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Aria ePrescribing v13.6 MR1.2 user training guide

Description: Aria E-Prescribing v13.6 MR1.2 User Training Guide Every effort has been made to ensure that the material in this manual was correct at the time of publication but cannot be held responsible for any errors or inaccuracies. We reserve the right to change or replace information contained in the manual without notice. For the most up to date version please refer to the UHS website. All references made to patient records are fictitious for the purpose of training only. Page 1 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager CONTENTS This training guide has been produced as a generic document for the 6 Trust of the former Central south coast cancer NETWORK (CSCCN); it can be used as an aid to producing cascade training guides either by role or profession at each individual trust if required.1 ................................................................General Course Information 2 2 Information Governance....................................................... 5 3 Logging on to Aria ................................................................ 7 4 Creating and Modifying a New Patient ................................. 9 5 Adding Patient History........................................................ 16 6 Patient EXAM..................................................................... 29 7 patient Vital Signs .............................................................. 53 8 PRESCRIBING .................................................................. 60 nb Once prescription Approved by prescriber and pharmacy either prescriber/nurse/pharmacy can move the date without the need to re-issue the prescription. By moving the date this will not produce a different pharmacy order number (yellow file) because no clinical amendments have been made. ................................................... 95 9 Pharmacy........................................................................... 96 10 nurse drug administration ................................................. 115 11 scheduling........................................................................ 127 12 Patient journal .................................................................. 149 13 Logging Off ...................................................................... 151 14 re-setting your Password.................................................. 152 15 Icon Glossary ................................................................... 153 16 Fault Reporting................................................................ 157 17 Help with using Aria ......................................................... 158 18 Version Control LoG ............................................................ 160 Varian have produced two reports for the SACT data; 182 SACT – Public Health Data – Patient Drug Administration Details – 2015 182 SACT – Public Health Date – Patient Drug Dispensed Details - 2015 182 THIS TRAINING GUIDE HAS BEEN PRODUCED AS A GENERIC DOCUMENT FOR THE 6 TRUST OF THE FORMER CENTRAL SOUTH COAST CANCER NETWORK (CSCCN); IT CAN BE USED AS AN AID TO PRODUCING CASCADE TRAINING GUIDES EITHER BY ROLE OR PROFESSION AT Page 2 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager EACH INDIVIDUAL TRUST IF REQUIRED. Page 3 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager 1 GENERAL COURSE INFORMATION COURSE TITLE METHOD OF TRAINING DURATION PRE-REQUISITES E-PRESCRIBING ABOUT THE COURSE The Aria E-Prescribing software is a computer system that is used across the 6 Trusts of the former Central South Central Cancer Network (CSCCN). This course is intended for users who will be prescribing chemotherapy to patients, approving and dispensing chemotherapy in pharmacy and recording the administration of chemotherapy by nursing staff within the Aria application. SUITABLE FOR This manual is suitable for any user requiring access to the Aria system. This includes Clerical and Administration staff, Nursing Staff, Pharmacy staff and Clinicians. OBJECTIVES This course will enable the student to perform the following: 1. To be able to log on and off of the system 2. To record relevant patient history, diagnosis and vital signs 3. To prescribe specific chemotherapy regimens 4. To approve and dispense drugs in pharmacy 5. To be able to record the administration of chemotherapy to patients 6. To be able to enter patients into the scheduling system Page 4 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager 2 INFORMATION GOVERNANCE Information Governance (IG) sits alongside the other governance initiatives of clinical, research and corporate governance. Information Governance is to do with the way the NHS handles information about patients/clients and employees, in particular, personal and sensitive information. It provides a framework to bring together all of the requirements, standards and best practice that apply to the handling of personal information. Information Governance includes the following standards and requirements: Information Quality Assurance The NHS Confidentiality Code of Practice Information Security The Data Protection Act 1998 Records Management The Freedom of Information Act 2000 Caldicott Report December 1997 What can you do to make Information Governance a success? Keep personal information secure Ensure confidential information is not unlawfully or inappropriately accessed. Comply with the Trust ICT security policy and Staff Code of Confidentiality. Do not share your password with others. Ensure you "log out" once you have finished using the computer. Do not leave manual records unattended. Lock rooms and cupboards where personal information is stored. Keep personal information confidential Only disclose personal information to those who legitimately need to know to carry out their role. Do not discuss personal information about your patients/clients/staff in corridors, lifts or the canteen Ensure that the information you use is obtained fairly Inform patients/clients of the reason their information is being collected. Organisational compliance with the Data Protection Act depends on employees acting in accordance with the law. The Act states information is obtained lawfully and fairly if individuals are informed of the reason their information is required, what will generally be done with that information and who the information is likely to be shared with. Make sure the information you use is accurate Check personal information with the patient. Information quality is an important part of IG. There is little point putting procedures in place to protect personal information if the information is inaccurate. Page 5 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Only use information for the purpose for which it was given Use the information in an ethical way. Personal information which was given for one purpose e.g. hospital treatment, should not be used for a totally separate purpose e.g. research, unless the patient consents to the new purpose. Share personal information appropriately and lawfully Obtain patient consent before sharing their information with others e.g. referral to another agency such as, social services. Comply with the law The Trust has policies and procedures in place which comply with the law and do not breach patient/client rights. If you comply with these policies and procedures you are unlikely to break the law. Page 6 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager 3 LOGGING ON TO ARIA Access to Aria is via a Citrix connection. However local Trust policy will govern how much you see of this login process. Most trusts will have an Icon on the desktop which will take them to the login boxes below. Type in your user ID in the User ID field Type password in to the Password field Select the appropriate institutions in the ‘From’ and ‘Login To’ drop down boxes. The ‘From’ field will always need to be CSCCN The ‘Login To’ field will define what work location you are logging into. For example, what Ward or Clinic do you wish to work in? Click OK On subsequent logins the above ‘From’ and ‘Login to’ fields will be pre-filled as the system remembers what you last logged into. This can be changed at any point. On your first login you will be required to change your password from the one issued to you with your username. The following box will display: Page 7 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager There are certain parameters that need to be observed when creating a new password. These are: The password must be between 6 and 10 characters long have a letter as the first character be mixed case contain at least 2 numeric's be unique from the previous 5 passwords Examples of how acceptable passwords may look are below: Sunsh1ne1 Sunshine01 sunSh11ne On your first login you will also be required to confirm your details are correct within the Aria System. DO NOT CHANGE any details in this box. If there are any changes that need to be made contact your local IT Support who will look into it. Click ok. Page 8 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager 4 CREATING AND MODIFYING A NEW PATIENT When logging into Aria Manager, the first window you see is the ‘Open Patient’ window. It is also possible to add patient status icons to appear attached to the patient record on the open patient window and other screens. Select Patient Workup – Patient Status icon from drop down menu Two icon that may be useful would be C/R (Concurrent Chemo-Rad) and Ambulance that could be used to indicate transport. Page 9 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Eg Chemo-Rad and Transport have been added to this patient and the icons appear on the top right of the screen The ‘open patient window’ shows all the patients who have been entered into Scheduling or who have had a ‘chart’ opened today. By highlighting a patient and then clicking on blue tick the following Patient Tracking window opens (actual Institution list may vary). Page 10 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager By highlighting a patient and then right clicking on it a brief Patient Information window appears By clicking on the clipboard icon (to right next to bar code) a list will appear of the last 15 patient charts opened by the user. Page 11 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager In this window you can add New patients or Modify an existing patient – click on the relevant button on right of screen. Either New, Modify or View. In most cases within the network the requirement to add new patients to the Aria system will not be needed as there will be a data feed from the local Patient Administration System that will populate it. However, to create a new patient click ‘New’ on the right hand side of the screen. This will open the Modify Patient Window. DO NOT create a patient on Aria if there is a PAS data feed within your Trust as this may create duplicates on the Aria database. In the event of duplicate patient entry found please contact system administrator (d.kimber@nhs.net or Debbie.wright@uhs.nhs.uk) who will investigate and contact Varian if required. Page 12 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Patient Modify window The Tabs are: General – Where name, DOB etc… is stored Patient IDs – contains NHS, Hospital etc… Temporary Address Contacts – Next of Kin details etc… Demographics – Patient personal details for example Ethnicity and Religion. This screen is useful to record Advance Directives such as ‘Organ Donor’ and Feeding Restriction alerts. Providers - Details of patient’s Consultant – needed for SACT report Referrals – Details of referring clinician unlikely to be used Photograph – Unlikely to be used within the NHS General Tab To enter a New Patient the same will appear but it will be a blank template You can enter details in any of the tabs, much of this information will be imported by the PAS interface, but anything can be updated or amended. Page 13 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Patient IDs Tab In this window the NHS number will always appear along with any internal hospital ID. If appropriate you can also add a CDF PT ID, a Private PT ID or a Study #. Temporary Address and Contacts can be amended as necessary. Demographics Tab Demographics – any of these can be amended, the down arrow on right of a field means a drop-down list will appear. Advance Directives, if yes then you can tick any of these and they will appear later on. Page 14 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Provider Tab Providers must be completed, top box is the consultant and the bottom box is the GP – this may, or may not, come over from PAS. When the Provider is added in this window it will automatically populate the Visit Provider in Scheduling. This field is required in many reports. NB Relationship must be entered as Consultant for GMC number to populate in SACT and other reports Page 15 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager 5 ADDING PATIENT HISTORY Once you have your patient in the system then you need to add some History. Highlight the patient, you can change the first window you view by amending the ‘Proceed to’ button on the top right of screen (next to bar code) e.g. Patient History. Click Open…button on top right The patient has opened in the Patient History window because that is what was selected under Proceed To. The second tool bar has now become available to use (starts Chart, History etc). If history wasn’t the default page then it can be selected by clicking on History (3rd button from left on top tool bar). The main sections to be completed are: Medical Procedure / surgical Family Social Allergies – this is essential Medications – this is essential Page 16 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager As information is entered the tab will change to blue in colour. Medical – this shows and then can be amended as necessary. Procedure/Surgical can also be entered here. Page 17 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Family – this window opens and then can be updated. Page 18 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Social – following window opens to be updated Allergies and Medications can be entered and this will then work in conjunction with the First Data Bank to look at drug interactions. Allergies – following window opens to be updated Page 19 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Click on New, select the Type eg Drug Page 20 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager For Drug allergy, start typing the drug name in the Allergy box eg asp and then click on the torch button (right of screen) Page 21 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager A list will of drugs will appear, select drug required eg penicillin V (tablet oral), OK Page 22 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Page 23 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Tick the Response or Other which will give a text box for comments. Click OK or Save – New to add another drug if necessary. The allergies will now appear on the Allergies window Page 24 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager If no allergies tick “No Known Allergies” – these icons will be seen in numerous screen indicating whether an allergy has been recorded, no known allergy or no allergy information has been recorded. Medications – following window opens to be updated Page 25 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Click New (bottom left) to add new medication, the following window will open Type in the start of the drug and then click the torch to search the First Data Bank and enter all relevant details, those will down arrows contain drop down selections. It is sufficient to only add the drug name because this is used to Page 26 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager check for drug interactions, contra indications etc, dose and frequency is not necessary. Click OK and drug now appears, this screen will also show any chemotherapy agents the patient is/has received. Page 27 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Page 28 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager 6 PATIENT EXAM Once the patient has History updated the following stop is to enter Exam. Open the patient, from Open Patient window, you can change the Proceed To to Exam and then Exam window will open or if you Proceed To another window e.g. Patient History, the second Tool Bar will be highlighted and then select Exam (6th button from right), the following window will open. NB if you add Diagnosis/Problems via the History window you will not see the prompt for Performance Status, therefore it is recommended that you always use the Exam window when entering a diagnosis. Click New.., the following window opens Page 29 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager In the Code section, click the magnifying glass on the right and the following window opens Page 30 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager This code type is ICD-10. In the search criteria select either Code or Key words, by selecting Keywords and typing lung the following appears Select the correct Clinical Description eg C34.2 Malignant neoplasm of bronchus or lung, unspecified and the following appears Page 31 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager The Definition page has now opened, and any of the white boxes can now be updated. There are also four other “tabs” now available Pathology – includes Cell Histology which is required to populate morphology in the SACT report Lesions Staging – required for SACT report Tumour Markers Pathology – following window opens Page 32 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Pathology Item Select Cell History (morphology for SACT) – following window opens to be updated Page 33 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Cell Category – drop down menu Cell Type drop down will populate once cell category has been selected Page 34 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Cell Grade drop down Page 35 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Lesions – open the following window Click New in either Local Lesions or Metastatic Lesions and the following window opens Local – Page 36 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Metastatic – Page 37 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Staging – opens the following window Click New (left of screen), some disease site staging will also have G (grade), all Criteria must to be completed to give Stage of the disease Page 38 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Select Tumour eg T1 and add a date into the Date Staged box To get a complete staging also enter assessments for both nodes and metastasis; ensure a date is entered into the Date Staged box. Page 39 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Nodes Metastasis Page 40 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Click Approve and the information now appears as follows Click Save (left of screen). If you click Close you will be asked it you want to save changes as well. Page 41 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Click Close (right of screen) and the information appears on the Diagnosis / Problems window Page 42 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager RoS/PE – Review of Symptoms/Physical Exam – review of symptoms window opens Page 43 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Click Assess and the following window opens Select system(s) and disease site(s), click OK. It is advisable to tick all as normal and then only tick Abnormal to those that apply, as below Page 44 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Click Approve and the following appears on the ROS/PE window. You will see that the abnormal symptom appears with a red A. Page 45 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Physical Exam – following window opens Click Assess and the following window opens Page 46 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Select system(s) and disease site(s), click OK. It is advisable to tick all as normal and then only tick Abnormal to those that apply, as below Page 47 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Click Approve and the following appear in the Physical Exam window, again showing any abnormal PE with a red circle. Page 48 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager NB: Both RoS/Physical Exam list can be customised by each Provider to show a shorter list if required. This is carried out in Manager (System AdminProvider/RoS Exam Defaults – select the Provider then Sites) Performance Status – the following window will appear Select Scale from drop down Page 49 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Select Performance Status from drop down Page 50 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager The following appears Click Approve and the information now appears on the Performance Status window Page 51 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Page 52 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager 7 PATIENT VITAL SIGNS Once Exam has been completed the next step is Vital Signs. In ‘Open Patient Window’ click to Open a highlighted patient, the second Tool Bar will then be available and click on Vital Signs, the following window will open. Enter the information; ALWAYS enter height and weight to calculate the BSA required to calculate drug doses. If a result is entered that is outside of the range set (see values in brackets) then alerts will be show; H = high value L = low value LL = very low value Alarm bell icon – can view extra information by clicking on it Page 53 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager See window below By clicking on the “pen” icon to the right of each line you can view Result History (selected from the drop down menu) Results can also be viewed in the Flow Sheet (click icon in second row) Page 54 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager If you right click on any of the results you can also View Details eg BMI shows Page 55 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager You can also see the doses of each drug administered and the toxicities recorded. NB Each drug has to be administered in the Drug Admin window to appear in the Flow Sheet Dose Recordings, therefore it is important that nurses do complete the drug administration. With a pathology interface you will also be able to view results in this window. Page 56 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager If a result has been entered incorrectly and then “errored” you can view the results by selecting Assessments from the top row, then Tests from the drop down menu and select the required date eg Dec 23, 2015 Select View from the Results section at the bottom of the screen Page 57 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Click ERR Result Set (top right of screen) to view the errored result Click on the E to view Reason For Error By clicking on the “pen” icon in the Results View window and selecting Result History from the drop down menu you can also view history eg Result History: Height Page 58 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Once all the details for the patient have been entered then treatment can be allocated. You must check you have completed the following data before you can enter any treatment for the patient; Modifying patient details/ entered new patient details History – including allergies Exam – including diagnosis / morphology / staging / performance status Vital Signs Once all the above have been entered then open the patient , change ‘Proceed To’ to Medication and open the patient, the following window will appear you can then select the treatment required, from the diagnosis already entered the list will then filter by disease site e.g. lung, breast etc and show the regimens entered in those disease areas. Page 59 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager 8 PRESCRIBING The system will default to regimens assigned to patient diagnosis No BSA (right of screen) indicated that no Vital Signs have been entered Eg for a lung diagnosis the following will appear in top box with sub folders, if applicable eg SCLC, NSCLC and mesothelioma Page 60 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Click the folder to show the regimens for lung NSCLC Select the regimen required, the following will appear Page 61 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager You can see that this is the first cycle, see Cycle on right of screen. NB: Information page (right of screen below Cycle box) – this is the protocol summary, however from October 2010 protocol summary will no longer be shown here. You can view protocols by clicking Applications – Protocols (top row of the screen) this will then open the UHS website page which contains protocols. Alternatively you need to view the protocol please refer to UHS website (http://www.uhs.nhs.uk/HealthProfessionals/Extranet/Services/Cancercare/Chemotherapy-protocols/Chemotherapy-protocols.aspx ) Select Blue square in select box on right of screen to select all the Order button will be available and a tick will appear in the Day 1 and Day 8 box (or manually tick Day 1 and/or Day 8). Day 1 + 8 can be ordered at the same time as two separate files will be produced for pharmacy orders. Page 62 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Click Order…, if no value is present for creatinine the following message will appear NB although creatinine result might be available via pathology interface it needs to appear after height and weight have been entered to be able to calculate the dose, therefore at cycle 1 it may be necessary to enter the result manually. Click CrCl button on right of screen and enter the Creatinine result in this window, then Approve Page 63 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Now select Order on top right of screen you will see the Dose Calculation Management pop up box to enable the height, weight and BSA to be reviewed Page 64 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Enter consultant in Ordered by, and complete Line of Tx, Tx Intent and Tx Use (these are required for SACT report) Page 65 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager By highlighting one of the drugs more buttons will become available on the right of the screen, as below To change the date for the whole regimen – click on the calendar page next to Start on below the Ordered by box. To change the date for an individual agent – click Adjust Start on right of the screen, and then select the required date. Page 66 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager By highlighting an agent and then clicking on the up and down arrows on the bottom right of the screen you can change the order of an agent. OR By clicking the “pen” icon (next to the Approve box) you can change the order of an agent eg move pre-medication to the top of the list, change the Rx Seq # to the correct order. You can now add any support eg extra antiemetic support (that are not already included as part of the regimen) or favorites eg antibiotics, as required. Click Favorites and the following window appears Page 67 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager A list of files will appear eg antiemetics, antibiotics, skin care etc, click the file to open and the list of drugs in that file will appear. Page 68 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Select the drug required and click Add to add it to the regimen. Support – click the support tab on top right, and the following window appears The support regimens have been set up in files. Click the yellow file and a drop down will appear (the same way treatment is allocated) Click on TTO Levomepromazine and the support regimens will appear. Page 69 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Tick the regimen (the same way treatment is allocated) and click Add to add to the regimen. NB – some support regimens selected here need to be added to each cycle individually they have not all been set up for cycles of treatment only courses eg 21 days. (see Appendix 2 and 3). You can Adjust Dose, Adjust Start etc. It is advisable NOT to adjust any drug dose using the Modify button only use the Adjust Dose button. Any dose banding will be removed if the dose is amended in the Modify window. Dose banding is only applied when using Adjust Dose button. Click Adjust Dose and the following window appears Page 70 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager You can select Dose Modification from the top line eg 75%, 50% etc however this will reduce all agents including any antiemetics that have been prescribed unless you select Change Chemo. Therefore it is advised to dose reduce per agent and remember to include a reason in the Modification Reason, either by clicking on the drop down arrow or entering text in the bottom right text box. In the Calculation / Rounding column the red dots denote dose rounding and the red circle dose banding has been applied to that particular agent. You will see that gemcitabine has been reduced to 75% of the original dose and the reason given was infection. Page 71 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager This message will appear when agent appears in more than one day of the cycle. The Order / Rx page now shows the dose reduction to 75% in red and at the end of the drug line the Dose Mod. Reason has a page with lines on it. Page 72 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager If the drug has been set up with dose banding (eg gemcitabine) when you Adjust Dose a red circle appears next to the Calculation/rounding dose Page 73 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager By clicking on the red circle you can view the dose banding table set up for the drug dose eg gemcitabine The red dot with a number indicated the agent is rounded to the nearest eg carboplatin in this regimen is rounded to the nearest 50mg If no “rounding” match is found for an agent then the default rounding is used; Up to the nearest 1 for calculated doses > =10 Up to the nearest 1/100th (0.01 decimal place) for calculated doses <10 Page 74 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager When ordering subsequent cycles you can view the previous doses from the last cycle Click on the note pad to the left of Last Ordered This shows the dose of current order at the top and the dose of the last order at the bottom. Once all drug doses are correct then the prescription has to be approved. Page 75 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Click the Approve button on the bottom of the screen and the following User Authentication will appear – this is the prescriber electronic signature Click Ok the First Databank Interaction Screening window appears Click Accept the printing window will appear select Internal to print agents for administration in hospital, select Pickup-Internal for TTOs or both as appropriate. Page 76 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager If you click Cancel at this point the prescription is put as “pending” in the Orders/Rx window, and a prescription will not be printed despite the printing box just having appeared on the screen. However when the treatment is “approved” the prescription will print (along with any that you “cancelled” at this point previously eg if you clicked Cancel twice 3 prescriptions will print one for each of the cancelled actions and the actual approved one – they will however all be the correct version) Although you can only see the oral dexamethasone all the drugs have been approved. In this window you are approving the prescription to be printed either to pharmacy, in clinic etc. Click Approve and the following window appears (Treatment) Page 77 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager By clicking on the pen in the Treatment box (next to 4 x 21 days) you can Modify / Delay / Discontinue / View Regimen decisions Modify – This currently shows the Active treatment days. Page 78 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Day 8 treatment can be omitted by clicking Inactive on the required drug Page 79 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Alternatively by clicking Custom you can state which cycle to Inactivate You need to click the speech bubble (next to Ordered By) before this action can be approved (NB the speech bubble only appears for a non-prescriber). Page 80 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager NB: Any notes that are entered when using the “speech bubble” do not show again anywhere on the screen in Aria but are kept in the database, they can only be viewed by a Varian database analyst if requested to do so for a full patient history audit. Therefore Varian suggests using the patient Journal (see section 12) which is aimed at being a running commentary of patient events. Click Ok and then Approve button will appear so that any modification can be approved. Page 81 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager This message will appear if no reason for making change is entered When back in the Treatment window the Inactive days will be shown in red. Page 82 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Delay – If a prescription has been Approved and Dispensed then use Delay here to move treatment date. You cannot Re-issue the prescription once dispensed. Also add a comment to the patient journal to record this action (see section 12). Page 83 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Ordered by must be selected and again the speech bubble (top right) must be completed before this action can be approved eg delay for 1 week Click OK then approve, the delayed regimen will show “delayed” in red against it Page 84 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager If any agent has been missed off or there is a need to add another agent after the treatment has been approved, click New (top right of screen) and then add the Favorite/Support as required. Page 85 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager This will now show as “Other Drugs Ordered”. Page 86 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager If you need to add any additional information to an agent eg actual start date for GCSF – highlight agent Click Modify The Admin Instructions box on the bottom left of the screen contains the information that will print of any prescription. Therefore enter the start date in the Admin Instructions box. Page 87 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Click OK Discontinue – the following message will appear By clicking yes the following box will appear, as above click the speech bubble before approving. Page 88 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager NB – If you are discontinuing a regimen but there are still agents to be administered ensure you select the correct dose recordings you wish to discontinue. It may be that you need to select “Starting from effective date ... “ to enable to the remaining agents from the cycle to be administered. Once approved the following will appear Page 89 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager By clicking on the medication history you will see all previous treatment. Page 90 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager A patient must have treatment discontinued before any new treatment can be allocated. NB – any extra antiemetic support medication associated with the treatment must also be discontinued BEFORE the treatment, it will not automatically be discontinued with the treatment, you need to select each regimen and discontinue as above. To delete an agent in a regimen: By highlighting an agent the Delete button becomes available (NB it is preferable to delete rather than discontinue to enable ability to “undelete” the agent in future cycles if necessary). This confirmation message will appear. Page 91 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager The deleted agent appears on the Orders/Rx window scored out and also when Approved in the Treatment window Page 92 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Another useful way of finding information about the current treatment is in the Treatment window; by clicking on the pen icon at the end of each line you can view information about each drug for each specific day of each cycle, the same information can also be found in Flow Sheet (see section 7). For example, gemcitabine - shows dose given, the red cross indicates not Dispensed For example gemcitabine - indicates a drug modification any Dose Mod Reason can be viewed by clicking on page to show any reason entered. Page 93 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager NB a red star appears next to Ordered if the dose administered in Drug Admin differs from that Approved by the prescriber, the reason for this may be that pharmacy made an amendment when dispensing the drug, which would follow through to the Drug Admin window but would not change the original prescribed dose. For this amended dose to appear in future cycle the prescriber would need to adjust the dose in the Treatment window. If a prescriber has Approved treatment and then wishes to amend any part of the prescription, in the Orders Rx window the order can be re-issued (5th button down on right of screen) causing the treatment to be put back into a Pending state for the prescriber to amend and then Approved in the usual. Page 94 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager However a prescription cannot be re-issued if pharmacy has already dispensed it, it would need to be discontinued or ‘un-dispensed’ by pharmacy. If only the dates need changing this could be carried out in the Drug Admin window (see section 10). NB Once prescription Approved by prescriber and pharmacy either prescriber/nurse/pharmacy can move the date without the need to re-issue the prescription. By moving the date this will not produce a different pharmacy order number (yellow file) because no clinical amendments have been made. Page 95 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager 9 PHARMACY Suggested order for pharmacy screening; Check patient journal to look at any relevant information entered by doctor, nurse, pharmacy etc Check bloods in flow sheet Check doctor approval time Pharmacy approve – check doses, can “review” prescription and screen Pharmacy dispense Once all the treatment has been approved pharmacy then need to review and approve the prescription. Click the Orders / Rx tab to open the following window (NB at this point the prescription can be re-issued back to the prescriber should any amendments be necessary – click Reissue button) You will now see that this treatment has been approved, if you click on the A after Approved you will see who prescribed (created), approved, signed (electronic authorisation box) and last modified the treatment (Prescription Order Audit Report). Page 96 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Click on the yellow folder in the Order # column to open the treatment Click Review tab on the right to review the prescription details in pharmacy Page 97 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager View on the top tool bar will show all users who have accessed the patient record (select View - Access Log from drop down menu) – it shows user with date and time. Page 98 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager By clicking on the Rx button (right of screen) you can show the BSA (Dose Calculation Management) If “Cap” appears because Aria has capped the dose at 2.4m² you can click “Actual” OR “Cap” to switch between them should you have a large patient that you do not want to cap at 2.4m². You cannot reduce the capped dose to 2m² at this point the prescriber would need to “modify” the dose in the treatment window. By clicking the Screen… button on the right of the screen the following window appears, this links to the First Data Bank drug system showing interactions, contraindications, warnings etc. Page 99 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Once pharmacy has reviewed the prescription it then needs to be approved and dispensed by pharmacy. Page 100 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Click on Pharmacy Approve button on the right of screen, following window appears Click on the yellow file to open the treatment, as below Tick the box next to the prescription and then click the Checked Approve button. Page 101 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager A button = Ordered by Audit eg prescriber By clicking on the Rx √ button you can see who approved the treatment in pharmacy This is for all agents you cannot select individual agents therefore when you see the Rx √ it means that the whole prescription will be approved and therefore OK to dispense. To dispense the prescription in pharmacy click the Pharmacy Dispense button, the following window appears Page 102 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Click on each yellow folder to open each drug, the Admin Date will appear Click the Dispense button on bottom left of the screen, the following window appears Page 103 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager At this point, if necessary, a pharmacy batch number can be added in the Drug Lot # field eg 124578 This can then be viewed by nurses in the drug admin window Any additional dispensing comments can be added in the note pad at the end of each agent, this can also be view by nurses in the drug admin window by clicking on the page icon next to Dispensing Page 104 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager At this point, if necessary, a drug dose could be modified by pharmacy, click Modify Dose button for the specific drug to be modified and the following window will appear. However this function should only be used as a last resort ie for compounding error so that the nurse drug administration screen is correct for the agent/vehicle supplied by pharmacy eg prescribed volume was 250ml but 500ml has been made or needs to be substituted to reduce wastage. It would be better to re-issue the prescription back to the prescriber to make any amendments. Page 105 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager When this Aria message box appears select No – this is because may agents have been set up as non standard Form/Route when dose banding was applied and if you click Yes you will be selecting a non dose banded agent. The reason for the dose modification can be entered and then will appear with a red star against each modified line. Page 106 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager The modification information can be viewed by clicking on the page button next to the red star and the following will appear as Dispensing Comments. Click Approve button on button right of screen this will return to the Prescription Dispensing window and the Dispensing details modified star now appears and the treatment is now showing as Dispensed Page 107 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager A button = the audit button in this window shows who has “dispensed” each agent Page 108 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager You can print the prescription from this screen by clicking on the printer button at the botton, the following window appears, select Prescription Type You can check the printer by clicking on the yellow folder/printer icon on top right Page 109 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Pharmacy can view all treatment for a day or date range by clicking on Pharmacy button on the top Tool Bar, select Pharmacy Dispensing on the drop down that appears and the following window appears This is colour code to show when orders have been approved. Page 110 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Select Show Prescription Details at the bottom to show order and administration date and pharmacy status Click the “magnifying glass” icon to show the treatment Page 111 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Highlight the line below the patient name if the Rx box is showing then the following window will appear showing the Pharmacy Approval Details. If a patient is highlighted by clicking on the yellow file with red arrow on the far right of the screen that patient’s treatment window will open and the following will appear which takes you straight to the Orders / Rx details. Page 112 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Where patient scheduling is being used for patients prescribed treatment in Aria then Pharmacy can also view a list of treatment by selecting Pharmacy on the top Tool Bar, and then Schedule Drug Orders from the drop down list, the following window appears Page 113 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager There are several different filters on the top of the screen that can be applied e.g. date, Sort By and Drug To View either by Ordered, Pending or Planned e.g. select Ordered and click Show Orders the following list appears This can be printed off in pharmacy if necessary. Page 114 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager 10 NURSE DRUG ADMINISTRATION Once the pharmacy have dispensed the medication then the nurse needs to do the drug administration, to open click the Drug Admin button on the second Tool Bar, the following window appears The patient Date of Birth can be seen after the name and gender on the top right of screen above Dose Recordings tab By clicking View on the top bar you can check patient demographics. By highlighting an agent and then clicking on the up and down arrows on the bottom right of the screen you can change the order of an agent. The days of administration can be amended by clicking Adjust or Adjust All buttons on the bottom on the screen, the following window appears. However this should not be used routinely but only as a last resort if not previously adjusted by the prescriber. Page 115 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager This can be adjusted by Days or Date, if Date is selected the current date and a calendar will appear next to the Days to Adjust box. Page 116 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Click Adjust (top right of screen) and the Admin date will change Click OK and the screen will return to the Drug Administration window Page 117 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Highlight the drug to be administered and click Record button on bottom left of screen, the following appears Page 118 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager You will see any Drug Lot # if entered by pharmacy when dispensing. If you click on page icon next to dispensing you can also view any pharmacy comments. Enter the time of administration and click OK, the screen will return to the Drug Administration window and a C will appear to the left of the date, showing the treatment has been started but not completed. Page 119 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager To enter the end of administration, highlight drug, click Record and enter the end time and click Approve the Drug Administration window is now only showing agents still to be administered. Page 120 of 182 Version 1 December 2015 D Kimber Network
Url: /Media/UHS-website-2019/Docs/Chemotherapy-SOPs1/User-guides/Aria-ePrescribing-v13.6-MR1.2-user-training-guide.pdf

