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Annual report 20-21

Description: 2020/21 Incorporating the quality report University Hospital Southampton NHS Foundation Trust Annual Report and Accounts 2020/21 Presented to Parliament
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Annual-reports-and-quality-accounts/annual-report-20-21.pdf

UHS AR 23-24 Final

Description: 2023/24 Incorporating the quality account University Hospital Southampton NHS Foundation Trust Annual Report and Accounts 2023/24 Presented to Parliament 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 - 29 November 2022

Description: Date Time Location Chair Agenda Trust Board – Open Session 29/11/2022 9:00 - 13:20 Conference Room, Heartbeat/Microsoft Teams Jenni Douglas-Todd 1 Chair’s Welcome, Apologies and Declarations of Interest 9:00 Note apologies for absence, and to hear any declarations of interest relating to any item on the Agenda. 2 Staff Story The staff story provides an opportunity for the Board to reflect on the experiences of patients and staff within the Trust and understand what the Trust could do better. 3 Minutes of Previous Meeting held on 29 September 2022 9:20 Approve the minutes of the previous meeting held on 29 September 2022 4 Matters Arising and Summary of Agreed Actions To discuss any matters arising from the minutes, and to agree on the status of any actions assigned at the previous meeting. 5 QUALITY, PERFORMANCE and FINANCE Quality includes: clinical effectiveness, patient safety, and patient experience 5.1 Briefing from the Chair of the Charitable Funds Committee (Oral) 9:30 Dave Bennett, Chair 5.2 Briefing from the Chair of the Finance and Investment Committee (Oral) 9:35 Jane Bailey, Chair 5.3 Briefing from the Chair of the Quality Committee (Oral) 9:40 Tim Peachey, Chair 5.4 Chief Executive Officer's Report 9:45 Receive and note the report Sponsor: David French, Chief Executive Officer 5.5 Integrated Performance Report for Month 7 10:05 Review and discuss the Trust's performance as reported in the Integrated Performance Report. Sponsor: David French, Chief Executive Officer 5.6 Finance Report for Month 7 10:35 Review and discuss the finance report Sponsor: Ian Howard, Chief Financial Officer 5.7 People Report for Month 7 10:45 Review and discuss the people report Sponsor: Steve Harris, Chief People Officer 6 Break 10:55 7 Infection Prevention and Control 2022-23 Q2 Report 11:05 Review and discuss the report Sponsor: Gail Byrne, Chief Nursing Officer Attendees: Julian Sutton, Interim Lead Infection Control Director/Julie Brooks, Head of Infection Prevention Unit 8 Medicines Management Annual Report 2021-22 11:15 Receive and discuss the report Sponsor: Paul Grundy, Chief Medical Officer Attendee: James Allen, Chief Pharmacist 9 Equality, Diversity and Inclusivity (EDI) Update including Workforce Race 11:25 Equality Standard (WRES) and Workforce Disability Equality Standard (WDES) Results 2022 Receive and discuss the reports Sponsor: Steve Harris, Chief People Officer Attendee: Ceri Connor, Director of OD and Inclusion 10 Annual Ward Staffing Nursing Establishment Review 11:35 Discuss and approve the review Sponsor: Gail Byrne, Chief Nursing Officer Attendee: Rosemary Chable, Head of Nursing for Education, Practice and Staffing 11 Guardian of Safe Working Hours Quarterly Report 11:45 Receive and discuss the report Sponsor: Paul Grundy, Chief Medical Officer Attendee: Diana Hulbert, Guardian of Safe Working Hours and Emergency Department Consultant 12 Learning from Deaths 2022/23 Quarter 2 Report 11:55 Review and discuss the report Sponsor: Paul Grundy, Chief Medical Officer Attendee: Ellis Banfield, Associate Director of Patient Experience 13 Freedom to Speak Up Report 12:05 Review and discuss the report Sponsor: Gail Byrne, Chief Nursing Officer Attendee: Christine Mbabazi, Equality & Inclusion Adviser/Freedom to Speak Up Guardian Page 2 14 Annual Assurance Process and Self-assessment against the NHS 12:15 England Core Standards for Emergency Preparedness, Resilience and Response (EPRR) Review and discuss the report Sponsor: Joe Teape, Chief Operating Officer Attendee: John Mcgonigle, Emergency Planning & Resilience Manager 15 STRATEGY and BUSINESS PLANNING 15.1 Board Assurance Framework (BAF) Update 12:25 Review and discuss the update Sponsor: Gail Byrne, Chief Nursing Officer Attendee: Craig Machell, Associate Director of Corporate Affairs and Company Secretary 16 CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 16.1 Register of Seals and Chair's Actions Report 12:35 Receive and ratify In compliance with the Trust Standing Orders, Financial Instructions, and the Scheme of Reservation and Delegation. Sponsor: Jenni Douglas-Todd, Trust Chair 16.2 Review of Standing Financial Instructions 2022-23 12:40 Review and approve the SFIs Sponsor: Ian Howard, Chief Financial Officer Attendee: Phil Bunting, Director of Operational Finance 16.3 Corporate Governance Update 12:50 Receive and discuss the update Sponsor: Gail Byrne, Chief Nursing Officer Attendee: Craig Machell, Associate Director of Corporate Affairs and Company Secretary 17 Any other business 13:00 Raise any relevant or urgent matters that are not on the agenda 18 Note the date of the next meeting: 31 January 2023 19 Items circulated to the Board for reading 19.1 CRN: Wessex 2022-23 Q2 Performance Report Note the report Sponsor: Paul Grundy, Chief Medical Officer Page 3 20 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. 21 Follow-up discussion with governors 13:05 Page 4 3 Minutes of Previous Meeting held on 29 September 2022 1 Draft Minutes TB 29 Sept 22 OS v2 Minutes Trust Board – Open Session Date Time Location Chair Present 29/09/2022 9:00 – 13:00 Microsoft Teams Jenni Douglas-Todd (JD-T) Jane Bailey (JB), Non-Executive Director (NED) Gail Byrne (GB), Chief Nursing Officer Cyrus Cooper (CC), NED (from item 5.4 part two) Jenni Douglas-Todd (JD-T), Chair Keith Evans (KE), NED David French (DAF), Chief Executive Officer Paul Grundy (PG), Chief Medical Officer Steve Harris (SH), Chief People Officer Jane Harwood (JH), NED Ian Howard (IH), Chief Financial Officer Tim Peachey (TP), NED Joe Teape (JT), Chief Operating Officer In attendance Jane Fisher, Head of Health and Safety Services (JF) (for item 7.3) Sarah Herbert, Deputy Chief Nursing Officer (SHe) (for item 5.7) Femi Macaulay (FM), Associate NED Corinne Miller, Named Nurse for Safeguarding Adults (CM) (for item 5.8) Karen McGarthy, Named Nurse for Safeguarding Children (KMcG) (for item 5.8) Christine McGrath (CMcG), Director of Strategy and Partnerships Helen Potton, Associate Director of Corporate Affairs and Company Secretary (Interim) (HP) Helen Ralph, Manager, Transformation Team (HR) (for item 6.1) Annabel Shawcroft, Clinical Programme Officer, Transformation Team (AS) (for item 6.1) Jason Teoh, Director of Data and Analytics (JTe) (for item 5.11) Diana Ward, Clinical Outcomes Manager (DW) (for item 5.10) One member of the public (observing) 3 governors (observing) 5 members of staff (observing) 1 members of the public (observing) Apologies Dave Bennett (DB), NED 1. Chair’s Welcome, Apologies and Declarations of Interest JD-T welcomed all those attending the meeting which was being held by Microsoft Teams. Apologies were received from DB. CC would be joining the meeting later. 2. Patient Story HP introduced the Patient Story which focused on the experience of a mother and daughter who had used the Trust’s services. Mum advised that during the pandemic, her daughter had been diagnosed with cancer in her abdomen at the age of nine years old. Page 1 Her daughter had surgery followed by nine rounds of chemotherapy at the Trust followed by radiotherapy in London. Whilst on maintenance chemotherapy her daughter had relapsed and sadly a decision was made that further treatment would not be beneficial. Her daughter’s response was to write a “bucket list”. Some of the items were for herself but some related to changes that she wanted for other people including wanting parents to be fed. Her daughter could not understand why, when she was asked what she wanted to eat, that this did not extend to her mum, when her mum was in the hospital supporting her. Her daughter had not wanted mum to leave to go and eat, and no one else could come to sit with her because of the COVID restrictions. Her daughter was scared and going through gruelling treatment and that made it very difficult for mum to leave her. In addition, her treatment had affected her smell, making her feel unwell which resulted in her mum eating in the ensuite toilet as there was nowhere else to sit and eat. After her daughter died, mum had been working on items from her daughter’s bucket list, with senior representatives of the NHS. Work focused on putting in place a national programme to feed parents, improve food for children and also the provision of play specialists. In terms of food, mum had been working with UHS’ Patient Support Hub since January. Initially snack and toiletry boxes were put into every parent room but now, every children’s ward across Portsmouth and Southampton, a total of 17 wards, received food and drink every week. A charity, Sophie’s Legacy, had been set up and a trial had started that provided parents with a £4 food voucher for the restaurant, which was in addition to the support provided by the Patient Support Hub. The initiative had been well received by parents. The hope is to roll this out across the Country as looking after parents was important to enable them to support the care of their children. JD-T thanked mum for sharing noting how devastating it must have been to lose her daughter and how amazing it was that she and her daughter had wanted to support others in this difficult time. GB also thanked mum for sharing the experience and the work that was being done in her daughter’s name, which was important to continue. DAF noted how extraordinary that at the age of nine her daughter was considering the future of others. DAF asked whether mum had good links with the hospital charity and SH confirmed that he would make contact to ensure that this happened. Action: SH JT noted the importance of good facilities being available including good quality, affordable food. It was important for the Board to look at this and also to look at the estate to ensure that there was appropriate spaces provided for parents. 3. Minutes of the Previous Meeting held on 28 July 2022 The minutes of the meeting held on 28 July 2022 were approved as an accurate record of the meeting save for the following amendments: Page 2 • Page 3 – Correct spelling of Beachcroft • Page 3 – 5.3 third bullet – should read compliant not complaint. 4. Maters Arising and Summary of Agreed Actions Actions that were due had been completed. Action 763 – The complaint data was being compiled and would be sent out shortly. The remaining actions were not yet due but were being taken forward. 5. QUALITY, PERFORMANCE and FINANCE 5.1 Briefing from the Chair of the Audit and Risk Committee KE provided a briefing following the meeting on 12 September. The External Auditors had signed off their opinion on the financial statements with a clean opinion being given. From the Internal Auditors three reviews had been completed. The incident management review had focused on smaller incidents, noting that major incidents would normally be highlighted quickly. A large number had been tested and the conclusion was that the Trust needed to work on turning the reports around within the ten-day period. The Cyber Security review was one of significant assurance. However, the report highlighted that the Trust did not have formal documentation in terms of a Cyber Security Strategy and that not much training was provided for staff. Finally, in terms of General Data Protection Regulation (GDPR) and personal information, the Trust was required to have a “record of processing activities” (ROPA). The Trust undertook hundreds of activities but did not have a ROPA for every activity and the recommendation was to review and put in place an appropriate policy to enable a more general approach for wider coverage. The final review was stage 2 of how the Trust managed and governed IT projects. The report had focused on three areas: • The initial assessment of the benefits of the IT project which had been found to be thorough and well thought out and documented. • More guidance was recommended on how to evaluate benefits particularly in terms of non financial benefits including safety benefits. • There were very few post benefit assessments being completed which would help with learning. Plans were in place to put additional controls in place by March 2023 and a review would take place as part of their follow up procedures. JT reminded members that he had arranged for Cyber training for the Board and had agreed to provide further assurance around some of the arrangements and the Internal Audit was aligned to this. JT noted that staffing arrangements would need to be reviewed as currently there was only one colleague within the digital team that worked on cyber security issues. HP informed the Board that work was already underway in terms of the work around ROPAs. Action: JT Page 3 5.2 Briefing from the Chair of the Finance and Investment Committee JB provided an update from the last meeting noting that discussions had taken place around the current financial position and the operational plan, both of which were due to be discussed in the closed board meeting. There was significant challenge particularly around the deficit position but overall there was a really good grip on exactly where the Trust currently was, with appropriate decisions being made to reflect the balance between managing the financial position, whilst continuing to support our people and activity. A number of ongoing actions around productivity were being addressed together with a clearer view of the future cash position of the Trust. Finally, JB noted that Model Hospital data had been reviewed to enable the Trust to drive efficiencies compared to other hospitals and to facilitate learning. 5.3 Chief Executive Officer’s Report DAF noted that this was the first time that the Board had met since the death of Her Majesty Queen Elisabeth II and wanted to formally recognise the fantastic public service that she had given. The state funeral, which gave an additional bank holiday, provided the Trust with some challenging operational issues, with little guidance being provided in terms of what the best approach should be. Where staff were not involved in urgent or emergency care, such as within outpatients, electives and day case procedures, they were given the choice that if they wanted to work that would be gratefully received, but similarly if they wanted to take the day off to pay their respects, they were able to. Some staff wanted to work and others wanted to take the day. More than two thirds of the scheduled activity had been undertaken. DAF thanked all staff for all of their hard work and dedication. He also noted that: • The pilot of the care village had been very successful and would be discussed further in the next item. • Junior doctor pay rates had been quite challenging and was symptomatic of where the Trust was with many members of the workforce. The Royal College of Nursing (RCN) had notified the Trust of an intended ballot for strike action. Also, the British Medical Association (BMA) had published a rate card that they wanted trusts to pay, which was in many cases, significantly above current ratees. DAF noted that there were groups of staff who had indicated that they would not work for the Trust unless paid the new rates. It was a period of instability and people were understandably wanting to protect their income which was manifesting in the behaviours that we were seeing. • The HR team had been recognised by the Chartered Institute of Professional Management (CIPD), for a National awards which was a testament to the good work that SH and his team did. • The number of COVID positive cases was increasing with around 70 currently in the hospital. Mask wearing had been re-introduced in clinical areas in an attempt to limit the number of nosocomial transmissions. Care homes were not willing to accept patients with COVID which would impact potential discharges. In terms of staff Page 4 absence from COVID this was also increasing and staff were being encouraged to have both COVID and influenza vaccinations. • UHS was in the process of finalising an IT contract which, at first glance looked like it could be a replacement for our Emergency Department (ED) IT system. The initial contract was small but included from a strategic perspective, as the Trust had recognised the potential for having a longer-term development partner. UHS remained committed to its “Best of Breed” strategy but had been struggling to recruit and retain the people needed to develop the systems and this could be a step to delivering this by working together in partnership. Ultimately this could result in UHS not only being able to bring to develop our systems but also had the potential to bring to the market a number of our IT products that we had developed. • At the previous month’s board, the Trust had been aware of its segmentation under the Single Oversight Framework (SOF) review, but had omitted to formally advise the board. The Trust remained in segment 2, with 1 being good and 4 being bad. Trusts in segments 3 and 4 received more dedicated support and oversight. This was a vote of confidence from the regulators in the Trust despite the challenges it was facing. TP noted that the BMA pay card had received much criticism and should be resisted unless there was a proper negotiation about the rates. In terms of the IT partnership this was excellent news. PG noted that the Trust had been very clear through the Local Medical Councils (LMC), and individual conversations with teams, that the Trust would not be entering into negotiations about the BMA rates. It was growing as an issue but was an untenable position to hold in front of the rest of the workforce. Meetings were taking place with teams noting that it was not just about money. PG had been clear with his medical consultant colleagues that he was not able to recommend that consultants were paid as much in one day for an overtime operating list, which was greater than the amount some staff received in a month. In a cost-of-living crisis this was wrong. Many colleagues had understood this approach but there was still many who were very unhappy. JH congratulated SH for the award noting that this was a very difficult award to achieve, with tough competition, and that to achieve it during the pandemic was outstanding. Decision: The Board noted the report. 5.4 Integrated Performance Report for Month 5 (part one) JT noted the challenges that the Trust was currently under and in particular highlighted: • The previous day had been particularly tough with every space in the hospital full and lots of patients in the ED waiting for beds. This was replicated nationally with many organisations had declared critical incidents due to the pressures being faced. It was caused by increased numbers of COVID positive patients and a big spike in the number of delayed patients in the hospital which had hit 245 patients at the start of the week, with almost a quarter of the bed base who could be treated elsewhere. Page 5 • There was a record number of cancer referrals with the waiting list being the highest it had ever been. The Trust continued to deliver more diagnostic capacity than it had ever delivered but continued to struggle with capacity in view of the increased demand. This was a very difficult position alongside a time where staff morale was low and staff were tired due to the pressures over the last couple of years. • One of the two spotlights related to cancer and the Board had a study session the following week with a deep dive. Referrals had grown by about 25% per month from around 1600 two-week referrals to consistently above 2000 per month. The backlog of patients who had breached 62 days had gone up three-fold in the last two years from around 100 to 370 patients. The overall number of patients on the cancer pathway had also doubled in this period. This was challenging for a group of patients that the Trust wanted to prioritise in terms of access to services and care. • Across the Wessex Alliance footprint the backlog remained better than the rest of the Country but it was not where we would want to be in terms of cancer services. It was likely that our performance would dip as we started to treat those patients which would impact the 62 day target, despite the levels of activity and delivering relatively well in terms of our peer groups. • There were some excellent new pathways being developed including the dermatology dream pathway which would make a significant impact on the skin pathway once implemented. Work was also being done with the cancer allowance to map what we had, against what we needed to understand better the gaps. DAF noted that the cancer performance metrics were a measure of the patients that had been treated. Once you had a number of patients above the 62 days, if you did not treat them and let them remain on the waiting list. your measure would remain strong. However, this was not the right thing to do but once you had treated them this would impact that metric which was likely to be poor over the coming months. TP noted that the waiting had continued to get bigger which would suggest that either the Trust was not coping with the numbers coming through and people were therefore waiting longer and longer or that there was a higher rate of cancer in the population. Was this as a result of COVID reducing the body’s ability to fight small cancers that would normally disappear. JD-T also noted the highest number of referrals happening in August and wondered whether there was any national modelling being done around this. JT informed members that Professor Peter Johnson would be one of the presenters at the board study session and this would be a good opportunity to explore this. Anecdotally we appeared to be seeing more sicker patients who had a number of co-morbidities presenting as more complex patients and work was underway to investigate this further particularly from an inequality lens in terms of the demographics that were being referred on the two week wait referrals. PG noted that during COVID people tended to not present which was part of the reason for a backlog of presentations but that diagnosis appeared to also be increasing. Understanding why was not yet known and a discussion in the study session would be helpful to understand that particularly better. In terms of the appraisals spotlight SH noted: Page 6 • That a key element from the People Strategy was the Trust’s ability to provide meaningful progression for our staff. From the feedback given in the staff survey many staff believed that during the pandemic they had not received the development, training or the appraisal focus that they would have wanted. • Work to address that included a multi disciplinary team who had focused on refreshing the appraisal paperwork which had been well received. The team had a wide breadth of staff including clinical, operational and trade union representatives. Previously the number of appraisals carried out had been good but the quality had been low so training for appraisals had been reviewed to improve the quality of the appraisal discussion. Whilst the Trust was better than its peers, this simply highlighted that the NHS was not particularly good at appraisals. • A pilot had been implemented to better align appraisals with objective setting to enable them to cascade down to staff better which would conclude shortly and would feed into the process. JD-T noted that Division D consistently outperformed the other Divisions in terms of completed appraisals. In addition the staff survey showed that they were the only division that achieved a green in terms of an appraisal helping staff to undertake their job. This showed a correlation between the two and wondered what was the learning was. SH noted that Division D had historically had good rates of completion and had been involved in the refresh and had highlighted the need to focus at every level of the team. JH asked whether those within Division D had better promotion and development opportunities which could link back into the value of conducting a good appraisal. SH advised that there was nothing obvious but Division D had some good engagement scores overall but this could be looked at further. GB noted that the new appraisal paperwork had removed the need to consider how an individual contributed to the values of the organisation, and although the values were still referenced, questioned how through appraisal the behaviours and values continued to sit within the process. SH noted that the review of the values work was important and it would be good to look at how that could be brought back into the appraisal process to add value. Decision: The Board noted the report. 5.5 Finance Report for Month 5 IH presented the report and highlighted: • The Trust continued to focus on the underlying deficit, which for months 1 – 4 had been around £3m which had slightly worsened to £3,5m as energy costs started to grow. A deep dive had taken place at the Finance & Investment (F&I) Committee looking at some of the actions being undertaken and some of the future forecasts before the energy cap would come in and whether this would help or otherwise. There would still be a small increase in run rate into the latter half of the year which would deteriorate the Trust’s underlying position as we entered the winter months. • The key drivers were consistent. As well as energy prices, there were some drug costs pressures as we were on a block contract, cost associated with COVID including backfill of staff together with all of the operational pressures that had already been discussed. Page 7 • Cost Improvement Programme (CIP) performance had improved following the introduction of the Cost Savings Group. The Trust was currently achieving more than 80% identified which should increase going forward. In month delivery had also been strong. Everything was being done to try and improve the financial position but there were a number of pressures that were outside our control that would impact this. • Elective recovery framework performance had dipped in line with the operational pressures discussed, but UHS continued to achieve 106%, above the required 104%. UHS was in the top Trusts both in the region and nationally in terms of activity levels compared to 2019/20 levels. However, this was not resolving the waiting list issue that continued to grow. UHS continued to do well in terms of 2019/20 levels compared to other Trusts but this did create a financial pressure. • The Trust had reported a £12m deficit. The Hampshire and Isle of Wight deficit was £53m. This was an outlier within the region, and the region was an outlier nationally. This had resulted in the system becoming an outlier in terms of financial performance which might have adverse consequences going forward including upon the SOF rating. • The underlying deficit reduced the Trust’s cash balance and that may put pressure on our future capital investment programme. KE referred to the financial risks table and asked what the difference was between the original worst case of £57m and the forecast assessments which showed, best, intermediate and worst case? IH noted that the original worstcase scenario had been presented to the Board as part of the planning submissions, to show the range of possible financial outcomes with everything that was known at the time. The current best, intermediate and worst case were the current assessments. KE noted that UHS could not control COVID costs, energy costs and inflationary measures and that this would need Treasury to provide support. IH reminded members that nationally there was a drive to find efficiencies. It was likely that many Trusts would go into deficit this year but it was not clear what the response would be to that. KE commended the work on the CIP which was a fantastic achievement. He questioned whether the position could improve further with more CIP savings. IH advised that a target date of Month 6 had been agreed in terms of everything being identified 100% and the position might improve next month. IH noted that UHS was at 106% activity levels with the national average being around 94%. The 12% from the Elective Recovery Fund (ERF) would be worth about £20m to the Trust. If the Trust had undertaken less activity the Trust’s financial position would be a lot less stark but UHS continued to put patients first and try and balance performance, money and quality. In response to a question from JD-T IH confirmed that as of today and what was currently known, UHS could still achieve the best-case scenario. DAF suggested that in view of what had happened in markets over the recent days it was unlikely that the NHS would want to approach the Treasury. UHS should proceed on the basis that there would be no financial support being provided. In those circumstances the Board would need to consider at what point more significant interventions would need to be made. Page 8 5.6 People Report for Month 5 JD-T noted that this was a new report for the board. Previously the report had been presented to the Trust Executive Committee (TEC) and following discussion in that forum a decision was made that it should be presented to the open board for discussion. SH presented the report and noted that the version before the Board was the detailed report presented to TEC. Going forward a more streamlined report, with key highlights, would be developed for the Board discussion. SH highlighted: • Some of the key actions that had been taken in relation to recruitment and retention and also the cost-of-living crisis. There had been discussions at a previous closed board meeting around concerns in relation to the recruitment and retention of certain staff groups and some actions had been put in place to mitigate those concerns. • SH highlighted the challenges around Advanced Clinical Practitioners (ACPs) and pay rates. A few local organisations including GP practices were providing a differential rate of pay with a higher pay band. In the short term this was being addressed by a recruitment and retention premium to bridge the gap, together with conducting a workforce review that would seek to understand the banding and whether there was a need for a permanent band change. However, it would be important to consider the possible impact on the change to other bands across the Trust and manage that appropriately. • UHS continued to undertake Health Care Assistant (HCA) recruitment well, but the challenge was retention. There were good pathways in place but work was needed to strengthen landing boards and increase the support available in the hubs and implement some band 2 to band 3 progression roles for those who did not want to utilise the nursing apprenticeship route. • Demand on the recruitment team had significantly increased with a 25% increase of requested support. Some additional resource had been agreed to support them both within the organisation but also to increase engagement outside of the organisation. • In terms of cost of living, SH had been undertaking a lot of work with partners across the Trust including trade unions and listening to staff voices. There were a number of elements that were not under the Trust’s control including the national pay award and the rising energy crisis so the approach being taking was to take a balanced and fair approach. A number of things would be implemented which would be highlighted to all staff. A substantial discount was being negotiated in the restaurant to help people to eat a broad range of foods at competitive prices. The cycle to work scheme was being expanded, and there was some targeted support for those with high mileage within the organisation. For the 200 or so families who used the nursery the price was being rolled back to April this year. • The Trust already has a range of general support which would be expanded to make sure that we were targeting the right people. Through a partnership with the ICS we were linking up with the Citizens Advice Bureau to provide really high quality financial advice to our staff. We were focusing on crisis, and working with the Charity, had set up a hardship fund of £20,000 which would be distributed to the most challenging cases where staff had been identified as a particular Page 9 hardship case they would be able to eat free at the restaurant. Arrangements had also been made with a local charity to provide vouchers and food parcels. Discussion had taken place as to whether a food bank should be set up on site which logistically would have been difficult, so the decision to work with the charity was agreed to be the best approach to deliver that service for us. • Discussions had taken place at the Trust Executive Committee (TEC) who had fully supported the measures noting the impact on the nonrecurrent spend. KE suggested that this was a very sensible, targeted group of things to support our people. However, asked if the cost of £2.3m was currently included in the financial reports. IH advised that it was not included although some of the nonrecurrent elements had a funding source so would not hit the underlying position. In terms of annual leave buy out there were accruals from previous years. However, there were some recurrent costs. The measures were targeted, proportionate and in line with the Trust’s values for the current pressures being faced and if the Trust did not do anything it would likely increase costs or consequences elsewhere. DAF noted that the report was the same as presented to the TEC at which there had been a more detailed conversation. It would be helpful to understand which areas of the report were more relevant and appropriate for the Board conversation which could be discussed at the next People and OD POD) Committee meeting. Action: SH. JH supported the proposals within the paper and noted that they had also been presented to the People and OD Committee (POD). POD would be tracking the progress of each of the initiatives to ensure that they were delivering as anticipated. JH asked if the Trust had looked at what others were doing to ensure that we were doing everything possible for our staff. SH confirmed that discussions had taken place locally and that the Trust was one of the first to implement the range of measures which were similar to those of others. Nationally, there had been a push to have a collective response, noting that the NHS employed 1.5m people and that there would be national support that would be available shortly. TP noted the importance of having a people report at the Board and whilst the contents were good suggested that they could be presented in a more accessible way. FM also noted the importance of the report and discussion but wondered what staff morale was. If the finance, performance and people report were considered as a whole it was clear that staff were facing a lot of pressure and there was insufficient staff due to high turnover. The volume of patients was increasing which meant that the staff that the Trust did have, had to work harder and longer with pay that was not great and a cost-of-living crisis to deal with. This must have an impact on staff morale and was there also an impact on patient care? SH noted that morale was challenged which was recognised in the executive updates. The Trust undertook a quarterly staff survey alongside the current national annual staff survey and those results have been included within the report. The recent results discussed motivation, engagement and advocacy in Page 10 the organisation and UHS scores were still consistently in the top 10 of the NHS. However, the entirety of that engagement score was deteriorating. Morale was challenged and how that impacted on care was discussed in other forums. GB chaired the Quality Governance Steering Group (QGSG) which fed into the Quality Committee and focused on quality whether that be from the engagement of our staff or other challenges. GB suggested that it was a mixed picture. People enjoyed working as a team and we can see them pull together and work as a team through the challenges. There were a number of different pockets in the organisation who believed that they were in a worst situation following the pandemic and it was important to move out of that space and recognise this as a whole. In terms of quality, it was important to retain a close focus on quality and in some other Trusts they were starting to experience a significant challenge with regards to their quality indicators. At UHS there were some potential early indications that were being closely monitored. Without a doubt staffing levels, and the way in which we looked at the wards, impacted on patient experience and outcome. JD-T noted that one of the proposals was for staff to be able to sell back annual leave and being able to easily access the bank but if this was considered in the wider context, we had staff who were tired and not able to take leave as they had sold it, and were looking to work extra hours on the bank. How did the Trust manage and balance this? How should we look at the overarching risks for the workforce, and consequently patient care and performance, and what were the things that we needed to do to balance that. It would be helpful if the report could address some of those challenges to help the Board’s understanding. In addition JD-T asked NEDs to feedback what they would want to see within the report to enable an effective discussion. Action: SH and All NEDs JH asked about exit surveys and wondered if there was any information from them that could support our approach. SH advised that approximately 30% of staff completed exit surveys which needed to be increased. Pay for the lower paid staff had become an issue. SH reminded members that he chaired the ICS people officers group and that group had been looking at how collectively they could support retention and were looking to purchase better exit surveys for the system pulling together their collective buying power. Decision: The Board noted the report. 5.4 Integrated Performance Report for Month 5 (part two) Having noted the previous discussions under items 5.5 and 5.6 JD-T suggested that a discussion on the remaining of the IPR would be helpful and the following questions and comments were made: • JB noted that on pages 31 and 35, F1 – F5 this suggested that in terms of digital we believed that this was going to transform our efficiencies but it was not clear what the metrics indicated nor were some of them very high. PG suggested that there was an amazing resource in my medical record which we were not really making the most of. Work was needed to raise awareness with both patients and clinicians. Having used it as a patient it had been really helpful and enabled him to go paperless. JT noted that there was a business case that was overdue Page 11 for my medical record around how we industrialised it across the Trust which should provide some huge benefits and would bring a timeline back as to when this would happen. Action: JT JT noted that there was some big digital change happening with the rolling out of speech recognition and some E tools. In addition it would be helpful to look at the indicators to understand whether they were the right ones and review them as part of the digital updates which could be discussed at F&I. Action: JT The Board discussed the importance of giving people an overwhelming reason to access my medical record noting that the NHS App had initially been used for COVID vaccinations but could now enable people to order prescriptions and book appointments. JD-T noted the Serious Incident reports and the number of harm falls which looked higher than previously and wondered in terms of the pressures we were seeing and the issues around workforce should the Board be concerned about this? GB advised that it had recently been falls awareness week. There had been a number of successful programmes in the Trust including bay watch, but with reduced staffing numbers that had became a challenge and some more deliberate high impact actions were needed to reduce those falls. A deep dive into this would be brought to a future meeting. Action: GB GB confirmed that COVID numbers were rising. There were 66 patients with COVID some of whom were both asymptomatic and symptomatic. 5.7 Break The break took place prior to the Safeguarding Annual Report. 5.8 Safeguarding Annual Report 2021-22 and Strategy 2022-25 JDT suggested that the strategy should be discussed first noting that both had been discussed at the Quality Committee. KMcG presented the strategy which had previously been presented to the Trust Board two years ago before Covid. The strategy had been reviewed and updated in line with new legislation and aligned to UHS values and now included maternity services. Some of the strategy linked to children and adult reviews and making safeguarding personal together with our partners and developing stronger links within maternity, the emergency department and the wider hospital. Joining this up with the domestic abuse strategy and ensuring that we were always improving particularly around training and education including level 3 requirements. In terms of the Annual Report from a children’s perspective there were three main highlights: Page 12 • A significant increase, from 3700 to 6004, in the number of information sharing forms (ICF) which come through the ED where a child may possibly be at risk. In particular numbers had increased in the number of children presenting with mental health problems, particularly the 0 – 4 age group. This had been discussed at the Health Safeguarding Looked After Children Partnership who were looking at the 0 – 19 service provision which had changed significantly with COVID and a possible pattern of children of parents accessing through ED rather than going via their GP. • In terms of mental health, for any child who presented in the ED with a mental health condition an ICF would be completed. The number of presentations remained high. Alongside this the number of deliberate harm incidents had risen from 676 to 898, drugs and alcohol referrals had risen as had assaults over the preceding year. • Level 3 safeguarding training was at about 61%. There were two main reasons for this which was capacity and demand for the service and also a change of reporting requirements impacting just over 2000 staff. Training was on the Integrated Care Board (ICB) Risk Register as it was a wider system issue. In terms of the Annual Report for adults CM highlighted the following: • A 31% increase in safeguarding activity from the previous year with a 162% increase in Section 42 inquiries. This was due to a number of reasons including the impact of COVID including the removal of social distancing rules. • A 35% increase in the number of allegations made against people in a position of trust which was something that was being seen across other local provider organisations. These were highly sensitive cases and required significant safeguarding oversight and management alongside collaboration with HR colleagues and the relevant clinical areas, which had a significant impact on the team. • The creation of a new Mental Capacity Act (MCA), Deprivation of Liberty (DoL) and Liberty Protection Safeguards (LPS) team who supported people over the age of 16. Both locally and nationally this was one of the first teams that had been established. The team had worked to embed MCA as every day business which was key to the preparation for when LPS become law later next year or early the following year. • In terms of Learning Disability and Autism there was a lack of local provision which had been acknowledged by the ICS and work was underway in relation to service review and what this needed to look like going forward. GB thanked the team noting how hard they worked to safeguard vulnerable adults and children. GB referenced the Panorama programme that had aired the previous night in terms of a number of safeguarding issues against a Mental Health Trust. Whilst often allegations against staff were not grounded they were taken very seriously and investigated thoroughly. JB noted the 35% increase against staff and wanted to understand what the outcomes of the investigations were and whether they were justified and whether allegations were being made against different groups. CM advised that one of the key areas of allegations focused on restraint and that the level Page 13 of restraint applied was disproportionate. These would always be reviewed. Security staff worked in pairs and wore body cameras which would always be reviewed. There had not been any cases recently where that had proved to be an issue. Although there had been a big increase the total number of cases was 38 so not large numbers. The previous year there had been 23 cases. CC questioned what element of this sat within the Trust and what sat with the ICS? SH noted the importance of remembering the broader picture. Nationally there had been a rise of safeguarding incidents, but it was important to remember that our workforce formed part of that population and had struggled with lockdown and were experiencing hardship. JD-T noted the need for a system approach to manage the increased mental health demand. However, safeguarding was a key focus for the Care Quality Commission (CQC) inspections post COVID, and a local provider had recently been deemed to be inadequate due to safeguarding issues and was an issue for UHS to pay particular attention to. KMcG noted that through legislation children had the Local Area Designated Officer (LADO) which was lacking in adults, which provided a really strong link with that external partner. TP noted that there had been a detailed presentation on this in the Quality Committee. This was a national trend in increased safeguarding problems. Whatever pressure we are put under it was important not to let our safeguarding procedures slip and it needed to be protected to ensure that it worked well. Decision: The Board received the report. 5.9 Medical Appraisal and Revalidation Annual Report including Board Statement of Compliance PG presented the report which was a statement of compliance with the medical regulations and had a robust and strong process in place. PG noted that a new appraisal system had been introduced which had been well received and enabled the ability for medical staff to collect all of their appraisal information within one system instead of the previous three systems. This was beneficial for not only staff but also for those managing the process as it provided real time feedback and information both from a quality assurance perspective but also would enable better management of the process and improve appraisal rates in the future. JD-T asked whether the doctor appraisal information was included within the IPR information that the Board received and SH confirmed that it was reported separately but included in the report and currently stood at 76.7%. CC suggested that the system was good but asked whether everyone was using it. PG confirmed that the system was a mandatory one and would be the only system going forward in the future. In terms of how many staff had undertaken the process this was a little ahead of the rest of the staff. However, the system enabled us to keep better track as people would need to have completed four appraisals within the previous five years to go forward with revalidation which provided a good incentive to keep on top of this. Page 14 JD-T asked for Board members to confirm that they approved the statement of compliance. Decision: The Board noted the report and approved the statement of compliance. 5.10 Clinical Outcomes Summary PG introduced the comprehensive summary noting that the clinical lead who had ran the service for a number of years, had now left UHS and a process of recruitment was currently underway which would provide an opportunity to refresh and review. DW presented the paper and focused on the outcome programme which was unique to UHS, with 64 services out of 86 reporting their outcomes. A total of 484 outcomes had been reported all of which had been reviewed by TP via the Quality Committee. There was a thriving clinical audit programme in place. The outcomes reported per care group covered a large proportion of patients and dealt with both national and international work. In particular DW highlighted: • The Research and Development (R&D) team and the work that they had undertaken internationally on the COVID booster trial. • The Bone Marrow Transparent unit. • Maternity and the nest support teams who focused on women who may need additional support because of serious mental illness, or they were from socially challenging situations, or were non-English speaking, addiction, were homeless or were suffering from domestic abuse and other difficult situations. 12% of patients that were being seen in maternity required nest care. KE asked why 18 services were not reported and DW advised that it was because they did not have the mechanisms in place to know what their outcomes were and work was underway to support them to develop those processes. KE asked whether any of the reds within the report were really poor and JD-T noted that the data used was for 2020 and did not understand why it was so out of date. TP advised that data was provided from national audits was often two years behind, because there was a year of collection, a year of analysis and then it would be published. Within his experience he had never come across a hospital that had measured nearly 500 clinical outcomes let alone p
