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Body modification

Description: Nearly twenty years ago, a court was faced with an agonising decision: whether the proposed separation of conjoined twins was lawful
Url: /HealthProfessionals/Clinical-law-updates/Body-modification.aspx

Rehabilitation pathway for MTC patients 12a

Description: Rehabilitation Pathway for complex multi-trauma patients (levels 2a / 1) December 2015 To date, there has been no rehabilitat
Url: /Media/SUHTExtranet/WessexTraumaNetwork/Rehabilitation-pathway-for-MTC-patients-12a.pdf

Rehab pathway for Msk patients 2016

Description: Rehabilitation Pathway for Complex Musculoskeletal Trauma - June 2016 To date, there has been no rehabilitation pathway written for multi-trauma patients with complex musculoskeletal (MSK) injuries in the Wessex Region. In fact, the paucity of services for this particular patient group has been highlighted nationally by the Trauma CRG . These patients often fall into levels 2a or 2b as outlined in the BSRM definitions (2009, 2010) and as such do not qualify for specialist funding. They cannot therefore access specialist rehabilitation services. These patients are a priority in terms of clinical need, cost to the NHS and lost tax to the exchequer if they are not managed well, and do not return to their former vocation. This document has been written in conjunction with local health / social workers, patients and commissioners, and in reference to the evidence base as it exists. The pathway aims at ideal care irrespective of whether it exists currently. (These patients generally have multiple limb fractures - often with significant external fixation - and often requiring plastic surgery input. Many of them have peripheral nerve injuries. Internal injuries and / or minor head injuries increase patients ISS scores. However, the rehabilitation community generally reports ISS scores bear no correlation with rehabilitation needs. These patients cover all age groups.) Pathway Acute Care Patients following a traumatic injury are taken to either: a/ University Hospitals Southampton (UHS) as the Multi-trauma Centre (MTC), or b/ a local Trauma Unit (TU). The patient may then be transferred to the MTC as a secondary transfer, and possibly on to Salisbury District Hospital which leads on Plastic Surgery across the WTN. Patients with these types of injuries are invariably sited in an Intensive Care Unit (ITU) whether at the MTC or TU. This can be as a result of the MSK injury or associated internal injuries to the lungs, spleen etc. A Rehabilitation Prescription, or equivalent document, should be filled in within 72 hours by a Rehabilitation Specialist (either Rehabilitation Consultant or Rehabilitation trained AHP ? Band 7 or upwards) as per national trauma guidelines. If possible / appropriate, an holistic assessment should be undertaken including family members / carers as appropriate. This should include physical, cognitive, communication, psychological and social needs and relevant history. If this is not appropriate at this point, it is expected that this would be done within the first 10 days and patients with, or expected to have, complex needs be identified. The rehabilitation specialist should have access to the full multi-disciplinary team (MDT) for their expertise as needed including nurses, Physiotherapists, Occupational Therapists, Consultants in Rehabilitation Medicine, Orthopaedics and / or Plastics, Psychologist, Psychiatrist, Dietetics, etc. The MDT should meet regularly to discuss the changing needs of patients in the acute setting. Acute rehabilitation should start as soon as clinically safe following medical protocols. Reassessment should occur regularly, at least weekly, as patient status changes quickly at this point in their journey. It is recommended that a Consultant and AHP `injury list' and `management plan' are written within 72 hours of arrival and that excellent communication between both groups occurs concerning them. It is likely that MSK patients will be transferred to a Trauma, Orthopaedic or Plastic ward at an appropriate point. Their acute rehabilitation would continue at this point. When the patient is medically stable, the rehabilitation team should consider onward referral. Services are currently limited at this point (this is the national picture). This pathway recommends that there should be appropriate referral options at this point depending on the patients need: specialist intensive rehabilitation Specialist community and / or outpatient management Referral should occur as early as possible with patient and carer involvement in all decision making. Complex MSK patients should be reviewed within one week of discharge from acute services. Intensive Rehabilitation Input There are currently very few intensive MSK rehabilitation facilities nationally. However, it is generally accepted, both locally and at national level, that complex MSK injuries require more input than most outpatient / community departments can offer. There are already clear guidelines for rehabilitation facilities and many of these are transferable to a MSK centre (See BSRM 2002, 2009, 2012). The armed forces and police / fire services are already employing such centres / services. Services must be patient focused and goal driven. They must have a strong, well trained and full MDT which meets regularly and can demonstrate evidence of regular training / CPD. Rehabilitation centres should be patient friendly in terms of environment, resources and culture. They must have all the resources / equipment requisite for providing appropriate treatment. These should include PT (Physiotherapy), OT (Occupational Therapy), early access to psychology, regular hydrotherapy (i.e. available > once per week), access to pain specialists and vocational rehabilitation facilities. Strong links with local orthotics and prothetics Departments are recommended with lower limb expertise in the team. Similarly, excellent communication with relevant Orthopaedic and / or Plastic Consultants. On arrival at a rehabilitation centre, appropriate, patient driven SMART goals should be set with the patient / carers and the MDT within the first week. These goals should be reviewed on a regular basis ? two to four weekly. The patient / carers should receive regular feedback from these meetings as should the patient's GP and relevant commissioners. The RP, or equivalent, should be repeated at appropriate time frames as part of this process. Nursing care needs vary for MSK patients. Initially, patients may require more intense nursing care but later they may be able to manage with minimal assistance e.g. staying in hostel type accommodation without nursing care. Services should reflect this changing need. MSK patients may also require further follow-up surgery and so move in and out of an intensive centre as their needs change over several years. It is essential that there is flexibility in planning and treatment so that patient programmes can be tailored to individual patient needs rather than service needs. Initial programme planning should be holistic addressing all needs identified on the RP or equivalent. Goals should be both long and short term. Length of stay in the centre should be agreed between the MDT and family at an early point ? although this might be revised later. Vocational goals should be set at an early stage and appropriate communication with employers to facilitate return to normal activities if possible, or plans for alternative employment. Patients may spend time in and out of the service as their rehabilitation progresses. It is recommended that therapy assistants (or fitness instructors / equivalent) are utilised regularly in intensive centres. Specialist community / outpatient services Currently, local outpatient departments and community services are the default referral option for most MSK injuries. It is recommended that complex trauma patients require management by specialists with MSK trauma expertise ? see below. Therapists should use a goal setting approach both with short term and long term goals. Services should be able to see patients as their therapy requires i.e. multiple times in a week if their level of injury requires it. Similarly, hydrotherapy should be available for multiple sessions per week if the patient requires it. Specialists should have access to appropriate rehabilitation equipment e.g. parallel bars, gymnasium equipment, supports, splints etc. There is clear data that the number of frail patients has increased in the recent past. It is also evident that the number varies geographically. It is important that such patients have access to appropriate input to manage co-morbidities. Services managing such patients should have expertise both in frailty and MSK trauma. All services should have access to timely vocational rehabilitation input. General Recommendations It is recommended that all complex MSK patients have a named key worker at all points through the rehabilitation journey. It is recommended that all complex MSK patients are managed by someone with relevant trauma expertise i.e. someone with upper or lower limb expertise (whether in intensive, community or outpatient services). It is recommended that rehabilitation services are within 45 minutes travel time (whether community, outpatient or intensive centres). It is recommended that complex MSK patients meet all relevant surgical teams at one appointment with relevant rehabilitation specialists to discuss / agree plans. Patients have reported at local and national meetings that multiple appointments are not helpful to efficient rehabilitation. In a similar vein, it is recommended that services should provide rehabilitation experts in all relevant limbs at one session rather than requiring patients to attend different appointments for different limbs' management / treatment. It is recommended that rehabilitation specialists use appropriate outcome measures e.g. EQ5D5L (a quality of life measure), LEFS (lower extremity functional scale), QDASH (functional tool for `disability assessment of the shoulder and hand'), etc. to demonstrate effective input to patients, clinicians, family members and commissioners. Appropriate seating should be easily available. Easy access to appropriate transport is essential. Current Services There is currently one intensive MSK service in the area fitting most of the above criteria, namely the Wessex Rehabilitation Centre in Salisbury. The centre treats patients from 9.30 ? 4.45 Monday to Thursday (assessments can be on a Friday). The centre has access to regular hydrotherapy, Physiotherapy in a custom built gymnasium, and Occupational Therapy including an industrial workshop and bungalow. The centre also has regular weekly input from a Specialist Nurse and Pain Consultant. Psychology is standardly included in treatment for appropriate patients and their input guides therapy programmes. There is hostel type accommodation for patients staying mid week. The Trauma Specialist Plastic Surgeons are partly based at Salisbury and therefore accessible. Patients are given a key therapist and are involved in goal setting from first assessment. The service has good links with the Trauma Centre in Southampton. There are agreements with commissioning bodies across the Wessex Network that mean complex trauma patients are able to access the service with a rehab prescription. Patients can be referred by Consultants, GPs or AHPs. Quality Indicators RP or equivalent filled in by Rehab Specialist (Cons or AHP B7), within 72 hrs Holistic r/v ? multiple professionals including psychosocial ax by 10/7 Evidence of reassessment (at least weekly) in acute setting (if appropriate) Y / N / NE Y / N / NE Y / N / NE Evidence of daily rehabilitation (if appropriate) input by MDT: PT, OT, SLT, Psychology etc. ? ---------------------------------- Clear involvement of patient in decision making concerning rehab options? Patient reviewed within one week of discharge from acute service Evidence of goalsetting, with patient involved, at regular time frames Access to psychology available if necessary? Access to vocational rehabilitation services if necessary? Regular access to hydrotherapy available? Service able to see patient multiple times weekly if necessary? Evidence of clearly assigned Key Worker at 1/52, 4/52, 10/52? Could the patient's injuries be rehabilitated in one setting? Did rehabilitation workers have relevant expertise? Evidence of use of relevant clinical and QOL outcome measures Evidence of communication with GP, relevant consultants and local services. Evidence of rehabilitation services being less than 45 minutes away Patient able to see orthoplastic team at one appointment Y / N / NE Y / N / NE Y / N / NE Y / N / NE Y / N / NE Y / N / NE Y / N / NE Y / N / NE Y / N / NE Y / N / NE Y / N / NE Y / N / NE Y / N / NE Y / N / NE NE = no evidence Quality Measures 1. 2. 3. 4. RP or equivalent filled in by Rehab Specialist (Cons or AHP B7), within 72 hrs y / n / NE Holistic r/v ? multiple professionals including psychosocial ax by 10/7 y / n / NE Evidence of reassessment (at least weekly) in acute setting (if appropriate) y / n / NE Evidence of daily rehabilitation (if appropriate) input by MDT PT, OT, SLT, Psychology etc. ? --------------------------------Date of medical stability clearly recorded Re-assessment of RP or equivalent within few days of above date? Evidence of communication to Rehab Centre within 2 days of above date? Evidence of involvement of family / carers in above decision making process concerning rehab centre? 5. Evidence of goal setting in acute setting if not transferred 1. 2. 3. 4. y / n / NE Y / n / NE Y / n / NE Y / n / NE y / n / NE --------------------------------1. 2. 3. 4. 5. Patient accepted at rehab centre within 2/52 of medical stability date Evidence of goal setting with patient / family / carer involvement, in first week Evidence of long term and short term goals Evidence of review of goals and RP within 4/52 and 8/52 Evidence of voc rehab consideration (if appropriate) y / n / NE y / n / NE y / n / NE y / n / NE y / n / NE 6. Evidence of clearly assigned key worker at 1/52, 4/52, 10/52 y / n / NE 7. Evidence of relevant clinical and QOL Outcome measures at rehab centre y / n / NE 8. Evidence of communication with: GP, Social Worker, Voluntary agencies. y / n / NE NE = no evidence
Url: /Media/SUHTExtranet/WessexTraumaNetwork/Rehab-pathway-for-Msk-patients-2016.pdf