Recipe book - For toddlers who need to make the most of every mouthful

Description: RECIPE BOOK For toddlers who need to get the most out of every mouthful Contents 04 Acknowledgements & introduction 06 Questions, tips & answers 12 Table 01: F
Url: /Media/UHS-website-2019/Docs/Services/Child-health/DietaryAdvice/Recipe-book-For-toddlers-who-need-to-make-the-most-of-every-mouthful.pdf

Annual report 2021-2022

Description: 2021/22 Incorporating the quality report University Hospital Southampton NHS Foundation Trust Annual Report and Accounts 2021/22 Present
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Annual-reports-and-quality-accounts/Annual-report-2021-2022.pdf

DVdSC (weekly cycles1-8) Bortezomib-Daratumumab-Dexamethasone Ver1

Description: Chemotherapy Protocol Myeloma DVd SC (weekly cycles 1-8) Bortezomib-Daratumumab-Dexamethasone Regimen • Myeloma – D
Url: /Media/UHS-website-2019/Docs/Chemotherapy-SOPs1/Myeloma/DVdSC-weekly-cycles1-8-Bortezomib-Daratumumab-Dexamethasone-Ver1.pdf

Ready steady go programme: Easy read booklet - patient information

Description: Easy read information about the Ready steady go programme
Url: /Media/UHS-website-2019/Patientinformation/Childhealth/ReadySteadyGo/Ready-steady-go-programme-Easy-read-booklet-2459-PIL.pdf