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UHS AR 22-23-6

Description: 2022/23 Incorporating the quality account University Hospital Southampton NHS Foundation Trust Annual Report and Accounts 2022/23 Presented to Parliament pursuant to Schedule 7, paragraph 25(4)(a) of the National Health Service Act 2006 © 2023 University Hospital Southampton NHS Foundation Trust Contents Welcome from our chair and chief executive 6 Overview and performance 8 Performance report 9 Overview 10 Accountability report 33 Directors’ report 34 Remuneration report 57 Staff report 71 Annual governance statement 91 Quality account 106 Statement on quality from the chief executive 107 Priorities for improvement and statements of assurance from the board 110 Other information 188 Annual accounts 222 Statement from the chief financial officer 223 Auditor’s report 224 Foreword to the accounts 230 Statement of Comprehensive Income 231 Statement of Financial Position 232 Statement of Changes in Taxpayers’ Equity 233 Statement of Cash Flows 234 Notes to the accounts 235 5 Welcome from the Chair and Chief Executive Officer University Hospital Southampton NHS Foundation Trust (‘UHS’ or the ‘Trust’) experienced another challenging year during 2022/23. Nonetheless, the Trust and its staff have continued to deliver for patients and the wider system in which it operates. Trust highlights from 2022/23 include: • Delivering an 8% increase in activity (compared to 2019/20) under the elective recovery programme, which places us as one of the top performing trusts in England. • Being recognised in the NHS staff survey as the seventh highest trust for recommendation as a place to work nationally and the best performing trust in opportunities for career development. • Celebrating 50 years as a medical school with the University of Southampton and continuing to pioneer UK and world-first research studies. • Enhancing the reputation of our specialist care – for example our bone marrow transplant team at UHS have the best patient outcomes in Europe. However, as was the picture across the country, UHS had an extremely challenging winter with attendances at our emergency department often in excess of 400 a day. This was driven in part by high prevalence of streptococcus A (strep A) in the community along with other seasonal illnesses such as influenza and high incidences of COVID-19 at times. Moreover, the lack of availability of care home beds and other care packages in the community has resulted in challenges in discharging patients who are ready to leave hospital and therefore we have been operating at or near to capacity throughout the year. At the time of writing, there continues to be operational pressures due to industrial action by the Royal College of Nursing and British Medical Association. Throughout the disputes, we have attempted to balance the right of our staff to strike with the need to minimise the impact on the Trust’s operations and patients and ensure that safety was not compromised. Our leadership team has engaged proactively with the unions to agree, where possible, derogations (i.e. services that will continue to be staffed during strikes) to ensure that the running of our hospitals can continue and that patients remain safe. We would like to express our thanks to all staff who have gone over and above during these periods of industrial action by being willing to do different work to usual, often at anti-social times of the day. While we cannot influence national negotiations, we are focusing on what we can control within UHS. Our people strategy published last year sets out how we will grow and deploy our workforce of today and the future as part of a thriving community to deliver world-class patient care. Building on this, we have recently launched our inclusion and belonging strategy so that as a leadership team we can deliver what is required for all our workforce to feel they can belong and thrive at UHS. The Trust achieved its Cost Improvement Plan (CIP) target of £45.6m for 2022/23, the highest in our history but despite this, ended the year with a deficit of £11m. The deficit was driven by a combination of factors including a substantial increase in energy prices, higher costs of medicines and equipment and temporary staffing costs as well as changes in recent years in respect of the NHS funding infrastructure, which adversely impacted the Trust relative to others during the year. In terms of the broader context, the Hampshire and Isle of Wight Integrated Care System, in which the Trust operates, reported an overall deficit for 2022/23 driven in part by a significant increase in staffing numbers when compared to 2019/20 as well as structural factors. 6 We have continued to make progress on our estates strategy, building new theatres and carrying out improvements to existing facilities, as well as opening a new park and ride for staff at Adanac Park and progressing plans for a new innovation campus there. During 2022/23 we invested over £88m of capital expenditure to meet our ambition of increasing capacity and improving services in order to manage the increasing demand. All development is underpinned by our green plan, which sets out areas of focus for decarbonising UHS and achieving the net zero target set by the NHS. The Trust has continued to support the Hampshire and Isle of Wight Integrated Care System, which was formed on 1 July 2022 to facilitate integration and collaboration across health and social care partners in the region. In particular, UHS has worked closely with the Integrated Care Board and other providers in the development of the operating plan for 2023/24. We have also continued to work with other partners in the region, including local authorities and the University of Southampton. The 13,000 staff of UHS are our greatest asset and we would like to express our gratitude to them for continuing to go above and beyond to put patients first under very challenging circumstances. Without our staff, we would be unable to fulfil our ambition to be a world-class organisation with world-class people delivering world-class care. Jenni Douglas-Todd Chair 26 June 2023 David French Chief Executive Officer 26 June 2023 7 PERFORMANCE REPORT Performance report Introduction from the Chief Executive Officer The Trust experienced another challenging year with the need to balance the delivery of quality patient care with a significant increase in demand for the Trust’s resources and the need to do so whilst maintaining a sustainable financial position. The Trust saw the number of patients on a waiting list under the 18-week referral to treatment pathway increase to just over 55,000 patients at the end of the year. Despite this, however, the Trust was successful in reducing the number of patients waiting more than 104 weeks to nil and in reducing the number of patients waiting more than 78 weeks to 14 by the end of the year. In addition, the Trust’s performance under the elective recovery programme placed it as one of the topperforming trusts in the country. Demand for non-elective care also significantly increased during the year with the emergency department seeing more than 400 attendances per day at some points, especially during the winter months. The industrial action seen in the latter part of 2022/23 placed further pressure on the Trust and resulted in a need to cancel elective procedures and outpatients appointments. However, on balance, the Trust was able to manage these events through effective planning and the engagement and support of its staff. Although the Trust was successful in recruiting to substantive roles, especially in terms of reducing the number of Health Care Assistant vacancies, the anticipated reduction in use of bank and agency staff was not seen. This, among other factors, such as the substantial increase in energy costs and the rate of inflation, posed a significant challenge in terms of the Trust’s financial position. Despite achieving savings of £45.6m, the Trust reported a deficit of £11m for 2022/23. 9 Overview About the Trust Our services University Hospital Southampton NHS Foundation Trust is one of the largest acute teaching trusts in England with a turnover of more than £1 billion in 2022/23. It is based on the coast in southeast England and provides services to over 1.9 million people living in Southampton and south Hampshire and specialist services, including neurosciences, respiratory medicine, cancer care, cardiovascular, obstetrics and specialist children’s services, to more than 3.7 million people in central southern England and the Channel Islands. The Trust is also a designated major trauma centre, one of only two places in the south of England to offer adults and children full major trauma care provision. As a leading centre for teaching and research, the Trust has close working relationships with the University of Southampton, the Medical Research Council, National Institute for Health and Care Research (NIHR), Wellcome Trust and Cancer Research UK. The Trust is consistently one of the UK’s highest recruiting trusts of patients to clinical trials and one of the top nationally for research study volumes as ranked by the NIHR Clinical Research Network. Every year the Trust: treats around 160,000 inpatients and day patients, including about 75,000 emergency admissions sees over 650,000 people at outpatient appointments deals with around 150,000 cases in our emergency department delivers more than 100 outpatient clinics across the south of England, keeping services local for patients The Trust provides most of its services from the following locations: • Southampton General Hospital – the Trust’s largest location, where a great number of specialist services are based alongside emergency and critical care and which includes Southampton Children’s Hospital. • Princess Anne Hospital – located across the road from Southampton General Hospital and providing maternity care and specialist care for women with medical problems during pregnancy and babies who need extra care around birth across the region. • Royal South Hants Hospital – although the Trust does not operate this site near the centre of Southampton it provides a smaller number of services from this location. • New Forest Birth Centre – located at Ashurst on the edge of the New Forest and run by experienced midwives and support staff it acts as a community midwifery hub. The services provided by the Trust are commissioned and paid for by the Hampshire and Isle of Wight Integrated Care System (ICS) and, in the case of more specialised services (such as treatments for rare conditions), by NHS England. Trust services are supported by clinical income, of which 55% is paid for by NHS England and 43% by the Hampshire and Isle of Wight Integrated Care Board. These are provided under a standard NHS contract, which incorporates ongoing monitoring of the Trust and the quality of the services provided. 10 Our structure UHS gained foundation trust status on 1 October 2011. A foundation trust is a public benefit corporation providing NHS services in line with the core NHS principles: that care should be universal, comprehensive and free at the point of need. The Trust is licensed as a foundation trust to provide these services by NHS England and the healthcare services we provide are regulated by the Care Quality Commission. Since 1 July 2022, the Trust has been part of the Hampshire and Isle of Wight Integrated Care System (ICS) when this was established through the Health and Social Care Act 2022. Each ICS has two statutory elements: an integrated care partnership (ICP) and an integrated care board (ICB). The ICP is a statutory committee jointly formed between the NHS integrated care board and all uppertier local authorities that fall within the ICS area. The ICP will bring together a broad alliance of partners concerned with improving the care, health and wellbeing of the population, with membership determined locally. The ICP is responsible for producing an integrated care strategy on how to meet the health and wellbeing needs of the population in the ICS area. The ICB is a statutory NHS organisation responsible for developing a plan for meeting the health needs of the population, managing the NHS budget and arranging for the provision of health services in the ICS area. The establishment of ICBs resulted in clinical commissioning groups (CCGs) being closed down. The Trust has been a university teaching hospital since 1971. The diagram below provides an overview of the overall organisational structure of the Trust. Division A Surgery Critical Care Opthalmology Theatres and Anaesthetics Public and foundation trust members Council of Governors Board of Directors Executive Directors Division B Division C Division D Cancer Care Emergency Medicine Helicopter Emergency Medical Services Medicine and Medicine for Older People Pathology Specialist Medicine Women and Newborn Maternity Child Health Clinical Support Cardiovascular and Thoracic Neurosciences Trauma and Orthopaedics Radiology Trust Headquarters Division 11 Our values Our values describe how we do things at UHS and act as a guide to all staff working with colleagues to deliver high quality patient care and a great patient experience every day. Our values are: Patients, their families and carers are at the heart of what we do. Their experience of our services will be our measure of success. Partnership between clinicians, patients and carers is critical to achieving our vision, both within hospital teams and extending across organisational boundaries in the NHS, social care and the third sector. We will ensure we are always improving services for patients through research, education, clinical effectiveness and quality improvement. We will continue to incorporate new ideas, technologies and create greater efficiencies in the services we provide. 12 Our strategy 2021-25 The Trust’s strategy was updated during 2020/21 to take account of everything our staff had experienced during the COVID-19 pandemic and what we had learnt from this. The vision for UHS is to become an organisation of world class people delivering world class care. Our strategy is organised around five themes and for each of these it describes a number of ambitions we aim to achieve by 2025. Theme Ambitions Outstanding patient outcomes, • We will monitor clinical outcomes, safety and experience of our experience and safety patients regularly to ensure they are amongst the best in the UK By 2025 we will strengthen our and the world. national reputation for outstanding • We will reduce harm, learning from all incidents through our patient outcomes, experience and proactive patient safety culture. safety, providing high quality care • We will ensure all patients and relatives have a positive experience and treatment across an extensive of our care, as a result of the environment created by our people range of services from foetal and our facilities. medicine, through all life stages and conditions, to end-of-life care Pioneering research • We will recruit and enable people to deliver pioneering research in and innovation Southampton. We will continue to be a leading teaching hospital with a growing, reputable and innovative research and development portfolio • We will optimise access to clinical research studies for our patients. • We will enable innovation in everything we do, and ensure that ‘cutting edge’ investigations and treatments are delivered in Southampton. that attracts the best staff and efficiently delivers the best possible treatments and care for our patients. World class people • We will recruit and develop enough people with the right Supporting and nurturing our knowledge and skills to meet the needs of our patients. people through a culture that values • We will provide satisfying and fulfilling roles, growing our talent diversity and builds knowledge and through development and opportunity for progression. skills to ensure everyone reaches • We will empower our people, embracing diversity and embedding their full potential. We must provide compassion, inclusion and equity of opportunity. rewarding career paths within empowered, compassionate, and motivated teams. Integrated networks and collaboration We will deliver our services with partners through clinical networks, collaboration and integration across geographical and organisational boundaries. • We will work in partnership with key stakeholders across the Hampshire and Isle of Wight integrated care system. • We will strengthen our acute clinical networks across the region, centralising when necessary and supporting local care when appropriate. • We will foster local integration with primary and community care as well as mental health and social care services for seamless delivery across boundaries. • We will build on our successful partnership with University of Southampton (UoS), growing our reputation as a national leading university teaching hospital. 13 Theme Foundations for the future Making our enabling infrastructure (finance, digital, estate) fit for the future to support a leading university teaching hospital in the 21st century and recognising our responsibility as a major employer in the community of Southampton and our role in broader environmental sustainability. Ambitions • We will deliver best value to the taxpayer as a financially efficient and sustainable organisation. • We will support patient self-management and seamless care across organisational boundaries through our ambitious digital programme, including real time data reporting, to inform our care. • We will expand and improve our estate, increasing capacity where needed and providing modern facilities for our patients and our people. • We will strengthen our role in the community as an employer of choice, a partner in delivery of services to our population and by leading the Greener NHS agenda locally. During each year of the strategy the Trust sets out a more detailed series of objectives to achieve and progress towards the delivery of its ambitions. In 2022/23 these objectives included: Outstanding patient outcomes, experience and safety Pioneering research and innovation World class people Integrated networks and collaboration Foundations for the future • Recovery, restoration and improvement of clinical services • Introducing a robust and proactive safety culture • Empowering and developing staff to improve services for patients • Always Improving strategy • Delivering a high-quality experience of care for all • Delivery of year two of the research and innovation investment plan • Strategy and partnership working • Growing, developing and innovating our workforce • A great place to work, develop and achieve • Compassionate and inclusive workplace for all • We Work in partnership with Integrated Care System and Primary Care Networks • Integrated Networks and Collaborations • Establishing Southern Counties Pathology Network • Establishing the Wessex Imaging Network • Develop Collaborations strategy • Creating a sustainable financial infrastructure • Making our corporate infrastructure fit for the future to support a leading university teaching hospital in the 21st century • Recognising our responsibility as a major employer in the community of Southampton and our role in delivering a greener NHS Performance against these objectives will be monitored and reported to the Trust’s Board on a quarterly basis. 14 Principal risks to our strategy and objectives The Board has identified and manages the principal risks to the delivery of its strategy and objectives through its board assurance framework. The principal risks to the delivery of its strategy and objectives identified by the Trust during 2022/23 were that: • There would be a lack of capacity to appropriately respond to emergency demand, manage the increasing waiting lists for elective demand, and provide timely diagnostics, that results in avoidable harm to patients. • Due to the current challenges, the Trust fails to provide patients and their families with a high-quality experience of care and positive patient outcomes. • The Trust would not effectively plan for and implement infection prevention and control measures that reduce the number of hospital-acquired infections and limit the number of nosocomial outbreaks of infection. • The Trust is unable to meet current and planned service requirements due to unavailability of qualified staff to fulfil key roles. • The Trust fails to develop a diverse, compassionate and inclusive workforce, providing a more positive experience for all staff. • The Trust fails to create a sustainable and innovative education and development response to meet the current and future workforce needs identified in the Trust’s longer-term workforce plan. • The Trust does not implement effective models to deliver integrated and networked care, resulting in sub-optimal patient experience and outcomes, increased numbers of admissions and increases in patients’ length of stay. • The Trust is unable to deliver a financial breakeven position and support prioritised investment as identified in the Trust’s capital plan within locally available limits (capital departmental expenditure limit (CDEL)). • The Trust does not adequately maintain, improve and develop its estate to deliver its clinical services and increase capacity. • The Trust fails to introduce and implement new technology and expand the use of existing technology to transform its delivery of care through the funding and delivery of the digital strategy. • The Trust fails to prioritise green initiatives to deliver a trajectory that will reduce its direct and indirect carbon footprint by 80% by 2028-2032 (compared with a 1990 baseline) and reach net zero direct carbon emissions by 2040 and net zero indirect carbon emissions by 2045. During 2022/23, the Trust continued to experience the impact of the COVID-19 pandemic. The need to ensure a safe environment for patients through stringent infection control processes impacted the Trust’s capacity due to the need to isolate patients with COVID-19 in separate areas of the hospital. In addition, outbreaks of norovirus during the winter months placed further pressure on hospital capacity. The impact of the pandemic continued to be felt in terms of staff absence due to becoming infected with COVID-19 as well as the significant impact on staff mental health. The higher than normal (i.e. pre-COVID) levels of staff absence placed additional strain on the Trust’s operations and led to increased expenditure due to the requirement to enlist bank and/or agency staff to maintain safe staffing levels. 15 Performance overview The Trust monitors a broad range of key performance indicators within its departments, divisions, directorates and through Trust executive committees. On a monthly basis, the Board and executive committee receives a performance report containing a variety of indicators intended to provide assurance in respect of the Trust’s strategy and that the care provided is safe, caring, effective, responsive and well-led. This report also includes the Trust’s performance against the national targets set by NHS England. The performance reports include a ‘spotlight’ section, which provides more detailed analysis of a particular area. Typically, this is one of either the national targets or the Trust’s performance against the expectations set out in the NHS Constitution. The monthly performance report is also published on the Trust’s website. The Chief Executive Officer provides a regular report on performance to the Council of Governors, which includes a range of non-financial and financial performance information. Capacity The pressures of the COVID-19 pandemic led to increases in the waiting times for patients and the number of patients waiting for more than a year increased significantly. During the year, the Trust achieved its goal of no patients waiting more than 104 weeks by July 2022 and finished the year with only 14 patients waiting for more than 78 weeks. However, the length of time patients are waiting for treatment remains one of the key risks for the Trust. This situation was compounded by the sustained demand for non-elective activity, which saw attendances at the emergency department rise to over 400 patients per day during some periods of 2022/23 and was consistently higher than previously was the case. The significant increase in referrals, often requiring more complex treatment, has seen the number of patients on a waiting list under the 18-week referral to treatment pathway increase to just over 55,000 patients at the end of the year. In addition, the industrial action during the year placed further strain on the Trust’s ability to both provide urgent care and manage its elective recovery programme. Quality and compliance Furthermore, difficulties in obtaining care home beds and other care packages in the community has resulted in challenges in discharging patients who are ready to leave hospital and therefore the Trust has been operating at or near to capacity throughout the year. The Trust continued to monitor the quality of care delivered throughout 2022/23. The Trust continued its focus on infection prevention and control, which had proven successful during the COVID-19 pandemic. The Trust progressed its Always Improving strategy and successfully supported the identification and implementation of 84 quality improvement projects. In addition, the Trust continued to implement the patient safety incident response framework as well as taking other steps to drive a safety culture within the organisation. Furthermore, the Trust conducted further trials of shared decision making between clinicians and patients and is a leading site nationally for shared decision-making principles. Further information can be found in the Quality Account. 16 Partnerships The new arrangements for integrated care systems were implemented in July 2022 with the Trust becoming part of the Hampshire and Isle of Wight Integrated Care System. As such, the Trust’s senior management frequently meets with peers from across the system to consider and agree matters of wider concern across the system. In addition, the Trust worked with the Integrated Care Board in order to develop its financial and capital plans for 2023/24 and beyond. The Trust also attends the Southampton Health and Wellbeing Board at Southampton City Council and in the Hampshire and Isle of Wight Acute Provider Partnership Board. During 2022/23, the Trust continued to progress research activities and opportunities with the University of Southampton and Wessex Health Partners. Workforce In addition, work continued in the development of an elective hub at Winchester with Hampshire Hospitals NHS Foundation Trust, which will provide the Trust with additional capacity to carry out its elective programme. The Trust’s key areas of focus during 2022/23 were in respect of increasing the substantive workforce and reducing staff turnover. Although the Trust was successful in recruiting to substantive posts, the expected reduction in reliance on bank and agency staff did not materialise, which meant that the Trust was 1,068 whole-time equivalents above its plan for 2022/23. Included in this figure is the TUPE transfer of genomics staff from Salisbury. A particular area of focus was the recruitment of Health Care Assistants where the Trust was successful in reducing the number of vacancies from 27% to 18%. Whilst the Trust was successful in reducing staff turnover from 14.9% in 2021/22 to 13.5%, it remained above the 12% target. However, the Trust did experience a reduction in staff absence from 4.7% in April 2022 to 4.3% in March 2023, and initiatives to improve staff wellbeing were an area of focus during the year. Estate Innovation and technology The industrial action in late 2022 and early 2023 posed significant challenges for the Trust, including in terms of the need to engage additional temporary staff to ensure patient safety. The Trust continued to invest in and develop its estate during 2022/23 including successful completion of the Paediatric Intensive Care Unit project, which delivered single rooms and specialist accent lighting alongside delivery of a ‘twin care’ room. There were a number of other significant projects during the year, including refurbishments of wards and work on creating new theatres as well as projects to improve staff wellbeing. These were part of over £88m of capital expenditure in 2022/23 that also included equipment, digital and the backlog maintenance programme. The Trust continued to promote research and development during 2022/23, including through partnerships with the University of Southampton and Wessex Health Partners. Furthermore, the Trust continued to examine ways to make use of technology to improve its service delivery. In particular, the Trust has promoted the use of MyMedicalRecord, which gives patients the ability to co-manage their healthcare online and through an app. 17 Sustainable financial model The Trust did not achieve breakeven status at the end of 2022/23 and reported a deficit of £11.037m at year-end. This was due to a number of factors, including the Trust’s underlying deficit as well as the increase in energy prices. The Trust was more exposed than most to fluctuations in the wholesale price of gas due to its reliance on a gas-powered energy supply. In addition, the Trust’s 8% uplift in elective activity when compared to 2019/20 was not fullyfunded, which placed further pressure on the Trust’s existing financial resources, which had been used to ensure a breakeven position in 2021/22. The continued use of bank and agency staff as well as the costs of industrial action in late 2022 and early 2023 further eroded the Trust’s financial position. Notwithstanding the above, the Trust did succeed in obtaining a number of sources of nonrecurrent funding during the year, including a successful bid for £29.4m of funding through the Public Sector De-Carbonisation Fund, which will be used to fund green initiatives as part of the Trust’s capital programme. The financial outlook across the NHS continues to appear very challenging during 2023/24 and the Hampshire and Isle of Wight Integrated Care System is forecasting one of the highest deficits in England. 18 Performance analysis COVID-19 Impacts Although the pandemic has ended and serious cases of COVID-19 have reduced significantly, the Trust continued to be impacted by COVID-19 during 2022/23. Heightened infection prevention control measures in respect of patients with COVID-19 placed additional stress on the Trust’s capacity due to the need to isolate those patients and there was a consequential reduction in the Trust’s ability to make most efficient use of its available spaces. Furthermore, the ongoing impact on the Trust’s staff has led to higher staff absence than was the case prior to the pandemic, particularly due anxiety, infectious diseases and colds and flu. • The Trust experienced an average number of 98.7 patients per day who tested positive for COVID-19. During the winter months, this number increased substantially to nearly 200. • During the year, an average of 3.6 intensive care/high-dependency beds per day were occupied by COVID-19 patients. However, at times this increased to as much as ten. • Although staff sickness rates remained higher than pre-pandemic, the Trust saw a decrease in the absence rate from 4.7% at the beginning of 2022/23 to 4.3% by the end of the period. COVID-19 Cases UHS average number of confirmed COVID-19 patients in bed (08:00 census) 250 200 150 100 50 0 4/1/20225/1/2022 6/1/20227/1/2022 8/1/2022 9/1/202210/1/202211/1/202212/1/2022 1/1/2023 2/1/20233/1/2023 Intensive care/higher care beds UHS average number of confirmed COVID-19 patients in an ICU/HDU bed (08:00 census) 12 10 8 6 4 2 0 4/1/20225/1/2022 6/1/20227/1/2022 8/1/2022 9/1/202210/1/202211/1/202212/1/2022 1/1/2023 2/1/20233/1/2023 19 Number of patients Emergency access through the emergency department The Trust continued to experience high demand from patients presenting to receive care in the emergency department throughout the year above that seen prior to the COVID-19 pandemic. In particular, during the period between January and March 2023, the Trust averaged 352 attendances per day compared to 301 during the same period in 2019/20, an increase of 17%. The Trust also saw a significant increase in attendances during December due to both seasonal illnesses, but also due to the prevalence of streptococcus A in the community with attendances sometimes over 400 per day. Furthermore, the industrial action during the latter part of 2022 and early 2023 placed further pressure on the Trust’s ability to deliver services. In addition, the difficulties in discharging patients in need of care either at home or in another setting resulted in reduced flow from the emergency department to the relevant ward(s), which placed further strain on the Trust’s performance. During the year, in order to reduce emergency department attendances, the Trust trialled using General Practitioners to triage and see more straightforward patients who would otherwise have presented to the emergency department. Although this trial did result in a slight reduction in terms of number of patients and waiting times in ambulatory majors and majors, the affordability and value for money of this scheme is under review. Number of patients presenting to the emergency department 16,000 14,000 12,000 10,000 8,000 6,000 4,000 2,000 0 Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 Mar-23 As a result of the increase in demand upon the emergency department, there continued to be a significant adverse impact on timeliness of care. The Trust failed to meet the national target of 95% of main emergency department/type 1 attendances seen within four hours, achieving 64.5% in March 2023, although this performance was above average in England. 