areas for organisations to listen to and support affected staff: • Ensuring staff can access the support they need • Involving staff networks in the organisational response • Dealing with instances of racism and discrimination • Demonstrating ongoing commitment to equality, diversity and inclusion The response can be read at: https://www.england.nhs.uk/long-read/nhs-response-to-2024-riots/ Hampshire Together HM Government has announced that it is pausing approval of the business cases for the ’40 new hospitals’, of which Hampshire Hospitals is one. Public consultation had recently been completed and submission of the final business case was anticipated before the end of this year but the timing of submission and approval of the business case is now uncertain pending the national review. Separately, the ‘Save Winchester Action Group’ has written to board members of HIOW ICB with concerns regarding the proposed changes at Winchester Hospital, specifically around the loss of acute services from the Winchester site. The overall programme was discussed at the ICS board meeting on 4 September 2024. The executive has a planned session with Hampshire Hospital NHS Foundation Trust executives at the end of September to discuss ideas around future models for services across all sites. Maternity Services Safe and Sustainable Staffing In August 2024, the Trust produced a briefing paper for the Care Quality Commission which provided a summary of the Trust’s action plan in respect of staffing of its Maternity services. The paper is attached as Appendix A. CQC Annual Hospital Inpatients Survey On 21 August 2024, the Care Quality Commission (CQC) published its adult inpatient survey for 2023. The survey examines the experiences of people over 16 who stayed at least one night in hospital during November 2023. The results showed a deterioration in people’s experiences of inpatient care since 2020, although the results for 2023 remained broadly consistent with those in 2022 and 2021. Most respondents reported a positive experience in their interactions with doctors and nurses, such as being treated with respect, dignity, kindness and compassion and being included in conversations. However, discharge from hospital remains a challenging part of people’s experience of care, with 29% saying that they had little to no involvement in decisions about their discharge, and only 48% saying that they were given enough notice about when they were going to leave. In addition, 23% of elective patients said they would have liked to have been admitted ‘a bit sooner’ and 19% ‘a lot sooner’, and 43% of elective patients believed that their health had deteriorated while waiting to be admitted. Page 3 of 9 The survey results can be viewed at: https://www.cqc.org.uk/publications/surveys/adult-inpatientsurvey Annual Regulation and Oversight Survey NHS Providers published the results of its annual regulation and oversight survey on 8 August 2024. According to the survey, trust leaders had reported an increased regulatory burden during the year, particularly noting a lack of coordination between regulators and questioning whether reporting requirements are proportionate or realistic. There were also questions as to whether regulators appropriately recognised the level of risks trusts had been absorbing in balancing the demands of financial and operational performance. Seventy-two per cent of trust leaders believed that the burden of integrated care board (ICB) regulation had increased, compared to 48% from NHS England and 36% from CQC. Less than a third of trusts were comfortable with the role of ICBs as performance managers and 62% saw their activity as duplicating that of NHS England. Respondents also questioned CQC’s credibility, feeling its judgements were not objective enough and inspection teams lacked sector-specific expertise. In addition, the majority of trust leaders would like to see a move away from the CQC’s one-word ratings, seeing it as too simplistic, often demoralising for staff, and confusing for patients. The survey report can be viewed at: https://nhsproviders.org/a-pivotal-moment-for-regulationregulation-and-oversight-survey-2024 Cass Review Implementation On 7 August 2024, NHS England published its plan to implement the advice from the Cass Review – the review of gender identity services for children and young people. This plan includes establishment of regional centres and changes to the referrals process to help trusts to deliver holistic, therapeutic and evidence-based care. The implementation plan can be read at: https://www.england.nhs.uk/long-read/children-andyoung-peoples-gender-services-implementing-the-cass-review-recommendations/ The Trust continues discussions with NHS England regarding whether Southampton could or should be one of these new regional centres. Aseptic Preparation Audit On 1 August 2024, the Trust was informed of the outcome of the external audit of unlicensed preparation of medicines for the pharmacy aseptic unit at Southampton General Hospital conducted on 4 June 2024. The unit’s operation was assessed as posing a low risk with respect to the quality of the medicines produced within it. The report also stated that the unit ‘is well managed and has good pharmaceutical quality systems in place’. Human Tissue Authority (HTA) inspection The HTA conducted an inspection of our mortuary arrangements in August. The formal feedback report has not been received but informal feedback has been shared by the inspection team. We expect the report to have no significant findings but we do anticipate a number of minor procedural and documentation recommendations. The inspection team advised us that the failings at Maidstone and Tunbridge Wells mortuary which enabled criminal activity to go unnoticed have triggered a recent ‘raising of the bar’, particularly regarding security / access arrangements. We will share the final inspection report when it is received, along with our response and action plan. Page 4 of 9 Appendix A UHS Briefing Paper to CQC Title: Maternity Services Safe and Sustainable Staffing Sponsor: Gail Byrne, Chief Nursing Officer Author(s): Emma Northover, Director of Midwifery Carly Springate, Head of Midwifery Marie Cann, Maternity and Neonatal Safety Lead Date: August 2024 Purpose: The purpose of this report is to note the current challenges in maternity staffing and provide assurance on the mitigations to maintain appropriate and safe staffing levels, which, in turn, ensures the delivery and support of high-quality care. Issue(s) to be addressed: Over recent weeks and months our Maternity Service has faced significant operational challenges, leading to more frequent than usual service diversions. This has led to impacts not only on the experience of our families and staff but across the wider Local Maternity and Neonatal System (LMNS). As from the beginning of July 2024, UHS Maternity Services have escalated to OPEL 4 on 23 occasions from the start of this year. Across the whole of 2023 OPEL 4 was declared 28 times. This shows a significant increase in service pressure that our Maternity Service is experiencing with staffing and acuity accounting for the majority of incidents. Whilst we are compliant with providing 1:1 care in active labour and we are safe, we are seeing an increase in other reportable red flags such as delays in induction and being unable to facilitate birthplace choices. In terms of our current position, staffing levels across the Maternity Service have remained challenging with vacancy rates across the registered workforce currently sit around 14%, equating to around 30 Whole Time Equivalents (WTE). Addressing these staffing challenges will require a coordinated effort and it is hoped that by collaborating with our partners we can develop a more comprehensive and effective approach to improving workforce provision. The enclosed plan of action sets out to address the staffing issues as much as possible until the newly qualified midwives start and vacancy is significantly reduced The DoM and the Senior Midwifery Leadership Team are committed to ensuring safe and sustainable staffing levels across UHS Maternity Services. We remain open and honest around our changing clinical environment as well as being sensitive and responsive to any rapidly changing picture. Escalation processes and frameworks are robust and well established. Further to this we have excellent engagement from our 1|Page Page 5 of 9 Maternity Safety Champions with whom we meet with regularly. This includes full support from Gail Byrne, Chief Nursing Officer and Executive Maternity Safety Champion, and Tim Peachey, Non-Executive Director and Maternity Safety Champion, who together ensure that the DoM has a platform and a voice at Trust Board. Despite the immediate challenges in respect of the Maternity Services workforce at UHS, we are looking to offer assurances to the CQC in terms of the actions both short and longer term that are being taken and the mitigations in place to reduce harm and maintain safety to our service users. Risks (top 3) of carrying out the change or not: Summary/ conclusion • 285 - Red 20 Maternity Staffing during peaks of activity • 259 - Red 16 Capacity and Demand in Maternity Services • 617 - Orange 12 Lack of postnatal care provision (staffing) • 815 - Red 15 Poor compliance with NICE guidance for Antenatal Bookings The CQC are asked to review this report and the mitigations in place and seek further assurance if required. Page 6 of 9 2|Page Maternity Staffing Action Plan Issue/Action Progress Lead Date 1. Following a successful newly • Our current preceptorship programme (18 months in hos- Practice Aug 2024 qualified midwife recruitment pital) has been recently reviewed in terms of content and Education lead drive, 34 WTE band 5 midwives structure to ensure that these staff are retained. to join UHS Maternity Services in November 2024. 2. Utilisation of contingency • Provides contingency measures in releasing and redeploy- Head of Aug 2024 framework ing additional staff. Midwifery RAG G 3. Utilise birthrate plus as a • The last assessment of UHS Maternity Services by BR+ in Director of framework for workforce planning 2018 suggested an overall clinical establishment based on Midwifery and strategic decision making a midwife V birth ratio of 1:24, calculated against an annual birth rate of 5500 births. This is soon to be recalculated Sept 2024 A 4. Increased staff support in the • We have retained 100% of our newly qualified preceptees Head of Aug 2024 G clinical environment in addition to who started with us in November 2023. Midwifery pastoral and psychological Practice support to enhance retention of Education Lead the workforce. 5. The senior leadership team, • To review how we maintain this going forward to ensure Director of Aug 2024 G including the Director of sustainability Midwifery / Chief Midwifery (DoM), commit to a Nursing Officer high number of out-of-hours on- calls to support the service when in escalation and when staffing does not match the acuity and activity across the acute clinical areas. 3|Page Page 7 of 9 6. Two fixed term matron roles have • This provides additional cushioning to the matron team and Director of been appointed to oversee a development opportunity for our existing workforce. Midwifery antenatal and postnatal pathways. 7. Development of a systematic • This live data is reflective of total staff unavailability in- Maternity process for workforce planning in clude vacancy rates, sickness ratios, maternity leave, and Business the form of a monthly dashboard. study time, all of which is compared alongside the budg- Support eted versus actual staffing establishment overall. Manager 8. The labour ward coordinator will • This enables the labour ward coordinator to have continu- Head of not take responsibility for any ous oversight of their clinical environment and oversee Midwifery patients, or cover breaks for other safety. members of staff. 9. An extensive listening exercise • To align with current service needs, and with staff wellbe- Director of has been undertaken place to ing as a central focus, the DoM and Senior Midwifery Midwifery help inform the future direction Leadership Team are reviewing the way the service is de- and structure of the Maternity livered with the potential of a workforce restructure. Service workforce. 10. 12 – 16 Registered nurses are to • Divisions seeking staff who are interested in supporting Director of be seconded to maternity in this and with the right skillset. Midwifery interim period to help release midwife time with roles such high • A review will be undertaken to see if this could be a dependency, vaccination, longer-term proposition to support the maternity workforce fundamentals of care 11. Dedicated programmes for career • Our prime focus is to consider new ways in which we can Director of development starting at band 2 future proof our Maternity Services going forward, whilst Midwifery and progressing to band 9. investing in our people. 12. A NHSP Incentive Scheme has been agreed to run over the summer months • This action has enabled staff to feel valued and appreciated Director of for all their gestures of good will and their contributions to Midwifery Page 8 of 9 Aug 2024 G Aug 2024 G Aug 2024 G Aug 2024 A Aug 2024 A Aug 2024 A Aug 2024 A 4|Page the workforce that are worked outside of contractual commitments. 13. A review to look at tipping points • Contact to be made with the ED to review learning and any Head of (as happens in Emergency processes and systems. Midwifery Department) to be scoped introduced 14. A roster review will be • Full review of the roster template to ensure fit for purpose Maternity undertaken to ensure the correct and staff allocated correctly. Business staffing levels and skills are in Support place. Manager Aug 2024 A Aug 2024 A 15. To introduce legacy midwives • Review of legacy midwives roles and recruitment Director of Aug 2024 A (recently retired midwives) to processes. Midwifery support newly qualified staff and Practice education Education Lead R Red: Immediate remedial action required A Amber: Action in progress G Green: Complete Page 9 of 9 5|Page Report to the Trust Board of Directors Title: Agenda item: Sponsor: Author: Date: Purpose: Issue to be addressed: Patient Safety and Quality of Care in Pressurised Services 5.5 Joe Teape, Chief Operating Officer Duncan Linning-Karp, Deputy Chief Operating Officer 10 September 2024 Assurance Approval or reassurance X Ratification Information Urgent and Emergency Care (UEC) services are under significant pressure nationally, with some high-profile cases of poor care highlighted, including in the press. In response NHSE has asked Trust Boards to assure themselves that they are doing all they can to: • Provide alternatives to emergency department attendance and admission, especially for those frail older people who are better served with a community response in their usual place of residence. • Maximise in-hospital flow with appropriate streaming, senior decision-making and board and ward rounds regularly throughout the day, and timely discharge, regardless of the pathway a patient is leaving hospital or a community bedded facility on. Response to the issue: This paper will outline UHS’s response to the above issues, including the improvement programmes focused on flow and the Emergency Department, the response to the UEC recovery plan year two document, work taking place across the local system and mitigations that take place when the Emergency Department becomes over-crowded. Implications: Clinical, organisational, governance, legal (Clinical, Organisational, Governance, Legal?) Risks: (Top 3) of carrying out the change / or not: • Harm to patients in the Emergency Department through prolonged waits and / or overcrowding. • Harm to patients who remain in hospital longer than necessary because of delayed discharge. • Harm to patients on an elective waiting list who are delayed because of a lack of capacity due to high levels of patients not meeting the criteria to reside. Summary: Conclusion Trust Board is asked to note this report. and/or recommendation Page 1 of 10 Introduction NHS England wrote to all NHS Trusts (see Appendix 1) to ask Trust Boards to assure themselves that Trusts, and wider systems, were doing all they can to reduce demand on Emergency Departments, improve flow across the UEC pathways including out of hospital, ensure basic standards of care are in place across all care settings and ensure executive visibility and leadership, and non-executive presence. This paper provides assurance to the Board, addressing the key requests outlined in the letter and benchmarks UHS’s response to the year two UEC plan. It also outlines work taking place in the local system to support admission avoidance and reduce delayed discharge. Finally, it outlines mitigations the organisation has put in place to manage risk at times when the Emergency Department (ED) is overcrowded, and to support flow through the hospital. Patient Safety and Quality of Care in Pressurised Services NHSE wrote to all Trusts to outline key actions Boards were required to assure themselves on to ensure patient safety and quality of care is maintained in pressurised services. The table below outlines those actions and UHS’s compliance against them. Request Provide alternatives to emergency department attendance and admission, especially for those frail older people who are better served with a community response in their usual place of residence. Maximise in-hospital flow with appropriate streaming, senior decision-making and board and ward rounds regularly throughout the day, and timely discharge, regardless of the pathway a patient is leaving hospital or a community bedded facility on. Their organisations and systems are implementing the actions set out in the UEC Recovery Plan year 2 letter. Basic standards of care, based on the CQC’s fundamental standards, are in place in all care settings. Services across the whole system are supporting flow out of ED and out of hospital, including making full and appropriate use of the Better Care Fund. Executive teams and Boards have visibility of the Seven Day Hospital Services audit results, as set out in the relevant Board Assurance Framework guidance. There is consistent, visible, executive leadership across the UEC pathway and appropriate escalation protocols in place Assurance There are community alternatives in place, including Urgent Community Response and virtual wards. More work is taking place to set-up Integrated Neighbourhood Teams. In-hospital flow is something UHS is continuously seeking to improve via the inpatient flow programme, focusing on all aspects of flow within the hospital’s control and ensuring patients only remain in hospital when necessary. Ward rounds take place daily with appropriate input from a senior decision maker. UHS is compliant with these actions, outlined in the following section. Fundamentals of care standards have been rolled out across the organisation. A CQC Oversight Group, chaired by the CNO, provides assurance on compliance against the standards. The wider system does support flow out of ED and the wider hospital, and the Better Care fund is used. However, the system continues to struggle with a high number of patients remaining in hospital who do not meet the criteria to reside. Seven Day Hospital Services are reported via the annual Quality Account to the Board and the Trust is compliant. A further audit is due in 2024. There is consistent, visible executive leadership across the UEC pathway including a fortnightly ED meeting chaired Page 2 of 10 every day of the week at both trust and system level. Regular non-executive director safety walkabouts take place where patients are asked about their experiences in real time and these are relayed back to the Board. by the Chief Executive, a monthly UEC Board chaired by the COO, a monthly CQC Oversight meeting chaired by the CNO and regular executive walkabouts. UHS has an internal escalation plan as does the wider system. The Trust appointed a clinical Director for Urgent and Emergency Care. Non-executive directors undertake walkabouts as part of Trust Board. Year two UEC Plan Benchmarking against the second year of the UEC plan shows that UHS is compliant against the key metrics. There has, however, been a reduction rather than an increase in some out of hospital capacity because of the financial challenges facing the ICB, Local Authorities and wider system. Request 1A. Maintain acute G&A beds at the level funded and agreed through operating plans in 2023/24. 1B. Maintain ambulance capacity and support the development of services that reduce ambulance conveyances to acute hospitals. 1C. Focus on reduction in ambulance handover delays to support system flow. 1D. Expand bedded and non-bedded intermediate care capacity, to support improvements in hospital discharge and enable community step-up care. 1E. Improve access to virtual wards through improvements in utilisation, access from home pathways, and a focus on frailty, acute respiratory infection, heart failure, and children and young people. 2A. Focus on reductions in admitted and non-admitted time in ED. Assurance UHS’s 2024/25 plan included the dual aspirations of halving the number of patients not meeting the criteria to reside and reducing length of stay by 5%. If these were both met, it is unlikely that we would require all current beds. However, while beds that are not needed would not be staffed, they will remain available if needed. In recent months routine surge capacity has remained closed b
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Papers Trust Board - 10 March 2026