Papers Sept 2020 held in closed session due to Covid-19

Description: Date Time Location Chair Agenda - Trust Board Meeting 29/09/2020 9:00 - 16:00 Microsoft Teams Peter Hollins 1 Chair’s Welcome, Apologies and Declarations of Interest 9:00 To note apologies for absence, and to hear any declarations of interest relating to any item on the Agenda. Minutes of Previous Closed Meeting held on 27 August 2020 (Not for publication) Matters Arising and Summary of Agreed Actions (Not for publication) OPEN ITEMS (For publication) 2 QUALITY, PERFORMANCE and FINANCE 2.1 Patient Story To receive feedback from patients, carers, or other stakeholders about their experience of the Trust's services. 2.2 Briefing from Chair of Charitable Funds Committee for review (Oral) 9:15 Dave Bennett, Chair 2.3 Briefing from Chair of Finance & Investment Committee for review (Oral) 9:20 Jane Bailey, Chair 2.4 Briefing from Chair of People & OD Committee for review (Oral) 9:25 Jenni Douglas-Todd, Chair 2.5 Integrated Performance Report for Month 5 for assurance 9:30 To review the Trust's performance as reported in the Integrated Performance Report Sponsor: Paula Head, Chief Executive 2.5.1 10:15 Access Targets: Cancer Trajectory Update for review Sponsor: Joe Teape, Chief Operating Officer 2.5.2 10:25 ED Performance & Recovery Plan Update for review Sponsor: Joe Teape, Chief Operating Officer 2.6 Violence and Aggression Progression Report for review 10:40 Sponsor: Joe Teape, Chief Operating Officer Attendee: Sandra Hodgkyns, Head of Security/Emergency Planning (LSMS) 2.7 Workforce Race Equality Standard (WRES) and Workforce Disability 10:50 Equality Standard (WDES) Annual Reports 2019/20 for review and Action Plans 2020/21 for review Sponsor: Steve Harris, Chief People Officer Attendee: Gemma Genco, Head of Equality, Diversity and Inclusivity 2.8 Black, Asian and Minority Ethnic (BAME) Experience Improvement Plan 11:05 for approval Sponsor: Steve Harris, Chief People Officer Attendees: Gemma Genco, Head of Equality, Diversity and Inclusivity/ John Norton, Chair, BAME One Voice Network 2.9 Finance Report for Month 5 for review 11:20 Sponsor: David French, Chief Financial Officer 3 CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 3.1 Feedback from Council of Governors' meeting 1 September 2020 (Oral) 11:35 Sponsor: Peter Hollins, Trust Chair 3.2 Register of Seals, and Chair's Actions for ratification 11:45 In compliance with the Trust Standing Orders, Financial Instructions, and the Scheme of Reservation and Delegation. Sponsor: Peter Hollins, Trust Chair 4 Follow-up Discussion with Governors 11:50 5 To note the date of the next meeting: 29 October 2020 in the Conference Room, Heartbeat/Microsoft Teams (Closed meeting only) 6 Items Circulated to the Board for reading 6.1 CRN: Wessex 2020/21 Quarter 1 Performance Report Sponsor: Derek Sandeman, Chief Medical Officer Page 2 2.5 Integrated Performance Report for Month 5 for assurance 1 Integrated Performance Report 2020-21 Month 5 Report to the Trust Board of Directors dated Tuesday 29 September 2020 Title: Agenda item: Sponsor: Date: Purpose Issue to be addressed: Integrated Performance Report 2020/21 Month 5 2.5 Chief Executive 22 September 2020 Assurance Approval or reassurance Y Ratification Information This report is intended to support the Trust Board in assuring that: • the care we provide is safe, caring, effective, responsive and well led in the context of the Covid 19 pandemic • at the same time we continue our journey toward our vision of World Class Care for Everyone. Response to the issue: For the year 2020/21 the Integrated Performance Report has adapted to reflect the current operating environment. In particular we have aligned it with the Care Quality Commission Key Lines of Enquiry and then cut it again to reflect delivery of our Strategic Goals and annual corporate objectives. Implications: This report covers a broad range of trust services and activities. It is (Clinical, Organisational, intended to assist the Board in assuring that the Trust meets regulatory Governance, Legal?) requirements and corporate objectives. Risks: (Top 3) of carrying This report is provided for the purpose of assurance. out the change / or not: Summary: Conclusion This report is provided for the purpose of assurance. and/or recommendation Page 1 of 24 Integrated KPI Board Report covering up to Aug 2020 Sponsor - Andrew Asquith, Director of Financial and Productivity Improvement, andrew.asquith@uhs.nhs.uk Page 2 of 24 Chart Type Cumulative Column Example Cumulative Column Year on Year Line Benchmarked Line Percentiles Control Chart Variance from Target Report Guide Explanation A cumulative column chart is used to represent a total count of the variable and shows how the total count increases over time. This example shows quarterly updates. A cumulative year on year column chart is used to represent a total count of the variable throughout the year. The variable value is reset to zero at the start of the year because the target for the metric is yearly. The line benchmarked chart shows our performance compared to the average performance of a peer group. The number at the bottom of the chart shows where we are ranked in the group (1 would mean ranked 1st that month). A line percentiles chart is used to represent the distribution of a variable. The 50th percentile shows the median value, we also show the 5th, 25th (lower quartile), 75th (upper quartile) and 95th centiles. A control chart shows movement of a variable in relation to it's control limits (the 3 lines = Upper control limit, Mean and Lower control limit). When the value shows special variation (not expected) then it is highlighted green (leading to a good outcome) or red (leading to a bad outcome). Values are considered to show special variation if they -Go outside control limits -Have 6 points in a row above or below the mean, -Trend for 6 points, -Have 2 out of 3 points past 2/3 of the control limit, -Show a significant movement (greater than the average moving range). Variance from target charts are used to show how far away a variable is from it's target each month. Green bars represent the value the metric is achieving better than target and the red bars represent the distance a metric is away from achieving it's target. 2 Page 3 of 24 Report to Trust Board in September 2020 Introduction The Trust Integrated Performance Report is presented to the Trust Board each month. For the year 2020/21 the Integrated Performance Report has adapted to reflect the current operating environment. In particular we have aligned it with the Care Quality Commission Key Lines of Enquiry and then cut it again to reflect delivery of our Strategic Goals and annual corporate objectives in order to: • Demonstrate that we can assure ourselves that the care we provide is safe, caring, effective, responsive and well led in the context of the Covid 19 pandemic • Ensure that at the same time we continue our journey toward our vision of World Class Care for Everyone. We might adjust/ or add to these indicators – informing the Board and keeping a comparative narrative – if the situation changes as we work through these unusual circumstances. An example of this might be measuring vulnerable groups as the evidence around COVID emerges. The monthly Trust Integrated Performance Report is currently complemented by a ‘Covid-19 Balanced Scorecard’ which is considered by the UHS Integrated Assurance Group, and also available to Board Members, on alternate weeks. August 2020 Summary During August the direct impact of Covid 19 infections upon the Trust continued to reduce. The number of beds occupied by patients with Covid 19 remained in low single figures and at times there were 0 Covid 19 inpatients. Over a 2 week period we tested 0 positive staff or patients. Covid 19 in the local community also remained low, with infection rates estimated at 4-7 per 100,000. Non-elective admission volumes in total remained at approximately 90% of their normal levels. Elective spells increased to approximately 72% of their normal levels. Elective activity continued to be adversely affected by the need to socially distance, particularly in outpatients, infection control guidance (which was relaxed for some cases in the middle of August) and the inability to fill theatre lists when patients cancelled at the last minute because of the need to isolate for 14 days. The trust has sought to prioritise the reduced elective capacity available towards those patients requiring assessment or treatment more urgently, and to provide assessments by telephone or video whenever appropriate. The trust started to develop detailed speciality specific recovery plans in August, in line with the Wave 3 letter, as well as each service 3 Page 4 of 24 Report to Trust Board in September 2020 RESPONSIVE • Emergency Department timeliness deteriorated in August, reaching 85.9% across the month (RE 10). Other Trusts have also seen similar deterioration, though UHS had the fourth best performance out of 8 ‘peer’ Major Trauma Centres (RE9). Attendance numbers increased to approximately 85% of the normal level (RE 8), whilst enhanced infection control precautions remained in place. • The percentage of patients waiting up to 18 weeks from referral to treatment improved marginally to 55% (RE 14). The total number of patients waiting is now above pre-Covid levels, at 34,900 patients (RE 15), and is expected to increase further, due to the recovery in the number of referrals being made to hospital (RE 12). The percentage of patients waiting more than 6 weeks for a diagnostic test (RE 20) improved from 35% to 40%, though the total number of patients waiting continued to increase and is now above pre-Covid levels (RE 19). The average waiting time for new outpatient appointments further reduced in August and is now at 8.8 weeks (RE 18). • Cancer performance measures for July indicate that UHS 62 day performance (RE 21) improved and is now the best amongst our 10 ‘peer’ teaching hospitals, and that 31 day performance (RE 22) further improved to 98.2% and achieved the national standard. The number of patients still waiting with pathways greater than 104 days (RE 23) reduced from 36 to 17. There remain challenges particularly in the head and neck tumour site. 4 Page 5 of 24 Report to Trust Board in September 2020 RESPONSIVE Jun Jul Aug Sep Oct Nov Dec Jan 6,800 6,533 RE1 Non-elective Spells (including CDU) Feb Mar Apr May Jun Jul Aug Monthly Target 6,058 - 4,000 7.5 RE2-L Non Elective LOS Rolling 12 months 6.42 6.0 250 RE3 Number of patients medically optimised for discharge Longer LOS Census average RE4-N (Patients with LOS > =21days) 0 211 227.34 180.19 133.04 - 6.10 123 - 137 - RE5-l Adult midday bed occupancy 95.2% 72.4% 90-95% RE6 Last minute cancelled operations not readmitted within 28 days 3 150 78 RE7 Hospital initiated cancelled ops 91% 80.3% 81% 85.04% 90.7% 71% 766545365325334 Patients spending less than 4hrs in ED RE10-N UHS Total (includes SGH all types and lymington until Jul 19) 91.51% 83.3% 75.05% 82.2% 85.9% 91.27% Q Target - 95% 95% RE11-N Total time spent in ED Total Percentiles UHS Mean, 3:16 50th, 3:06 90th, 4:07 Mean, 2:50 - - 50th, 2:47 RE12 Accepted Referrals 25000 22249 14883 - - RE13 Elective spells 0 2,000 0 1,453 1,191 - - 6 Page 7 of 24 Report to Trust Board in September 2020 RESPONSIVE RE14-N % Patients on an open 18 week pathway (within 18 weeks ) Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug 83% 84.0% 78% 72% 54.75% Target > =92% 35000 Total number of patients on a waiting RE15-N list (18 week referral to treatment pathway) RE16 Face to face outpatient attendances 28000 50,000 52,480 33746 34903 24,043 - RE17 Non-face to face outpatient attendances 0 50,000 7,948 0 RE17 - Latest month is awaiting approx ~3k outpatient attendances to be reported 12,900 - RE18 Average weeks waited for first outpatient appointment 9,000 RE19 Patients waiting for diagnostics 4,000 RE20-N % of Patients waiting over 6 weeks for diagnostics 19% 121%% 7.5 7004 2.8% 8.8 - 8794 - 39.61% RE22-N 31 day cancer wait performance (latest data held by UHS) no.patients Target to recover QTD Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul /July 1 94.5% 78.4% N=> N = 12 90% L=> L= 17 of 84% 76.5% 72.6% 95% 111.5 36578645655121 0.5 96.2% 92.4% 88.5% 98.22% N=> 96% N=0 of 805 0.9665821 RE23 Snapshot of waits > 104 days (from referral on a 62 day pathway) 33 38 41 55 52 41 29 35 27 29 11 25 36 17 - - 100% RE24-N 28 Day Faster Diagnosis 70% 10,000 RE25 My Medical Record - UHS patient logins 5,000 0 2500 RE26 Number of Estates Help desk requests and percentage completed on time 900 100% 85% 75% 4,634 1620 81.0% 85% => 75 % - 7,132 - 1516 - 89.6% > 85% 50% 79.80% 89.0% 8 Page 9 of 24 Report to Trust Board in September 2020 RESPONSIVE 50% Monthly Target Target QTD /July - Jan Jan Jan Jan Jan Jan Jan Jan Jan Jan Jan Jan Jan Jan Elective inpatient activity - % of same time last year 60.00% 50.19% RE27 UHS Corporate peer average ------------------------------Rank--> 48.32% 000000000047330 0.00% Non-elective inpatient activity - % of same time last year RE28 UHS 110.00% 108.41% 100.61% Corporate peer average ------------------------------Rank--> 000000000046650 0.00% 1st outpatient attendances - % of same time last year 100.00% 96.80% RE29 UHS Corporate peer average ------------------------------Rank--> 70.70% 000000000065570 0.00% 9 Page 10 of 24 Report to Trust Board in September 2020 SAFE • The majority of measures indicate that safety has been maintained during August. • New Covid-19 diagnoses amongst hospital inpatients (SA5, SA6) have reduced significantly, and there were no cases of ‘probable’ transmission or ‘healthcare-acquired’ Covid-19 in UHS inpatient services in August. The Covid 0 campaign continued to be rolled out, focusing on the absolute importance of stopping nosocomial COVID infection. The campaign encourages all people to follow government guidance when walking apart, wear a mask where you can’t, and continue to wash your hands as often as possible. • Statutory and mandatory training compliance further reduced in August. • Both clinical and Serco cleaning scores showed an improvement in August; with both meeting 100. • As expected CHPPD for all areas this month is still elevated at 11.0 (RN 6.7, HCA 4.3) with ward only areas also elevated at 9.4 (RN 5.0, HCA 4.4). This is reflective of new ward configurations, roster changes, additional staff deployments and reduced patient numbers in some areas. • In UHS ward-based areas, the data shows that total nursing staff vacancies have increased to 9.63%. Registered nurse vacancies in ward-based areas have decreased this month to 15.52%. This position is being continuously validated as data, sourced from rosters, has been affected by the significant ward changes in size and specialty focus that have occurred as a result of the COVID-19 restart plan. Annual ward staffing reviews are currently taking place to confirm required levels against the changed configurations. Monthly Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Target YTD YTD Target SA1-N Cumulative Clostridium difficile 2 SA2 MRSA bacterium 0 100 SA3 Clinical cleaning scores for very high risk areas 99 95 SA4 Serco cleaning scores for very high risk areas 100 99 95 27 5 32 32 0 0 100 98 - 14days after admission 00 0 0 0 0 0 0 0 0 20 30 14 1 0 0 Probable hospital-associated 50 SA6 COVID infection: COVID-positive sample taken > 7 days and 95% - 96.3% YTD Target - - > 95% 12 Page 13 of 24 Report to Trust Board in September 2020 CARING • The majority of measures indicate that UHS has continued to provide caring services during August. • Friends and family negative scores remained below target, at 3.7% (CA1), although maternity saw an increase for the second month, rising to 8.3% (CA2). • Complaints per 1,000 units remained significantly below the target, at 0.27 (CA4). The number of complaints closed on time continues to make a slow recovery following the pausing of complaints investigation at the height of Covid 19. In August the Trust achieved 46%, compared to 41% in July (CA5) • The percentage of women receiving ‘Continuity of Care’ within the Maternity service remained static at 11% and remains well below the target of 35%. A plan has been developed to drive improvements in this aspect of care. • The number of non-clinically justified overnight ward moves rose slightly in August, to 68 (CA9). An action plan is being developed to reduce these. Monthly Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Target 0.6% CA1-N FFT Negative Score - Inpatients 5% =35% 1.30 CA4-L Complaints per 1000 units 0.00 CA5-L % Complaints closed within 35 days 80% 0% 0.38 81% Page 14 of 24 =70% 13 Report to Trust Board in September 2020 0% Jun Jul Aug Sep 100% % Patients reporting being CA6 involved in decisions about care and treatment 50% 100% % Patients reporting finding CA7 somebody to talk to about worries and fears 50% 100% % Patients with a CA8 disability/additional needs reporting those needs/adjustments were met 50% CA9 Overnight ward moves with a reason marked as non-clinical Jun Jul Aug Sep 135.76 99 76.96 18.16 18.0 Total nursing staff all inpatient CA10 areas - Care hours per patient day13.0 (CHPPD) 8.0 40.0 Same Sex Accommodation CA11 (Non Clinically Justified Breaches) 20.0 2 0.0 9.0 11 4 4 CARING Oct Nov Dec Jan Feb Mar Apr May Jun Oct Nov Dec Jan Feb Mar Apr May Jun 32 12 1 1 0 15 0 0 0 Monthly Target Jul Aug 84% > =90% 91% > =90% 94% > =90% Monthly Jul Aug Target 68 - 11.0 - - 0 0 14 Page 15 of 24 Report to Trust Board in September 2020 EFFECTIVE • The number of patients screened for alcohol and smoking continued to significantly exceed the 80% target, at 97% (EF5) • The number of patients found to have either a moderate or high dependence on alcohol (EF6), or to smoke (EF7) who were given advice or an onward referral continued to exceed the targets, at 80% and 94% respectively. EF1-L Cumulative Specialities with Outcome Measures Developed Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug 47 52 52 53 54 223 234 250 255 260 Monthly Target +1 100% EF2 Developed Outcomes RAG ratings 75% 78% 77% 79% 80% 81% 50% 100 EF3-N HSMR - UHS HSMR - SGH 81 75 4.5% EF4 HSMR - Crude Mortality Rate 2.9% 80% 15 Page 16 of 24 Report to Trust Board in September 2020 EFFECTIVE 80% Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug % patients screened & found to EF6-N have either moderate or high alcohol dependence given advice 90% 87% 80% or referral 70% % patients screened & found to 100% 83% 94% EF7-N smoke given brief advice or a medication offer 60% Monthly Target > 90% > 90% 16 Page 17 of 24 Report to Trust Board in September 2020 WELL LED • Turnover this month has increased due to the student nurses who joined the trust to support for covid have started to return to their University courses and this has strongly affected the turnover % this month, and is likely to continue next month as these students are leaving UHS. • In clinical ward areas there are 163 registered nurses and 153 healthcare assistants in the covid ‘at risk’ categories who are unable to be deployed to some patient-facing activities. The majority of these staff have now been deployed to low risk areas, as risk levels are continuously reviewed. All nursing staff have been flexibly deployed to manage this deployment safely. A review is ongoing with covid assessments to move our system to be covid age instead of risk level 1 – 3. • This month staffing remains amber overall because some key targets have been missed for staff turnover, sickness and appraisals. The in-month sickness absence rate has seen a decrease and is below its normal position, but the 12 month figure is elevated due to the spoke during the pandemic. • Statutory and mandatory training compliance has seen some slippage (with 6 of 12 measures meeting target) due to COVID-19 and the reductions in training release during that time. • Recognising the pause in appraisals during COVID efforts are now being focused on improving quantity undertaken whilst retaining the important focus on quality of discussion as reflected in our staff survey. • UHS has seen an increase in rates of employment for BAME Band 7+ to 9.37%, but is still on an upwards trend. UHS is now monitoring BAME individual occupying 35 key medical leadership positions. This will be reported on a quarterly basis. WL1-L Substantive Staff - Turnover Monthly Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Target 13.90% 13.18% 12.46% 12.8% 13.3% 92% 77.24% 17 Page 18 of 24 Report to Trust Board in September 2020 WELL LED Monthly Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Target WL3-L 100.00% Staff - Medical appraisals completed - Rolling 12-months 50.00% 0.00% 60.00% WL4-L Staff vacancies 10.00% 5.00% 0.00% 4.09% WL5-L Staff - Sickness absence 4.43% 3.7% 2.99% 3.31% 2.91% =76% 30% 20% WL9-L Black & Minority Ethnic Band 7+ Percentage 9% 8.8% 9.4% 15% by 2023 7% WL10 Cumulative Number of staff trained in QI 1001 1064 1171 WL10 - QI training programme, and reporting, is currently temporarily suspended as team members support urgent change programmes as part of our Covid 19 response and recovery WL11 Statutory & Mandatory Training Achieving Target 8 8 8 8 7 7 7 7 7 7 7 6 6 6 6 4 4 4 4 5 5 5 5 5 5 5 6 6 6 6 - 100 WL12 Number of Apprenticeship Starts 53 - 50 29 28 23 0 19 Page 20 of 24 Report to Trust Board in September 2020 WELL LED 0 Monthly Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Target WL13-L Comparative CRN Recruitment Performance by clinical specialty 44% 44% 52% 56% 52% > =50% 2 WL14-L Comparative CRN Recruitment Performance - weighted 4 5 5 6 Top 5 WL15-L Comparative CRN Recruitment - contract commercial 15 15 13 13 13 Proportion of studies closing in FY on 88% WL16-L time and to recruitment target - 59% 65% 65% 50% non-commercial 452 WL17 NIHR CRF & BRC publications Year on year growth 329 246 137 Top 10 > =80% 20 Page 21 of 24 Report to Trust Board in September 20C20hanges and Corrections Section Responsive Responsive Responsive KPI KPI Name Type Elective inpatient activity - % RE26 of same time last year Addition Non-elective inpatient RE27 activity - % of same time last Addition year 1st outpatient attendances - RE28 % of same time last year Addition Detail Addition of benchmark position - % activity compared to same time last year, with rank and average of corporate peer group CAMBRIDGE UNIVERSITY HOSPITALS NHS FOUNDATION TRUST NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST OXFORD UNIVERSITY HOSPITALS NHS FOUNDATION TRUST SHEFFIELD TEACHING HOSPITALS NHS FOUNDATION TRUST UNIVERSITY HOSPITALS BRISTOL AND WESTON NHS FOUNDATION TRUST UNIVERSITY HOSPITALS OF LEICESTER NHS TRUST 21 Page 22 of 24 Nursing and midwifery staffing hours - Aug 2020 Report notes Our staffing levels are monitored daily and we will risk assess and fill any gaps to ensure that safe staffing levels are always maintained The total hours planned is our planned staffing levels to deliver care across all of our areas but does not represent a baseline safe staffing level. We plan for an average of one registered nurse to every five or seven patients in most of our areas but this can change as we regularly review the care requirements of our patients and adjust our staffing accordingly. Staffing on intensive care and high dependency units is always adjusted depending on the number of patients being cared for and the level of support they require. Therefore the numbers will fluctuate considerably across the month when compared against our planned numbers. Enhanced Care (also known as Specialling) Occurs when patients in an area require more focused care than we would normally expect. In these cases extra, unplanned staff are assigned to support a ward. If enhanced care is required the ward may show as being over filled. If a ward has an unplanned increase or decrease in bed availability the ward may show as being under or over filled, even though it remains safely and appropriately staffed. CHPPD (Care Hours Per Patient Day) This is a measure which shows on average how many hours of care time each patient receives on a ward /department during a 24 hour period from registered nurses and support staff - this will vary across wards and departments based on the specialty, interventions, acuity and dependency levels of the patients being cared for. The maternity workforce consists of teams of midwives who work both within the hospital and in the community offering an integrated service and are able to respond to women wherever they choose to give birth. This means that our ward staffing and hospital birth environments have a core group of staff but the numbers of actual midwives caring for women increases responsively during a 24 hour period depending on the number of women requiring care. During