20 % standard met Emergency access 4hr standard UHS vs NHSE average Type 1 performance 70% 0 10 60% 20 50% 30 40 40% 50 Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-2 2 Oct-22 Nov-22 Dec-22 Jan-23 Feb-2 3 Mar-23 UH S NHSE average UHS rank amongst NHSE trusts Rank Ambulance handovers are an area of focus for NHS England, with a target of all handovers having to take place within 15 minutes and none waiting more than 30 minutes. The Trust performed well in this area with an average handover time of 17 minutes, having made the conscious decision to ensure that patients did not queue in ambulances at the expense of patients being queued within emergency department majors – thus impacting the Trust’s four-hour target, but meaning that ambulances were not queued outside the hospital as was seen in other areas of the country. Elective Waiting times Demand The year saw a continuation of the trend of increasing elective referrals experienced in 2021/22 following the pandemic, and referral rates continued to be above those seen prior to the pandemic. UHS Accepted Referrals 30,000 25,000 20,000 15,000 10,000 5,000 0 Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-2 2 Oct-22 Nov-22 Dec-22 Jan-23 Feb-2 3 Mar-23 Number of accepted referrals 21 Activity The Trust experienced significant increases in terms of the number of hospital appointments, diagnostic tests and elective admissions during the year, exceeding levels in previous years. The Trust was one of the top performing trusts in terms of its elective recovery programme, achieving an 8% increase in its elective activity during the year when compared to 2019/20. However, performance in this area and in terms of outpatients appointments was negatively affected by the industrial action by nurses, junior doctors and other members of staff, which took place in late 2022 and early 2023 due to the need to cancel non-urgent procedures and appointments in favour of maintaining safe staffing levels in areas such as the emergency department. In addition, the continued presence of COVID-19 as well as other illnesses such as influenza and norovirus placed significant pressure at times on the Trust’s capacity due to the need to implement appropriate infection prevention control measures. Furthermore, difficulties in discharging patients fit to be discharged, but in need of a care package, placed additional strain on the Trust’s capacity. Elective admissions (including day case) Post-COVID-19 pandemic Elective (including day case) recovery (% of same month compared between March 2019 – February 2020) 105% 100% 95% 90% 85% 80% 75% Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 % recovery Outpatient attendances Post-COVID-19 pandemic outpatient seen recovery (% of same month compared between March 2019 – February 2020) 140% 0 90% 10 20 40% 30 Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 UH S UHS rank amongst NHSE trusts % recovery Rank 22 Diagnostics The Trust measures performance on a total of 15 frequently used diagnostic tests. In March 2023, 22% of patients were waiting more than six weeks for diagnostics compared with the national target of less than 1%. Patients waiting for a diagnostic test to be performed (sum of 15 different frequently used tests) UHS diagnostic waiting list volume 12,000 11,500 11,000 10,500 10,000 9,500 Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-2 2 Oct-22 Nov-22 Dec-22 Jan-23 Feb-2 3 Mar-23 Diagnostic waiting list volume Percentage of patients waiting over 6 weeks for a diagnostic test to be performed Diagnostic 6 week wait performance UHS vs. NHSE average 35% 30% 25% 20% 15% 10% 5% 0% Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 Mar-23 UH S NHSE average % standard met 23 Referral to Treatment The Trust continued to see an increase in the number of patients being referred for treatment during 2022/23 with just over 55,000 patients on a waiting list under the 18-week referral to treatment pathway at the end of the year. Averaged across the year, the volume of referrals exceeded the Trust’s theoretical capacity by around 3.5%. Due to this significant demand, the Trust only achieved 63.2% of patients being treated within 18 weeks of referral in March 2023 compared with the monthly target of more than 92%. However, despite this, the Trust remained in the top quartile when compared to other teaching hospitals, reflecting that this growth in demand continues to be a national challenge. During 2022/23, the national target was to ensure that there were no patients waiting over two years for treatment by July 2022, and that there were no patients waiting more than 78 weeks by the end of March 2023. Long-waiting patients were an area of particular focus for the Trust during the year with no reported two-year waits since November 2022 and only two between the period June-November due to patients choosing to delay their treatment. This was a significant improvement compared to the peak of 171 patients reported in December 2021. Similarly, the Trust made progress in reducing the number of patients waiting over 78 weeks for treatment. In February 2023, the Trust reported 84 patients in this category compared to the peak of over 900 patients in September 2021. By the end of March 2023, the Trust had managed to further reduce this number of patients to 14, with those in breach of the target all due to the complexity of the cases. UHS referral to treatment waiting list 56,000 54,000 52,000 50,000 48,000 46,000 44,000 Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 Mar-23 24 Number on waiting list % standard met Percentage of patients waiting up to 18 weeks between referral and treatment RTT 18 week performance UHS vs. NHSE average 70% 65% 60% 55% 50% Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 Mar-23 UH S NHSE average Percentage of patients waiting more than 52 weeks between referral and commencement of a treatment for their condition Number of patients Rank UHS Referral to treatment patients waiting more than 52 weeks 3,000 0 2,500 10 2,000 20 1,500 30 1,000 40 500 50 0 60 Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 Mar-23 UH S UHS rank amongst NHSE trusts % of RTT patients RTT % of patients waiting more than 52 weeks UHS vs. NHSE average 5.0% 0 4.5% 20 40 4.0% 60 3.5% 80 Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 Mar-23 UH S UHS rank amongst NHSE trusts Rank 25 % standard met Cancer Waiting Times The Trust is one of 12 regional cancer centres in the UK offering treatment for rare and complex cancers as well as cancer in children and brain cancer. The Trust has historically been in the upper quartile, relative to teaching hospital peers. Due to loss of key members of staff and industrial action, the Trust’s performance has slipped over the year with 72.5% of patients seen within two weeks in March 2023 following referral by a General Practitioner for suspected cancer (national target: > 93% per month). Cancer waiting times - 2 week wait performance UHS vs NHSE average 100% 0 80% 50 60% 100 40% 150 Apr-22May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23Mar-23 UH S NHSE average UHS rank amongst NHSE trusts Rank Referrals for January to March 2023 were at the highest for that month for the past five years and overall referral volumes in 2022/23 averaged 2,049 patients per month, 8% higher than in 2021/22 and 28% higher than in 2019/20. The national target was for 96% of patients to commence treatment within 31 days of diagnosis. However, in March 2023, the Trust only achieved 87.9%, but this figure hides considerable variation dependent on the tumour site and type of cancer with a range of 100% for haematology and children’s cancers to 71% for skin. The high rate of referrals led to a significant backlog in terms of patients waiting longer than 62 days for treatment. However, the Trust took steps to reduce this backlog by more than 50% through a dedicated recovery programme. In March 2023, the Trust treated 54.8% of patients within 62 days of referral compared to the target of more than 85%. Treatment for Cancer within 62 days of an urgent GP referral to hospital Cancer waiting times 62 day RTT performance UHS vs. NHSE average 80% 60% 40% 20% 0% Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 Mar-23 UH S NHSE average % standard met 26 First definitive treatment for cancer within 31 days of a decision to treat % standard met Cancer waiting times 31 day RTT performance UHS vs. NHSE average 95% 90% 85% 80% 75% Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 Mar-23 UH S NHSE average Quality priorities The Trust set eight quality priorities in 2022/23, which were aimed at ensuring it continued to deliver the highest quality of care. The quality priorities were shaped by a range of national and regional factors as well as local and Trust‐wide considerations. The Trust recognised the overriding issues of significant operational pressures being felt right across the health and social care system, including those associated with the previous two years of the COVID-19 pandemic. The challenge was to deliver the best quality care in the context of these operational pressures, and the Trust set its quality priorities accordingly. Out of the eight priories set, the Trust achieved five and partially achieved three. Priority One: Enhancing capability in Quality Improvement (QI) through our Always Improving strategy The transformation team has grown to over thirty team members including project support officers, project managers, benefit realisation managers. This has allowed the Trust to develop that systematic organisational approach to guide and support its staff in their QI projects. The Trust originally set a target of delivering fifty quality improvement projects but have successfully supported a total of 84 (55 local and 29 flow improvements). These are local change projects which were identified, proposed, led, and delivered by the people who do the work. To date over 1500 people have been trained in the Trust’s improvement approach, which exceeds the original target of 500. The Trust also developed a QI project register and held an Always Improving conference. Priority Two: Developing a culture of kindness and compassion to drive a safety culture The Trust only partially achieved this priority as plans to fully deliver training were affected by operational pressures. However, during the year a variety of communication platforms were used to make sure staff understood the Trust’s vision and were kept up to date with plans and progress. The Trust worked to develop and embed a ‘just culture’ allowing staff to speak up and ask, “what happened and how do we learn?” and developed ‘stop for safety’ staff huddles. Priority Three: We will improve mental health care across the Trust including support for staff delivering care The Trust only partially achieved this priority as several key quality improvement projects have not yet been delivered, and the mental health strategy not yet been finalised. However, a training needs analysis was completed and significant staff training and an education scheme were introduced in response to the findings of the analysis. Mental health champion training has been delivered to 153 staff and IT systems have been improved to help capture vital data to help shape the Trust’s service. 27 Priority Four: Recognising and responding to deterioration in patients During 2021/22 the Trust successfully introduced national Paediatric Early Warning System (nPEWS) into its Southampton Children’s Hospital and UHS is now part of the national test and trial of nPEWS which is assessing the usability of the scoring system. The Trust has also explored how nPEWS can be adapted for children with complex medical conditions requiring interventions (including non-invasive ventilation) as part of their normal care. A daily heat map of escalation times over a 24-hour period was piloted in 2022 and will be rolled out across all adult’s inpatient areas during 2023. The Trust has also performed well with its cardiac arrest audits, and training and education programmes have consistently been delivered. September 2022 saw the implementation of a 24-hour paediatric outreach service. There is a deteriorating patient group and several successful QI projects have been introduced. Priority Five: Improving how the organisation learns from deaths The Trust only partially achieved this priority as it has been unable to establish a learning from deaths steering group. The Trust has introduced a mortality governance coordinator/analyst and grown its bereavement care service. Priority Six: Shared Decision Making (SDM) The shared decision models started at UHS in 2021/22 and have continued to grow with investment in pilot roles to expand these models, which include several advanced nurse practitioner roles, models in paediatrics bringing Shared Decision Making to patients who are transitioning from paediatric to adult services, while in maternity we have introduced SDM in birth planning. When assessing delivery of SDM against NICE guidelines, UHS performs well, especially in targets related to Trust buy-in, governance and practices of pilot areas. This year the Trust has implemented training through key platforms and expanded patient involvement in the project. As a leading site nationally for SDM principles, UHS have worked with NHS England on creating materials for others to learn from. Priority Seven: Working with our local community to expose and address health inequalities During the year the Trust refocused its efforts on making sure that its involvement and participation activities support the health inequalities agenda, while also working to deliver responsive information and advice to patients, carers, and families. Priority Eight: Ensure patients are involved, supported, and appropriately communicated with on discharge During the year the Trust has focused on improved patient, carer and family involvement, and improved communication during the discharge process as well as prompting a more collaborative working between social and health care staff. Strong partnership working with external agencies has been developed to support a system approach to hospital discharge, develop digital solutions, develop the patient hub to support discharge and delivered education to UHS staff. More information can be found about how the Trust delivered and measured its quality priorities, including feedback from patients and staff and improvement aims and quality priorities for 2023/24, in the Trust’s Quality Account for 2022/23. 28 Financial performance The Trust delivered a deficit of £11 million from a revenue position of over £1.2 billion, once items deemed as “below the line” by NHS England, such as the financial position of the Southampton Hospitals Charity, were removed. The Trust was unable to deliver the planned breakeven position. Several material cost pressures were incurred, including unfunded high-cost drugs costs and energy prices. These were unable to be off set in full by a savings programme, despite delivery of £45.6m of efficiencies (2021/22: £15m). Trust operating income rose by £64m from the previous financial year, most notably funding the NHS pay award, as well as additional elective recovery funding. Income reduced from the prior year in relation to ending a nationally funded project regarding testing for COVID-19. The Trust has however been successful in increasing funding for research and development. Trust operating expenditure rose by £78m, incorporating funded inflationary costs as well as the cost pressures outlined above. The Trust has also continued its reinvestment of surplus cash into infrastructure for the Trust, with capital investmen
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Annual-report-2018-19

Description: ANNUAL REPORT AND ACCOUNTS 2018/19 incorporating the quality account 2018/19 Presented to Parliament pursuant to Schedule 7, paragraph 25 (4) (a) of the National Health Service Act 2006 University Hospital Southampton NHS Foundation Trust Annual report and accounts 2018/19 incorporating the quality account 2018/19 Presented to Parliament pursuant to Schedule 7, paragraph 25 (4) (a) of the National Health Service Act 2006 3 ©2019 University Hospital Southampton NHS Foundation Trust 4 TABLE OF CONTENTS Overview and performance report Welcome from our Chair 7 A word from the chief executive 8 Overview of the Trust Statement of purpose and activities 9 History of UHS 9 Our executive team structure 10 Structure of our services 11 Our vision and values 12 Our priorities, key issues and risks 13 Performance report Going concern disclosure 16 Reporting structure 16 Key performance indicators 17 How we monitor performance 18 Detailed analysis and explanation of the development and performance of UHS 18 Regulatory body ratings 23 Environmental matters 24 Social, community, anti-bribery and human rights issues 25 Accountability report Members of the Trust Board 27 Trust Board purpose and structure 31 Board meeting attendance record 2018/19 32 Well-led framework 33 Strategy and finance committee 34 Quality committee 34 Audit and risk committee 35 External auditors 36 Governance code 36 Performance evaluation of Trust Board and its committees 36 Remuneration 36 Countering fraud and corruption 36 Independence of external auditor 37 Internal audit service 37 Better payment practice code 37 Statement as to the disclosures to auditors 37 Disclosures 37 Income disclosures 38 Governance disclosures 38 Approach to quality governance 38 Council of Governors 40 Annual remuneration statement 49 Remuneration and appointments committee 52 Governors’ nomination committee 54 Staffing report 58 Staff survey results 62 Trade union facility time 66 Statement of chief executive’s responsibilities as the accounting officer 69 Annual governance statement 70 Voluntary disclosures Equality, diversity and inclusion 78 Environmental sustainability and climate change 80 Southampton Hospital Charity 84 Developments in informatics 85 Leading research into better care 85 Investing for the future 86 Quality account and quality report 2018/19 Chief executive’s welcome 88 Our approach to quality assurance 90 Our commitment to safety 90 Duty of candour 91 Our commitment to staff 91 Freedom to speak up 94 Our commitment to education and training 95 Our commitment to staffing rota gaps 96 Our commitment to technology to support quality 97 Our commitment to the Care Quality Commission 98 Our commitment to improving the environment for our patients 100 Review of quality performance 101 Clinical research 101 Review of services 102 CQUIN payment framework 103 Data quality 103 Participation in national clinical audits and confidential enquiries 104 How we are implementing the priority clinical standards for seven day hospital services 105 Learning from deaths 106 Progress against 2018/19 priorities 109 Priorities for improvement 2019/20 128 Conclusion 132 Responses to our quality account 133 Statement of directors’ responsibilities 138 Independent auditor’s report 139 Quality account appendix Appendix 1: Our quality priorities 2019/20 143 Appendix 2: Quality performance data 144 Appendix 3: CQUIN data 151 Appendix 4: Clinical audit and confidential enquiries data 154 Appendix 5: British Society of Urogynaecology 156 Appendix 6: National clinical audit: actions to improve quality 157 Appendix 7: Local clinical audit: actions to improve quality 161 Appendix 8: Shared decision making 173 Appendix 9: Registration with the Care Quality Commission 174 Annual accounts Statement from the chief financial officer 177 Foreword to the accounts 178 Independent auditor’s report 179 Financial accounts and notes 186 5 OVERVIEW AND PERFORMANCE REPORT OVERVIEW AND PERFORMANCE REPORT Welcome from our chair 2018/19 was a year of change in the leadership of UHS. Following the departure of Fiona Dalton in March 2018 to run a hospital group in Canada, David French took on the role of interim chief executive officer. On behalf of the Trust Board I would like to thank David for agreeing to do so and also for doing such an outstanding job. During the year we welcomed three new non-executive directors to the Trust; Jane Bailey, Professor Cyrus Cooper and Catherine Mason. Catherine’s talents were also recognised by Solent NHS Trust and she has since left to help lead their organisation as chair. We were delighted to welcome Paula Head as chief executive in September after a rigorous and robust recruitment process. Paula’s experience as chief executive of Royal Surrey County Hospital NHS Trust and, prior to that of Sussex Community NHS Foundation Trust, shone through and we were confident that under her leadership UHS would continue to develop, grow and improve. Demand for our services continues to rise rapidly as the result of a changing demographic and other factors, and at a rate far greater than our income. Despite this our staff continue to deliver exceptional care. I was delighted that this was recognised by the Care Quality Commission in their recent inspection when they again rated us as Good. The revised NHS Long Term Plan will inevitably require us to adapt to the changing pattern of healthcare, but we do so with enthusiasm. This year has shown just how adept we are as an organisation at responding positively to change, not only rising to the challenges it presents, but thriving with it. This is evident in the significant investments we have made in the Trust’s estate this year. Phase one of our new children’s emergency department is complete thanks to the continued support of the Murray Parish Trust. We also approved one of the largest capital investments in our history with the updating and expansion of our general intensive care unit. We recognised that it was as crucial to invest, not just in the physical environment within which we provide healthcare, but within the digital environment too, acknowledging that UHS is an NHS digital exemplar. We have invested significantly in information technology to enhance accessibility and improve both patient and staff experience. We look forward with confidence to helping lead the NHS into a new phase of delivering health and care for the United Kingdom into 2019/20. Peter Hollins Chair 7 OVERVIEW AND PERFORMANCE REPORT A word from the chief executive Since arriving at UHS to take up my position as chief executive officer, I have heard and witnessed some incredible achievements by staff at the Trust. Dr Joanne Horne was named biomedical scientist of the year at the Advancing Healthcare Awards for her work in histopathology; Dr Beth McCausland, quality improvement fellow in dementia care, was named foundation doctor of the year by Royal College of Psychiatrists; Sarah Charters, consultant nurse and mental health lead for the emergency department was awarded an MBE for services to vulnerable adults and her vulnerable adult support team were also winners of a Nursing Times Award in the emergency and critical care category. The medicine for older people therapy team led by Hannah Wood was named most inspiring team at the national #EndPJParalysis awards while Marie Nelson, matron in research and development, and senior research sisters Jane Forbes and Kirsty Gladas won the silver award for clinical research site of the year at the PharmaTimes International Clinical Researcher of the Year Awards. Jean Piernicki, senior nurse manager in occupational health, was awarded the title of Queen’s Nurse in recognition of her high level of commitment to patient care and nursing practice. Fiona Chaâbane, a senior clinical nurse in neurosciences was named winner of the nursing and midwifery award at the BBC’s The One Show Patients Awards. The medicines advice service, led by Dr Simon Wills, picked up the HSJ Value Award for training and development for its medicines learning portal and Matthew Watts, head of news, was named operational services support worker of the year for the south of England at the Our Health Heroes Awards 2018. We were also delighted that the energy and sustainability team collected the clinical NHS Sustainability Award for its green wards project. These are just a few of the individual and team successes achieved this year. Our entire organisation can also be incredibly pleased and encouraged by the outcome of the recent Care Quality Commission (CQC) inspection, which rated UHS ‘good’ overall, with many individual areas being recognised as outstanding by the CQC. You can find full details of the inspection on page 98 of the quality account. Such positive inspection results link to equally positive staff survey results which saw UHS ranked as the second highest acute trust for staff satisfaction and fifth highest for staff recommending the Trust as a place to work and receive treatment. It’s made me incredibly proud to be able to say that I am part of such a driven team and it’s clear that the UHS team share my drive and determination to improve things for patients and staff every day. This is evident in both the successes I have already mentioned, but also in the pioneering work that is taking place across every department. Informatics has been pioneering new digital initiatives which they recently shared with Hadley Beeman, chief technology adviser to the secretary of state and social care. Surgeons Bhaskar Somani and Stephen Griffin have created a ‘twin surgeon’ model that has revolutionised the treatment of kidney stones in children. Dr John Paisey, consultant cardiologist, and his team were among the first in the world to implant and programme a pacemaker using Bluetooth technology. They performed four of the first five procedures in the world. While Professor Mike Grocott and his team created ‘surgery school’ which is transforming the fitness of patients prior to their operations and thereby reducing length of stay. These are by no means the entirety of our achievements this year and I would like to take the opportunity to thank every single member of staff at the Trust who continues to make UHS one of the leading trust’s in the UK. Paula Head Chief executive officer 8 OVERVIEW AND PERFORMANCE REPORT Overview of the Trust Statement of purpose and activities UHS is a large teaching hospital located on the south coast of England. We have a tripartite mission to provide clinical care, educate current and future healthcare professionals, and undertake research to improve healthcare for the future. Our clinical care encompasses local acute and elective care for 680,000 people who live in Southampton, the New Forest, Eastleigh and Test Valley. We also provide care for the residents of the Isle of Wight for many services. As the major university hospital on the south coast, UHS provides the full range of tertiary medical and surgical specialities (with the exception of transplantation, renal services and burns) to over 3.7 million people in central southern England and the Channel Islands. UHS is a centre of excellence for training the doctors, nurses and other healthcare professionals of the future. We work with the University of Southampton and Solent University to educate and develop staff at all levels, including a large apprenticeship programme, undergraduate and post-graduate education. Our role in research, developed in active partnership with the University of Southampton, is to contribute to the development of treatments for tomorrow’s patients. This work distinguishes us as a hospital that works at the leading edge of healthcare developments in the NHS and internationally. In particular we have nationally-leading research into cancer, respiratory disease, nutrition, cardiovascular disease, bone and joint conditions and complex immune system problems. We are one of the largest recruiters of patients into clinical trials in the country. Over 11,900 people work at the Trust, making it one of the area’s biggest employers. We also benefit from the contributions of over 1,000 volunteers. Our turnover in 2018/19 was more than £878m. History of UHS The Trust has its origins in the 1900s when the Shirley Warren Poor Law Infirmary was built on the site of what is now Southampton General Hospital. In the early half of the century, the site began to expand, including the opening of the school of nursing and the creation of the Wessex Neurological Unit. In 1971 a new medical school was opened in Southampton and the 1970s and 1980s saw a significant building programme encompassing the current footprint of Southampton General Hospital, Princess Anne Hospital and Countess Mountbatten House. During the 1990s, services were increasingly centralised at the general hospital, with the eye hospital and cancer services being relocated from elsewhere in the city. The Wellcome Trust funded a clinical research facility at the hospital in 2001 and this unit remains the foundation for much of the Trust’s groundbreaking medical research. In the last decade, development has continued with the opening of the North Wing Cardiac Centre in 2006, the creation of a major trauma centre with on-site helipad and the opening in 2014 of Ronald McDonald House for the relatives of sick children. Organisationally, Southampton University Hospitals Trust was formed in 1993, creating a single management board for acute services in Southampton. Eighteen years later, University Hospital Southampton NHS Foundation Trust (UHS) was formed (1 October 2011) when Southampton University Hospitals NHS Trust was licensed as a foundation trust by the then regulator, Monitor (now known as NHS Improvement (NHSI)). 9 OVERVIEW AND PERFORMANCE REPORT Our executive team structure Associate director of corporate affairs (interim) Charlie Helps Constitution; Council of governors; legal services; insurance; risk management; policy management; freedom of information (FOI) general data protection regulations (GDPR) Chief executive Paula Head Director of HR Steven Harris Employee relations; pay and reward; resourcing and temporary staffing; staff engagement; staff performance and appraisal; occupational health and wellbeing; childcare services; communications Medical director Dr Derek Sandeman MD for research & development; clinical effectiveness; clinical practices and outcomes; professional regulation & standards; GP relationships Director of nursing & organisational development Gail Byrne Chief financial officer & deputy chief executive David French Clinical governance & patient safety; education; patient experience; clinical practice & outcomes; professional regulation & standards; complaints/PALS; HR/workforce; voluntary services; fundraising Caldicott Guardian Financial management; financial strategy; investment & ROI; audit; procurement; capital programme management; estates; Commercial development Division A Surgery Cancer care Critical care & theatres Chief operating officer Caroline Marshall Major incident planning; security Division B Division C Emergency medicine Women & newborn Specialist medicine/ ophthalmology Pathology Child health Support services Director of transformation & improvement Jane Hayward Division D Cardiovascular & thoracic Neurosciences Trauma & orthopaedics Cost improvement & transformation; information technology; information governance; core platform systems; informatics development; strategy; commissioning; business & capacity planning Senior Information Risk Owner (SIRO) Radiology 10 OVERVIEW AND PERFORMANCE REPORT Structure of our services Our organisation is split into five areas, with our clinical services grouped into four divisions. Within each division there are care groups. Each division, with the exception of Trust headquarters, is led by a divisional management team consisting of: • divisional clinical director (DCD) • divisional director of operations (DDO) • divisional head of nursing/professions (DHN) • divisional research and development lead • divisional finance manager • divisional planning and business development (or strategy) manager • divisional education lead • division HR business partner • divisional governance manager (DGM) The diagram below outlines the five divisions and care groups/services within each. Each care group has a clinical lead, care group manager and matron/s for specific services as a minimum. Division A Surgery Cancer care Critical care Theatres Division B Emergency medicine Medicine for older people Pathology Specialist medicine and ophthalmology Genetics Division C Child health Women and newborn Support services Division D Cardiovascular and thoracic Neurosciences Trauma and orthopaedics Major trauma centre Radiology TRUST HQ Corporate affairs Communications Finance Human resources Informatics Patient support services Claims and litigation Cost improvement and transformation Estates and capital developments Research and development 11 OVERVIEW AND PERFORMANCE REPORT Our vision and values Our Forward vision outlines who we are and what we stand for, as well as describing the current challenges we face and our priorities for the future. It also provides an in-depth review of our three Trust values, which are summarised below: putting patien putting patien putting patien putting patien putting patien putting patien putting patien putting patien putting patien king together king together king together king together king together king together king together king together king together ts first ts firwsotr ts firwsotr wor ts first ts firwsotr ts firwsotr wor ts first ts firwsotr ts firwsotr wor always imparlwovaiynsg imparlwovaiynsg improving always imparlwovaiynsg imparlwovaiynsg improving always imparlwovaiynsg imparlwovaiynsg improving ts first ts first ts first wor wor wor putting patien putting patien putting patien king together king together king together always imparlwovaiynsg imparlwovaiynsg improving Patients and families will be at Our clinical teams will provide the heart of what we do and services to patients and are their experience within the crucial to our success. hospital, and their perception We have launched a leadership ofmtheeasTurruensgtop,aftwiesnuitlslcfbcnigreesptsaosti.euntrs fnigrsptatients first clsintrrikacintageltgomgyetahtnherkraianggtteoegmnetsehuernkrrintegstteoogaeumthresr are engaged in the day-to-day management and governance of the Trust. alw alw alw Our growing reputation in research and development and our approach to education and training will continue ays improtvoinagiyns icmoprropvionagrysaitmeprnoveinwg ideas, technologies and greater efficiencies in the services we provide tients first tients first tients first together together together mproving mproving mproving putti putting pa putti putting pa putti putting pa wo working wo working wo working always i always i always i 12 OVERVIEW AND PERFORMANCE REPORT Our priorities, key issues and risks Our top eight priorities 1 Promote and live our values. We will: • be clearer about the behaviours we expect from our staff • recruit, train and promote people who demonstrably share our values in everything they do 2 Improve safety, quality and productivity. We will: • Sign up to safety and deliver on our promises to patients as part of this campaign • Focus on improving outcomes by measuring and publishing clinical outcomes for all specialties • Focus on improving the whole patient experience, so that patients feel treated with compassion by all staff in every contact • Develop the concept of excellent administrative care, organising our services well so that the patient journey runs smoothly • Commit to productivity improvement across all areas • Develop innovative solutions that allow us to deliver services more efficiently while making better use of our capacity 3 Our staff and education mission. We will: • Attract the best staff by offering them a better deal and the best place to work • Continue to invest in education and training opportunities for our staff including leadership development • Ensure that our leaders and staff understand and deliver our equality and diversity agenda • Prioritise excellent communication that allows the voice of our staff to be heard and acted on • Focus on the staff of the future by developing our education and training capability for clinical and non-clinical staff • Work with our local education providers to offer excellent education opportunities and bring high calibre people into healthcare roles in our hospitals 4 Become a hospital without walls. We will: • Increase the number of patients we care for who are not inpatients within the hospital. Some of these will be cared for in another residential location or at home in partnership between ourselves and other organisations • Be clear about services where we wish to provide end-to-end integrated care, and those where we wish to work with partners to integrate care across organisations • Work with health and social care partners (public, private and third sector), where necessary using new organisational models, to ensure that patients are always cared for in the right setting • Work more closely with general practices and support innovation being led by primary care 13 OVERVIEW AND PERFORMANCE REPORT 5 Specialised services. We will: • Engage with commissioners to plan changes in service models according to national service specifications • Continue to plan and manage the ongoing drift of sub-specialist work particularly in paediatrics and complex surgical services • Maintain and develop the critical mass that is increasingly required to care for complex and specialist patients • Work with Salisbury NHS Foundation Trust, the University of Southampton and other partners to play our part in the genomic revolution, building on the Genomic Medicine Centre and seeking to become a Genomics Central Laboratory Hub for the region • Develop our clinical informatics ability to ensure that we can take advantage of new information available for the benefit of patients 6 Preventative care. We will: • Continue to expand our screening programmes as national policy and commissioning intentions develop • Take every opportunity to further support and improve the health of our staff • Ensure that our clinical translational research programme, much of which is directly relevant to health promotion, accelerates translation of research into benefit for the local population 7 Discovery. We will: • Develop a detailed plan to continue increasing the number of UHS patients who are offered access to clinical trials and maximise the impact of the research we undertake • Work with the University of Southampton to submit a strong bid for the next round of Biomedical Research Centre / Biomedical Research Unit funding opportunities • Support the University of Southampton to create an international centre for cancer immunology to accelerate the development of new immune therapies to treat cancer 8 All stages of life. We will: • Continue to expand our paediatric services in partnership with community and local acute paediatrics and develop the physical infrastructure of a modern children’s hospital as quickly as finances allow • Continue to improve transition and the care of teenagers and young adults • Develop elderly care services that are integrated across the acute and community sectors • Continue to develop our end of life care 14 OVERVIEW AND PERFORMANCE REPORT Key issues and risks 1 Failure to deliver national access targets, which impacts patient experience and patient safety. Whilst we are meeting some of the national constitutional standards in waiting times, we are not meeting them all. A number of actions have been taken in relation to improving responsiveness and working with local health and social care partners to reduce delayed transfers of care. The Trust will continue to work to reduce delayed transfers of care, as well as reviewing the efficiency of discharge processes during 2019/20. 2 Capacity and occupancy, which impacts on patient flow and the quality and timeliness of care. Operational risks have been identified across a number of services/specialties linking to issues around increasing referrals, system capacity and delayed transfers of care. We have mitigated this by implementing daily reviews to assess system capacity and escalation requirements aligning capacity plans with the wider system, developing plans to reduce length of stay with strong clinical leadership and oversight and working with local health and social care partners to reduce delayed transfers of care. 3 Staffing, both in terms of recruitment and retention. To mitigate this risk we will continue to focus on making UHS an attractive employer by: • developing band four posts and apprentices • leveraging the ‘Think UHS’ recruitment brand • continuing to recruit within Europe and further afield • working with universities to increase student nurses • enhancing medical overseas fellows posts • reviewing all junior doctor rotas in light of the new contract • using flexible and temporary staff when needed • creating different roles linked to our research agenda • reviewing training and education to enhance retention. 15 OVERVIEW AND PERFORMANCE REPORT Performance report Going concern disclosure After making enquiries, the directors have a reasonable expectation that the Trust has adequate resources to continue in operational existence for the foreseeable future. For this reason, they continue to adopt the going concern basis in preparing the accounts. Reporting structure As a large NHS university hospital foundation trust, UHS monitors performance within individual teams throughout the year with feedback processes in place to escalate issues to more senior management teams. At a corporate level we have an established executive reporting structure. Monthly Trust Board Public meeting where executive directors present high level summary to chairman and non-executive directors. For further information see page 31. Audit and risk committee Strategy and finance committee Quality committee Trust executive committee (TEC) Review performance/issues/risks in greater depth For further detail on role of these committees please refer to the annual governance statement section on page 70. Trust Board study sessions Trust Board members meet to focus on a specific issue. Performance meetings Operational management team (led by chief operating officer) and division and care group management teams focus on individual patient and service pathways to develop improvement plans. 16 OVERVIEW AND PERFORMANCE REPORT Key performance indicators (KPIs) The Trust publishes a monthly integrated KPI Board report on our website which provides both the Board and the public with an overview of our performance. This report is constantly evolving as new areas of monitoring are developed and new areas of national focus become apparent. For 2018/19 the format of the monthly report followed the five key Care Quality Commission (CQC) questions: • Are we safe? • Are we effective? • Are we caring? • Are we responsive? • Are we well-led? The monthly report features the following sections: • Overview – Aggregation of commentary supporting all sections of the report • Safe • Effective • Caring • Activity • Emergency access • Referral to treatment and diagnostics • Cancer waiting times • Flow • Staffing • Research and development • Estates • Digital This report also includes summary versions of quarterly reports submitted to the Trust executive committee, which go into greater detail about patient experience, patient safety, clinical effectiveness outcomes, and infection prevention. In addition, a separate finance Board report is submitted to Trust Board on a monthly basis. The Emergency Access, Activity and Flow section have several KPI’s that are relevant to the key risk of delivering the national access target. Some of the KPI’s are: • Number of attendances • Time to initial assessment • Hospital red/black alerts • Delayed transfers of care • Non-elective length of stay The Activity and Flow section have several KPI’s that are relevant to the key risk of capacity and occupancy. Some of the KPI’s are: • Length of stay • New referrals • Number of attendances • Bed occupancy • Hospital red/black alerts The Staffing (HR) section has several KPI’s that are relevant to the key risk of Staffing. Some of the KPI’s are: • Staff turnover • Nursing vacancies • Friends and Family Test – percentage of staff who recommend UHS as a place to work You can see full copies of the monthly report by visiting www.uhs.nhs.uk 17 OVERVIEW AND PERFORMANCE REPORT How we monitor performance In addition to reviewing the data submitted to the Trust Board in these papers, we have a suite of tools available to compare UHS performance to that of comparable trusts around the country. Depending on the measures being monitored, UHS has a number of peer groups to benchmark against including other local providers, major trauma centres and university hospital teaching trusts. Each NHS trust will service a different size and type of population and will offer a slightly different range of services so it is important to understand that this benchmarking provides an initial indication of performance rather than an absolute guide to our position nationally. In 2018/19 we continue to review the National Model Hospital data as it is published from NHS Improvement. The data and ability to compare our performance has helped to highlight areas of excellent practice and areas where there is potential to improve. The Trust is engaging with the model hospital team and has a member of staff on the ‘model hospital ambassador program’, as well as reviewing areas highlighted as having potential opportunities alongside finance and operational teams. Detailed analysis and explanation of the development and performance of UHS Activity, capacity and occupancy Over the past three years we have seen significant increases in all types of activity. This is linked to demographic growth, new specialist techniques and services transferring from other providers, including vascular services from Portsmouth. In addition, UHS now has responsibility for surgical services at Lymington. The graph and table below demonstrate this increase in activity. UHS growth in activity – 2016/17 to 2018/19 800,000 700,000 600,000 500,000 400,000 300,000 200,000 100,000 0 Inpatient spells (inc. day cases) 2013/14 2016/17 Outpatient appointments 2017/18 2018/19 ED attendances (type one) Referrals (excl March) Inpatient spells (inc. day cases Outpatient appointments ED attendances (type one) Referrals (excl March) 2016/17 160,000 630,045 99,273 189,194 2017/18 157,993 658,147 104,616 197,522 2018/19 168,791 695,343 110,771 207,209 Increase 2016/17 to 2018/19 5.5% 10.4% 11.6% 9.5% 18 OVERVIEW AND PERFORMANCE REPORT Hospital alert status The hospital alert status is decided by the operations centre after assessing the bed and staffing position, and is recorded twice daily at the Trust bed meetings (though the status may change at any time). Black alert is the highest level of alert and is issued when there are no empty beds available across the Trust with no expected discharges, the emergency department is full, and if actions are not taken several ambulances are likely to be delayed for long periods of time, stopping them from responding to 999 calls (this is based on a national definition of escalation). Red alert is when the majority of the hospital is under significant operational pressure and is likely to include a mismatch between supply and demand of beds and/or there are no beds available, with patients waiting more than three hours in the emergency department, and patients with a clinical decision for admission but no bed identified for them to move to. The Trust will undertake a wide range of actions in response to this, including the opening of additional overnight beds (usually within day wards), the redistribution of staff or bed capacity to support areas under most pressure, Trust-wide communication to request a focus on actions which will enable patients to be discharged or the admission avoided and the potential review of less urgent elective operations to maintain bed availability for patients with more urgent needs. In 2015/16 a black alert was recorded seven times at the twice daily bed meetings. In 2016/17 this was increased to eleven, in 2017/18 this increased to twenty, however in 2018/19 there were no black alerts. The chart below shows red alerts logged during 2018/19. Red alerts 2018/19 60 Number of AM and PM alerts 45 30 15 0 4/1/18 6/1/18 8/1/18 10/1/18 12/1/18 2/1/19 Contributing to this change has been an increase in day cases and an increase in length of stay (LoS) for elective patients linked to a more complex case mix. UHS delayed transfers of care 2018/19 The chart below shows the total bed days attributable to delayed transfers of care at UHS in 2018/19. 