Papers CoG - 29.01.2025

Description: Date Time Location Chair Agenda Council of Governors 29/01/2025 14:00 - 15:30 Conference Room, Heartbeat/Microsoft Teams Jenni Douglas-Todd 1 Chair’s Welcome and Opening Comments 14:00 2 Declarations of Interest 14:03 3 Minutes of Previous Meeting 14:04 Approve the minutes of the previous meeting held on 23 October 2024 4 Matters Arising/Summary of Agreed Actions 14:05 There are no outstanding actions 5 Strategy, Quality and Performance 5.1 Chief Executive Officer's Performance Report 14:06 Receive and note the report Sponsor: David French, Chief Executive Officer 6 Governance 6.1 Chair and Non-Executive Director Appraisal Process 14:26 Approve the Chair and Non-Executive Director Appraisal Process Sponsor: Jenni Douglas-Todd, Trust Chair Attendee: Steve Harris, Chief People Officer 6.2 Audit and Risk Committee Terms of Reference 14:41 Provide feedback on the proposed changes before presentation to the Board of Directors Sponsor: Keith Evans, Audit and Risk Committee Chair Attendee: Craig Machell, Associate Director of Corporate Affairs and Company Secretary 6.3 Governors' Nomination Committee Terms of Reference 14:46 Approve the proposed changes to the Governors' Nomination Committee Terms of Reference Sponsor: Jenni Douglas-Todd, Trust Chair Attendee: Craig Machell, Associate Director of Corporate Affairs and Company Secretary and Karen Russell, Council of Governors' Business Manager 6.4 Annual Business Plan 14:49 Approve the Annual Business Plan for 2025/26 Sponsor: Jenni Douglas-Todd, Trust Chair Attendee: Karen Russell, Council of Governors' Business Manager 6.5 Non-Executive Director Appointment 14:52 Note the commencement of appointment of David Liverseidge Sponsor: Jenni Douglas-Todd, Trust Chair Attendee: Craig Machell, Associate Director of Corporate Affairs and Company Secretary and Karen Russell, Council of Governors' Business Manager 6.6 Governor Attendance at Council of Governors’ Meetings 14:57 Review governor attendance at Council of Governors' meetings Sponsor: Jenni Douglas-Todd, Trust Chair Attendee: Karen Russell, Council of Governors' Business Manager 6.7 Break 15:00 7 Membership Engagement and Governor Activity 7.1 Membership Engagement 15:10 Receive the report Sponsor: Jenni Douglas-Todd, Trust Chair Attendee: Sam Dolton, Events and Membership Officer 7.2 Governors' Nomination Committee Feedback 15:20 Chair: Jenni Douglas-Todd, Trust Chair 8 Review of Meeting 15:25 Review and feedback on the content of this meeting Sponsor: Jenni Douglas-Todd, Trust Chair 9 Any Other Business 15:27 Raise any relevant or urgent matters that are not on the agenda 10 Date of Next Meeting: 29 April 2025 15:29 Note the date of the next meeting Page 2 Minutes - Council of Governors (CoG) Open Session Date Time Location Chair Present 23 October 2024 14.35-15.45 Conference Room, Heartbeat Education Centre and Microsoft Teams Jenni Douglas-Todd, Trust Chair Jenni Douglas-Todd, Trust Chair JDT Shirley Anderson, Elected, New Forest, Eastleigh and Test Valley SA Katherine Barbour, Elected, Southampton City KB Lesley Gilder, Elected, Southampton City LG Sathish Harinarayanan, Elected, Medical Practitioners and Dental SH Staff Councillor Pam Kenny, Appointed, Southampton City Council PK Jenny Lawrie, Elected, Southampton City JL Brian Lovell, Elected, Rest of England and Wales BL Esther O’Sullivan, Elected, New Forest, Eastleigh and Test Valley EO Councillor Louise Parker-Jones, Appointed, Hampshire County LPJ Council Karen Smith, Elected, Health Professional and Health Scientist KS Staff Jake Smokcum, Elected, Nursing and Midwifery Staff JS Professor Emma Wadsworth, Appointed, Solent University EW Mike Williams, Elected, New Forest, Eastleigh and Test Valley MW In attendance Tracey Burt, Minutes TB Sam Dolton, Events and Membership Officer SD David French, Chief Executive Officer (for item 5.1) DF Craig Machell, Associate Director of Corporate Affairs and CM Company Secretary Farhanah Miah, Associate Governor FM Neylia Mustafapour, Associate Governor NM Karen Russell, Council of Governors’ Business Manager KR Apologies Patricia Crates, Elected, New Forest, Eastleigh and Test Valley PC Helen Eggleton, Hampshire and Isle of Wight Integrated Care HE Board (ICB) Professor Mandy Fader, Appointed, University of Southampton MF Ben Grassby, Elected, New Forest, Eastleigh and Test Valley BG Linda Hebdige, Elected, Southampton City LH 1 Chair’s Welcome and Opening Comments The Chair welcomed everyone to the meeting. In particular, the new governors and young Associate Governors. 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 24 July 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 JDT welcomed DF, Chief Executive, to the meeting. For the benefit of the new governors, he advised that he had joined the Trust in 2016 as its Chief Financial Officer and had then become CEO four years ago. He highlighted the following: • new theatres had recently been opened on F Level which would allow for greater activity. • the waiting list was now stable at around 60,000 having previously been increasing at approximately 1,000 patients per month. He acknowledged the significant effort of staff in reducing the figure. • the Trust had delivered elective activity at 126% of pre-pandemic levels (2019/20), which placed it in the top quartile of peer teaching hospitals across the country. • over the last year, the volume of first time Outpatient appointments had increased by 9%, whilst follow up appointments had reduced by 9%. The challenge was to ensure that every follow up appointment added value. • in September 2024, the hospital’s ED performance had ranked 4th when compared to 20 peer teaching hospitals across the UK. • UHS had been asked to send its financial recovery plan to NHS England (NHSE). • the hospital was constantly looking for ways to stretch itself to do even better (e.g. theatre utilisation, Outpatients and length of stay) but that was a particular challenge, when UHS was already in the top quartile of peer teaching hospitals in the UK. • UHS was working with its local system partners to reduce the number of mental health patients admitted to the hospital, when they should be seen in more appropriate settings. • each day there were around 200/250 frail, elderly patients at UHS who did not meet the criteria to reside (nCTR). On a more positive note, DF advised that: • the new system to log and communicate pathology results (LIMS) had gone live in July 2024. The previous system had been approximately 25 years old and whilst there had been some initial issues externally, the new system was now more stable. • an event ‘We are UHS’ had taken place last week in the Trust. It had provided an opportunity for staff to recognise and celebrate the work done in the hospital. The highlight had been a UHS Staff Awards night at the Hilton Hotel in West End, sponsored by Southampton Hospital Charity and hosted by DF and Gail Byrne, Chief Nursing Officer. Around 400 staff had attended the event. In response to various questions from governors, DF advised that: 2 • the Trust did not always receive extra funding for doing additional activity. The government’s view was that the NHS was still not as productive as it had been prior to the pandemic and that it should be doing more, with fewer resources. DF did not consider that staff should be asked to work any harder and instead, ways needed to be found to ensure that processes were less labour intensive. • the number of Southampton City Council (SCC) and Hampshire County Council (HCC) residents, in the hospital, who did nCTR was very similar. Both councils had been subject to significant cuts in funding and were unable to fund sufficient care home places/domiciliary packages, which would enable those patients to leave the hospital. • the investigation regarding the Never Event that had occurred in September was still underway. KS said that she had been encouraged to hear DF talk about the LIMS project and the incredible work done by the Pathology Team, which she would feedback to the wider pathology community. DF advised that the Trust had commissioned an external review, which would be shared internally and externally. It was hoped that the review would help other hospitals who would, in the future, implement LIMS. 6 Governance 6.1 Governor Attendance at Council of Governors’ Meetings KR advised that under the Trust’s constitution, if a governor failed to attend two successive meetings of the CoG, without good reason, their tenure of office would be terminated. At the time of review, one governor had missed two successive meetings but this had been discussed and was with good cause. Decision: The CoG confirmed that it was satisfied that the failure of the governor to attend two successive meetings of the CoG had been due to reasonable cause and that they would attend future meetings within a reasonable period. No termination of office was therefore required. 6.2 Appointment to the Governors’ Nomination Committee KR advised that a vacancy had arisen on the Governors’ Nomination Committee (GNC) when Kelly Lloyd had left the Trust on 30 June 2024. Governors had been asked to express an interest in joining the GNC, which JL had done. The CoG had decided by unanimous vote to approve her appointment to the GNC. 6.3 Meeting with the Hampshire and IoW ICB - Chair Appointments JDT advised governors that Hampshire and IoW Integrated Care Board (ICB) would be meeting with them on 31 October 2024 at 4 p.m. The intention of the meeting was for the ICB to set out its aspirations for the future of healthcare within Hampshire and the IoW. The ICB had already begun talks with UHS about it working more closely with Hampshire Hospitals NHS Foundation Trust and they also planned for Portsmouth and Isle of Wight hospitals to work together more closely. KR advised that she would circulate the finalised agenda to governors in due course. 3 6.4 Strategy Session Planning KR advised that there would be a Strategy Session for the CoG on Wednesday 11 December 2024 in the Conference Room, Heartbeat Suite. She asked governors to suggest topics for the session and the following were mentioned: • Prof. Chris Kipps, Clinical Director of Research and Development, the Wessex secure data environment and public engagement. • the management of infection prevention within the hospital (e.g. C. difficile) and keeping staff and patients safe. It was suggested that Julie Brooks, Head of Infection Prevention, was invited to the session. • making boards of governors more effective/looking at case studies. SA and JL mentioned an excellent presentation they had heard by NHS Providers. KR said that Martin De Sousa, Director of Strategy and Partnerships, was already booked to attend the session. KR advised that she would circulate further details regarding the Strategy Session in due course. 7 Membership Engagement and Governor Activity 7.1 Membership Engagement SD introduced the Membership Engagement report. He advised that the Communications Team had been involved in organising the recent UHS Staff Awards night and he said that there had been good engagement on social channels and from the Daily Echo. The event would also be featured in the quarterly Connect digital magazine to be published in November. The team was now focussed on the Annual Members’ Meeting and Open Evening to be held on 21 November 2024 in the Heartbeat Lecture Theatre and Conference Room. Around 50 members had already signed up to attend and he was hoping that would rise to 80. He encouraged governors (6 had already signed up) to attend, as it would provide them with a good opportunity to engage with the membership. He advised that in December the virtual event research series would continue with an event on healthy ageing. The following comments were made: • JDT said that the data on emails sent out and the number of bounces was interesting. It suggested that there was some merit in a more focussed/targeted approach. • JDT noted the low engagement with the appeal for second hand clothing for patients to go home in. Governors wondered whether it was due to it being an appeal that had been done before, rather than one that was new. 7.2 Feedback from Strategy and Finance Working Group EO advised that Jake Wilkins, Associate Director, Always Improving, had given an interesting talk to the group on how the Trust’s strategy, transformation plans and improvement goals were delivered. KR noted that he had emailed a copy of his presentation direct to governors. 4 7.3 Feedback from Patient and Staff Experience Working Group KR advised that Shona Small, Complaints Manager and Debbie Watson, Head of Patient and Family Relations, had attended the group to discuss the annual complaints report, which they had circulated prior to the meeting. They had highlighted the nature and complexity of complaints and the challenges of dealing with people who could be difficult to help. The team had been struggling with a lack of resources but that was beginning to ease and they had been positive above the support they received from senior leadership and from one another. The team did also receive positive feedback but governors noted that there was no regulatory requirement for that to be recorded. 7.4 Feedback from Membership and Engagement Working Group SD advised that there had been a discussion about the Annual Members’ Meeting and the role of governors, on the evening. It had been decided that governors could choose whether they roamed, chatting to attendees, or manned the stand that would be in the Conference Room. JDT encouraged all governors to interact with members both at the event and, more generally, in their constituencies. 8 Review of Meeting Governors felt that the sound quality had improved, both in the room and for those who had joined via Teams. It was, however, noted that some attendees still spoke too quietly. FM said that she had been encouraged that governors’ views were valued and listened to. There was a suggestion that governors should bring their own cups for drinks and they asked to be reminded prior to the meetings. 9 Any Other Business There was no other business. 10 Date of Next Meeting The next meeting of the CoG would be held on 29 January 2025. 5 Item 5.1 Report to the Council of Governors - 29 January 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 Y 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 N/A N/A N/A 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 January 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 October 2024 to December 2024, noting that some quarterly performance data is reported further in arrears. Notable features of the last quarter include: • A significantly high volume of attendances to our Emergency Department in the period, averaging 448 patients per day. A reflection of a challenging national position which has significantly impacted four-hour performance. • An extremely challenging number of patients not meeting the criteria to reside with volumes peaking above 250 in recent weeks. These patients continue to occupy hospital beds, restricting flexibility in our elective programmes, and impacting flow through the hospital. • Whilst the waiting list has stabilised across the quarter, volumes continue to be above 60,000 with pressure predominantly in referral cohort. However, good progress has been made in reducing the longest waiting patients at both 78+ and 65+ weeks. • The organisation continues to benchmark well for cancer services, ranking in 1st place compared to peer teaching hospitals for two of the three standard waiting time metrics • The financial environment remains extremely challenging and is being monitored closely. UHS reported an £18.2m deficit after eight months which is £14.8m behind plan. This is predominantly due to savings targets not being fully achieved particularly those related to system transformation. • The trust remains on target to spend its full capital allocation for 2024/25 and has delivered elective recovery fund activity (ERF) at 128% of 2019/20 levels which is 15% above the trust’s target. 