Description: Date Time Location Chair Apologies Agenda Trust Board – Open Session 10/03/2026 9:00 - 13:00 Conference Room, Heartbeat Education Centre Jenni Douglas-Todd Steve Peacock 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 13 January 2026 9:15 Approve the minutes of the previous meeting held on 13 January 2026 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 Audit and Risk Committee 9:20 Ian Howard, Chief Financial Officer, for Chair 5.2 Briefing from the Chair of the Finance, Investment & Cash Committee 9:25 David Liverseidge, Chair 5.3 Briefing from the Chair of the People and Organisational Development 9:30 Committee Jane Harwood, Chair 5.4 Briefing from the Chair of the Quality Committee 9:35 including Interim Maternity and Neonatal Safety Report Tim Peachey, Chair 5.5 Chief Executive Officer's Report 9:40 Receive and note the report Sponsor: David French, Chief Executive Officer 5.6 Performance KPI Report for Month 10 10:10 Review and discuss the report Sponsor: Andy Hyett, Chief Operating Officer 5.7 Break 10:40 5.8 Finance Report for Month 10 10:55 Review and discuss the report Sponsor: Ian Howard, Chief Financial Officer 5.9 ICB System Report for Month 10 11:05 Receive and discuss the report Sponsor: Ian Howard, Chief Financial Officer 5.10 People Report for Month 10 11:10 Review and discuss the report Sponsor: Steve Harris, Chief People Officer 5.11 Freedom to Speak Up Report 11:20 Review and discuss the report Sponsor: Natasha Watts, Acting Chief Nursing Officer Attendee: Christine Mbabazi, Equality & Inclusion Adviser/Freedom to Speak Up Guardian 5.12 11:35 Guardian of Safe Working Hours Quarterly Report and Update on 10-Point Plan Review and discuss the report and update Sponsor: Paul Grundy, Chief Medical Officer Attendee: Diana Hulbert, Guardian of Safe Working Hours and Emergency Department Consultant 6 STRATEGY and BUSINESS PLANNING 6.1 Corporate Objectives 2025-26 Quarter 3 Update 11:50 Review and feedback on the corporate objectives Sponsor: David French, Chief Executive Officer Attendee: Martin de Sousa, Director of Strategy and Partnerships 6.2 Board Assurance Framework (BAF) Update 12:00 Review and discuss the update Sponsor: Natasha Watts, Acting Chief Nursing Officer Attendee: Craig Machell, Associate Director of Corporate Affairs and Company Secretary 7 CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Feedback from the Council of Governors' (CoG) Meeting 29 January 2026 12:15 (Oral) Sponsor: Jenni Douglas-Todd, Trust Chair Page 2 7.2 Register of Seals and Chair's Actions Report 12:20 Receive and ratify the report In compliance with the Trust Standing Orders, Financial Instructions, and the Scheme of Reservation and Delegation. Sponsor: Jenni Douglas-Todd, Trust Chair 7.3 Audit and Risk Committee Terms of Reference 12:25 Review and approve the Terms of Reference Sponsor: Ian Howard, Chief Financial Officer, for Committee Chair Attendee: Craig Machell, Associate Director of Corporate Affairs and Company Secretary 7.4 Quality Committee Terms of Reference 12:30 Review and approve the Terms of Reference Sponsor: Tim Peachey, Committee Chair Attendee: Craig Machell, Associate Director of Corporate Affairs and Company Secretary 7.5 Remuneration and Appointment Committee Terms of Reference 12:35 Review and approve the Terms of Reference Sponsor: Jenni Douglas-Todd, Trust Chair Attendee: Craig Machell, Associate Director of Corporate Affairs and Company Secretary 8 Any other business 12:40 Raise any relevant or urgent matters that are not on the agenda 9 Note the date of the next meeting: 14 May 2026 10 Items circulated to the Board for reading 10.1 South Central Regional Research Delivery Network (SC RRDN) 2025-26 Q3 Performance Report Note the report Sponsor: Paul Grundy, Chief Medical Officer 11 Resolution regarding the Press, Public and Others Sponsor: Jenni Douglas-Todd, Trust Chair To agree, as permitted by the National Health Service Act 2006 (as amended), the Trust's Constitution and the Standing Orders of the Board of Directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. 12 Follow-up discussion with governors 12:45 Page 3 Agenda links to the Board Assurance Framework (BAF) 10 March 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) 5.6 Performance KPI Report for Month 10 5.8 Finance Report for Month 10 5.9 ICB System Report for Month 10 5.10 People Report for Month 10 5.11 Freedom to Speak Up Report 5.12 Guardian of Safe Working Hours Quarterly Report and Update on 10-Point Plan 1a, 1b, 1c 5a 5a 3a, 3b, 3c 3b 3b 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 4x4 16 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 Minutes Trust Board – Open Session Date Time Location Chair 13/01/2026 9:00 – 13:00 Conference Room, Heartbeat Education Centre Jenni Douglas-Todd (JD-T) Present Jenni Douglas-Todd, Chair (JD-T) Keith Evans, Non-Executive Director (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 and Deputy Chair (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) James Allen, Chief Pharmacist (JA) (item 5.12) Julie Brooks, Deputy Director of Infection Prevention and Control (JB) (item 5.11) Blue Cunningham, Patient Engagement & Involvement Officer (item 2) John Mcgonigle, Emergency Planning & Resilience Manager (JMc) (item 6.1) Jenny Milner, Associate Director of Patient Experience (JM) (item 5.10) Julian Sutton, Clinical Lead, Department of Infection (JS) (item 5.11) 4 governors (observing) 5 members of staff (observing) 2 members of the public (observing) Apologies Diana Eccles, NED (DE) 1. Chair’s Welcome, Apologies and Declarations of Interest The Chair welcomed attendees to the meeting. There were no interests to declare in the business to be transacted at the meeting. It was noted that apologies had been received from Diana Eccles. The Chair provided an overview of meetings she had held and events that she had attended since the previous Board meeting. 2. Patient Story Blue Cunningham was invited to present the Patient Story on behalf of Jade […], whose nine-year-old daughter, Lucy, had had a bowel resection at the Trust. It was noted that: • Lucy was a very structured child, who relied heavily on planning and knowing outcomes as well as having sensitivities to lots of different sensory inputs. Page 1 • In their treatment of Lucy, staff paid particular attention to Lucy’s needs and adapted their behaviour and took the time to make Lucy’s stay in hospital as comfortable as possible. • This Patient Story clearly demonstrated the Trusts’ values and the time taken in the handling of Lucy by staff likely saved time and effort in the long run by not distressing the patient and then having to manage this situation. 3. Minutes of the Previous Meeting held on 11 November 2025 The draft minutes tabled to the meeting were agreed to be an accurate record of the meeting held on 11 November 2025, subject to reassigning action 1296 to James Allen. 4. Matters Arising and Summary of Agreed Actions The matters arising and actions were noted. • Action 1293: work had commenced on a broader MRI strategy. This work would be presented to the Quality Committee in due course – the action remained open. • Action 1294: this formed part of a larger piece of work, which would be addressed through the planning cycle. The action could be closed. • Action 1295: a solution had been developed, but the Trust was waiting on a third party to be able to implement the solution. The action could be closed. • Action 1296 was addressed as part of item 5.12 below. It was explained that the metric was based on day cases and national statistics and was intended to show usage levels of the most critical antibiotics. 5. QUALITY, PERFORMANCE and FINANCE 5.1 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 24 November and 15 December 2025, the contents of which were noted. It was further noted that: • The Trust had reported an in-month deficit of c.£5m and, at the end of November 2025, had reported a year-to-date deficit of £40m. • The committee had received an update in respect of the Trust’s theatres improvement plans, noting that there had been a 3% increase in utilisation and a 3% reduction in cancellations. • The committee had received a report on the Trust’s productivity based on the national framework and noted that further work was required to understand the metrics behind the national framework. • The committee had reviewed the Trust’s cash position and supported a proposal to request further cash support for January 2026. • The committee noted that whilst the Trust’s transformation plans were ambitious, they were nonetheless grounded in reality. • In its review of the proposed capital plans for 2026/27-2029/30, the committee noted the challenge of having to balance the Trust’s allocation of Capital Departmental Expenditure Limit (CDEL) with the cash available to the Trust. • The committee reviewed the Trust’s medium-term plan ahead of the first submission to NHS England on 17 December 2025. It was noted that the assumed reductions in patients with no criteria to reside and mental health Page 2 patients were those reasonably considered to be within the Trust’s control rather than reductions which were dependent on third parties. • The committee supported a proposal for transforming the Southern Counties Pathology network. 5.2 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 21 November and 15 December 2025, the contents of which were noted. It was further noted that: • Whilst there had been reductions in the size of the substantive workforce, this had been offset by an increase in temporary staff due to a combination of demand, sickness absence, patients with no criteria to reside, and mental health patients. • The committee noted changes with respect to statutory and mandatory training, which would facilitate ‘passporting’ between NHS organisations. • The committee received an update in respect of the Trust’s Inclusion and Belonging strategy, noting that progress had been slower than anticipated due to available resource. It was further noted that the external political environment had also created additional challenges in this area. • The committee received an update regarding the Trust’s refreshed approach to violence and aggression, noting a greater willingness to take action against violent/abusive patients and members of the public. It was further noted that the communications accompanying the new approach would be key. • The committee reviewed the Trust’s performance against the ten-point plan for resident doctors, noting that the Trust was, subject to a few exceptions, in a good position. • Whilst the results of the Staff Survey were still under an embargo, early indications were that the participation rate was lower than hoped for. • The Trust’s seasonal vaccination campaign had been successful with over 50% of staff having been vaccinated against influenza. 5.3 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 24 November 2025, the content of which was noted. It was further noted that: • The committee noted that the Trust’s Complaints service, particularly Patient Advice and Liaison Service (PALS), was fragile. There was a backlog of c.500 emails due to resource constraints. • The committee noted that despite the financial pressure the Trust was under, it had sought to maintain staff numbers to ensure patient safety. A significant proportion of the reduction in staff during the year had been from administrative staffing groups. Whilst the Trust had successfully reduced the size of the clinical administrative workforce, it had not been possible to transform how this service was delivered through technical or other means. Therefore, there was a risk of bottlenecks due to insufficient administrative staff with the high level of demand falling on a smaller number of staff. • NHS England had launched changes to maternity care reporting with additional reporting requirements with the aim of developing national standards and approaches. • The committee had reviewed the Trust’s Maternity and Neonatal Safety report for the second quarter and noted that the Trust had demonstrated compliance with the requirements for the NHS Resolution Maternity Incentive Scheme. Page 3 5.4 Chief Executive Officer’s Report David French was invited to present the Chief Executive Officer’s Report, the content of which was noted. It was further noted that: • NHS England had published latest segmentation and league tables under the NHS Oversight Framework for Quarter 2. The Trust had fallen slightly from 48 out of 134 to 51 out of 134. The Trust remained in segment 5 due to being in the Recovery Support Programme. • The number of patients waiting over 65 weeks in October 2025 had resulted in the Trust entering Tier 1 for elective performance. However, since that time, the Trust had successfully reduced the number of patients waiting over 65 weeks to c.80, with a target to reduce this number to nil by the end of March 2026. • The Employment Rights Bill received Royal Assent on 18 December 2025. The Act included a number of changes which would impact the Trust. These changes were to be reviewed in detail by the People and Organisational Development Committee. • During further strike action by resident doctors between 17 December and 22 December 2025, the Trust had met the national target of maintaining 95% of activity. Roughly one-third of resident doctors had taken part in the industrial action, which compared favourably to other trusts – some had reported a participation rate of 80-90%. • University Hospitals Sussex NHS Foundation Trust had been fined in connection with the death of a patient with severe mental health problems who had absconded from a ward at the trust and subsequently committed suicide. This case was pertinent for the Trust given the number of mental health patients currently being cared for at the Trust in the absence of a more appropriate setting. It was noted that the Trust’s policy was clear on the approach to be taken in the event of a similar situation to that faced by University Hospitals Sussex NHS FT. • On 2 January 2026, the Trust had been informed that its endoscopy service had had its accreditation renewed until 1 November 2026 following an annual review by the Royal College of Physicians’ Joint Advisory Group on Gastro- Intestinal Endoscopy. • Alison Tattersall had been appointed as the Trust’s second Nominated Trustee on the board of the Southampton Hospitals Charity. • The Trust’s department of clinical law – a service established to deal with clinical questions relating to regulatory and legal principles within the Trust – had been in existence for 16 years. 5.5 Performance KPI Report for Month 8 Andy Hyett was invited to present the ‘spotlight’ report in respect of Cancer waiting time targets, the content of which was noted. It was further noted that: • There had been an increase in referrals over recent years, but despite this increase, the Trust had maintained performance, particularly in respect of the 28-day faster diagnosis pathway. • Consideration was being given in terms of demographic groups to be targeted in view of the success of the Targeted Lung Health Check programme and its efforts to target particular sections of the population. • The main challenge in terms of improving performance was in terms of diagnostic capacity, including access to magnetic resonance imaging (MRI) and other imaging services. Improving the diagnostics services remained a key priority, including development of a longer-term strategy for imaging. It was noted that MRI and computed tomography (CT) scan capacity in the UK was lower than that in comparable nations such as those in the US and EU. Page 4 • The Trust maintained a good relationship with the Wessex Cancer Alliance, which was an effective route for obtaining additional funding for cancer care. Action Andy Hyett agreed to provide Jane Harwood with further data regarding the stage at which cancer was diagnosed by socio-economic group. Andy Hyett was invited to present the Performance KPI Report for Month 8, the content of which was noted. It was further noted that: • The Trust’s overall Referral To Treatment (RTT) waiting list for November 2025 had decreased by 0.9% and the Trust had made significant progress in reducing the number of patients waiting more than 65 weeks. • The number of patients waiting for diagnostics marginally increased, but the Trust had maintained its previous performance with c.80% of patients waiting under six weeks for the fourth month in a row. • The Trust’s performance against the four-hour emergency department target had improved by 5.8% since October 2025, achieving 60.4% in November 2025, which was above its in-year performance plan submitted at the beginning of 2025/26. The Board discussed the Performance KPI Report for Month 8. This discussion is summarised below: • In terms of the Trust’s RTT waiting list, it was forecast that there would be c.60,000 patients on this list by the end of March 2026 with performance against the 18-week target expected to be c.67%. • The Trust’s performance in respect of the number of mental health patients spending over 12 hours in accident and emergency was considered to be reflective of the need to admit mental health patients where there was no more appropriate venue available. This situation also gave rise to increased use of agency staff. A workshop had been held with Hampshire and Isle of Wight Healthcare NHS Foundation Trust (HIOWH) and an action plan had been agreed. It was noted that HIOWH was also experiencing challenges in terms of its ability to discharge patients. • The reduction in the percentage of virtual appointments as a proportion of all outpatient consultations compared to 2024/25 was being looked at. • As of 13 January 2026, there were 295 patients with no criteria to reside – equivalent to 12 wards – at Southampton General Hospital. Work was ongoing to create wards specifically for this cohort of patients. It was noted that Hampshire and Isle of Wight Integrated Care System was ranked 39 out of 42 in terms of its number of patients with no criteria to reside. 5.6 Break 5.7 Finance Report for Month 8 Ian Howard was invited to present the Finance Report for Month 8, the content of which was noted. It was further noted that: • The Trust had reported a £4.9m deficit for Month 8 (£40.8m deficit, year-to- date), which was in line with its Financial Recovery Plan. This in-month deficit had also been maintained for Month 9, with the year-to-date deficit increasing to £45.6m. • The Trust’s underlying deficit remained at c.£6m per month with continued high numbers of patients with no criteria to reside and mental health patients coupled with operational pressures. Page 5 • The Trust had carried out between £20m and £30m of unfunded work during the year and had incurred £10m-15m of costs associated with patients with no criteria to reside and mental health patients. • The Trust expected to deliver £90m of savings under its Cost Improvement Programme against its target of £110m. • The Trust had requested £8.4m of additional cash support for January 2026 and expected to require a further £3m of support in March 2026. 5.8 ICS System Report for Month 8 Ian Howard was invited to present the ICS System Report for Month 8, 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 £65m, which represented a variance of £36m from plan. It was noted that the Trust was a significant contributor to this variance, but that other organisations were also now reporting variances to plan. • The Trust had achieved the best ambulance handover time performance in the system, but further work was ongoing across the system with South Central Ambulance Service (SCAS) to improve performance. 5.9 People Report for Month 8 Steve Harris was invited to present the People Report for Month 8, the content of which was noted. It was further noted that: • The overall workforce fell marginally during November 2025, with reduction in substantive staff of 52 whole-time-equivalents (WTE) being partially offset by an increase in temporary staff usage due to operational pressures and sickness absence. • The Trust remained above its 2025/26 plan by 214 WTE despite a decrease of nearly 400 WTE since 31 March 2025. In order to meet its Financial Recovery Plan, the Trust’s workforce needed to reduce by a further 137 WTE. • Sickness absence continued to increase with 4.2% being reported during November and 4.8% being reported for December 2025. • The 2025 Staff Survey had closed. It was noted that the results were expected to be challenging. • The Trust had hit its target of 58% of staff having been vaccinated against flu, which placed the Trust in the top 15 nationally and second in the South East. • There was a significant amount of work ongoing to refresh the Trust’s approach and policies in respect of violence and aggression, including policy changes, training and communications. 5.10 Learning from Deaths 2025-26 Quarter 2 Report Jenny Milner was invited to present the Learning from Deaths report for the second quarter, the content of which was noted. It was further noted that: • The Trust continued to benchmark well against other organisations. It was one of only 11 trusts nationally with a lower than anticipated mortality rate based on its summary hospital-level mortality indicator (SHMI) score. • The Medical Examiner Service had reviewed a total of 1,078 deaths, of which 36% had occurred at the Trust’s sites. • Patients with learning disabilities remained an area of concern, although progress was being made in this area. The Trust was one of only a few Page 6 organisations to hold separate meetings to discuss deaths of patients with learning disabilities. • The Trust had procured a system to support organisation-wide learning from Morbidity and Mortality outcomes. 5.11 Infection Prevention and Control 2025-26 Quarter 2 Report Julian Sutton and Julie Brooks were invited to present the Infection Prevention and Control report for the second quarter, the content of which was noted. It was further noted that: • For the period covered by the report (July-September 2025), the Trust had exceeded all measures in terms of the annual limits for incidences of bacteraemia. The Trust was in a similar position to other organisations nationally. • There had been two cases of Methicillin-resistant Staphylococcus aureus (MRSA) and 34 cases of Clostridioides difficile (C-diff) during the period. • There had been a focus on invasive device care management (such as cannulas and catheters) and on hand hygiene. • The Trust had successfully managed the Candidozyma auris outbreak, with only three new cases identified since the beginning of 2025, the last of which was identified in April 2025. 5.12 Medicines Management Annual Report 2024-25 James Allen was invited to present the Medicines Management Annual Report 2024/25, the content of which was noted. It was further noted that: • The Trust’s expenditure on medicines during 2024/25 was £215m, a 2% reduction compared to 2023/24 and was on track to spend only £207m during 2025/26. These reductions indicated that the strategy of using less expensive generic and biosimilar medicines had been effective in reducing costs. • The number of approvals for clinical trials and research activity had continued to improve. • The Trust had completed work to decommission nitrous oxide manifolds, which was expected to reduce the Trust’s nitrous oxide emissions by 600,000 litres per year, equivalent to 354 tonnes of carbon dioxide emissions. • An area of focus was the deployment of digital systems. Action Ian Howard agreed to look at the level of savings achieved in terms of medicines costs and how costs of medicines were budgeted for. 5.13 Ward Staffing Nursing Establishment Review 2025 Natasha Watts was invited to present the Ward Staffing Nursing Establishment Review 2025, the content of which was noted. It was further noted that: • The report set out the results of the ward staffing review undertaken between July and October 2025. • There was a renewed national focus on safe staffing. • Overall, the Trust’s staffing establishments remain appropriate and within recommended guidelines. Page 7 • Continued high levels of enhanced care demand, a significantly more junior workforce, managing additional surge areas, and the impact of financial controls had been highlighted as ongoing challenges. 6. CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 6.1 Annual Assurance for the NHS England Core Standards for Emergency Preparedness, Resilience and Response (EPRR) Jon Mcgonigle was invited to present the Annual Assurance for the NHS England Core Standards for Emergency Preparedness, Resilience and Response, the content of which was noted. It was further noted that: • NHS England required all trusts to complete an annual self-assessment against a number of core standards. In its assessment against 62 applicable core standards, the Trust was fully compliant with 56 and not yet fully compliant with 6 standards. • Of the areas where the Trust was not yet fully compliant, these related primarily to governance maturity, exercising and testing, workforce training consistency, and assurance evidence, rather than the absence of emergency response arrangements. • Since an initial report had been submitted to the Trust Executive Committee in November 2025, the Trust had completed development and approval of the Business Continuity Management System, completed the consultation and adoption of Protective Security and Emergency Lockdown arrangements, and had commenced consultation and system engagement for Evacuation and Shelter. • Training was scheduled to take place between February and May 2026 for on- call staff in charge. It was intended to hold a tabletop exercise during 2027. • It was noted that it had been some time since the Trust had practised a major incident response with other partners. • The Trust was on schedule to embed the ‘protect’ duty under the Terrorism (Protection of Premises) Act 2025 by March 2027. Action John Mcgonigle agreed to look at scheduling a major incident response exercise with other partners involved. 7. Any other business It was noted that the Trust had declared a critical incident on 10/11 December 2025 due to an IT system failure. It was noted that this was Keith Evans’ final formal meeting, as his second threeyear term as a non-executive director was due to expire on 31 January 2026. The Board expressed its thanks to Keith Evans for his service and support. 8. Note the date of the next meeting: 10 March 2026 Page 8 9. Resolution regarding the Press, Public and Others Decision: The Board resolved that, as permitted by the National Health Service Act 2006 (as amended), the Trust’s Constitution and the Standing Orders 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 11/11/2025 - 5.6 Performance KPI Report for Month 6 1293. MRI scanners and imaging Hyett, Andy 10/03/2026 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. TB 13/01/26: work had commenced on a broader MRI strategy. This work would be presented to the Quality Committee in due course – the action remained open. Trust Board – Open Session 09/09/2025 - 8 Any other business 1286. Organ donation Machell, Craig Explanation action item Craig Machell agreed to add organ donation to the agenda of a future Trust Board Study Session. 