the last 2 weeks in March and beyond a number of our clinical areas started to change specialty and size to respond to the COVID-19 situation (e.g G5-G9, Critical Care and RHDU). Repurposing of wards to respond to the COVID-19 social distancing recommendations and to enable the separation and restart of services continues with changes sometimes being swift in nature. The data may in some cases not be fully reflective of these changes. WARD C4 (Solent ward) C4 (Solent ward) C6 C6 C6 (Teenage Cancer Trust unit) C6 (Teenage Cancer Trust unit) D2 D2 D3 D3 Critical Care Critical Care E5A E5A E5B E5B F10 E F10 E F11 F11 ASU ASU F6 F6 F5 F5 Acute medical unit Acute medical unit D5 D5 D6 D6 D8 D8 D9 D9 E7 E7 Respiratory high dependency unit Respiratory high dependency unit C5 C5 D10 D10 f7 f7 G5 G5 G6 G6 G7 G7 G8 G8 G9 G9 Registered nurses Total hours planned Registered nurses Total hours worked Unregistered staff Total hours planned Unregistered staff Total hours worked Registered nurses % Filled Day 1383.7 1370.1 1048.9 1253.3 99.0% Night 1069.3 1011.8 713.0 1176.8 94.6% Day 2791.3 2783.6 183.5 414.7 99.7% Night 2049.3 2097.4 102.4% 0.0 320.0 Day 727.5 564.5 331.9 334.8 77.6% Night 674.0 597.0 88.6% 0.0 96.7 Day 1303.0 1671.0 1108.0 909.8 128.2% Night 1057.5 1058.3 713.0 759.0 100.1% Day 1685.5 1641.7 689.2 1157.0 97.4% Night 1046.3 1083.5 686.3 812.5 103.6% Day 21459.4 18076.5 4440.8 2978.6 84.2% Night 20549.2 17565.5 2736.5 2251.8 85.5% Day 1339.7 1171.4 723.4 1019.4 87.4% Night 714.0 679.5 356.5 701.5 95.2% Day 1413.6 1190.3 811.5 1112.0 84.2% Night 713.0 713.0 356.5 597.8 100.0% Day 2313.5 1483.1 623.0 1277.7 64.1% Night 1069.5 1001.5 713.0 793.5 93.6% Day 1953.9 1405.9 774.8 1011.3 72.0% Night 713.0 713.8 713.0 885.5 100.1% Day 1480.3 1056.8 417.5 589.0 71.4% Night 695.0 718.0 356.5 327.5 103.3% Day 2306.0 1384.7 576.8 1345.9 60.0% Night 1069.5 1030.8 701.5 850.0 96.4% Day 1969.1 1534.2 1322.9 1268.3 77.9% Night 1069.5 991.5 712.5 873.5 92.7% Day 3572.8 4020.6 3294.5 3737.1 112.5% Night 3548.8 4008.4 2495.5 3893.3 113.0% Day 1255.0 1313.0 1668.0 1572.3 104.6% Night 1046.5 993.0 934.5 858.0 94.9% Day 1120.5 1061.3 1522.0 1441.5 94.7% Night 713.0 750.5 945.5 820.5 105.3% Day 1134.0 1009.5 1467.5 1700.0 89.0% Night 713.0 794.5 945.5 954.0 111.4% Day 1247.0 1350.7 1711.0 1590.8 108.3% Night 1069.5 978.0 945.5 980.5 91.4% Day 1080.5 1102.5 1232.0 1466.2 102.0% Night 713.0 681.5 713.0 702.5 95.6% Day 1256.3 992.0 521.0 346.5 79.0% Night 1143.0 1037.3 356.5 164.5 90.7% Day 860.0 1037.7 1285.0 602.0 120.7% Night 701.5 678.5 437.0 352.0 96.7% Day 1122.5 995.2 1301.0 1377.0 88.7% Night 702.0 656.5 713.0 552.0 93.5% Day 1083.7 980.4 1749.5 1649.0 90.5% Night 977.5 805.5 713.0 724.5 82.4% Day 1021.0 1277.2 1799.3 1700.8 125.1% Night 1058.8 932.3 701.5 839.5 88.1% Day 1061.9 1049.9 1782.5 1866.0 98.9% Night 1046.5 943.0 713.0 782.0 90.1% Day 742.5 742.5 1354.5 1679.5 100.0% Night 701.5 708.5 1069.5 1092.5 101.0% Day 1079.7 1041.6 1841.2 1829.0 96.5% Night 1069.5 874.0 713.0 805.0 81.7% Day 1080.8 1063.0 1768.8 1910.3 98.4% Night 1070.5 932.5 713.0 736.0 87.1% Unregistered staff % Filled 119.5% 165.0% 226.0% Shift N/A 100.9% Shift N/A 82.1% 106.5% 167.9% 118.4% 67.1% 82.3% 140.9% 196.8% 137.0% 167.7% 205.1% 111.3% 130.5% 124.2% 141.1% 91.9% 233.4% 121.2% 95.9% 122.6% 113.4% 156.0% 94.3% 91.8% 94.7% 86.8% 115.8% 100.9% 93.0% 103.7% 119.0% 98.5% 66.5% 46.1% 46.8% 80.5% 105.8% 77.4% 94.3% 101.6% 94.5% 119.7% 104.7% 109.7% 124.0% 102.2% 99.3% 112.9% 108.0% 103.2% CHPPD Registered midwives/ nurses CHPPD Care Staff 5.0 5.1 8.0 1.2 10.4 3.9 6.2 3.8 5.0 3.6 26.3 3.9 3.7 3.5 3.8 3.4 4.8 4.0 4.1 3.6 8.1 4.2 3.5 3.2 4.1 3.4 7.9 7.5 3.2 3.4 3.4 4.3 2.7 3.9 2.8 3.1 3.1 3.8 16.6 4.2 9.8 5.4 3.3 3.9 3.5 4.6 2.9 3.3 2.9 3.9 3.5 6.6 2.6 3.5 2.9 3.8 CHPPD Overall 10.0 9.2 14.2 10.0 8.6 30.1 7.2 7.2 8.8 7.7 12.3 6.6 7.5 15.5 6.6 7.7 6.6 5.9 7.0 20.8 15.2 7.2 8.1 6.2 6.9 10.1 6.1 6.7 Comments Safe staffing levels maintained. Safe staffing levels maintained. Safe staffing levels maintained; additional staff used for enhanced care - Support workers. Safe staffing levels maintained. Staff moved to support other wards; Staffing appropriate for number of patients. Staff moved to support other wards; Staffing appropriate for number of patients. Safe staffing levels maintained. Safe staffing levels maintained. Safe staffing levels maintained; additional staff used for enhanced care - Support workers. Safe staffing levels maintained. Beds flexed to match staffing. Beds flexed to match staffing. Safe staffing levels maintained; Band 4 staff working to support registered nurse numbers; Additional staff used for enhanced care Support workers. Safe staffing levels maintained; Band 4 staff working to support registered nurse numbers; Additional staff used for enhanced care Support workers. Safe staffing levels maintained; Band 4 staff working to support registered nurse numbers. Safe staffing levels maintained; Band 4 staff working to support registered nurse numbers. Safe staffing levels maintained; Band 4 staff working to support registered nurse numbers; Additional staff used for enhanced care Support workers; Additional staff working in this area due to covid restrictions. Safe staffing levels maintained. Safe staffing levels maintained; Band 4 staff working to support registered nurse numbers; Additional staff used for enhanced care Support workers. Safe staffing levels maintained; Additional staff used for enhanced care - Support workers. Safe staffing levels maintained; Band 4 staff working to support registered nurse numbers. Safe staffing levels maintained. Safe staffing levels maintained; Band 4 staff working to support registered nurse numbers; Additional staff used for enhanced care Support workers. Safe staffing levels maintained. Safe staffing levels maintained by sharing staff resource; Staffing appropriate for number of patients. Safe staffing levels maintained by sharing staff resource; Staffing appropriate for number of patients. Band 4 staff working to support registered nurse numbers; Beds flexed to match staffing; Safe staffing levels maintained; Covid testing zone requiring additional staffing. Band 4 staff working to support registered nurse numbers; Beds flexed to match staffing; Safe staffing levels maintained; Covid testing zone requiring additional staffing. Safe staffing levels maintained. Safe staffing levels maintained. Safe staffing levels maintained. Skill mix swaps undertaken to support safe staffing across the Unit; Safe staffing levels maintained. Band 4 staff working to support registered nurse numbers; Safe staffing levels maintained; Additional staff used for enhanced care Support workers. Additional staff used for enhanced care - RNs; Safe staffing levels maintained. Additional staff used for enhanced care - RNs; Safe staffing levels maintained. Band 4 staff working to support registered nurse numbers; Safe staffing levels maintained. Band 4 staff working to support registered nurse numbers; Safe staffing levels maintained. Safe staffing levels maintained. Beds flexed to match staffing; Staff moved to support other wards; Band 4 staff working to support registered nurse numbers; Safe staffing levels maintained. Beds flexed to match staffing; Staff moved to support other wards; Band 4 staff working to support registered nurse numbers; Safe staffing levels maintained. Skill mix swaps undertaken to support safe staffing across the Unit; Beds flexed to match staffing; Safe staffing levels maintained. Beds flexed to match staffing; Safe staffing levels maintained. Band 4 staff working to support registered nurse numbers; Safe staffing levels maintained; Beds flexed to match staffing. Staff moved to support other wards; Safe staffing levels maintained; Beds flexed to match staffing. Band 4 staff working to support registered nurse numbers; Safe staffing levels maintained. Band 4 staff working to support registered nurse numbers; Safe staffing levels maintained. Band 4 staff working to support registered nurse numbers; Safe staffing levels maintained. Band 4 staff working to support registered nurse numbers; Safe staffing levels maintained. Band 4 staff working to support registered nurse numbers; Safe staffing levels maintained. Band 4 staff working to support registered nurse numbers; Safe staffing levels maintained. Band 4 staff working to support registered nurse numbers; Additional staff used for enhanced care - Support workers; Safe staffing levels maintained. Band 4 staff working to support registered nurse numbers; Additional staff used for enhanced care - Support workers; Safe staffing levels maintained. Band 4 staff working to support registered nurse numbers; Safe staffing levels maintained. Band 4 staff working to support registered nurse numbers; Safe staffing levels maintained. Band 4 staff working to support registered nurse numbers; Safe staffing levels maintained. Band 4 staff working to support registered nurse numbers; Safe staffing levels maintained. Page 23 of 24 Nursing and midwifery staffing hours - Aug 2020 Report notes Our staffing levels are monitored daily and we will risk assess and fill any gaps to ensure that safe staffing levels are always maintained The total hours planned is our planned staffing levels to deliver care across all of our areas but does not represent a baseline safe staffing level. We plan for an average of one registered nurse to every five or seven patients in most of our areas but this can change as we regularly review the care requirements of our patients and adjust our staffing accordingly. Staffing on intensive care and high dependency units is always adjusted depending on the number of patients being cared for and the level of support they require. Therefore the numbers will fluctuate considerably across the month when compared against our planned numbers. Enhanced Care (also known as Specialling) Occurs when patients in an area require more focused care than we would normally expect. In these cases extra, unplanned staff are assigned to support a ward. If enhanced care is required the ward may show as being over filled. If a ward has an unplanned increase or decrease in bed availability the ward may show as being under or over filled, even though it remains safely and appropriately staffed. CHPPD (Care Hours Per Patient Day) This is a measure which shows on average how many hours of care time each patient receives on a ward /department during a 24 hour period from registered nurses and support staff - this will vary across wards and departments based on the specialty, interventions, acuity and dependency levels of the patients being cared for. The maternity workforce consists of teams of midwives who work both within the hospital and in the community offering an integrated service and are able to respond to women wherever they choose to give birth. This means that our ward staffing and hospital birth environments have a core group of staff but the numbers of actual midwives caring for women increases responsively during a 24 hour period depending on the number of women requiring care. During the last 2 weeks in March and beyond a number of our clinical areas started to change specialty and size to respond to the COVID-19 situation (e.g G5-G9, Critical Care and RHDU). Repurposing of wards to respond to the COVID-19 social distancing recommendations and to enable the separation and restart of services continues with changes sometimes being swift in nature. The data may in some cases not be fully reflective of these changes. Paediatric high dependency unit Paediatric high dependency unit Paediatric medical unit Paediatric medical unit Paediatric intensive care unit Paediatric intensive care unit Piam Brown ward Piam Brown ward E1 E1 G2 G2 G3 G3 G4 G4 Bramshaw women's unit Bramshaw women's unit Neonatal unit Neonatal unit Maternity service Maternity service Cardiac high dependency unit Cardiac high dependency unit Coronary care unit Coronary care unit D4 D4 E2 E2 E3 Green E3 Green E3 Blue E3 Blue E4 E4 Acute stroke unit Acute stroke unit Regional transfer unit Regional transfer unit E Neuro E Neuro Hyper acute stroke unit Hyper acute stroke unit D neuro D neuro SPI F4 Neuro SPI F4 Neuro Brooke ward Brooke ward Trauma Assessment Unit Trauma Assessment Unit F1 F1 F2 F2 F3 F3 F4 F4 Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night 1627.5 1069.5 1835.4 1707.5 6762.1 5697.8 3695.9 1415.1 2068.0 1380.0 759.3 744.0 2410.6 1705.0 2429.0 1705.0 1120.0 713.0 6894.9 5439.5 8456.9 5383.8 4548.2 3653.1 1412.2 1331.8 1756.2 820.0 1721.2 704.0 1574.8 704.0 1181.7 665.0 1652.1 1100.5 1518.5 1023.0 773.0 682.0 1975.5 1364.0 1564.0 1358.0 1941.0 1364.5 1817.4 1089.0 1171.2 1069.5 535.5 341.0 2428.4 1781.8 1655.7 1023.0 1606.3 1023.3 1470.0 1023.0 1320.0 1162.5 2753.9 2438.4 4695.4 4443.2 2723.0 1178.6 1523.8 1193.8 780.1 793.0 1683.9 1350.8 1994.5 1324.5 1047.3 712.5 4472.4 3814.3 7597.2 4577.8 3991.0 3358.8 1864.8 1613.0 1425.2 780.3 1057.2 706.0 1394.2 682.0 975.7 621.0 1320.7 1069.0 1520.0 880.0 729.5 506.0 1719.0 1265.0 1181.5 924.0 1831.8 1310.0 1254.7 924.0 917.5 736.0 648.7 617.3 1980.8 1736.9 1455.8 803.0 1320.0 869.3 1364.2 860.3 0.0 0.0 352.2 680.5 726.2 587.8 93.0 0.0 620.0 371.3 0.0 0.0 1691.0 1023.0 1188.0 682.0 656.5 345.0 1551.0 1353.0 3137.4 2046.0 2233.7 1366.0 1089.0 968.0 1057.5 1012.0 866.4 341.0 1398.5 788.3 1150.5 682.0 1285.9 396.0 2674.5 1705.0 387.5 330.0 1031.0 1021.5 397.5 319.0 2033.5 1715.0 1143.0 1043.0 600.3 356.5 313.6 341.0 1936.3 1755.3 2000.5 1375.3 1791.2 1364.3 1217.2 693.8 81.1% Shift N/A 92.0 15.6 0.6 Non-ward based staff supporting areas; Safe staffing levels maintained. 16.2 108.7% 0.0 Shift N/A Safe staffing levels maintained. 150.0% 182.0% Additional beds open in the month; Patient requiring 24 hour 1:1 nursing in the month; Safe staffing levels maintained. 640.9 21.0 5.5 26.5 713.5 142.8% 104.8% Additional beds open in the month; Patient requiring 24 hour 1:1 nursing in the month; Safe staffing levels maintained. 269.0 472.8 69.4% 78.0% 37.0% 80.4% Beds flexed to match staffing. 39.1 3.2 42.2 Beds flexed to match staffing. 158.5 73.7% 170.4% 12.4 0.5 Band 4 staff working to support registered nurse numbers; Safe staffing levels maintained. 12.9 83.3% 0.0 Shift N/A Beds flexed to match staffing; Safe staffing levels maintained. 641.0 73.7% 103.4% 7.8 Band 4 staff working to support registered nurse numbers; Non-ward based staff supporting areas; Safe staffing levels maintained. 3.6 11.4 614.8 86.5% 165.6% Band 4 staff working to support registered nurse numbers; Safe staffing levels maintained. 102.7% Shift N/A 0.0 12.0 0.0 Safe staffing levels maintained. 12.0 106.6% 0.0 Shift N/A Safe staffing levels maintained. 791.0 69.9% 46.8% 8.4 Non-ward based staff supporting areas; Safe staffing levels maintained; Beds flexed to match staffing. 3.6 12.0 532.5 79.2% 52.1% Beds flexed to match staffing; Safe staffing levels maintained. 885.5 82.1% 74.5% 8.4 Non-ward based staff supporting areas; Safe staffing levels maintained; Beds flexed to match staffing. 3.7 12.1 583.0 77.7% 85.5% Beds flexed to match staffing; Safe staffing levels maintained. 609.0 93.5% 92.8% Safe staffing levels maintained. 8.1 4.4 12.6 345.0 99.9% 100.0% Safe staffing levels maintained. 1605.5 64.9% 103.5% 10.7 3.3 Staffing flexed to match bed numbers. 14.0 946.0 70.1% 69.9% Staffing flexed to match bed numbers. 2498.7 89.8% 79.6% Safe staffing levels maintained. 5.3 1.9 7.2 1770.8 85.0% 86.5% Safe staffing levels maintained. 1394.4 803.0 87.7% 91.9% 62.4% 58.8% Staff moved to support other wards; Skill mix swaps undertaken to support safe staffing across the Unit; Band 4 staff working to support 19.0 5.7 24.7 registered nurse numbers. Staff moved to support other wards; Skill mix swaps undertaken to support safe staffing across the Unit; Band 4 staff working to support registered nurse numbers. 132.0% 81.1% Additional beds open in the month; Staff moved to support other wards; Skill mix swaps undertaken to support safe staffing across the 883.5 9.5 4.6 14.1 Unit. 814.0 121.1% 84.1% Additional beds open in the month; Staff moved to support other wards; Skill mix swaps undertaken to support safe staffing across the Unit. 81.2% 139.7% Band 4 staff working to support registered nurse numbers; Safe staffing levels maintained; Support workers used to maintain staffing 1477.8 4.4 4.9 9.3 numbers. 95.2% 92.9% Band 4 staff working to support registered nurse numbers; Safe staffing levels maintained; Support workers used to maintain staffing 940.0 numbers. 61.4% 163.7% Staffing appropriate for number of patients; Staff moved to support other wards; Band 4 staff working to support registered nurse 1418.5 3.9 4.7 8.6 numbers. 687.4 100.3% 201.6% Staffing appropriate for number of patients; Staff moved to support other wards; Increased night staffing to support raised acuity. 1381.3 88.5% 98.8% 3.8 Band 4 staff working to support registered nurse numbers; Safe staffing levels maintained. 4.0 7.8 801.3 96.9% 101.6% Band 4 staff working to support registered nurse numbers; Safe staffing levels maintained. 1119.0 781.0 1192.9 748.0 2645.5 1815.0 234.5 396.0 1594.5 1439.5 495.0 427.8 1668.0 1550.5 1435.5 1197.0 585.8 563.5 827.6 660.0 2307.9 1852.0 2242.3 1572.3 2170.0 1486.0 1033.7 915.5 82.6% 93.4% 79.9% 97.1% 100.1% 86.0% 94.4% 74.2% 87.0% 92.7% 75.5% 68.0% 94.4% 96.0% 69.0% 84.8% 78.3% 68.8% 121.1% 181.0% 81.6% 97.5% 87.9% 78.5% 82.2% 84.9% 92.8% 84.1% 97.3% 114.5% 92.8% 188.9% 98.9% 106.5% 60.5% 120.0% 154.7% 140.9% 124.5% 134.1% 82.0% 90.4% 125.6% 114.8% 97.6% 158.1% 263.9% 193.5% 119.2% 105.5% 112.1% 114.3% 121.1% 108.9% 84.9% 132.0% Band 4 staff working to support registered nurse numbers; Patient requiring 24 hour 1:1 nursing in the month. 4.1 4.8 8.9 Band 4 staff working to support registered nurse numbers; Patient requiring 24 hour 1:1 nursing in the month. Band 4 staff working to support registered nurse numbers; Staffing appropriate for number of patients; Support workers used to maintain 5.8 4.7 10.6 staffing numbers. Additional staff used for enhanced care - Support workers; Skill mix swaps undertaken to support safe staffing across the Unit; Support workers used to maintain staffing numbers. Patient requiring 24 hour 1:1 nursing in the month; Band 4 staff working to support registered nurse numbers; Support workers used to 3.1 5.7 8.7 maintain staffing numbers. Patient requiring 24 hour 1:1 nursing in the month; Band 4 staff working to support registered nurse numbers; Support workers used to maintain staffing numbers. Band 4 staff working to support registered nurse numbers; Support workers used to maintain staffing numbers; Patient requiring 24 hour 1:1 nursing in the month; Low bed numbers but staff on roster being used in neuro swabbing hub making it look like working on ward in 18.2 9.3 27.4 report. Band 4 staff working to support registered nurse numbers; Support workers used to maintain staffing numbers; Patient requiring 24 hour 1:1 nursing in the month. Band 4 staff working to support registered nurse numbers; Support workers used to maintain staffing numbers; Patient requiring 24 hour 5.9 6.0 11.8 1:1 nursing in the month. Band 4 staff working to support registered nurse numbers; Support workers used to maintain staffing numbers; Patient requiring 24 hour 1:1 nursing in the month. Band 4 staff working to support registered nurse numbers; Support workers used to maintain staffing numbers; Patient requiring 24 hour 14.0 6.2 20.2 1:1 nursing in the month. Band 4 staff working to support registered nurse numbers; Support workers used to maintain staffing numbers; Patient requiring 24 hour 1:1 nursing in the month. Patient requiring 24 hour 1:1 nursing in the month; Band 4 staff working to support registered nurse numbers; Support workers used to 5.8 5.9 11.8 maintain staffing numbers. Patient requiring 24 hour 1:1 nursing in the month; Band 4 staff working to support registered nurse numbers; Support workers used to maintain staffing numbers. Band 4 staff working to support registered nurse numbers; Support workers used to maintain staffing numbers; Patient requiring 24 hour 5.3 6.4 11.6 1:1 nursing in the month. Band 4 staff working to support registered nurse numbers; Support workers used to maintain staffing numbers; Patient requiring 24 hour 1:1 nursing in the month. Safe staffing levels maintained by sharing staff resource; Staff moved to support other wards; Skill mix swaps undertaken to support safe 5.2 3.6 8.8 staffing across the Unit. Safe staffing levels maintained by sharing staff resource; Staff moved to support other wards; Skill mix swaps undertaken to support safe staffing across the Unit. Safe staffing levels maintained by sharing staff resource; This ward has a high number of admissions and acuity/dependency of patients 8.7 10.3 19.0 which means more Registered nurse and support workers are required. Safe staffing levels maintained by sharing staff resource; This ward has a high number of admissions and acuity/dependency of patients which means more Registered nurse and support workers are required. Patient requiring 24 hour 1:1 nursing in the month; Safe staffing levels maintained by sharing staff resource; Skill mix swaps undertaken to 4.5 5.1 9.6 support safe staffing across the Unit; Staff moved to support other wards. Patient requiring 24 hour 1:1 nursing in the month; Safe staffing levels maintained by sharing staff resource; Skill mix swaps undertaken to support safe staffing across the Unit; Staff moved to support other wards. Patient requiring 24 hour 1:1 nursing in the month; Safe staffing levels maintained by sharing staff resource; Skill mix swaps undertaken to 3.2 5.3 8.5 support safe staffing across the Unit; Staff moved to support other wards. Patient requiring 24 hour 1:1 nursing in the month; Safe staffing levels maintained by sharing staff resource; Skill mix swaps undertaken to support safe staffing across the Unit; Staff moved to support other wards. Patient requiring 24 hour 1:1 nursing in the month; Safe staffing levels maintained by sharing staff resource; Skill mix swaps undertaken to 3.9 6.5 10.3 support safe staffing across the Unit; Staff moved to support other wards. Patient requiring 24 hour 1:1 nursing in the month; Safe staffing levels maintained by sharing staff resource; Skill mix swaps undertaken to support safe staffing across the Unit; Staff moved to support other wards. Patient requiring 24 hour 1:1 nursing in the month; Safe staffing levels maintained by sharing staff resource; Skill mix swaps undertaken to 4.5 3.9 8.4 support safe staffing across the Unit; Staff moved to support other wards. Patient requiring 24 hour 1:1 nursing in the month; Safe staffing levels maintained by sharing staff resource; Skill mix swaps undertaken to support safe staffing across the Unit; Staff moved to support other wards. Page 24 of 24 2.5.1 Access Targets: Cancer Trajectory Update for review 1 Access Targets: Cancer Trajectory Update Report to the Trust Board of Directors dated 29 September 2020 Title: Agenda item: Sponsor: Date: Purpose Issue to be addressed: Response to the issue: Access Targets: Cancer Trajectory Update 2.5.1 Joe Teape, Chief Operating Officer 16 September 2020 Assurance Approval or reassurance Ratification Information Yes To provide an update to Trust Board on cancer performance following the last report that went to Trust Board in March 2020 and the impact of Covid19 on performance. The report provides an update on UHS cancer performance and covers the following; • Current performance against the key cancer metrics • Challenges faced during Covid-19 and impact on demand • Changes made in managing patients on a cancer pathway Implications: (Clinical, Organisational, Governance, Legal?) Clinical Organisational Governance and risk Risks: (Top 3) of carrying out the change / or not: The top 3 risks are: • Inability to meet required cancer standard targets • Inability to manage cancer patients during a Covid-19 pandemic • Risk of increase in cancer referrals of patients whose cancer may have spread so that the cancer will be harder to treat or no longer be curative Summary: Conclusion and/or recommendation The Trust Board is asked to consider the recent cancer performance and note the impact of COVID 19 has had on activity/demand and performance. The Board is asked to note whilst we have seen improvements in performance since April 2020 there remain significant risks to achievement and further work is being undertaken to develop mitigations & assess the impact of improving referral times from other organizations which impact on UHS. Page 1 of 7 1. Introduction/Background In March 2020 Trust Board was provided with an update on cancer performance and plans on acti
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Finance and Performance Reports 2023-24 Month 6 September 2023