2. Safety Infection Control MRSA Bacterium infection Clostridium Difficile infection Target 0 78.0% Oct 2024 Nov 2024 Dec 2024 66.6% 59.4% 57.7% Attendances to the Emergency Department (ED) increased further in quarter three, averaging 448 per day across October, November and December in 2024. This represents an increase of 6.6% compared to the previous quarter and a 5.8% increase compared to the same period last year. The pressure on the emergency department across the festive period presented significant challenges on hospital flow and bed state - the four hour performance position reducing to 57.7% in December 2024. This position places the hospital in the third quartile when compared to twenty peer teaching hospitals for Type 1 attendances. Referral to Treatment (RTT) % incomplete pathways within 18 weeks in month Total patients on a waiting list Target => 92% Oct 2024 63.41% 60,879 Nov 2024 62.44% 60,338 Dec 2024 62.04% 60,387 Despite a small decrease in December, the trust’s RTT waiting list remained above 60,000 in every month within quarter three. The main pressure continues to be the referral element of the pathway with the number of patients waiting for surgery reducing. 62% of patients on the waiting list have been waiting less than 18 weeks - the organisation has consistently benchmarked in the top quartile when compared to peer teaching organisations for this metric. UHS continues to make good progress in reducing the longest waiting patients. UHS reported zero patients waiting over 78 weeks in December 2024 and 22 patients waiting over 65 weeks. The majority of these patients remain those impacted by the national shortage of corneal tissue. The organisation’s focus for the remainder of the year continues to be patients waiting over 52 weeks. Cancer Target Faster Diagnosis - within 28 days > =77% 31 Day target - decision to treat to first definitive treatment 62 day target - urgent referral to first definitive treatment => 96% => 70% Sep 2024 82.4% 93.1% 78.1% Oct 2024 84.8% 94.2% 77.5% Nov 2024 86.2% 94.4% 78.9% The organisation has made positive progress in improving cancer waiting times in quarter three. Delivery against the 28 day faster diagnosis has remained above the national target and seen month on month improvement achieving 86.2% for November. This places the organisation in first place compared to 20 peer teaching hospitals across the country. The hospital also ranks in first place for the 62day target. Page 4 of 6 The organisation continues to prioritise cancer patients and their treatments for all tumour sites and cancer types. Pathway efficiencies particularly around pathology and diagnostics are constantly being explored as well as regular dialogue with Wessex Cancer Alliance and the ICB on improvements and innovative techniques to ensure referrals are appropriate and timely. 5. Finance The financial environment remains extremely challenging as we head into the final quarter of 2024/25. The annual plan for 2024/25 was originally approved as a £14.5m deficit which was reduced to £3.3m following central support funding being issued for organisations in deficit. UHS is currently reporting an £18.2m deficit after eight months which is £14.8m behind plan. This is predominantly due to savings targets not being fully achieved particularly those related to system transformation not yet yielding financial benefits. These were always known to have greater risk attached due to the scale of change required. Of note both non criteria to reside and mental health schemes are challenged with patient numbers remaining at similar levels to 2023/24. Both these areas were targeted for significant reduction with the aim of delivering both quality and financial savings. The non delivery of system transformation schemes YTD means £9m of planned savings have not been achieved. Other challenges around industrial action and pay disputes have in many areas now been resolved although there are several areas still under discussion with unions. It should also be noted that UHS continues to deliver activity over and above its funded block contract levels which is valued at £20m YTD. This mainly relates to Emergency Department and Non Elective activity. The YTD deficit and underlying deficit run rate means there is now a significant challenge in delivering the financial plan for the year that would require a surplus to be delivered across the remaining four months and over delivery on efficiency savings targets within the plan. In response to this challenge UHS continues to work with both internal and external stakeholders on how improvements can be achieved. Despite this challenge the organisation has made significant efforts in making sure workforce growth is controlled and agency costs minimised. Agency expenditure is below 1% of total pay expenditure and continues to benchmark favourably when compared to similar organisations. Surge capacity (beds not normally commissioned) have also remained much lower levels than the previous year although has known peaks and troughs with the winter period often more challenging. The trust has also delivered elective recovery fund activity (ERF) at 128% of 2019/20 levels which is 15% above the trust’s target. iThis has helped deliver additional revenues of £20m across the first half of 2023/24 and helping to reduce long waiting patient numbers. Internal transformation initiatives also continue to drive incremental improvement in theatres productivity, outpatient productivity and length of stay with the former two workstreams showing noticeable improvements across the first half of 2024/25. Due to the scale of risk around financial delivery however, for both UHS and the HIOW system, the trusts financial recovery journey continues to be monitored closely as continuing to run in a deficit is not sustainable for the trusts cash or capital position. The trust however remains positive that in working with system partners, improvements can be achieved in time returning the trust to a breakeven footing. Further to this the trust remains on target to spend its full capital allocation for 2024/25 totalling £86m. This includes £1.75m funding (awaiting approval) towards Same Day Emergency Care (SDEC), £18m related to continued investment in decarbonisation funded via a Salix grant, and £7m related to the completion of the Southampton Community Diagnostics Centre planned for the Royal South Hants hospital (centrally funded). This continued investment in capacity, digital and estates infrastructure helps support continued efficiency improvement that provide foundations for the future. Page 5 of 6 6. Human Resources Indicator Staff recommend UHS as a place to work % Staff survey engagement score (out of 10) Q2 24/25 64.1% 6.84 Q3 24/25 Results under national embargo Results under national embargo The annual staff survey takes place throughout September to November. The survey has now closed and we have started to receive the initial results from our supplier, Picker. The HR and OD teams are analysing the initial results and will continue to do so as we receive further results. The participation rate decreased this year, from the previous year, and we will be sharing the results over the coming months as per the national embargo timeline, which is expected to lift February-March 2025. Following this we will be sharing the results trust-wide and supporting teams to receive and respond to the feedback. Indicator Staff Turnover (internal target; rolling 12 month) Sickness absence 12 month rolling (internal target) Target <=13.6% <=3.9% Oct 2024 10.8% 3.87% Nov 2024 10.6% 3.9% Dec 2024 10.7% 3.92% Turnover: In December 2024, there was a total of 99.5 WTE leavers, 22.5 WTE more than November 2024 (77 WTE). The highest since September 2024. Division C recorded the highest number of leavers (28 WTE). Within Division C, Allied Health Professionals staff group had the highest number of leavers (7 WTE), followed by the Nursing and Midwifery Registered staff group at 6 WTE. Divisions B and D had the second and third highest number of leavers (22 and 22 WTE respectively); with the largest numbers being Administrative and Clerical staff group for Div B (8 WTE), and Nursing and Midwifery Registered staff group for Div D (9 WTE). Sickness: In December 2024, the Trusts rolling 12-month sickness absence rate increased to 3.92% (0.02% above target). While the in-month sickness absence reduced from 4.2% in November 2024 to 4.1% in December 2024. Over November and December 2024, anxiety, stress and depression remained at 1% while cold, cough and flu – influenza increased from 0.7% in November to 0.9% in December. Page 6 of 6 Item 6.1 Report to the Council of Governors - 29 January 2025 Title: Chair and Non-Executive Director Appraisal Process 2024/25 Sponsor: Jenni Douglas-Todd, Trust Chair Author: Steve Harris, Chief People Officer and Karen Russell, Council of Governors Business Manager Purpose (type an ‘x’ in the appropriate box(es)) (Re)Assurance Approval Ratification Information Y 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 N/A N/A N/A N/A N/A Executive Summary: The NHS Foundation Trust Code of Governance requires that the Council of Governors (CoG) should take the lead on agreeing a process for the evaluation of the chair and the non-executive directors (NEDs). The Governors’ Nomination Committee (GNC) advises the CoG on that process. The appraisal process supports the board of directors (Board) in ensuring its overall effectiveness by making sure that any individual or collective development needs are identified and that the chair and non-executive directors continue to have capacity to meet the time commitment required for the role. The outcome of appraisal will also be relevant to any decision by the CoG to reappoint a non-executive director. Following recommendation by the GNC at its meeting on 15 January 2025, the CoG is asked to approve the Chair and NED appraisal process for 2024/25. Contents: The attached paper sets out the proposed appraisal process for 2024/25. Risk(s): N/A Equality Impact Consideration: N/A Chair and Non-Executive Director (NED) Appraisal Process for 2024/25 1. Introduction and purpose 1.1 The NHS Foundation Trust Code of Governance requires that the Council of Governors (CoG) should take the lead on agreeing a process for the evaluation of the chair and the non-executive directors (NEDs). The Governors’ Nomination Committee (GNC) advises the CoG on that process. The results of the appraisals are shared with the GNC and the CoG. 1.2 The Trust normally aims to complete the process by 31 March each year. 1.3 The new NHS England (NHSE) Fit and Proper Person Framework for boards was introduced with effect from 30 September 2023. NHSE are expected to launch new appraisals processes for all board members as part of a revised national framework for the management of senior leaders. A refreshed appraisal process for chairs was released in 2024, however the remaining board member processes are still outstanding with no clear date yet for implementation. 1.4 It is recommended therefore the Trust proceeds with the use of the existing NED appraisal framework and uses the new framework provided for the Chair appraisal. 1.5 This paper sets out the proposed process and timescales for the Chair and NED appraisals for 2024/25. 2. Overview of the process 2.1 The Chair of the Trust has responsibility for undertaking the appraisals for NEDs. The Chair’s appraisal process is conducted by the Senior Independent Director (SID). 2.2 Jenni Douglas-Todd, as Trust Chair, will undertake the NED appraisals. Jane Harwood, in her role as SID, will undertake the Chair’s appraisal. 2.3 The process will aim to: • Provide a structured review of performance against personal and organisational objectives set, and the performance of the Trust. • Reflect on demonstration of the Trust values. • Review attendance at key Trust meetings. • Plan for the future, including objective setting for the next year and the identification of a personal development plan. • Provide overall reporting and assurance to the GNC and CoG. Self evaluation Monitoring and reporting to GNC Seeking structured feedback from others Appraisal meeting and personal development plan Evaluation against organisational and personal objectives Appraisal of living the Trust values 2.4 The Trust will use the guidance forms provided by NHSE for NED appraisal. The Trust’s NED appraisal process is in line with guidance published by NHS England (NHSE). 3. NHSE Framework for Chair’s appraisal 3.1 NHSE have a national framework for appraisals of Chairs of provider organisations which was refreshed in 2024. This requests that Trusts ensure a robust multi-source feedback process is conducted. In the refreshed process this is now to be undertaken with consideration given to the NHSE new leadership framework. A summary of these 6 areas can be found in appendix A. The full framework can be found here. 3.2 A summary of the Chair’s appraisal is also required to be provided to the NHSE Regional Director. 3.3 It is intended that UHS use the templates provided for the Chair’s appraisal, and also include our own local values. Multi-source feedback will continue to be requested from Trust Board members and the CoG. Feedback will also be sought from the ICS. 4. Scope of Appraisal 4.1 Appraisals will cover all non-executive directors. This includes: • Jenni Douglas-Todd (Trust Chair) • Keith Evans (Deputy Chair) • Jane Harwood (Senior Independent Director) • Dave Bennett • Professor Diana Eccles • Dr Tim Peachey • Alison Tattersall An objective setting process will take place with David Liverseidge as very recent new starter. 5. Proposed process 5.1 The following is proposed as the process for the 2024/25 round of appraisals: • Use of the standard NED NHSE appraisal template. • Use a system of gaining qualitative feedback on each NED to be appraised from both the CoG and from the Board. • The Chair will meet with each NED to conduct the appraisal once feedback has been collated. • The SID will conduct the appraisal for the Chair. 5.2 To ensure meaningful views can be obtained, it is suggested that the CoG will be asked to provide positive feedback and areas of development in respect of the NEDs as individuals, and as a group. The Lead Governor (Shirley Anderson) will be asked to seek feedback from the council members. 6. Timetable of events Action Agree process and timescales with GNC Details GNC briefed on process and timescales. Who JDT and SH To be completed by 15 January 2025 Booking appraisal Appraisal meetings to be booked by KB meetings JDT (KB) 31 January 2025 Sending out forms All feedback forms to be sent out to SH appraisees and to Governors by close of play on 1 February 2024. Feedback forms to be sent to: • Governors (Via Lead Governor) • All Executives • All NEDs 1 February 2025 Seeking feedback Feedback to be provided to the Chief SA People Officer, who will collate it. SH 21 February 2025 Booking appraisal Appraisal meetings to be booked by KB meetings JDT (KB) 31 January 2025 Appraisal meetings held JDT to hold appraisal meetings with: JDT • Dave Bennett • Professor Diana Eccles • Keith Evans • Jane Harwood 31 March 2025 • Dr Tim Peachey • Alison Tattersall Objective setting meeting to be held with David Liverseidge as a new NED JH to hold appraisal meeting with JDT JH Summary reporting to GNC SH, JDT and JH to draft a summary report to be shared with GNC covering: • Feedback • Areas for development • Objectives going forward SH, JDT and JH Report to be provided to the GNC by SH, JDT and JH. Reporting to COG GNC, supported by Chief People Officer and Chair, to provide a summary report and assurance to the CoG. SH, JDT and JH Reporting to NHSE Summary report to be provided to SH NHSE in line with framework process. 31 March 2025 22 April 2025 29 April 2025 30 April 2025 7. The role of the GNC in assurance and scrutiny 7.1 The GNC will be provided with an annual report written by the Chair, supported by the Chief People Officer, which will provide an overview of the appraisals undertaken, including an overall performance summary and objectives. 7.2 The GNC will have a direct role in endorsing the appraisal process for the Chair. The SID will undertake the appraisal and provide a key summary to the GNC who will be asked to endorse the outcome. 