16/04/2026 Pending Update: Item deferred to TBSS on 16/04/26. 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. Page 1 of 2 Agenda item Assigned to Deadline Status Trust Board – Open Session 13/01/2026 - 5.5 Performance KPI Report for Month 8 1311. Cancer diagnosis Hyett, Andy 10/03/2026 Pending Explanation action item Andy Hyett agreed to provide Jane Harwood with further data regarding the stage at which cancer was diagnosed by socio-economic group. Trust Board – Open Session 13/01/2026 - 5.12 Medicines Management Annual Report 2024-25 1312. Medicines costs Howard, Ian 10/03/2026 Pending Explanation action item Ian Howard agreed to look at the level of savings achieved in terms of medicines costs and how costs of medicines were budgeted for. Trust Board – Open Session 13/01/2026 - 6.1 Annual Assurance for the NHS England Core Standards for Emergency Preparedness, Resilience and Response (EPRR) 1313. Major incident response exercise Mcgonigle, John Hyett, Andy 10/03/2026 Pending Explanation action item John Mcgonigle agreed to look at scheduling a major incident response exercise with other partners involved. Page 2 of 2 Agenda Item 5.1 Committee Chair’s Report to the Trust Board of Directors 10 March 2026 Committee: Audit & Risk Committee Meeting Date: 27 January 2026 Key Messages: Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) • The committee considered the accounting policies and management judgements in respect of the 2025/26 annual accounts, noting the impact of the review of the Modern Equivalent Asset valuation estimation methodology. This review was to ensure that the valuation reflects specialised assets based on a modern, functionally equivalent facility at an alternative location, rather than simply replicating the current buildings and equipment. • The committee received an update in respect of the work on the Trust’s interim accounts, noting that there had been significant improvements in terms of use and recording of manual adjustments, with an objective of further reducing the use of manual adjustments in future. • The committee noted the work undertaken to address the issues identified in the production of the 2023/24 and 2024/25 accounts. • The committee reviewed the Trust’s compliance with the Code of Governance for NHS Provider Trusts, noting that the Trust was compliant in all areas or had appropriate explanations for areas of non-compliance, of which there were only a few. • The committee received a report on compliance with the Trust’s Standards of Business Conduct Policy, noting that the level of declarations of interest had remained largely static and that further work would be required to review the Trust’s approach in this area. • The committee received updates in respect of the internal audit programme, including the reports in respect of an audit of cyber security and the Trust’s core financial systems. • An update was provided in respect of the work of the counter-fraud team. It was noted that the risk of temporary worker impersonation was a particular area of focus. In addition, the committee noted the work undertaken to review the Trust’s compliance with the Economic Crime and Corporate Transparency Act 2023. 6.2 Board Assurance Framework (BAF) Update Assurance Rating: Risk Rating: Substantial N/A • All risks had been reviewed with the relevant executive director(s). • There had been no significant changes in ratings or target dates since the BAF had been last reviewed in October 2025. However, the committee challenged how realistic some of the target dates were on the basis that many of the actions required were reliant on third parties. • The committee suggested that the rating for risk 5c should be reconsidered in view of the increasing cyber risk. • It was noted that the actions from the internal audit on the Trust’s risk management maturity were on track. Page 1 of 2 Any Other Matters: 7.4 Audit and Risk Committee Assurance Rating: Risk Rating: Terms of Reference Substantial N/A • The committee reviewed its Terms of Reference and no changes were proposed. • The committee recommended that the Board approve the revised Terms of Reference. N/A Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Limited Assurance Controls in place are not sufficient to ensure that 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 10 March 2026 Committee: Finance, Investment and Cash Committee Meeting Date: 26 January 2026 Key Messages: Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) • The committee received the Finance Report for Month 9. The Trust had reported an in-month deficit of £4.9m and continued to report in line with the Financial Recovery Plan. The Trust had also delivered £10.3m of savings under the Cost Improvement Programme during the month. The modern equivalent assets review had been completed, which delivered £3m of benefit during the month. • The committee carried out a deep-dive into the Trust’s underlying financial position, noting that there had been £15.8m of one-off adjustments and that the underlying deficit was £61.4m year-to-date. The monthly underlying deficit continued to be c.£6m and therefore the 2025/26 exit position was assessed to be £72m. • The committee received an update on the Trust’s medium term planning submission, noting that it was expected that the Trust would submit a non-compliant plan. There remained a significant gap between the level of performance required under the framework and the available funding and an absence of proposals from Specialised Commissioning. It was noted that the assumptions regarding noncriteria to reside numbers were based on factors within the Trust’s control, rather than those dependent on third parties. • The committee received an update on financial improvement, noting that the Trust was £4m behind its CIP plan for 2025/26, expecting to deliver £88m of savings by year end compared to the £110m target. The Trust was targeting £50m of CIP savings for 2026/27. Based on national data, the Trust had the tenth smallest opportunity for productivity savings. • The committee considered the Trust’s cash position as at 31 December 2025 and the forecast cash position for the remainder of the financial year. The Trust expected to require a further £2.9m of cash support in March 2026, which the committee supported. • The committee received an update in respect of the Trust’s outsourced cleaning and catering services contract. N/A 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. Page 1 of 2 Reasonable Assurance Limited Assurance No Assurance Not Applicable There is a series of controls in place, however there are potential risks that may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Where assurance is not required and/or relevant. Risk Rating: Low Medium High Not Applicable Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda Item 5.2 ii) Committee Chair’s Report to the Trust Board of Directors 10 March 2026 Committee: Finance, Investment and Cash Committee Meeting Date: 23 February 2026 Key Messages: • • • • • • • • • The committee received the Finance Report for Month 10 (see below). The committee received an update in respect of the impact of the fire at Southampton General Hospital on 1 February 2026, including in respect of the actions being taken to restore the lost services and the Trust’s claims under the NHS Resolution Property Expenses Scheme and under its commercial insurance policy. The committee received an update following the submission of the Trust’s medium term plan on 12 February 2026, noting that the Trust’s current proposed deficit made it an outlier. There remained a significant gap between the level of funding available from commissioners and the performance required under the framework. The committee enquired as to the possible route to resolve and supported the view that pricing of activity needed to be set at a level which did not create an increasing deficit as it currently does in critical care areas. Following the external review recommendations, the committee look forward to a deeper dive into the drivers of the increases in the Trust’s cost base over the past 5-6 years as this has increased at a greater rate than activity levels. This is planned for the March 2026 meeting. The committee received an update in respect of the Always Improving programme, noting that the fire had prompted something of a re-think in terms of organisational and system fundamentals. It was noted that there had been changes in the Trust’s risk appetite in terms of management of patients having no criteria to reside and outpatient appointments. Sustaining the improvements in these areas was considered to be a key priority. The committee received a report on the roll out of the MIYA system in the Trust’s emergency department, which went live on 8 October 2025. It was noted that whilst there had been some initial impact on performance during the first weeks, this had been expected, and the issues appeared to have been largely resolved. The system had delivered improvements in clinical management and in terms of data analytics. The committee noted that the Trust had been awarded £39m in capital funding for 2025/26. It was noted that this was a significant amount of funding to be used during the final months of 2025/26 and that work was ongoing to secure this funding through placing of orders and other activity. The committee received an update in respect of the Trust’s proposed tender for car parking services. The committee supported the proposals to obtain mobile endoscopy units to address the loss of the Trust’s endoscopy service in the fire on 1 February 2026. The committee noted proposals in respect of changes to NHS Property Services. Page 1 of 3 Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) Any Other Matters: 5.8 Finance Report for Month 10 Assurance Rating: Risk Rating: Substantial High • The Trust had submitted a revised forecast to NHS England of a deficit of £49.9m following a request for an ‘art of the possible’ reforecast. The Trust had since received additional funding, which reduced the 2025/26 forecast deficit to c.£45m. • The Trust had reported a year-to-date deficit of £44.8m, with the underlying monthly deficit remaining between £5.5-6m. The Trust expected additional one-offs during the final months, but there was significant risk associated with this. • The Trust was forecasting CIP delivery of £94m for 2025/26, with £78m achieved year-to-date. • Whilst there had been some increase in workforce numbers in December 2025 and January 2026, it was considered normal for this to occur during this period, however this was creating a deviation from the planned workforce numbers. This was explained as the result of the decision taken to address 65- and 52-week waits which had therefore impacted staff numbers. The resulting increased income from additional work had yet to register in the Trust's revenue numbers but was expected in February and March.. 6.2 Board Assurance Framework (BAF) Update Assurance Rating: Risk Rating: N/A • Risk 5a remained the Trust’s highest-rated risk at 25 and the target date for reduction had been extended by six months due to continued uncertainty around the funding available during 2026/27 and the impact of the fire on 1 February 2026. • Risk 5b had been assessed following the fire, but it was considered that whilst there had been significant disruption, the event and subsequent activities had been well-managed and demonstrated the effectiveness of the Trust’s evacuation and business continuity plans. Accordingly, no changes were proposed to the rating. • There had been an increase in the rating of risk 5c, largely due to risks surrounding the age of the Trust’s digital infrastructure and uncertainty regarding the OneEPR programme. The committee reviewed the Trust’s cash position and forecast, and the committee supported the additional request to be submitted in February 2026 for cash support up to a maximum of £10m to be received in April 2026. The trajectory for cash support in 2026/27 was to be reviewed at the March 2026 meeting. Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Page 2 of 3 Limited Assurance No Assurance Not Applicable Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Where assurance is not required and/or relevant. Risk Rating: Low Medium High Not Applicable Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trus
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Papers Trust Board - 11 November 2025

Description: Date Time Location Chair Agenda Trust Board – Open Session 11/11/2025 9:00 - 13:00 Conference Room, Heartbeat Education Centre Jenni Douglas-Todd 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 (item deferred) 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 9 September 2025 Approve the minutes of the previous meeting held on 9 September 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 Audit and Risk Committee 9:05 Keith Evans, Chair 5.2 Briefing from the Chair of the Finance, Investment & Cash Committee 9:10 David Liverseidge, Chair 5.3 Briefing from the Chair of the People and Organisational Development 9:15 Committee Jane Harwood, Chair 5.4 Briefing from the Chair of the Quality Committee 9:20 Tim Peachey, Chair 5.5 Chief Executive Officer's Report 9:25 Receive and note the report Sponsor: David French, Chief Executive Officer 5.6 Performance KPI Report for Month 6 10:00 Review and discuss the report Sponsor: Andy Hyett, Chief Operating Officer 5.7 Break 10:40 5.8 Finance Report for Month 6 10:55 Review and discuss the report Sponsor: Ian Howard, Chief Financial Officer 5.9 ICB System Report for Month 6 11:05 Receive and discuss the report Sponsor: Ian Howard, Chief Financial Officer 5.10 11:10 People Report for Month 6 Review and discuss the report Sponsor: Steve Harris, Chief People Officer 5.11 NHSE Audit and review of 'Developing Workforce Safeguards' including 11:20 UHS Self-Assessment Return Review and approve the self-assessment return Sponsor: Natasha Watts, Acting Chief Nursing Officer 5.12 11:30 Guardian of Safe Working Hours Quarterly Report and Update on 10-Point Plan Review and discuss the report and update Sponsor: Paul Grundy, Chief Medical Officer Attendee: Diana Hulbert, Guardian of Safe Working Hours and Emergency Department Consultant 5.13 Annual Clinical Outcomes Summary Report 11:45 Review and discuss the report Sponsor: Paul Grundy, Chief Medical Officer Attendees: Lucinda Hood, Head of Medical Directorate/Kate Pryde, Clinical Director for Improvement and Clinical Effectiveness 6 STRATEGY and BUSINESS PLANNING 6.1 Corporate Objectives 2025-26 Quarter 2 Review 11:55 Review and feedback on the corporate objectives Sponsor: David French, Chief Executive Officer Attendee: Martin de Sousa, Director of Strategy and Partnerships 6.2 Board Assurance Framework (BAF) Update 12:05 Review and discuss the update Sponsor: Natasha Watts, Acting Chief Nursing Officer Attendees: Craig Machell, Associate Director of Corporate Affairs and Company Secretary/Lauren Anderson, Corporate Governance and Risk Manager Page 2 7 CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Feedback from the Council of Governors' (CoG) meeting 28 October 2025 12:15 (Oral) Sponsor: Jenni Douglas-Todd, Trust Chair 7.2 Register of Seals and Chair's Actions Report 12:25 Receive and ratify In compliance with the Trust Standing Orders, Financial Instructions, and the Scheme of Reservation and Delegation. Sponsor: Jenni Douglas-Todd, Trust Chair 7.3 Health and Safety Services Annual Report 2024-25 12:30 Receive and discuss Sponsor: Natasha Watts, Acting Chief Nursing Officer Attendees: Vickie Purdie, Head of Patient Safety/Scott Spencer, Health and Safety Adviser 8 Any other business 12:40 Raise any relevant or urgent matters that are not on the agenda 9 Note the date of the next meeting: 13 January 2026 10 Items circulated to the Board for reading 12:45 10.1 South Central Regional Research Delivery Network (SC RRDN) 2025-26 Q2 Performance Report Note the report Sponsor: Paul Grundy, Chief Medical Officer 11 Resolution regarding the Press, Public and Others Sponsor: Jenni Douglas-Todd, Trust Chair To agree, as permitted by the National Health Service Act 2006 (as amended), the Trust's Constitution and the Standing Orders of the Board of Directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. 12 Follow-up discussion with governors 12:45 Page 3 Agenda links to the Board Assurance Framework (BAF) 11 November 2025 – Open Session Overview of the BAF Risk 1a: Lack of capacity to appropriately respond to emergency demand, manage the increasing waiting lists for elective demand, and provide timely diagnostics, that results in avoidable harm to patients. 1b: Due to the current challenges, we fail to provide patients and their families / carers with a high-quality experience of care and positive patient outcomes. 1c: We do not effectively plan for and implement infection prevention and control measures that reduce the number of hospital-acquired infections and limit the number of nosocomial outbreaks of infection. 2a: We do not take full advantage of our position as a leading University teaching hospital with a growing, reputable, and innovative research and development portfolio, attracting the best staff and efficiently delivering the best possible treatments and care for our patients. 3a: We are unable to meet current and planned service requirements due to the unavailability of staff to fulfil key roles. 3b: We fail to develop a diverse, compassionate, and inclusive workforce, providing a more positive staff experience for all staff. 3c: We fail to create a sustainable and innovative education and development response to meet the current and future workforce needs identified in the Trust’s longer-term workforce plan. 4a: We do not implement effective models to deliver integrated and networked care, resulting in sub-optimal patient experience and outcomes, increased numbers of admissions and increases in patients’ length of stay. 5a: We are unable to deliver a financial breakeven position, resulting in: inability to move out of the NHS England Recovery Support Programme, NHS England imposing additional controls/undertakings, and a reducing cash balance impacting the Trust’s ability to invest in line with its capital plan, estates/digital strategies, and in transformation initiatives. 5b: We do not adequately maintain, improve and develop our estate to deliver our clinical services and increase capacity. 5c: Our digital technology or infrastructure fails to the extent that it impacts our ability to deliver care effectively and safely within the organisation, 5d: We fail to prioritise green initiatives to deliver a trajectory that will reduce our direct and indirect carbon footprint by 80% by 2028-2032 (compared with a 1990 baseline) and reach net zero direct carbon emissions by 2040 and net zero indirect carbon emissions by 2045. Agenda links to the BAF No Item Linked BAF risk(s) 5.6 Performance KPI Report for Month 6 5.8 Finance Report for Month 6 5.9 ICB System Report for Month 6 5.10 People Report for Month 6 5.11 Workforce Safeguards Self-Assessment 5.12 Guardian of Safe Working Hours Quarterly Report 5.13 Clinical Outcomes Summary Report 1a, 1b, 1c 5a 5a 3a, 3b, 3c 1a, 3a 3a, 3b 1a, 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 Minutes Trust Board – Open Session Date 09/09/2025 Time 9:00 – 13:00 Location Conference Room, Heartbeat/Microsoft Teams Chair Jenni Douglas-Todd (JD-T) Present Diana Eccles, NED (DE) Keith Evans, Deputy Chair and NED (KE) 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) Alison Tattersall, NED (AT) In attendance Craig Machell, Associate Director of Corporate Affairs and Company Secretary (CM) Lauren Anderson, Corporate Governance and Risk Manager (LA) (item 6.1) Danielle Honey, Named Nurse for Safeguarding Children (DH) (item 5.14) Lucinda Hood, Head of Medical Directorate (LH) (item 5.15) Duncan Linning-Karp, Deputy Chief Operating Officer (DL-K) (item 5.6) Corinne Miller, Named Nurse for Safeguarding Adults (CMi) (item 5.14) Jenny Milner, Associate Director of Patient Experience (JM) (items 5.11-5.12) 1 member of the public (item 2) 30 members of staff (observing) 6 members of the public (observing) Apologies Gail Byrne, Chief Nursing Officer (GB) David French, Chief Executive Officer (DAF) Tim Peachey, NED (TP) 1. Chair’s Welcome, Apologies and Declarations of Interest The Chair welcomed attendees to the meeting. There were no interests to declare in the business to be transacted at the meeting. It was noted that apologies had been received from Gail Byrne, David French and Tim Peachey. The Chair provided an overview of meetings she had held and events that she had attended since the previous Board meeting. 2. Patient Story Aelwen Emmett, a volunteer at the Trust and former patient was invited to present her experience, focusing particularly on her work to improve the standard of food offered to patients. 3. Minutes of the Previous Meeting held on 15 July 2025 The draft minutes tabled to the meeting were agreed to be an accurate record of the meeting held on 15 July 2025. Page 1 4. Matters Arising and Summary of Agreed Actions The matters arising and actions were noted. In respect of action 1246, it was noted that virtual outpatient appointments had now been built into the Trust’s programme. Furthermore, meetings were to be held with commissioners and the cancer network to improve the quality of referrals. It was noted that action 1246 could be closed. 5. QUALITY, PERFORMANCE and FINANCE 5.1 Briefing from the Chair of the Finance and Investment Committee David Liverseidge was invited to present the Committee Chair’s Reports in respect of the meetings held on 21 July and 2 September 2025, the content of which was noted. It was further noted that: • In July 2025, the Trust had reported that it was £1.1m adverse to its plan, but that the underlying trajectory was improving. • The committee received an update from Wessex NHS Procurement Limited, noting that the company was on track in terms of its Cost Improvement Programme target. • The committee had received an update in respect of both the proposed Hampshire and Isle of Wight elective hub and a possible Urgent Treatment Centre at Southampton. • The committee reviewed the Finance Report for Month 4 (item 5.8), noting that the Trust had reported a year-to-date deficit of £19.5m, which was £5.8m adverse to plan. Key drivers for the Trust’s financial position included the lack of improvement in the number of patients having no criteria to reside and mental health patients, the continued difference between funded and actual activity under block contracts, lower than anticipated income, and higher than planned workforce numbers. • The Trust was ahead of its plan on Cost Improvement Programme delivery. • The committee reviewed the Trust’s proposed Financial Recovery Plan and noted the need to ensure that the long-term impact of decisions needed to be taken into account. • The committee reviewed the Trust’s cash position and noted that cash support would be required in the Autumn and that the committee would be amending its terms of reference to expand its role in terms of cash monitoring and oversight. • The committee reviewed the Board Assurance Framework risks within its remit, noting that Risk 5a had increased to 25 due to the risk associated with the Trust’s cash position (item 6.1). 