3,600 Percentage of bed days lost 3,200 2,800 2,400 2,000 April 2018 June 2018 August 2018 October 2018 December 2018 February 2019 19 OVERVIEW AND PERFORMANCE REPORT Referral to treatment (18 weeks) performance National target: 92% of all patients on 18 week pathway and not yet treated should have waited 18 weeks or less at the end of the month (incomplete pathways target). How did we do? UHS did not meet the target this year. Achievement of this target in 2018/19 should be set against a rise in patient referrals, which highlights the increased demands being placed on the Trust. The Trust has finished the financial year with no patients waiting greater than 52 weeks, and a total referral to treatment waiting list lower than in March 2018. Emergency department (ED) performance There are three types of emergency departments: Type Type Type ONE TWO THREE 3 24 hour with full resuscitation facilities 3 Consultant-led 3 Designated accommodation for patients admitted via ED 3 Single specialty emergencies (eye or dental) 3 Consultant-led 3 Designated accommodation 3 Minor injuries/walk-in centres 3 Doctor or nurse-led 3 Can be routinely accessed without appointment 3 May be co-located within an ED or sited in the community We run all three types of departments and all three types are subject to the national target and are therefore reflected in our figures. National target: The constitutional standard states that 95% of patients should be treated and either admitted or discharged within fours of arrival into ED. However, NHS Improvement set local targets for all NHS organisations with an ambition that the NHS would return to meet the 95% target by March 2019. The local targets set by quarter (to allow for seasonal variations) for UHS were: Quarter 1 - 90% Quarter 2 - 91.4% Quarter 3 - 90% Quarter 4 - 90-95% How did we do? 2018/19 was another challenging year for emergency patients for the whole Hampshire and Isle of Wight area. Whilst we had a positive start to the year achieving quarter 1 and 2 targets, we did not meet quarter 3 or 4 targets. We did, however, meet out local delivery system targets. 20 OVERVIEW AND PERFORMANCE REPORT The graph below shows our performance against the four hour target over the last year (including all UHS types and Lymington). National 4 hour access target – UHS performance 100% 95% 90% 87.1% 85% 80% 82.1% 82.3% 87.4% 87.4% 93.0% 90.5% 84.7% 82.9% 85.7% 90.7% 88.9% 84.8% 77.9% 81.1% 75% Jan 2018 Feb 2018 Mar 2018 Apr 2018 May 2018 June 2018 July 2018 Aug 2018 Sep 2018 Oct 2018 Nov 2018 Dec 2018 Jan 2019 Feb 2019 Mar 2019 The graph below shows our local delivery system performance against the four hour target over the last year (including all SGH types, Lymington and Southampton Treatment Centre). National 4 hour access target – Local delivery system 100% 95% 91.0% 90% 91.1% 95.1% 92.8% 88.7% 87.1% 89.2% 91.5% 85% 92.9% 88.4% 83.3% 85.9% 80% 75% Apr 2018 May 2018 June 2018 July 2018 Aug 2018 Sep 2018 Oct 2018 Nov 2018 Dec 2018 Jan 2019 Feb 2019 Mar 2019 21 OVERVIEW AND PERFORMANCE REPORT Cancer waiting times There are nine separate cancer waiting times standards (below), each of which can then be split into tumour site specific performance groups. Measures Urgent GP referrals seen in two weeks Breast symptoms referral seen in two weeks Treatment started within 62 days of urgent GP referral Treatment started within 62 days of referral (breast, cervical and bowel screening) 62 day consultant upgrades Treatment started within 31 days of decision to treat Second or subsequent treatment (surgery) started within 31 days of decision to treat Second or subsequent treatment (anti-cancer drugs) started within 31 days of decision to treat Second or subsequent treatment (radiotherapy) started within 31 days of decision to treat Target > 93% > 93% > 85% > 90% > 86% > 96% > 94% > 98% > 98% 18/19 YTD (up to and including Feb 19) 86% 50% 74% 80% Achieved 8 8 8 8 86% 3 93% 8 85% 8 100% 3 100% 3 The number of patients referred under the two week wait urgent suspected cancer protocol seen within two weeks of their referral, rose by 7.7% in 2018/19. The chart below shows the rise in demand for UHS cancer services over the past three years UHS growth in cancer actvity – 2016/17 to 2018/19 (up to and including month 11) 18,000 16,000 14,000 12,000 10,000 8,000 6,000 4,000 2,000 0 Two week waits 2016/17 up to and incl Feb 62 day target patients 31 day target patients 2017/18 up to and incl Feb 2018/19 up to and incl Feb For staffing performance, please refer to page 58. For financial performance please see page 177. Paula Head, chief executive officer 28 May 2019 22 OVERVIEW AND PERFORMANCE REPORT Regulatory body ratings Single Oversight Framework NHS Improvement’s Single Oversight Framework provides the framework for overseeing providers and identifying potential support needs. The framework looks at five themes: 1. Quality of care 2. Finance and use of resources 3. Operational performance 4. Strategic change 5. Leadership and improvement capability (well-led) Based on information from these themes, providers are segmented from one to four where ‘4’ reflects providers receiving the most support, and ‘1’ reflects providers with maximum autonomy. A foundation trust will only be in segments three or four where it has been found to be in breach or suspected breach of its licence. Segmentation During 2018/19 the Trust was confirmed as being placed within segment ‘2’. This segmentation information is the Trust’s position as at 31 March 2019. Current segmentation information for NHS trusts and foundation trusts is published on the NHS Improvement website. Finance and use of resources The finance and use of resources theme is based on the scoring of five measures from ‘1’ to ‘4’, where ‘1’ reflects the strongest performance. These scores are then weighted to give an overall score. Given that finance and use of resources is only one of the five themes feeding into the Single Oversight Framework, the segmentation of the Trust disclosed above might not be the same as the overall finance score here. Area Financial sustainability Financial sustainability Financial sustainability Overall scoring Care Quality Commission ratings: Metric Capital service cover Liquidity Income and expenditure margin Distance from financial plan Agency spend Q1 Q2 Q3 Q4 2 2 1 1 1 1 1 1 1 1 1 1 1 2 2 1 1 1 1 1 1 1 1 1 Overall rating for this trust Are services at this trust safe? Are services at this trust effective? Are services at this trust caring? Are services at this trust responsive? Are services at this trust well-led? Good Requires improvement Outstanding Good Requires improvement Good 23 OVERVIEW AND PERFORMANCE REPORT In December 2018, the CQC inspected four core services; urgent and emergency care, medicine, maternity and outpatients. It also looked at management and leadership, and effective and efficient use of resources. The CQC report (published on the 17 April 2019) rated the Trust as ‘good’ overall and ‘outstanding’ for providing effective services. “Our inspectors found a strong patient-centred culture with staff committed to keeping their people safe, and encouraging them to be independent. Patients’ needs came first and staff worked hard to deliver the best possible care with compassion and respect. Inspectors saw many areas of outstanding practice, with care delivered by compassionate and knowledgeable staff. Several teams led by example with a continuous focus on quality improvement. The Trust did face some challenges especially with the ageing estates. Some patient environments were showing significant signs of wear and tear – but again staff were doing their utmost to deliver compassionate care”. Dr Nigel Acheson Deputy chief inspector of hospitals (South) Environmental matters We recognise that the Trust’s business has an impact on the environment. As a large hospital we undertake a wide range of activities and use a large amount of resources, for example: • The Trust generates approximately 3,000 tonnes of waste yearly, half of which is clinical waste. If not properly treated this huge amount of waste can cause soil, water and air pollution depending on the disposal route. • Due to the large number of visitors and deliveries we attract every day, traffic congestion is regularly experienced on and around the site, which impacts the air quality around the hospital. We are committed to environmental sustainability and consider it as part of the business culture. We acknowledge that reducing waste and minimising the consumption of scarce resources is consistent with financial sustainability. Our sustainability disclosure section on page 80 provides greater detail on the steps we are taking to reduce our activities’ impact on the environment. 24 OVERVIEW AND PERFORMANCE REPORT Social, community, anti-bribery and human rights issues We recognise our responsibilities under the European Convention on Human Rights (included in the Human Rights Act 1998 in the UK), which are relevant to health and social care. These rights include the: • right to life • right not to be subjected to torture, inhuman or degrading treatment or punishment • right to liberty • right to respect for private and family life The Trust is committed to ensuring it fully takes into account all aspects of human rights in our work. At University Hospital Southampton we value our reputation for top quality care and financial probity and conduct our business in an ethical manner. The Bribery Act 2010 was introduced to make it easier to tackle the issue of bribery which is a damaging practice. Bribery can be defined as ‘giving someone a financial or other advantage to encourage them to perform their duties improperly or reward them for having done so’. To limit our exposure to bribery we have in place an Anti-Fraud, Bribery and Corruption Policy, a Standards of Business Conduct Policy and a Freedom to Speak Up (formerly Raising Concerns) Policy. These apply to all staff and to individuals and organisations who act on behalf of UHS. We also employ a local counter fraud specialist who will investigate, as appropriate, any allegations of fraud, bribery or corruption. The success of our anti-bribery approach depends on our staff playing their part in helping to detect and eradicate bribery. Therefore, we encourage staff, service users and others associated with UHS to report any suspicions of bribery and we will rigorously investigate any allegations. In addition, we hold a register of interest for directors, staff, and governors and ask staff not to accept gifts or hospitality that will compromise them or the Trust. The Board of Directors carries out its business in an open and transparent way. We are committed to the prevention of bribery as well as to combating fraud and expect the organisations we work with to do the same. Doing business in this way enables us to reassure our patients, members and stakeholders that public funds are properly safeguarded. There are no important events since the year end affecting the foundation trust. No political donations have been made. The Trust has no overseas branches. 25 FR STAND BODY ACCOUNTABILITY REPORT Members of the Trust Board Board member Name Title Paula Head Chief executive officer David French Deputy chief executive officer and chief financial officer Gail Byrne Director of nursing and organisational development Jane Hayward Director of transformation and improvement Biography Declarations Paula joined the Trust as chief executive in September 2018, having been chief executive at the Royal Surrey County NHS Foundation Trust in Guildford and before that at Sussex Community NHS Foundation Trust. She began her career as a pharmacist working in the community, hospitals and at health authorities before moving into general management and her first board position at Kingston Hospital. Since then she has spent time on the boards of commissioners and providers, including director of transformation at Frimley Park Hospital NHS FT. Paula lives in Hampshire and has a daughter studying medicine at the University of Southampton. Daughter is a medical student at University of Southampton; Member of Hampshire & Isle of Wight Sustainability and Transformation Partnership Executive Delivery Group David joined the Trust in February 2016 and led on finance, procurement, estates and commercial development until March 2018, when he became interim chief executive officer. He read Economics and Social Policy at the University of London before joining ICI plc, where he qualified as a chartered management accountant. David has extensive healthcare experience from the pharmaceutical industry, mostly Eli Lilly and Company where he held many commercial and financial roles in the UK and overseas. He joined the NHS in 2010 as chief financial officer of Hampshire Hospitals NHS Foundation Trust. He also serves as a non-executive director for Vivid Housing Limited, a social housing provider across Hampshire and the Solent. Non-executive director and chair of audit and risk committee, Vivid Housing Limited; Director, UHS Estates Limited, a wholly-owned subsidiary of UHSFT; Director, Southampton Commercial Estates Development Partnership (CEDP) Project Company Limited, a whollyowned subsidiary of UHSFT; Member of Solent Acute Alliance; Member of Hampshire & Isle of Wight Counter Fraud Board; Member of Hampshire & Isle of Wight Sustainability and Transformation Partnership Capital Planning Panel (from May 2018) Gail joined the Trust in 2010 as deputy director of nursing and head of patient safety. Prior to this, she has worked at the Strategic Health Authority as head of patient safety, and director of clinical services at Portsmouth Hospital. Gail has also worked in Brisbane, Australia as a hospital Macmillan nurse, and as general manager of a special purpose vehicle company for the private finance initiative at South Manchester Hospitals. Husband is a consultant surgeon in the Trust; Daughter is a midwife at UHS (from March 2019) Jane joined the Trust in 2000 as a clinical services manager for the cardiothoracic directorate after spending two years in Hertfordshire as director of performance and 11 years at Barts and the London Hospitals in various roles including planning, finance and commissioning. Jane has led on human resources, information management and technology, improvement and modernisation and has been chief operating officer. Jane joined the Trust Board in February 2008 and became director of transformation and improvement in January 2014. Director, UHS Estates Limited, a wholly-owned subsidiary of UHSFT; Father and mother are UHSFT simulated patients (voluntary position) Dr Derek Medical Sandeman director Dr Caroline Marshall Chief operating officer Derek was appointed to the Trust as a consultant physician in 1993 and went on to develop a regional endocrine service. Throughout his career he has had extensive clinical leadership experience, most recently serving eight years as clinical director. Derek’s leadership roles have also included programme director for postgraduate education and the Wessex Endocrine Royal College representative. He has a strong history of wider system engagement, working collaboratively with partners to improve systems resilience and pathways. Caroline joined the Trust in 1997 as a consultant hepatobiliary and neuroanaesthetist. She has held the posts of college tutor for the Royal College of Anaesthetists and UHS mentoring and coaching lead. In 2008, she became clinical service director for critical care, and then divisional clinical director for division A between 2010 and 2013. Caroline served as interim chief operating officer between January to December 2014, and was then appointed to the substantive post. Her portfolio includes the executive lead for cancer and the executive lead for major trauma. Director of UHS Pharmacy Limited, a wholly-owned subsidiary of UHSFT; Member of Hampshire & Isle of Wight Sustainability and Transformation Partnership Clinical Executive Group Daughter is employed within the emergency department at UHS (from 1 August 2018) 27 ACCOUNTABILITY REPORT Non-executive directors Name Title Peter Hollins Chair Simon Porter Senior independent director and deputy chair Dr Mike Non-executive Sadler director Biography Declarations Peter graduated in chemistry from Hertford College, Oxford. Joining Imperial Chemical Industries in 1973, he undertook a series of increasingly senior roles in marketing and then general management. Following three years in the Netherlands as general manager of ICI Resins BV, he was appointed in 1992 as chief operating officer of EVC in Brussels – a joint venture between ICI and Enichem of Italy. He played a key role in the flotation of the company in 1994, returning in 1998 to the UK as chief executive officer of
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Annual-report-2017-18

Description: ANNUAL REPORT AND ACCOUNTS 2017/18 incorporating the quality account 2017/18 Presented to Parliament pursuant to Schedule 7, paragraph 25 (4) (a) of the National Health Service Act 2006 University Hospital Southampton NHS Foundation Trust Annual report and accounts 2017/18 incorporating the quality account 2017/18 Presented to Parliament pursuant to Schedule 7, paragraph 25 (4) (a) of the National Health Service Act 2006 3 ©2018 University Hospital Southampton NHS Foundation Trust 4 TABLE OF CONTENTS Overview and performance report Statement from the chairman and chief executive 7 Statement of purpose and activities 8 History of UHS 8 Structure of executive team 9 Structure of our services 10 Our vision and values 11 Priorities, key issues and risks 12 Going concern disclosure 15 Performance report 15 Regulatory body ratings 22 Environmental matters 23 Social, community and human rights issues 24 Accountability report Directors’ report – the Trust Board 26 Well-led framework 32 Audit and risk committee 32 Disclosures 35 Council of Governors 43 Annual remuneration statement 52 Remuneration and appointments committee 55 Governors’ nomination committee 57 Staffing report 61 Responding to the staff annual attitude survey 66 Statement of chief executive’s responsibilities as the accounting officer 71 Annual governance statement 72 Review of economy, efficiency and effectiveness of the use of resources 79 Equality, diversity and inclusion 83 Environmental sustainability and climate change 85 Southampton Hospital Charity 89 Developments in informatics 90 Leading research into better care 90 Investing for the future 91 Quality account and report Chief executive’s welcome 139 Our approach to quality assurance 141 Our commitment to safety 142 Our commitment to staff 143 Our commitment to education and training 145 Our commitment to technology to support quality 146 Our commitment to the Care Quality Commission 147 Review of quality performance 149 Progress against 2017/18 priorities 157 Clinical research 149 Review of services 150 CQUIN payment framework 150 Data quality 151 Clinical audits and confidential enquiries 152 Seven day hospital services 153 Learning from deaths 154 Priorities for improvement 2018/19 175 Conclusion 191 Responses to our quality account 192 Statement of directors’ responsibilities 198 Independent auditor’s report 199 Appendix Appendix one Quality improvement framework 2018/19 203 Appendix two Quality performance data 204 Appendix three CQUIN data 211 Appendix four Clinical audit and confidential enquiries data 214 Appendix five Registration with the Care Quality Commission 216 Appendix six Glossary of acronyms 217 Annual accounts Statement from the chief financial officer 93 Foreward to the accounts 94 Independent auditor’s report 95 Financial statements 101 5 OVERVIEW AND PERFORMANCE REPORT OVERVIEW AND PERFORMANCE REPORT A word from the chairman and chief executive Staff at UHS achieved some amazing things in 2017/18, a year in which the Trust faced the huge challenge of continuing to deal with rapidly rising demand for our services at a time when, like many hospitals, we were already under great pressure. Perhaps the most obvious achievement was that the Care Quality Commission (CQC) rated UHS as good for the quality of care which it provides overall and outstanding for leadership. It is no coincidence that the results from our latest NHS staff survey were so positive. We were particularly pleased that our response rate had increased and that UHS staff rated us the fourth best nationally for staff recommending the hospital as a place to work or receive care. We are also the seventh best nationally for staff engagement and results show that our staff feel able to contribute fully towards improvements. However, it’s truly in times of adversity, such as that we experienced over the winter period, that you see teamwork and commitment shine through. On several occasions we supported our neighbouring hospitals by providing care to their patients. We were also immensely proud of the way our staff pulled together during the days of thick snow with many staying on site overnight to ensure we had enough staff to care for our patients. Others stayed to look after stranded patients who were unable to get home. Staff with 4x4 vehicles collected colleagues for work and drove patients home. It was a monumental and incredibly uplifting effort from all. Our staff have indeed continued to strive tirelessly to provide both the quality of care and the speed of access to treatment to which we aspire. We are confident that we have done the former but the rapid increase in patient numbers has at times made it difficult to achieve the latter. We are determined to improve our performance to achieve the standards our patients expect. We are encouraged by the terrific results we achieve in the NHS Friends and Family test, with patients overwhelmingly recommending UHS as a place to have their hospital care. As the result of achieving our financial target for 2016/17 we became eligible for additional national cash incentive payments, which meant that in 2017/18 we were able to commit to the biggest capital investment programme the Trust has ever seen. As part of this programme we were able to address some of the areas of our estate that were highlighted as requiring improvement in a previous CQC report. We are delighted to say that we have again delivered our financial target for 2017/18 and will as a result be able to sustain a high rate of investment in upgrading our hospitals. We have also recently been able to start work on a £5m project to build a new Children’s Emergency Department as the result of generous support from the public for Southampton Hospital Charity and our partnership with the Murray Parish Trust without which the project would have been impossible. It will transform the environment in which our young patients are treated. Sadly at the end of the year we waved goodbye to Fiona Dalton, our chief executive for the last four years, who took the opportunity of a lifetime to live and work in Vancouver where she will lead a major Canadian healthcare group. Fiona was a remarkable chief executive, both immensely liked and admired throughout UHS and she left with the goodwill and best wishes of everyone. Peter Hollins David French Chairman Interim chief executive officer 7 OVERVIEW AND PERFORMANCE REPORT Overview of the Trust Statement of purpose and activities UHS is a large teaching hospital located on the south coast of England. We have a tripartite mission to provide clinical care, educate current and future healthcare professionals, and undertake research to improve healthcare for the future. Our clinical care encompasses local acute and elective care for 680,000 people who live in Southampton, the New Forest, Eastleigh and Test Valley. We also provide care for the residents of the Isle of Wight for many services. As the major university hospital on the south coast, UHS provides the full range of tertiary medical and surgical specialities (with the exception of transplantation, renal services and burns) to over 3.7 million people in central southern England and the Channel Islands. UHS is a centre of excellence for training the doctors, nurses and other healthcare professionals of the future. We work with the University of Southampton and Solent University to educate and develop staff at all levels, including a large apprenticeship programme, undergraduate and post-graduate education. Our role in research, developed in active partnership with the University of Southampton, is to contribute to the development of treatments for tomorrow’s patients. This work distinguishes us as a hospital that works at the leading edge of healthcare developments in the NHS and internationally. In particular we have nationally-leading research into cancer, respiratory disease, nutrition, cardiovascular disease, bone and joint conditions and complex immune system problems. We are one of the largest recruiters of patients into clinical trials in the country. Over 11,454 people work at the Trust, making it one of the area’s biggest employers. We also benefit from the contributions of over 1,000 volunteers. Our turnover in 2017/18 was more than £810m. History of UHS The Trust has its origins in the 1900s when the Shirley Warren Poor Law Infirmary was built on the site of what is now Southampton General Hospital. In the early half of the century, the site began to expand, including the opening of the school of nursing and the creation of the Wessex Neurological Unit. In 1971 a new medical school was opened in Southampton and the 1970s and 1980s saw a significant building programme encompassing the current footprint of Southampton General Hospital, Princess Anne Hospital and Countess Mountbatten House. During the 1990s, services were increasingly centralised at the general hospital, with the eye hospital and cancer services being relocated from elsewhere in the city. The Wellcome Trust funded a clinical research facility at the hospital in 2001 and this unit remains the foundation for much of the Trust’s groundbreaking medical research. In the last decade, development has continued with the opening of the North Wing Cardiac Centre in 2006, the creation of a major trauma centre with on-site helipad and the opening in 2014 of Ronald McDonald House for the relatives of sick children. Organisationally, Southampton University Hospitals Trust was formed in 1993, creating a single management board for acute services in Southampton. Eighteen years later, University Hospital Southampton NHS Foundation Trust (UHS) was formed (1 October 2011) when Southampton University Hospitals NHS Trust was licensed as a foundation trust by the then regulator, Monitor (now known as NHS Improvement (NHSI)). 8 OVERVIEW AND PERFORMANCE REPORT The way we’re structured Structure of the executive team Associate director of corporate affairs Amanda Lowe Constitution; Council of governors; legal services; insurance; risk management; policy management; freedom of information (FOI) general data protection regulations (GDPR) Chief executive (interim) David French Director of HR Steven Harris Employee relations; pay and reward; resourcing and temporary staffing; staff engagement; staff performance and appraisal; occupational health and wellbeing; childcare services Medical director Dr Derek Sandeman MD for research & development; clinical effectiveness; clinical practices and outcomes; professional regulation & standards; GP relationships Director of nursing & organisational development Gail Byrne Chief financial officer (interim) Paul Goddard Clinical governance & patient safety; education; patient experience; clinical practice & outcomes; professional regulation & standards; complaints/PALS; HR/workforce; voluntary services; fundraising Caldicott Guardian Financial management; financial strategy; investment & ROI; audit; procurement; capital programme management; estates; Commercial development Division A Surgery Cancer care Critical care & theatres Chief operating officer Caroline Marshall Major incident planning; security; communications Division B Division C Emergency medicine Women & newborn Specialist medicine/ ophthalmology Pathology Child health Support services Director of transformation & improvement Jane Hayward Division D Cardiovascular & thoracic Neurosciences Trauma & orthopaedics Cost improvement & transformation; information technology; information governance; core platform systems; informatics development; strategy; commissioning; business & capacity planning Senior Information Risk Owner (SIRO) Radiology 9 OVERVIEW AND PERFORMANCE REPORT Structure of our services Our services are split into five divisions and within each division there are care groups. Each division, with the exception of Trust headquarters, is led by a divisional management team consisting of: • divisional clinical director (DCD) • divisional director of operations (DDO) • divisional head of nursing/professions (DHN) • divisional research and development lead • divisional finance manager • divisional planning and business development (or strategy) manager • divisional education lead • division HR business partner • divisional governance manager (DGM) The diagram below outlines the five divisions and care groups/services within each. Each care group has a clinical lead, care group manager and matron/s for specific services as a minimum. Division A Surgery Cancer care Critical care Theatres Division B Emergency medicine Medicine for older people Pathology Specialist medicine and ophthalmology Genetics Division C Child health Women and newborn Support services Division D Cardiovascular and thoracic Neurosciences Trauma and orthopaedics Major trauma centre Radiology TRUST HQ Corporate affairs Communications Finance Human resources Informatics Patient support services Claims and litigation Cost improvement and transformation Estates and capital developments Research and development 10 OVERVIEW AND PERFORMANCE REPORT Our vision and values Our Forward vision outlines who we are and what we stand for, as well as describing the current challenges we face and our priorities for the future. It also provides an in-depth review of our three Trust values, which are summarised below: putting patien putting patien putting patien putting patien putting patien putting patien putting patien putting patien putting patien king together king together king together king together king together king together king together king together king together ts first ts firwsotr ts firwsotr wor ts first ts firwsotr ts firwsotr wor ts first ts firwsotr ts firwsotr wor always imparlwovaiynsg imparlwovaiynsg improving always imparlwovaiynsg imparlwovaiynsg improving always imparlwovaiynsg imparlwovaiynsg improving ts first ts first ts first wor wor wor putting patien putting patien putting patien king together king together king together always imparlwovaiynsg imparlwovaiynsg improving Patients and families will be at Our clinical teams will provide the heart of what we do and services to patients and are their experience within the crucial to our success. hospital, and their perception We have launched a leadership ofmtheeasTurruensgtop,aftwiesnuitlslcfbcnigreesptsaosti.euntrs fnigrsptatients first clsintrrikacintageltgomgyetahtnherkraianggtteoegmnetsehuernkrrintegstteoogaeumthresr are engaged in the day-to-day management and governance of the Trust. alw alw alw Our growing reputation in research and development and our approach to education and training will continue ays improtvoinagiyns icmoprropvionagrysaitmeprnoveinwg ideas, technologies and greater efficiencies in the services we provide tients first tients first tients first together together together mproving mproving mproving putti putting pa putti putting pa putti putting pa wo working wo working wo working always i always i always i 11 OVERVIEW AND PERFORMANCE REPORT Our priorities, key issues and risks Our top eight priorities 1 Promote and live our values. We will: • be clearer about the behaviours we expect from our staff • recruit, train and promote people who demonstrably share our values in everything they do 2 Improve safety, quality and productivity. We will: • Sign up to safety and deliver on our promises to patients as part of this campaign • Focus on improving outcomes by measuring and publishing clinical outcomes for all specialties • Focus on improving the whole patient experience, so that patients feel treated with compassion by all staff in every contact • Develop the concept of excellent administrative care, organising our services well so that the patient journey runs smoothly • Commit to productivity improvement across all areas • Develop innovative solutions that allow us to deliver services more efficiently while making better use of our capacity 3 Our staff and education mission. We will: • Attract the best staff by offering them a better deal and the best place to work • Continue to invest in education and training opportunities for our staff including leadership development • Ensure that our leaders and staff understand and deliver our equality and diversity agenda • Prioritise excellent communication that allows the voice of our staff to be heard and acted on • Focus on the staff of the future by developing our education and training capability for clinical and non-clinical staff • Work with our local education providers to offer excellent education opportunities and bring high calibre people into healthcare roles in our hospitals 4 Become a hospital without walls. We will: • Increase the number of patients we care for who are not inpatients within the hospital. Some of these will be cared for in another residential location or at home in partnership between ourselves and other organisations • Be clear about services where we wish to provide end-to-end integrated care, and those where we wish to work with partners to integrate care across organisations • Work with health and social care partners (public, private and third sector), where necessary using new organisational models, to ensure that patients are always cared for in the right setting • Work more closely with general practices and support innovation being led by primary care 12 OVERVIEW AND PERFORMANCE REPORT 5 Specialised services. We will: • Engage with commissioners to plan changes in service models according to national service specifications • Continue to plan and manage the ongoing drift of sub-specialist work particularly in paediatrics and complex surgical services • Maintain and develop the critical mass that is increasingly required to care for complex and specialist patients • Work with Salisbury NHS Foundation Trust, the University of Southampton and other partners to play our part in the genomic revolution, building on the Genomic Medicine Centre and seeking to become a Genomics Central Laboratory Hub for the region • Develop our clinical informatics ability to ensure that we can take advantage of new information available for the benefit of patients 6 Preventative care. We will: • Continue to expand our screening programmes as national policy and commissioning intentions develop • Take every opportunity to further support and improve the health of our staff • Ensure that our clinical translational research programme, much of which is directly relevant to health promotion, accelerates translation of research into benefit for the local population 7 Discovery. We will: • Develop a detailed plan to continue increasing the number of UHS patients who are offered access to clinical trials and maximise the impact of the research we undertake • Work with the University of Southampton to submit a strong bid for the next round of Biomedical Research Centre / Biomedical Research Unit funding opportunities • Support the University of Southampton to create an international centre for cancer immunology to accelerate the development of new immune therapies to treat cancer 8 All stages of life. We will: • Continue to expand our paediatric services in partnership with community and local acute paediatrics and develop the physical infrastructure of a modern children’s hospital as quickly as finances allow • Continue to improve transition and the care of teenagers and young adults • Develop elderly care services that are integrated across the acute and community sectors • Continue to develop our end of life care 13 OVERVIEW AND PERFORMANCE REPORT Key issues and risks 1 Failure to deliver national access targets, which impacts patient experience and patient safety. Whilst we are meeting some of the national constitutional standards in waiting times, we are not meeting them all. A number of actions have been taken in relation to improving responsiveness and working with local health and social care partners to reduce delayed transfers of care. The Trust will continue to work to reduce delayed transfers of care, as well as reviewing the efficiency of discharge processes during 2018/19. 2 Capacity and occupancy, which impacts on patient flow and the quality and timeliness of care. Operational risks have been identified across a number of services/specialties linking to issues around increasing referrals, system capacity and delayed transfers of care. We have mitigated this by implementing daily reviews to assess system capacity and escalation requirements aligning capacity plans with the wider system, developing plans to reduce length of stay with strong clinical leadership and oversight and working with local health and social care partners to reduce delayed transfers of care. 3 Staffing, both in terms of recruitment and retention. To mitigate this risk we will continue to focus on making UHS an attractive employer by: • developing band four posts and apprentices • leveraging the ‘Think UHS’ recruitment brand • continuing to recruit within Europe and further afield • working with universities to increase student nurses • enhancing medical overseas fellows posts • reviewing all junior doctor rotas in light of the new contract • using flexible and temporary staff when needed • creating different roles linked to our research agenda • reviewing training and education to enhance retention. 14 OVERVIEW AND PERFORMANCE REPORT Performance report Going concern disclosure After making enquiries, the directors have a reasonable expectation that the Trust has adequate resources to continue in operational existence for the foreseeable future. For this reason, they continue to adopt the going concern basis in preparing the accounts. Reporting structure As a large NHS university hospital foundation trust, UHS monitors performance within individual teams throughout the year with feedback processes in place to escalate issues to more senior management teams. At a corporate level we have an established executive reporting structure. Monthly Trust Board Public meeting where executive directors present high level summary to chairman and non-executive directors. For further information see page 30. Audit and risk committee Strategy and finance committee Quality committee Trust executive committee (TEC) Review performance/issues/risks in greater depth For further detail on role of these committees please refer to the annual governance statement section on page 72. Trust Board study sessions Trust Board members meet to focus on a specific issue. Performance meetings Operational management team (led by chief operating officer) and division and care group management teams focus on individual patient and service pathways to develop improvement plans. 