7.3 The CoG will receive assurance from the GNC that appropriate performance appraisal of the Chair and NEDs has taken place. 8. Recommended next steps 8.1 Following recommendation by the GNC at its meeting on 15 January 2025, the CoG is asked to approve the Chair and NED appraisal process for 2024/25. Steve Harris Chief People Officer January 2025 Appendix A – Refreshed leadership framework competencies for the Chair Appraisal Driving high-quality and sustainable outcomes The skills, knowledge and behaviours needed to deliver and bring about high quality and safe care and lasting change and improvement - from ensuring all staff are trained and well led, to fostering improvement and innovation which leads to better health and care outcomes. Setting strategy and delivering long-term transformation The skills that need to be employed in strategy development and planning, and ensuring a system wide view, along with using intelligence from quality, performance, finance and workforce measures to feed into strategy development. Promoting equality and inclusion, and reducing health and workforce inequalities The importance of continually reviewing plans and strategies to ensure their delivery leads to improved services and outcomes for all communities, narrows health and workforce inequalities, and promotes inclusion. Providing robust governance and assurance The system of leadership accountability and the behaviours, values and standards that underpin our work as leaders. This domain also covers the principles of evaluation, the significance of evidence and assurance in decision making and ensuring patient safety, and the vital importance of collaboration on the board to drive delivery and improvement. Creating a compassionate, just and positive culture The skills and behaviours needed to develop great team and organisation cultures. This includes ensuring all staff and service users are listened to and heard, being respectful and challenging inappropriate behaviours. Building a trusted relationship with partners and communities The need to collaborate, consult and co-produce with colleagues in neighbouring teams, providers and systems, people using services, our communities, and our workforce. Strengthening relationships and developing Agenda item 6.2 Report to the Council of Governors - 29 January 2025 Title: Audit and Risk Committee Terms of Reference Sponsor: Keith Evans, Chair Author: Craig Machell, Associate Director of Corporate Affairs Purpose (Re)Assurance Approval Ratification Information x Strategic Theme Outstanding patient outcomes, safety and experience Pioneering research and innovation World class people Integrated networks and collaboration Foundations for the future x Executive Summary: The terms of reference for all Board committees should be reviewed regularly, and at least once annually, to ensure that these reflect the purpose and activities of each committee. The Code of Governance for NHS Provider Trusts requires that Council of Governors is consulted on the terms of reference. The terms of reference are approved by the Board of Directors. It is proposed to amend 10.2 to Code of Governance for NHS Provider Trusts and remove Charitable Funds Committee from Appendix A. No other changes are proposed. The Council of Governors is requested to provide any feedback on the proposed changes to the terms of reference prior to their submission to the Board of Directors for approval. Contents: Audit and Risk Committee Terms of Reference Risk(s): N/A Equality Impact Consideration: N/A Audit and Risk Committee Terms of Reference Version: 67 Date Issued: Review Date: Document Type: 29 February 2024 11 March 2025 30 January 2025 January 2026 Committee Terms of Reference Contents Paragraph 1 2 3 4 5 6 7 8 9 10 Role and Purpose Constitution Membership Attendance and Quorum Frequency of Meetings Conduct and Administration of Meetings Duties and Responsibilities Accountability and Reporting Review of Terms of Reference and Performance and Effectiveness References Appendices Appendix A Committee and Reporting Structure Page 2 2 2 3 3 3 4 6 6 6 Page 7 Document Status This is a controlled document. Whilst this document may be printed, the electronic version posted on the intranet is the controlled copy. Any printed copies of this document are not controlled. As a controlled document, this document should not be saved onto local or network drives but should always be accessed from the intranet. Page 1 of 8 1. Role and Purpose 1.1 The Audit and Risk Committee (the Committee) is responsible for overseeing, monitoring and reviewing corporate reporting, the adequacy and effectiveness of the governance, risk management and internal control framework and systems and areas of legal and regulatory compliance at University Hospital Southampton NHS Foundation Trust (UHS or the Trust) and the external and internal audit functions. 1.2 The Committee provides the board of directors of the Trust (the Board) with a means of independent and objective review of financial and corporate governance, assurance processes and risk management across the whole of the Trust’s activities both generally and in support of the annual governance statement. 1.3 The duties and responsibilities of the Committee are more fully described in paragraph 7 below. 2. Constitution 2.1 The Committee has been established by the Board. The Committee has no executive powers other than those set out in these terms of reference. It is supported in its work by other committees established by the Board as shown in Appendix A. 2.2 The Committee is authorised by the Board to investigate any activity within its terms of reference. It is authorised to seek any information it requires from any member of staff and all members of staff are directed to cooperate with any request made by the Committee. 2.3 In carrying out its role the Committee will primarily utilise the work of internal audit, external audit and other assurance functions. It is also authorised to seek reports and assurance from executive directors and managers and will maintain effective relationships with the chairs of other Board committees to understand their processes of assurance and links with the work of the Committee. 2.4 The Committee is authorised to obtain external legal or other independent professional advice if it considers this necessary, taking into consideration any issues of confidentiality and the Trust’s standing financial instructions. 3. Membership 3.1 The members of the Committee will be appointed by the Board and will be independent non-executive directors of the Trust (other than the chair of the Board). The Committee will consist of not less than three members, at least one of whom will have recent and relevant financial experience, ideally with a qualification from one of the professional accountancy bodies. 3.2 The Board will appoint the chair of the Committee from among its members (the Committee Chair).The Committee Chair may be the deputy chair of the Board. However, in the event that the deputy chair must act as chair of the Board for an extended period of time, the deputy chair will resign as Committee Chair. In the absence of the Committee Chair and/or an appointed deputy, the remaining members present will elect one of themselves to chair the meeting. 3.3 Only members of the Committee have the right to attend and vote at Committee meetings. However, the following will be invited to attend meetings of the Committee on a regular basis: 3.3.1 representative(s) from the external auditor; 3.3.2 representative(s) from the internal auditor; Page 2 of 8 3.3.3 representative(s) from the local counter fraud service; 3.3.4 Chief Financial Officer; 3.3.5 Chief Nursing Officer; and 3.3.6 Associate Director of Corporate Affairs/Company Secretary. 3.4 The Chief Executive Officer will be invited to attend meetings of the Committee, at least annually, to discuss with the Committee the process for assurance that supports the annual governance statement. 3.5 Other individuals may be invited to attend for all or part of any meeting, as and when appropriate and necessary, particularly when the Committee is considering areas of risk or operation that are the responsibility of a particular executive director or manager. 3.6 Governors may be invited to attend meetings of the Committee. 4. Attendance and Quorum 4.1 Members should aim to attend every meeting and should attend a minimum of 75% of meetings held in each financial year. Where a member is unable to attend a meeting they should notify the Committee Chair or Company Secretary in advance. 4.2 The quorum for a meeting will be two members. A duly convened meeting of the Committee at which a quorum is present will be competent to exercise all or any of the authorities, powers and discretions vested in or exercisable by the Committee. 4.3 When an executive director or manager is unable to attend a meeting they should appoint a deputy to attend on their behalf. 5. Frequency of Meetings 5.1 The Committee will meet at least four times each year and otherwise as required. 5.2 At least once each financial year the Committee will meet with representatives of the external and internal auditors without management being present to discuss their remit and any issues arising from their audits. 5.3 Outside of the formal meeting programme, the Committee Chair will maintain a dialogue with key individuals involved in the Trust’s governance, including the chair of the Board, the Chief Executive Officer, the Chief Financial Officer, the Chief Nursing Officer, the external audit lead partner and the head of internal audit. 6. Conduct and Administration of Meetings 6.1 Meetings of the Committee will be convened by the secretary of the Committee at the request of the Committee Chair or any of its members, or at the request of external or internal auditors if they consider it necessary. 6.2 The agenda of items to be discussed at the meeting will be agreed by the Committee Chair with support from the Chief Financial Officer and the Company Secretary. The agenda and supporting papers will be distributed to each member of the Committee and the regular attendees no later than five working days before the date of the meeting. Distribution of any papers after this deadline will require the agreement of the Committee Chair. 6.3 The secretary of the Committee will minute the proceedings of all meetings of the Committee, including recording the names of those present and in attendance and any declarations of interest. 6.4 Draft minutes of Committee meetings and a separate record of the actions to be taken forward will be circulated promptly to all members of the Committee. Once approved by Page 3 of 8 the Committee, minutes will be circulated to all other members of the Board unless it would be inappropriate to do so in the opinion of the Committee Chair. 7. Duties and Responsibilities The Committee will carry out the duties below for the Trust. 7.1 Integrated Governance, Risk Management and Internal Control 7.1.1 The Committee will review the establishment and maintenance of an effective system of integrated governance, risk management and internal control across the whole of the Trust’s activities (clinical and non-clinical), that supports the achievement of the Trust’s objectives. In particular, the Committee will review the adequacy and effectiveness of: 7.1.1.1 all risk and control related disclosure statements (in particular the annual governance statement), together with the head of internal audit opinion, external audit opinion or other appropriate independent assurances, prior to submission to the Board; 7.1.1.2 the underlying assurance processes that indicate the degree of achievement of the Trust’s objectives, the effectiveness of the management of principal risks and the appropriateness of annual disclosure statements; and 7.1.1.3 the policies and arrangements for ensuring compliance with relevant regulatory, legal and code of conduct requirements and any related reviews, reporting and selfcertifications, including the NHS Constitution, the Trust’s NHS provider licence, registration with the Care Quality Commission and the Trust’s constitution, standing orders and standing financial instructions and management of conflicts of interest. 7.2 Internal Audit 7.2.1 The Committee will ensure that there is an effective internal audit function that meets the Public Sector Internal Audit Standards and provides appropriate independent assurance to the Committee, Accounting Officer and Board. This will be achieved by: 7.2.1.1 considering the provision of the internal audit service and the costs involved; 7.2.1.2 reviewing and approving the annual internal audit plan and more detailed programme of work, ensuring that this is consistent with the audit needs of the Trust as identified in any risk assessment; 7.2.1.3 considering the major findings of internal audit work (and the appropriateness and implementation of management responses) and ensuring coordination between the internal and external auditors to optimise audit resources; 7.2.1.4 ensuring the internal audit function is adequately resourced and has appropriate standing within the Trust; and 7.2.1.5 monitoring the effectiveness of internal audit and carrying out an annual review. 7.3 External Audit 7.3.1 The Committee will review and monitor the external auditors’ integrity, independence and objectivity and the effectiveness of the external audit process. In particular, the Committee will review the work and findings of the external auditors and consider the implications and management’s response to their work. This will be achieved by: 7.3.1.1 considering the appointment and performance of the external auditors, including providing information and recommendations to the council of governors in connection with the appointment, reappointment and removal of the external auditors in line with criteria agreed by the council of governors and the Committee; Page 4 of 8 7.3.1.2 discussing and agreeing with the external auditors, before the external audit commences, the nature and scope of the audit as set out in the annual external audit plan; 7.3.1.3 discussing with the external auditors their evaluation of audit risks and assessment of the Trust and the impact on the audit fee; 7.3.1.4 reviewing all external audit reports, including reports addressed to the Board and the council of governors, and any work undertaken outside the annual external audit plan, together with any significant findings and the appropriateness and implementation of management responses; and 7.3.1.5 ensuring that there is in place a clear policy for the engagement of external auditors to supply non-audit services taking into account relevant ethical guidance. 7.4 Financial Reporting 7.4.1 The Committee will monitor the integrity of the financial statements of the Trust and any formal announcements relating to the Trust’s financial performance. 7.4.2 The Committee will ensure that the systems for financial reporting to the Board, including those of budgetary control, are subject to review as to the completeness and accuracy of the information provided to the Board. 7.4.3 The Committee will review the annual report and financial statements before these are presented to the Board in order to determine their completeness, objectivity, integrity and accuracy and the letter of representation addressed to the external auditors from the Board. This review will cover but is not limited to: 7.4.3.1 the annual governance statement and other disclosures relevant to the work of the Committee; 7.4.3.2 areas where judgment has been exercised; 7.4.3.3 appropriateness and adherence to accounting policies and practices; 7.4.3.4 explanation of estimates or provisions having material effect and significant variances; 7.4.3.5 the schedule of losses and special payments, which will also be reported on separately during the financial year; 7.4.3.6 any significant adjustments resulting from the audit and unadjusted audit differences; and 7.4.3.7 any reservations and disagreements between the
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Papers-CoG-24.07.2024