5.2 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 21 July and 1 September 2025, the content of which was noted. It was further noted that: • The committee reviewed the People Report for Month 4 (item 5.10), noting that there continued to be significant demands on the Trust’s workforce, especially due to the number of patients having no criteria to reside and patients with a primary mental health need. Whilst the Trust’s substantive workforce had reduced, there had been an increase in the number of temporary staff resulting in the Trust reporting that it was 55 whole-time- equivalents above its plan. Page 2 • The committee considered the impact of the recruitment controls on the administrative and clerical workforce and the potential for shortages in these areas causing issues elsewhere. • The committee received an update in respect of the Mutually Agreed Resignation Scheme (MARS), noting that 65 applications had been approved. • The committee received an update on the recruitment of newly qualified nurses, noting that the Trust had pre-empted the announcement of a ‘guarantee’ by the Secretary of State. • The committee reviewed the workforce related elements of the Trust’s Financial Recovery Plan, noting the challenges in delivering what was required and the Trust’s reliance on improvements in patients having no criteria to reside and mental health patients. • The committee reviewed its terms of reference, proposing to make only minor changes (item 7.2). 5.3 Briefing from the Chair of the Quality Committee Diana Eccles was invited to present the Committee Chair’s Report in respect of the meeting held on 18 August 2025, the content of which was noted. It was further noted that: • The committee considered the proposal to revise enhanced rates paid to temporary staff in certain areas to remove the enhancement and bring rates into line with Agenda for Change rates. The committee noted the impact on staff and the concerns expressed by staff members. However, it was further noted that the enhancements were not intended to be permanent. • The committee received the Experience of Care report and noted a continuation in the trend observed during Quarter 4 of staff attitudes featuring as a reason for complaint. It was considered likely that this was indicative of the pressures on staff. • The committee reviewed the Maternity and Neonatal Safety 2025-26 Quarter 1 Report, noting that an action plan was in place in respect of the Maternity Triage Line to address some shortcomings identified in the process. • The committee received the Learning from Deaths 2025-26 Quarter 1 Report (item 5.11), noting that the Trust was one of only 11 trusts out of 119 with a lower-than-expected death rate during the period. • The committee reviewed the Safeguarding Annual Report 2024-25 and Strategy 2025-26 (item 5.14), noting that activity levels remained consistent with prior years, but the complexity of cases had increased. 5.4 Chief Executive Officer’s Report Paul Grundy was invited to present the Chief Executive Officer’s Report, the content of which was noted. It was further noted that: • The NHS league tables for 2025 had been published on 9 September 2025. The Trust had ranked 48th out of 134 and had been placed in segment 3 of the NHS Oversight Framework due to the effect of the ‘financial override’. The Trust was temporarily in segment 5 due to being in the Recovery Support Programme. • Trusts were required to submit self-assessments for the Provider Capability Assessment during October 2025. This would inform decisions relating to which organisations to place in the Performance Improvement Programme. • Resident doctors undertook strike action between 25 and 30 July 2025. Approximately one-third of those eligible at the Trust took part in the industrial action and the Trust had performed well in terms of mitigating the impact on activity. Page 3 • The Royal College of Nursing had published results of its analysis of violence and aggression against nursing staff in emergency departments, noting that the number of incidents had increased from 2,093 in 2019 to 4,054 in 2024. • NHS England had published a series of urgent and emergency care improvement guides to assist organisations with managing the winter period. • A number of changes to the organisation of local councils in Hampshire and Southampton were proposed as part of national plans to create unitary councils in place of existing county and district/borough councils. 5.5 Performance KPI Report for Month 4 Andy Hyett was invited to present the Performance KPI Report for Month 4, the content of which was noted. It was further noted that: • The Trust had reported an increase in the number of patients waiting over 52, 65 and 78 weeks alongside an increase in the overall waiting list. The Trust had entered Tier 2 escalation for Referral To Treatment performance. • The Trust had been placed in Tier 1 escalation due to the gap between its current Emergency Department performance and its performance plan for 2025/26. However, indicative data for August and September 2025 showed improved performance. • Work was ongoing to improve flow with task and finish groups established to review the discharge process and to implement rapid improvements. • The number of patients having no criteria to reside and those with a primary mental health need remained high. A workshop had been set up with Hampshire and Isle of Wight Healthcare NHS Foundation Trust in respect of mental health patients. • Steps were being undertaken to reduce the number of inappropriate attendances in the Emergency Department with patients potentially redirected to other areas. However, an Urgent Treatment Centre would be key to alleviating pressure on the Emergency Department in the longer term. The Board discussed the Trust’s performance against national standards. This discussion is summarised below: • Performance against the 62-day standard for cancer waiting times was an area of focus to ensure more consistent performance. • Work was ongoing to extend shared decision-making in order to involve patients in decisions about their care and treatment, noting however that this was more of a challenge with inpatients. • There was a challenge in terms of managing the demand for patients requiring diagnostic services. It was noted that there had been issues with availability of equipment over the summer period. It was acknowledged that diagnostics performance also impacted other areas such as cancer and Emergency Department metrics. • The percentage of over 65s attending the Emergency Department was expected to be a key metric to monitor over the winter period. Actions Andy Hyett agreed to look at the roll out of Pharmacy First. Andy Hyett agreed to carry out a deep-dive into Diagnostics to be either provided as a ‘Spotlight’ in the Performance KPI Report or via a Trust Board Study Session. Page 4 5.6 UHS Operating Plan 2025-26 and Board Assurance Statement Andy Hyett was invited to present the Operating Plan 2025-26 and Board Assurance Statement, the content of which was noted. It was further noted that: • The Operating Plan provided a summary of plans from October 2025 to September 2026, sitting alongside other key policies such as those relating to infection prevention control, major incidents, and influenza. • The Operating Plan would also serve as the Trust’s winter plan, which was recognised as a period of increased pressure. The Board discussed the proposed Operating Plan for 2025/26, this discussion is summarised below: • It was considered likely that, even with delivery of the demand management schemes being led by the Integrated Care Board (ICB), there would be a gap between demand and capacity over the winter period in particular. Therefore, further interventions to improve discharge rates and to reduce the number of patients having no criteria to reside would be necessary. In addition, the Trust would be required to make potentially difficult decisions in respect of prioritisation of patients and possible cancellation of elective procedures. • Concerns were expressed in relation to the trend of low uptakes of seasonal vaccinations, such as that against influenza, which had been seen since the COVID-19 pandemic. This situation would likely create further challenges due to patients with seasonal illnesses requiring additional infection prevention control measures. Furthermore, low uptake by staff members would likely result in increased rates of staff sickness and, accordingly, reduced capacity and/or increased expenditure on temporary staffing. • It was understood that there was a NHS campaign to encourage staff in particular to be vaccinated against influenza, and that plans were in place for senior leaders to visibly support this campaign through being vaccinated. • The Board challenged whether the Trust could meet the targets set out in the Operating Plan given the financial and other pressures currently experienced. • It was additionally noted that the Trust was reliant on external support and delivery of external demand management programmes led by the ICB in order to be able to meet the performance targets, especially in terms of management of the number of patients having no criteria to reside and those with a primary mental health need. • Furthermore, the Trust’s financial position was such that it was required to produce a financial recovery plan, which would require additional financial savings to be made. • It was agreed that the Board should fully consider whether to approve the Operating Plan once it had considered the Trust’s financial recovery plan in the Closed Session of the meeting. [Note: the matters below forming part of item 5.6 were discussed following the approval of the Trust’s financial recovery plan in the Closed Session.] Noting that the Board had discussed and supported the Trust’s financial recovery plan, subject to certain caveats, the Board again discussed the proposed Operating Plan for 2025/26. This discussion is summarised below: • The Trust’s financial recovery plan would need to be supported by NHS England and would also need to deliver in order for the Trust to be able to meet the performance targets set out in the Operating Plan. • The Trust continued to have significant dependence on third parties, especially other providers, the Integrated Care Board, and local authorities, to be able to successfully reduce the number of patients having no criteria to Page 5 reside or number of mental health patients. Without these reductions, the Trust would face significant capacity constraints, which would impact its performance, especially during periods of high demand. Decision Noting the discussions in the Closed Session in respect of the financial recovery plan, and having reviewed the proposed Operating Plan 2025-26 and accompanying Board Assurance Statement, the Board approved the Operating Plan 2025-26 and its submission, subject to the following: • delivery of system-wide programmes to manage demand and reduce numbers of non-criteria to reside and mental health patients, • appropriate support being provided by third parties, including local providers, the Integrated Care Board, and local authorities, especially in terms of supporting discharges and managing numbers of non-criteria to reside and mental health patients, and • support from NHS England for and delivery of the Trust’s financial recovery plan. In addition, the Board authorised the Chair and Chief Executive Officer to sign the Board Assurance Statement. 5.7 Break 5.8 Finance Report for Month 4 Ian Howard was invited to present the Finance Report for Month 4, the content of which was noted. It was further noted that: • The Trust had reported an in-month deficit of £6.8m (£4.8m above plan), although the underlying deficit was showing improvement, reducing to £6.6m. However, this trajectory was not sufficient to deliver the plan. • The Trust was carrying out approximately £2.5m of unfunded activity per month. In order to tackle some of this amount, the Trust had conducted negotiations with other providers and systems to address underfunding on contracts. • There were concerns about whether the Trust’s elective over-performance during the first half of the year would be fully funded. Whilst agreement had been reached in respect of funding three months of over-performance, it was not clear whether this would be replicated in the future. • The Trust would be seeking an activity management plan, which would detail which activities to cease to perform on the basis that the Trust continuing to over-perform against agreed funded activity levels was financially unsustainable and that it was not reasonable that the Trust should be criticised for falling performance in areas such as waiting lists as it sought to manage its finances. • The Trust’s cash position remained an area of concern with cash support to be requested from NHS England. • There appeared to be an emerging risk of slippage against the Trust’s capital programme, which was to be discussed at the Finance and Investment Committee. 5.9 ICS Operational Delivery Report for Month 4 Ian Howard was invited to present the ICS Operational Delivery Report for Month 4, the content of which was noted. It was further noted that: • The Trust was the only organisation within the system currently reporting being off plan. However, there were indicators from other providers with Page 6 significant risks being highlighted about organisations’ abilities to meet their 2025/26 plans. • There was an error in the report in respect of the Trust’s workforce numbers. A correction to the report had been requested. • The Hampshire and Isle of Wight ICS plan was for a breakeven position at the end of 2025/26. However, this was reliant on receipt of £60m of deficit support funding from NHS England, which was at risk because the Trust was no longer reporting being on plan. 5.10 People Report for Month 4 It was noted that two questions had been received from members of the public prior to the meeting (see Annex A), both of which related to the decision to remove the enhancement from NHS Professionals rates paid to staff in certain areas of the Trust such as in Theatres and in the Emergency Department. It was further noted that: • A discussion had also been held with staff prior to the Board meeting, at which a number of other questions had been raised. In particular, staff had expressed concerns about their feeling valued by the organisation. • The reasoning behind the decision to remove the enhancement previously paid on temporary staffing rates was explained as being to provide consistency with other staffing groups and with other providers by aligning rates paid with Agenda for Change rates. This change was part of a package of measures to improve the financial position of the Trust. • The decision to remove the enhancement was supported by an Equality and Quality Impact Assessment as part of the Trust’s process for making decisions of this nature. [Post meeting note: Following the meeting, the Royal College of Nursing, on behalf of its members in the affected areas, submitted a collective dispute. The questions raised in advance of the meeting, together with other related points, were to be addressed as part of the collective dispute process.] Steve Harris was invited to present the People Report for Month 4, the content of which was noted. It was further noted that: • The Trust’s plan for 2025/26 was for a reduction in whole-time-equivalents (WTE) by 765. Whilst the Trust had reduced the size of its workforce, it was still 55 WTE off-plan. • The Trust had reduced the number of divisions from four to three and had implemented recruitment controls whereby only 70% of clinical posts would be recruited to and a prohibition on recruitment to non-clinical posts. • The Trust had also carried out a Mutually Agreed Resignation Scheme (MARS) and had made some redundancies in discrete areas. It was noted, however, that there was a lack of funding for severance payments, which limited the Trust’s options with respect to steps it could take to reduce its workforce. • Temporary staffing was a particular area of focus, both in terms of numbers of temporary staff but also in terms of the cost paid for such staff. This aligned with the work of the South East temporary staffing collaborative which aimed to reduce the price of temporary labour in both bank and agency. Page 7 • Despite its challenges during 2025/26, the Trust had proactively offered roles to newly-qualified nurses ahead of the Secretary of State’s announcement of a ‘graduate guarantee’ on the basis that, from a strategic perspective, the Trust needed to take into account its future workforce requirements. Action Steve Harris and Andy Hyett agreed to respond to the questions and points raised at the meeting held with staff in respect of the NHS Professionals rates matter. 5.11 Learning from Deaths 2025-26 Quarter 1 Report Jenny Milner was invited to present the Learning from Deaths 2025/26 Quarter 1 Report, the content of which was noted. It was further noted that: • The Trust’s summary hospital-level mortality indicator (SHMI) score continued its downward trajectory and was the lowest value recorded since 2018. As such, the Trust was one of only 11 trusts nationally to achieve a lower-thanexpected mortality rate. • Work was ongoing to disseminate lessons from end-of-life care and an additional module for the Ulysses system had been purchased to facilitate data capture and standardisation for Morbidity and Mortality meetings. Action Jenny Milner was to provide further information to the Board in respect of why the Trust’s SHMI score remained low. 5.12 Annual Complaints Report 2024-25 Jenny Milner was invited to present the Annual Complaints Report 2024/25, the content of which was noted. It was further noted that: • The report provided details of complaints received between 1 April 2024 and 31 March 2025 and was the first full year of reporting against the new standard introduced by the Parliamentary and Health Service Ombudsman (PHSO). • Complaints activity had increased by 40% and the Trust was not currently meeting response targets. • The Trust benchmarked higher than others in terms of complaints not upheld. The Board discussed the Trust’s approach to complaints handling and, in particular, whether the Trust was an outlier in terms of the number of complaints not upheld. The Board challenged whether complaints deemed as ‘not upheld’ ought, in some instances, to be considered ‘partially upheld’. Consideration should therefore be given to reviewing the Trust’s complaints against PHSO referrals and outcomes. Action Jenny Milner was to provide further information regarding how the Trust was planning to meet complaints response times. Page 8 5.13 Medical Appraisal and Revalidation Annual Report including Board Statement of Compliance Paul Grundy was invited to present the Medical Appraisal and Revalidation Annual Report, the content of which was noted. It was further noted that: • The framework published by NHS England was designed to allow the Trust to provide assurance that its professional standards processes meet the relevant statutory requirements and support quality improvement. • Feedback in respect of the appraisals process had been largely positive. • Appraisal compliance rates had continued to rise across the year with a current average of 88.8%. • The Board was required to approve a Statement of Compliance confirming that the Trust was compliant with the Medical Profession (Responsible Officers) Regulations 2010 (as amended). Decision Having considered the Medical Appraisal and Revalidation Annual Report tabled to the meeting, the Board authorised the Chair or Chief Executive Officer to sign the Statement of Compliance. 5.14 Safeguarding Annual Report 2024-25 and Strategy 2025-26 Danielle Honey was invited to present the Safeguarding Annual Report 2024/25 and Strategy for 2025/26, the content of which was noted. It was further noted that: • The report summarised the activity of the Trust’s safeguarding service in 2024/25. It was noted that the service had contributed to reviews of 56 patients where a statutory review had been considered. • The number of referrals under section 42 of the Care Act 2014 caused by Southampton City Council had reduced following the implementation of the council’s new processes. This was not reflective of a reduction in the number of UHS referrals or the complexity of the referrals responded to. • There had been an increase in the number of open cases with Southampton City Council and there had been a 13% increase in the number of patients subject to Deprivation of Liberty Safeguards (DoLS) under the Mental Capacity Act 2005. • There had also been an increase in the number of scoping reviews compared to prior years, although fewer were progressing to formal reviews. • Following a survey of staff, work was underway to improve the visibility of the team and there was a focus on team wellbeing with support from the psychology team. • The situation in respect of expected changes in the role of integrated care boards was being monitored due to the potential for changes in the team’s scope and remit. Page 9 6. STRATEGY and BUSINESS PLANNING 6.1 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: • All risks had been reviewed by the relevant executive directors since July 2025. • The revised risk appetites agreed by the Board in July 2025 were being embedded. • The rating of Risk 5a had increased from 20 to 25 due to the lack of agreement for cash support. However, once this agreement had been obtained and the Financial Recovery Plan was in place, it was expected that this risk would again reduce to 20. • An audit of the Trust’s risk management maturity by the Trust’s internal auditors was near to completion. 7. CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Feedback from the Council of Governors’ (COG) Meeting 16 July 2025 The Chair presented a summary of the Council of Governors’ meeting held on 16 July 2025. It was noted that the meeting had considered the following matters: • Chief Executive Officer’s Performance Report • The Trust’s 2025/26 Operating Plan • Council of Governors’ Terms of Reference • Membership Engagement • Feedback from the Governors’ Nomination Committee Furthermore, the Council of Governors approved the extension of the appointment of Tim Peachey as a non-executive director for a period of 12 months. 7.2 People and Organisational Development Committee Terms of Reference Craig Machell was invited to present the proposed changes to the People and Organisational Development Committee’s Terms of Reference, the content of which was noted. It was further noted that: • The People and Organisational Development Committee had reviewed its terms of reference at its meeting on 1 September 2025. • It was proposed to make only minor changes to remove reference to the Charitable Funds Committee, which no longer existed. Decision Having considered the proposed amendments to the People and Organisational Development Committee’s Terms of Reference, the Board approved the changes. Page 10 8. Any other business It was noted that it was organ donation week during 22-28 September 2025. Action Craig Machell agreed to add organ donation to the agenda of a future Trust Board Study Session. 9. Note the date of the next meeting: 11 November 2025 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 11 Annex A Questions: 1. The Board has agreed a cut in bank pay rates for nursing staff, resulting in local staff being unlikely to maintain their bank roles in this organisation, (based on a survey of over 450 nurses within the affected areas). Currently these roles provide staffing in areas such as theatres and other specialised areas, the impact being these departments can use local skills and knowledge to provide seamless operational delivery. How can the board provide assurance that, a) this will not impact on safety for patients, and b) they truly value nurses for the professional skills they provide for this Trust. 2. Our Emergency Department has recently been placed under Tier 1 monitoring by NHS England, reflecting serious national concerns about safety and performance. The department is already regularly understaffed, with patient care frequently delayed as a result. In light of this, how can the Trust justify reducing NHSP pay rates for Emergency Department nurses — a decision that risks deterring skilled staff from covering shifts and further compromising patient safety and the delivery of safe, timely care? What specific steps will the Trust take to mitigate these risks to patients and staff if the changes go ahead? Page 12 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 Watts, Natasha 13/01/2026 Pending Explanation action item Christine Mbabazi to include data from other mechanisms for reporting concerns in future Freedom to Speak Up reports. Trust Board – Open Session 09/09/2025 - 5.5 Performance KPI Report for Month 4 1281. Pharmacy First Hyett, Andy 11/11/2025 Pending Explanation action item Andy Hyett agreed to look at the roll out of Pharmacy First. 