15 OVERVIEW AND PERFORMANCE REPORT Key performance indicators (KPIs) The Trust publishes a monthly Integrated KPI Board Report on its website which provides both the Board and the public with an overview of performance within the Trust. This report is constantly evolving as new areas of monitoring are developed and new areas of national focus become apparent. For 2017/18 the format of the monthly report followed the five key Care Quality Commission (CQC) questions: • Are we safe? • Are we effective? • Are we caring? • Are we responsive? • Are we well-led? The monthly report features the following sections: • Executive digest – update on the previous month’s performance written by the director of transformation and improvement. • Trust overview – the top KPIs identified by Trust Board, RAG-rates for the previous 13 months • Safe • Effective • Caring • Activity • Emergency department (ED) • Referral to treatment (RTT/18 weeks) • Cancer waiting times • Flow • Staffing (HR) • Education and training • Research and development • Estates This report also includes summary versions of quarterly reports submitted to TEC which go into greater detail about patient experience, patient safety, clinical effectiveness and outcomes, and infection prevention. In addition, a separate Finance Board Report is submitted to Trust Board on a monthly basis. The emergency department, Activity and Flow section have several KPI’s that are relevant to the key risk of delivering the national access target. Some of the KPI’s are: • Number of attendances • Time to initial assessment • Hospital red/black alerts • Delayed transfers of care • Non-elective length of stay The Activity and Flow section have several KPI’s that are relevant to the key risk of capacity and occupancy. Some of the KPI’s are: • Length of stay • New referrals • Number of attendances • Bed occupancy • Hospital red/black alerts The Staffing (HR) section has several KPI’s that are relevant to the key risk of Staffing. Some of the KPI’s are: • Staff turnover • Nursing vacancies • Friends and Family Test – percentage of staff who recommend UHS as a place to work You can see full copies of the monthly report by visiting www.uhs.nhs.uk 16 OVERVIEW AND PERFORMANCE REPORT How we monitor performance In addition to reviewing the data submitted to the Trust Board in these papers, we have a suite of tools available to compare UHS performance to that of comparable trusts around the country. Depending on the measures being monitored, UHS has a number of peer groups to benchmark against including other local providers, major trauma centres and university hospital teaching trusts. Each NHS Trust will service a different size and type of population and will offer a slightly different range of services so it is important to understand that this benchmarking provides an initial indication of performance rather than an absolute guide to our position nationally. In 2017/18 we continue to review the National Model Hospital data as it is published from NHS Improvement. The data and ability to compare our performance has helped to highlight areas of excellent practice and areas where there is potential to improve. The Trust now has a model hospital steering group which identifies potential improvement projects from the data and reports to transformation board. Detailed analysis and explanation of the development and performance of UHS Activity, capacity and occupancy Over the past three years we have seen significant increases in all types of activity. This is linked to demographic growth, new specialist techniques and services transferring from other providers including vascular services from Portsmouth. In addition, UHS now has responsibility for surgical services at Lymington. The graph and table below demonstrate this increase in activity. UHS growth in activity – 2015/16 to 2017/18 700,000 600,000 500,000 400,000 300,000 200,000 100,000 0 Inpatient spells (inc. day cases Outpatient appointments 2015/16 2016/17 2017/18 ED attendances (type one) Referrals Inpatient spells (inc. day cases Outpatient appointments ED attendances (type one) Referrals 2015/16 146,066 562,972 95,217 191,888 2016/17 155,780 596,621 99,493 204,840 2017/18 154,224 624,083 102,547 208,872 Increase 15/16 to 17/18 5.6% 10.9% 7.7% 8.9% 17 OVERVIEW AND PERFORMANCE REPORT Hospital alert status The hospital alert status is decided by the operations centre after assessing the bed and staffing position, and is recorded twice daily at the Trust bed meetings (though the status may change at any time). Black alert is the highest level of alert and is issued when there are no empty beds available across the Trust with no expected discharges, the emergency department is full, and if actions are not taken several ambulances are likely to be delayed for long periods of time, stopping them from responding to 999 calls (this is based on a national definition of escalation). Red alert is when the majority of the hospital is under significant operational pressure and is likely to include a mismatch between supply and demand of beds and/or there are no beds available, with patients waiting more than three hours in the emergency department, and patients with a clinical decision for admission but no bed identified for them to move to. The Trust will undertake a wide range of actions in response to this, including the opening of additional overnight beds (usually within day wards), the redistribution of staff or bed capacity to support areas under most pressure, Trust-wide communication to request a focus on actions which will enable patients to be discharged or the admission avoided and the potential review of less urgent elective operations to maintain bed availability for patients with more urgent needs. In 2015/16 a black alert was recorded seven times at the twice daily bed meetings. In 2016/17 this was increased to eleven and in 2017/18 this increased again to twenty. The chart below shows red and black alerts logged during 2017/18. 50 Number of AM and PM alerts 40 30 20 10 0 Mar 17 Apr 17 May 17 Jun 17 Jul 17 Aug 17 Sep 17 Oct 17 Nov 17 Dec 17 Jan 18 Feb 18 Mar 18 Red alerts Black alerts Contributing to this change has been an increase in length of stay (LoS) for elective patients linked to a more complex case mix and an increase in day cases. The chart below shows the total bed days attributable to delayed transfers of care at UHS in 2017/18. UHS delayed transfers of care 2017/18 Percentage of bed days lost 3,400 3,200 3,000 2,800 2,600 2,400 2,200 2,000 Mar 2017 April 2017 May 2017 June 2017 July 2017 Aug 2017 Sept 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Mar 2018 18 OVERVIEW AND PERFORMANCE REPORT Referral to treatment (18 weeks) performance National target: 92% of all patients on 18 week pathway and not yet treated should have waited 18 weeks or less at the end of the month (incomplete pathways target). How did we do? UHS met the target in quarter one of 2017/18 but did not meet the target for the rest of the year. Achievement of this target in 2017/18 should be set against a rise in patient referrals, which highlights the increased demands being placed on the Trust. We have identified a reporting issue at our satellite outpatient clinics in Salisbury and are investigating the impact on referral to treatment reporting. Emergency department (ED) performance There are three types of emergency departments: Type Type Type ONE TWO THREE 3 24 hour with full resuscitation facilities 3 Consultant-led 3 Designated accommodation for patients admitted via ED 3 Single specialty emergencies (eye or dental) 3 Consultant-led 3 Designated accommodation 3 Minor injuries/walk-in centres 3 Doctor or nurse-led 3 Can be routinely accessed without appointment 3 May be co-located within an ED or sited in the community We run all three types of departments and, in August 2017 we also took over the operation of Lymington Minor Injuries Unit and opened the Urgent Care Hub at Southampton General in October 2017. All three types are subject to the national target and are therefore reflected in our figures. National target: The constitutional standard remains at 95% but a national recovery trajectory was agreed as: Patients should be treated and either admitted or discharged within four hours of arrival 85% achievement target set for April 17 90% achievement target in or before September 2017 95% achievement target by March 2018. How did we do? December 2017 was an extremely challenging month for emergency patients for the whole Hampshire and Isle of Wight area. UHS saw an increase in patients admitted to the Trust with influenza and, alongside our own bed pressures, we took ambulance diverts from other hospitals in order to maintain patient safety across Hampshire. Our Trust received formal letters of thanks from local commissioners and providers for the part we played during this difficult period. 19 OVERVIEW AND PERFORMANCE REPORT The graph below shows our performance against the four hour target over the last year. National 4 hour access target – UHS performance 100% 95% 89.4% 90% 85% 80% 87.4% 86.7% 91.4% 89.5% 93.3% 91.9% 90.5% 87.1% 83.2% 82.1% 82.5% 75% April 2017 May 2017 June 2017 July 2017 Aug 2017 Sept 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Mar 2018 Cancer waiting times There are ten separate cancer waiting times measures (below) that the Trust reports to the Department of Health on a monthly basis, each of which can then be split into tumour site specific performance groups. In 2017/18 the Trust met six of these measures. Number Measures Achieved 1 a maximum one month (31-day) wait from the date a decision to treat (DTT) is made to the first definitive 8 treatment for all cancers 2 a maximum 31-day wait for subsequent treatment where the treatment is surgery 8 3 a maximum 31-day wait for subsequent treatment where the treatment is a course of radiotherapy 3 4 a maximum 31-day wait for subsequent treatment where the treatment is an anti-cancer drug regimen 3 5 a maximum two month (62-day) wait from urgent referral for suspected cancer to the first definitive 8 treatment for all cancers 6 a maximum 62-day wait from referral from an NHS cancer screening service to the first definitive treatment 3 for cancer 7 a maximum 62-day wait for the first definitive treatment following a consultant’s decision to upgrade the 3 priority of the patient (all cancers) 8 a maximum two-week wait to see a specialist for all patients referred with suspected cancer symptoms 3 9 a maximum two-week wait to see a specialist for all patients referred for investigation of breast symptoms, 8 even if cancer is not initially suspected 10 A maximum 31-day wait (urgent GP referral to treatment) for first treatment for rarer cancers 3 The number of patients referred under the two week wait urgent suspected cancer protocol seen within two weeks of their referral, rose by 5.2% in 2017/18. The chart overleaf shows the rise in demand for UHS cancer services over the past three years. 20 OVERVIEW AND PERFORMANCE REPORT UHS growth in cancer actvity – 2015/16 to 2017/18 20,000 18,000 16,000 14,000 12,000 10,000 8,000 6,000 4,000 2,000 0 Two week waits 62 day target patients 2015/16 2016/17 2017/18 31 day target patients For staffing performance, please refer to page 61. For financial performance please see page 93. David French Interim chief executive officer 24 May 2018 21 OVERVIEW AND PERFORMANCE REPORT Regulatory body ratings Single Oversight Framework NHS Improvement’s Single Oversight Framework provides the framework for overseeing providers and identifying potential support needs. The framework looks at five themes: 1. Quality of care 2. Finance and use of resources 3. Operational performance 4. Strategic change 5. Leadership and improvement capability (well-led) Based on information from these themes, providers are segmented from one to four where ‘4’ reflects providers receiving the most support, and ‘1’ reflects providers with maximum autonomy. A foundation trust will only be in segments three or four where it has been found to be in breach or suspected breach of its licence. Segmentation During 2017/18 the Trust was confirmed as being placed within segment ‘2’. This segmentation information is the Trust’s position as at 31 March 2018. Current segmentation information for NHS trusts and foundation trusts is published on the NHS Improvement website. Finance and use of resources The finance and use of resources theme is based on the scoring of five measures from ‘1’ to ‘4’, where ‘1’ reflects the strongest performance. These scores are then weighted to give an overall score. Given that finance and use of resources is only one of the five themes feeding into the Single Oversight Framework, the segmentation of the Trust disclosed above might not be the same as the overall finance score here. Area Financial sustainability Financial sustainability Financial sustainability Overall scoring Care Quality Commission ratings: Metric Capital service cover Liquidity Income and expenditure margin Distance from financial plan Agency spend Q1 Q2 Q3 Q4 2 2 2 1 2 2 1 1 1 1 1 1 1 1 2 1 1 1 1 1 1 1 1 1 Overall rating for this trust Are services at this trust safe? Are services at this trust effective? Are services at this trust caring? Are services at this trust responsive? Are services at this trust well-led? Good Requires improvement Good Outstanding Requires improvement Outstanding 22 OVERVIEW AND PERFORMANCE REPORT The CQC inspected all key questions in four of the eight core services of surgery, critical care, end of life care and outpatient and diagnostic imaging and noted the Trust had a stable leadership team in place since their last inspection. The previous inspection in 2015 had found safety of medicine and maternity services, along with responsiveness of urgent and emergency care and children’s services ‘required improvement’. At the 2017 inspection the following observation was made: ‘At this inspection we saw significant improvement across the areas we inspected. There were improvements in surgery, critical care, end of life care and outpatients. Critical care is rated overall as ‘Outstanding’, with surgery, end of life care, and outpatients and diagnostic imaging as ‘Good’ overall. These services had been rated requires improvement in 2015. The improvements were in line with the trust’s improvement plan and had been assisted by the trust board and executive leadership team’ Professor Sir Mike Richards Chief Inspector of Hospitals Environmental matters We recognise that the Trust’s business has an impact on the environment. As a large hospital we undertake a wide range of activities and use a large amount of resources, for example: • The Trust generates approximately 3,000 tonnes of waste yearly, half of which is clinical waste. If not properly treated this huge amount of waste can cause soil, water and air pollution depending on the disposal route. • Due to the large number of visitors and deliveries we attract every day, traffic congestion is regularly experienced on and around the site, which impacts the air quality around the hospital. We are committed to environmental sustainability and consider it as part of the business culture. We acknowledge that reducing waste and minimising the consumption of scarce resources is consistent with financial sustainability. Our sustainability disclosure section on page 85 provides greater detail on the steps we are taking to reduce our activities’ impact on the environment. 23 OVERVIEW AND PERFORMANCE REPORT Social, community, anti-bribery and human rights issues We recognise our responsibilities under the European Convention on Human Rights (included in the Human Rights Act 1998 in the UK), which are relevant to health and social care. These rights include the: • right to life • right not to be subjected to torture, inhuman or degrading treatment or punishment • right to liberty • right to respect for private and family life The Trust is committed to ensuring it fully takes into account all aspects of human rights in our work. At University Hospital Southampton we value our reputation for top quality care and financial probity and conduct our business in an ethical manner. The Bribery Act 2010 was introduced to make it easier to tackle the issue of bribery which is a damaging practice. Bribery can be defined as ‘giving someone a financial or other advantage to encourage them to perform their duties improperly or reward them for having done so’. To limit our exposure to bribery we have in place an Anti-Fraud, Bribery and Corruption Policy, a Standards of Business Conduct Policy and a Freedom to Speak Up (formerly Raising Concerns) Policy. These apply to all staff and to individuals and organisations who act on behalf of UHS. We also employ a local counter fraud specialist who will investigate, as appropriate, any allegations of fraud, bribery or corruption. The success of our anti-bribery approach depends on our staff playing their part in helping to detect and eradicate bribery. Therefore, we encourage staff, service users and others associated with UHS to report any suspicions of bribery and we will rigorously investigate any allegations. In addition, we hold a register of interest for directors, staff, and governors and ask staff not to accept gifts or hospitality that will compromise them or the Trust. The Board of Directors carries out its business in an open and transparent way. We are committed to the prevention of bribery as well as to combating fraud and expect the organisations we work with to do the same. Doing business in this way enables us to reassure our patients, members and stakeholders that public funds are properly safeguarded. There are no important events since the year end affecting the foundation trust. No political donations have been made. The Trust has no overseas branches. 24 FR STAND BODY ACCOUNTABILITY REPORT Directors’ report – the Trust Board Board member Name Title Fiona Dalton Chief executive (until March 2018) David French Interim chief executive (chief financial officer until March 2018) Gail Byrne Director of nursing and organisational development Jane Hayward Director of transformation and improvement Biography Declarations Fiona was appointed as chief executive in 2013. Prior to re-joining the Trust she held the combined position of deputy chief executive and chief operating officer at Great Ormond Street Hospital for Children. Fiona joined the NHS management training scheme after graduating from Oxford University with a degree in human sciences and began her career in hospital management at Oxford Radcliffe Hospitals NHS Trust in 1996. She then spent four years at UHS as director of strategy and business development before moving to Great Ormond Street Hospital. NHS representative on Office for the Strategic Co-ordination of Health Research (OSCHR) Board; Director, Southampton Commercial Estates Development Partnership (CEDP) Project Company Limited, a whollyowned subsidiary of UHSFT. David joined the Trust in February 2016 and led on finance, procurement, estates and commercial development until March 2018, when he became interim chief executive officer. He read Economics and Social Policy at the University of London before joining ICI plc, where he qualified as a chartered management accountant. David has extensive healthcare experience from the pharmaceutical industry, mostly Eli Lilly and Company where he held many commercial and financial roles in the UK and overseas. He joined the NHS in 2010 as chief financial officer of Hampshire Hospitals NHS Foundation Trust. He also serves as a non-executive director for Vivid Housing Limited, a social housing provider across Hampshire and the Solent. Non-executive director and chair of audit and risk committee, Vivid Housing Limited; Director, UHS Estates Limited, a wholly-owned subsidiary of UHSFT; Director, Southampton Commercial Estates Development Partnership (CEDP) Project Company Limited, a wholly-owned subsidiary of UHSFT; Member of Solent Acute Alliance Gail joined the Trust in 2010 as deputy director of nursing and head of patient safety. Prior to this, she has worked at the Strategic Health Authority as head of patient safety, and director of clinical services at Portsmouth Hospital. Gail has also worked in Brisbane, Australia as a hospital Macmillan nurse, and as general manager of a special purpose vehicle company for the private finance initiative at South Manchester Hospitals. Husband is a consultant surgeon in the Trust; Trustee of Naomi House Children’s Hospice (until 10 February Jane joined the Trust in 2000 as a clinical services manager for the cardiothoracic directorate after spending two years in Hertfordshire as director of performance and 11 years at Barts and the London Hospitals in various roles including planning, finance and commissioning. Jane has led on human resources, information management and technology, improvement and modernisation and has been chief operating officer. Jane joined the Trust Board in February 2008 and became director of transformation and improvement in January 2014. Director, UHS Estates Limited, a wholly-owned subsidiary of UHSFT; Father is mental health act manager, Southern Foundation Trust (voluntary position) (until 31 August 2017), member of assessment committee for Clinical Excellence Awards South and Public Health England (lay member) (until January 2018), a UHSFT simulated patient (voluntary position); Mother is a UHSFT simulated patient (voluntary position) Dr Derek Medical Sandeman director Dr Caroline Marshall Chief operating officer Derek was appointed to the Trust as a consultant physician in 1993 and went on to develop a regional endocrine service. Throughout his career he has had extensive clinical leadership experience, most recently serving eight years as clinical director. Derek’s leadership roles have also included programme director for postgraduate education and the Wessex Endocrine Royal College representative. He has a strong history of wider system engagement, working collaboratively with partners to improve systems resilience and pathways. Caroline joined the Trust in 1997 as a consultant hepatobiliary and neuroanaesthetist. She has held the posts of college tutor for the Royal College of Anaesthetists and UHS mentoring and coaching lead. In 2008, she became clinical service director for critical care, and then divisional clinical director for division A between 2010 and 2013. Caroline served as interim chief operating officer between January to December 2014, and was then appointed to the substantive post. Her portfolio includes the executive lead for cancer and the executive lead for major trauma. Director of UHS Pharmacy Limited, a wholly-owned subsidiary of UHSFT; Daughter-in-law employed at UHSFT as medical support to department of innovation (from January 2017 – December 2017) Daughter is in an administration role at UHS (from July 2017) 26 ACCOUNTABILITY REPORT Board member Name Title Biography Declarations Paul Goddard Interim chief financial officer (from April 2018) Paul joined the Trust in June 2007 as assistant director of finance and become the deputy director in December 2012. Paul has spent over 25 years in NHS finance having worked in many different organisations. A fellow of the Association of Chartered Certified Accountants, Paul became interim chief financial officer at UHS from April 2018. Serves as a director of the Trust’s wholly owned subsidiary company, UHS Pharmacy Limited. Sits on the Southampton Hospital Charity committee. Non-executive directors Peter Hollins Simon Porter Chair Senior independent director and deputy chair Peter graduated in chemistry from Hertford College, Oxford. Joining Imperial Chemical Industries in 1973, he undertook a series of increasingly senior roles in marketing and then general management. Following three years in the Netherlands as general manager of ICI Resins BV, he was appointed in 1992 as chief operating officer of EVC in Brussels – a joint venture between ICI and Enichem of Italy. He played a key role in the flotation of the company in 1994, returning in 1998 to the UK as chief executive officer of British Energy where he remained until 2001. From 2001, he held various chairmanships and non-executive directorships. In 2003, he decided to return to an executive role as chief executive of the British Heart Foundation in which post he remained until retirement in March 2013. He joined Southampton University Hospital Trust as a nonexecutive director in 2010, became senior independent director and deputy chairman of UHS in 2014, and was appointed chair in April 2016. Partner in the Jubilee Film Partnership; Chair of CLIC Sargent Cancer Care for Children (a company limited by guarantee); Council member of University of Southampton Simon was born and educated in Southampton and then Oxford, graduating with a degree in modern languages (Italian and French). He is a qualified chartered accountant, having spent most of his career with the London office of Ernst & Young, where he specialised first in audit, then in transactions and finally risk management. He was a partner with Ernst & Young from 1994 to 2010. He joined the Trust Board on 1 January 2011 as a designate non-executive director and became non-executive director from 1 June 2011. He is chair of the audit and risk committee and a member of the strategy and finance committee. He also holds non-executive board positions in the social housing sector. Former partner in Ernst & Young LLP; Non-executive director and chair of audit committee, Radian Group; Non-executive director and chair of audit committee, Octavia Housing Dr Mike Sadler Non-executive director Mike joined UHS as a clinical non-executive director in September 2014, from a similar position at an NHS foundation trust providing mental health, learning disability and community services. He has chaired our quality committee since June 2016. He works as an advisor and consultant on health and social care services, recently advising on health reform in the Middle East, and in Ireland. He has been chair and technical adviser to the Diabetes Professional Care Conference since 2015, and also worked for the CQC as a specialist adviser in primary care. External clinical associate for PricewaterhouseCoopers; Member of the Advisory Board for xim (from 1 May) Mike graduated from Nottingham University, and was a GP principal in Hampshire before moving into public health medicine. Having achieved an MSc with distinction at the London School of Hygiene and Tropical Medicine, he joined Portsmouth and South East Hampshire Health Authority, holding the joint posts of deputy director of public health and medical adviser. He has since held a series of senior clinical leadership roles in national organisations in both the public and private sector, including as a chief operating officer at NHS Direct and Serco’s health division. His last full time role, up until July 2013 when he commenced his portfolio career, was as director of health and social care at West Sussex County Council. 27 ACCOUNTABILITY REPORT Board member Name Title Jenni Non-executive Douglas- director Todd Biography
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Chemotherapy - patient information

Description: This factsheet contains information about the common side effects of chemotherapy.
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Annual-report-and-quality-account-2019-20

Description: ANNUAL REPORT AND ACCOUNTS 2019/20 Incorporating the quality account 2019/20 Page 2 University Hospital Southampton NHS Foundation Trust Annual report and accounts 2019/20 incorporating the quality account 2019/20 Presented to Parliament pursuant to Schedule 7, paragraph 25 (4) (a) of the National Health Service Act 2006 Page 4 ©2020 University Hospital Southampton NHS Foundation Trust Page 5 TABLE OF CONTENTS Overview and performance report Welcome from our chair A word from the chief executive Overview of the Trust Statement of purpose and activities History of UHS Our executive team structure Structure of our services Our vision and values Our priorities, key issues and risks Voluntary disclosures Equality, diversity and inclusion 92 8 9 Environmental sustainability and climate chan ge 95 Quality account 10 Chief executive welcome 101 10 11 Annual accounts 12 Statement from the Chief financial officer 183 13 Independent Auditors report 185 14 Foreword to accounts 192 Performance report Going concern disclosure 16 Reporting structure 16 Key performance indicators 18 How we monitor performance 19 Overview of performance of UHS 18 Regulatory body ratings 19 Environmental matters 23 Social, community, anti-bribery and human rights issues 23 Accountability report Members of the Trust Board 25 Trust Board purpose and structure 30 Board meeting attendance record 2018/19 31 Well-led framework 32 Finance and investment committee 34 Quality committee 33 Audit and risk committee 35 External auditors 36 Governance code 36 Performance evaluation of Trust Board and its committees 36 Remuneration 36 Countering fraud and corruption 37 Independence of external auditor 37 Internal audit service 37 Better payment practice code 37 Statement as to the disclosures to auditors 38 Disclosures 38 Income disclosures 38 Governance disclosures 38 Approach to quality governance 38 Council of Governors 41 Annual remuneration statement 51 Remuneration and appointments committee 54 Governors’ nomination committee 57 Staffing report 61 Staff survey results 65 Trade union facility time 68 Statement of chief executive’s responsibilities as the accounting officer 72 Annual governance statement 73 Page 6 OVERVIEW AND PERFORMANCE REPORT Page 7 OVERVIEW AND PERFORMANCE REPORT Welcome from our chair 2019/20 was another challenging year for University Hospital Southampton NHS Foundation Trust (UHS). Demand for our services continued to rise rapidly, partly because of the ageing of the population we are here to serve and partly because of challenges in the external environment, but also because of our ability to offer exciting innovations for a range of conditions. As a result, we were not always able to offer treatment as rapidly as we wished. A major challenge towards the end of the year was the need to prepare the Trust for the COVID-19 pandemic, resulting in the need to re-engineer services on an unprecedented scale. The response of UHS staff to these challenges has, from start to finish, been magnificent. We saw major innovation in improved patient pathways to accommodate rising demand, and the creativity of colleagues in readying the Trust for COVID-19 was truly breath-taking in its scope and energy. UHS has had a long record of effective financial management. By constantly seeking operational innovation and better value for money in procurement, the Trust has been able to generate the funds necessary to make a number of capital investments which will provide huge patient benefit in future. There has been rapid progress in our major project to refurbish and extend our general intensive care unit. Our £2.2m investment in our new urology unit was completed this year; it will transform our patients’ experiences. We have continued wherever possible to work with partners and we are delighted that work on the £5m Maggie’s Centre has started. Quite apart from the need to navigate our way through the COVID-19 crisis and into the world beyond it, the Trust needs to prepare to play its full role in the Hampshire and Isle of Wight healthcare system as it develops in a way consistent with the NHS Long Term Plan. The responsibility for this falls of course to the Trust Board and I believe that even after having had more change on the Board this year than for some time, we continue to have a strong and committed leadership team. Following the retirement of Caroline Marshall, our long-serving chief operating officer, in September 2019 we welcomed Joe Teape into the position. Joe had not been at the Trust long before we were thrust into the COVID-19 pandemic and got to grips with it impressively rapidly. During the year we said farewell to three non-executive directors (NEDs); Catherine Mason who left us to become chair of Solent Healthcare, Mike Sadler our clinical NED and Simon Porter. After a series of rigorous selection processes, we were delighted to welcome Dave Bennett, Dr Tim Peachey and Keith Evans as replacements. Simon had been both deputy chair and senior independent director (SID) and on his departure Jenni Douglas-Todd succeeded him in both roles. The work of the Board is supported, stimulated and, quite correctly, challenged by the Council of Governors (COG) whose enthusiasm is of huge value to the proper governance of UHS. All of the elections to the COG were competitive, in some cases by a multiplicity of candidates. Unfortunately, one of those vacancies resulted from the death of Edward Osmond. Although Edward had only recently been elected as a governor, he had shown huge commitment to the role and I am sure would have gone on to make a major contribution to UHS. We welcomed nine new governors and one new young governor. I look forward to working with them and all the other governors as we move through and beyond the COVID-19 world. Peter Hollins Chair Page 8 OVERVIEW AND PERFORMANCE REPORT A word from the chief executive My first full year as chief executive officer of UHS has been exciting, inspiring, and extremely rewarding but not, as you would expect, without a considerable degree of challenge! The pressures on the NHS have been well publicised as we strive to provide the highest possible standard of care at a time when demand for our services escalates rapidly. At the same time, at UHS we need to play our full part in working out how we shape and deliver the health and care provision for our community into the future. During the year we have done a great deal of work on how we turn our vision for the Trust, world-class care for everyone, into what happens on the front line every day. While the vision may be new it is built firmly on our long-standing values; patients first, working together, and always improving, which together describe who we are as an organisation. These values were central to the development of our new clinical and corporate strategy which sets out an exciting future for UHS over the coming decade. It includes how we will deliver the safest care, delivering the best outcomes, as well as how we will focus on improving the health of our population, supporting both health and wellbeing. The values also provided the basis for our CQC rating of ‘Good’ awarded during the year as were some other fantastic accolades. These included a prestigious British Medical Journal award for improving care for older patients with the development of our frailty unit and activity hub. Our women’s and maternity care at the Princess Anne Hospital was named as being among the best in the world. In addition, we adopted prehabilitation for cancer patients, a pioneering service. There are countless other examples of innovation which have sprung from the creativity and innovative spirit at UHS. Some of these have involved better outcomes for patients, some an improved patient experience and others simply lower the cost of doing things, liberating money which we can then invest in improving other services. I’d like to thank every one of our staff for creating the spirit of UHS which means that the extraordinary happens every day. The world of health and social care is changing dramatically and we continue to be integral to the Hampshire and Isle of Wight Sustainability and Transformation Partnership (STP). UHS will have a leading part to play in ensuring that, with our partners, we forge a pattern for the provision of healthcare across the local system and beyond, delivering the highest possible standards of care on an enduring basis. As we entered 2020, we began preparing to face COVID-19, the largest pandemic we have seen. Some areas of the hospital are truly unrecognisable as we have adapted to the fight against this virus. The loss of life as a result of COVID-19 has been utterly devastating and it has, I am sure, touched us all personally. It has also challenged the health and wellbeing of all our staff, but particularly our frontline staff, in a unique way. I am not sure whether I am prouder of the spirit with which our staff have responded to the challenge or of the fact that they made us by common consent one of the best prepared trusts in the country. Finally, I’d like to recognise the acts of kindness I see throughout the Trust on a daily basis. It is one of the things that has struck me the most as I have got to know this organisation and the people within it. I watch how they support one another through challenging times, how they support patients and visitors in their own time and in work time, and how they go above and beyond every day for the people they’re caring for. Every day they make me hugely privileged to lead this amazing organisation. Paula Head Chief executive officer Page 9 OVERVIEW AND PERFORMANCE REPORT Overview of the Trust Statement of purpose and activities UHS is a large teaching hospital located on the south coast of England. We have a tripartite mission to provide clinical care, educate current and future healthcare professionals, and undertake research to improve healthcare for the future. Our clinical care encompasses local acute and elective care for 680,000 people who live in Southampton, the New Forest, Eastleigh and Test Valley. We also provide care for the residents of the Isle of Wight for many services. As the major university hospital on the south coast, UHS provides the full range of tertiary medical and surgical specialities (with the exception of transplantation, renal services and burns) to over 3.7 million people in central southern England and the Channel Islands. UHS is a centre of excellence for training the doctors, nurses and other healthcare professionals of the future. We work with the University of Southampton and Solent University to educate and develop staff at all levels, including a large apprenticeship programme, undergraduate and postgraduate education. Our role in research, developed in active partnership with the University of Southampton, is to contribute to the development of treatments for tomorrow’s patients. This work distinguishes us as a hospital that works at the leading edge of healthcare developments in the NHS and internationally. In particular we have nationally-leading research into cancer, respiratory disease, nutrition, cardiovascular disease, bone and joint conditions and complex immune system problems. We are one of the largest recruiters of patients into clinical trials in the country. Over 12,000 people work at the Trust, making it one of the area’s biggest employers. We also benefit from the contributions of over 1,000 volunteers. Our turnover in 2019/20 was £912m. History of UHS The Trust has its origins in the 1900s when the Shirley Warren Poor Law Infirmary was built on the site of what is now Southampton General Hospital. In the early half of the century, the site began to expand, including the opening of the school of nursing and the creation of the Wessex Neurological Unit. In 1971 a new medical school was opened in Southampton and the 1970s and 1980s saw a significant building programme encompassing the current footprint of Southampton General Hospital, Princess Anne Hospital and Countess Mountbatten House. During the 1990s, services were increasingly centralised at the general hospital, with the eye hospital and cancer services being relocated from elsewhere in the city. The Wellcome Trust funded a clinical research facility at the hospital in 2001 and this unit remains the foundation for much of the Trust’s groundbreaking medical research. In the last decade, development has continued with the opening of the North Wing Cardiac Centre in 2006, the creation of a major trauma centre with on-site helipad and the opening in 2014 of Ronald McDonald House for the relatives of sick children. Organisationally, Southampton University Hospitals Trust was formed in 1993, creating a single management board for acute services in Southampton. Eighteen years later, University Hospital Southampton NHS Foundation Trust (UHS) was formed (1 October 2011) when Southampton University Hospitals NHS Trust was licensed as a foundation trust by the then regulator, Monitor (now known as NHS Improvement (NHSI)). Page 10 OVERVIEW AND PERFORMANCE REPORT Our executive team structure Executive team structure as at 31/03/2020 Page 11 OVERVIEW AND PERFORMANCE REPORT Structure of our services Our organisation is split into five areas, with our clinical services grouped into four divisions. Within each division there are care groups. Each division, with the exception of Trust headquarters, is led by a divisional management team consisting of: • divisional clinical director (DCD) • divisional director of operations (DDO) • divisional head of nursing/professions (DHN) • divisional research and development lead • divisional finance manager • divisional planning and business development (or strategy) manager • divisional education lead • division HR business partner • divisional governance manager (DGM) The diagram below outlines the five divisions and care groups/services within each. Each care group has a clinical lead, care group manager and matron/s for specific services as a minimum. Page 12 OVERVIEW AND PERFORMANCE REPORT Our vision and values Our vision outlines who we are and what we stand for, as well as describing the current challenges we face and our priorities for the future. It also provides an in-depth review of our three Trust values, which are summarised below: Patients first Patients and families will be at the heart of what we do and their experience within the hospital, and their perception of the Trust, will be our measure of success. Working together Our clinical teams will provide services to patients and are crucial to our success. We have launched a leadership strategy that ensures our clinical management teams are engaged in the day-today management and governance of the Trust. Always improving Our growing reputation in research and development and our approach to education and training will continue to incorporate new ideas, technologies and greater efficiencies in the services we provide Page 13 OVERVIEW AND PERFORMANCE REPORT Our priorities, key issues and risks Our goals 1. Improving patient journeys (system focus, integration) We will: • Write a strategic plan for integrated ‘front door; services to address capacity and demand mismatch and enable flow • Secure influence in primary care by establishing the hospital’s role in supporting primary care networks • Promote value-based healthcare, particularly: Introduce ‘advanced decision making’ • Redesign services to provide timely safe care and meet constitutional access trajectories • Deliver priorities relevant to UHS in the first year of the long-term plan including commissioning and long-term changes 2. Delivering value-based health and care We will: • Deliver the Trust financial plan and maximise any national funding • Prepare UHS for the new NHS financial regime • Deliver the Trust Quality Improvement plan to improve safety/experience and outcomes • Build capability for change by embedding quality improvement, innovation and transformation at a leadership level • Deliver the Cost Improvement Plan (CIP) without compromising on quality 3. Supporting health lives (prevention, wellbeing inequalities, outcomes and experience) We will: • Improve staff health and wellbeing • Improve population health, maximising the impact of UHS touch points • Develop an early warning tool to identify any deterioration in quality 4. Building an expert and inclusive workforce (diversity, engagement, leadership) We will: • Close the staffing supply gap in priority groups/services to provide high quality and timely care • Manage overall workforce cost to meet CIP challenge • Measure improvement in staff engagement by increasing participation in staff survey • Increase representation of diverse groups in leadership and decision making • Improve the staff engagement score 5. Being agile in meeting people’s needs (organisational elegance/design/flexibility) We will: • Reset organisational structure as necessary, responding to changes outlined in the NHS long-term plan • Leverage digital capability to support patient empowerment and self-care • Measure staff user satisfaction with the Trust IT systems and use this to support the digital strategy • Be agile in flexing resources, responding to fluctuating demand • Secure strategic influence by establishing UHS role in the transition from STP to ICS 6. Leading edge research, education and innovation (research and outcomes) We will: • Identify the capacity constraints to expand research and plan to address • Identify priority areas without a research base and set strategy • Improve quality and breadth of education and training programme Page 14 OVERVIEW AND PERFORMANCE REPORT The novel coronavirus (COVID-19) will continue to have a significant impact on public health, morbidity and mortality if adequate prevention and control is not in place. The Trust put rapid and robust arrangements in place early on to prepare for the potential surge in COVID-19 patients. As the government now announces the easing of the lockdown restrictions, the COVID-19 challenge continues to unfold and still represents a very significant future risk to the organization. Our response and mitigations will continue to evolve through 2020/21. Further details on our response to the COVID-19 challenge are in included in the Annual Governance Statement on page 73.. Key issues and risks 1. Inability to develop partnerships and redesign services innovatively renders the Trust unable to meet the expectations of the NHS long-term plan, our strategic plan, and sustainable elective and non-elective pathways. UHS continues to actively develop partnerships across the region and work within the Integrated Care System whilst promoting value-based healthcare and delivering priorities relevant to UHS in the first year of the longterm plan. 2. Failure to deliver regulatory requirements results in license breach and loss of local control with an enforced change in leadership, impacting on Goals 1 to 6. UHS continues to monitor progress against NHSI Performance framework at committee and Board level and build capability for change by embedding quality improvement, innovation and transformation at a leadership level. 