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

Aria ePrescribing v13.6 MR1.2 user training guide

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

Standing Financial Instructions

Description: These Standing Financial Instructions (SFIs) are issued for the regulation of the conduct of Trust members and officers in relation to all financial matters with which they are concerned.
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Finance/StandingFinancialInstructions.pdf

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
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Papers Trust Board - 30 January 2024

Description: Date Time Location Chair Apologies Agenda Trust Board – Open Session 30/01/2024 9:00 - 13:00 Conference Room, Heartbeat/Microsoft Teams Jenni Douglas-Todd Diana Eccles 1 Chair’s Welcome, Apologies and Declarations of Interest 9:00 Note apologies for absence, and to hear any declarations of interest relating to any item on the Agenda. 2 Patient Story The patient or 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 Break 9:15 4 Minutes of Previous Meeting held on 30 November 2023 9:25 Approve the minutes of the previous meeting held on 30 November 2023 5 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. 6 QUALITY, PERFORMANCE and FINANCE Quality includes: clinical effectiveness, patient safety, and patient experience 6.1 Briefing from the Chair of the Audit and Risk Committee (Oral) 9:35 Keith Evans, Chair 6.2 Briefing from the Chair of the Finance and Investment Committee (Oral) 9:40 Dave Bennett, Chair 6.3 Briefing from the Chair of the People and Organisational Development 9:45 Committee (Oral) Jane Harwood, Chair 6.4 Briefing from the Chair of the Quality Committee (Oral) 9:50 Tim Peachey, Chair 6.5 Chief Executive Officer's Report 9:55 Receive and note the report Sponsor: David French, Chief Executive Officer 6.6 Performance KPI Report for Month 9 10:25 Review and discuss the report Sponsor: David French, Chief Executive Officer 6.7 Finance Report for Month 9 10:55 Review and discuss the report Sponsor: Ian Howard, Chief Financial Officer 6.8 People Report for Month 9 11:15 Review and discuss the report Sponsor: Steve Harris, Chief People Officer 6.9 11:35 Break 6.10 Maternity Safety 2023-24 Quarter 3 Report 11:45 Review and discuss the report Sponsor: Gail Byrne, Chief Nursing Officer Attendees: Emma Northover, Director of Midwifery/Marie Cann, Maternity/Neonatal Safety Lead/Alison Millman, Safety & Quality Assurance Matron 7 STRATEGY and BUSINESS PLANNING 7.1 Corporate Objectives 2023-24 Quarter 3 Review 12:00 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 7.2 Board Assurance Framework (BAF) Update 12:10 Review and discuss the update Sponsor: Gail Byrne, Chief Nursing Officer Attendees: Craig Machell, Associate Director of Corporate Affairs and Company Secretary/Lauren Anderson, Corporate Governance and Risk Manager 8 CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 8.1 Register of Seals and Chair's Actions Report 12:20 Receive and ratify In compliance with the Trust Standing Orders, Financial Instructions, and the Scheme of Reservation and Delegation. Sponsor: Jenni Douglas-Todd, Trust Chair Page 2 8.2 Review of Standing Financial Instructions 2023-24 12:25 Review and approve the SFIs Sponsor: Ian Howard, Chief Financial Officer Attendee: Phil Bunting, Director of Operational Finance 8.3 Finance and Investment Committee Terms of Reference 12:30 Review and approve the Terms of Reference Sponsor: Dave Bennett, Committee Chair Attendee: Craig Machell, Associate Director of Corporate Affairs and Company Secretary 8.4 Quality Committee Terms of Reference 12:35 Review and approve the Terms of Reference Sponsors: Tim Peachey, Committee Chair Attendee: Craig Machell, Associate Director of Corporate Affairs and Company Secretary 9 Any other business 12:40 Raise any relevant or urgent matters that are not on the agenda 10 Note the date of the next meeting: 28 March 2024 11 Resolution regarding the Press, Public and Others Sponsor: Jenni Douglas-Todd, Trust Chair To agree, as permitted by the National Health Service Act 2006 (as amended), the Trust's Constitution and the Standing Orders of the Board of Directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. 12 Follow-up discussion with governors 12:45 Page 3 Minutes Trust Board – Open Session Date Time 30/11/2023 9:00 – 13:00 Location Chair Present Microsoft Teams Jenni Douglas-Todd (JD-T) Dave Bennett, NED (DB) Gail Byrne, Chief Nursing Officer (GB) Keith Evans, Deputy Chair and NED (KE) David French, Chief Executive Officer (DAF) Paul Grundy, Chief Medical Officer (PG) Steve Harris, Chief People Officer (SH) Jane Harwood, NED/Senior Independent Director (JH) Duncan Linning-Karp, Deputy Chief Operating Officer (DL-K) (for J Teape) Ian Howard, Chief Financial Officer (IH) Femi Macaulay, Interim NED (FM) Tim Peachey, NED (TP) In attendance Martin De Sousa, Director of Strategy and Partnerships (MDeS) Craig Machell, Associate Director of Corporate Affairs and Company Secretary (CM) James Allen, Chief Pharmacist (JA) (item 5.12) Lauren Anderson, Corporate Governance and Risk Manager (LA) (item 6.2) Julie Brooks, Head of Infection Prevention Unit (JB) (item 5.13) Marie Cann, Maternity/Neonatal Safety Lead (MC) (item 5.9) Rosemary Chable, Head of Nursing for Education, Practice and Staffing (RC) (item 5.15) Diana Hulbert, Guardian of Safe Working Hours and Emergency Department Consultant (DH) (item 5.11) Christine Mbabazi, Equality & Inclusion Adviser/Freedom to Speak Up Guardian (CM) (item 5.15) John Mcgonigle, Emergency Planning & Resilience Manager (JM) (item 7.1) Alison Millman, Safety & Quality Assurance Matron (AM) (item 5.9) Jenny Milner, Associate Director of Patient Experience (JM) (item 5.10) Emma Northover, Director of Midwifery (EN) (item 5.9) Danielle Sinclair, Deputy Emergency Planner (DS) (item 7.1) Julian Sutton, Interim Lead Infection Control Director (JS) (item 5.13) 1 member of the public (item 2) 5 governors (observing) 1 member of staff (observing) 5 members of the public (observing) Apologies Diana Eccles, NED (DE) Joe Teape, Chief Operating Officer (JT) 1. Chair’s Welcome, Apologies and Declarations of Interest The Chair welcomed attendees to the meeting. Tim Peachey informed the Board that he now sits on the combined Portsmouth Hospitals University NHS Foundation Trust and Isle of Wight NHS Trust board, following the recent organisational changes. There were no further interests to declare in the business to be transacted at the meeting. Page 1 The Chair provided an overview of her activities since October 2023, including visits to hospital departments, meetings with peers and other key stakeholders. 2. Patient Story Karol Muir was invited to speak about her experience as a patient when she was diagnosed with neck and tongue cancer in early 2021. It was noted that: • Ms Muir’s experience was mixed with some poor experiences when given the diagnosis and by a staff member lacking compassion when addressing her claustrophobia. • In other instances, Ms Muir received a good service such as when a mask was being made for her radiotherapy and her experience on the acute oncology ward. • The Board acknowledged that kindness and compassion was very important. • The Board also noted that it was important to hear both good and bad aspects of patients’ experiences to enable the Trust to improve its services. 3. Minutes of the Previous Meeting held on 28 September 2023 The draft minutes tabled to the meeting were agreed to be an accurate record of the meeting held on 28 September 2023, subject to one minor amendment to item 5.2. 4. Matters Arising and Summary of Agreed Actions It was noted that all actions had either been completed or were not yet due. 5. QUALITY, PERFORMANCE and FINANCE 5.1 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 27 November 2023. It was noted that: • The committee reviewed the Finance Report for Month 7 (item 5.5), much of which formed the basis of the Trust’s submission for the second half of 2023/24. • The committee examined the Trust’s capital re-prioritisation plans along with proposals for 2024/25 and 2025/26. • The Trust had identified £71.3m of Cost Improvement Programme schemes, which, when adjusted for risk, represented approximately £59m of savings. It was noted that the Trust was underweight in terms of recurrent savings. • The committee reviewed the Trust’s productivity on the basis of both the NHS methodology and a revised methodology, which took into account factors such as an appropriate rate of inflation. Under the NHS methodology, the NHS’s underperformance was 16% compared to 2019/20 and the Trust was 18% below that in 2019/20. However, under the revised model, the Trust was under-performing by only 6-7%. • The committee reviewed a proposal for an Integrated Care System-wide electronic patient record system. 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 November 2023. It was noted that: • The committee reviewed the People Report for Month 7 (item 5.7). It was noted that the Trust’s substantive workforce continued to grow and whilst Page 2 agency use was under control, there had been an increase in use of bank staff, particularly due to demands in the Emergency Department, mental health nursing and staffing of surge areas. • It was noted that self-reporting of disabilities by staff and the rate of appraisals had both declined. • The initial indication in terms of the response rate to the staff survey showed a lower response rate than in previous years. 5.3 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 27 November 2023. It was noted that: • The committee reviewed the Trust’s quality indicators and noted that the rate of falls and infections gave rise to concerns about the application of fundamentals of care principles. It was considered possible that the different focus during Covid-19 was a possible contributory factor. • The Trust had reported an increase in the number of complaints, although much of this increase was due to a change in the criteria of what was deemed to be a complaint. • The committee reviewed the results of the Experience of Care survey. Although the national picture had worsened, the Trust’s position remained essentially as before. • The Trust’s approach to end-of-life care was generally very good, although consideration needed to be given to the delivery of mandatory training to all staff. • In view of the general election due to take place before the end of 2024, it was considered likely that the Trust would receive an increased number of Freedom of Information Act requests. 5.4 Chief Executive Officer’s Report David French was invited to present the Chief Executive Officer’s Report, the content of which was noted. It was further noted that: • The Chancellor of the Exchequer had delivered his autumn statement on 22 November 2023, and although there were no specific announcements concerning the health and care sector, there was an expectation of increased public sector productivity. It was noted that the Government had previously announced £800m of additional winter funding for the NHS, although this was mostly repurposed existing funding. • A proposed pay settlement for senior doctors was expected to be voted on by British Medical Association members. • The Care Quality Commission had commenced a roll out of its new single assessment framework in the South region. • The public hearings for module 2 of the UK Covid-19 Inquiry had commenced on 3 October 2023. • The Trust had identified 181 cases of lung cancer through the Targeted Lung Health Check Programme. The financial impact of this programme was difficult to quantify, as it had led to a higher surgical workload, but reduced need for chemo- and radiotherapy. Other conditions had also been discovered through the screening programme. 5.5 Performance KPI Report for Month 7 Duncan Linning-Karp was invited to present the Performance KPI Report for Month 7, the content of which was noted. It was further noted that: • In terms of benchmarking against other trusts, the Trust was in the top quartile in all areas except one. Page 3 • There had been 23 breaches of the target for long-waiters. • The Trust was facing challenges in meeting the 31-day cancer treatment target due to increases in demand for radiotherapy and demand for prostate cancer treatment. The Board noted the spotlight on the Emergency Department. It was further noted that: • There had been a 17% increase in demand since 2019/20. • The Trust was targeting 76% of type 1 patients being seen within four hours, but this would be challenging and dependent on the General Practitioners (GPs) working at the Emergency Department and on a reduction in the number of patients with no criteria to reside. • The Trust was reviewing its processes to free up space and provide options to bypass the Emergency Department when individuals were referred by their GP. In addition, admission and discharge processes were also being reviewed. • It was noted that the GP ‘village’ in the Emergency Department would be insufficient on its own to reach the 76% target. • The biggest constraints in terms of performance were the speed of decisionmaking and the availability of beds. 5.6 Finance Report for Month 7 Ian Howard was invited to present the Finance Report for Month 7, the content of which was noted. It was further noted that: • The Trust had submitted to the Integrated Care Board its plans for the second half of the financial year, which anticipated a revised end-of-year deficit of £31.5m. • The Trust had a year-to-date deficit of £25m, although this was prior to receipt of anticipated additional funding for the costs of industrial action. • The Trust was consistently delivering above the ceilings agreed for services under ‘block’ contracts, which meant that the additional activity was unfunded. • The Trust’s Elective Recovery performance remained good, and the resultant funding received was £4.5m above the Trust’s plan. 5.7 People Report for Month 7 Steve Harris was invited to present the People Report for Month 7, the content of which was noted. It was further noted that: • The workforce grew by 93 whole-time equivalents during the month, and the total workforce was 270 over the plan submitted to NHS England. This increase was driven in particular by newly qualified nurses still within the supernumerary period, increased temporary staffing and a small increase in sickness absence. • Participation in the NHS staff survey was lower than that in previous years at around 40% compared to 55% during 2022/23. • Turnover and sickness rates remained lower than the Trust’s target levels. • There continued to be a high demand for mental health nursing staff, and it seemed likely that a system approach would be necessary to address this issue. 5.8 Break Page 4 5.9 Midwifery, Neonatal and Obstetric Anaesthetic Workforce Report Emma Northover, Marie Cann and Tim Peachey were invited to present the Midwifery, Neonatal and Obstetric Anaesthetic Workforce Report, the content of which was noted. It was further noted that: • Oversight of the midwifery, neonatal and obstetric workforce was a requirement of the NHS Resolution Maternity Incentive Scheme. It was noted that the obstetric element of the report would be provided at the next Board meeting on 19 December 2023. • The workforce faced a number of challenges, particularly in terms of recruiting to specialisms where there was a national shortage, and that activity in the service was unpredictable. • The Trust had in place a number of strategies to recruit staff and was also focusing on growing its own workforce in terms of skills where these were unobtainable in the market. • There were staff shortages in both maternity and neonatal teams. The maternity team was on a trajectory to fill its current vacancies and the shortages in the neonatal team were to be addressed through upskilling the Trust’s own workforce. • There had been a significant increase in the number of elective caesarean births, possibly driven by reduced confidence on the part of the public in maternity services due to recent media stories. • Due to the nature of the Trust’s services, it received a high number of high-risk patients, which placed further demands on its capacity. 