1282. Diagnostics Hyett, Andy 11/11/2025 Pending Explanation action item Andy Hyett agreed to carry out a deep-dive into Diagnostics to be either provided as a ‘Spotlight’ in the Performance KPI Report or via a Trust Board Study Session. Trust Board – Open Session 09/09/2025 - 5.10 People Report for Month 4 1283. NHS Professionals rates Harris, Steve Hyett, Andy 11/11/2025 Pending Explanation action item Steve Harris and Andy Hyett agreed to respond to the questions and points raised at the meeting held with staff in respect of the NHS Professionals rates matter. Page 1 of 2 Agenda item Assigned to Deadline Status Trust Board – Open Session 09/09/2025 - 5.11 Learning from Deaths 2025-26 Quarter 1 Report 1284. SHMI score Milner, Jenny Watts, Natasha 11/11/2025 Pending Explanation action item Jenny Milner was to provide further information to the Board in respect of why the Trust’s SHMI score remained low. Trust Board – Open Session 09/09/2025 - 5.12 Annual Complaints Report 2024-25 1285. Response times Milner, Jenny Watts, Natasha 11/11/2025 Pending Explanation action item Jenny Milner was to provide further information regarding how the Trust was planning to meet complaints response times. Trust Board – Open Session 09/09/2025 - 8 Any other business 1286. Organ donation Machell, Craig 18/12/2025 Pending Explanation action item Craig Machell agreed to add organ donation to the agenda of a future Trust Board Study Session. Update: To be scheduled 18/12/25 or 03/02/26. Page 2 of 2 Agenda Item 5.1 Committee Chair’s Report to the Trust Board of Directors 11 November 2025 Committee: Audit & Risk Committee Meeting Date: 13 October 2025 Key Messages: • • • • • • • • • The committee reviewed and discussed the outputs of a ‘lessons learned’ activity following the late publication of the Trust’s annual report and accounts. It was noted that a number of actions had been agreed and that a trial run would be conducted at Month 9. The committee noted the proposal to tender for new valuers for 2025/26 and the review of the Modern Equivalent Asset estimation methodology that would be carried out during the year. The committee agreed with a proposal to write off historical debt from private (mostly overseas) patients on the basis that it was irrecoverable. There had been 68 waivers of competitive tendering during the first half of 2025/26, most of which related to continued service provision. It was noted that the submission as part of the National Cost Collection exercise had been completed in July 2025 and that the Trust was 7% more efficient than the average based on the data. An update was received in respect of Information Governance. The Trust’s Data Security and Protection Toolkit was now rated as ‘approaching standards’ and progress had been made in respect of the backlog in subject access requests. The committee received an update in respect of legal expenditure and claims during 2024/25. The committee reviewed the internal audit reports on the Data Security and Protection Toolkit, CQC Readiness, and risk maturity. The committee received an update on the progress of the Trust’s local counter-fraud team against the plan for 2025/26, noting that imposter fraud was an area of focus. Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) 6.2 Board Assurance Framework (BAF) Update Assurance Rating: Risk Rating: Substantial N/A • The committee had last reviewed the BAF in March 2025, and there had been a definite increase in the level of risk with the ratings of four of the risks having increased since then. • Approximately 25% of the risks on the Trust’s operational risk register were rated ‘critical’ (i.e. 15 or above). • The internal audit of risk management had been positive and the Trust’s risk management framework was considered as being mature. Any Other N/A Matters: 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 5.2 i) Committee Chair’s Report to the Trust Board of Directors 11 November 2025 Committee: Finance and Investment Committee Meeting Date: 22 September 2025 Key Messages: • • • • • • • • • The committee reviewed the Finance Report for Month 5. The Trust had reported an in-month deficit of £5.9m and £25.4m deficit year-todate. The in-month deficit was £4.2m above the original plan, but was in line with the trajectory in the Financial Recovery Plan. The Trust’s underlying deficit had continued to improve, reducing to £6.2m, although this improvement was not yet at the pace required. The main drivers of the variance to plan were variances in income compared with what had been expected during 2025/26 and variances in terms of pay costs. The Trust was expecting to be 95 whole-timeequivalents above plan at year end based on current assumptions. It was noted that the Trust had identified 100% of Cost Improvement Programme savings at Month 5 and 76% of schemes were fully developed. Approximately £37m of savings had been delivered between Months 1 and 5, although higher than anticipated levels of non-recurrent savings had been delivered. The committee reviewed the Trust’s capital forecast, noting that there was a risk of a shortfall against the Trust’s internal CDEL. An update was received regarding the Urgent and Emergency Care transformation programme. The committee received the annual assurance report from UHS Pharmacy Limited, noting the company’s performance during the year and the work being done to expand services internally and externally. The committee considered the Trust’s cash forecast for Month 5, noting that the Trust’s underlying deficit was steadily eroding the Trust’s cash balance. The Trust had introduced strict treasury management measures and had previously received advance payments from the ICB as a means to mitigate the cash position. However, it had been necessary to submit a request for revenue support from NHS England in September 2025 and further such applications would be required from November 2025 onwards. In order to increase the focus on and governance of cash-related matters, the committee reviewed its terms of reference to strengthen the cash-related provisions and agreed to recommend to the Board that the committee be re-constituted as the Finance, Investment and Cash Committee with an Operating Cash Group reporting into the committee. Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) N/A Any Other Matters: The revised terms of reference for the committee were reviewed and approved at the Board meeting held on 7 October 2025. 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 5.2 ii) Committee Chair’s Report to the Trust Board of Directors 11 November 2025 Committee: Finance, Investment and Cash Committee Meeting Date: 3 November 2025 Key Messages: • • • • • • • • The committee reviewed the Finance Report for Month 6 (see below). The committee received an update in respect of the Trust’s performance against its Financial Recovery Plan, noting that progress had been made in terms of putting plans in place regarding patients with no criteria to reside and mental health patients. Good progress had also been made in respect of the ‘grip and control’ measures. At Month 6, the Trust remained on track with the Financial Recovery Plan. An overview of the recently published Medium Term Planning framework was provided. It was noted that the first submission of the Trust’s three-year plan was due before
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Papers Trust Board - 13 May 2025

Description: Agenda Trust Board – Open Session Date Time Location Chair Apologies In attendance 13/05/2025 9:00 - 13:00 Conference Room, Heartbeat Education Centre Jenni Douglas-Todd Keith Evans, Alison Tattersall Helena Blake, Head of Clinical Quality Assurance (shadowing Gail Byrne) Raquel Domene Luque, Interim Lead Matron, Ophthalmology (shadowing Gail Byrne) 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 (This item has been postponed until the next meeting) 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 March 2025 Approve the minutes of the previous meeting held on 11 March 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 Audit and Risk Committee 9:10 Keith Evans, Chair 5.2 Briefing from the Chair of the Finance and Investment Committee 9:15 Dave Bennett, Chair 5.3 Briefing from the Chair of the People and Organisational Development 9:20 Committee Jane Harwood, Chair 5.4 Briefing from the Chair of the Quality Committee 9:25 Tim Peachey, Chair including Maternity and Neonatal Safety 2024-25 Quarter 3 Report 5.5 9:30 5.6 10:00 5.7 10:40 5.8 10:55 5.9 11:05 5.10 11:10 5.11 11:20 5.12 11:30 5.13 11:40 6 6.1 11:50 Chief Executive Officer's Report Receive and note the report Sponsor: David French, Chief Executive Officer Performance KPI Report for Month 12 Review and discuss the report Sponsor: David French, Chief Executive Officer Break Finance Report for Month 12 Review and discuss the report Sponsor: Ian Howard, Chief Financial Officer ICS Finance Report for Month 12 Receive and discuss the report Sponsor: Ian Howard, Chief Financial Officer People Report for Month 12 Review and discuss the report Sponsor: Steve Harris, Chief People Officer UHS Annual Staff Survey Results 2024 Report Discuss and note the report Sponsor: Steve Harris, Chief People Officer Attendees: Ceri Connor, Director of OD and Inclusion/Sophie Limb, HR Project Manager Guardian of Safe Working Hours Quarterly Report Receive and discuss the report Sponsor: Paul Grundy, Chief Medical Officer Attendee: Diana Hulbert, Guardian of Safe Working Hours and Emergency Department Consultant Learning from Deaths 2024-25 Quarter 3 and 4 Reports Review and discuss the reports Sponsor: Paul Grundy, Chief Medical Officer Attendee: Jenny Milner, Associate Director of Patient Experience STRATEGY and BUSINESS PLANNING Corporate Objectives 2024-25 Quarter 4 Review Review and feedback on the corporate objectives Sponsor: David French, Chief Executive Officer Attendees: Martin De Sousa, Director of Strategy and Partnerships/Kelly Kent, Head of Strategy and Partnerships Page 2 6.2 Board Assurance Framework (BAF) Update 12:00 Review and discuss the update Sponsor: Gail Byrne, Chief Nursing Officer Attendees: Craig Machell, Associate Director of Corporate Affairs and Company Secretary/Lauren Anderson, Corporate Governance and Risk Manager 6.3 South Central Regional Research Delivery Network (SC RRDN) 2024-25 12:10 Annual Performance Review and 2025-26 Annual Plan Receive and note the annual report and plan Sponsor: Paul Grundy, Chief Medical Officer Attendee: Clare Rook, Chief Operating Officer, CRN: Wessex 7 CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Feedback from the Council of Governors' (CoG) meeting 29 April 2025 12:25 (Oral) Sponsor: Jenni Douglas-Todd, Trust Chair 7.2 Register of Seals and Chair's Actions Report 12:30 Receive and ratify In compliance with the Trust Standing Orders, Financial Instructions, and the Scheme of Reservation and Delegation. Sponsor: Jenni Douglas-Todd, Trust Chair 8 Any other business 12:35 Raise any relevant or urgent matters that are not on the agenda 9 Note the date of the next meeting: 15 July 2025 10 Resolution regarding the Press, Public and Others Sponsor: Jenni Douglas-Todd, Trust Chair To agree, as permitted by the National Health Service Act 2006 (as amended), the Trust's Constitution and the Standing Orders of the Board of Directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. 11 Follow-up discussion with governors 12:40 Page 3 Agenda links to the Board Assurance Framework (BAF) 13 May 2025 – Open Session Overview of the BAF Risk 1a: Lack of capacity to appropriately respond to emergency demand, manage the increasing waiting lists for elective demand, and provide timely diagnostics, that results in avoidable harm to patients. 1b: Due to the current challenges, we fail to provide patients and their families / carers with a high-quality experience of care and positive patient outcomes. 1c: We do not effectively plan for and implement infection prevention and control measures that reduce the number of hospital-acquired infections and limit the number of nosocomial outbreaks of infection. 2a: We do not take full advantage of our position as a leading University teaching hospital with a growing, reputable, and innovative research and development portfolio, attracting the best staff and efficiently delivering the best possible treatments and care for our patients. 3a: We are unable to meet current and planned service requirements due to the unavailability of staff to fulfil key roles. 3b: We fail to develop a diverse, compassionate, and inclusive workforce, providing a more positive staff experience for all staff. 3c: We fail to create a sustainable and innovative education and development response to meet the current and future workforce needs identified in the Trust’s longer-term workforce plan. 4a: We do not implement effective models to deliver integrated and networked care, resulting in sub-optimal patient experience and outcomes, increased numbers of admissions and increases in patients’ length of stay. 5a: We are unable to deliver a financial breakeven position, resulting in: inability to move out of the NHS England Recovery Support Programme, NHS England imposing additional controls/undertakings, and a reducing cash balance impacting the Trust’s ability to invest in line with its capital plan, estates/digital strategies, and in transformation initiatives. 5b: We do not adequately maintain, improve and develop our estate to deliver our clinical services and increase capacity. 5c: Our digital technology or infrastructure fails to the extent that it impacts our ability to deliver care effectively and safely within the organisation, 5d: We fail to prioritise green initiatives to deliver a trajectory that will reduce our direct and indirect carbon footprint by 80% by 2028-2032 (compared with a 1990 baseline) and reach net zero direct carbon emissions by 2040 and net zero indirect carbon emissions by 2045. Agenda links to the BAF No Item Linked BAF risk(s) 5.6 Performance KPI Report for Month 12 5.8 Finance Report for Month 12 5.9 ICS Finance Report for Month 12 5.10 People Report for Month 12 5.11 UHS Staff Survey Results 2024 Report 5.12 Guardian of Safe Working Hours Quarter 3 Report 6.1 Corporate Objectives 2024-5 Quarter 3 Review 6.3 South Central Regional Research Delivery Network Annual Performance Review and 2025-26 Annual Plan 1a, 1b, 1c 5a 5a 3a, 3b, 3c 3b 3b, 3c All 1b, 2a Appetite (Category) Minimal (Safety) Current risk rating 4x5 20 Cautious (Experience) Minimal (Safety) 3x3 9 4x4 16 Open (Technology & Innovation) 3x3 9 Open (workforce) Open (workforce) Open (workforce) 4x5 20 4x3 12 4x4 16 Cautious (Effectiveness) 3x3 9 Cautious (Finance) 4x5 20 Target risk rating 4 x 2 Apr 6 27 3 x 2 Mar 6 26 2 x 3 Apr 6 27 3 x 2 Dec 6 25 4 x 3 Mar 12 26 4 x 2 Mar 8 27 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 2x3 6 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 Minutes Trust Board – Open Session Date Time 11/03/2025 9:00 – 13:00 Location Chair Conference Room, Heartbeat/Microsoft Teams Jenni Douglas-Todd (JD-T) Present Dave Bennett, NED (DB) Gail Byrne, Chief Nursing Officer (GB) Jenni Douglas-Todd, Chair (JD-T) Diana Eccles, NED (DE) Keith Evans, Deputy Chair and NED (KE) David French, Chief Executive Officer (DAF) Paul Grundy, Chief Medical Officer (PG) Steve Harris, Chief People Officer (SH) Jane Harwood, NED/Senior Independent Director (JH) Ian Howard, Chief Financial Officer (IH) Duncan Linning-Karp, Interim Chief Operating Officer (DL-K) David Liverseidge, NED (DL) Tim Peachey, NED (TP) Alison Tattersall, NED (AT) In attendance Martin De Sousa, Director of Strategy and Partnerships (MDeS) Craig Machell, Associate Director of Corporate Affairs and Company Secretary (CM) Lauren Anderson, Corporate Governance and Risk Manager (LA) (item 6.2) Kelly Kent, Head of Strategy and Partnerships (KK) (item 6.1) 2 members of the public (item 2) 5 governors (observing) 7 members of staff (observing) 1 members of the public (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. 2. Patient Story Gregg and Serra [SURNAME] were invited to present their experience as the parents of a child who underwent successful open-heart surgery at Southampton General Hospital in September 2024, having been diagnosed with an atrioventricular septal defect in 2023. It was noted that: • The care provided by the Trust’s staff had been exceptional, including for being able to put matters into layman’s terms to assist understanding. • The interaction between staff and the child patient was also praised, with the parents reporting that their child had been viewed first of all as a person, rather than as simply another patient. 3. Minutes of the Previous Meeting held on 7 January 2025 The draft minutes tabled to the meeting were agreed to be an accurate record of the meeting held on 7 January 2025. Page 1 4. Matters Arising and Summary of Agreed Actions An update was provided in respect of the following actions: • 1200: it was noted that discussions had been had with Natasha Watts and Jenny Milner and the action was ongoing. • 1201: it was noted that an update would be presented in the closed session of the meeting. • 1202: the Trust had written to the Integrated Care Board. • 1203: it was noted that a meeting had been arranged to discuss Freedom to Speak Up on 21 March 2025. 5. QUALITY, PERFORMANCE and FINANCE 5.1 Briefing from the Chair of the Audit and Risk Committee The chair of the Audit and Risk Committee was invited to present the Committee Chair’s Report in respect of the meeting held on 20 January 2025, the content of which was noted. It was further noted that: • The committee considered the accounting policies and management judgements for the 2024/25 annual accounts. • The committee reviewed the Trust’s compliance with the Code of Governance for NHS Provider Trusts, noting that the Trust was compliant in all areas or had appropriate explanations for the few areas of non-compliance. • The committee had received a report on cyber risk, noting that the main risk was from suppliers not having adequate protection and the Trust’s operations being impacted as a result of the loss of service. • The committee considered a report in respect of the risk of individuals impersonating agency staff and noted the Trust’s controls to mitigate against this risk. 5.2 Briefing from the Chair of the Finance and Investment Committee The chair of the Finance and Investment Committee was invited to present the Committee Chair’s Reports in respect of the meetings held on 27 January and 24 February 2025, the content of which was noted. It was further noted that: • The committee reviewed the Finance Report for Month 10 (item 5.8), noting that the Trust was forecasting a year-end deficit of £17.65m and delivery of £76m in efficiencies under the Cost Improvement Programme. • It was further noted that the Trust was anticipating that it would have carried out c.£40m of unpaid activity by the end of the year. • The committee considered a draft of the Trust’s annual plan submission, noting that 2025/26 would present a significant challenge. 5.3 Briefing from the Chair of the People and Organisational Development Committee The chair of the People and Organisational Development Committee was invited to present the Committee Chair’s Reports in respect of the meetings held on 24 January and 24 February 2025, the content of which was noted. It was further noted that: • The committee reviewed the People Report for Month 10 (item 5.10), noting that whilst the Trust was forecasting to be 125 whole-time-equivalents (WTE) above its 2024/25 plan, the total substantive workforce would be 50 WTE lower than in March 2024. • There had been high levels of sickness absence over the period, which had resulted in increased use of bank staff. Concern was expressed in respect of the low uptake rate for vaccinations by staff compared to previous years. Page 2 • Appraisal rates were lower than anticipated, but it was possible that this was due to issues with the transfer of recording of appraisals to the Virtual Learning Environment system. 5.4 Briefing from the Chair of the Quality Committee The chair of the Quality Committee was invited to present the Committee Chair’s Report in respect of the meeting held on 27 January 2025, the content of which was noted. It was further noted that: • The committee had received an update in respect of the ‘Fundamentals of Care’ programme and noted that the programme was progressing well. • The committee reviewed the progress of the Always Improving outpatients and discharge programmes. • The committee reviewed the interim Maternity and Neonatal Safety Report, noting that there was nothing to escalate to the Board. 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: • There had been significant changes in the leadership of NHS England with effectively all executive directors having resigned. Furthermore, there were expected to be significant reductions in the NHS England workforce and changes in the relationship between NHS England and the Department for Health and Social Care. • The Trust had received a request to provide feedback on a proposed management and leadership standard for the NHS. The Trust intended to respond to the consultation. • Concerns had been raised in respect of the Trust’s adult cardiac waiting list due to a mismatch in referrals against operations performed, which had resulted in an improvement plan being submitted to NHS South East Region and a quality visit on 4 February 2025. The Trust’s congenital cardiac team was also under pressure due to insufficient capacity. • Positive feedback had been received following a visit to the Trust’s maternity services by NHS South East Region and the Local Maternity and Neonatal System team. • On 28 February 2025, the Trust had announced the opening of the refurbished Muslim prayer room facilities. • The Trust’s mechanical thrombectomy service was now a 24/7 service and that it was expected that the service would treat up to 1,200 patients a year over the next five years. • Dr Stephen Harden, a consultant in cardiothoracic radiology at the Trust, had been elected as the incoming president of the Royal College of Radiologists for a three-year term commencing on 1 September 2025. 5.6 Performance KPI Report for Month 10 Duncan Linning-Karp was invited to present the Performance KPI Report for Month 10, the content of which was noted. It was further noted that: • The Emergency Department remained under significant pressure due to the level of attendances (11,728 during January 2025), with performance against the four-hour wait target being 61% in January 2025 and 55% in February 2025. • The average number of patients having no criteria to reside was 232 during January 2025. • The Trust’s performance in respect of the 62- and 28-day cancer targets remained high at 79.1% and 83.6% respectively for December 2024. The Page 3 Trust’s performance in these areas was higher than the national targets for March 2026. • Compared to equivalent teaching hospitals, the Trust was second in the country for 65-week waits and joint first in the country for 78-week waits. It was expected that the outstanding 65-week wait patients at March 2025 would be limited to those awaiting material for corneal transplants, of which there was a national shortage, and a small number of complex patients. • The Trust’s mortality rate had fallen as expected and the Trust was ranked as having one of the lowest mortality rates in England. • There had been an increase in the number of incidents of pressure ulcers during January and February 2025. It was noted that often there was an increased number of patients with co-morbidities during the winter months, who were at greater risk of developing pressure ulcers. • Whilst staffing levels had been problematic during September and October 2024 in the Maternity service, the situation had since improved as newlyqualified nurses became substantive. • Further work was ongoing to promote wider use of virtual clinics as an alternative to face-to-face appointments. • The Trust was intending to spend £1.5m on hardware by the end of the year to address the issues caused by the average age of the Trust’s IT estate. Action Craig Machell agreed to add A/I to a future Trust Board Study Session agenda. Gail Byrne agreed to present a deep-dive on pressure ulcers to the Quality Committee. 