3. Failure to achieve financial targets results in a shortfall in cash required to deliver the capital programme. A robust cost improvement programme is in place, continuously monitored through governance processes with a focus on delivery of the Trust’s financial plan. 4. Reduced access to resources compromises the quality of services. We will implement the Trust Quality Improvement plan to improve safety/ experience and outcomes. 5. Capacity and capability gaps in the workforce lead to an inability to provide safe and timely care. To mitigate this risk, we will continue to develop initiatives to improve staff health and wellbeing with proactive recruitment and retention initiatives in place. Staff engagement is monitored through staff survey and leadership and development training in place. 6. Lack of inclusion and diversity results in the failure to get the best from every individual. UHS has an equality, diversity and inclusion strategy, with established Trust networks and inclusive talent management programmes. Page 15 OVERVIEW AND PERFORMANCE REPORT Performance report Going concern disclosure After making enquiries, the directors have a reasonable expectation that the Trust has adequate resources to continue in operational existence for the foreseeable future. For this reason, they continue to adopt the going concern basis in preparing the accounts. Reporting structure As a large NHS university hospital foundation trust, UHS monitors performance within individual teams throughout the year with feedback processes in place to escalate issues to more senior management teams. At a corporate level we have an established executive reporting structure. Page 16 OVERVIEW AND PERFORMANCE REPORT Monthly Trust Board Public meeting where executive directors present high level summary to chairman and non-executive directors. Audit andrisk committee Finance and Investment committee Quality Committee People & Organisational Development Committee Trust executive committee (TEC) Review performance/issues/risks in greater depth For further detail on role of these committees please refer to the annual governance statement section. Trust Board study sessions Trust Board members meet to focus on a specific issue. Performance meetings Operational management team (led by chief operating officer) and division and care group management teams focus on individual patient and service pathways to develop improvement plans. Page 17 OVERVIEW AND PERFORMANCE REPORT Key performance indicators (KPIs) The Trust publishes a monthly integrated KPI Board report on our website which provides both the Board and the public with an overview of our performance. This report is constantly evolving as new areas of monitoring are developed and new areas of national focus become apparent. The format of the monthly report follows our six strategic goals: • Improve patient journeys • Value-based health and care • Healthy lives • An expert and inclusive workforce • Being agile in meeting people’s needs • Leading edge research, education and innovation The monthly report features the following sections: • Overview – Aggregation of commentary supporting all sections of the report • Safe • Effective • Caring • Activity • Emergency access • Referral to treatment and diagnostics • Cancer waiting times • Flow • Staffing • Research and development • Estates • Digital This report also includes summary versions of quarterly reports submitted to the Trust executive committee, which go into greater detail about patient experience, patient safety, clinical effectiveness outcomes, and infection prevention. In addition, a separate finance Board report is submitted to Trust Board on a monthly basis. The Emergency Access, Activity and Flow section has several KPIs that are relevant to the key risk of delivering the national access target. Some of the KPIs are: • Number of attendances • Time to initial assessment • Delayed transfers of care • Non-elective length of stay The Activity and Flow sections have several KPIs that are relevant to the key risk of capacity and occupancy. Some of the KPIs are: • Length of stay • New referrals • Number of attendances • Bed occupancy The Staffing (HR) section has several KPIs that are relevant to the key risk of Staffing. Some of the KPIs are: • Staff turnover • Nursing vacancies • Friends and Family Test – percentage of staff who recommend UHS as a place to work You can see full copies of the monthly report by visiting www.uhs.nhs.uk Page 18 OVERVIEW AND PERFORMANCE REPORT How we monitor performance In addition to reviewing the data submitted to the Trust Board in these papers, we have a suite of tools available to compare UHS performance to that of comparable trusts around the country. Depending on the measures being monitored, UHS has a number of peer groups to benchmark against, including other local providers, major trauma centres and university hospital teaching trusts. Each NHS trust will service a different size and type of population and will offer a slightly different range of services so it is important to understand that this benchmarking provides an initial indication of performance rather than an absolute guide to our position nationally. In 2020/21 we continue to review the National Model Hospital data as it is published from NHS Improvement. The data and ability to compare our performance has helped to highlight areas of excellent practice and areas where there is potential to improve. The Trust is engaging with the model hospital team and has a member of staff on the ‘model hospital ambassador program’, as well as reviewing areas highlighted as having potential opportunities alongside finance and operational teams. Overview of performance Improving patient journeys 2019/20 was a challenging year in which we made only modest progress against some objectives to ‘Improve Patient Journeys’, and deteriorated in performance against others. • Inpatient length of stay remained stable but didn’t reduce as significantly as we had intended. The percentage of bed days used due to ‘Delayed Transfers of Care’ to other settings increased to nearly twice the national target. This, combined with growth in non-elective admissions (2.8% YTD excluding M12), resulted in occupancy rates which often exceeded our target, and an increase in patients cared for as ‘outliers’ away from their own speciality wards. • Emergency Access Performance (patients spending less than four hours in the emergency department) remained below both the national and local targets, though performance did show modest improvement during the year. There has been a further substantial increase in the volume of emergency department attendances. • The number of ‘elective’ patients waiting for treatment, the percentage of patients waiting within 18 weeks, and also the waiting time for first outpatient appointments, deteriorated significantly during the year. This has, in part, been impacted upon by reduced availability of clinical capacity due to staff concerns about the impact of new pension/tax regulations. There are, however, good indications that service changes are being implemented to increase consultation capacity in an efficient way as we had aimed to. There has been a substantial increase in consultations provided through ‘non-face-to-face’ routes, and a small decrease in the number of more traditional face-to-face consultations. • Urgent GP referrals for suspected cancer seen within two weeks saw a substantial and sustained improvement compared to the previous year, exceeding that target. • Performance against treatment within 62 days measures also demonstrated modest improvement during the year. Significant improvement in cancer performance continues to be required in order for UHS to deliver the national targets for timeliness of treatment. Page 19 OVERVIEW AND PERFORMANCE REPORT Delivering value-based healthcare • Complaints about UHS care have remained low, with the percentage of complaints ‘closed’ within 35 days above target for the first 11 months of 2019/2020. • Pleasingly, the availability of nursing care to our inpatients (expressed as care hours per patient per day) has increased progressively through the year from 8.6 to 8.9. An active overseas nursing recruitment and induction process has supplemented domestic recruitment and training. • The Trust has formed a 50/50 joint venture company with Hampshire Hospitals NHS Foundation Trust called Wessex NHS Procurement Limited (WPL). From 1 December 2019, WPL is providing procurement, supply chain and materials management services to the Trust. The objectives of this innovative partnership include the consolidation of supplies purchases for both Trusts (combined revenue £1.4bn) to leverage better prices from suppliers and increased productivity through the elimination of previously duplicated procurement activity. Supporting healthy lives • There was very good performance on the Hospital Standardised Mortality Ratio. The standard is 100 and we are consistently below this (83 in December, results are reported nationally retrospectively). This measure includes all patients in England with the same condition and compares those who have died with those that have survived. Being below 100 is a strong indicator of good care. • We continue to receive feedback, which is largely positive, through the national ‘Friends and Family’ survey for both our inpatient and maternity care. • The Board monitors a range of quality indicators. Of these, exceeding the target number of patients infected with clostridium difficile by six is of some concern, we are pleased that the number of severe/moderate medication errors has been maintained well below our target level, and following an increase in the number of Serious Incidents Requiring Investigation (SIRI) that were reported to Board in the early part of the year both the number of SIRIs has reduced and the timeliness of investigation has significantly improved. • Staff sickness levels were on target through the summer months, but significantly in excess of this through the winter months. As a whole, this is a cause for some concern. Building an expert and inclusive workforce • Very pleasingly, nursing vacancies were reduced significantly during the year, from 18% to 15%. Though still a challenge, this supports increases in the treatment capacity we can make available in the Trust, in our ability to open additional bed capacity to reduce our inpatient occupancy rates, and increases the care hours provided per patient per day. • Turnover rates have been in excess of our target throughout the year and there has also been a reduction in the percentage of staff who would recommend UHS as a place to work, though we remain above our target of 76%. The percentage of non-medical appraisals taking place within 12 months remains below target and is declining. • We have made steady progress this year towards our target of 15% of staff at Band 7 and above being from Black and Minority Ethnic backgrounds by 2023 (above 9% in March 2020). Being agile in meeting people’s needs • 2019/2020 has seen further progress in the implementation of digital tools that enable patients and clinicians to review and discuss patient specific clinical information in new ways, for example, large increases in usage of ‘My Medical Record’ and ‘digi-rounds’, modest further progress in electronic requesting and acknowledgement of tests, and stable usage of other tools. Page 20 OVERVIEW AND PERFORMANCE REPORT Leading edge research, education and innovation • The majority of recruitment targets have been achieved during 2019/20. • In Q4 UHS ranked 13th for contract commercial study recruitment, which is the same position achieved in the previous year and thus did not achieve our target of Top 10, with a constraint on pharmacy research capacity being a contributing factor. • The proportion of commercial studies closing in the 2019/20 financial year on time and to recruitment target ended the year below the 80% target at 68%, though the year-end target for the proportion of non-commercial studies closing on time and to recruitment target was exceeded at 88% compared to 80% target. Details of UHS performance can be found in the Integrated Performance report which is available in the Trust Board papers section of our website www.uhs.nhs.uk. UHS performance is scrutinised by the Board on a monthly basis. Paula Head, chief executive officer 22 June 2020 Regulatory body ratings Single Oversight Framework NHS Improvement’s Single Oversight Framework provides the framework for overseeing providers and identifying potential support needs. The framework looks at five themes: 1. Quality of care 2. Finance and use of resources 3. Operational performance 4. Strategic change 5. Leadership and improvement capability (well-led) Based on information from these themes, providers are segmented from one to four where ‘4’ reflects providers receiving the most support, and ‘1’ reflects providers with maximum autonomy. A foundation trust will only be in segments three or four where it has been found to be in breach or suspected breach of its licence. Segmentation During 2019/20 the Trust was confirmed as being placed within segment ‘2’. This segmentation information is the Trust’s position as at 31 March 2020. Current segmentation information for NHS trusts and foundation trusts is published on the NHS Improvement website. Finance and use of resources The finance and use of resources theme is based on the scoring of five measures from ‘1’ to ‘4’, where ‘1’ reflects the strongest performance. These scores are then weighted to give an overall score. Given that finance and use of resources is only one of the five themes feeding into the Single Oversight Framework, the segmentation of the Trust disclosed above might not be the same as the overall finance score here. The Trust was on track to deliver a use of resources score of ‘2’. However, as a direct result of COVID-19 our staff were unable to take their full complement of annual leave. The Trust was required Page 21 OVERVIEW AND PERFORMANCE REPORT to allow for this additional cost, which was an unfunded cost pressure allowable by NHS Improvement. This had the impact of moving the distance from financial plan score to a ‘4’ and subsequently the overall use of resources score to a ‘3’. Area Financial sustainability Financial sustainability Financial sustainability Overall scoring Metric Capital service cover Liquidity Income and expenditure margin Distance from financial plan Agency spend Q1 Q2 Q3 Q4 Year 3 3 2 2 2 1 1 1 1 1 3 1 1 1 1 1 1 2 4 4 1 1 1 1 1 2 1 2 3 3 Care Quality Commission ratings: Overall rating for this trust Are services at this trust safe? Are services at this trust effective? Are services at this trust caring? Are services at this trust responsive? Are services at this trust well-led? Good Requires improvement Outstanding Good Requires improvement Good In December 2018, the CQC inspected four core services; urgent and emergency care, medicine, maternity and outpatients. It also looked at management and leadership, and effective and efficient use of resources. The CQC report (published on the 17 April 2019) rated the Trust as ‘good’ overall and ‘outstanding’ for providing effective services. All sites and services across the organisation are now rated as ‘good’ in the effective and caring domains, with Southampton General Hospital rated as ‘outstanding’ in these areas. The Well-Led section of this report provides further details of the inspectors’ findings. “Our inspectors found a strong patient-centred culture with staff committed to keeping their people safe, and encouraging them to be independent. Patients’ needs came first and staff worked hard to deliver the best possible care with compassion and respect. Inspectors saw many areas of outstanding practice, with care delivered by compassionate and knowledgeable staff. Several teams led by example with a continuous focus on quality improvement. The Trust did face some challenges especially with the ageing estates. Some patient environments were showing significant signs of wear and tear – but again staff were doing their utmost to deliver compassionate care”. Dr Nigel Acheson Deputy chief inspector of hospitals (South) Page 22 OVERVIEW AND PERFORMANCE REPORT Environmental matters We recognise that the Trust’s business has an impact on the environment. As a large hospital, we undertake a wide range of activities and use a large amount of resources. We are committed to environmental sustainability and consider it as part of the business culture. We continue to invest in energy saving initiatives and staff awareness campaigns that focus on promoting sustainability. We acknowledge that reducing waste and minimising the consumption of scarce resources is consistent with financial sustainability. Our sustainability disclosure section on pages 86 and 95 provides greater detail on the steps we are taking to reduce our activities’ impact on the environment. Social, community, anti-bribery and human rights issues We recognise our responsibilities under the European Convention on Human Rights (included in the Human Rights Act 1998 in the UK), which are relevant to health and social care. These rights include the: • right to life • right not to be subjected to torture, inhuman or degrading treatment or punishment • right to liberty • right to respect for private and family life The Trust is committed to ensuring it fully takes into account all aspects of human rights in our work. At University Hospital Southampton we value our reputation for top quality care and financial probity and conduct our business in an ethical manner. The Bribery Act 2010 was introduced to make it easier to tackle the issue of bribery which is a damaging practice. Bribery can be defined as ‘giving someone a financial or other advantage to encourage them to perform their duties improperly or reward them for having done so’. To limit our exposure to bribery we have in place an Anti-Fraud, Bribery and Corruption Policy, a Standards of Business Conduct Policy and a Freedom to Speak Up (formerly Raising Concerns) Policy. These apply to all staff and to individuals and organisations who act on behalf of UHS. We also employ a local counter-fraud specialist who will investigate, as appropriate, any allegations of fraud, bribery or corruption. The success of our anti-bribery approach depends on our staff playing their part in helping to detect and eradicate bribery. Therefore, we encourage staff, service users and others associated with UHS to report any suspicions of bribery and we will rigorously investigate any allegations. In addition, we hold a register of interest for directors, staff, and governors, and ask staff not to accept gifts or hospitality that will compromise them or the Trust. The Board of Directors carries out its business in an open and transparent way. We are committed to the prevention of bribery as well as to combating fraud, and expect the organisations we work with to do the same. Doing business in this way enables us to reassure our patients, members and stakeholders that public funds are properly safeguarded. There are no important events since the year end affecting the Foundation Trust. No political donations have been made. The Trust has no overseas branches. Page 23 OVERVIEW AND PERFORMANCE REPORT Page 24 ACCOUNTABILITY REPORT Members of the Trust Board Board member Name Title Paula Head Chief executive officer David French Deputy chief executive officer and chief financial officer Gail Byrne Director of nursing and organisational development Biography Paula joined the Trust as chief executive in September 2018, having been chief executive at the Royal Surrey County NHS Foundation Trust in Guildford and before that at Sussex Community NHS Foundation Trust. She began her career as a pharmacist working in the community, in hospitals and at health authorities before moving into general management and her first board position at Kingston Hospital. Since then she has spent time on the boards of commissioners and providers, including director of transformation at Frimley Park Hospital NHS FT. Paula lives in Hampshire and has a daughter studying medicine at the University of Southampton. David joined the Trust in February 2016 and served as interim chief executive officer from April to September 2018. He read Economics and Social Policy at the University of London before joining ICI plc, where he qualified as a chartered management accountant. David has extensive healthcare experience from the pharmaceutical industry, mostly Eli Lilly and Company where he held many commercial and financial roles in the UK and overseas. He joined the NHS in 2010 as chief financial officer of Hampshire Hospitals NHS Foundation Trust. He also serves as a non-executive director for Vivid Housing Limited, a social housing provider across Hampshire and the Solent. Gail joined the Trust in 2010 as deputy director of nursing and head of patient safety. Prior to this, she has worked at the Strategic Health Authority as head of patient safety, and director of clinical services at Portsmouth Hospital. Gail has also worked in Brisbane, Australia as a hospital Macmillan nurse, and as general manager of a special purpose vehicle company for the private finance initiative at South Manchester Hospitals. Declarations Daughter is a medical student at University of Southampton; Member of Hampshire & Isle of Wight Sustainability and Transformation Partnership Executive Delivery Group Non-executive director and chair of audit and risk committee, Vivid Housing Limited; Director, UHS Estates Limited, a wholly-owned subsidiary of UHSFT; Director, Southampton Commercial Estates Development Partnership (CEDP) Project Company Limited, a joint-venture company owned 50/50 by UHSFT and Prime plc; Member of Hampshire & Isle of Wight Counter Fraud Board; Member of Hampshire & Isle of Wight Sustainability and Transformation Partnership Capital Planning Panel; Director of Wessex NHS Procurement Limited (WPL), a joint venture company owned 50/50 by UHSFT and Hampshire Hospitals NHS Foundation Trust (from December 2019) Husband is a consultant surgeon at UHS; Daughter is a midwife at UHS (from March 2019) Dr Derek Sandeman Joe Teape Medical director Chief operating officer Derek was appointed to the Trust as a consultant physician in 1993 and went on to develop a regional Director of UHS Pharmacy Limited, endocrine service. Throughout his career he has had a wholly-owned subsidiary of extensive clinical leadership experience, most recently serving eight years as clinical director. Derek’s leadership roles have also included programme director for postgraduate education and the Wessex Endocrine Royal College representative. He has a strong history of wider system engagement, working collaboratively with partners to improve systems resilience and pathways. UHSFT; Member of Hampshire & Isle of Wight Sustainability and Transformation Partnership Clinical Executive Group Joe joined the Trust as chief operating officer in December Nil 2019. Previously he was deputy chief executive and director of operations of a large health board in Wales which managed integrated services across three counties including four district general hospitals as well as mental health, learning disability and community services. Prior to this, Joe worked in director roles across finance and strategy within provider acute trusts across the south west of England. Joe is passionate about providing leadership and support for all staff, whatever their profession, and contributing to excellent patient care. He is committed to open and ongoing engagement with the general public and often uses social media to engage with colleagues and with those who have an interest in healthcare. Page 25 ACCOUNTABILITY REPORT Non-executive directors Name Title Peter Hollins Chair Dr Tim Peachey Non-executive director David Bennett Non-executive director Biography Declarations Peter graduated in chemistry from Hertford College, Chair of CLIC Sargent Cancer Care Oxford. Joining Imperial Chemical Industries in 1973, for Children (a company limited by he undertook a series of increasingly senior roles in guarantee) (until December 2019); marketing and then general management. Following Council member of University of three years in the Netherlands as general manager of Southampton ICI Resins BV, he was appointed in 1992 as chief operating officer of EVC in Brussels – a joint venture between ICI and Enichem of Italy. He played a key role in the flotation of the company in 1994, returning in 1998 to the UK as chief executive officer of British Energy where he remained until 2001. From 2001, he held various chairmanships and non- executive directorships. In 2003, he decided to return to an executive role as chief executive of the British Heart Foundation in which post he remained until retirement in March 2013. He joined Southampton University Hospital Trust as a non- executive director in 2010, became senior independent director and deputy chairman of UHS in 2014, and was appointed chair in April 2016. Tim qualified as a doctor from Kings College Hospital Director, TP Medcon Ltd; Clinical School of Medicine in 1983. For nearly 20 years, he Safety Officer, Block Solutions Ltd; worked as a consultant anaesthetist at the Royal Free Non-executive director and Quality Hospital in London, specialising in pancreatic cancer Committee chair, Isle of Wight NHS surgery, liver surgery and liver transplantation. He also Trust developed an interest in medical leadership and management and has held positions such as clinical director, divisional director and medical director at the Royal Free. In 2012, Tim moved into full-time management as chief executive of Barnet and Chase Farm Hospitals NHS Trust until its acquisition by the Royal Free. He then worked as the London associate medical director at the NHS Trust Development Authority before moving to Barts Health NHS Trust as improvement director and subsequently became deputy chief executive. Tim now holds two NHS non-executive posts. In addition to his role at University Hospital Southampton, Tim also serves on the board for Isle of Wight NHS Trust as deputy chair. He is a practicing mediator specialising in the healthcare sector. He also consults for companies in the medical information technology industry. Dave graduated in chemistry from the University of Director, Davox Consulting Limited; Southampton before entering management consulting, Non-executive director, Faculty of becoming a partner in Accenture’s strategy practice. Leadership and Medical In 2003 he joined Exel Logistics (later bought by DHL), Management (from November managing the company’s healthcare business across 2019); Director Royal College of Europe and the Middle East. During this time, he General Practitioners (RCGP) established NHS Supply Chain, a UK organisation Enterprises Ltd and RGCP responsible for procuring and delivering medical Conferences Ltd (from November consumables for the NHS in England, as well as sourcing 2019) capital equipment. Dave joined the board of Cable & Wireless as sales director in 2008. He later set up his own strategy consulting practice serving the healthcare sector, completing numerous projects in the UK and the US. Dave has also served as a non-executive director at The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust between 2009 and 2016. He chaired the Trust’s quality committee. Page 26 ACCOUNTABILITY REPORT Board member Name Title Jenni DouglasTodd Senior independent director/deputy chair (from 01/02/2020) Biography Jenni is a former chief executive of Hampshire Police Authority and the office of the Hampshire police and crime commissioner. After beginning her career in the probation service, she was headhunted into the civil service, at the Home Office, where she spent four years before becoming director of policy and research for the Independent Police Complaints Commission. In the latter role she was responsible for establishing governance of the new police complaints system. She then spent two and a half years as a resident twinning adviser for the UK, based in Turkey to help set up a law enforcement complaints system before taking up the role of chief executive of the county’s police authority. During her three years in the post, she supported the authority in developing effective governance processes to increase accountability and transparency. She also helped the organisation deliver cost-savings whilst still improving performance and developing closer working relations with neighbouring forces. Declarations Independent chair, Dorset Integrated Care System. Managing director, Diversa Consultancy Limited; Member of the Judicial Conduct Investigative Office; Nonexecutive director, Hampshire Cricket Board; Trustee, NACRO; Member of English Cricket Board’s Regulatory Committee. Professor Non-executive Cyrus director Cooper In 2012, she became chief executive and monitoring officer for the Hampshire police and crime commissioner, where she led the development of the office’s vision, mission, values and organisational strategy. She took on the role of investigating committee chair for the General Dental Council in 2014 and, in April that year, founded the Diversa Consultancy, which supports organisations with changes in business, culture and behaviour. She is also a member of the Judicial Conduct Investigating Office, a public appointment. Cyrus Cooper is professor of rheumatology and director of the MRC Lifecourse Epidemiology Unit. He’s also vicedean of the faculty of medicine at the University of Southampton and professor of epidemiology at the Nuffield Department of Orthopaedics (rheumatology and musculoskeletal sciences, University of Oxford). He leads an internationally competitive programme of research into the epidemiology of musculoskeletal disorders, most notably osteoporosis. His key research contributions have been: • discovery of the developmental influences which contribute to the risk of osteoporosis and hip fracture in late adulthood • demonstration that maternal vitamin D insufficiency is associated with sub-optimal bone mineral accrual in childhood • characterisation of the definition and incidence rates of vertebral fractures • leadership of large pragmatic randomised controlled trials of calcium and vitamin D supplementation in the elderly as immediate preventative strategies against hip fracture. Director and professor of rheumatology, Medical Research Council (MRC) Lifecourse Epidemiology Unit; Vice-D
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Papers CoG 29.04.2025 v2

Description: Date Time Location Chair Agenda Council of Governors 29/04/2025 14:00 - 15:45 Conference Room, Heartbeat/Microsoft Teams Jenni Douglas-Todd 1 Chair’s Welcome and Opening Comments 14:00 2 Declarations of Interest 14:04 3 Minutes of Previous Meeting 14:05 Approve the minutes of the previous meeting held on 29 January 2025 4 Matters Arising/Summary of Agreed Actions 14:06 5 Strategy, Quality and Performance 5.1 Chief Executive Officer's Performance Report 14:07 Receive and note the report Sponsor: David French, Chief Executive Officer Attendee: Gail Byrne, Chief Nursing Officer 5.2 Annual Report and Quality Accounts Timetable 2024/25 14:27 Note the timetable Sponsor: David French, Chief Executive Officer Attendee: Karen Russell, Council of Governors Business Manager 5.3 Draft Quality Accounts 2024/25 14:32 Review and feedback Sponsor: Gail Byrne, Chief Nursing Officer Attendee: Helena Blake, Head of Clinical Quality Assurance 5.4 Corporate Objectives 14:42 Review and feedback Sponsor: David French, Chief Executive Officer Attendee: Kelly Kent, Head of Strategy and Partnerships 5.5 Non-NHS Activity 14:52 Receive and note the update Sponsor: Ian Howard, Chief Financial Officer Attendee: Pete Baker, Commercial and Enterprise Director 5.6 Break 15:02 6 Governance 6.1 Governor Attendance at Council of Governors' Meetings 15:12 Review governor attendance at Council of Governors' meetings Sponsor: Jenni Douglas-Todd, Trust Chair Attendee: Karen Russell, Council of Governors' Business Manager 6.2 Council of Governors' Elections 2025 15:17 Note the timetable Sponsor: Jenni Douglas-Todd, Trust Chair Attendee: Karen Russell, Council of Governors' Business Manager 6.3 Appointment to the GNC 15:19 Sponsor: Jenni Douglas-Todd, Trust Chair Attendee: Karen Russell, Council of Governors' Business Manager 7 Membership Engagement and Governor Activity 7.1 Membership Engagement 15:21 Receive the report Sponsor: Jenni Douglas-Todd, Trust Chair Attendee: Sam Dolton, Events and Membership Officer 7.2 Governors' Nomination Committee Feedback 15:31 Chair: Jenni Douglas-Todd, Trust Chair 8 Review of Meeting 15:36 Review and feedback on the content of this meeting Sponsor: Jenni Douglas-Todd, Trust Chair 9 Any Other Business 15:41 Raise any relevant or urgent matters that are not on the agenda 10 Date of Next Meeting: 16 July 2025 15:44 Note the date of the next meeting Page 2 Minutes - Council of Governors (CoG) Open Session Date Time Location Chair Present 29 January 2025 14.00-15.30 Conference Room, Heartbeat Education Centre and Microsoft Teams Jenni Douglas-Todd, Trust Chair Jenni Douglas-Todd, Trust Chair Shirley Anderson, Elected, New Forest, Eastleigh and Test Valley Theresa Airiemiokhale, Elected, Southampton City Katherine Barbour, Elected, Southampton City Patricia Crates, Elected, New Forest, Eastleigh and Test Valley Sandra Gidley, Elected, New Forest, Eastleigh and Test Valley Lesley Gilder, Elected, Southampton City Ben Grassby, Elected, Rest of England and Wales Linda Hebdige, Elected, Southampton City Councillor Pam Kenny, Appointed, Southampton City Council Professor Sue Latter, Appointed, University of Southampton Jenny Lawrie, Elected, Southampton City Brian Lovell, Elected, Rest of England and Wales Councillor Louise Parker-Jones, Appointed, Hampshire County Council Cat Rushworth, Elected, Isle of Wight Karen Smith-Baker, Elected, Health Professional and Health Scientist Staff Jake Smokcum, Elected, Nursing and Midwifery Staff Mike Williams, Elected, New Forest, Eastleigh and Test Valley JDT SA TA KB PC SG LG BG LH PK SL JL BL LPJ CR KSB JS MW In attendance Tracey Burt, Minutes TB Sam Dolton, Events and Membership Officer SD David French, Chief Executive Officer (for item 5.1) DF Steve Harris, Chief People Officer (for item 6.1) SHa Craig Machell, Associate Director of Corporate Affairs and CM Company Secretary Karen Russell, Council of Governors’ Business Manager KR Apologies Professor Cathy Barnes, Appointed, Solent University CB Sathish Harinarayanan, Elected, Medical Practitioners and Dental SH Staff Esther O’Sullivan, Elected, New Forest, Eastleigh and Test Valley EO Liz Taylor, Elected, Non-Clinical and Support Staff LT 1 Chair’s Welcome and Opening Comments The Chair welcomed everyone to the meeting and in particular, BG and SL, who were attending their first CoG, although they had attended the strategy day at the end of last year. 1 2 Declarations of Interest There were no new declarations of interest relating to matters on the agenda. 3 Minutes of Previous Meeting The minutes of the meeting held on 23 October 2024 were approved as an accurate record of the meeting. 4 Matters Arising/Summary of Agreed Actions All actions had been completed. 5 Strategy, Quality and Performance 5.1 Chief Executive Officer’s Performance Report The Chair welcomed DAF who joined the meeting to present the performance report. He highlighted the following from the report and commented on various national issues:- • the Trust had been under significant pressure related to urgent and emergency care. Whilst this was also a national problem, attendances at the UHS Emergency Department had been higher than last year, averaging 448 patients a day. During the Christmas period, attendances and admissions had been exacerbated by Covid-19 and flu. Various Trusts had declared critical incidents but UHS had not, although it had been close to doing so. • pressure on the Emergency Department had eased slightly in January but during the last week it had increased again. At midnight on 27 January 2025 there had been 150 patients in the department, which was double the normal capacity. • infection prevention was a greater challenge when the hospital was under intense pressure but the Trust was focussed on it. • the Trust had seen an increase in Never Events. A theme related to invasive procedures and missed opportunities to stop, before procedures had started, had been identified. A plan to mitigate such events had been put in place and the Trust would implement the National Safety Standards for Invasive Procedures (NatSSIPs). • the Trust’s referral to treatment (RTT) waiting list had remained above 60,000 in quarter three. 62% of patients on the waiting list had been waiting less than 18 weeks, which meant that UHS was in the top quartile when compared to peer teaching hospitals. • UHS had delivered elective recovery fund activity (ERF) at 128% of 2019/20 levels, which was 15% above the Trust’s target. • the physical capacity of the UHS estate continued to be a challenge. • the funding mechanism related to how ERF money was paid, continued to be a challenge for the Trust. It was hoped that national planning guidance, due out on 30 January 2025, would provide clarity. • the annual staff survey had now closed and the Trust was beginning to receive initial results. These would be shared in due course. • there had been a slight increase in staff sickness absence, largely due to Covid-19 and flu. • the Trust had a significant financial deficit and needed to get back to breakeven. 2025/26 was likely to be another difficult year and it was known that three national priorities would be safe emergency care, reductions in the elective waiting list and the need for Trusts to live within their means. BL queried whether the Trust had done everything it could, in terms of its financial situation. DAF advised that UHS had recently received productivity benchmarking data, which showed that it was fourth in the country, when compared to others, so the Trust was struggling to see what it could do better. 2 SG queried whether all activity for 2025/26 had been capped. DAF advised that new operations and elective outpatient procedures were presently paid for on a price per unit basis, whilst almost everything else was on a block contract. UHS was generally doing more activity than the block assumed and it was likely that elective activity would also be capped next year. The Trust may, therefore, need to consider pulling back on the things that added the least value. CR noted that people were generally living longer and asked whether that was being considered, from a financial perspective. DAF advised that UHS would always support clinical decisions, regardless of a patient’s age. The Chair thanked DAF for attending CoG. 6 Governance 6.1 Chair and Non-Executive Director Appraisal Process The Chair welcomed SHa to the meeting and noted that as a Foundation Trust, UHS was required to conduct a robust appraisal process. The process started in January and would conclude in April. The governors had a vital role in providing feedback on the work of the Non-Executive Directors (NEDs) and system partners would also be asked to provide feedback on the Chair. The Chair would conduct the NEDs appraisals and Jane Harwood, Senior Independent Director (SID) would undertake the Chair’s appraisal. SHa advised that NHS England was due to launch a new appraisal process, nationally, for NEDs but it was still outstanding. However, a refreshed appraisal process for Chairs had been released in 2024. SA noted that governors often found it difficult to provide feedback on the NEDs and advised that she had some helpful tips to share with them, at the end of the CoG meeting. Decision: The CoG approved the Chair and NED appraisal process for 2024/25. 6.2 Audit and Risk Committee Terms of Reference CM advised that the Audit and Risk Committee had carried out the annual review of its Terms of Reference and two minor amendments had been proposed: • to amend 10.2 to Code of Governance for NHS Provider Trusts. • to remove Charitable Funds Committee from Appendix A. Decision: the CoG supported the proposed changes to the Audit and Risk Committee Terms of Reference. 6.3 Governors’ Nomination Committee Terms of Reference CM advised that the Governors’ Nomination Committee had reviewed its Terms of Reference on the 15 January 2025 and the CoG was asked to approve the removal of the words “deputy chair” from paragraph 3.2. Decision: the CoG approved the proposed, minor change, to paragraph 3.2. 6.4 Council of Governors’ Annual Business Plan 2025/26 KR advised that each year the CoG was required to review its Annual Business Plan for the coming financial year. Decision: the CoG approved its Annual Business Plan for 2025/26. 3 6.5 Non-Executive Director Appointment The Chair reminded the CoG that at its meeting on 15 April 2024 it had approved the appointment of David Liverseidge as a NED, for a three-year term. However, due to his position at Ramsay Health Care UK and the potential conflict of interest, it had been agreed to delay his appointment until his retirement at the end of 2024. The CoG was therefore asked to note that following completion of the Fit and Proper Persons checks and declaration processes, his appointment as a NED had commenced on 1 January 2025. 6.6 Governor Attendance at Council of Governors’ Meetings KR introduced the report and advised that if a governor failed to attend two successive meetings of the CoG, their appointment would be terminated unless the absences were due to reasonable cause. The Chair, CM or KR would contact the governor, to understand the reasons and would then provide confirmation to the CoG that the causes were reasonable. BL said that he would find it difficult to approve the continued tenure of a governor, if he did not know the reasons for their absence. The Chair clarified that the CoG would be asked to confirm that it was satisfied the Chair or Company Secretary had followed the process, rather than be asked to approve the reasons for any absence. SG queried what was meant by a “reasonable period” and the Chair advised that it would depend on the circumstances, which would be discussed with the individual governor. Action: It was agreed that CM and KR would review the constitution to check whether any amendments to the wording were needed. 