5.10 Learning from Deaths 2023-24 Quarter 2 Report Jenny Milner was invited to present the Learning from Deaths Report for Quarter 2, the content of which was noted. It was further noted that: • In-patient deaths had fallen by 10% compared to the previous year, with deaths below the national average. • Five cases had been referred to internal morbidity and mortality meetings. • The Medical Examiner’s Office and Bereavement teams had been moved into the same structure in order to reduce administration and to also reduce the number of calls to families. 5.11 Guardian of Safe Working Hours Quarterly Report Diana Hulbert was invited to present the Guardian of Safe Working Hours Quarterly Report, the content of which was noted. It was further noted that: • The Trust had been fined for the first time since 2016 due to seven breaches of the maximum 13-hour shift length. There was considered to be a possible issue with the handover process, which resulted in the breaches of shift duration. • Suggestions had been sought from staff in order to improve the Trust’s processes. Page 5 5.12 Medicines Management Annual Report 2022-23 James Allen was invited to present the Medicines Management Annual Report for 2022/23, the content of which was noted. It was further noted that: • Over the course of the year, the Trust had improved its resilience in areas such as oncology pharmacy and had an increased focus on research. In addition, the aseptic site programme at Adanac Park was progressing. • The Trust was facing challenges in terms of its IT infrastructure and in filling clinical trials. • The next area of focus was to be on the storage of medicines. • There had been flooding in radio-pharmacology, but there had been minimal impact due to interventions undertaken and use of mutual aid. 5.13 Infection Prevention and Control 2023-24 Quarter 2 Report Julian Sutton and Julie Brooks were invited to present the Infection Prevention and Control Report for Quarter 2, the content of which was noted. It was further noted that: • The Trust continued to not meet the national standards for E-coli and C-Diff, although it compared reasonably well with comparator organisations. • Rapid gastro-intestinal testing continued to be of significant benefit in preventing norovirus outbreaks. • Respiratory testing time had increased, and the amount of time required for a person to be deemed a Covid-19 contact had been increased. • Approximately 50 patients had been impacted by a candida auris outbreak since March 2023. It was proving difficult to eradicate the source of the infections, and there was little understanding globally as yet of the pathogen. • The importance of adhering to fundamentals of care principles was emphasised, as there had been a number of preventable incidents due to poor hygiene practices. • The Hampshire and Isle of Wight Integrated Care Board was focusing on overprescribing of antibiotics, particularly by GPs. 5.14 Annual Ward Staffing Nursing Establishment Review 2023 Rosemary Chable and Gail Byrne were invited to present the Annual Ward Staffing Nursing Establishment Review 2023, the content of which was noted. It was further noted that: • It was a requirement for the Board to undertake a systematic ward staffing establishment review. • The Trust’s staffing levels were generally in line with expectations and staffing numbers have improved due to the Trust’s success in recruiting new staff. However, the influx of new, less experienced members of staff was placing pressure on more senior members of staff. When challenged on how staffing requirements were determined, it was noted that this assessment was based on analysis of data from multiple sources along with professional judgement. Page 6 5.15 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: • Eighty-one cases had been raised in 2023/24. • Consideration was being given to publishing lessons learned from some of the Freedom to Speak Up cases on the staff intranet. • Additional support to line managers was also being examined such that staff were comfortable in approaching their managers, rather than utilising the Freedom to Speak Up process. • Some groups, such as junior doctors and some ethnic minorities, were generally less likely to engage with the Freedom to Speak Up process. • The Trust was recruiting more Freedom to Speak Up champions, especially from less engaged groups of staff. 6. STRATEGY and BUSINESS PLANNING 6.1 Board Assurance Framework (BAF) Update The Board Assurance Framework Update was noted. It was further noted that the Board Assurance Framework was due to be discussed in detail at the Trust Board Study Session scheduled to take place on 19 December 2023. 7. CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Annual Assurance for the NHS England Core Standards for Emergency Preparedness, Resilience and Response (EPRR) Duncan Linning-Karp and John Mcgonigle were invited to present the paper, ‘Emergency Preparedness, Resilience and Response Delivery Group (EPRR-DG) – Assurance Report’, the content of which was noted. It was further noted that: • The Trust’s preparedness had been assessed within ten domains, covering 62 core standards and multiple performance indicators within each. • The Trust was fully compliant with 60 of the 62 standards and was therefore ‘substantially compliant’. • The main area for improvement was in preparedness for a mass evacuation of the hospital. The Trust was working through a scenario for a full evacuation. • The Trust was also non-compliant in the area of a mass casualty scenario, as there had been new guidance released in this area. Work was ongoing to align with this new guidance. • Training in incident management had been delivered to senior leaders. 8. Any other business There was no other business. 9. Note the date of the next meeting: 30 January 2024 10. Items Circulated to the Board for reading The item circulated to the Board for reading was noted. Page 7 11. Resolution regarding the Press, Public and Others Decision: The Board resolved that, as permitted by the National Health Service Act 2006 (as amended), the Trust’s Constitution and the Standing Orders of the board of directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. The meeting was adjourned. Page 8 List of action items Agenda item Assigned to Deadline Status Trust Board – Open Session 28/09/2023 6.2 Health and Safety Annual Report 2022-23 1041. Violence and aggression update Byrne, Gail Harris, Steve Machell, Craig 29/02/2024 Pending Explanation action item Gail Byrne, Steve Harris and Craig Machell agreed to schedule a further update in respect of violence and aggression at a future Trust Board Study Session. Page 1 of 1 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 6.5 David French, Chief Executive Officer 30 January 2024 Assurance Approval or reassurance Ratification Information X My report this month covers updates on the following items: • Operational Update • National Audit Office qualification of DHSC accounts • External Recruitment Status • South Hampshire College Group • DHSC Consultation on New Nursing Spine Pay Points • NHS Providers Governance Survey 2023 • Intensive Care Society’s 2023 National Awards 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 Operational Update January 2024 has been a very challenging month operationally for everyone within the Trust. Having safely navigated the period of industrial action by doctors in training between the 2nd and 8th January 2024, the Trust has experienced a period of heightened operational pressures which has seen record levels of patients within the hospital without criteria to reside (medically fit). These reached record levels on one day of 270 (over 25% of adult inpatient general acute bed base) coupled with significant infection outbreaks resulting in further wards closed (three at the time of writing) and closure of 23 bays across the wards. This in turn has caused a significant backlog of patients within the emergency department and has also sadly resulted in a significant increase in ambulance handover delays and queues within the adult emergency department footprint. The Trust has continued to manage these pressures as best as it can through hospital incident management arrangements and significant oversight of available beds and discharges daily. Unfortunately, the Trust has also had to cancel some elective operations due to lack of available beds despite all surge bed areas in the hospital being fully open. The Chief Nursing Officer has also implemented a number of enhanced infection prevention measures including wearing surgical masks in adult clinical areas and has also introduced temporary visitor restrictions to further limit the risk of spreading infection. Looking forward, the Trust continues to do all it can to respond to the current challenges and has invited the Emergency Care Intensive Support Team from NHS England to review its processes via an invited visit during January 2024. The Trust is also currently reframing its flow programme to focus on operational oversight. In addition, the Trust is rigorously eliminating all discharge delays within its control as well as continuing to work with community partners across health and social care to try and deal with the longer-term issues of capacity outside of the hospital. According to ‘Winter Watch’ published by NHS Providers, an overview of the situation in NHS England, during the week commencing 8 January 2024: • 93.3% of general and acute beds were occupied and 586 beds were closed due to diarrhoea and vomiting and norovirus. • A total of 90,294 patients arrived by ambulance, an increase of 25% compared to the previous year. • There was an average of 23,645 patients each day who no longer met the criteria to reside. Of these, over half (57.7%) remained in hospital. • An average of 49,039 staff were absent each day. National Audit Office qualification of DHSC accounts The NAO has qualified DHSC accounts for financial year 2022/23 due to the way in which the elective recovery fund (ERF) was administered. The Government established the ERF in 2022/23 to incentivise trusts to increase their activity after Covid-19. The money was paid to trusts and ICBs on the assumption targets would be met, but there were intended to be financial penalties if the activity goal (104% of 2019/20 baseline) was not met. However, the clawback mechanism was suspended over fears this would destabilise local systems, most of which were underperforming on their elective targets. As a result, local organisations were allowed to keep the funding, regardless of the number of patients they treated. Page 2 of 5 In their audit statement, NAO state “ERF was required to be ‘earned’ by integrated care systems hitting elective recovery targets. Where elective recovery targets were not met, the cash received by the department should have been returned to the consolidated fund.” NHSE’s 2022/23 accounts state: “The lower levels of elective activity were due to ongoing Covid19 pressures and longer lengths of stay, factors for which no additional funding had been provided. Therefore, we decided to allow providers to retain the elective funding to cover these costs, which the government has now deemed to be irregular.” UHS was one of only a handful of providers which achieved the ERF target of 104%; UHS achieved 108% whereas the average performance for the country was 97%. Of course, like all providers, UHS incurred the costs described in the NHS accounts for Covid-19 pressures and longer lengths of stay for which the ERF money was used to cover, but also incurred the costs of delivering additional elective activity which others did not. No income was received to cover the UHS cost of activity between 104% and the national average of 97%, whereas other providers were able to keep the money originally intended to fund the 104% target. We estimate the UHS cost of this 7% additional activity to be around £10m. The £10m cost of this activity has subsequently been ‘baked’ into the UHS baseline and is therefore a significant contributor to UHS’s current financial challenge and a strong headwind affecting the Trust’s ability to return to financial break-even. External Recruitment Status The Board is aware that following an update to the Trust’s forecasted headcount for 31 March 2024, additional recruitment controls were introduced on 22 December 2023 which remain in place. The executive team has been working through the detail of how the controls operate effectively but also with due regard to clinical quality and safety. One of the major challenges has been the dissonance between how it feels on the ground (busier than ever) and the explicit financial direction received from the Centre. This has been a fast-moving and dynamic situation and we will update the Board during the Board meeting on how we are navigating that challenge and how we are ensuring that clinical safety and quality is protected. South Hampshire College Group During January 2024, the Chief People Officer and Head of Education met the senior leadership team from the newly formed South Hampshire College Group (SHCG). This new organisation is the result of a merger between Eastleigh, Southampton City, and Fareham colleges, bringing together over 3,000 students across the area. The Trust will be working to create an overarching partnership with the group focused on growing vocational and entry-level opportunities for students into roles at the Trust (health-related, estates, business administration and digital). This supports the Trust’s People Strategy objectives of extending the diversity of our relationships with education providers to support a wider range of education to employment opportunities. It also supports the ambitions of the NHS long-term workforce plan, particularly around apprenticeship opportunities for non-graduate entry roles. SHCG can play an important role in the career promotion of the Trust, including working in partnership on industry placements. Senior leads from SHCG and the Trust will be meeting again in the Spring to take these activities forward. Department of Health and Social Care Consultation on New Nursing Spine Pay Points In May 2023, the government agreed a deal for the Agenda for Change (AfC) workforce through the NHS Staff Council. During negotiations, concerns were raised about how the AfC pay structure is affecting the career progression and professional development of nurses, and the direct impact that this is having on recruitment and retention. The Royal College of Nursing (RCN) Page 3 of 5 suggested that a separate pay spine for nursing staff could address these concerns. At present the same pay scales are used for all roles covered by Agenda for Change with banding (pay grade) determined through job evaluation. This call for evidence is being published to explore these specific concerns, to understand the benefits and challenges of a separate nursing pay spine, and to explore other potential approaches to addressing any issues identified. This exploration does not form part of the AfC deal that was agreed with the NHS Staff Council. The consultation is public and can be responded to as an individual (within or outside healthcare) or as an NHS organisation. The Trust will be participating in the consultation through evidence sessions being organised by NHS Employers and through its own written response. NHS Providers Governance Survey 2023 In September and October 2023, NHS Providers invited chairs, company secretaries and other corporate governance leads in NHS trusts and foundation trusts to complete a survey in relation to boards, their assurance committees and how trusts are developing in relation to the systems they are part of. The results of the survey were published on 15 December 2023. In summary: • 86% of respondents agreed or strongly agreed that the board has time to focus on key risks and issues, but the comments provided gave a clear sense that it can be challenging to prioritise and effectively cover everything. • Almost all respondents (99%) agreed or strongly agreed that the way the committees report to the board can provide it with assurance. • However, many respondents stated that space on agendas is under pressure, often attributing this to initiatives from the centre as well as new system and partnership-working related matters. This contributes to reduced bandwith for