Description: Report to the Trust Board of Directors Title: Agenda item: Sponsor: Author: Date: Purpose Finance Report 2023-24 Month 6 12.3 Ian Howard – Chief Financial Officer Philip Bunting – Director of Operational Finance David O’Sullivan – Assistant Director of Finance – Financial Performance 9 November 2023 Assurance or reassurance Approval Ratification Information X Issue to be addressed: Response to the issue: The finance report provides a monthly summary of the key financial information for the Trust. Finance and Investment Committee reviewed a detailed monthly finance report, including a review of forecast outturn and a spotlight on the capital and cash position. The full report is available to Trust Board members for background reading. The Committee agreed to highlight: M6 Financial Position UHS is reporting a deficit of £1.8m in September compared with a deficit plan of £2.3m. This is therefore £0.5m favourable to plan. The in-month position does however include nonrecurrent benefits relating to ERF (assumed to be non-recurrent at this stage), VAT reviews and additional back-dated income. YTD the deficit is £22.6m compared to a plan of £19m so £3.6m adverse to plan. The variance is due to the following three specific items: • Underfunded 22/23 non-consolidated pay award (Serco) - £1m. • 23/24 underfunded AfC pay award - £1m pressure YTD (£2m estimated for 23/24). This has reduced from the previous month as partial mitigations have been identified. • 23/24 underfunded medical pay award - £1.6m pressure YTD (£3.2m estimated for 23/24). This has also reduced in month as £1.4m of mitigations (full year calculation) have been identified mainly relating to education funding. ERF and Industrial Action ERF income of £1.2m is reported in month relating to a reassessment of prior period performance following the receipt of a further month of national data. The YTD position now includes £4.8m of ERF income with performance estimated at 114% against a revised target of 111%. Performance for September was 109% despite the significant challenge of managing industrial action which took place jointly for consultants and junior doctors. This covered a four-day period with three days of junior doctor strikes and two days of consultant strikes, one of which took place concurrently with junior doctors. Estimates value the loss of activity due to industrial action at £4.6m YTD as shown in the table below with a further £1.2m incurred in additional premium backfill costs. Page 1 of 31 Industrial Action Financial Impact Assessment (£m) Direct Cost Impact Estimated Loss of (Backfill less strike Month Income pay reductions) April 1.50 0.30 May 0.00 0.00 June 0.30 0.10 July 1.00 0.30 August 0.80 0.30 September 1.00 0.20 Total 4.60 1.20 Total Financial Impact 1.80 0.00 0.40 1.30 1.10 1.20 5.80 So far, the only adjustment to the ERF target relates to months up to April which reduced the annual target by 2%. Further announcements are expected in coming weeks although remain unconfirmed. We are however anticipating full relief for the impact of industrial action on the financial position of the Trust. Underlying Position The September reported position included several one-off items, as reported above. The Committee asked for the underlying position calculation to be reviewed, to included additional ERF income that would have been earned without industrial action, as well as adjusting for true non-recurrent savings only. This will be completed for M7, with the position expected to be in the region of £5m deficit per month. Deficit Drivers The underlying deficit continues to be driven by a number of underlying system pressures seen in 22/23, for which we have not been able to recover to date: • Non-pay inflation beyond funded levels • Impact of energy prices (with gas prices impacting UHS particularly hard) • High-cost drugs spend (previously pass-through) • Number of patients not meeting criteria to reside, impacting capacity (opening expensive “surge” capacity / bed capacity restricting elective activity) In 23/24, we are now seeing further pressures, notably: • Unfunded elements of pay awards - £0.4m per month. • The impact of industrial action is impacting our performance, both activity levels and capacity to deliver recurrent CIP. • Workforce pressures as substantive recruitment is not offset with temporary staffing reductions - £0.7m per month. • Covid testing funding reductions not immediately offset with cost reductions - £0.2m per month. • Mental health nursing pressures - £0.2m per month. • Tariff efficiency reductions not offset by recurrent CIP delivery - £0.7m per month. • Further growth in the number of patients not meeting the criteria to reside. These have been consistently at 200 with some weeks peaking at over 240. Unfunded additional activity is a further pressure for UHS where we are YTD providing activity above block funded level for free in the following areas: • £6.5m of outpatient follow up appointments • £3.8m of non-elective • £2.4m of other treatments UHS continues to target demand management within these areas shifting outpatients to patient initiated follow up protocols often via the My Medical Record platform. Page 2 of 31 Forecast Our submitted forecast to NHS England maintains delivery of a £26m deficit. This was underpinned by a £0.3m per month improvement to the financial position during 2023/24. The current YTD performance and run rate suggests it will be extremely challenging to achieve the planned position without additional funding due to industrial action costs. Finance Committee considered several potential forecasts, ranging from £26m deficit to £50m deficit, depending on the level of financial relief from industrial action and funding of pay-award pressures, as well as the level of H2 financial improvement being delivered. Due to the current funding uncertainty, it was recommended and agreed that the forecast remains at £26m until further clarity is received. Cost Improvement Plans Whilst £72m of CIP opportunities have been identified, the most-likely risk assessed position sits at £59m. Whilst we have made good progress with CIP performance, it is heavily supported by non-recurrent delivery that cannot be relied upon for underlying financial improvement. Capital A capital spotlight report highlighted that due to slippage and changes to funding, the Trust had a risk of under-spending against its CDEL target. However, we have identified £5.8m of schemes to bring-forward from the 2024/25 approved capital programme into 2023/24, mainly accelerating strategic maintenance schemes and medical equipment replacement. A further additional £1.3m of schemes have been prioritised as must-do schemes due to emerging risks (e.g., steam ducts propping). We are therefore slightly over-programmes, which is likely to be offset by further slippage risk and is within manageable levels. The risk of under-delivery has therefore been mitigated. The capital prioritisation process for 2024/25 and 2025/26 will soon commence using the multiyear programme already shared with finance and investment committee as a starting point. Planning 2024/25 The planning process for 2024/25 has been launched internally within the ICS in order to give an early indication of scale of financial challenge for the next financial year. Further updates will be provided at future finance and investment committees. Cash Spotlight The Committee considered a spotlight report into cash, which highlighted that cash has reduced from £105m to £68m in-year, driven largely by the Trust’s underlying deficit. The report highlighted the work of the finance team to maximise and safeguard the Trust’s cash position going forwards. A number of cash forecasts were considered, dependent on the underlying financial position of the Trust. However, it was anticipated the Trust would end the year with cash of circa £30m and may be required to request national cash support in either Q1 or Q2 of 2024/25. This is of course heavily dependent on income levels, industrial action relief and the impact of financial recovery measures across the ICB. Due to the scale of deterioration the Trust is rightfully ensuring future investment decisions show a cognisance of the scale of cash attrition to ensure projects can be completed and investments made responsibly with financing an important consideration. Page 3 of 31 Implications: • Financial implications of availability of funding to cover growth, cost pressures and new activity. • Organisational implications of remaining within statutory duties. Risks: (Top 3) of carrying out the change / or not: • Financial risk relating to the underlying run rate and projected potential deficit if the run rate continues. • Investment risk related to the above • Cash risk linked to volatility above • Inability to maximise CDEL (which cannot be carried forward) and the risk of a reducing internal CDEL allocation for 2024/25 due to the forecast deficit for 2023/24. Summary: Trust Board is asked to: Conclusion • Note the finance position. and/or • Note the update on capital. recommendation • Note the risk on the Trust’s cash position. Page 4 of 31 M6 Finance Report Page 5 of 31 Report to Trust Board October 2023 Ian Howard, CFO Philip Bunting, DOOF David O’Sullivan, Asst DOF Summary Page 6 of 31 2 Finance Dashboard Position (objective 5a) YTD vs. Plan Forecast Underlying Capital (objective 5d) YTD Forecast CIP (objective 5a) Identification Delivery Productivity (objective 5a) Page 7 of 31 3 Overall Position Page 8 of 31 4 Executive Summary In Month and Year to date Highlights: 1. In Month 6, UHS reported a deficit position of £1.8m which was £0.5m favourable to plan. YTD the deficit is now £ 22.6m which is £3.6m adverse to plan. The total plan for the year is £26m deficit which is currently forecast for delivery. The YTD shortfall to plan is a result of funding pressures relating to national pay awards for Agenda for Change and Medical staff. 2. The underlying position in September is a £6.1m deficit, which is in line with previous months run rates. This position exclu des the favourable impact of ERF overperformance within the overall trust position. 3. CIP delivery is reporting marginally behind plan YTD with £27.1m delivered vs plan of £27.8m. Of the value identified to date, £17.9m is non-recurrently delivered CIP. Annually, £71.7m of savings have been identified in plans, 104% of the trust target of £69m. A risk assessment of schemes has taken place which reduces the expected yield of schemes down to £59.1m - 86%. There is continued focus on savings identification and delivery to support financial recovery. 4. The themes seen in M6 were: 1. UHS is over its elective recovery target to the end of M6 at 114% / £4.8m favourable. Performance continues to be impacted by both industrial action and an increase in non-elective activity. Further changes to ERF targets are anticipated nationally but are not yet known. 2. Medical Pay Awards costs have been paid within the M6 position. This has resulted in a £1.8m pressure (above funded levels) YTD. The forecast annual impact of this is £3.2m. 3. Underlying drivers for the monthly financial deficit largely remain as per 22/23 including inflation, energy, drugs and incre ased volumes of patients not meeting the criteria to reside. 4. Upward workforce trends remain a risk with particular pressures around additional nursing spend related to providing safe car e for mental health patients and costs relating to cover for industrial action. 5. Surge capacity also remains open at times to support flow at times of peak bed pressure. Page 9 of 31 5 Overall Financial Position Income Clinical Income Pass-through Drugs & Devices Other Income Total Revenue Costs Pay - Substantive Pay - Bank Pay - Agency Drugs Pass-through Drugs & Devices Clinical Supplies Other non pay Total Operating Expenses Remove Depreciation and Amortisation Donated Income Profit/(Loss) from Operations (EBITDA) Add Less Non Operating Income Non Operating Expenditure Budget Full Year £000's Plan £000's Current Actual £000's Variance £000's Plan £000's Year to date Actual £000's Variance £000's 839,728 186,582 176,791 1,203,101 69,978 15,548 14,117 99,643 69,964 16,141 14,190 100,295 14 (592) (73) (652) 419,869 93,291 85,439 598,599 431,921 101,091 82,321 (12,052) (7,800) 3,118 615,333 (16,734) 630,404 43,631 15,070 35,928 186,582 67,008 225,801 1,204,424 38,037 (16,583) 20,131 2,166 (34,189) 52,521 3,876 1,287 2,994 15,548 5,793 18,749 100,769 3,128 (617) 1,385 181 (3,486) 55,136 4,189 1,092 3,223 16,141 1,497 18,764 100,041 3,024 (886) 2,392 391 (3,905) 2,615 313 (195) 228 592 (4,297) 15 (728) (104) (269) (1,007) (210) 419 313,401 23,667 8,254 17,966 93,291 35,797 114,749 607,124 18,972 (6,231) 4,216 1,086 (19,296) 331,885 24,948 6,751 16,529 101,091 31,589 115,700 628,493 18,383 (4,560) 663 2,585 (22,360) 18,484 1,281 (1,503) (1,436) 7,800 (4,208) 950 21,368 (589) 1,671 3,553 (1,499) 3,064 Net Surplus / (Deficit) incl Impairments & Donation Less Donated Income Less Profit on disposals Less Gain/ Loss on absorption Add back Donated Depreciation Add back Impairments Total Net Surplus / (Deficit) (11,892) (16,583) 0 0 2,475 0 (26,000) (1,920) (617) 0 0 204 0 (2,333) (1,122) (886) 0 0 178 0 (1,830) (798) (13,994) (19,112) 269 (6,231) (4,560) 0 0 0 0 0 0 26 1,225 1,041 0 0 0 (503) (19,000) (22,631) Page 10 of 31 5,118 (1,671) 0 0 184 0 3,631 UHS has submitted an annual plan position of £26m deficit for the 2023/24 financial year. In September a deficit position of £1.8m was reported, £0.5m favourable to plan. The YTD position of £22.6m deficit is £3.6m adverse to the planned deficit target of £19.0m. In Clinical Income ERF overperformance is reported at £4.8m YTD. This figure include an adjustment to April ERF baseline target at 2%. Future amendments are anticipated but have not been confirmed to date. The balance of the YTD favourable position on clinical income is as a result of pay award funding received above initial planning assumptions totalling £10.4m. Pay expenditure continues to exceed plan, due to pressures from the national pay awards, requirements for mental health nursing support, staffing of surge capacity areas, unfunded workforce growth in prior periods and lower than planned pay CIP Delivery. £10.4m of the pay variance is additional pay award funding offset within clinical income. Non pay categories (excluding pass through) are under plan YTD largely as a result of several nonrecurrent benefits taken in year. 6 Run Rates • The UHS run rate position has continued in M6 at a deficit of £1.8m which is lower than planned levels, however is the result of a number of non recurrent benefits released into the position. • The improved run rate trend in the second half of 2022/23 financial year was delivered by non recurrent means with the underlying position remaining challenging. This has continued into 2023/24. • Pressures continue across all expenditure and income types with notable challenges experienced in month detailed below. • Pay – Continued pressures as a result of national pay awards for AFC and medical staff, industrial action and mental health nurs ing. • Non Pay – Cost pressures relating to Energy increases and inflationary pressures on clinical supplies. Trends can be volatile du e to pass through drugs and devices which are not uniform each month. • Income – the run rate reduced in month following receipt of funding towards medical pay awards and ERF in M5. YTD ERF performance is reporting over plan by £4.8m / 114%. Page 11 of 31 7 Run Rates Page 12 of 31 8 Underlying Position / Risk Analysis Tbals The graph shows the underlying position for the Trust from April 2022 to present. This differs from the reported financial position as it has been adjusted for non recurrent items (one offs) to get a true picture of the run rate. Risk Variable Unidentified CIP Workforce Pressures CIP Delivery Risk Inflationary Pressure Unfunded Activity MH Nursing Covid Testing Criteria to Reside / Surge Capacity Energy Unfunded Pay Award Total Risk Mitigations Additional CIP ERF (Including IA adjustments) Stretch CIP Net Risk Risk @ Plan £m 15.8 0.0 18.2 8.0 0.0 0.0 0.0 0.0 0.0 0.0 42.0 (18.0) 0.0 0.0 Pag2e41.30of 31 Risk - current £m 0.0 8.4 9.9 0.0 2.5 2.3 1.2 1.2 2.1 6.2 33.8 0.0 (19.8) (7.5) 6.5 The average underlying position for 23/24 to date is £6.0m deficit. M6 figures showed a position of £6.1m. Due to the variability and unknown national picture on ERF (due to industrial action pressures), these figures have been excluded from underlying calculations. The decline since 2022/23 has primarily been driven by escalating pay award pressures, pressures related to activity, including the need for surge beds and impacts of strike actions in addition to the challenge of delivering efficiencies. A table outlining risks is also shown matching forecast scenario 2 on slide 12. 9 Key Variance Drivers Page 14 of 31 Key variance bridge A recurrent underlying deficit position was carried forward from the previous financial year of circa £4m per month. Trust plans were for month on month improvement reaching breakeven by financial year end. The graph to the left provides the following analysis: Stage 1) Items driving the Trust adverse position from planned £19.0m deficit to £22.6m reported YTD. Stage 2) Sets out non recurrent benefits to the position that bridge to the underlying deficit at M6 of £36.2m. ERF overperformance has also been removed from the underlying position. 10 Key Variance Drivers Page 15 of 31 Key variance pressures The following table sets out the key recurrent drivers that have resulted in adverse movements to plan in the underlying position during the 2023/24 financial year. - The yellow boxes represent pressures out of the organisations direct control and total £5.6m YTD of the adverse position to plan. - The red boxes identify pressures within the organisations control and total £11.6m YTD of the additional deficit to plan. - ERF overperformance has been removed from underlying position figures. These items require mitigation to deliver a breakeven underlying position moving forwards in addition to delivering the originally planned deficit reductions. 11 Forecasting / Forward View Page 16 of 31 The graphs provide forecast scenarios on a monthly and cumulative scenario for remainder of the financial year. 1) Delivery of plan. Resulting in a year end out turn deficit of £26m. 2) Original plan plus full impact of pay award pressures, receipt of industrial action support and £7.5m additional run rate efficiency improvement - £32.5m out turn. 3) Original plan plus full impact of pay award pressures, receipt of industrial action support, no further efficiency improvements - £40.0m out turn. 4) Original plan plus full impact of pay award pressures, no industrial action support or further efficiency improvements £50m out turn. 12 Cost Improvement Programme Page 17 of 31 UHS Total - £71.7m identified 104% of the total 23/24 requirement of £69m. Of the identified UHS total, £9.9m is Pay, £32.3m is Non-Pay, and £29.5m Income. Divisions and Directorates - £42.0m of CIP schemes identified. This represents 98% of the 23/24 target of £43.1m Central Schemes - £29.7m of CIP schemes identified. This represents 115% of the 23/24 target of £25.9m M 6 Trust YTD delivery is £27.1m. An increase in month of £6.3m. YTD delivery is below plan by £0.7m. Of the £27.1m delivered: £12.9m has been transacted by Divisions and Directorates £14.3m has been transacted through Central Schemes. £17.9m is non-recurrent. This includes £9.8m of non-recurrent Central Schemes. 13 Cost Improvement Programme • A risk assessment has been undertaken of the identified schemes to date in the table above. • The expected yield from plans is currently £59.1m, 86% of the 23/24 requirement • A significant reduction to total identification has taken place in month following review of the highest risk assessed items. Due to insufficient enabling plans and progress at ICS level, the £11.2m of system wide schemes based upon Carnall Farrar opportunity assessment for improved patient flow and reduction of non ‘criteria to reside’ occupancy have been removed. Page 18 of 31 14 Capital Page 19 of 31 Summary Position: Total capital expenditure (trust and external) YTD is £13.7m vs plan of £23.8m with a forecast outturn of £55.2m. To achieve the forecast position, £4.6m of expenditure has been agreed to be brought forward from 24/25 to replace slippage on 23/24 schemes. Trust Funded: To the end of M6, £12.2m has been spent on trust funded schemes against a YTD plan of £23.2m, with an annual forecast outturn of £47.7m Exte rnally Funded: To the end of September, £1.5m has been spent on externally funded schemes vs a YTD plan of £0.6m, with an annual forecast spend of £7.5m. 15 Capital Top 5 schemes by YTD Expenditure Value £000s Oncology Centre Ward Expansion Levels D&E Donated Estates Schemes Information Technology Programme Decarbonisation Schemes Strategic Maintenance Plan 6,235 2,262 2,178 4,500 2,124 Year to Date Actual 3,152 2,528 2,013 1,941 1,663 Variance 3,083 (266) 165 2,559 461 Plan 7,135 2,624 5,800 11,259 5,200 Forecast Actual 6,926 3,317 5,800 11,259 7,240 Variance 209 (693) 0 0 (2,040) • Spend on the wards expansion scheme remains high on a monthlybasis as the skyway link bridge element is constructed. • The Banksy funded staff welfare schemes (the welfare hub, PAH roof garden and staff room refurbishment) are complete • Informatics YTD expenditure has been incurred mainlyon staffing, core infrastructure and the ED & Flow contract. • The first milestone of the decarbonisation scheme has been reached meaning that £1.3m of costs are now due for payment. • Strategic Maintenance costs were high in month 6 at £1.1m, due to significant expenditure on the PAH substation (£0.6m) Top 5 Schemes by YTD Variance Year to Date Forecast £000s Plan Actual Variance Plan Actual Fit out of F Level Theatres (VE) 3,396 73 3,323 8,500 6,827 Oncology Centre Ward Expansion Levels D&E 6,235 3,152 3,083 7,135 6,926 Decarbonisation Schemes 4,500 1,941 2,559 11,259 11,259 Neonatal Expansion 2,283 287 1,996 10,030 7,917 CT Scanner 1,560 0 1,560 1,560 1,560 Variance 1,673 209 0 2,113 0 • Phase 3a of the F level theatres is now due to start in October and complete around Aug 24. • All works on the oncologyward expansion scheme (including the skywaylink bridge) will not be complete until Jan 24. • Decarbonisation scheme onlycommenced in August, but plans are in place to ensure the planned £11.3m of the grant are completed byMar 24. • Phase 1 of the neonatal expansion has commenced, and the scheme should complete in Jun 24. • The installation of the CT scanner will be later than originallyplannPeadgaen2d0woifll3th1erefore be accounted for Mar 24. 16 Statement of Financial Position 2022/23 M1 M2 M3 M4 M5 M6 MoM Statement of Financial Position YE Act Act Act Act Act Act Act Movement £m £m £m £m £m £m £m £m The September statement of financial position illustrates net assets of £566.6m which is £4.0m down on August. Fixed Assets Inventories Receivables Cash Payables Current Loan Current PFI and Leases 620,431 15,753 95,056 105,018 (229,641) (1,533) (12,580) 617,160 18,104 93,552 105,475 (237,019) (1,533) (12,202) 619,161 18,074 89,834 85,892 (218,352) (1,533) (12,153) 620,900 18,455 73,434 81,557 (202,499) (1,533) (11,347) 622,082 16,941 75,632 66,895 (195,495) (1,533) (11,228) 621,364 19,317 92,177 62,611 (212,574) (1,533) (10,705) 621,497 19,487 53,710 68,286 (184,559) (1,533) (10,272) 133 170 (38,467) 5,675 28,015 0 433 Net Assets 592,504 583,537 580,923 578,967 573,294 570,657 566,616 (4,041) Non Current Liabilities (24,624) (22,798) (22,759) (22,848) (21,545) (21,307) (21,426) (119) Non Current Loan (5,302) (5,302) (5,302) (4,802) (4,802) (4,802) (4,534) 268 Non Current PFI and Leases (108,576) (105,561) (107,100) (108,888) (107,948) (107,416) (104,644) 2,772 Total Assets Employed 454,002 449,876 445,762 442,429 438,999 437,132 436,012 (1,120) Public Dividend Capital Retained Earnings Revaluation Reserve 286,212 102,068 65,722 286,212 97,942 65,722 286,212 93,828 65,722 286,212 90,494 65,722 286,212 87,065 65,722 287,328 84,082 65,722 287,328 82,962 65,722 0 (1,120) 0 Total Taxpayers' Equity 454,002 449,876 445,762 442,428 438,999 437,132 436,012 (1,120) Page 21 of 31 Cash increased by £5.7m to £68.3m, following receipt of additional clinical and R&D income in month. The main movements in month were due to: - Receivables: Decreased by £38.5m following a reduction of £6.1m in accrued clinical income and £12.9m decrease in prepayments largely due to timings of M6 invoices paid in August. - Payables: Decreased by £28.0m in M6. This was due to £7.3m relating to medical and serco pay awards now paid, £4.9m decrease in PDC creditor as the half year payment was made in month. There were also entries that netted off between receivables and payables totalling £15m. 17 Cash and Payments Page 22 of 31 The cash balance increased by £5.7m to £68.3m in September. The reduction in year has been driven chiefly by the underlying deficit. In year volatility has however been influenced by: - The timing of pay award funding versus payments made to staff and HMRC/NHS Pensions Authority - Capital programme timings including slippage versus plan - Higher R&D receipts and VAT recovery The minimum cash holding position is set at £30m. Based on current trajectory, we are expected to reach this level by the end of the financial year in April 2024. There is on average a £5.5m cash outflow per the detailed inputs. This has moved out from December as per the M05 forecast due to maintaining the cash position in M06, which has been improved due to paying invoices as they fall due, rather than processed. Better Payment Practice Code (BPPC) performance in September is over the 95% target for both count and value. 