5.7 Break 5.8 Finance Report for Month 10 Ian Howard was invited to present the Finance Report for Month 10, the content of which was noted. It was further noted that: • The Trust had been working with system partners to agree a ‘landing plan’ for the system for 2024/25 to deliver a break-even position. The Trust’s forecast was for a year-end deficit of £17.65m. • The Trust had recorded a £7.5m in-month surplus and a year-to-date deficit of £15.2m, £11.8m behind its plan. However, there remained an underlying deficit of c.£6.5m, which would pose a significant challenge for 2025/26. • The Trust was forecasting to have insufficient cash in May 2025 and therefore would require additional cash support. It was noted that cash support would require certain commitments from applicants and that requests were not always fulfilled. • The messaging from NHS England appeared to be that difficult decisions would be required to deliver a financially sustainable NHS and that there would be no additional funding. It was noted that a number of these decisions would be better made at a national level to ensure consistency across the country. 5.9 ICB Finance Report for Month 10 The ICB Finance Report for Month 10 was noted. 5.10 People Report for Month 10 Steve Harris was invited to present the People Report for Month 10, the content of which was noted. It was further noted that: Page 4 • Unison had put an offer to its members to resolve the dispute over Band 2/3 pay. It was expected that the vote would conclude at the end of March 2025. • The consultation in respect of the transfer of staff to UHS Estates Limited had progressed well, with the transfer expected to take place on 1 April 2025. • Progress continued to be made in respect of the action plan agreed with portering staff. • The Trust had exceeded its workforce plan by 153 whole-time-equivalents (WTE) at the end of January 2025. There had been a significant increase in use of bank staff due to continued high levels of sickness absence and the need to open surge capacity. • It was forecast that the Trust would be 125 WTE above its plan for 2024/25. It was noted that the Trust had anticipated a reduction in staffing numbers of c.220 WTE due to reductions in patients having no criteria to reside and delivery of system transformation programmes. However, these assumptions had not materialised. 5.11 Mortuary Standards Compliance Update Gail Byrne was invited to provide an update in respect of the actions required following the Fuller Inquiry, the content of which was noted. It was further noted that: • The action plan and outputs from the Fuller Inquiry had been presented to the Board at its meeting held on 6 June 2024. • It was noted that all the actions identified had been completed. 6. STRATEGY and BUSINESS PLANNING 6.1 Corporate Objectives 2024-25 Quarter 3 Review Martin De Sousa and Kelly Kent were invited to present the ‘Corporate Objectives 2024-25 Quarter 3 Review’, the content of which was noted. It was further noted that fifty per cent of objectives were on track to be delivered in full (a reduction compared to the second quarter), 37.5% were amber and 12.5% were red. 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: • There were six risks rated as ‘critical’ (i.e. 15 or above), with one risk (risk 3c) having been upgraded from 12 due to increased likelihood given reductions in the available funding and workforce. • The target dates for six risks had also been extended, including two out to April 2030 due in part to uncertainty in respect of funding availability. 7. CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Feedback from the Council of Governors’ (CoG) meeting 29 January 2025 The Chair presented a summary of the Council of Governors’ meeting held on 29 January 2025. It was noted that the meeting had considered the following matters: • Chief Executive Officer’s Performance Report Page 5 • Chair and Non-Executive Director Appraisal Process • Audit and Risk Committee Terms of Reference • Governors’ Nomination Committee Terms of Reference • Annual Business Plan • Noting the appointment of David Liverseidge following the original approval given in 2024. • Governor Attendance • Membership Engagement 7.2 Register of Seals and Chair’s Actions Report The paper ‘Register of Seals and Chair’s Actions Report’ was presented to the meeting, the content of which was noted. It was further noted that the following items had been sealed on 7 March 2025: • TP1 Land Registry between University Hospital Southampton NHS Foundation Trust and Prime Infrastructure Management Services 4 Limited (the Transferor) and University Hospital Southampton NHS Foundation Trust (Transferee) relating to Land forming part of an accessway adjoining Plot 2, Bargain Farm, Frogmore Lane, Nursling, Southampton, Hampshire SO16 0XS. Seal number 291 on 7 March 2025 • TP1 Land Registry between University Hospital Southampton NHS Foundation Trust and Prime Infrastructure Management Services 4 Limited (Transferor) and University Hospital Southampton NHS Foundation Trust (the Transferee) relating to Land forming part of an accessway adjoining Plot 2, Bargain Farm, Frogmore Lane, Nursling, Southampton, Hampshire SO16 0XS. Seal number 292 on 7 March 2025. • Underlease between Just Retirement Limited (the Landlord) and University Hospital Southampton NHS Foundation Trust (the Tenant) relating to Aseptic Pharmacy and Offices on the Ground, 1st and 2nd Floors at Plot 2 Adanac Health and Innovation Campus, Nursling, Southampton, Hampshire SO16 0XS. Seal number 293 on 7 March 2025. • Reversionary Underlease between Just Retirement Limited (the Landlord) and University Hospital NHS Foundation Trust (the Tenant) relating to Ground and first Floor Sterile Services Unit and Offices at Plot 2 Adanac Health and Innovation Campus, Nursling, Southampton, Hampshire SO16 0XS. Seal number 294 on 7 March 2025. • Underlease between Just Retirement Limited (the Landlord), IHSS Limited (the Tenant) and University Hospital Southampton NHS Foundation Trust (the Trust) relating to Ground and first Floor Sterile Services Unit and Offices at Plot 2 Adanac Health and Innovation Campus, Nursling, Southampton, Hampshire SO16 0XS. Seal number 295 on 7 March 2025. • Sub-Underlease between University Hospital NHS Foundation Trust (Landlord) and UHS Estates Limited (Tenant) of Aseptic Pharmacy and Offices on the Ground, 1st and 2nd Floors at Plot 2 Adanac Health and Innovation Campus, Nursling, Southampton, Hampshire SO16 0XS. Seal number 296 on 7 March 2025. Page 6 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 in respect of the items listed above. 7.3 Audit and Risk Committee Terms of Reference Craig Machell was invited to present the proposed changes to the Audit and Risk Committee’s Terms of Reference, the content of which was noted. It was further noted that: • The Audit and Risk Committee had reviewed its terms of reference at its meeting on 20 January 2025, following which input had been sought from the Council of Governors at its meeting held on 29 January 2025. • It was proposed to amend a reference in paragraph 10.2 and to update Appendix A. Decision Having considered the proposed amendments to the Audit and Risk Committee’s Terms of Reference, the Board approved the changes. 7.4 Finance and Investment Committee Terms of Reference Craig Machell was invited to present the proposed changes to the Finance and Investment Committee’s Terms of Reference, the content of which was noted. It was further noted that: • The Finance and Investment Committee had reviewed its terms of reference at its meeting on 27 January 2025. • It was proposed to update Appendix A. Decision Having considered the proposed amendments to the Finance and Investment Committee’s Terms of Reference, the Board approved the changes. 7.5 Quality Committee Terms of Reference Craig Machell was invited to present the proposed changes to the Quality Committee’s Terms of Reference, the content of which was noted. It was further noted that: • The Quality Committee had reviewed its terms of reference at its meeting on 27 January 2025. • It was proposed to amend a reference in paragraph 10.2 and to update Appendix A. Decision Having considered the proposed amendments to the Quality Committee’s Terms of Reference, the Board approved the changes. 7.6 Remuneration and Appointment Committee Terms of Reference Craig Machell was invited to present the Remuneration and Appointment Committee’s Terms of Reference, the content of which was noted. It was further noted that: Page 7 • The Remuneration and Appointment Committee had reviewed its terms of reference at its meeting on 11 March 2025. • No changes were proposed. Decision Having considered the Remuneration and Appointment Committee’s Terms of Reference, the Board approved the terms of reference. 7.7 Trust Executive Committee Terms of Reference Craig Machell was invited to present the proposed changes to the Trust Executive Committee’s Terms of Reference, the content of which was noted. It was further noted that: • The Trust Executive Committee (TEC) had reviewed its terms of reference at its meeting on 12 February 2025. • It was noted that the most significant amendments were in respect of the following: o Introduction of the pre-TEC process for business cases requiring additional expenditure; o The role of the TEC as a forum for discussion of significant strategic matters; o The TEC’s role in identification of opportunities for system collaboration; o Updates to reflect the current role of the Trust Investment Group and the TEC under the Standing Financial Instructions; and o Other amendments to add clarity about the TEC’s operation and reports received. Decision Having considered the proposed amendments to the Trust Executive Committee’s Terms of Reference, the Board approved the changes. 8. Any other business There was no other business. 9. Note the date of the next meeting: 13 May 2025 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. 10. Resolution regarding the Press, Public and Others Decision: The Board resolved that, as permitted by the National Health Service Act 2006 (as amended), the Trust’s Constitution and the Standing Orders of the board of directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. The meeting was adjourned. Page 8 List of action items Agenda item Assigned to Deadline Status Trust Board – Open Session 25/07/2024 5.4 Briefing from the Chair of the Quality Committee (Oral) 1163. Impact of technology Machell, Craig 03/06/2025 Pending Explanation action item Craig Machell agreed to add an item covering the impact of technology over the next 5-10 years to a future Trust Board Study Session agenda. Update: Item deferred to Study Session on 03/06/2025. Trust Board – Open Session 07/01/2025 5.13 Infection Prevention and Control 2024-25 Quarter 2 Report 1204. Infection prevention Byrne, Gail 03/06/2025 Pending Explanation action item Gail Byrne agreed to include an item on infection prevention control at a future Trust Board Study Session to include details of an Australian study, point of care testing, and progress on the roll out of the Fundamentals of Care programme. Update: Item tentatively scheduled for TBSS on 03/06/2025. Trust Board – Open Session 11/03/2025 5.6 Performance KPI Report for Month 10 1217. Artificial Intelligence (A/I) Machell, Craig Explanation action item Craig Machell agreed to add A/I to a future Trust Board Study Session agenda. 03/06/2025 Pending Update: Tentatively scheduled for TBSS on 03/06/2024. Agenda item Assigned to Trust Board – Open Session 11/03/2025 5.6 Performance KPI Report for Month 10 1218. Pressure ulcers Byrne, Gail Explanation action item Gail Byrne agreed to present a deep-dive on pressure ulcers to the Quality Committee. Deadline Status 13/05/2025 Pending Page 2 of 2 Agenda item 5.1 Committee Chair’s Report to the Trust Board of Directors 13 May 2025 Committee: Audit & Risk Committee Meeting Date: 17 March 2025 Key Messages: • • • • • • The committee considered the going concern assessment for the 2024/25 accounts and agreed that the accounts should be prepared on a ‘going concern’ basis. The external auditor reported that there had been no significant issues resulting from the transfer to a new finance system. The committee received a report on losses and special payments during 2024/25 and noted that the levels were similar to previous years. These payments were generally related to lost patient property. The committee reviewed the Trust’s Treasury Policy, confirmed the current bank mandate and approved certain minor changes to the Treasury Policy. An update was received in respect of Information Governance. It was noted that the Trust – in common with most others – was not expected to meet the standards set out in the Data Security and Protection Toolkit for 2024/25 due to the introduction of the Cyber Assurance Framework. The Trust had reported six breaches to the Information Commissioner since 1 January 2024, but none of the incidents resulted in further action on the part of the regulator. The committee agreed the Fraud team’s work plan for 2025/26. Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) 6.2 Board Assurance Framework (BAF) Update Assurance Rating: Risk Rating: Substantial N/A • All risks had been reviewed with the relevant executive director(s). • It was suggested that Risk 3c should be reconsidered in terms of what the main risk was given the increase in risk rating to 16, particularly whether the main concern was running out of trained staff as opposed to being unable to deliver training and development. Any Other Matters: • The committee reviewed the outputs from the internal audit reports in respect of rostering, the discharge process, and core financial controls noting that there was nothing significant which required escalation to the Board. 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 i) Committee Chair’s Report to the Trust Board of Directors 13 May 2025 Committee: Finance & Investment Committee Meeting Date: 24 March 2025 Key Messages: • • • • • • The committee received an update in respect of the Trust’s 2025/26 annual plan. It was noted that the NHS in England was forecasting a deficit of £6.6bn, which had resulted in significant intervention by Government, including the abolition of NHS England and 50% reductions in integrated care boards’ costs. These reductions would be supplemented by a national mutually agreed resignation scheme. The Trust anticipated running out of cash in May 2025, but it was understood that cash support would no longer be provided. The Hampshire and Isle of Wight Integrated Care System was aiming to reach a breakeven position in 2025/26. This would necessitate additional controls on recruitment and 5-10% reductions in expenditure/headcount as well as achievement of challenging Cost Improvement Programme targets. The committee reviewed the Finance Report for Month 11. It was noted that the Trust had recorded an in-month surplus of £8.2m due to a number of one-off items. There had been an increase in the use of bank staff due to the need to open surge capacity and the demand resulting from patients with mental health issues. The committee received an update in respect of the transformation plans regarding the ‘living within our means’, urgent and emergency care, and elective care recovery workstreams. The committee reviewed the quarterly update from Estates, Facilities and Capital Development. It was noted that there was a plan for removal of all reinforced autoclaved aerated concrete (RAAC) on the Southampton General Hospital site. It was further noted that the steam ducts on the site continued to be an issue and there was a risk that the Trust was at the limit for electricity usage on the site. Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) N/A Any Other Matters: The committee considered a business case in respect of a Hampshire and Isle of Wight Elective Hub in Winchester. It was noted that this proposal was reviewed and approved at the Trust Board meeting on 25 March 2025. 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. Page 1 of 2 Reasonable Assurance Limited Assurance No Assurance Not Applicable There is a series of controls in place, however there are potential risks that may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Where assurance is not required and/or relevant. Risk Rating: Low Medium High Not Applicable Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda Item 5.2 ii) Committee Chair’s Report to the Trust Board of Directors 13 May 2025 Committee: Finance and Investment Committee Meeting Date: 28 April 2025 Key Messages: • • • • • • • The committee reviewed the Finance Report for Month 12 (see below). The committee received an update in respect of the Trust’s cash position, noting that the Trust’s cash position had been relatively stable during the fourth quarter due to receipt of additional one-off funding and careful supplier payment management. However, the Trust was highly likely to require cash support in either Q1 or Q2. The committee noted the report from the Trust’s digital services, noting the successful negotiation of a discount for purchasing new laptops due to the number required. In addition, there had been a leak in GICU which had impacted the switch network, but which had since been rectified. It was further noted that, during the first months of the year, the Trust had blocked more attempted cyber attacks than in the whole of 2024. It was noted that trusts had been set challenging targets for reducing the size of their corporate services, and as such were expected to reduce the size of these services by 50% of the growth since 2018/19. The committee received an update on the Trust’s 2025/26 capital plan, noting that the plan was under review owing to the Trust’s cash position. In addition, it had been agreed to prioritise maintaining the Trust’s level of expenditure on strategic maintenance and to defer the refurbishment of the neuro theatres. The committee reviewed the update from the Trust’s commercial team, including in respect of private and overseas patients, the proposed private patient unit, and Adanac Park. The committee supported the Trust’s participation in the proposed Elective Hub at Winchester. Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) 5.8 Finance Report for Month 12 Assurance Rating: Risk Rating: Substantial High • The Trust had successfully ended the year at where it expected to do so with a deficit of £7m at year end. • The Trust’s underlying position remained a concern with a £6.9m deficit recorded during the month. • The committee reviewed the high use of bank staff during months 8 to 12, noting that the Trust had opened surge capacity during this period and was experiencing significant demand. • The Trust had achieved 127% elective recovery performance against the national target of 113%, and had also delivered its 2024/25 Cost Improvement Programme target in full (£85m). • The Trust had also spent £96m of capital during 2024/25. 6.2 Board Assurance Framework (BAF) Update Assurance Rating: Risk Rating: Substantial N/A • Risks 5a, 5b and 5c have been updated, following discussions with the respective Executive Director(s). Page 1 of 2 Any Other Matters: • The committee discussed whether the 2030 target for risk 5b was realistic and whether the rating to be achieved by 2030 should be increased. N/A Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Limited Assurance Controls in place are not sufficient to ensure that 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 5.3 i) Committee Chair’s Report to the Trust Board of Directors 13 May 2025 Committee: People & Organisational Development Committee Meeting Date: 24 March 2025 Key Messages: • • The committee reviewed the People Report for Month 11. It was noted that February 2025 had continued to be challenging due to high sickness rates, with the Trust close to calling a critical incident. This had driven much higher bank rates. There had been a lower than forecast number of leavers during the month (44 whole-timeequivalents (WTE) against a forecast of 100). The Trust was 267 WTE above its plan. The Trust’s draft Workforce Plan for 2025/26 was reviewed. The Trust was required to deliver a breakeven plan. Accordingly, the Trust was anticipating a freeze on all non-clinical vacancies and holding 30% of clinical vacancies. In addition, there would potentially be a target to reduce headcount by 5-10% as well as additional reductions in use of bank and agency staff. It was further proposed to reorganise the four existing Divisions into three in order to deliver efficiencies. It was noted that even if the Trust achieved fully against all performance targets and implemented the restrictions and reductions above, there would still be a deficit. Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) 5.11 UHS Staff Survey Results 2024 Report Assurance Rating: Risk Rating: Reasonable Low • The committee reviewed the Staff Survey results for 2024. • The Trust had maintained its above average position across all of the People Promise domains. • The Trust’s results remained broadly similar to those in 2023, although there had been improvements in some areas, such as satisfaction with immediate managers, flexible working, appraisals, and confidence in reporting unsafe practice, violence, bullying and harassment. • The participation rate was low at 39%, which gave rise to some concern about how reflective of the workforce the results were. A significant difference in engagement between non-clinical and clinical staff was noted. 6.2 Board Assurance Framework Assurance Rating: Risk Rating: Update Substantial N/A • Risks 3a, 3b and 3c had been updated, following discussions with the respective Executive Director(s). • Risk 3c had been upgraded from 12 to 16 to reflect the reduction in national funding for education and training and the more restrictive funding framework. In addition, it was noted that the intended reduction in NHS corporate infrastructure would impact training and development staff. • The committee agreed to review the Board Assurance Framework again once the 2025/26 plan had been approved. Any Other Matters: • The committee received an update in respect of the Band 2/3 pay dispute and in respect of the portering department. 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 5.3 ii) Committee Chair’s Report to the Trust Board of Directors 13 May 2025 Committee: People & Organisational Development Committee Meeting Date: 25 April 2025 Key Messages: • • • • • • • The committee reviewed the People Report for Month 12 (see below). The committee noted the significant challenges for 2025/26 in delivering the Trust’s Annual Plan and the implications for its workforce. In particular, the Trust was anticipating having to reduce its overall workforce by 6% during the year, coupled with a 20% reduction in bank staff and 30% reduction in agency staff. It was noted that the organisational changes would need to happen at pace, but that there was not presently central funding to support this. The Trust had implemented strict recruitment controls, including a freeze on all non-clinical recruitment and would hold 30% of clinical vacancies. Delivery of the Trust’s 2025/26 plan also assumed significant reductions in the numbers of mental health patients and in patients having no criteria to reside. It had been announced that the Trust would be restructuring its divisions, reducing from four to three. It was anticipated that this would be completed by 1 July 2025. Furthermore, the Trust had a medium- to long-term objective of developing and implementing shared services with other organisations in the Hampshire and Isle of Wight Integrated Care System. The organisational and workforce changes envisaged were to be supported by both an equality and a quality impact asse
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UHS AR 22-23-6