those producing and seeking to digest reporting and assurance information and putting pressure on the time available for effective discussion and scrutiny. • The pressures on executive directors were highlighted and there were concerns about too much detail coming through to boards and committees. • More than half of respondents (58%) said that their trust has associate non-executive directors, with the most common reason being developmental and to aid succession-planning. • Trusts’ experience in systems remains variable and whilst there has been some improvement, for the most part, the picture remains one of considerable variation. Of 36 comments in relation to this subject, 23 were critical of the way systems are working at present and a further eight said it was too soon to say. • Improvements were reported in relation to trust boards’ ability to influence the development of the systems they are part of, and in non-executive directors’ perceived confidence about their role and responsibilities in systems. • Only 20% of respondents expressed confidence about approaches to continuous improvement across systems and the lowest level of confidence was reported for how risk was managed across systems (12%, compared to 20% in the prior year). • 42% of respondents have a board member who is also a trust partner member on an Integrated Care Board, and chairs and governance leads were positive about the influence and access they felt having a board member in this role gave them. The full report can be read at: https://nhsproviders.org/resources/surveys/governance-surveyresults-2023 Page 4 of 5 Intensive Care Society’s 2023 National Awards The neuro-physiotherapy team, who work closely with the Trust’s Neuro Intensive Care Unit, were awarded ‘Team of the Year’ at the Intensive Care Society’s national awards. Footage of the award ceremony can be viewed at: https://www.youtube.com/watch?v=fHPem9G_JGo (watch from 9 minutes 35 seconds in). I would like to congratulate the team on this achievement. Page 5 of 5 Report to the Trust Board of Directors Title: Agenda item: Sponsor: Author Date: Purpose Performance KPI Report 2023-24 Month 9 6.6 David French, Chief Executive Officer Sam Dale, Associate Director of Data and Analytics 30 January 2024 Assurance or Approval reassurance Y Ratification Information Issue to be addressed: The report aims to provide assurance: • Regarding the successful implementation of our strategy • That the care we provide is safe, caring, effective, responsive, and well led Response to the issue: The Performance KPI Report reflects the current operating environment and is aligned with our strategy. Implications: This report covers a broad range of trust performance metrics. It is (Clinical, intended to assist the Board in assuring that the Trust meets Organisational, regulatory requirements and corporate objectives. Governance, Legal?) Risks: (Top 3) of carrying out the change / or not: This report is provided for the purpose of assurance. Summary: Conclusion and/or recommendation This report is provided for the purpose of assurance. Page 1 of 29 Report to Trust Board in January 2023 Performance KPI Board Report Covering up to December 2023 Sponsor – David French, Chief Executive Officer Author – Sam Dale, Associate Director of Data and Analytics Page 2 of 29 Report to Trust Board in January 2023 Report guide Chart type Example Cumulative Column Cumulative Column Year on Year Line Benchmarked Line & bar Benchmarked Control Chart Variance from Target Explanation A cumulative column chart is used to represent a total count of the variable and shows how the total count increases over time. This example shows quarterly updates. A cumulative year on year column chart is used to represent a total count of the variable throughout the year. The variable value is reset to zero at the start of the year because the target for the metric is yearly. The line benchmarked chart shows our performance compared to the average performance of a peer group. The number at the bottom of the chart shows where we are ranked in the group (1 would mean ranked 1st that month). The line shows our performance, and the bar underneath represents the range of performance of benchmarked trusts (bottom = lowest performance, top = highest performance) A control chart shows movement of a variable in relation to its control limits (the 3 lines = Upper control limit, Mean and Lower control limit). When the value shows special variation (not expected) then it is highlighted green (leading to a good outcome) or red (leading to a bad outcome). Values are considered to show special variation if they -Go outside control limits -Have 6 points in a row above or below the mean, -Trend for 6 points, -Have 2 out of 3 points past 2/3 of the control limit, -Show a significant movement (greater than the average moving range). Variance from target charts is used to show how far away a variable is from its target each month. Green bars represent the value the metric is achieving better than target and the red bars represent the distance a metric is away from achieving its target. Page 3 of 29 Report to Trust Board in January 2023 Introduction The Performance KPI Report is presented to the Trust Board each month to provide assurance: • regarding the successful implementation of our strategy; and • that the care we provide is safe, caring, effective, responsive, and well led. The content of the report includes the following: • The ‘Spotlight’ section, to enable more detailed consideration of any topics that are of particular interest or concern. The selection of topics is informed by a rolling schedule, performance concerns, and requests from the Board. • An ‘NHS Constitution Standards’ section, summarising the standards and performance in relation to service waiting times; and • An ‘Appendix,’ with indicators presented monthly, aligned with the five themes within our strategy. Due to the earlier timing of the December 2023 Board, at the time of publishing last months’ report several of the validated IPR data points were not yet available but have now been updated within this report. • 31 - Patients on an open 18 week pathway (within 18 weeks) • 33 - Patients on an open 18 week pathway (within 52 weeks) • 34 - Patients on an open 18 week pathway (within 65 weeks) • 35 - Patients on an open 18 week pathway (within 78 weeks) • 35a - Patients on an open 18 week pathway (within 104 weeks) • 32 - Total number of patients on a waiting list (18 week referral to treatment pathway) • 36 - Patients waiting for diagnostics • 37 - % of patients waiting over 6 weeks for diagnostics Other changes of note within the report include: • 7 –MRSA bacteraemia: A correction in the November 2023 data, which was reported as 1 case, but on review has been changed to 2 cases. • 13 – Serious Incidents Requiring Investigation: As part of the move to the new Patient Safety Incident Response Framework (PSIRF) from October 2023, the metrics have removed the reporting of SIRIs, although Patient Safety Incident Investigations (PSII) are still being reported in this measure. • 38 – Cancer 2 Week Wait: In December 2023 NHS England stopped publishing 2 week wait data. Benchmark data is available for the period up until October 2023 for other hospitals. UHS will continue to publish our own performance against this metric. • 41 / 42 – Cancer 31 Day Performance / Cancer 31 Day Subsequent Treatment performance: From December 2023, NHS England measurement methodology changed, and published data from October 2023 onwards for 31 Day Cancer Performance combines both First and Subse quent treatment performance. As a result, metric 42 (Cancer 31 Day Subsequent Treatment) has been removed. Page 4 of 29 Report to Trust Board in January 2023 Summary This month’s spotlight covers Cancer performance. It highlights how UHS has seen improving levels of performance against the three new national cancer metrics, and the interventions that have been made to improve performance despite the ongoing challenges of increased demand. Detail is also provided by tumour site, outlining the specific challenges and actions taken by Care Groups to address performance. Areas of note in the appendix of performance metrics include: 1. As outlined within the Cancer spotlight, our increased focus on Cancer performance has led to significant improvements in 2 Week Wait performance (increasing to 88.9% in November 2023), UHS being in the top three teaching hospitals for 62 Day performance, and being the top teaching hospital for 28 Day Faster Diagnosis for the last three months – with an improvement in performance to 85.4%. 2. The Emergency Department (ED) four hour performance saw a small improvement in performance in December 2023 to 58.0%, although this remains below our H2 recovery ambitions. The GP programme has also led to some diversions away from the department which might otherwise have further improved performance. However, ED performance continues as a national issue, as illustrated by UHS remaining within the top quartile of teaching hospitals. 3. We have seen a further increase in the number of patients not meeting the Criteria to Reside in hospital which remains extremely high at an average of 203 patients through December 2023 – even though we would normally see a reduction over the Christmas period. 4. A positive ongoing reduction in the proportion of patients being readmitted within 28 days of discharge continues, with this standing at 10.6%. 5. There was a second consecutive month in the reduction of the waiting list to just over 58,000 patients. However, this remains significantly higher than pre-COVID, and there is often a softening of demand over the Christmas period. 6. We have also seen a continued reduction in the Diagnostic waiting list, which now stands at under 8,000 patients. The size of this waiting list is now broadly in line with pre-COVID levels, although the proportion of patients breaching the six week diagnostic standard is still higher. Ambulance response time performance The latest unvalidated weekly data is provided by the South Coast Ambulance Service (SCAS). Due to the significant challenges within the ED department, and the wider challenge with flow experienced in the trust since the New Year, we have seen an increase in handover times. In the week commencing 15 January 2024, our average handover time was 22 minutes 38 seconds across 675 emergency handovers, and 32 minutes 26 seconds across 35 urgent handovers. There were 73 handovers over 30 minutes, and 44 handovers taking over 60 minutes within the unvalidated data. Page 5 of 29 Report to Trust Board in January 2023 Spotlight Spotlight: Cancer performance 1. Introduction Cancer is a large basket of disparate diseases across every organ and tissue type of the body, unified by its biology in which abnormal cells divide without control and can invade nearby tissues. Cancer cells can also spread (metastasise) to other parts of the body. These cancerous diseases have very different treatments and prognoses. The other uniting factor underlying this name is that for many patients the word cancer generates significant anxiety and fear and recognising this, UHS works hard to provide the most streamlined service that we can offer to patients referred to our service. UHS is one of 12 regional cancer centres in the UK offering treatment for rare and complex cancers as well as children's cancer and brain cancer. We offer a wide range of treatments including novel therapies. UHS has historically benchmarked in the upper quartile, relative to our teaching hospital peers. We continue to perform well against the 28 day faster diagnosis and 62 day standards, but face challenges in meeting the 31 day standard. Recovery plans are in place focusing on the three key areas affecting this standard, radiotherapy, prostate surgery and skin (plastics). More d etail follows below. We continue to monitor cancer performance through regular performance meetings. However, there is an ongoing risk, with many tumour sites dependant on relatively few individuals to deliver, meaning that unexpected or unplanned absences can quickly affect performance. 2. Changes to Cancer Waiting Time Standards (CWT) In August 2023, NHS England received government approval to implement changes to the cancer waiting times standards from 1 October 2023. These changes were the outcome of a long term consultation which had the full support of NHS staff, patient groups and cancer. The proposed standards are in line with recommendations made by the Independent Cancer Taskforce in 2015 and the subsequent clinical review which was started in 2018. The three new standards (detailed below) are aligned to the requirements of modern cancer care, with a greater focus on outcomes and ensuring equitable access to care. The new treatment standards will measure waiting time for all patients regardless of their route into the system, rather than just those who were urgently referred by their GP. 1. The 28-day faster diagnosis standard (FDS). Patients with suspected cancer who are referred for urgent cancer checks from a GP, screening programme or other route should be diagnosed or have cancer ruled out within 28 days 2. A 62-day referral to treatment standard. Patients who have been referred for suspected cancer via any route and go on to receive a diagnosis should start treatment within 62 days of their referral. Page 6 of 29 Report to Trust Board in January 2023 Spotlight 3. A 31-day decision to treat to treatment standard. Patients, regardless of how they came to be diagnosed with cancer, should receive their treatment within a month of a decision to treat their cancer. These changes will still set the same high-performance bar for the same groups of patients as were covered by the previous standards and will increase the number and proportion of patients covered by the standards. They are designed to focus on two clear goals: achieving the fastest possible diagnosis, and for those who are diagnosed and require treatment, ensuring they receive treatment as quickly as possible. The new standards will also put all patients on a level playing field, regardless of the origin of their referral. Trusts do not need to make significant changes in terms of their data submissions – the only change of note in terms of overall process will be their reporting of performance against the 62-day standard to include patients who’ve entered cancer pathways via screening or consultant upgrades as well as those who were referred by their GP. In this paper, we explore early performance against the national targets in place for each of the new standards, UHS position compared to comparator Trusts and an exploration of the drivers and actions in place to improve performance for key tumour sites. 3. Cancer Referral Volumes At the start of the 2023 calendar year, the Trust experienced a 3000 period of significant volatility on cancer referrals which reached a five year high when 2,524 referrals were received in June 2023. 2500 2000 This high volume of referrals has remained since, but with some stabilisation of the monthly variance seen in the first half of the 1500 year. As expected, the festive period sees a reduction with 1000 December 2023 at 1,774. Despite this levelling off in recent 500 months, the referral volumes in 2023 averaged at 2,213 per month which overall is 7% higher than 2022 and 21% higher than 0 the 2021 calendar year. Ja n-22 Fe b -22 Ma r-22 Apr-22 Ma y-22 Jun-22 Jul -22 Aug-22 Se p -22 Oct-22 Nov-22 D e c-22 Ja n-23 Fe b -23 Ma r-23 Apr-23 Ma y-23 Jun-23 Jul -23 Aug-23 Se p -23 Oct-23 Nov-23 D e c-23 2022 2023 Graph 1: Cancer referral volumes by month Page 7 of 29 Report to Trust Board in January 2023 Spotlight 3,000 2,500 2,000 1,500 1,000 500 0 Jan Feb Mar Apr May Jun Jul Au g Sep Oct Nov Dec 2020 2021 2022 2023 Graph 2: Cancer Referrals – historic monthly comparison 4. Overall cancer waiting list (PTL) and patients waiting over 62 days (backlog) The overall waiting list size is heavily dependent on the number of two week wait referrals and the speed of seeing these patients, as the large majority of patients will leave the cancer waiting list at the point of being told that they don’t have cancer. Throughout
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Papers Trust Board - 15 July 2025