18 Further Analysis of Position Page 23 of 31 19 Income / ERF The graph shows the ERF performance for 23/24 as well as a trend against plan for 22/23. In 23/24 the Trust has a target to achieve 111% (reduced from 113% following industrial action) of 19/20 activity for elective inpatients, outpatient first attendances and outpatient procedures. Delivery above this targeted level will generate additional funding for the Trust. ERF Performance (Target = 113%) Elective Spells Daycase Outpatients Firsts Outpatients Procedures Overall ERF Performance Excess Outpatient Follow Ups £'000s Excess Non Elective and ED £'000s Excess Other £'000s At the end of Month 6, ERF activity has been reported above plan to the value of £4.8m / 114%. Apr-23 May-23 Jun-23 108% 124% 100% 114% 108% 119% 115% 125% 112% 131% 133% 126% 118% 123% 110% £940 £1,388 £1,013 £34 £867 £1,709 £390 £536 £753 Jul-23 104% 112% 113% 133% 112% £894 -£4 £31 Aug-23 Sep-23 109% 90% 111% 115% 125% 125% 128% 125% 115% 109% £1,290 £1,010 £828 £322 -£65 £757 Oct-23 Nov-23 Dec-23 Jan-24 Page 24 of 31 Feb-24 Mar-24 Total 104% 113% 119% 127% 114% £6,535 £3,756 £2,402 No further decisions have been made to date on further national reductions to the ERF baseline following industrial action days between May and September. The table shows monthly achievement by POD type vs 19/20 baseline. Significant non ERF related activity is currently being provided by UHS above its block funded levels, totalling £12.7m. 20 Clinical Income - Elective Page 25 of 31 21 Clinical Income – Non Elective and Other Page 26 of 31 22 Staff Costs Pay Expenditure: • Pay costs have been normalised for the backdated impact of pay awards on the above graph (Payments made in M4 AFC and M6 Medical). • The normalised pay spend has increased by £0.6m between August and September. Of which £0.4m related to increased substantive costs and £0.2m for temporary staffing. • The main drivers of substantive cost increases in the month were: - ACP staff received pay arrears (backdated to April 23) of £0.25m following completion of a regrading exercise. - Increased Junior Doctor costs of circa £0.1m following an increase in WTE headcount in months 5 and 6. • Costs of staffing surge capacity in month totalled £0.11m, up from £0.07m in M5. Total spend YTD is now £0.59m. • Mental health temporary staffing costs remained flat in month at £0.67m. This sees a continued increase in average spend in the area compared with 22/23 values £0.40m and 23/24 average to date of £0.59m. Total spend YTD to the end of M6 is £3.56m. • Staffing WTE has increased by 84 WTE in month. This growth takes WTE actuals further away from planned values for the year. Page 27 of 31 23 Temporary Staffing Costs Page 28 of 31 Bank: Bank expenditure increased in month from £4.1m up to £4.2m. Increases have been experienced in: - Nursing up £72k - Admin staff up £72k Decrease of costs were experienced in: - Medical staff down £39k. - Scientific and Technical down £2k Age ncy: Agency costs increased in month by £0.1m up to £1.4m overall. Reductions were experienced in: - Nursing Staff down by £63k - Scientific and Technical down by £13k Increases were experienced across other staff groups: - Admin Staffing up by £158k - Medical Staff up £4k 24 Non-Pay Costs Non Pay Expenditure: • Other non pay has reduced in month back to expected levels following high costs in M5 relating to backdated inflation costs for Propco. • Non pass through drugs spend has increased in month by £0.8m overall. Increase were experienced within the care groups of Cancer, Specialist Medicine and Child Health. Costs are being investigated in collaboration with pharmacy to understand drivers and if pass through income may be available. • Clinical supplies costs have reduced in month by £4.0m, this is predominately due to non recurrent one-off benefits recognised in September. Page 29 of 31 25 CIP – Recurrent Pay Identification WTE and £ Re current Pay CIP: • The above table demonstrates the Pay CIP target for the organisation in 2023/24 based on WTE and £ values • On a WTE basis 61 WTE have been identified YTD, 16% of the 392 WTE target • On a £’s basis £3.2m have been identified YTD, 22% of the £14.6m target Page 30 of 31 26 Page 31 of 31 Report to the Trust Board of Directors Title: Agenda item: Sponsor: Author Date: Purpose Performance KPI Report 2023-24 Month 6 12.2 David French, Chief Executive Officer Sam Dale, Associate Director of Data and Analytics 9 November 2023 Assurance or Approval reassurance Y Ratification Information Issue to be addressed: The report aims to provide assurance: • Regarding the successful implementation of our strategy • That the care we provide is safe, caring, effective, responsive, and well led Response to the issue: The Performance KPI Report reflects the current operating environment and is aligned with our strategy. Implications: This report covers a broad range of trust performance metrics. It is (Clinical, intended to assist the Board in assuring that the Trust meets Organisational, regulatory requirements and corporate objectives. Governance, Legal?) Risks: (Top 3) of carrying out the change / or not: This report is provided for the purpose of assurance. Summary: Conclusion and/or recommendation This report is provided for the purpose of assurance. Page 1 of 22 Report to Trust Board in October 2023 Performance KPI Board Report Covering up to September 2023 Sponsor – David French, Chief Executive Officer Author – Sam Dale, Associate Director of Data and Analytics Page 2 of 22 Report to Trust Board in October 2023 Report guide Chart type Cumulative Column Example Cumulative Column Year on Year Line Benchmarked Line & bar Benchmarked Control Chart Variance from Target Explanation A cumulative column chart is used to represent a total count of the variable and shows how the total count increases over time. This example shows quarterly updates. A cumulative year on year column chart is used to represent a total count of the variable throughout the year. The variable value is reset to zero at the start of the year because the target for the metric is yearly. The line benchmarked chart shows our performance compared to the average performance of a peer group. The number at the bottom of the chart shows where we are ranked in the group (1 would mean ranked 1st that month). The line shows our performance, and the bar underneath represents the range of performance of benchmarked trusts (bottom = lowest performance, top = highest performance) A control chart shows movement of a variable in relation to its control limits (the 3 lines = Upper control limit, Mean and Lower control limit). When the value shows special variation (not expected) then it is highlighted green (leading to a good outcome) or red (leading to a bad outcome). Values are considered to show special variation if they -Go outside control limits -Have 6 points in a row above or below the mean, -Trend for 6 points, -Have 2 out of 3 points past 2/3 of the control limit, -Show a significant movement (greater than the average moving range). Variance from target charts are used to show how far away a variable is from its target each month. Green bars represent the value the metric is achieving better than target and the red bars represent the distance a metric is away from achieving its target. Page 3 of 22 Report to Trust Board in October 2023 Introduction The Performance KPI Report is presented to the Trust Board each month. The report aims to provide assurance: • regarding the successful implementation of our strategy; and • that the care we provide is safe, caring, effective, responsive, and well led. The content of the report includes the following: • The ‘Spotlight’ section, to enable more detailed consideration of any topics that are of particular interest or concern. The selection of topics is informed by a rolling schedule, performance concerns, and requests from the Board; • An ‘NHS Constitution Standards’ section, summarising the standards and performance in relation to service waiting times; and • An ‘Appendix,’ with indicators presented monthly, aligned with the five themes within our strategy. This month, the following changes have been made to the report. • Data change: The medication errors data (metric 11) for August 2023 has been reduced from 4 to 3 cases as the severity for one case has been re- assessed and downgraded • Data Omission. The latest HSMR metrics reflect the July position as the latest statistics are yet to be published on the Healthcare Evaluation Data (HED) dashboards. Page 4 of 22 Report to Trust Board in October 2023 Summary This month the ‘Spotlight’ section contains an update on performance for RTT Waiting Times. The RTT spotlight highlights that: • Excluding a small cohort of corneal transplant patients impacted by national availability of tissue grafts, there are zero patients on the UHS RTT waiting list who have been waiting over 104 weeks for their elective treatment and three patients waiting over 78 weeks at the end of September. • The hospital targeted zero (non-corneal) patients waiting over 78 weeks by the end of October, however the extreme operational pressures experienced in the hospital at the end of October required a handful of complex but lower priority 78 week cases to be rescheduled into November. • The trust is in line with its submitted forecast which committed to having zero patients waiting over 65 weeks by March 2024. Performance against this target is being closely monitored and discussed with caregroups in weekly performance meetings. • A national Patient Initiated Digital Mutual Aid System (PIDMAS) will be launched imminently to understand how many patients on the waiting list would consider being treated at an alternative provider if deemed clinically appropriate. Areas of note in the appendix of performance metrics include: 1. We await the validated September position for Cancer waiting times, however August’s position reflects a further increase on two week wait performance (74.0%) putting UHS into the second quartile for this metric and the 62 day standard when compared to other Teaching Hospitals 2. The diagnostic waiting list continues to decrease every month within this financial year and now stands at 8,447 with 20% of patients waiting over six weeks. 3. Despite a decline in the number of category 2 pressure ulcers per 1000 bed days, both category 2 and 3 remain above the year to date target position. An ongoing campaign to increase awareness and enable staff to feel more confident with pressure ulcer prevention is underway and we are seeing a huge rise in the uptake of this education in the last quarter. 4. The percentage of births delivered by caesarean continue at the same increased rate. Whilst the department are implementing training and education strategies to ensure birth preference conversations happen early in the pathway, this will take time to reflect in the metrics. 5. The percentage of UHS women booked onto a continuity of carer pathway has remained below target throughout the year. The current CoC provision was affected by staffing and operational pressures over the summer. The majority of this has affected continuity around intrapartum care. The maternity service is trialling a different way to recruit into these teams by offering more flexible options for midwives to increase recruitment into these rewarding but very challenging roles. To give assurance the maternity service monitors and audits 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 o utcomes. Page 5 of 22 Report to Trust Board in October 2023 6. The decline in the September metric for Research and Development income reflects the cessation of the £20m COVBOOST grant which was previously contributing approximately £1m per month. The department also reprofiled Biomedical Research Centre funding from the National Institute of Health Research as it is expected to be deferred until 2024/25. Ambulance response time performance The latest unvalidated weekly data provided by the South Coast Ambulance Service (SCAS) shows that UHS does not significantly contribute to ambulance handover delays. In the week commencing 16th October 2023, our average handover time was 18 minutes 9 seconds across 801 emergency handovers, and 20 minutes 52 seconds across 45 urgent handovers. There were 44 handovers over 30 minutes, and 20 handovers taking over 60 minutes (the majority on 21 October) within the unvalidated data. Page 6 of 22 Report to Trust Board in October 2023 Spotlight Report Spotlight: Referral to Treatment Waiting Times The following information is based on the validated September 2023 submission, with operational insight based on the latest position for our long waiters. Overview In the 2023/24 NHS operational planning guidance, the priority for elective care was to eliminate waits of over 65 weeks by March 2024 (except where patients choose to wait longer or in specific specialties). In 2022/23, an equivalent priority was set for waits of over 78 weeks. To support and monitor Trust trajectories against the 2023/24 target, the national team have laid out additional in-year targets around patient pathway validation and outpatient referrals waiting for their first attendance. This is alongside the roll out of a national Patient Initiated Digital Mutual A id scheme (PIDMAS). This spotlight paper outlines the Trust’s current and forecast position against the national target, illustrates how we compare with our peer Trusts and explores some of the challenges, specialties and interventions which are influencing our position. Waiting Times Overview Graph 1 highlights the recent slowing down of the growth of the UHS PTL (patient treatment list) compared to the significant increases seen since January 2020. Graph 1 – RTT PTL volumes by waiting time The PTL was 59,253 at the end of September 2023, an increase of 5% since April 2023 (56,568). This compares to a PTL increase of 10% which seen across the equivalent period in 2022. It also highlights the waiting time cohort changes as we transition our focus from patients waiting over 78 weeks to the in-year target focussed on patients waiting over 65 weeks. Within the current PTL, there are 21 patients who have been waiting over 78 weeks and 349 who have been waiting over 65 weeks . In September 2022, the equivalent numbers were 286 (78 weeks) and 986 (65 weeks). Page 7 of 22 Report to Trust Board in October 2023 Spotlight Report Patients waiting over 78 and 104 weeks The only UHS patients waiting over 104 weeks in 23/24, are a small cohort of Ophthalmology patients (one in October) waiting for corneal transplants. This clinical situation is echoed across the country as the procedure is reliant on graft tissue being made available by the NHS Blood and Transfusion Centre. Excluding corneal patients, the Trust had three patients waiting over 78 weeks at the end of September. These patients have been within a handful of challenged specialties including Gynaecology, Urology and Paediatrics. In most cases, the required surgery is complex often requiring joint surgeons and was provisionally booked before 78 weeks. However, industrial action, clinical complications or managing a higher priority patient has required a cancellation. Any 78 week breaches have always been rebooked in the following month. We targeted zero (non corneal) patients waiting over 78 weeks by the end of October, however the very recent extreme pressures on our emergency services and elective capacity particularly within Trauma & Orthopaedics has inevitably impacted the planned surgery dates for a small cohort of long waiting patients, who have now been rescheduled for November. Patients waiting over 65 weeks At the end of September the Trust had 425 patients on the PTL who have been waiting over 65 weeks. As part of the Trust’s commitment to achieve the national target of zero 65 week waits by March’24, we submitted a glide which we are pro-actively monitoring every month. The performance team meet with each division to review individual patients who have not been booked against a target which we have stepped down from 78 weeks in April’23 to 65 weeks by December’23. This gives us clear line of sight against our glide, ensures services are pro-actively managing the appropriate cohorts and highlights consultants who need capacity plans or alternative pathway options to be explored. The Trust is currently in line with the 65 week glide submitted (see graph 4). Graph 2: Volume of patients waiting over 78 weeks by month Graph 3: Volume of patients waiting over 65 weeks by month Page 8 of 22 Report to Trust Board in October 2023 Spotlight Report 30,000 25,000 20,000 15,000 10,000 5,000 Apr/23 May/23 Jun/23 Jul/23 Aug/23 Sep/23 Oct/23 Nov/23 Dec/23 Jan/24 Feb/24 Mar/24 All Divisions Glide All Divisions Actual Graph 4: UHS 65 week performance glide and actual position Comparison with other Trusts In the latest available data (August’23) UHS places in the top quartile for the number of patients waiting over 65 weeks compared to other Teaching Hospital. This is illustrated in Graph 5. It should be noted that the metric is based on overall volume of patients rather than a percentage of the Trust’s overall PTL size which has not been made available. Graph 5: Teaching hospital comparator: patients waiting over 65 weeks Page 9 of 22 Report to Trust Board in October 2023 Spotlight Report Outpatient Referrals To support and gain assurance on our 65 week trajectories, the national team asked Trusts to ensure all patients who could breach 65 weeks by 31st March 2024, had their first outpatient appointment before the end of October 2023. Each service has therefore been working to ensure first outpatient appointments for this cohort are brought forward where necessary and appropriate. We envisage that a handful of specialties do not have the capacity to hit that target leaving approximately 800 patients unseen before 31st October, however, the majority of these patients have appointments in November with a small tail following soon after. The UHS glide against this target is shown in graph 6. The main challenged specialties are ENT, Paediatric Orthopaedics and Neurology. Volume of patients who will have breached 65 weeks by 31st March 24 and haven't had a first OP appointment 1000 800 600 400 200 0 Aug-23 Sep-23 Oct-23 Nov-23 Dec-23 Jan-24 Feb-24 Mar-24 UHS Graph 6: 65 week risk cohort waiting for a first OP appointment Patient Validation To ensure patient treatment lists are appropriately validated by hospitals, we have also been set a target of 90% of patients waiting over 12 weeks to have been validated by the end of October. This validation process ensures that patients are being reported on the appropriate waiting time and pathway and do still wish to proceed with their intended treatment, diagnostic or consultation. UHS employ both a central validation team and validation leads in each of the caregroups to support this process. This is now alongside our patient texting service which ensures appropriate contact is maintained with the patient and changes in need are understood. The Trust expects to achieve the 90% target through a combination of these approaches. PIDMAS The national team will imminently roll out a patient initiated digital mutual aid system. At the time of writing, the digital solution has been tested in a handful of pilot sites with an intended launch for all trusts at the end of October. The process is to enable patients to declare whether they would consider being offered to an alternative provider for their treatment. This will initially be offered to patients waiting over 40 weeks and will involve a text to a patient redirecting them to a digital platform where they can express their preference and how far they are willing to travel for treatment. This will then be reliant on clinical approval for suitability and another Trust declaring appropriate capacity. The process is being overseen by the I CB. Whilst the intention is to improve waiting times for patients, the solution is still in its infancy and not being used to influence the UHS forecast pos ition on long waiting patients. Page 10 of 22 Report to Trust Board in October 2023 Spotlight Report NHS Constitution - Standards for Access to services within waiting times The NHS Constitution* and the Handbook to the NHS Constitution** together set out a range of rights to which people are entitled, and pledges that the NHS is committed to achieve, including: The right to access certain services commissioned by NHS bodies within maximum waiting times, or for the NHS to take all reasonable steps to offer you a range of suitable alternative providers if this is not possible • Start your consultant-led treatment within a maximum of 18 weeks from referral for non-urgent conditions • Be seen by a cancer specialist within a maximum of 2 weeks from GP referral for urgent referrals where cancer is suspected The NHS pledges to provide convenient, easy access to services within the waiting times set out in the Handbook to the NHS Constitution • All patients should receive high-quality care without any unnecessary delay • Patients can expect to be treated at the right time and according to their clinical priority. Patients with urgent conditions, such as cancer, will be able to be seen and receive treatment more quickly The handbook lists 11 of the government pledges on waiting times that are relevant to UHS services, such pledges are monitore d within the organisation and by NHS commissioners and regulators. Performance against the NHS rights, and a range of the pledges, is summarised below. Further information is available within the Appendix to this report. * https://www.gov.uk/government/publications/the-nhs-constitution-for-england/the-nhs-constitution-for-england ** https://www.gov.uk/government/publications/supplements-to-the-nhs-constitution-for-england/the-handbook-to-the-nhs-constitution-for-england Page 11 of 22 Report to Trust Board in October 2023 NHS Constitution Monthly Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep target YTD 75% % Patients on an open 18 week pathway (within 18 weeks ) 31 UHSFT 65.1% 63.2% 4 5 6 5 5 5 5 5 4 4 4 4 5 4 ≥92% Teaching hospital average (& rank of 20) South East average (& rank of 17) 6 6 6 5 5 5 5 5 6 6 5 5 6 6 50% 63.7% % Patients following a GP referral for 100% suspected cancer seen by a specialist within 8 9 89.1% 10 13 17 14 13 15 17 17 17 16 16 16 2 weeks (Most recently externally reported 38 data, unless stated otherwise below) UHSFT Teaching hospital average (& rank of 20) 4 4 8 18 11 16 11 13 10 18 19 16 13 74.0% 10 South East average (& rank of 17) 55% ≥93% Cancer waiting times 62 day standard - 100% Urgent referral to first definitive treatment (Most recently externally reported data, 39 unless stated otherwise below) UHSFT 11 11 17 14 17 14 18 14 14 9 14 13 10 15 66.3% 63.7% Teaching hospital average (& rank of 19) South East average (& rank of 17) 4 40% 4 10 11 7 12 11 7 14 5 9 3 7 6 ≥85% 100% Patients spending less than 4hrs in ED - 58.6% (Type 1) 62.3% 7 5 4 9 12 9 8 8 12 28 UHSFT 7 4 5 7 6 6 ≥95% Teaching hospital average (& rank of 16) South East average (& rank of 16) 25% 4 3 4 4 4 4 3 3 3 5 7 5 5 5 7 40% 24.8% % of Patients waiting over 6 weeks for diagnostics 37 UHSFT Teaching Hospital average (& rank of 20) 9 9 11 11 11 12 12 12 8 10 7 7 7 8 7 9 20.0% 8 7 9 8 8 8 12 11 11 11 10 10 ≤1% South East Average (& rank of 18) 0% 70.8% 65.4% 62.2% 21.0% Page 12 of 22 Report to Trust Board in October 2023 Outstanding Patient Outcomes,Safety and Experience Appendix Outcomes 1 HSMR - UHS HSMR - SGH 2 HSMR - Crude Mortality Rate Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep 88.76 86.95 84.99 83.48 75 3.1% 2.9% 2.7% Monthly target ≤100 <3% YTD 82.7 2.6% YTD target ≤100 <3% 2.5
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Trust-governance-and-corporate-docs/2023-Trust-documents/Finance-and-Performance-Reports-2023-24-Month-6-September-2023.pdf