Description: 2022/23 Incorporating the quality account University Hospital Southampton NHS Foundation Trust Annual Report and Accounts 2022/23 Presented to Parliament pursuant to Schedule 7, paragraph 25(4)(a) of the National Health Service Act 2006 © 2023 University Hospital Southampton NHS Foundation Trust Contents Welcome from our chair and chief executive 6 Overview and performance 8 Performance report 9 Overview 10 Accountability report 33 Directors’ report 34 Remuneration report 57 Staff report 71 Annual governance statement 91 Quality account 106 Statement on quality from the chief executive 107 Priorities for improvement and statements of assurance from the board 110 Other information 188 Annual accounts 222 Statement from the chief financial officer 223 Auditor’s report 224 Foreword to the accounts 230 Statement of Comprehensive Income 231 Statement of Financial Position 232 Statement of Changes in Taxpayers’ Equity 233 Statement of Cash Flows 234 Notes to the accounts 235 5 Welcome from the Chair and Chief Executive Officer University Hospital Southampton NHS Foundation Trust (‘UHS’ or the ‘Trust’) experienced another challenging year during 2022/23. Nonetheless, the Trust and its staff have continued to deliver for patients and the wider system in which it operates. Trust highlights from 2022/23 include: • Delivering an 8% increase in activity (compared to 2019/20) under the elective recovery programme, which places us as one of the top performing trusts in England. • Being recognised in the NHS staff survey as the seventh highest trust for recommendation as a place to work nationally and the best performing trust in opportunities for career development. • Celebrating 50 years as a medical school with the University of Southampton and continuing to pioneer UK and world-first research studies. • Enhancing the reputation of our specialist care – for example our bone marrow transplant team at UHS have the best patient outcomes in Europe. However, as was the picture across the country, UHS had an extremely challenging winter with attendances at our emergency department often in excess of 400 a day. This was driven in part by high prevalence of streptococcus A (strep A) in the community along with other seasonal illnesses such as influenza and high incidences of COVID-19 at times. Moreover, the lack of availability of care home beds and other care packages in the community has resulted in challenges in discharging patients who are ready to leave hospital and therefore we have been operating at or near to capacity throughout the year. At the time of writing, there continues to be operational pressures due to industrial action by the Royal College of Nursing and British Medical Association. Throughout the disputes, we have attempted to balance the right of our staff to strike with the need to minimise the impact on the Trust’s operations and patients and ensure that safety was not compromised. Our leadership team has engaged proactively with the unions to agree, where possible, derogations (i.e. services that will continue to be staffed during strikes) to ensure that the running of our hospitals can continue and that patients remain safe. We would like to express our thanks to all staff who have gone over and above during these periods of industrial action by being willing to do different work to usual, often at anti-social times of the day. While we cannot influence national negotiations, we are focusing on what we can control within UHS. Our people strategy published last year sets out how we will grow and deploy our workforce of today and the future as part of a thriving community to deliver world-class patient care. Building on this, we have recently launched our inclusion and belonging strategy so that as a leadership team we can deliver what is required for all our workforce to feel they can belong and thrive at UHS. The Trust achieved its Cost Improvement Plan (CIP) target of £45.6m for 2022/23, the highest in our history but despite this, ended the year with a deficit of £11m. The deficit was driven by a combination of factors including a substantial increase in energy prices, higher costs of medicines and equipment and temporary staffing costs as well as changes in recent years in respect of the NHS funding infrastructure, which adversely impacted the Trust relative to others during the year. In terms of the broader context, the Hampshire and Isle of Wight Integrated Care System, in which the Trust operates, reported an overall deficit for 2022/23 driven in part by a significant increase in staffing numbers when compared to 2019/20 as well as structural factors. 6 We have continued to make progress on our estates strategy, building new theatres and carrying out improvements to existing facilities, as well as opening a new park and ride for staff at Adanac Park and progressing plans for a new innovation campus there. During 2022/23 we invested over £88m of capital expenditure to meet our ambition of increasing capacity and improving services in order to manage the increasing demand. All development is underpinned by our green plan, which sets out areas of focus for decarbonising UHS and achieving the net zero target set by the NHS. The Trust has continued to support the Hampshire and Isle of Wight Integrated Care System, which was formed on 1 July 2022 to facilitate integration and collaboration across health and social care partners in the region. In particular, UHS has worked closely with the Integrated Care Board and other providers in the development of the operating plan for 2023/24. We have also continued to work with other partners in the region, including local authorities and the University of Southampton. The 13,000 staff of UHS are our greatest asset and we would like to express our gratitude to them for continuing to go above and beyond to put patients first under very challenging circumstances. Without our staff, we would be unable to fulfil our ambition to be a world-class organisation with world-class people delivering world-class care. Jenni Douglas-Todd Chair 26 June 2023 David French Chief Executive Officer 26 June 2023 7 PERFORMANCE REPORT Performance report Introduction from the Chief Executive Officer The Trust experienced another challenging year with the need to balance the delivery of quality patient care with a significant increase in demand for the Trust’s resources and the need to do so whilst maintaining a sustainable financial position. The Trust saw the number of patients on a waiting list under the 18-week referral to treatment pathway increase to just over 55,000 patients at the end of the year. Despite this, however, the Trust was successful in reducing the number of patients waiting more than 104 weeks to nil and in reducing the number of patients waiting more than 78 weeks to 14 by the end of the year. In addition, the Trust’s performance under the elective recovery programme placed it as one of the topperforming trusts in the country. Demand for non-elective care also significantly increased during the year with the emergency department seeing more than 400 attendances per day at some points, especially during the winter months. The industrial action seen in the latter part of 2022/23 placed further pressure on the Trust and resulted in a need to cancel elective procedures and outpatients appointments. However, on balance, the Trust was able to manage these events through effective planning and the engagement and support of its staff. Although the Trust was successful in recruiting to substantive roles, especially in terms of reducing the number of Health Care Assistant vacancies, the anticipated reduction in use of bank and agency staff was not seen. This, among other factors, such as the substantial increase in energy costs and the rate of inflation, posed a significant challenge in terms of the Trust’s financial position. Despite achieving savings of £45.6m, the Trust reported a deficit of £11m for 2022/23. 9 Overview About the Trust Our services University Hospital Southampton NHS Foundation Trust is one of the largest acute teaching trusts in England with a turnover of more than £1 billion in 2022/23. It is based on the coast in southeast England and provides services to over 1.9 million people living in Southampton and south Hampshire and specialist services, including neurosciences, respiratory medicine, cancer care, cardiovascular, obstetrics and specialist children’s services, to more than 3.7 million people in central southern England and the Channel Islands. The Trust is also a designated major trauma centre, one of only two places in the south of England to offer adults and children full major trauma care provision. As a leading centre for teaching and research, the Trust has close working relationships with the University of Southampton, the Medical Research Council, National Institute for Health and Care Research (NIHR), Wellcome Trust and Cancer Research UK. The Trust is consistently one of the UK’s highest recruiting trusts of patients to clinical trials and one of the top nationally for research study volumes as ranked by the NIHR Clinical Research Network. Every year the Trust: treats around 160,000 inpatients and day patients, including about 75,000 emergency admissions sees over 650,000 people at outpatient appointments deals with around 150,000 cases in our emergency department delivers more than 100 outpatient clinics across the south of England, keeping services local for patients The Trust provides most of its services from the following locations: • Southampton General Hospital – the Trust’s largest location, where a great number of specialist services are based alongside emergency and critical care and which includes Southampton Children’s Hospital. • Princess Anne Hospital – located across the road from Southampton General Hospital and providing maternity care and specialist care for women with medical problems during pregnancy and babies who need extra care around birth across the region. • Royal South Hants Hospital – although the Trust does not operate this site near the centre of Southampton it provides a smaller number of services from this location. • New Forest Birth Centre – located at Ashurst on the edge of the New Forest and run by experienced midwives and support staff it acts as a community midwifery hub. The services provided by the Trust are commissioned and paid for by the Hampshire and Isle of Wight Integrated Care System (ICS) and, in the case of more specialised services (such as treatments for rare conditions), by NHS England. Trust services are supported by clinical income, of which 55% is paid for by NHS England and 43% by the Hampshire and Isle of Wight Integrated Care Board. These are provided under a standard NHS contract, which incorporates ongoing monitoring of the Trust and the quality of the services provided. 10 Our structure UHS gained foundation trust status on 1 October 2011. A foundation trust is a public benefit corporation providing NHS services in line with the core NHS principles: that care should be universal, comprehensive and free at the point of need. The Trust is licensed as a foundation trust to provide these services by NHS England and the healthcare services we provide are regulated by the Care Quality Commission. Since 1 July 2022, the Trust has been part of the Hampshire and Isle of Wight Integrated Care System (ICS) when this was established through the Health and Social Care Act 2022. Each ICS has two statutory elements: an integrated care partnership (ICP) and an integrated care board (ICB). The ICP is a statutory committee jointly formed between the NHS integrated care board and all uppertier local authorities that fall within the ICS area. The ICP will bring together a broad alliance of partners concerned with improving the care, health and wellbeing of the population, with membership determined locally. The ICP is responsible for producing an integrated care strategy on how to meet the health and wellbeing needs of the population in the ICS area. The ICB is a statutory NHS organisation responsible for developing a plan for meeting the health needs of the population, managing the NHS budget and arranging for the provision of health services in the ICS area. The establishment of ICBs resulted in clinical commissioning groups (CCGs) being closed down. The Trust has been a university teaching hospital since 1971. The diagram below provides an overview of the overall organisational structure of the Trust. Division A Surgery Critical Care Opthalmology Theatres and Anaesthetics Public and foundation trust members Council of Governors Board of Directors Executive Directors Division B Division C Division D Cancer Care Emergency Medicine Helicopter Emergency Medical Services Medicine and Medicine for Older People Pathology Specialist Medicine Women and Newborn Maternity Child Health Clinical Support Cardiovascular and Thoracic Neurosciences Trauma and Orthopaedics Radiology Trust Headquarters Division 11 Our values Our values describe how we do things at UHS and act as a guide to all staff working with colleagues to deliver high quality patient care and a great patient experience every day. Our values are: Patients, their families and carers are at the heart of what we do. Their experience of our services will be our measure of success. Partnership between clinicians, patients and carers is critical to achieving our vision, both within hospital teams and extending across organisational boundaries in the NHS, social care and the third sector. We will ensure we are always improving services for patients through research, education, clinical effectiveness and quality improvement. We will continue to incorporate new ideas, technologies and create greater efficiencies in the services we provide. 12 Our strategy 2021-25 The Trust’s strategy was updated during 2020/21 to take account of everything our staff had experienced during the COVID-19 pandemic and what we had learnt from this. The vision for UHS is to become an organisation of world class people delivering world class care. Our strategy is organised around five themes and for each of these it describes a number of ambitions we aim to achieve by 2025. Theme Ambitions Outstanding patient outcomes, • We will monitor clinical outcomes, safety and experience of our experience and safety patients regularly to ensure they are amongst the best in the UK By 2025 we will strengthen our and the world. national reputation for outstanding • We will reduce harm, learning from all incidents through our patient outcomes, experience and proactive patient safety culture. safety, providing high quality care • We will ensure all patients and relatives have a positive experience and treatment across an extensive of our care, as a result of the environment created by our people range of services from foetal and our facilities. medicine, through all life stages and conditions, to end-of-life care Pioneering research • We will recruit and enable people to deliver pioneering research in and innovation Southampton. We will continue to be a leading teaching hospital with a growing, reputable and innovative research and development portfolio • We will optimise access to clinical research studies for our patients. • We will enable innovation in everything we do, and ensure that ‘cutting edge’ investigations and treatments are delivered in Southampton. that attracts the best staff and efficiently delivers the best possible treatments and care for our patients. World class people • We will recruit and develop enough people with the right Supporting and nurturing our knowledge and skills to meet the needs of our patients. people through a culture that values • We will provide satisfying and fulfilling roles, growing our talent diversity and builds knowledge and through development and opportunity for progression. skills to ensure everyone reaches • We will empower our people, embracing diversity and embedding their full potential. We must provide compassion, inclusion and equity of opportunity. rewarding career paths within empowered, compassionate, and motivated teams. Integrated networks and collaboration We will deliver our services with partners through clinical networks, collaboration and integration across geographical and organisational boundaries. • We will work in partnership with key stakeholders across the Hampshire and Isle of Wight integrated care system. • We will strengthen our acute clinical networks across the region, centralising when necessary and supporting local care when appropriate. • We will foster local integration with primary and community care as well as mental health and social care services for seamless delivery across boundaries. • We will build on our successful partnership with University of Southampton (UoS), growing our reputation as a national leading university teaching hospital. 13 Theme Foundations for the future Making our enabling infrastructure (finance, digital, estate) fit for the future to support a leading university teaching hospital in the 21st century and recognising our responsibility as a major employer in the community of Southampton and our role in broader environmental sustainability. Ambitions • We will deliver best value to the taxpayer as a financially efficient and sustainable organisation. • We will support patient self-management and seamless care across organisational boundaries through our ambitious digital programme, including real time data reporting, to inform our care. • We will expand and improve our estate, increasing capacity where needed and providing modern facilities for our patients and our people. • We will strengthen our role in the community as an employer of choice, a partner in delivery of services to our population and by leading the Greener NHS agenda locally. During each year of the strategy the Trust sets out a more detailed series of objectives to achieve and progress towards the delivery of its ambitions. In 2022/23 these objectives included: Outstanding patient outcomes, experience and safety Pioneering research and innovation World class people Integrated networks and collaboration Foundations for the future • Recovery, restoration and improvement of clinical services • Introducing a robust and proactive safety culture • Empowering and developing staff to improve services for patients • Always Improving strategy • Delivering a high-quality experience of care for all • Delivery of year two of the research and innovation investment plan • Strategy and partnership working • Growing, developing and innovating our workforce • A great place to work, develop and achieve • Compassionate and inclusive workplace for all • We Work in partnership with Integrated Care System and Primary Care Networks • Integrated Networks and Collaborations • Establishing Southern Counties Pathology Network • Establishing the Wessex Imaging Network • Develop Collaborations strategy • Creating a sustainable financial infrastructure • Making our corporate infrastructure fit for the future to support a leading university teaching hospital in the 21st century • Recognising our responsibility as a major employer in the community of Southampton and our role in delivering a greener NHS Performance against these objectives will be monitored and reported to the Trust’s Board on a quarterly basis. 14 Principal risks to our strategy and objectives The Board has identified and manages the principal risks to the delivery of its strategy and objectives through its board assurance framework. The principal risks to the delivery of its strategy and objectives identified by the Trust during 2022/23 were that: • There would be a 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. • Due to the current challenges, the Trust fails to provide patients and their families with a high-quality experience of care and positive patient outcomes. • The Trust would not effectively plan for and implement infection prevention and control measures that reduce the number of hospital-acquired infections and limit the number of nosocomial outbreaks of infection. • The Trust is unable to meet current and planned service requirements due to unavailability of qualified staff to fulfil key roles. • The Trust fails to develop a diverse, compassionate and inclusive workforce, providing a more positive experience for all staff. • The Trust fails 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. • The Trust does 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. • The Trust is unable to deliver a financial breakeven position and support prioritised investment as identified in the Trust’s capital plan within locally available limits (capital departmental expenditure limit (CDEL)). • The Trust does not adequately maintain, improve and develop its estate to deliver its clinical services and increase capacity. • The Trust fails to introduce and implement new technology and expand the use of existing technology to transform its delivery of care through the funding and delivery of the digital strategy. • The Trust fails to prioritise green initiatives to deliver a trajectory that will reduce its 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. During 2022/23, the Trust continued to experience the impact of the COVID-19 pandemic. The need to ensure a safe environment for patients through stringent infection control processes impacted the Trust’s capacity due to the need to isolate patients with COVID-19 in separate areas of the hospital. In addition, outbreaks of norovirus during the winter months placed further pressure on hospital capacity. The impact of the pandemic continued to be felt in terms of staff absence due to becoming infected with COVID-19 as well as the significant impact on staff mental health. The higher than normal (i.e. pre-COVID) levels of staff absence placed additional strain on the Trust’s operations and led to increased expenditure due to the requirement to enlist bank and/or agency staff to maintain safe staffing levels. 15 Performance overview The Trust monitors a broad range of key performance indicators within its departments, divisions, directorates and through Trust executive committees. On a monthly basis, the Board and executive committee receives a performance report containing a variety of indicators intended to provide assurance in respect of the Trust’s strategy and that the care provided is safe, caring, effective, responsive and well-led. This report also includes the Trust’s performance against the national targets set by NHS England. The performance reports include a ‘spotlight’ section, which provides more detailed analysis of a particular area. Typically, this is one of either the national targets or the Trust’s performance against the expectations set out in the NHS Constitution. The monthly performance report is also published on the Trust’s website. The Chief Executive Officer provides a regular report on performance to the Council of Governors, which includes a range of non-financial and financial performance information. Capacity The pressures of the COVID-19 pandemic led to increases in the waiting times for patients and the number of patients waiting for more than a year increased significantly. During the year, the Trust achieved its goal of no patients waiting more than 104 weeks by July 2022 and finished the year with only 14 patients waiting for more than 78 weeks. However, the length of time patients are waiting for treatment remains one of the key risks for the Trust. This situation was compounded by the sustained demand for non-elective activity, which saw attendances at the emergency department rise to over 400 patients per day during some periods of 2022/23 and was consistently higher than previously was the case. The significant increase in referrals, often requiring more complex treatment, has seen the number of patients on a waiting list under the 18-week referral to treatment pathway increase to just over 55,000 patients at the end of the year. In addition, the industrial action during the year placed further strain on the Trust’s ability to both provide urgent care and manage its elective recovery programme. Quality and compliance Furthermore, difficulties in obtaining care home beds and other care packages in the community has resulted in challenges in discharging patients who are ready to leave hospital and therefore the Trust has been operating at or near to capacity throughout the year. The Trust continued to monitor the quality of care delivered throughout 2022/23. The Trust continued its focus on infection prevention and control, which had proven successful during the COVID-19 pandemic. The Trust progressed its Always Improving strategy and successfully supported the identification and implementation of 84 quality improvement projects. In addition, the Trust continued to implement the patient safety incident response framework as well as taking other steps to drive a safety culture within the organisation. Furthermore, the Trust conducted further trials of shared decision making between clinicians and patients and is a leading site nationally for shared decision-making principles. Further information can be found in the Quality Account. 