7 Membership Engagement and Governor Activity 7.1 Membership Engagement SD introduced the Membership Engagement report and highlighted the following:- • the monthly newsletters continued to keep members updated. • the quarterly Connect digital magazines had been sent out in November 2024 and January 2025. There had been an emphasis on health inequalities in the community, in the latter edition. • the open evening and annual members’ meeting had been held, in person, at UHS in November 2024. It had not been as well attended as he would have hoped (it had snowed that day) and going forward, ways to maximise attendance would be considered. However, there had been positive feedback from those who had attended. • during December 2024 a virtual event, focused on healthy ageing, had been held. He encouraged governors to register for the forthcoming virtual event on cancer research. • due to the extreme pressures on the hospital, the team had actively used social media channels to remind people of the alternatives available, rather than attending the emergency department. • the opening of Woodland Ward, special care baby unit at the Princess Anne Hospital, had featured in the quarterly update. • the continued production of the monthly updates and the Spring edition of the Connect quarterly digital magazine were priorities for the team. 4 • attendance at external events (e.g. the Mela Festival) and opportunities to collaborate with other teams, were being planned and governors were encouraged to offer their support. Governors made the following comments:• it was helpful to have an engaging activity available at external events, as these helped to draw people in. • whether it would be appropriate to attend the Southampton marathon, which attracted a large number of people. SD advised that the team had attended in the past but had not found it the ideal event to have conversations with people. He would, however, contact the hospital charity, to see whether there was information that could be handed out. • SL suggested that she and SD discuss ways to recruit students as members. The Chair thanked SD for his informative report. 7.2 Governors’ Nomination Committee Feedback The Chair advised that the Governors’ Nomination Committee had met on the 15 January. It had undertaken the annual review of its Terms of Reference and had looked at the appraisal process for the Chair and NEDs. It had also noted the commencement of David Liverseidge as a NED. 8 Review of Meeting The governors said that they had found the meeting very informative, with the right level of information provided. 9 Any Other Business The following were mentioned by governors:- • the increased aggression towards staff was noted and the Chair advised that greater detail would be available once the annual staff survey results were available. • KB advised that she had visited Heartbeat House (on the edge of the UHS site) where friends and relatives of patients undergoing cardiac surgery could stay. A coffee morning was held every Tuesday morning in Heartbeat House and KB encouraged governors to attend, as it provided a good opportunity to meet members of the public. She also raised awareness of the Heart & Stroll event being held on 29 June 2025 to raise funds towards the renovation of the Heart Failure Unit at UHS. • CM advised that due to changes in the Hampshire and Isle of Wight Integrated Care Board (ICB) and a possible conflict of interest, the ICB did not intend to replace Helen Eggleton, who had previously represented them as a governor on the CoG. It was therefore proposed to reduce the number of governors to 21, which would require the constitution to be amended. The CoG expressed its disappointment at the ICB’s decision and the Chair agreed to discuss the decision, when she next met with the Chair of the ICB. • the Chair advised that with effect from 11th March, all UHS Trust Board meetings would be held in person. A hybrid option would, however, still be available for the CoG meetings. • the Chair asked governors to ensure that they advised KR of any board committees they wished to attend, at least a week in advance. This would enable KR to liaise with the committee Chair, to ensure that it was appropriate for a governor to attend. 10 Date of Next Meeting The next meeting of the CoG would be held on 29 April 2025. 5 List of action items Agenda item Assigned to Deadline Status Council of Governors 29/01/2025 6.6 Governor Attendance at Council of Governors’ Meetings 1199 Governor Attendance at Council of Governors’ Meetings . Machell, Craig Russell, Karen 29/04/2025 Completed Explanation action item Under the Trust’s constitution if a governor failed to attend two successive meetings of the council of governors, his or her tenure of office is to be immediately terminated by the CoG unless the CoG is satisfied that the absences were due to reasonable cause; and he/she will be able to attend meetings of the CoG within such a period as the CoG considers reasonable. The CoG was happy to confirm it was satisfied that the correct process had been carried out but could not comment on the reasons for absence or their ability to attend future meetings within a reasonable period of time, as these had been a confidential part of the discussion with the governor. CM and KR agreed to look at the Trust's constitution to establish if an amendment was required to the wording regarding this. Explanation Russell, Karen The wording in the constitution relating to this issue requires amendment and this will be carried out when the Trust's constitution is reviewed during 2025/26. In the meantime, the wording in future papers relating to governor attendance at CoG meetings will be adjusted accordingly. Item 5.1 Report to the Council of Governors - 29 April 2025 Title: Chief Executive Officer’s Performance Report Sponsor: David French, Chief Executive Officer Author: Sam Dale, Associate Director of Data and Analytics Purpose (type an ‘x’ in the appropriate box(es)) (Re)Assurance Approval Ratification Information x Strategic Theme (type an ‘x’ in the appropriate box(es)) Outstanding patient Pioneering research World class people outcomes, safety and innovation and experience Integrated networks and collaboration Foundations for the future x x x Executive Summary: Information about Trust performance supports the Council of Governors in their role. This report is intended to inform the Council of Governors about aspects of the Trust’s performance. Contents: The Chief Executive Officer’s Performance Report is attached. Risk(s): N/A Equality Impact Consideration: N/A UHS Council of Governors April 2025 Chief Executive’s Performance Report 1. Purpose and Context The purpose of this report is to summarise the Trust’s performance against a range of key indicators. Where available, this report covers data from the period January to March 2025, noting that some performance data is reported further in arrears and therefore unavailable. As the organisation transitions to the national 25/26 NHS priorities, notable features of 24/25 quarter four include: • The financial position of the organisation remains extremely challenging as the trust prioritises the national request to live within its means despite restrictions on funding for emergency activity and elective growth. • Despite the economic challenges, the organisation continues to benchmark well for productivity measures including theatre utilisation and length of stay whilst recognising there remains an opportunity to go further. • The waiting list continued to grow in quarter four, however the trust has maintained performance on 18 week targets and reduced the volume of patients waiting over 65 weeks to a small cohort of services. • The organisation has maintained robust performance on cancer and diagnostic waiting times and anticipates that the validated year end position will place the organisation in the top quartile compared to peer organisations. • The volume of patients with no criteria to reside remains above 200 per day which continues to place a barrier on our bed availability. • The trust ranking for recommendation as a place to work has improved four places placing UHS at 18th out of 122 trusts. 2. Safety Infection Control Clostridium Difficile infection MRSA Bacterium infection Target 78.0% January 2025 39 35 74 70 40 24 33 7 0 January 2025 63.9% February 2025 44 12 56 46 33 19 27 5 0 February 2025 57.4% March 2025 54 25 79 59 43 25 36 2 0 March 2025 60.1% Performance against the emergency access target continues to be challenging with attendances growing by 3.2% compared to the previous financial year. In March 2025, 60.1% of patients spent less than four hours in the department which places the trust in the third quartile when compared to peer teaching hospitals. There is significant focus on improving this, with the plan based on two areas; improving decision making speed within the Emergency Department and improving timely flow from the department when patients need admission. The former is looking at consistency of practice, speciality in-reach into the department, and ensuring rotas reflect known peaks in attendance. The latter is looking at enhanced access, and increased pathways, to same day emergency care, flow and discharge throughout the hospital and embedding internal professional standards. Referral to Treatment (RTT) Target January 2025 % incomplete pathways within 18 weeks in month Total patients on a waiting list => 92% 62.0% 60,910 February 2025 61.5% 61,333 March 2025 62.5% 61,686 Whilst the trust continues to deliver more elective activity year on year, the RTT (referral to treatment) waiting list has continued to climb in each month of quarter four peaking at 61,686 at the end of the financial year. Despite this the organisation has maintained performance of 62% for the percentage of patients on the waiting list who are below 18 weeks. The trust ensures the appropriate prioritisation of our longest waiting patients with those of more urgent clinical need. The hospital reported just one patient waiting over 78 weeks in March 2025 due to the continued national delays for corneal tissue release. There were 21 patients waiting over 65 weeks - whilst some were also corneal transplant patients, others were services impacted by the prioritisation of urgent cancer patients or services managing unexpected emergency demand. Page 3 of 5 The trust is now transitioning focus to new 25/26 national waiting list targets. The organisation is committed to maintaining the strong improvements seen in 24/25 for theatre utilisation, length of stay reduction and optimisation of outpatient clinics. Alongside this, the organisation is closely reviewing referral trends and opportunities to manage them through increased advice and guidance. Cancer Target Faster Diagnosis - within 28 days 31 Day target - decision to treat to first definitive treatment 62 day target - urgent referral to first definitive treatment > =77% => 96% => 70% December 2024 83.6% 94.9% 82.2% January 2025 80.6% 95.1% 79.9% February 2025 84.4% 92.8% 72.1% The organisation continues to prioritise cancer patients and their treatments for all tumour sites and cancer types. The trust has maintained its strong performance against the 28 day faster diagnosis standard, consistently hitting the target and benchmarking in the top quartile compared to peer teaching hospitals across the country. Diagnostic capacity and the impact of provider referrals into UHS specialised services impacted our 62 day performance in February but unvalidated data provides assurance that the position has recovered to above 80% in March 2025. 5. Finance The financial environment remains extremely challenging for UHS. One off income received by the ICB and several technical adjustments have however helped reduce the scale of the deficit to £7m at the end of February 2025. This is £3.7m behind the annual plan of £3.3m deficit. The trust is targeting a breakeven position in March 2025 to ensure the deficit doesn’t further deteriorate and HIOW ICS can achieve a breakeven position for the year. The trust’s underlying position, so removing one off income, is significantly more challenging than this with an underlying deficit of c£6.5m per month. The organisation therefore continues to put significant focus on financial recovery with the aim of ensuring the organisation ‘lives within its means’ and makes progress towards the delivery of a breakeven run rate. The deficit drivers remain similar to those previously reported, focusing on three key areas: 1. Urgent and Emergency activity is in excess of block funding levels by c£2m per month. This has meant surge capacity has been required across all months of the financial year with peak usage in winter months. Demand management schemes are under development with HIOW ICS partners as part of agreeing plans for 2025/26 as is an increased funding envelope. 2. Non-criteria to reside numbers have increased to peaks of 250 from an average of 220. This is c20% of the trusts bed base and has a significant cost in addition to clinical risks of patient deconditioning and infection. This remains a focus of the inpatient flow programme. 3. Mental health patient demands have also increased noticeably over previous years with patients requiring enhanced levels of support often at a significant cost premium to the trust. UHS continues to work with system providers on improvements for this patient group. Despite these pressures however the trust has continued to ensure value for money remains an organisational priority with £73m of savings achieved YTD particularly focused on transforming services under the three workstreams of theatre optimisation, outpatients and inpatient flow. The trust also continues to overperform on the elective recovery target which supports financial sustainability via increased tariff income and helps support waiting list reduction targets. Currently 126% of 2019/20 levels of elective, daycase and outpatient first attendances are being delivered compared to a target of 113%. YTD this has generated over £26m of additional income for the trust. Page 4 of 5 Further to this the trust remains on target to spend its full capital allocation for 2024/25 totalling over £95m including £20m on decarbonisation and improved energy infrastructure which is externally funded. This continued investment in capacity, digital and infrastructure helps support continued ongoing financial sustainability and efficiency improvements. Despite the scale of the financial challenge the trust continues to look forward with optimism that our investments in infrastructure and transformation provide the right “foundations for the future”, including sustainable finances, and supporting “world class people, delivering world class care” as outlined in our strategy. 6. Human Resources Indicator Staff recommend UHS as a place to work Staff survey engagement score (out of 10) Q3 24/25 68.3% 7.0 Q4 24/25 66.4% 6.8 Trust wide, we have maintained our above average position across all the People Promise domains in the annual staff survey (Q3), with results remaining broadly unchanged from 2023 across all questions, with minimal improvements or declines which would be considered statistically significant. Year-on-year results over a three-year period shows there to be continued improvements in relation to satisfaction with immediate managers, opportunities for flexible working, appraisals, and increased confidence in reporting of incidences of unsafe practice, violence, bullying and harassment. However, we continue to see downward trends associated with civility and respect, and team dynamics which align to the themes in recent patient safety events and F2SU themes. Additionally, our national ranking for recommendation as a place to work has improved four places from last year, we now rank 18th out of 122 trusts, compared to 22nd in 2023. Participation rate has continued to decline to 39% from 41% in 2023, a 15% drop since 2022. This represents a total participation of 5,410 people out of a total eligible of 13,795 including subsidiaries. When reviewing the quarterly survey results, such as Q4 above, it must be noted that these results are less representative of views across UHS as we hear from less people. We maintain around a 20% response rate with quarterly surveys, hearing from 2,878 staff in Q4 out of an eligible 14,636 (this number is higher as more staff are eligible to participate in the quarterly surveys. WPL do their own quarterly survey so are not included). Indicator Target January 2025 Staff Turnover (internal target; rolling 12 month) Sickness absence 12 month rolling (internal target) 75% of staff in each area has received training, including neonatal medical team. • Trolley dashes. • Train the trainer. Progress Metrics Audit of compliance: • Has it been undertaken for the appropriate babies? • Was the frequency of observation undertaken correctly? • Was the score accurately calculated? • Did escalation take place if required? • Was the response to escalation appropriate? Quality Improvement Priority Four: Implementation of the National Safety Standards for Invasive Procedures (NatSSIPs) 2 at UHS. Core Dimension Patient Safety Rationale for Selection The new National Safety Standards for Invasive Procedures (NatSSIPs 2) represent the progression of the original NatSSIPs. The key aim to standardise, harmonise and educate (SHE) across organisations and procedural teams remains central to the NatSSIPs purpose. Critical changes include bolstered organisational standards and proportionate checks that recognise different levels of risk during major and minor invasive procedures, and the adaptions to processes that may be necessary in life-threatening situations. This standardisation, harmonisation and education goals are set out in the table below. Investigations into the increase of never events in 2023 and 2024 has identified that the majority of these had contributing factors related to stop points for safety. The key learning identified: All these factors will be addressed through NatSSIPs2 implementation. Safer invasive procedures is to be included as a local quality indicator by the ICB within the 2025/26 national contract. Key Aims • Establish a NatSSIPs oversight committee. • Set up an invasive procedures committee. • Establish the following workstreams: o Audit of stops point for safety in theatres and for minor procedures in outpatient and ward areas o Multi-disciplinary safety walkabouts o VLE and induction workstream • Education: recruitment of medical education led to set up simulation-based MDT training. • Patient involvement • NatSSIPs 8 and communications. • Stop points for safety staff resources. Progress Metrics • Increase in the completion of VLE stop points training. • Develop and implement a programme to deliver non-technical skills to the MDT. • All areas with a never event in the last two years have an up-to-date audit and action plan for compliance with NatSSIPs2. Quality Improvement Priority Five: Fundamentals of Care Core Dimension Patient safety Rationale for selection The term Fundamentals of Care (FoC) describes the eight standards that staff across the Trust have committed to in collaboration with the patient, to support the physical and emotional needs of patients’, relatives, and carers. This is not a new concept, it underpins the core values of what it means to be a healthcare professional, to truly ‘care’ and will build upon our achievements in year one. Operational challenges have led the workforce to become more task-focused and less person-focused, taking away from that personalised care experience but we are committed to changing that culture, following our trust value, Patients First. The FoC exemplifies how the interdisciplinary team connects and builds relationships with our patients, getting to know them and what matters to them as a person, not just as a patient, supporting and encouraging independence and rehabilitation from the beginning of their hospital stay. These activities are the essentials of our daily living such as personal hygiene, skin care, oral hygiene, toileting, eating and drinking, and mobilising. Communication is also essential and includes both listening and hearing patients, understanding what is important to them using communication tools they need, coming to shared decisions with patients about their care and recognising the diversity of our population, embracing accessibility for those with people with learning disabilities, sight/hearing loss or other disabilities, or if English may not be their primary language. In addition, the FoC encourages us as healthcare professionals to consider the whole person, support cultural, spiritual, mental health, emotional wellbeing and dignity needs of people we care for and those that matter to them. We know here at UHS that not everyone experiences this level of care, but we acknowledge the need to change the rhetoric from ‘we are busy’ to ‘we are never too busy to care’ empowering and educating our staff at all levels to challenge the ‘we have not got time’ rhetoric and ensure fundamental care is at the heart of what we do at UHS. Thus improving, patient care and experience. Key Aims We will grow the multi-disciplinary engagement and involvement in workstreams that embrace the FoC and encourage person centred to care. We will continue to pursue the digitalisation of the Friends and Family Test (FFT), using this data and the national inpatient and urgent and emergency care survey as a baseline, while linking with involved patients where required with to encourage feedback on the FoC. We will listen to the voice of our patients, their relatives, and carers to make sure their stories and experiences are heard by our workforce to encourage the organisation wide change. We will ensure the FoC will has clear and measurable improvement metrics as part of a live clinical quality dashboard that will afford ward managers and senior leaders, the opportunity to monitor, review and report on to FoC in their areas. We will embed the FoC into the matron walkabout and CAS processes, supported by consistent evaluation metrics that ask the patients about their experiences and encourage clinical areas to continually assess and evaluate the FoC in their areas through a self-assessment tool. We will enhance the availability of existing resources on our virtual learning wnvironment (VLE) in collaboration with our patient partners for all staff groups and embed the FoC into training across the organisation, to improve the knowledge, skills and awareness ensuring the delivery of quality care. We will continue to test and evaluate the What Matters To Me project, growing our volunteer role to support staff in finding out what is important to the patient and using their personalised board to remind staff of the ‘person’ they are caring for. We will continue to establish project links in child health, maternity and outpatients to ensure a bespoke, but collaborative roll out of FoC, considering how these different care environments may impact care. Progress Metrics • Patient hygiene – We will see an improvement in the number of patients who report having their personal care needs met, particularly within their first 24 hours coming through emergency admission routes. • Skin integrity – We will support the reduction in incidences of avoidable pressure ulcers across the organisation. • Communication – We see an increase in the number of people accessing our interpreting services and a reduction in complaints related to interpretation. • Pain – We will see an improvement in patients reporting that their pain was well controlled when coming through the emergency department. • Mouthcare – We will see a positive uptake in the implementation of the new mouthcare assessment tool and an improvement in patients reporting that their oral hygiene needs have been met. • Nutrition and hydration – We will see an increase in patients reporting they are being offered adequate food and drink provisions throughout their hospital stay, including access to equipment for those with conditions or disabilities that impact their ability to do so independently. • Bowel and bladder care – We will see improved assessment of bowel and bladder habits through increased documentation using the Inpatient Noting system. • Enhancing safe movement – We will support a reduction in the incidence of high harm falls and high harm falls that have preventable causes. • Infection prevention – We will see a reduction in nosocomial infections through increased hand hygiene standards and more effective cleaning of equipment Quality Improvement Priority Six Develop the Trusts’ approach to reducing the impact of health inequalities (HIs) - year two. Core Dimension Clinical effectiveness Rationale for selection Tackling health inequalities is a key priority for the NHS. At UHS we have been working to have an impact on health inequalities for several years. In 2024/25 we formalised these efforts with a governing board, chaired by our chief medical officer and with a clear programme of improvement based on recognised priorities. This formed the basis of our quality priority in 2024/25. This year’s quality priority is a continuation of the work that started in 2024/25. We intend to continue to grow our understanding and actions as an organisation, improving the equity of access, outcomes and experience of our services across our community. Key Aims We are continuing our health inequalities board, with focus on five priorities: enabling our organisation, data and measurement, clinical service priorities, communication and engagement and strategy and approach. Each of these priorities have aligned directors to oversee improvement and a detailed delivery plan. Key priorities and expected outcomes from each of these are listed below: Enabling the organisation: • Developing supporting structures - set up governance so that teams who identify health inequality related issues know where they can go for help, so that we can understand frequently arising challenges and notice when a problem raised might be affecting other of the hospital too. This will aid improvement, learning from issues identified and escalation of issues that cannot be resolved locally • Capability building - develop training for our staff to understand health inequalities, identify them within services and access tools to make improvement. • Delivery of the health inequalities officer role - grow knowledge of the health inequalities officer role across the organisation and utilise this role to share knowledge, training and support improvements. Data and measurement • Continue to develop our understanding of inequalities in access across outpatients and diagnostics, inpatients, theatres and the emergency department. • Enable the measurement of improvement in areas recognised as clinical priorities. • Enable completion of national reporting. Clinical priorities • Improve services and support for patients and staff with obesity (children and adults). • Improve identification and control of hypertension. • Improve services and support for patients and staff who smoke. Communication and engagement • Adopt health inequalities into leadership and decision making. • Learning from our communities and our staff. • Communicating improvements internally and externally. • Staff support campaign. Strategy and approach • Overseeing and agreeing UHS approach and strategy for HIs. • Overseeing annual delivery against priorities. • Aligning programme resource. • Maintaining collaborative working with public health and Integrated Care Board teams and other local healthcare providers. • Keeping up to date with national recommendations and expectations, sharing this knowledge with our organisation. • Overseeing trustwide improvement and health inequalities maturity. Progress Metrics • Increasing numbers of staff trained. • Numbers of health inequalities issues reported (expected to increase through understanding before reducing due to improvement work). • Case studies shared of successful improvement projects. • Increased involvement and collaboration with patients and public on improvement. • Increased use of QEIA templates in decision making. • Demonstration of improved access to care for obesity, tobacco dependency and hypertension. 2.3 Statements of assurance from the Board This section includes mandatory statements about the quality of services that we provide relating to the financial year 2024/25. This information is common to all quality accounts and can be used to compare our performance with that of other organisations. The statements are designed to provide assurance that the board of directors has reviewed and engaged in cross-cutting initiatives which link strongly to quality improvement. 2.3.1 Review of services During 2024/25 UHS provided and/or sub-contracted 118 relevant health services (from total Trust activity by specialty cumulative 2024/25 contractual report). UHS has reviewed all the data available to them on the quality of care in all these relevant health services. The income generated by the relevant health services reviewed in 2024/25 represents 100% of the total income generated from the provision of relevant health services by UHS for 2024/25. 2.3.2 Participation in national clinical audits and confidential enquiries The UHS clinical audit programme was developed in support of the Trust’s vision by putting patients first, working together and always improving. This leads on to a specific strategy for clinical outcomes, to ensure robust and measurable processes are in place to plan locally and participate strategically. Healthcare Quality Improvement Partnership (HQIP) produces a National Clinical Audit & Enquiries Directory which identifies those national audits which are included in the NHS England Quality Account List 2024/25, those audits which are part of National Clinical Audit and Patient Outcomes Programme (NCAPOP). NCAPOP audits are commissioned and managed on behalf of NHS England by HQIP. These collect and analyse data supplied by local clinicians to provide a national picture of care standards for that specific condition. On a local level, NCAPOP audits provide local trusts with individual benchmarked reports on their compliance and performance, feeding back comparative findings to help participants identify necessary improvements for patients. The audits listed on the NCAPOP are ‘must-do’ national audits. The quality accounts national clinical audit list includes audits which we regard as ‘best practice’ to participate in (in addition to those from the NCAPOP) and for that reason we always include these in our corporate audit plans as a priority where they are relevant to our Trust. UHS has a strong history for completing clinical audits. The clinical effectiveness team has a robust approach to governing and supporting the completion. We’ve opened discussions with senior clinical leadership within Hampshire and Isle of Wight Integrated Care Board regarding the current challenges with contributing to and using the outputs of national audits. Benchmarked data resulting from national audits provides strong guidance on areas of excellence and improvement, however completion can be challenging in its complexity and resource intensiveness, and timeliness of outputs can reduce our ability to be responsive to indications. Real time data supports our clinical teams to be proactive in striving to meet our always improving objectives. During 2024/25 68 national clinical audits and four national confidential enquiries covered NHS services that UHS provides. During 2024/25 UHS participated in 97% of national clinical audits and 100% national confidential enquiries of which it was eligible to participate in. NCEPOD studies participated in during 2024/25 were: • Emergency (non-elective) surgery in children and young people. • Juvenile idiopathic arthritis. • Blood sodium (hyponatraemia). • Acute Limb Ischaemic. UHS fully supports the Maternal, Newborn and Infant Clinical Outcome Review Programme (MBRRACE-UK) and all the reviews that take place under this umbrella. The national clinical audits that UHS participated in, and for which data collection was complete during 2024/25, are listed below (Table A) alongside the number of cases submitted to each audit or enquiry as a percentage of the number of registered cases required by the terms of that audit or enquiry if known at time of writing this report. Eligible (68) Participated 66 = 97%) Table A. Total number of NCAs UHS were eligible to participate in (n=68) % Actual cases submitted / expected submissions 1. BAUS Penile Fracture Audit ✓ Not yet started 2. BAUS I-DUNC (impact of Diagnostic Ureteroscopy on Radical ✓X Nephroureterectomy and Compliance with Standard of care practices) 3. BAUS Environmental lessons learned and applied to the bladder cancer ✓ care pathway audit (ELLA) 4. Breast and Cosmetic Implant Registry ✓✓ 5. Case Mix Programme (CMP) (ICNARC) ✓✓ 1677 for 3 quarters 6. Emergency Medicine QIPs – Time critical medications ✓✓ 63 pts 7. Emergency Medicine QIPs – Care of older people ✓✓ 182 pts 8. Falls and Fragility Fractures Audit Programme (FFFAP) national hip ✓✓ 971 all pts fracture database 9. Falls and Fragility Fractures Audit Programme (FFFAP) fracture liaison ✓ ✓ 2910 all pts database 10. Falls and Fragility Fractures Audit Programme (FFFAP) National Audit of ✓ ✓ Inpatient Falls 11. Learning disability and autism programme - Learning from lives and ✓✓ 100% deaths of people with a learning disability and autistic people (LeDeR) 12. National Adult Diabetes Audit – National Diabetes Inpatient Safety ✓✓ audit 13. National Adult Diabetes Audit – National Pregnancy in Diabetes ✓✓ 100% 14. National Diabetes Audit - transition ✓ ✓ Collects data from database 15. National Diabetes audit – gestational diabetes ✓ ✓ Collects data from database 16. National respiratory Audit Programme (NRAP) - asthma in children ✓✓ 17. National respiratory Audit Programme (NRAP) - asthma in adults ✓✓ 18. National respiratory Audit Programme (NRAP) - COPD secondary care ✓ ✓ 19. National respiratory Audit Programme (NRAP) Pulmonary rehabilitation ✓ ✓ 20. National Audit of Care at the End of Life (NACEL) ✓✓ 250 pts 21. National Cancer Audit Collaborating Centre - National Audit of ✓ ✓ Data entry not Metastatic Breast Cancer required 22. National Cancer Audit Collaborating Centre - National Audit of Primary ✓ ✓ collected Breast Cancer nationally 23. National Cancer Audit Collaborating Centre – National Kidney Cancer ✓✓ Audit (NKCA) 24. National Cancer Audit Collaborating Centre – Non-Hodgkin Lymphoma ✓ ✓ Audit (NNHLA) 25. National Cancer Audit Collaborating Centre –National Pancreatic ✓✓ Cancer Audit 26. National Cancer Audit Collaborating Centre - National Bowel Cancer ✓✓ Audit (NBOCA) 27. National Cancer Audit Collaborating Centre - National Oesophago- ✓✓ gastric Cancer (NOGCA) 28. National Cancer Audit Collaborating Centre - National Lung Cancer ✓✓ Audit (NLCA) 29. National Cancer Audit Collaborating Centre - National Prostate Cancer ✓ ✓ Audit (NPCA) 30. National Cardiac Arrest Audit (NCAA) ✓✓ 150 Approx 31. National Cardiac Audit Programme (NCAP) - Adult cardiac surgery ✓✓ 32. National Cardiac Audit Programme (NCAP) - Cardiac Rhythm ✓✓ Management (CRM) 33. National Cardiac Audit Programme (NCAP) - congenital heart disease ✓✓ (CHD) paeds 34. National Cardiac Audit Programme (NCAP) - Heart Failure audit ✓✓ 35. National Cardiac Audit Programme (NCAP) - Acute Coronary Syndrome ✓ ✓ 100% or Acute Myocardial Infarction 36. National Cardiac Audit Programme (NCAP) - Percutaneous coronary ✓✓ 100% interventions (PCI) 37. National Cardiac Audit Programme (NCAP) - The UK Transcatheter ✓✓ Aortic Valve Implantation (TAVI) Registry 38. National Cardiac Audit Programme (NCAP) -Left Atrial Appendage ✓✓ Occlusion (LAAO) Registry 39. National Cardiac Audit Programme (NCAP) – Patent Foramen Ovale ✓✓ Closure (PFOC) Registry 40. National Cardiac Audit Programme (NCAP) – Transcatheter Mitral & ✓✓ Tricuspid Valve (TMTV) Registry 41. National Child Mortality Database (NCMD) ✓✓ 100% 42. National Clinical Audit of Seizures and Epilepsies for Children and ✓✓ *1 pt Young People (Epilepsy12) 43. National Comparative Audit of Blood Transfusion – Audit of NICE ✓✓ Quality Standard QS138 44. National Comparative Audit of Blood Transfusion – Bedside Transfusion ✓ ✓ Audit 45. National Early Inflammatory Arthritis Audit (NEIAA) ✓✓ 46. National Emergency Laparotomy Audit (NELA) - Laparotomy ✓✓ 47. National Emergency Laparotomy Audit (NELA) – No lap ✓✓ 48. National Joint Registry ✓ ✓ 834 (data run to 10/02/2025) 49. National Major Trauma Registry ✓ ✓ 600 for 3 quarters 50. National Maternity and Perinatal Audit (NMPA) ✓✓ 51. National Neonatal Audit Programme (NNAP) (Neonatal Intensive and ✓✓ 100% Special Care) 52. National Ophthalmology Audit Database ✓✓ 53. National Paediatric Diabetes Audit ✓✓ 54. National Vascular Registry (NVR) ✓✓ **100% 55. Paediatric Intensive Care Audit Network (PICANet) ✓✓ 100% 56. Perinatal Mortality Review Tool (PMRT) ✓✓ 100% 57. Perioperative quality improvement programme ✓✓ 12 pts 58. Quality & Outcomes in Oral & Maxillofacial Surgery (QOMS) – Oncology ✓ Data taken & reconstruction straight from 59. Quality & Outcomes in Oral & Maxillofacial Surgery (QOMS) – Trauma ✓ other 60. Quality & Outcomes in Oral & Maxillofacial Surgery (QOMS) – ✓ databases Orthognathic surgery 61. Quality & Outcomes in Oral & Maxillofacial Surgery (QOMS) – Non- ✓ melanoma skin cancers 62. Quality & Outcomes in Oral & Maxillofacial Surgery (QOMS) – Oral & ✓ Dentoalveolar Surgery 63. Sentinel Stroke National Audit Programme (SSNAP) continuous SSNAP ✓ ✓ Clinical patient Audit, organisational audit 64. Serious Hazards of Transfusion (SHOT) UK National haemovigilance ✓✓ scheme 65. Society for Acute Medicine's
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Governors/Papers-CoG-29.04.2025-v2.pdf

Papers Trust Board - 25 July 2024