DVdSC (weekly cycles 9 onwards) DaratumumabSC-Bortezomib-Dexamethasone Ver1

Description: Chemotherapy Protocol Myeloma DVd SC (weekly) Bortezomib Daratumumab Dexamethasone Cycles 9 onwards Regimen • Myeloma – Bortezomib with daratumumab and dexamethasone Indication • Daratumumab in combination with bortezomib and dexamethasone is recommended for use as an option for treating relapsed multiple myeloma in people who have had 1 previous treatment. • This weekly bortezomib regimen is for patients who experience neuropathy or those with pre-existing neuropathy. Note both the twice weekly and weekly bortezomib regimens include 32 doses of bortezomib; therefore bortezomib continues to the end of cycle 10 in the weekly regimen. Ensure the correct daratumumab cycle 9 onwards is selected. Toxicity Drug Daratumumab Dexamethasone Adverse Effect Infusion related reactions, hypotension, headache, rash, urticaria, pruritus, nausea, vomiting, respiratory tract infections (including pneumonia), neutropenia, thrombocytopenia, anaemia, lymphopenia, peripheral neuropathy, diarrhoea, muscle spasms, fatigue, pyrexia and peripheral oedema, blood transfusion related events. Weight gain, gastrointestinal disturbances, hyperglycaemia, CNS disturbances, Cushingoid changes, glucose intolerance. The adverse effects listed are not exhaustive. Please refer to the relevant Summary of Product Characteristics for full details. Monitoring Drugs • FBC, U&Es, Ca2+ and LFTs prior to day one of each cycle of treatment. • Paraprotein and / or light chains prior to each cycle. • All patients should be tested for hepatitis B virus (HBV) before initiating treatment with daratumumab. Those patients who test positive for HBV infection should be discussed with a consultant specialising in HBV prior to initiating treatment with daratumumab to plan monitoring requirements whilst on treatment. Patients may also be tested for hepatitis C, CMV and HIV at the same time if clinically appropriate. • Send a blood sample to transfusion and inform patient and transfusion laboratory that patient is due to commence daratumumab. Patient will require red cell phenotyping as cross match fails due to binding of daratumumab to red cells. Version 1(July 2019) Myeloma –DVd (weekly) Bortezomib Daratumumab (S/C) Dexamethasone Cycles 9 onwards. Page 1 of 11 • Regular monitoring of blood glucose is considered good practice due to dexamethasone use. Dose Modifications The dose modifications listed are for haematological, liver and renal function and drug specific toxicities only. Dose adjustments may be necessary for other toxicities as well. In principle all dose reductions due to adverse drug reactions should not be re-escalated in subsequent cycles without consultant approval. It is also a general rule for chemotherapy that if a third dose reduction is necessary treatment should be stopped. Please discuss all dose reductions / delays with the relevant consultant before prescribing, if appropriate. The approach may be different depending on the clinical circumstances. Haematological No dose reductions of daratumumab are recommended. Dose delay may be required to allow recovery of blood cell counts in the event of haematological toxicity. Always refer to the responsible consultant, as any dose delays will be dependent on clinical circumstances and treatment intent. Low counts can be a consequence of bone marrow infiltration as well as drug toxicity. Consider blood transfusion or the use of erythropoietin according to NICE TA323 if patient symptomatic of anaemia or where the haemoglobin is less than 8g/dL (80g/L). Consider growth factor support as an alternative to the options below, particularly where there is evidence of bone marrow suppression. To initiate a new cycle of daratumumab, the neutrophil count should be 1x109/L or greater and the platelet count should be 50x109/L or greater, unless the low counts are due to bone marrow infiltration with myeloma. In this situation the daratumumab may be administered at the discretion of the treating consultant haematologist with the appropriate blood product and growth factor support. Neutrophils (x109/L) Dose Modifications Daratumumab Less than 0.5x109/L or febrile neutropenia (fever greater than or equal to 38.5°C and neutrophils less than 1) Interrupt daratumumab treatment and monitor FBC weekly. Bortezomib - Consider treatment delay or dose reduction or growth factor support. Seek consultant advice. Platelets (x109/L) Dose Modifications Daratumumab Less than 50x109/L Bortezomib Less than 25x109/L Interrupt daratumumab treatment and monitor FBC weekly. Once platelets recover to 50x109/L or greater resume Consider treatment delay or dose reduction or platelet transfusion. Seek consultant advice. Hepatic Impairment Please note that the approach may be different where abnormal liver function tests are due to disease involvement. Version 1(July 2019) Myeloma –DVd (weekly) Bortezomib Daratumumab (S/C) Dexamethasone Cycles 9 onwards. Page 2 of 11 Drug Bortezomib Daratumumab Bilirubin μmol/L 1.5xULN or below greater than 1.5xULN AST/ALT units/L N/A N/A Dose (% of original dose) 100% Initiate treatment at 0.7mg/m2. The dose may be escalated to 1mg/m2 or reduced to 0.5mg/m2 in subsequent cycles based on patient tolerability. No formal studies of daratumumab in patients with hepatic impairment have been conducted. Based on population pharmacokinetic analysis no dosage adjustments are necessary for patients with hepatic impairment Renal Impairment Drug Bortezomib Daratumumab Creatinine Clearance (ml/min) greater than 20 Dose (% of original dose) 100% 20 and below Clinical decision No adjustments necessary Other Dose reductions or interruptions in therapy are not necessary for those toxicities that are considered unlikely to be serious or life threatening. For example, alopecia, altered taste or nail changes Infusion related reactions (IRR) DARZALEX solution for subcutaneous injection can cause severe and/or serious IRRs, including anaphylactic reactions. In clinical studies, approximately 11% (52/490) of patients experienced an IRR. Most IRRs occurred following the first injection and were Grade 1-2. IRRs occurring with subsequent injections were seen in less than 1% of patients. The median time to onset of IRRs following DARZALEX injection was 3.7 hours (range 0.1583 hours). The majority of IRRs occurred on the day of treatment. Delayed IRRs have occurred in less than 1% of patients. Signs and symptoms of IRRs may include respiratory symptoms, such as nasal congestion, cough, throat irritation, allergic rhinitis, wheezing as well as pyrexia, chest pain, pruritis, chills, vomiting, nausea, and hypotension. Severe reactions have occurred, including bronchospasm, hypoxia, dyspnoea, hypertension and tachycardia. Patients should be pre-medicated with antihistamines, antipyretics, and corticosteroids as well as monitored and counselled regarding IRRs, especially during and following the first and second injections. If an anaphylactic reaction or life-threatening (Grade 4) reactions Version 1(July 2019) Myeloma –DVd (weekly) Bortezomib Daratumumab (S/C) Dexamethasone Cycles 9 onwards. Page 3 of 11 occur, appropriate emergency care should be initiated immediately. DARZALEX therapy should be discontinued immediately and permanently. To reduce the risk of delayed IRRs, oral corticosteroids should be administered to all patients following DARZALEX injection. Patients with a history of chronic obstructive pulmonary disease may require additional post-injection medicinal products to manage respiratory complications. The use of post-injection medicinal products (e.g. short- and longacting bronchodilators and inhaled corticosteroids) should be considered for patients with chronic obstructive pulmonary disease. Interference with Serlogical Testing Daratumumab binds to CD38 in red blood cells and results in a positive indirect antiglobulin test (Coombs test). Daratumumab mediated positive indirect antiglobulin test may persist for up to six months after the last daratumumab infusion. Daratumumab bound red blood cells masks detection of antibodies to minor antigens in the patients serum. The determination of a patients ABO and Rh blood type are not impacted. Blood transfusion must be informed that a patient is receiving daratumumab. Patients must be typed and screened prior to daratumumab. All patient must be given an identification card that should be carried for six months after stopping therapy and agree to inform all healthcare professionals who treat them that they have received daratumumab. Daratumumab is a human IgG kappa monoclonal antibody detectable on both the serum electrophoresis and immunofixation assays used for the clinical monitoring of endogenous M-protein. This interference can impoact the determination of complete response and of disease progression in all patients with IgG kappa myeloma. Reactivation of Hepatitis B Virus Hepatitis B virus reactivation has been reported in patients treated with daratumumab. All patients must be screened for hepatitis B before initiation of treatment. This includes all patients with unknown serology who are on treatment already. Monitoring is required for patients with positive serology for clinical and laboratory signs of hepatitis B reactivation during treatment and for at least six months after completion of datatumumab. Those with positive serology must seek medical help immediately if they experience symptoms of hepatitis B. Daratumumab must be stopped if hepatitis B reactivation occurs during treatment. Regimen 28 day cycle. Continue daratumumab until disease progression. Note that cycle length changes from 21 days to 28 days from cycle 9 onwards. Cycle 9 and 10 Drug Bortezomib Dose 1.3mg/m2 Days 1,8,15, 22 Administration Subcutaneous Daratumumab 1800mg 1 Dexamethasone 20mg once a day 1 Version 1(July 2019) Myeloma –DVd (weekly) Bortezomib Daratumumab (S/C) Dexamethasone Cycles 9 onwards. Subcutaneous Oral Can be given as dose Page 4 of 11 Dexamethasone 20mg once a day 2, 8, 9, 15, 16, 22, 23 equivalent as iv bolus Reduce dose to 10mg (or iv dose equivalent) in over 75yrs Oral Reduce dose to 10mg in over 75yrs Cycle 11 onwards Drug Daratumumab Dexamethasone Dose 1800mg 20mg Dexamethasone 4mg Days 1 1 2 and 3 Administration Subcutaneous Oral Can be given as dose equivalent as IV bolus To reduce the risk of delayed infusion reactions Dose Information • Dexamethasone is available as 4mg, 2mg and 500microgram tablets and 3.3mg in 1ml injection (equivalent to 4mg orally) Administration Information • Additionally, for patients with a history of chronic obstructive pulmonary disease, the use of post-injection medicinal products including short and long-acting bronchodilators, and inhaled corticosteroids should be considered. Following the first four injections, if the patient experiences no major IRRs, these inhaled post-injection medicinal products may be discontinued at the discretion of the physician. • Inject 15 mL Daratumumab solution for subcutaneous injection into the subcutaneous tissue of the abdomen approximately 7.5 cm to the right or left of the navel over approximately 3-5 minutes. Do not inject Daratumumab solution for subcutaneous injection at other sites of the body as no data are available. • Injection sites should be rotated for successive injections • Daratumumab solution for subcutaneous injection should never be injected into areas where the skin is red, bruised, tender, hard or areas where there are scars. • Pause or slow down delivery rate if the patient experiences pain. In the event pain is not alleviated by slowing down the injection, a second injection site may be chosen on the opposite side of the abdomen to deliver the remainder of the dose. Version 1(July 2019) Myeloma –DVd (weekly) Bortezomib Daratumumab (S/C) Dexamethasone Cycles 9 onwards. Page 5 of 11 • During treatment with Daratumumab solution for subcutaneous injection, do not administer other medicinal products for subcutaneous use at the same site as Daratumumab. Additional therapy • No anti-emetics are required • Premedication required 1 to 3 hours before every daratumumab infusion: - dexamethasone – see regimen for dose details - chlorphenamine 4mg oral - paracetamol 1000mg oral • Consider anti-infective prophylaxis including; - aciclovir 400mg twice a day oral - co-trimoxazole 960mg once a day oral on Monday, Wednesday and Friday only - fluconazole 100mg once a day oral if recurrent oral candidiasis • Bisphosphonates in accordance with local policies. • Mouthwashes according to local or national policy on the treatment of mucositis. • Gastric protection with a proton pump inhibitor or an H2 antagonist may be considered in patients considered at high risk of GI ulceration or bleed. • As required for the treatment of infusion related reactions for patients at high risk of respiratory complications; - salbutamol 2.5mg nebulised - hydrocortisone sodium succinate 100mg intravenous - chlorphenamine 10mg intravenous - paracetamol 1000mg oral - oxygen as required Additional Information • All instances of infusion related reaction must be recorded on ARIA. Daratumumab will continue to be administered at the cycle one rate until a reaction free infusion is noted. • Daratumumab interferes with indirect antiglobulin tests as it binds to CD38 on red blood corpuscles (RBCs) and interferes with compatibility testing, including antibody screening and cross matching. Daratumumab interference mitigation methods include treating reagent RBCs with dithiothreitol (DTT) to disrupt daratumumab binding or other locally validated methods. Since the Kell blood group system is also sensitive to DTT treatment, Kell-negative units should be supplied after ruling out or identifying alloantibodies using DTT-treated RBCs. Alternatively, phenotyping or genotyping may also be considered. • Daratumumab may be detected on serum protein electrophoresis (SPE) and immunofixation (IFE) assays used for monitoring disease monoclonal Version 1(July 2019) Myeloma –DVd (weekly) Bortezomib Daratumumab (S/C) Dexamethasone Cycles 9 onwards. Page 6 of 11 immunoglobulins (M protein). This can lead to false positive SPE and IFE assay results for patients with IgG kappa myeloma protein impacting initial assessment of complete responses by International Myeloma Working Group (IMWG) criteria. In patients with persistent very good partial response, consider other methods to evaluate the depth of response. Coding • Procurement –X71.5 • Delivery – X72.1 References 1. Janssen-Cilag Limited (18 Dec 2018). Darzalex 20mg/ml Summary of Product Characteristics. Electronic Medicines Compendium. Online at https://www.medicines.org.uk/emc/product/7250 , accessed 01 July 2019. 2. National Institute for Health and Care Excellence (2019). Daratumumab with bortezomib and dexamethasone for previously treated multiple myeloma. [TA573]. London: National Institute for Health and Care Excellence. 3. Thames Valley Strategic Cancer Network Myeloma Group MM47 DaraVelDex Protocol version 2.0 April 2019. 4. 90 minute daratumumab infusion is safe in multiple myeloma. Leukemia. Hallie Barr et al. Accessed 27/11/18 https://doi.org/10.1038/s41375-018-0120-2. Version 1(July 2019) Myeloma –DVd (weekly) Bortezomib Daratumumab (S/C) Dexamethasone Cycles 9 onwards. Page 7 of 11 REGIMEN SUMMARY Myeloma DVd (weekly) Bortezomib Daratumumab SC Dexamethasone Cycles 9 onwards Cycle 9 and 10 Day 1 1. Warning – Check if Antihistamine Taken Administration Instructions Ensure the patient has taken the antihistamine premedication. If not please administer one of the following according to local formulary choice; Chlorphenamine 4mg Oral Loratadine 10mg Oral Cetirizine 10mg Oral Fexofenadine 120mg Oral Acrivastine 8mg Oral 2. Warning – Check if the Dexamethasone Taken Administration Instructions Ensure the patient has taken the dexamethasone premedication. If not please administer dexamethasone 20mg oral or intravenous if the patient is unable to tolerate the oral dose.. 3. Warning – Check if the Paracetamol Taken Administration Instructions Please check if the patient has taken paracetamol. If not please administer paracetamol 1000mg. The maximum dose is 4000mg/24 hours 4. Daratumumab 1800mg subcutaneous injection over 3 – 5 minutes Administration Instructions Inject daratumumab 1800mg solution for subcutaneous injection into the subcutaneous tissue of the abdomen approximately 7.5 cm to the right or left of the navel over approximately 3-5 minutes. Do not inject daratumumab solution for subcutaneous injection at other sites of the body as no data are available.Injection sites should be rotated for successive injectionsDaratumumab solution for subcutaneous injection should never be injected into areas where the skin is red, bruised, tender, hard or areas where there are scars.Pause or slow down delivery rate if the patient experiences pain. In the event pain is not alleviated by slowing down the injection, a second injection site may be chosen on the opposite side of the abdomen to deliver the remainder of the dose.During treatment with daratumumab solution for subcutaneous injection, do not administer other medicinal products for subcutaneous use at the same site as daratumumab. 5. Bortezomib 1.3mg/m2 subcutaneous injection 6. Chlorphenamine 10mg intravenous when required for the relief of infusion related reactions 7. Hydrocortisone 100mg intravenous when required for the relief of infusion related reactions 8. Paracetamol 1000mg oral when required for the relief of infusion related reactions Please check if the patient has taken paracetamol. The maximum dose is 4000mg/24 hours 9. Salbutamol 2.5mg nebulised when required for the relief of infusion related reactions Cycle 9 and 10 Day 8, 15 and 22 10. Bortezomib 1.3mg/m2 subcutaneous injection Cycle 9 and 10 Take home medicines 11. Dexamethasone 20mg on days 2, 8, 9, 15, 16, 22 and 23 oral Administration Information Reduce dose to 10mg in patients over 75 years old Take in the morning with or after food. Please dispense all days on day 1 of the cycle. This may be dispensed in one Version 1(July 2019) Myeloma –DVd (weekly) Bortezomib Daratumumab (S/C) Dexamethasone Cycles 9 onwards. Page 8 of 11 bottle, or individual bottles according to local practice. 12. Dexamethasone 20mg on day 1 of the next cycle Take in the morning of daratumumab injection Note to pharmacy – please dispense 1 dose of dexamethasone 20mg to be taken on day 1 of the following cycle prior to daratumumab 13. Aciclovir 400mg twice a day for 28 days oral Administration Instructions Please supply 28 days or an original pack if appropriate. 14. Anthistamine on the days of daratumumab administration Administration Instructions Take on the day of daratumumab administration. To be taken 1 -3 hours prior to daratumumab infusion Please supply 1 x OP. This is to cover all cycles. To be supplied as per local formulary choice Chlorphenamine 4mg Oral Loratadine 10mg Oral Cetirizine 10mg Oral Fexofenadine 120mg Oral Acrivastine 8mg Oral 15. Co-trimoxazole 960mg once a day on Monday, Wednesday and Friday only for 28 days oral Administration Instructions Co-trimoxazole 960mg once a day on Mondays, Wednesdays and Fridays. Please supply 28 days. This may be dispensed as 480mg twice a day on Mondays, Wednesdays and Fridays according to local practice. 16. Gastric Protection Administration Instructions The choice of gastric protection is dependent on local formulary choice and may include; - esomeprazole 20mg once a day oral - omeprazole 20mg once a day oral - lansoprazole 15mg once a day oral - pantoprazole 20mg once a day oral - rabeprazole 20mg once a day oral - cimetidine 400mg twice a day oral - famotidine 20mg once a day oral - nizatidine 150mg twice a day oral - ranitidine 150mg twice a day oral Please supply 28 days or the nearest original pack size. Cycle 11 onwards day 1 17. Warning – Check if Antihistamine Taken Administration Instructions Ensure the patient has taken the antihistamine premedication. If not please administer one of the following according to local formulary choice; Chlorphenamine 4mg Oral Loratadine 10mg Oral Cetirizine 10mg Oral Fexofenadine 120mg Oral Acrivastine 8mg Oral 18. Warning – Check if the Dexamethasone Taken Administration Instructions Ensure the patient has taken the dexamethasone premedication. If not please administer dexamethasone 20mg oral or intravenous if the patient is unable to tolerate the oral dose 19. Warning – Check if the Paracetamol Taken Administration Instructions Please check if the patient has taken paracetamol. If not please administer paracetamol 1000mg. The maximum dose is 4000mg/24 hours Version 1(July 2019) Myeloma –DVd (weekly) Bortezomib Daratumumab (S/C) Dexamethasone Cycles 9 onwards. Page 9 of 11 20. Daratumumab 1800mg subcutaneous injection over 3 – 5 minutes Administration Instructions Inject daratumumab 1800mg solution for subcutaneous injection into the subcutaneous tissue of the abdomen approximately 7.5 cm to the right or left of the navel over approximately 3-5 minutes. Do not inject daratumumab solution for subcutaneous injection at other sites of the body as no data are available.Injection sites should be rotated for successive injectionsDaratumumab solution for subcutaneous injection should never be injected into areas where the skin is red, bruised, tender, hard or areas where there are scars.Pause or slow down delivery rate if the patient experiences pain. In the event pain is not alleviated by slowing down the injection, a second injection site may be chosen on the opposite side of the abdomen to deliver the remainder of the dose.During treatment with daratumumab solution for subcutaneous injection, do not administer other medicinal products for subcutaneous use at the same site as daratumumab. 21. Chlorphenamine 10mg intravenous when required for the relief of infusion related reactions 22. Hydrocortisone 100mg intravenous when required for the relief of infusion related reactions 23. Paracetamol 1000mg oral when required for the relief of infusion related reactions Please check if the patient has taken paracetamol. The maximum dose is 4000mg/24 hours 24. Salbutamol 2.5mg nebulised when required for the relief of infusion related reactions Take home medicines 25. Dexamethasone 4mg on days 2 and 3 oral Administration Information Take in the morning with or after food. Days 2 and 3 i.e. for two days starting the day after daratumumab administration to reduce the risk of delayed infusion reactions 26. Dexamethasone 20mg on day 1 of the next cycle Administration Information Take in the morning of daratumumab injection Note to pharmacy – please dispense 1 dose of dexamethasone 20mg to be taken on day 1 of the following cycle prior to daratumumab 27. Aciclovir 400mg twice a day for 28 days oral Administration Instructions Please supply 28 days or an original pack if appropriate. 28. Co-trimoxazole 960mg once a day on Monday, Wednesday and Friday only for 28 days oral Administration Instructions Co-trimoxazole 960mg once a day on Mondays, Wednesdays and Fridays. Please supply 28 days. This may be dispensed as 480mg twice a day on Mondays, Wednesdays and Fridays according to local practice. 29. Gastric Protection Administration Instructions The choice of gastric protection is dependent on local formulary choice and may include; - esomeprazole 20mg once a day oral - omeprazole 20mg once a day oral - lansoprazole 15mg once a day oral - pantoprazole 20mg once a day oral - rabeprazole 20mg once a day oral - cimetidine 400mg twice a day oral - famotidine 20mg once a day oral - nizatidine 150mg twice a day oral - ranitidine 150mg twice a day oral Please supply 28 days or the nearest original pack size. Version 1(July 2019) Myeloma –DVd (weekly) Bortezomib Daratumumab (S/C) Dexamethasone Cycles 9 onwards. Page 10 of 11 DOCUMENT CONTROL Version Date Amendment Written By Approved By 1 Oct 2020 None Nanda Basker Pharmacist Dr Mathew Jenner Consultant Haematologist This chemotherapy protocol has been developed as part of the chemotherapy electronic prescribing project. This was and remains a collaborative project that originated from the former CSCCN. These documents have been approved on behalf of the following Trusts; Hampshire Hospitals NHS Foundation Trust NHS Isle of Wight Portsmouth Hospitals NHS Trust Salisbury NHS Foundation Trust University Hospital Southampton NHS Foundation Trust Western Sussex Hospitals NHS Foundation Trust All actions have been taken to ensure these protocols are correct. However, no responsibility can be taken for errors that occur as a result of following these guidelines. These protocols should be used in conjunction with other references such as the Summary of Product Characteristics and relevant published papers. Version 1(July 2019) Myeloma –DVd (weekly) Bortezomib Daratumumab (S/C) Dexamethasone Cycles 9 onwards. Page 11 of 11
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UHS AR 23-24 Final