16 Partnerships The new arrangements for integrated care systems were implemented in July 2022 with the Trust becoming part of the Hampshire and Isle of Wight Integrated Care System. As such, the Trust’s senior management frequently meets with peers from across the system to consider and agree matters of wider concern across the system. In addition, the Trust worked with the Integrated Care Board in order to develop its financial and capital plans for 2023/24 and beyond. The Trust also attends the Southampton Health and Wellbeing Board at Southampton City Council and in the Hampshire and Isle of Wight Acute Provider Partnership Board. During 2022/23, the Trust continued to progress research activities and opportunities with the University of Southampton and Wessex Health Partners. Workforce In addition, work continued in the development of an elective hub at Winchester with Hampshire Hospitals NHS Foundation Trust, which will provide the Trust with additional capacity to carry out its elective programme. The Trust’s key areas of focus during 2022/23 were in respect of increasing the substantive workforce and reducing staff turnover. Although the Trust was successful in recruiting to substantive posts, the expected reduction in reliance on bank and agency staff did not materialise, which meant that the Trust was 1,068 whole-time equivalents above its plan for 2022/23. Included in this figure is the TUPE transfer of genomics staff from Salisbury. A particular area of focus was the recruitment of Health Care Assistants where the Trust was successful in reducing the number of vacancies from 27% to 18%. Whilst the Trust was successful in reducing staff turnover from 14.9% in 2021/22 to 13.5%, it remained above the 12% target. However, the Trust did experience a reduction in staff absence from 4.7% in April 2022 to 4.3% in March 2023, and initiatives to improve staff wellbeing were an area of focus during the year. Estate Innovation and technology The industrial action in late 2022 and early 2023 posed significant challenges for the Trust, including in terms of the need to engage additional temporary staff to ensure patient safety. The Trust continued to invest in and develop its estate during 2022/23 including successful completion of the Paediatric Intensive Care Unit project, which delivered single rooms and specialist accent lighting alongside delivery of a ‘twin care’ room. There were a number of other significant projects during the year, including refurbishments of wards and work on creating new theatres as well as projects to improve staff wellbeing. These were part of over £88m of capital expenditure in 2022/23 that also included equipment, digital and the backlog maintenance programme. The Trust continued to promote research and development during 2022/23, including through partnerships with the University of Southampton and Wessex Health Partners. Furthermore, the Trust continued to examine ways to make use of technology to improve its service delivery. In particular, the Trust has promoted the use of MyMedicalRecord, which gives patients the ability to co-manage their healthcare online and through an app. 17 Sustainable financial model The Trust did not achieve breakeven status at the end of 2022/23 and reported a deficit of £11.037m at year-end. This was due to a number of factors, including the Trust’s underlying deficit as well as the increase in energy prices. The Trust was more exposed than most to fluctuations in the wholesale price of gas due to its reliance on a gas-powered energy supply. In addition, the Trust’s 8% uplift in elective activity when compared to 2019/20 was not fullyfunded, which placed further pressure on the Trust’s existing financial resources, which had been used to ensure a breakeven position in 2021/22. The continued use of bank and agency staff as well as the costs of industrial action in late 2022 and early 2023 further eroded the Trust’s financial position. Notwithstanding the above, the Trust did succeed in obtaining a number of sources of nonrecurrent funding during the year, including a successful bid for £29.4m of funding through the Public Sector De-Carbonisation Fund, which will be used to fund green initiatives as part of the Trust’s capital programme. The financial outlook across the NHS continues to appear very challenging during 2023/24 and the Hampshire and Isle of Wight Integrated Care System is forecasting one of the highest deficits in England. 18 Performance analysis COVID-19 Impacts Although the pandemic has ended and serious cases of COVID-19 have reduced significantly, the Trust continued to be impacted by COVID-19 during 2022/23. Heightened infection prevention control measures in respect of patients with COVID-19 placed additional stress on the Trust’s capacity due to the need to isolate those patients and there was a consequential reduction in the Trust’s ability to make most efficient use of its available spaces. Furthermore, the ongoing impact on the Trust’s staff has led to higher staff absence than was the case prior to the pandemic, particularly due anxiety, infectious diseases and colds and flu. • The Trust experienced an average number of 98.7 patients per day who tested positive for COVID-19. During the winter months, this number increased substantially to nearly 200. • During the year, an average of 3.6 intensive care/high-dependency beds per day were occupied by COVID-19 patients. However, at times this increased to as much as ten. • Although staff sickness rates remained higher than pre-pandemic, the Trust saw a decrease in the absence rate from 4.7% at the beginning of 2022/23 to 4.3% by the end of the period. COVID-19 Cases UHS average number of confirmed COVID-19 patients in bed (08:00 census) 250 200 150 100 50 0 4/1/20225/1/2022 6/1/20227/1/2022 8/1/2022 9/1/202210/1/202211/1/202212/1/2022 1/1/2023 2/1/20233/1/2023 Intensive care/higher care beds UHS average number of confirmed COVID-19 patients in an ICU/HDU bed (08:00 census) 12 10 8 6 4 2 0 4/1/20225/1/2022 6/1/20227/1/2022 8/1/2022 9/1/202210/1/202211/1/202212/1/2022 1/1/2023 2/1/20233/1/2023 19 Number of patients Emergency access through the emergency department The Trust continued to experience high demand from patients presenting to receive care in the emergency department throughout the year above that seen prior to the COVID-19 pandemic. In particular, during the period between January and March 2023, the Trust averaged 352 attendances per day compared to 301 during the same period in 2019/20, an increase of 17%. The Trust also saw a significant increase in attendances during December due to both seasonal illnesses, but also due to the prevalence of streptococcus A in the community with attendances sometimes over 400 per day. Furthermore, the industrial action during the latter part of 2022 and early 2023 placed further pressure on the Trust’s ability to deliver services. In addition, the difficulties in discharging patients in need of care either at home or in another setting resulted in reduced flow from the emergency department to the relevant ward(s), which placed further strain on the Trust’s performance. During the year, in order to reduce emergency department attendances, the Trust trialled using General Practitioners to triage and see more straightforward patients who would otherwise have presented to the emergency department. Although this trial did result in a slight reduction in terms of number of patients and waiting times in ambulatory majors and majors, the affordability and value for money of this scheme is under review. Number of patients presenting to the emergency department 16,000 14,000 12,000 10,000 8,000 6,000 4,000 2,000 0 Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 Mar-23 As a result of the increase in demand upon the emergency department, there continued to be a significant adverse impact on timeliness of care. The Trust failed to meet the national target of 95% of main emergency department/type 1 attendances seen within four hours, achieving 64.5% in March 2023, although this performance was above average in England. 20 % standard met Emergency access 4hr standard UHS vs NHSE average Type 1 performance 70% 0 10 60% 20 50% 30 40 40% 50 Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-2 2 Oct-22 Nov-22 Dec-22 Jan-23 Feb-2 3 Mar-23 UH S NHSE average UHS rank amongst NHSE trusts Rank Ambulance handovers are an area of focus for NHS England, with a target of all handovers having to take place within 15 minutes and none waiting more than 30 minutes. The Trust performed well in this area with an average handover time of 17 minutes, having made the conscious decision to ensure that patients did not queue in ambulances at the expense of patients being queued within emergency department majors – thus impacting the Trust’s four-hour target, but meaning that ambulances were not queued outside the hospital as was seen in other areas of the country. Elective Waiting times Demand The year saw a continuation of the trend of increasing elective referrals experienced in 2021/22 following the pandemic, and referral rates continued to be above those seen prior to the pandemic. UHS Accepted Referrals 30,000 25,000 20,000 15,000 10,000 5,000 0 Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-2 2 Oct-22 Nov-22 Dec-22 Jan-23 Feb-2 3 Mar-23 Number of accepted referrals 21 Activity The Trust experienced significant increases in terms of the number of hospital appointments, diagnostic tests and elective admissions during the year, exceeding levels in previous years. The Trust was one of the top performing trusts in terms of its elective recovery programme, achieving an 8% increase in its elective activity during the year when compared to 2019/20. However, performance in this area and in terms of outpatients appointments was negatively affected by the industrial action by nurses, junior doctors and other members of staff, which took place in late 2022 and early 2023 due to the need to cancel non-urgent procedures and appointments in favour of maintaining safe staffing levels in areas such as the emergency department. In addition, the continued presence of COVID-19 as well as other illnesses such as influenza and norovirus placed significant pressure at times on the Trust’s capacity due to the need to implement appropriate infection prevention control measures. Furthermore, difficulties in discharging patients fit to be discharged, but in need of a care package, placed additional strain on the Trust’s capacity. Elective admissions (including day case) Post-COVID-19 pandemic Elective (including day case) recovery (% of same month compared between March 2019 – February 2020) 105% 100% 95% 90% 85% 80% 75% Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 % recovery Outpatient attendances Post-COVID-19 pandemic outpatient seen recovery (% of same month compared between March 2019 – February 2020) 140% 0 90% 10 20 40% 30 Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 UH S UHS rank amongst NHSE trusts % recovery Rank 22 Diagnostics The Trust measures performance on a total of 15 frequently used diagnostic tests. In March 2023, 22% of patients were waiting more than six weeks for diagnostics compared with the national target of less than 1%. Patients waiting for a diagnostic test to be performed (sum of 15 different frequently used tests) UHS diagnostic waiting list volume 12,000 11,500 11,000 10,500 10,000 9,500 Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-2 2 Oct-22 Nov-22 Dec-22 Jan-23 Feb-2 3 Mar-23 Diagnostic waiting list volume Percentage of patients waiting over 6 weeks for a diagnostic test to be performed Diagnostic 6 week wait performance UHS vs. NHSE average 35% 30% 25% 20% 15% 10% 5% 0% Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 Mar-23 UH S NHSE average % standard met 23 Referral to Treatment The Trust continued to see an increase in the number of patients being referred for treatment during 2022/23 with just over 55,000 patients on a waiting list under the 18-week referral to treatment pathway at the end of the year. Averaged across the year, the volume of referrals exceeded the Trust’s theoretical capacity by around 3.5%. Due to this significant demand, the Trust only achieved 63.2% of patients being treated within 18 weeks of referral in March 2023 compared with the monthly target of more than 92%. However, despite this, the Trust remained in the top quartile when compared to other teaching hospitals, reflecting that this growth in demand continues to be a national challenge. During 2022/23, the national target was to ensure that there were no patients waiting over two years for treatment by July 2022, and that there were no patients waiting more than 78 weeks by the end of March 2023. Long-waiting patients were an area of particular focus for the Trust during the year with no reported two-year waits since November 2022 and only two between the period June-November due to patients choosing to delay their treatment. This was a significant improvement compared to the peak of 171 patients reported in December 2021. Similarly, the Trust made progress in reducing the number of patients waiting over 78 weeks for treatment. In February 2023, the Trust reported 84 patients in this category compared to the peak of over 900 patients in September 2021. By the end of March 2023, the Trust had managed to further reduce this number of patients to 14, with those in breach of the target all due to the complexity of the cases. UHS referral to treatment waiting list 56,000 54,000 52,000 50,000 48,000 46,000 44,000 Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 Mar-23 24 Number on waiting list % standard met Percentage of patients waiting up to 18 weeks between referral and treatment RTT 18 week performance UHS vs. NHSE average 70% 65% 60% 55% 50% Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 Mar-23 UH S NHSE average Percentage of patients waiting more than 52 weeks between referral and commencement of a treatment for their condition Number of patients Rank UHS Referral to treatment patients waiting more than 52 weeks 3,000 0 2,500 10 2,000 20 1,500 30 1,000 40 500 50 0 60 Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 Mar-23 UH S UHS rank amongst NHSE trusts % of RTT patients RTT % of patients waiting more than 52 weeks UHS vs. NHSE average 5.0% 0 4.5% 20 40 4.0% 60 3.5% 80 Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 Mar-23 UH S UHS rank amongst NHSE trusts Rank 25 % standard met Cancer Waiting Times The Trust is one of 12 regional cancer centres in the UK offering treatment for rare and complex cancers as well as cancer in children and brain cancer. The Trust has historically been in the upper quartile, relative to teaching hospital peers. Due to loss of key members of staff and industrial action, the Trust’s performance has slipped over the year with 72.5% of patients seen within two weeks in March 2023 following referral by a General Practitioner for suspected cancer (national target: > 93% per month). Cancer waiting times - 2 week wait performance UHS vs NHSE average 100% 0 80% 50 60% 100 40% 150 Apr-22May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23Mar-23 UH S NHSE average UHS rank amongst NHSE trusts Rank Referrals for January to March 2023 were at the highest for that month for the past five years and overall referral volumes in 2022/23 averaged 2,049 patients per month, 8% higher than in 2021/22 and 28% higher than in 2019/20. The national target was for 96% of patients to commence treatment within 31 days of diagnosis. However, in March 2023, the Trust only achieved 87.9%, but this figure hides considerable variation dependent on the tumour site and type of cancer with a range of 100% for haematology and children’s cancers to 71% for skin. The high rate of referrals led to a significant backlog in terms of patients waiting longer than 62 days for treatment. However, the Trust took steps to reduce this backlog by more than 50% through a dedicated recovery programme. In March 2023, the Trust treated 54.8% of patients within 62 days of referral compared to the target of more than 85%. Treatment for Cancer within 62 days of an urgent GP referral to hospital Cancer waiting times 62 day RTT performance UHS vs. NHSE average 80% 60% 40% 20% 0% Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 Mar-23 UH S NHSE average % standard met 26 First definitive treatment for cancer within 31 days of a decision to treat % standard met Cancer waiting times 31 day RTT performance UHS vs. NHSE average 95% 90% 85% 80% 75% Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 Mar-23 UH S NHSE average Quality priorities The Trust set eight quality priorities in 2022/23, which were aimed at ensuring it continued to deliver the highest quality of care. The quality priorities were shaped by a range of national and regional factors as well as local and Trust‐wide considerations. The Trust recognised the overriding issues of significant operational pressures being felt right across the health and social care system, including those associated with the previous two years of the COVID-19 pandemic. The challenge was to deliver the best quality care in the context of these operational pressures, and the Trust set its quality priorities accordingly. Out of the eight priories set, the Trust achieved five and partially achieved three. Priority One: Enhancing capability in Quality Improvement (QI) through our Always Improving strategy The transformation team has grown to over thirty team members including project support officers, project managers, benefit realisation managers. This has allowed the Trust to develop that systematic organisational approach to guide and support its staff in their QI projects. The Trust originally set a target of delivering fifty quality improvement projects but have successfully supported a total of 84 (55 local and 29 flow improvements). These are local change projects which were identified, proposed, led, and delivered by the people who do the work. To date over 1500 people have been trained in the Trust’s improvement approach, which exceeds the original target of 500. The Trust also developed a QI project register and held an Always Improving conference. Priority Two: Developing a culture of kindness and compassion to drive a safety culture The Trust only partially achieved this priority as plans to fully deliver training were affected by operational pressures. However, during the year a variety of communication platforms were used to make sure staff understood the Trust’s vision and were kept up to date with plans and progress. The Trust worked to develop and embed a ‘just culture’ allowing staff to speak up and ask, “what happened and how do we learn?” and developed ‘stop for safety’ staff huddles. Priority Three: We will improve mental health care across the Trust including support for staff delivering care The Trust only partially achieved this priority as several key quality improvement projects have not yet been delivered, and the mental health strategy not yet been finalised. However, a training needs analysis was completed and significant staff training and an education scheme were introduced in response to the findings of the analysis. Mental health champion training has been delivered to 153 staff and IT systems have been improved to help capture vital data to help shape the Trust’s service. 27 Priority Four: Recognising and responding to deterioration in patients During 2021/22 the Trust successfully introduced national Paediatric Early Warning System (nPEWS) into its Southampton Children’s Hospital and UHS is now part of the national test and trial of nPEWS which is assessing the usability of the scoring system. The Trust has also explored how nPEWS can be adapted for children with complex medical conditions requiring interventions (including non-invasive ventilation) as part of their normal care. A daily heat map of escalation times over a 24-hour period was piloted in 2022 and will be rolled out across all adult’s inpatient areas during 2023. The Trust has also performed well with its cardiac arrest audits, and training and education programmes have consistently been delivered. September 2022 saw the implementation of a 24-hour paediatric outreach service. There is a deteriorating patient group and several successful QI projects have been introduced. Priority Five: Improving how the organisation learns from deaths The Trust only partially achieved this priority as it has been unable to establish a learning from deaths steering group. The Trust has introduced a mortality governance coordinator/analyst and grown its bereavement care service. Priority Six: Shared Decision Making (SDM) The shared decision models started at UHS in 2021/22 and have continued to grow with investment in pilot roles to expand these models, which include several advanced nurse practitioner roles, models in paediatrics bringing Shared Decision Making to patients who are transitioning from paediatric to adult services, while in maternity we have introduced SDM in birth planning. When assessing delivery of SDM against NICE guidelines, UHS performs well, especially in targets related to Trust buy-in, governance and practices of pilot areas. This year the Trust has implemented training through key platforms and expanded patient involvement in the project. As a leading site nationally for SDM principles, UHS have worked with NHS England on creating materials for others to learn from. Priority Seven: Working with our local community to expose and address health inequalities During the year the Trust refocused its efforts on making sure that its involvement and participation activities support the health inequalities agenda, while also working to deliver responsive information and advice to patients, carers, and families. Priority Eight: Ensure patients are involved, supported, and appropriately communicated with on discharge During the year the Trust has focused on improved patient, carer and family involvement, and improved communication during the discharge process as well as prompting a more collaborative working between social and health care staff. Strong partnership working with external agencies has been developed to support a system approach to hospital discharge, develop digital solutions, develop the patient hub to support discharge and delivered education to UHS staff. More information can be found about how the Trust delivered and measured its quality priorities, including feedback from patients and staff and improvement aims and quality priorities for 2023/24, in the Trust’s Quality Account for 2022/23. 28 Financial performance The Trust delivered a deficit of £11 million from a revenue position of over £1.2 billion, once items deemed as “below the line” by NHS England, such as the financial position of the Southampton Hospitals Charity, were removed. The Trust was unable to deliver the planned breakeven position. Several material cost pressures were incurred, including unfunded high-cost drugs costs and energy prices. These were unable to be off set in full by a savings programme, despite delivery of £45.6m of efficiencies (2021/22: £15m). Trust operating income rose by £64m from the previous financial year, most notably funding the NHS pay award, as well as additional elective recovery funding. Income reduced from the prior year in relation to ending a nationally funded project regarding testing for COVID-19. The Trust has however been successful in increasing funding for research and development. Trust operating expenditure rose by £78m, incorporating funded inflationary costs as well as the cost pressures outlined above. The Trust has also continued its reinvestment of surplus cash into infrastructure for the Trust, with capital investmen
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