Description: Agenda Trust Board – Open Session Date 25/07/2024 Time 9:00 - 13:00 Location Anaesthetic Seminar Room (CE95/99), E Level, Centre Block, SGH/ Microsoft Teams Chair Jenni Douglas-Todd Apologies Gail Byrne (Natasha Watts to deputise) In attendance Kerrie Montoute, Head of Programmes, CDO Directorate at NHSE (shadowing Jenni Douglas-Todd) 1 9:00 2 3 9:15 4 5 5.1 9:20 5.2 9:25 5.3 9:30 5.4 9:35 5.4.1 Chair’s Welcome, Apologies and Declarations of Interest Note apologies for absence, and to hear any declarations of interest relating to any item on the Agenda. 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. Minutes of Previous Meeting held on 6 June 2024 Approve the minutes of the previous meeting held on 6 June 2024 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. QUALITY, PERFORMANCE and FINANCE Quality includes: clinical effectiveness, patient safety, and patient experience Briefing from the Chair of the Audit and Risk Committee (Oral) Keith Evans, Chair Briefing from the Chair of the Finance and Investment Committee (Oral) Dave Bennett, Chair Briefing from the Chair of the People and Organisational Development Committee (Oral) Jane Harwood, Chair Briefing from the Chair of the Quality Committee (Oral) Tim Peachey, Chair Maternity and Neonatal Safety 2024-25 Quarter 1 Report 5.5 Chief Executive Officer's Report 9:45 Receive and note the report Sponsor: David French, Chief Executive Officer 5.6 Performance KPI Report for Month 3 10:15 Review and discuss the report Sponsor: David French, Chief Executive Officer 5.7 Break 10:45 5.8 Finance Report for Month 3 11:00 Review and discuss the report Sponsor: Ian Howard, Chief Financial Officer 5.9 People Report for Month 3 11:15 Review and discuss the report Sponsor: Steve Harris, Chief People Officer 5.10 Annual Complaints Report 2023-24 11:30 Receive and discuss the report Sponsor: Gail Byrne, Chief Nursing Officer Attendee: Natasha Watts, Interim Deputy Chief Nursing Officer 6 STRATEGY and BUSINESS PLANNING 6.1 Corporate Objectives 2024-25 Quarter 1 Review 11:45 Review and feedback on the corporate objectives Sponsor: David French, Chief Executive Officer Attendees: Martin De Sousa, Director of Strategy and Partnerships/Kelly Kent, Head of Strategy and Partnerships 6.2 Research and Development Plan 2024-25 12:00 Discuss and approve the plan Sponsor: Paul Grundy, Chief Medical Officer Attendees: Karen Underwood, Director of R&D/Marie Nelson, R&D Head of Nursing and Health Professions 6.3 Board Assurance Framework (BAF) Update 12:20 Review and discuss the update Sponsor: Gail Byrne, Chief Nursing Officer Attendees: Craig Machell, Associate Director of Corporate Affairs and Company Secretary/Lauren Anderson, Corporate Governance and Risk Manager Page 2 7 CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Feedback from the Council of Governors' Meeting 24 July 2024 (Oral) 12:30 Sponsor: Jenni Douglas-Todd, Trust Chair 7.2 Register of Seals and Chair's Actions Report 12:35 Receive and ratify In compliance with the Trust Standing Orders, Financial Instructions, and the Scheme of Reservation and Delegation. Sponsor: Jenni Douglas-Todd, Trust Chair 8 Any other business 12:40 Raise any relevant or urgent matters that are not on the agenda 9 Note the date of the next meeting: 10 September 2024 10 Resolution regarding the Press, Public and Others Sponsor: Jenni Douglas-Todd, Trust Chair To agree, as permitted by the National Health Service Act 2006 (as amended), the Trust's Constitution and the Standing Orders of the Board of Directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. 11 Follow-up discussion with governors 12:45 Page 3 Minutes Trust Board – Open Session Date 06/06/2024 Time 9:00 – 13:00 Location Conference Room, Heartbeat/Microsoft Teams Chair Jenni Douglas-Todd (JD-T) Present Gail Byrne, Chief Nursing Officer (GB) Keith Evans, Deputy Chair and NED (KE) David French, Chief Executive Officer (DAF) Paul Grundy, Chief Medical Officer (PG) Steve Harris, Chief People Officer (SH) Jane Harwood, NED/Senior Independent Director (JH) Ian Howard, Chief Financial Officer (IH) Tim Peachey, NED (TP) (until 12:00) Joe Teape, Chief Operating Officer (JT) In attendance Craig Machell, Associate Director of Corporate Affairs and Company Secretary (CM) Lauren Anderson, Corporate Governance and Risk Manager (LA) (item 6.3) Christine Mbabazi, Equality & Inclusion Advisor/Freedom to Speak Up Guardian (CM) (item 5.12) Jenny Milner, Associate Director of Patient Experience (JM) (item 5.11) Suzy Pike, Divisional Director of Nursing/Professions, Division B (SP) (item 5.13) Clare Rook, Chief Operating Officer, CRN: Wessex (CR) (item 6.1) Julian Sutton, Interim Lead Infection Control Director (JS) (item 5.10) 1 member of the public (item 2) 5 governors (observing) 6 members of staff (observing) 2 members of the public (observing) Apologies Dave Bennett, NED (DB) Diana Eccles, NED (DE) Alison Tattersall, NED (AT) 1. Chair’s Welcome, Apologies and Declarations of Interest The Chair welcomed attendees to the meeting. There were no interests to declare in the business to be transacted at the meeting. It was noted that apologies had been received from Diana Eccles, Alison Tattersall and Dave Bennett. The Chair provided an overview of her activities since April 2024, including visits to hospital departments, meetings with peers and other key stakeholders. 2. Patient Story Hannah Pilka was invited to relate the story of her father, Karol Pilka, who died suddenly in hospital on 31 December 2023. The care and compassion shown by the nurse caring for Karol Pilka was highlighted. This greatly assisted the family with the grieving process. The Trust’s bereavement team was also praised. The Board noted the importance of care and compassion by the Trust’s staff. Page 1 3. Minutes of the Previous Meeting held on 28 March 2024 The draft minutes tabled to the meeting were agreed to be an accurate record of the meeting held on 28 March 2024. 4. Matters Arising and Summary of Agreed Actions It was noted there were no matters arising or overdue actions. 5. QUALITY, PERFORMANCE and FINANCE 5.1 Briefing from the Chair of the Audit and Risk Committee The chair of the Audit and Risk Committee was invited to provide an overview of the meeting held on 20 May 2024. It was noted that: • The committee reviewed the Trust’s National Cost Collection submission for 2023/24. • A report on waivers of competitive tendering was received, and it was noted that these were mostly due to urgent requirements or where there was only a single supplier. • The committee reviewed the Trust’s draft Annual Report and Accounts for 2023/24. • The draft internal audit report for 2023/24 was expected to provide a ‘clean’ opinion and there were no outstanding actions from previous audits. • The Trust received a ‘green’ assessment from the review against the Counter- Fraud Functional Standard. 5.2 Briefing from the Chair of the People and Organisational Development Committee The chair of the People and Organisational Development Committee was invited to provide an overview of the meeting held on 22 May 2024. It was noted that: • The committee reviewed the People Report for Month 1 (item 5.9) and noted that performance in this area was positive. • The additional workforce controls appeared to be working in terms of managing the size and composition of the Trust’s workforce. • The controls in respect of use of bank and agency staff also appeared to have had a significant effect. • The committee received an update on the Trust’s Inclusion and Belonging Strategy, noting that a number of initiatives were underway. • The committee reviewed progress against the objectives for year three of the Trust’s People strategy and expressed concern with the level of resource available to deliver these. 5.3 Briefing from the Chair of the Finance and Investment Committee The chair of the Finance and Investment Committee was invited to provide an overview of the meeting held on 3 June 2024. It was noted that: • The committee reviewed the Finance Report for Month 1 (item 5.7) and received an update in respect of the Trust’s annual plan for 2024/25. • The committee received an update on the Trust’s Cost Improvement Programme, noting that it had achieved £2.5m to date out of the £82m target. • UHS Estates was broadly on budget and was delivering and a positive report was also noted in respect of Wessex Procurement Limited. Page 2 5.4 Briefing from the Chair of the Quality Committee The chair of the Quality Committee was invited to provide an overview of the meeting held on 3 June 2024. It was noted that: • The committee noted an increase in the number of high-harm falls, which was a concern. • The committee also expressed concern at the resource demand posed by Inquests and post-mortems, particularly in terms of the number of witnesses now being called by Coroners. • The committee had reviewed a draft of the Trust’s Quality Account for 2023/24. • In reviewing the relative risk of mortality, it was noted that patients were 16% less likely to die at the Trust compared to the average mortality rate. • In terms of infection prevention and control, it was noted that this was at a higher rate than was acceptable, although there was a national issue in terms of infection prevention and control (item 5.10). 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: • It was the 80th anniversary of Operation Overlord, the Allied landings in Normandy. • The Infected Blood Inquiry had published its report on 20 May 2024. As a result of which, the UK Government has established a compensation scheme for those impacted. In addition, NHS England had commissioned an ongoing patient support service for those affected, and it was expected that the Trust would be one of the two providers in the region offering this service. • The Prime Minister had announced that a general election would be held on 4 July 2024. As a result, there were a number of implications for the Trust as a public body during the ‘pre-election period’. • Further industrial action by junior doctors was scheduled to take place between 27 June 2024 and 2 July 2024. The Trust was taking appropriate steps to manage this. • Paula Melhuish, Deputy Director of Estates and Capital Development, had received the Outstanding Service Award from the Health Estates and Facilities Management Association on 13 May 2024. • The Trust had been awarded additional capital funding due to its Emergency Department performance at the end of 2023/24. It was likely that some of this funding would be used to increase same-day emergency care capacity. • The Trust’s plan for 2024/25 had yet to be agreed in common with other trusts across NHS England. • Discussions were ongoing in respect of the Integrated Care Board’s transformation programmes, and it was noted that David French had been appointed to head the workforce transformation programme. 5.6 Performance KPI Report for Month 1 Joe Teape was invited to present the Performance KPI Report for Month 1, the content of which was noted. It was further noted that: • The data for March 2024 showed that the Trust was in the top-half or top- quarter in terms of its comparative performance. • There were 15 patients waiting longer than 78 weeks for a corneal transplant due to a lack of available materials beyond the Trust’s control. • Emergency Department performance had improved during May 2024 with use of surge capacity of only 14 per day (out of 50) and a reduction in the number Page 3 of patients with no criteria to reside of about 10%, although this was mostly due to the time of the year. • The Trust’s Diagnostics performance had been good over the period, with all but two areas achieving the 95% target. Recovery plans were in place for the areas not achieving the target and the Trust had informed trusts with cardiac magnetic resonance imaging capability that referrals would no longer be supported. • The Trust’s overall key performance indicators showed good or improving performance. However, there were concerns about the sustainability of this trajectory and some areas were vulnerable to loss of key personnel. • The Quality Committee was to carry out a deep-dive into falls and pressure ulcers, and a hydration trial to reduce the number of falls was being considered. The Board noted the reported ransomware attack against Synnovis on 3 June 2024, which had impacted trusts in London as well as the NHS Blood and Transplant service. It was noted that the Trust did use the supplier, but was unaffected by the incident. However, the impact on the NHS Blood and Transplant service would likely cause potential issues for the Trust in terms of the availability of blood and transplant services. Action: JT agreed to include Digital as an agenda item at a future Trust Board Study Session. 5.7 Finance Report for Month 1 Ian Howard was invited to present the Finance Report for Month 1, the content of which was noted. It was further noted that: • Planning for 2024/25 was still ongoing, and a further submission was to be made on 12 June 2024. As a result of the delays in the planning process, there was currently no formal reporting to NHS England. • The Trust had recorded a deficit of £3.8m during the month, which was in line with its current plan. • The Trust’s underlying deficit was between £4-4.5m per month. However, during month 1, this was nearer to £6m due to lower elective recovery performance during the period. 5.8 Break 5.9 People Report for Month 1 Steve Harris was invited to present the People Report for Month 1, the content of which was noted. It was further noted that: • There had been an overall reduction in whole-time equivalents during April 2024, with a reduction in bank and agency use. It was noted that 60-80 agency staff were related to patients with a mental health-related care need. • The Trust’s annual workforce plan had been submitted, but this was reliant on delivery by the Integrated Care System on a number of assumptions in terms of patients with no criteria to reside and provision of mental health care. • The Trust had received a silver award under the Defence Employer Recognition Scheme. Page 4 • The Trust was the second-lowest user of bank and agency staff in the southeast region. This represented a significant turnaround within a short period, although it was noted that there were some areas of fragility within the Trust. 5.10 Infection Prevention and Control 2023-24 Annual Report Julian Sutton was invited to present the Infection Prevention and Control 2023/24 Annual Report, the content of which was noted. It was further noted that: • There were a number of concerns stemming from application of ‘fundamentals of care’, such as a failure to apply risk reduction measures appropriately. • There had been seven cases of Methicillin-resistant Staphylococcus aureus (MRSA) during the year. • An update was provided in respect of the candida aureus outbreak, with approximately 70 patients colonised. • Rapid upper gastro-intestinal tract testing had resulted in benefits due to the speed of detecting infections and/or ruling them out quicker, thereby freeing up capacity. • An update was provided in respect of the incidence of measles since April 2024, which necessitated a significant amount of work to carry out contact tracing and to notify those potentially exposed. • There was a general increase in the infection rate nationally, and the Trust generally was in the middle in terms of its performance, dependent on the particular infection category. 5.11 Learning from Deaths 2023-24 Quarter 4 Report Jenny Milner and Paul Grundy were invited to present the Learning from Deaths report for Quarter 4, the content of which was noted. It was further noted that: • In line with a national trend, there had been an increase in the number of deaths during the fourth quarter. • A new application was being trialled to facilitate the sharing of the learnings from morbidity and mortality meetings. Work was also being carried out to standardise morbidity and mortality meetings, which would further facilitate the dissemination of learning. • Due to performance by the current provider below the standard expected, the Trust was tendering for a new supplier for baby funerals. • The Medical Examiner service was prepared for the changes due to be implemented nationally in September 2024 requiring the review of all deaths. • Based on the whole-year average, the Trust had the fifth-lowest mortality rate in England. • The Trust’s bereavement service had some constraints on resources, which was impacting out-of-hours and weekend support. 5.12 Freedom to Speak Up Report Christine Mbabazi was invited to present the Freedom to Speak Up Report, the content of which was noted. It was further noted that: • Between the period November 2023 – May 2024, the Trust had recorded 56 Freedom to Speak Up cases, compared to 44 during the same period in 2022/23. Page 5 • The reintroduction of face-to-face meetings following the COVID-19 pandemic had resulted in quicker resolution of issues. • The Trust was moving away from the term ‘whistleblowing’ owing to the possible negative connotations of the term, in favour of ‘speaking up’. • Investigations into cases raised via the Trust’s Freedom to Speak Up service always had involvement by an individual who was independent. • There was an issue with complaints found to be untrue where the complainant was anonymous and how to handle these cases, especially in terms of where an individual was subject to an unfounded allegation of wrongdoing. • The cases raised were similar in terms of the themes as the rest of the country. • Freedom to Speak Up should be a last resort, where possible, concerns should be dealt with at the local level. • Although most cases were resolved satisfactorily, communicating the outcome could be a challenge due to the need to preserve confidentiality in respect of matters such as disciplinary processes. • Support was provided to the Trust’s Freedom to Speak Up champions, including mental health/wellbeing support where appropriate. 5.13 Fuller Inquiry Report Suzi Pike was invited to present the Fuller Inquiry Report, the content of which was noted. It was further noted that in November 2021, an independent inquiry was established to investigate how an NHS estates member of staff was able to carry out inappropriate and unlawful actions in the mortuary of Maidstone and Tunbridge Wells NHS Trust, and how and why this activity went unnoticed for so long. The inquiry was split into two phases, and this report was to provide detail of the 17 recommendations arising from the inquiry’s phase one report and the Trust’s response to these. 6. STRATEGY and BUSINESS PLANNING 6.1 CRN Wessex 2023-24 Annual Performance Report Clare Rook and Paul Grundy were invited to present the CRN Wessex 2023/24 Annual Performance Report, the content of which was noted. It was further noted that: • The network was assessed against three high-level objectives concerning recruitment onto commercial and non-commercial studies and experience survey participation rates. • The network did not meet the objective in respect of open studies, but was close to the target for non-commercial studies. The network did achieve the experience survey participation objective. • The changes in the research network were expected to result in positive opportunities, although were consuming significant amounts of time managing the HR aspects of the transition. Page 6 6.2 Board Assurance Framework (BAF) Update Lauren Anderson was invited to present the Board Assurance Framework (BAF) update, the content of which was noted. It was further noted that: • The BAF had been reviewed and updated since it was last presented to the Board in March 2024. • The likelihood rating of the Estates risk (risk 5b) had increased, resulting in an increase from 16 to 20. • Work was being carried out to further embed the Trust’s risk appetite and to link the Trust’s operational risks with the BAF. This included consideration of the creation of an intermediate, division-level risk register in order to bridge the gap between the operational and BAF risks. 7. CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Feedback from the Council of Governors’ (CoG) Meeting 1 May 2024 The Chair provided an overview of the Council of Governors’ meeting held on 1 May 2024. It was noted that the Council of Governors had considered the following matters: • A report from the Chief Executive Officer • The Trust’s 2024/25 corporate objectives • Non-NHS activity • The annual report and quality account timetable • Terms of Reference • Governor vacancies and elections • Membership engagement 7.2 Register of Seals and Chair’s Actions Report The paper ‘Register of Seals and Chair’s Actions Report’ was presented to the meeting, the content of which was noted. Decision: The Board agreed to ratify the application of the Trust Seal to the documents listed in the ‘Register of Seals and Chair’s Actions Report’. 8. Any other business There was no other business. 9. Note the date of the next meeting: 25 July 2024 10. Resolution regarding the Press, Public and Others Decision: The Board resolved that, as permitted by the National Health Service Act 2006 (as amended), the Trust’s Constitution and the Standing Orders of the board of directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. The meeting was adjourned. Page 7 List of action items Agenda item Assigned to Deadline Status Trust Board – Open Session 28/03/2024 4.14 Guardian of Safe Working Hours Quarterly Report 1127. Junior Doctors Grundy, Paul Hulbert, Diana 24/10/2024 Pending Explanation action item Paul Grundy and Diana Hulbert agreed to include an item regarding junior doctors on a future Trust Board Study Session agenda. Update: Due to industrial action on 27 June, this item has been deferred to the next TBSS on 24/10/2024. Trust Board – Open Session 06/06/2024 5.6 Performance KPI Report for Month 1 1152. Digital Teape, Joe 24/10/2024 Explanation action item JT agreed to include Digital as an agenda item at a future Trust Board Study Session. Pending Update: This item is tentatively scheduled for TBSS on 24/10/2024. Page 1 of 1 Report to the Trust Board of Directors Title: Agenda item: Sponsor: Author: Date: Purpose: Issue to be addressed: Maternity & Neonatal (MatNeo) Safety Report 2024-25 Quarter 1 (Qtr.1) 5.4.1 Gail Byrne, Chief Nursing Officer Emma Northover, Director of Midwifery and Professional Lead for Neonatal Services Jess Bown, Quality & Safety Midwifery Matron Hannah Mallon, Quality & Safety Neonatal Matron Marie Cann, MatNeo Safety Lead 25 July 2024 Assurance or reassurance  Approval Ratification Information  This report constitutes the agreed Maternity & Neonatal (MatNeo) Services Qtr.1 safety report, provides a key overview of our services in, providing assurance to the members for the following: 1. Perinatal Quality Surveillance Qtr.1 (Appendix 1) 2. Serious Incidents (Appendix 2), Learning Slide (Appendix 2a) 3. Perinatal Mortality Review Tool (PMRT) (Appendix 3) 4. ATAIN Qtr.1 Report (Appendix 4) 5. Quality & Safety Shared Learning Slide (Appendix 5 MNSI QRM) 6. Culture Score Survey 7. MatNeo Service User Feedback (Appendix 6 CQC Maternity Survey Improvement plan/Birth trauma enquiry response) 8. MNVP Update 9. Trust Claims Scorecard 10. Midwifery Staffing Report 11. Maternity Safety Champions & Quad Team Update 12. NHSR (Maternity Incentive Scheme Year 6) NB 2, 6, 7, 8, 9 & 10 are reportable as per NHSR Year 6 NB Appendices 1-6 available in iBabs Documents. Response to the issue: 1. Perinatal Quality Surveillance – Maternity Neonatal Dashboard (Appendix 1) The Maternity & Neonatal Dashboard provides a perinatal quality surveillance overview of indicators for our services. The dashboard outcomes continue to be scrutinised by the Quality and Safety Team and reported to the MatNeo Safety Champions. The following section of the report will provide an update on the key indicators. The remaining red flags on the dashboard are ‘ongoing’, with no new concerns identified. As requirements change additional indictors will be added with recent changes including: • Late fetal losses (16+0-23+6) • Intrapartum stillbirths • PROMPT obstetric emergencies training (work in progress) • Newborn Life Support (NLS) (Data coming) • Maternity Day Assessment Unit (MDAU) Triage times. Page 1 of 9 1.1 % of Bookings by 9+6 weeks (NICE recommendation) Overall compliance for Qtr.1 was  31%. The action plan discussed in the previous report has been extended to continue for 3 months, taking us until the end of July 2024. This remains as a feature (Risk 815 Red 15) on the Risk Register until further notice. NB. As a result of the action and improvement plan mentioned above the number of bookings in May was 633, which is a significant increase from 448 in April. This increase should settle now that the backlog has been cleared. April 5.8% May 30% June 58% 1.2 Timeliness of testing KPI for sickle cell and Thalassemia screening Overall compliance for Qtr.1 was 36%. This surveillance indicator is set against a national benchmark and provides the indicator for the proportion of pregnant women and birthing people having had antenatal sickle cell and thalassemia screening for whom a screening result is available ≤10 weeks + 0 days gestation. This result enables prompt partner testing and the offer of prenatal diagnostic testing if required. The improvements seen in respect to compliance levels in screening have been as a direct result of the changes made to the booking processes. We anticipate further improvements to the screening data as service changes within the self-referral team become formalised. April 6.4% May 33% June 68% The action plan discussed in the previous report has been extended to continue for 3 months, taking us until the end of July 2024. This remains as a feature (Risk 37 Red 15) on the Risk Register until further notice. To note this indicator is intrinsically linked to the % of Bookings by 9+6 weeks and as this compliance increases so will screening compliance. 1.3 Booked onto Continuity of Carer (CoC) pathway The Maternity Continuity of Care Model (MCoC) is a key model that ensures all families, particularly those most vulnerable, have safer and improved outcomes. The outcomes are as follows: • Total booked onto a CoC pathway Current rate for Qtr.1 is 13%, within the target being > 35%. • Global Majority booked onto a CoC pathway Current rate for Qtr. 1 is 23%, which has increased from 14.7% in March, target being > 51%. This workstream has additional team lead oversight to ensure we are targeting those most at risk. April 24% May 22% June 22% Page 2 of 9 • Total booked who are living in IMD1 area booked onto a CoC pathway Current rate for Qtr. 1 is 65%, these women/birthing people are being identified early to ensure they are booked onto a CoC pathway and close oversight by the senior leadership team and NEST team leads. April 41% May 56.5% June 98% 1.4 Education and Training NHSR Year 6 - Safety Action 8 asks Trusts to evidence compliance of 90% for the 3 ‘in-house’ one day multi-professional training days. The Quality and Safety Team have close oversight working with the education leads to ensure progress is maintained for training and education. The need has been identified early and provision sought for additional training days, due to increased acuity operationally and staff being redeployed to work clinically, with the additional resources we are on track to meet compliance by 30 November 2024. 1.5 Neonatal Life Support (NLS) NHSR Year 6 – Safety Action 8 also asks Trusts for evidence of compliance of 90% for neonatal life support. This is included within PROMPT for Maternity Services but is taught separately within Neonatal Services. Targeted education is planned for Autumn 2024 to ensure compliance will be met by the end of the reporting period (November 2024). The process for providing the annual NLS updates within Neonatal Services is being reviewed to apportion it across the year, which includes having an allocated time within the doctor’s induction and adding to the rolling education rota. 2 Serious Incidents (SI) including Maternity and Newborn Safety Investigations (MNSI) and PMRT cases Appendix 2 provides assurance to the members that the appropriate reporting has taken place for Qtr.1. The report includes all new MNSI cases, of which there were 2, and any PSII cases. Also providing an update on all cases closed within the same timeframe, together with any thematic learning identified. Information will also be included which relates to new and closed perinatal mortality cases even where there are no patient safety care concerns for the service to continue to be transparent. 2.1 Appendix 2 also includes a summary of the Moderate incidents reported in April/May 2024 to date. There were 2 cases closed in Qtr.1 and the learning slides featured within the last report: • MNSI 029127 case closed Trust shared learning slide • MNSI 031668 case closed Trust shared learning slide. 2.2 Appendix 2a highlights the Iodine skin prep case learning slide which has been shared with the Local Maternity and Neonatal System (LMNS), case currently an ongoing PSII. 3 Perinatal Mortality Review Tool Report (PMRT) See Appendix 3 for a summary of Qtr.1 PMRT cases and learning. The MatNeo service can confirm that there is high level oversight of reported and processed cases to ensure reviews and feedback from and to families are captured within appropriate timeframes. Page 3 of 9 Case information is reviewed at a level where the service can look to identify any themes or vulnerable groups. Learning has been identified within the information and is shared with our LMNS. 4 ATAIN Qtr.1 Report For Qtr.1 2024/25, there were a total of 41 unexpected admissions. The process for reviewing term admissions has changed and the reasons for admission have also been amended slightly. However, poor perinatal adaptation continues to be the most common reason for admission. Appendix 4 provides a deep dive into Quarter 1 admissions. 5 Quality and Safety Shared Learning Our service continues to drive quality and ensure that safe care is provided to our families. Appendix 5 provides Committee members with an overview of the key learning from the Trust’s quarterly MNSI review meeting. 6 Perinatal Culture Score Survey The Trust is holding feedback sessions with the workforce, facilitated by Korn Ferry (the Score Survey provider), looking to obtain further narrative to support and inform the Change Team (improvement leads) to ensure meaningful results and a positive improvement. 7 MatNeo Service User Feedback 7.1 Friends & Family Overall, for Qtr.1 the Friends and Family feedback continues to be above Trust target at 32.0% with 89% recommending our service. This feedback is reviewed by the senior team and any thematic concerns are identified and improvements planned. 7.2 CQC Maternity Survey Action Plan Appendix 6 outlines the Maternity Improvement Plan following the 2023 CQC Women’s Experiences of Maternity Care Survey, combined with the themes identified in the recent Birth Trauma Enquiry report. Locally we have reviewed the results and have developed an action plan to address the findings. 8 Maternity & Neonatal Voices Partnership (MNVP) Chair Update The Hampshire and Isle of Wight ICB advertised the MNVP chair role on the 24 May 2024, with the closing date of 7 July 2024, subject to recruitment the Trust hopes to have a chair in place soon to support the MatNeo Service to ensure the patient voice is heard and service user engagement in shaping our MatNeo service. 9 Trust Claims Scorecard Qtr.1 Claims Scorecard will be reviewed by the Safety Champions and targeted interventions aimed at improving patient safety would be developed. This will come to the Quality Committee in August for noting as per NHSR Year 6 reporting requirements. Page 4 of 9 10 Midwifery Staffing Report 10.1 A clear breakdown of BirthRate Plus (BR+) or equivalent calculations to demonstrate how the required establishment has been calculated In line with national drivers for assurance in relation to safe staffing levels within maternity services, UHS Maternity Services currently utilise BirthRate Plus (BR+) as a system and framework for workforce planning and strategic decision making. The last assessment of UHS Maternity Services by BR+ in 2018 suggested an overall clinical establishment based on a midwife V birth ratio of 1:24, calculated against an annual birth rate of 5500 births. At the time, the required total establishment as calculated by BR+ to ensure safe staffing levels equated to 226.55 WTE which was inclusive of support staff contribution. UHS recently commissioned a revised BR+ review in March 2024. Whilst we await our final report, early indicators show our service to be operating in a staffing deficit, which indeed feels accurate on a day-to-day basis. Despite a lower birthrate in 23/24 of around 5000, the growing complexity of maternity calls for more input and midwifery care hours throughout pregnancies across the service, whilst also increasingly requiring wider MDT input. Birthrate Plus data shows that UHS continues to see a higher than average case mix with 77% of people falling within the highest acuity / care requirement categories compared to 68% in 2018. In July 2023, we saw a peak in this activity where 91% of women / birthing people delivered on our labour ward or in theatre. This rate has continued into 2024 with the average only falling to around 88% each month. Our normal birth rate has stabilised with an average of 45% however the rising trend we have seen over the last 12 months in caesarean section births, continues to be high and consistently account for over 40% of all births in our service. 10.2 In line with Midwifery staffing recommendations from Ockenden, Trust Boards must provide evidence of funded establishment being compliant with outcomes of BirthRate+ or equivalent calculations Over the last 3 years, UHS Maternity Services have at times been working with midwife V birth ratios that are more suggestive of 1:27. This has felt uncomfortable but with contingency frameworks in place, the service has remained safe. With a vacancy rate of 22.49 WTE currently for registered staff we are presently operating a 1:29 midwife V birth ratio. This situation is further compounded by short-term sickness, an increased national demand for education and training and a high maternity leave rate of 9%. This inevitably results in a workforce that is significantly overstretched carrying an overall headroom percentage of 31%. We have increased staff support in the clinical environment in addition to pastoral and psychological support to enhance retention of the workforce. We are pleased to say that with this initiative, we have retained 100% of our newly qualified preceptees who started with us in November 2023. UHS Maternity Services has a very detailed, robust escalation and contingency plan which is activated when the service is under pressure to maintain safety and improve maternal and neonatal outcomes. The leadership team, including the Director of Midwifery, commit to a high number of out of hours on calls to support the service when in escalation and when staffing does not match the acuity and activity across the acute clinical areas. Page 5 of 9 Whilst effective in bridging gaps for the most part, this is not a sustainable way of working and it is resulting in burnout across the midwifery leadership team. 10.3 Where Trusts are not compliant with a funded establishment based on BirthRate+ or equivalent calculations, Trust Board minutes must show the agreed plan, including timescale for achieving the appropriate uplift in funded establishment. The plan must include mitigation to cover any shortfalls In support of the BR+ acuity tool, UHS Maternity Services have developed a systematic process for workforce planning in the form of a monthly dashboard. This live data is reflective of total staff unavailability to include vacancy rates, sickness ratios, maternity leave, and study time, all of which is compared alongside the budgeted versus actual staffing establishment overall. The data recorded within the monthly dashboard is lifted directly from maternity Erostering and ESR systems. As such the staffing ratios are recorded in real time and will represent staffing levels in their most accurate form. The monthly dashboard not only records an accurate position for midwifery staffing at the current time but also offers a projected forecast for staff unavailability in the months going forward. This ensures and supports an ongoing process for rolling recruitment, involving both qualified and unqualified staff groups. Utilising the dashboard in this way will see the Maternity Service reduce the current vacancy rate down from a predicted 26.58WTE in October 2024 to fully recruited as per our current funded establishment by 1st February 2025, assuming that we are able to maintain engagement from all our new recruits. With national evidence directly linking reduced midwifery staffing levels and poor maternity and neonatal outcomes for families, recruitment to clinical maternity roles, both registered and unregistered has been supported by the Trust Board and prioritised at recruitment panels. With this support, Maternity Services have continued to recruit to vacant posts and following a successful newly qualified midwife recruitment drive, we are expecting 34WTE B5 midwives to join UHS Maternity Services on our preceptorship programme in November 2024. Recognising the level of support that our new colleagues will need, and to create a balanced skill mix across our workforce, we also have a rolling B6 recruitment process which is returning a steady stream of experienced B6 midwives also joining our service. 10.4 Midwifery red flag reporting – Evidencing compliance that all women / birthing people receive 1:1 midwifery care in active labour and the protected supernumerary status of the labour ward coordinator UHS Maternity Services record our staffing V acuity data every 4 hours across the intrapartum areas using the BR+ tool. Within our staffing template the labour ward coordinator is rostered and protected to maintain a supernumerary status at all times. This standard is achieved and maintained across the entirety of every shift, not just the start which is the reportable required standard. The skillset of this staff group is pertinent to the safe running of the labour ward, our most acute and high risk clinical area. The table below offers assurance to the Trust Board that UHS Maternity Services consistently meet this safety standard with no red flag events recorded for the whole of 2023 and to date in 2024. The labour ward coordinator team recognise the specialist nature of their role and reliably respond to cover unexpected vacant shifts. Across our operational Page 6 of 9 and leadership teams, we have staff who also hold the labour ward coordinator skillset as a dual or previous role which offers extra flexibility and redeployment options at times where a substitute coordinator may be required. At UHS, the labour ward coordinator does not take responsibility for any patients nor do they cover breaks for other members of staff enabling them to have continuous oversight of their clinical environment. Red Flag Report - Labour Ward (scheduled assessments only) Red Flag Red Flag Description 2023 total Jan Feb Mar Apr May Any occasion when 1 midwife is not able to provide continuous RF9 one-to-one care and 0 0000 0 support to a woman during established labour RF10 Labour ward coordinator not supernumerary status 0 0000 0 Red Flag Report - Broadlands (scheduled assessments only) Red Flag Red Flag Description 2023 total Jan Feb Mar Apr May Any occasion when 1 midwife is not able to provide continuous RF9 one-to-one care and 0 00 0 0 0 support to a woman during established labour Another red flag that is closely monitored and reportable to the Trust Board as a measure of good practice is the assurance that all women / birthing people receive 1:1 care in active labour across all birth environments. At UHS Maternity Services we respond quickly and effectively to the fast paced, unpredictable nature of intrapartum care and evoke our maternity escalation plan to source additional midwives for intrapartum care. Currently midwives are redeployed often to meet the needs of the service which can cause uncertainty and frustration for them at times. Morale and job satisfaction levels are low amongst midwives who are continuously called upon for support, however all would agree that safe care is the priority. It is only through this escalation that we continue to provide safe care to the women / birthing people accessing our service in the right place, at the right time and by the right people. If we cannot provide 1:1 care in active labour, UHS Maternity Services will declare the highest level of escalation, OPEL 4, and look to divert incoming people in labour to neighbouring Trusts across the region. Since the start of 2024, UHS Maternity Services have escalated to OPEL 4 on 23 occasions. Across the whole of 2023 OPEL 4 was declared 28 times. This is a significant and stark increase in service pressure that our Maternity Service Page 7 of 9 is experiencing with staffing and acuity accounting for the majority of cases. Whilst we report that we are compliant with providing 1:1 care in active labour and we are safe, we are seeing an increase in other reportable red flags such as delays in induction and being unable to facilitate birthplace choices. 10.5 Maternity Workforce Development – Next Steps/Way Forward Over the last year, an extensive listening exercise has taken place to help inform the future direction and structure of the Maternity Service workforce. To align with current service needs, and with staff wellbeing as a central focus, the Director of Midwifery and Midwifery Senior Leadership Team are reviewing the way the service is delivered with the potential of a workforce restructure. Ensuring that an appropriately skilled practitioner is available to meet service demands in the most responsive and efficient way remains pivotal in the success of this potential project. This will be pertinent to models and pathways of care provision, operating both in and out of the hospital setting, including homebirth and intrapartum services within our low-risk birth centres. Drivers around flexible working, retention and restorative practice will all underpin the direction and future of the way in which we work. In terms of strategic workforce planning, there is currently a significant focus around the issue of supply and demand for maternity staff, particularly registered midwives. Some options for workforce development see alternative training pathways for health care workers who previously may not have benefitted from such openings and include shortened midwifery conversion courses for registered nurses, return to practice midwifery courses, midwifery apprenticeship models and foundation programmes for aspiring maternity support workers. It is anticipated that by broadening the gateway into careers within maternity services, whilst allowing training and education to be both accessible and affordable, a wider audience of prospective candidates will be achieved. In these current times where maternity workforce tensions are so prominent, we recognise that succession planning is of prime importance, and therefore are busy creating new opportunities for staff upskilling and professional development. UHS Maternity Services are committed to investing in their people and as such have dedicated programmes for career development starting at band 2 and progressing to band 9. Our prime focus is to consider new ways in which we can future proof our maternity services going forward, whilst investing wholly in the health and wellbeing of our existing workforce. 11 Maternity & Neonatal Safety Champions & Quad Team Update Safety Champions Gail Byrne (Exec) Tim Peachey (Non-Exec) Victoria Puddy (Neonatal) Jillian Connor (Obstetric) Marie Cann (Midwifery) QUAD Bala Thyagarajan (Care Group Clinical Lead) Ganga Verma (Obstetric Clinical Lead) Hannah Kedzia (Care Group Manager) Marie Cann (Midwifery) The Safety Champions and Quad met on the 1 May 2024 for a joint meeting and safety walkabout of the service. There were no additional concerns or actions identified, just the ongoing challenges around staffing and estates recognised. Page 8 of 9 12 NHSR – Maternity Incentive Scheme year 6 The last Quality Committee report provided an exception report for the 10 safety actions. The Trust met with the LMNS on the 27 June 2024 for the first quarterly review meeting, to assess progress against the 10 safety actions, and the trajectory for complete submission is on track. The next review meeting is planned for August, to review progress, ahead of end of the reporting period on the 30 November 2024. Implications: (Clinical, Organisational, Governance, Legal?) The risk implications for the UHS Trust and MatNeo services sit within several frameworks including: • Reputational – Safety concerns can be raised by the public to both NHS Resolution and the CQC. • Financial – Compliance with NHS Resolution Maternity Safety Actions to meet all ten safety actions remains to be an expectation for maternity safety requirements. • Governance – Safety concerns can be escalated to the Care Quality Commission for their consideration and to NHS England, the NHS Improvement Regional Director, the Deputy Chief Midwifery Officer, the Regional Chief Midwife. • Safety - Non-compliance with requirements or recommendations would have a detrimental impact on the women and their families leading to increased poor outcomes and staff wellbeing. MNSI can raise concerns regarding the safety of MatNeo services and instigate reviews. Risks: (Top 3) of Top Risks: carrying out the • 788 (Red) Elective theatre capacity change / or not: • 258 (Red) Maternity staffing • 259 (Red) Capacity and demand in Maternity services • 260 (Red) MDAU • 262 (Red) Induction of Labour Summary: This Qtr.1 MatNeo services safety report provides an overview of the key safety Conclusion workstreams and aims to provide committee members with the actions and and/or mitigations in place to improve areas of significant concern. The report recommendation: encompasses the perinatal quality surveillance minimum requirements and aims to fulfil the reporting requirements for NHSR MIS year 6. The report will continue to be adapted and responsive to safety concerns or issues within our service providing assurance around safety improvements impacting our families, services and staff. The MatNeo dashboard provides the board with the Perinatal Quality Surveillance information and will continue to be refined to provide a platform for clear oversight of key outcomes and measures. We continue to work on ways to ensure the dashboard clearly highlights any action and improvement plans where areas of risk have been identified. The information provided is for assurance and reassurance, whilst meeting the requirements of NHSR Year 6, and highlights the safety improvement work and learning from all aspects of the services including serious incident and MNSI cases. We ask members to continue to support the MatNeo Services and provide monitoring and scrutiny as required. Page 9 of 9 Report to the Trust Board of Directors Title: Agenda item: Sponsor: Date: Purpose: Issue to be addressed: Response to the issue: Chief Executive Officer’s Report 5.5 David French, Chief Executive Officer 25 July 2024 Assurance Approval or reassurance Ratification Information X My report this month covers updates on the following items: • General Election • COVID-19 Inquiry • Forgotten Generation • Ligature Risk • Care Quality Commission • Haemophilia Treatment • LIMS system The response to each of these issues is covered in the report. Implications: Any implications of these issues are covered in the report. (Clinical, Organisational, Governance, Legal?) Summary: Conclusion The Board is asked to note the report. and/or recommendation Page 1 of 5 General Election On 4 July 2024, the UK’s general election result was a clear mandate for the Labour party, returning 412 Members of Parliament which represents a 174-seat majority. Labour’s manifesto commitments in terms of health included: • Using spare capacity in the independent sector to ensure that patients are diagnosed and treated more quickly. • Reform of the NHS to ensure that mental health is given the same attention and focus as physical health. • Modernising the Mental Health Act to address treatment of people with autism and learning difficulties, and racial inequalities perpetuated by the Act. • Implement professional standards and regulate NHS managers. • Set an explicit target to close the black and Asian mortality gap. • Implement the expert recommendations of the Cass Review, the independent review of gender identity services. • Ensure the publication of regular, independent workforce planning across he
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