Description: 2023/24 Incorporating the quality account University Hospital Southampton NHS Foundation Trust Annual Report and Accounts 2023/24 Presented to Parliament pursuant to Schedule 7, paragraph 25(4)(a) of the National Health Service Act 2006 © 2024 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 37 Directors’ report 38 Remuneration report 62 Staff report 75 Annual governance statement 95 Quality account 111 Statement on quality from the chief executive 112 Priorities for improvement and statements of assurance from the board 115 Other information 180 Annual accounts 207 Statement from the chief financial officer 208 Auditor’s report 210 Foreword to the accounts 217 Statement of Comprehensive Income 218 Statement of Financial Position 219 Statement of Changes in Taxpayers’ Equity 220 Statement of Cash Flows 221 Notes to the accounts 222 5 Welcome from the Chair and Chief Executive Officer This has been another busy and undoubtedly challenging year across the NHS and UK health and social care system, and much of what has impacted the national picture has been reflected in the operational focuses and patient and people priorities for University Hospital Southampton NHS Foundation Trust (‘UHS’ or the ‘Trust’) over the last year. Meeting and continuing to overcome the challenges we have faced has required an organisation-wide team effort, and looking back at the successes we feel incredibly proud of the achievements of our 13,000 staff. Particular highlights include: • In the top ten in the country (7th) against government targets for elective recovery performance with 118% of activity compared with 2019. • Top-quartile performance against most performance metrics compared to similar sized teaching hospitals, including Emergency Department access, long-waiting patients on Referral to Treatment pathways, Diagnostics and Cancer performance. • Significant investment in new capacity through building new wards and theatres and refurbishing existing areas of the hospital. • Delivery of our highest ever Cost Improvement Programme saving. These achievements place us among the best performing trusts in England in several areas and are even more remarkable against a backdrop of continued periods of industrial action and increasing demand for our services, with many people coming to us with higher levels of acuity than ever before. The Trust’s performance in terms of elective recovery places it as one of the best-performing trusts in England and demonstrates the impact of the Trust’s decision to invest in additional capacity in prior years by building new wards and theatres. The Trust’s Emergency Department performance in respect of its four-hour waiting target at the end of March 2024 has attracted additional capital funding as part of an incentive scheme. Some of this funding will be used to increase the department’s same-day emergency care capacity during 2024/25. From a financial perspective, balancing the complexities of today’s challenges alongside the need to protect and ensure the long-term stability and quality of our service provision, has required the Board to take a number of considered and crucial efficiency improvement actions this year. Whilst challenging, the Trust has seen significant progress in delivering on both its forecasted finance position for 2023/24 and productivity targets. Achieving long-term financial stability is key to us continuing to invest in much needed upgrades and improvements to the parts of our estate that are ageing, and to developing new state-of-the-art facilities and infrastructure that increases our capabilities and capacity into the future. In the last year parts of the hospital have been transformed, with the opening of new wards, theatres and a skybridge to link the estate. Construction of a sterile services and aseptics facility has begun at Adanac Park and the expansion of our neonatal department, where we treat and care for some of our most vulnerable babies and their families, is underway. The development of a new aseptic facility at Adanac Park will have capacity to serve other hospitals within the region and is a significant opportunity for improved system-wide working. 6 We have also worked with our people to design spaces where they can rest, relax and recharge - including a new wellbeing hub and rooftop garden on the Princess Anne Hospital site. In addition, 40 staff rooms across the site have been refurbished thanks to funding from Southampton Hospitals Charity. During the year, the Trust worked to establish the Southampton Hospitals Charity as a separate charitable company to improve its ability to both raise and spend funds. This process completed on 1 April 2024. Work was carried out to refurbish a children’s ward during the year in partnership with the charity. Our people are our greatest asset, and we are pleased to see improvements from the annual staff survey in several areas - such as how people can work more flexibly, access to learning and development and improved satisfaction in support from line managers. We recognise the pressures and demands that come with working in this environment and will continue to ensure everyone working here feels heard, encouraged and supported when raising concerns. At UHS, every opportunity is taken to recognise and celebrate the incredible things our people do here every day, including the return of our in-person annual awards ceremony, monthly staff recognition events and the first ever ‘We Are UHS Week’. These occasions are an important reminder that, even when faced with challenges, there is so much to be proud of and celebrate across the whole Trust. Working together, both within the Trust and across organisational boundaries, remains one of our core values. The partnership between UHS and the University of Southampton is as strong as it has ever been, with more than 250,000 individuals having now taken part in research studies in Southampton. As the lead partner member for Acute Hospital Services on the Hampshire and Isle of Wight Integrated Care Board, we are proactively working with other trusts and healthcare providers in the region to improve the health of the community we serve. In addition, the Trust has continued to work in partnership with other providers across the system to build a shared elective orthopaedic hub in Winchester. It is anticipated that the health and social care system will continue to be a challenging environment in 2024/25. We recognise that many of the big challenges we face can only be solved in partnership with wider local partners, and we are committed to actively playing our part in delivering system-wide solutions. Equally, we will continue to focus on improving whatever is within our internal control, and to work collaboratively with our people to ensure our patients’ experience, safety and outcomes remain central to our decision-making and the actions of everyone at UHS. Jenni Douglas-Todd Chair 19 July 2024 David French Chief Executive Officer 19 July 2024 7 PERFORMANCE REPORT Performance report Introduction from the Chief Executive Officer As with 2022/23, this was another challenging year with continued increasing demand for the Trust’s resources and the need to balance this with the need to deliver quality patient care and at the same time maintain a sustainable financial position. Demand for non-elective care continued to increase with an average of 375 attendances per day to our main Emergency Department. In addition, the number of patients on the 18-week Referral to Treatment pathway rose to 58,000. Patients having no clinical criteria to reside in hospital, but unable to be discharged due to the lack of funded care in a more suitable location, posed and continues to pose a significant challenge for the Trust. The number of patients within this category was as high as 270 at times and was consistently higher throughout the year when compared to 2022/23. Despite this the Trust continued to perform well when compared to other comparable organisations, achieving some of the best Emergency Department and elective recovery fund performance in England. The Trust’s financial position continued to be difficult, which required some difficult decisions in respect of spending controls and controls on recruitment. The Trust focused in particular on controlling spending on temporary and agency staff, but in view of the overall workforce numbers compared to the 2023/24 plan, further controls were implemented in respect of substantive recruitment. Due to the additional controls and the Trust’s best delivery to date on its Cost Improvement Programme (£63.4m), the Trust achieved an end of year deficit of £4.5m, compared to the deficit of £26m anticipated in its 2023/24 plan. 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 £1.3 billion in 2023/24. It is based on the coast in south east England and provides services to over 1.9 million people living in Southampton and south Hampshire and specialist services, including neurosciences, respiratory medicine, cancer care, cardiovascular, obstetrics and specialist children’s services, to nearly four 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 155,000 inpatients and day patients, including about 70,000 emergency admissions sees over 750,000 people at outpatient appointments deals with around 150,000 cases in our emergency department 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 54% is paid for by NHS England and 43% by integrated care boards, predominantly the Hampshire and Isle of Wight Integrated Care Board (ICB). 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 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. The ICP is a statutory committee jointly formed between the NHS integrated care board and all upper-tier local authorities that fall within the ICS area. The ICP brings 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 Trust has been a university teaching hospital since 1971. The diagram below provides an overview of the overall organisational structure of the Trust. Public and foundation trust members Council of Governors Board of Directors Executive Directors Division A Division B Division C Division D Surgery Critical Care Opthalmology Theatres and Anaesthetics 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 The Trust’s values describe how things are done 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. These 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 its staff had experienced during the COVID-19 pandemic and what had been learnt from this. The vision for UHS is to become an organisation of world class people delivering world class care. The Trust’s strategy is organised around five themes and for each of these it describes a number of ambitions UHS aims 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 2023/24 these objectives included: Outstanding patient outcomes, experience and safety Pioneering research and innovation World class people Integrated networks and collaboration Foundations for the future • Increasing the number of reported Shared Decision-Making conversations. • Increasing the number of specialities reporting outcomes that matter to patients. • Rolling out the Patient Safety Incident Reporting Framework across the Trust. • Working with patients as partners to improve patient satisfaction. • Treating patients according to need but aiming for no patient to wait, other than through patient choice, more than 65 weeks for treatment. • Delivering national metrics for site set-up time to target for clinical research studies. • Improving the Trust’s position against peers. • Delivering year three of the Trust’s research and innovation investment plan. • Developing the five-year research and development strategy implementation plan and delivery of the first year. • Strengthening and broadening the partnership between the Trust and the University of Southampton. • Supporting delivery of the Trust’s workforce plan for 2023/24. • Reducing turnover and sickness absence rates. • Increasing overall participation in the NHS staff survey and maintaining overall staff engagement score. • Increasing the proportion of appraisals completed. • Delivering the first year objectives of the Inclusion and Belonging strategy. • Working in partnership with acute trusts to agree and implement the acute services strategy. • Producing and embedding an internal framework for network development. • Working with the local delivery system on vertical integration to reduce the number of patients without criteria to reside. • Working with system partners to open a surgical elective hub. • For the Trust to be seen as an ‘anchor institution’ in the local area. • Delivering the Trust’s financial plan for 2023/24. • Engaging the organisation in the challenge to manage demand so that capacity and demand are in equilibrium. • Delivery of the Always Improving strategy priorities. • Delivering the Trust’s capital programme in full. • Entering into a new energy performance contract and delivering the first year of the Public Sector Decarbonisation Scheme. Performance against these objectives was monitored and reported to the Trust’s Board on a quarterly basis. 14 At the end of 2023/24, the Trust had met the objectives set as follows: Corporate Ambition Outstanding patient outcomes, safety and experience Pioneering research and innovation World class people Integrated networks and collaboration Foundations for the future Totals Number of Objectives 5 5 5 5 5 25 Achieved in full 4 3 2 3 2 14 Partially achieved 1 2 2 1 3 9 Not achieved 0 0 1 1 0 2 Particular areas to highlight where the Trust has achieved strong delivery during the year include: • Delivery of quality priorities in Shared Decision-Making and the roll out of the Patient Safety Incident Response Framework. • Achieving the Trust’s 65-week waiter glide path. • Successful delivery of a number of research and development priorities, including work with the University of Southampton. • Maintaining sickness absence and turnover well below the targets set at the beginning of the year, and successfully delivering the first year of the Trust’s Inclusion and Belonging strategy. • Delivery of the Trust’s full available capital budget and completion of the first year of the Trust’s decarbonisation scheme. 15 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 2023/24 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 or carers with a highquality 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 does not take full advantage of its 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 its patients. • 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, 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 and digital strategies and in transformation initiatives. • 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 2023/24, the Trust saw continued increased demand for its services, particularly in the Emergency Department In addition, the number of patients having no clinical criteria to reside in hospital, but unable to be discharged due to a lack of appropriate care packages was higher than anticipated and spiked during winter, which significantly impacted patient flow through the hospital and required the Trust to engage additional temporary staff. The number of patients in this category peaked at 270 during the winter. There were particular challenges in respect of those patients with a primary mental health care need who would be better cared for in a more suitable alternative setting. 16 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 Trust continued to experience high demand for its services, especially in the Emergency Department, with average demand during the year being around 375 patients presenting per day in the main adult and children’s emergency department. In addition, the Trust experienced a significant impact on flow within the hospital due to a high number of patients having no clinical criteria to reside in hospital but unable to be discharged. This number was as high as 270 at times during winter: an increase of around 50 patients when compared to the prior year. The Trust also saw an increase in the number of referrals with the number of patients on a waiting list under the 18-week Referral to Treatment pathway rising from approximately 55,000 to 58,000 by the end of the year. In common with other trusts, the ongoing industrial action also impacted the Trust’s ability to provide urgent care and deliver on its elective recovery programme. Quality and compliance Despite the challenges, the Trust’s Emergency Department performance was one of the highest in England in March 2024, which resulted in additional capital funding being awarded. In addition, the Trust’s elective recovery performance was one of the best in England at 118% compared to 2019. The Trust continued to monitor the quality of care delivered throughout 2023/24 through a number of established quality assurance programmes. Clinical leaders monitored key quality, safety and patient experience indicators such as falls, pressure ulcers and venous thromboembolisms. Quality peer reviews were carried out, most significantly through Matron-led Quality Walkabouts every week in and out of hours focusing on the five key CQC questions – safe, effective, responsive, caring, and well-led. The Trust’s Clinical Accreditation Scheme builds on this intelligence, with clinical areas completing self-assessments of performance and review teams completing onsite visits. Patient representatives were included in these review teams. Learning was shared at the Clinical Leaders’ Group and via quarterly reports. The Trust was an active partner in a South-East accreditation network, offering advice and a steer to providers who are just setting up or looking to develop their own scheme, and extended that advice and support to other providers in England. 17 On 15 May 2023, the CQC inspected the maternity and midwifery service at Princess Anne Hospital as part of their national maternity inspection programme. The inspection report was published 11 August 2023, and the Trust retained its overall rating of ‘good’. This year UHS introduced its Fundamentals of Care (FOC) initiative. Whilst this is not a new concept, there were concerns that missed fundamental care had been amplified during the COVID- 19 pandemic. This initiative aims to empower and educate staff at all levels to ensure fundamental care is at the heart of what the Trust does. The Trust completed its transition to the Patient Safety Incident Response Framework (PSIRF) and collaborated with the ICB to develop a PSIRF plan and policy to underpin the change. The Trust implemented the requirements in respect of ‘Martha’s Rule’ where patients, relatives and carers have a legal right to a rapid review by a critical care outreach team during an acute deterioration episode in and out of hours. The Trust continued its focus on infection prevention and control, responding rapidly to rises in infection over the winter, and successfully flexing initiatives and innovations to achieve successful management in a responsive manner. The Trust progressed its Always Improving strategy and successfully supported the identification and implementation of further quality improvement projects. This included improvements across theatres, inpatient flow and outpatient programmes. During the year, average length of stay was reduced by 1.64%, day theatre cancellations were reduced by 200, and 42,350 patients were placed onto Patient Initiated Follow Up (PIFU) pathways. Further information can be found in the Quality Account. Partnerships The Trust works within the Hampshire and Isle of Wight Integrated Care System, and is an active member of a number of partner groups including the Acute Provider Collaborative Board and the Health and Wellbeing Board. The Trust develops and agrees its annual financial plans with the Integrated Care Board. The Trust is a member of a number of specific partnership groups for particular services, including the Central and South Genomics Medicine Service, the Children’s Hospital Alliance and the Southern Counties Pathology Network. The Trust works actively as a partner with other provider organisations around clinical networks, particularly with acute Trusts within the Integrated Care System and others closely located geographically. The Trust also links closely with the University of Southampton on a number of topics including research, commercial development and education and has a developed meeting structure to oversee this. 18 Workforce The Trust’s key areas of focus during 2023/24 were in respect of increasing the substantive workforce whilst also reducing reliance on bank and agency usage, and reducing staff turnover and sickness. 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 331 whole-time equivalents above its plan for 2023/24. The Trust was successful in reducing staff turnover from 13.5% in 2022/23 to 11.4%, achieving the local target of . Cancer Waiting Times - 2 Week Wait Performance Cancer Waiting Times - 2 Week Wait Performance 100% 90% 80% 70% 60% 50% 40% Apr-23 May-23 Jun-23 Jul-23 Aug-23 Sep-23 Oct-23 Nov-23 Dec-23 Jan-24 Feb-24 Mar-24 Performance % standard met The national target was for 96% of patients to commence treatment within 31 days of diagnosis. In March 2024, the Trust achieved 92% and performed in the range of 86%-94% throughout the year. The Trust has continued to make progress against the target for treatment of cancer within 62 days of an urgent GP referral, improving performance from 64% in April 2023 to 76% in March 2024 (NHS average: 69%). First definitive treatment for cancer within 31 days of a decision to treat % standard met Cancer waiting times 31 day RTT performanceUHS vs. NHSE average Cancer waiting times 31 day RTT performance UHS vs. NHSE average 96% 94% 92% 90% 88% 86% 84% 82% 80% 78% 76% Apr-23 May-23 Jun-2 3 Jul-2 3 Aug-23 Sep-2 3 Oct-23 Nov-2 3 Dec-23 Jan-24 Feb-2 4 Mar-24 Performance NHS Average 27 Treatment for Cancer within 62 days of an urgent GP referral to hospital Cancer Waiting Times 62 Day RTT Performance UHS vs NHSE Average Cancer Waiting Times 62 Day RTT Performance UHS vs NHSE Average % standard met 1 00% 80% 60% 40% 20% 0% Apr-23 May-23 Jun-23 Jul-23 Aug-23 Sep-23 Oct-23 Nov-23 Dec-23 Jan-24 Feb-24 Mar-24 Performance NHS Average 28 Quality priorities Priorities for improvement 2023/24 Last year the Trust continued its ambition to deliver the highest quality care shaped by a range of national, regional, local, and Trust-wide factors. During the year the Trust continued to experience unprecedented demand on its services, with flow, capacity, infection prevention and safety all presenting challenges. However, the Trust was confident in its ability to keep a focus on its quality priorities, and its teams worked hard to achieve their goals even in these difficult circumstances. Priorities are aligned to the three core dimensions of quality: • Patient experience – how patients experience the care they receive. • Patient safety – keeping patients safe from harm. • Clinical effectiveness – how successful is the care provided? Out of the six priories set, the Trust achieved five and partially achieved one. Overview of success Quality Priority One Improving care for people with learning disabilities and autistic (LDA) people across the Trust. Supporting staff delivering this care. Outcome against goals: achieved Key achievements: • LDA working group reestablished. • Development of an improvement plan using the NHS Learning Disability Improvement standards. • The LDA team has moved to the virtual enhanced care group in Division B where operational and governance support, leadership, and peer support/learning opportunities has been strengthened. • Sensory Boxes have been introduced for all clinical areas, funded by the Hampshire and Isle of Wight (HIOW) Integrated care board (ICB). These boxes include noise cancelling headphones, fidget toys, communication books and visual cards to support patients and wards. • Recruited additional Learning Disability Champions. • Established links with the parent carer forum (PCF) for the local area and are now attending regular events. A representative from the PCF sits on the LDA working group. The LDA team are working with the Trust lead for patient experience to develop this aspect of the LDA workplan over the next year. Quality Priority Two Supporting patients, service users and staff to overcome their tobacco dependence via a smoking cessation programme. Outcome against goals: achieved Key achievements: • Package of support available to patients who may be smokers and who need to be supported not to smoke during their treatment. • Fully trained team of tobacco advisors working in the hospital and an advisor working in the outpatient setting supporting the patients once they have returned home. • Devised the IT changes the Trust would like to implement to improve its service and referral process. • Recruited 30 smoke-free champions. • Successfully supported 1,131 patients with a self-confirmed quit rate of 45.6% at 28 days. • Supported 109 outpatients who have successfully achieved a 60% quit rate. • On track to achieve the goal to go smoke-free by April 2024 including the removal of smoking shelters. 29 Quality Priority Three Ensure carers are fully supported, involved, and valued across all our services by developing the carers support service across the Trust in partnership with Southampton Hospitals. Outcome against goals: partially achieved Key achievements: • Carers now have a more comprehensive package of concessions and vouchers to help support their cared-for person (e.g. free parking available onsite for blue badge owners is now available). • Listening events were held to put patients at the centre of transforming the way we deliver care is delivered, enabling their voices to improve the quality of care and outcomes for all. • Developed joint working with local partners (e.g. Children’s Society and No Limits to support young carers). Not yet achieved: • The ‘pathway to support, has not yet been developed. Work is ongoing to develop a new strategy. • A charity-funded carers’ support worker has not yet been appointed. • The carers’ training package has not yet been relaunched. Quality Priority Four Put patients at the centre of transforming the way care is delivered, enabling their voices to improve the quality of care and outcomes for all. Outcome against goals: achieved Key achievements: • Work has continued to work across corporate and divisional services to embed patients and carers into quality and service improvement, creating new patient groups (e.g. Mesh Support Group). • Successfully developed our engagement with various local communities, working to ensure that a range of care experiences are considered ( e.g. there is now a Gypsy, Roma, and Irish Traveller community health liaison officer to ensure that these communities are engaged with and brought into work to improve the inclusivity of our services). • Attending multiple public engagement opportunities (Young Carers’ Festival, Mela, University Freshers’ Fayres, Carers’ Listening Lunch, Hoglands Park Play Day, visits to local temples and ‘Love Where You Live’). • Youth and Young Adult Ambassador involvement has increased, including attendance toat meetings of the Council of Governors, and supporting hospital projects. • A Celebration of Carers Week and Volunteers Week were run. • The Trust has analysed its reported outcome measures to identify health inequalities in its services. This information has been used to set a new quality priority for 2024/25. • An SMS friends and family test text survey has been introduced to improve the response rate on patient feedback from the Emergency Department. In the first three months following the survey launch, responses increased from 24 to 424. 30 Quality Priority Five To develop the Trust’s clinical effectiveness process, connecting to the Trust’s Always Improving approach to measuring, understanding, and using outcomes to improve patient care. Outcome against goals: achieved Key achievements: • The Trust has developed its clinical effectiveness process across the Trust with involvement of informatics, governance and management teams, clinical effectiveness leads as well as reporting committees. • Patient representation onhas been included in the clinical assurance meeting for effectiveness and outcomes (CAMEO) to ensure conversations focus on what matters to patients. • The CAMEO template has been changed to focus discussions on areas the specialty is proud of (strong or improving outcomes), areas for improvement (poorly benchmarked or worsening outcomes) and planned actions. • The Trust encourages the use of run and/or statistical process control charts along with benchmarking where available. • Details of NICE and quality standards and national and regional reviews are included to cover breadth of clinical effectiveness. • How the clinical effectiveness team works has been reorganised, aligning each of them to each division giving a named link which helps to deepen understanding and improve links with governance and improvement activities locally. • Working with informatics to establish a core set of clinical outcome measures which are meaningful to patients, which can be reported centrally (starting with surgical specialities). • Starting to develop an education strategy and platform to support staff with a number of tools used in clinical effectiveness as well as clarity on where and how to record and evidence audit and service improvement. • A revised strategy has been drafted. Quality Priority Six Developing a culture where all clinical staff have a basic knowledge of diabetes. Outcome against goals: achieved Key achievements: • Launch of the ‘Start with the Diabasics’ Initiative, designed to help give diabetes visibility across UHS. • Delivered an extensive education programme to clinical staff across the professions and bands, including the introduction of some e-learning and a Diabasics introductory video has been shown at all trust staff inductions since July 2023. • Supported the development of 45 diabetes link nurses, resulting in all ward areas now having a named diabetes link nurse. • Improved triage for referrals. • Established processes for ‘lessons learned’. • Developed IT solutions to improvingimprove alerts and guidance. • A ‘Ketone Wednesdays’ initiative has been created in response to overuse of blood ketone testing (estimated waste cost of £100,000 per year). • The Trust’s lead diabetes specialist nurse and the Diabasics Initiative were both shortlisted for National Quality in the Care Diabetes Awards (October 2023). • The Diabasics Initiative was mentioned as a case study on the Diabetes UK charity website as an example of good practice that could be reproduced elsewhere. 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 2024/25, in the Trust’s Quality Account for 2023/24. 31 Financial performance The Trust delivered a deficit of £4.5m from a revenue position of over £1.3bn, following receipt of £24.6m one-off cash support from NHS England. UHS started the year with an underlying deficit as a result of a number of cost pressures, notably demand for services being above block contract levels and the cost of national pay awards being above funded levels. The Trust has also continued to face a number of pressures, including high numbers of patients who no longer meet the criteria to reside in the hospital, and high demand for patients with a primary mental health need. In 2023/24, the Trust delivered a record savings level of £63.4m (5%) across a range of programmes. Trust operating income rose by £107m from the previous financial year, most notably funding the NHS pay award, as well as additional elective recovery funding. Trust operating expenses rose by £89m, incorporating funded inflationary costs as well as costs relating to the cost pressures outlined above. The Trust has also continued its reinvestment of surplus cash into infrastructure for the Trust, with capital investment of over £75m, including investment in new wards, theatres, decarbonisation, digital infrastructure, neonatal expansion and backlog maintenance. Trust cash and cash equivalents finished the year at £79m, a reduction of £24m from the previous year due to the operating loss and capital investment outlined above. Whilst liquidity remained strong in 2023/24 supported by NHS England cash support, the underlying financial deficit means it is likely to decline further in 2024/25. The Trust is continuing to monitor its cash position closely and is considering whether additional cash support may be required in 2024/25. Sustainability The Trust recognises that everyone has a part to play in responding to the climate crisis. In March 2022, the Trust agreed its own green plan in response to the challenge of the NHS becoming the world’s first health service to reach carbon net zero. Now in its third year, the plan identifies the Trust’s key areas of focus and its ambitions and has seen progress across all areas of the plan. The plan sets out the scale of the challenge, the Trust’s commitment to reducing the impact on the environment and the steps to be taken across the following categories: • Estates and facilities • Clinical and medicines • Digital transformation • Supply chain and procurement • Travel and transport • Waste and resources • Food and nutrition • Adaptation • Biodiversity • Wider sustainability The Trust continues to progress through its green plan and has completed the ‘Greener NHS’ reporting tool for several quarters, which has demonstrated good progress. In addition, the Trust is planning to launch its ‘Our Sustainable UHS’ app for staff, which will give tips on sustainability and create personalised travel plans, including identifying potential contacts for car sharing. In addition, the Trust is considering proposals to implement additional solar power, smart metering and expanding the use of LED lighting. 32 In 2022/23, the Trust was successful in bidding for £29.4m of funding through the Public Sector DeCarbonisation Fund, which will be used to fund green initiatives as part of the Trust’s capital programme. During the year the Trust successfully bid for £823k in National Energy Efficiency Funding which has been used to upgrade the lighting at Princess Anne Hospital. Social, community, anti-bribery and human rights issues The Trust recognises its responsibilities under the European Convention on Human Rights (included in the Human Rights Act 1998 in the UK). These rights include: • right to life • right not to be subjected to inhuman or degrading treatment or punishment • right to liberty and freedom • right to respect for privacy and family life. These are reflected in the duty, set out in the NHS Constitution, to each and every individual that the NHS serves, to respect their human rights and the individual’s right to be treated with dignity and respect. The Trust is committed to ensuring it fully takes into account all aspects of human rights in its work. An equality impact assessment is completed for each Trust policy. For patients, the Trust’s safeguarding policies protect and support the right to live in safety, free from abuse and neglect and other policies and standards are designed to optimise privacy and dignity in all aspects of patient care. Feedback from patients and the review of complaints, concerns, claims, incidents and audit help to monitor how the Trust is achieving these objectives. The Trust’s green plan, approved by the board of directors in March 2022, recognises the Trust’s broader role and responsibility to address the issues of climate change, air pollution, waste and environmental decline present to the city of Southampton and the impact that these issues have on the health and wellbeing of the local population served. Although the Modern Slavery Act 2015 does not apply to the Trust, its green plan sets out an ambition to stop modern slavery. The Trust is also committed to maintaining an honest and open culture within the Trust; ensuring all concerns involving potential fraud, bribery and corruption are identified and rigorously investigated. The Trust has a Fraud, Bribery and Corruption Policy, a Standards of Business Conduct Policy and a Raising Concerns (Whistleblowing) Policy. These apply to all staff and to individuals and organisations who act on behalf of UHS. Anti-bribery is part of the Trust’s work to counter fraud. This work is overseen by the Audit and Risk Committee, which receives regular reports from the local counter fraud specialist on the effectiveness of these policies through its monitoring and reviews, providing recommendations for improvement, as well as an annual report from the freedom to speak up guardian. You can read more about the work of the Audit and Risk Committee and the Trust’s approach to counter fraud in the Accountability Report. Events since the end of the financial year There have been no important events since the end of the financial year affecting the Trust. Overseas operations The Trust does not have any overseas operations. 33 Equality in service delivery NHS trusts have an essential role in tackling health inequalities, both as part of the services they provide, but also through work with the wider system. By working with those in integrated care systems, local authorities and third sector organisations, the Trust can have a significant impact on the health of the local population. The national focus on health inequalities is growing. This comes with new legal duties around reporting information and expectations to report on improvement programmes. In September 2023, a health inequalities steering group was initiated, under the leadership of the Chief Medical Officer, with representation from clinical, operational, transformation, patient experience, research, organisational development and culture, informatics, public health and the Integrated Care Board. The group focused on scoping future priorities aligned to national guidelines, contractual obligations and priorities, regional priorities, feedback from clinical teams and patients, understanding where action is already being taken, and what the data is showing. Overall, the group
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Annual-reports-and-quality-accounts/UHS-AR-23-24-Final.pdf

Papers Trust Board - 13 January 2026

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