Description: Agenda Trust Board – Open Session Date 15/07/2025 Time 9:00 - 13:00 Location Conference Room, Heartbeat Education Centre Chair Jenni Douglas-Todd Apologies Alison Tattersall In attendance Lauren Anderson, Corporate Governance and Risk Manager (from 9:30) (shadowing Craig Machell) 1 Chair’s Welcome, Apologies and Declarations of Interest 9:00 Note apologies for absence, and to hear any declarations of interest relating to any item on the Agenda. 2 Patient Story The patient story provides an opportunity for the Board to reflect on the experiences of patients and staff within the Trust and understand what the Trust could do better. 3 Minutes of Previous Meeting held on 13 May 2025 9:15 Approve the minutes of the previous meeting held on 13 May 2025 4 Matters Arising and Summary of Agreed Actions To discuss any matters arising from the minutes, and to agree on the status of any actions assigned at the previous meeting. 5 QUALITY, PERFORMANCE and FINANCE Quality includes: clinical effectiveness, patient safety, and patient experience 5.1 Briefing from the Chair of the Audit and Risk Committee 9:20 Keith Evans, Chair 5.2 Briefing from the Chair of the Finance and Investment Committee 9:25 Dave Bennett, Chair 5.3 Briefing from the Chair of the People and Organisational Development 9:30 Committee Jane Harwood, Chair 5.4 Briefing from the Chair of the Quality Committee 9:35 Tim Peachey, Chair including Maternity and Neonatal Safety 2024-25 Quarter 4 Report and Maternity and Neonatal Workforce Report 5.5 Chief Executive Officer's Report 9:40 Receive and note the report Sponsor: David French, Chief Executive Officer 5.6 Performance KPI Report for Month 2 10:10 Review and discuss the report Sponsor: David French, Chief Executive Officer 5.7 Break 10:40 5.8 Finance Report for Month 2 10:55 Review and discuss the report Sponsor: Ian Howard, Chief Financial Officer 5.9 ICS Operational Delivery Report for Month 2 11:05 Receive and discuss the report Sponsor: Ian Howard, Chief Financial Officer 5.10 People Report for Month 2 11:10 Review and discuss the report Sponsor: Steve Harris, Chief People Officer 5.11 Freedom to Speak Up Report 11:20 Review and discuss the report Sponsor: Gail Byrne, Chief Nursing Officer Attendee: Christine Mbabazi, Equality & Inclusion Adviser/Freedom to Speak Up Guardian 5.12 Infection Prevention and Control 2024-25 Annual Report 11:30 Receive and discuss Sponsor: Gail Byrne, Chief Nursing Officer Attendees: Julian Sutton, Clinical Lead, Department of Infection/Julie Brooks, Deputy Director of Infection Prevention and Control 5.13 Guardian of Safe Working Hours Quarterly Report 11:40 Receive and discuss the report Sponsor: Paul Grundy, Chief Medical Officer 6 STRATEGY and BUSINESS PLANNING 6.1 Corporate Objectives 2025-26 Quarter 1 Review 11:50 Review and feedback on the corporate objectives Sponsor: David French, Chief Executive Officer Attendee: Martin De Sousa, Director of Strategy and Partnerships 6.2 Research and Development Plan 2025-26 12:00 Discuss and approve the plan Sponsor: Paul Grundy, Chief Medical Officer Attendees: Christopher Kipps, Clinical Director of R&D/Karen Underwood, Director of R&D/Laura Purandare, Deputy Director of R&D Page 2 6.3 Board Assurance Framework (BAF) Update and Risk Appetite Statement 12:10 Review and discuss the update. Review and ratify the risk appetite statement. Sponsor: Gail Byrne, Chief Nursing Officer Attendees: Craig Machell, Associate Director of Corporate Affairs and Company Secretary/Lauren Anderson, Corporate Governance and Risk Manager 7 CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Register of Seals and Chair's Actions Report 12:30 Receive and ratify In compliance with the Trust Standing Orders, Financial Instructions, and the Scheme of Reservation and Delegation. Sponsor: Jenni Douglas-Todd, Trust Chair 7.2 Review of Standing Financial Instructions 2025 12:35 Review and approve the SFIs Sponsor: Ian Howard, Chief Financial Officer Attendee: Phil Bunting, Director of Operational Finance 8 Any other business 12:40 Raise any relevant or urgent matters that are not on the agenda 9 Note the date of the next meeting: 9 September 2025 10 Resolution regarding the Press, Public and Others Sponsor: Jenni Douglas-Todd, Trust Chair To agree, as permitted by the National Health Service Act 2006 (as amended), the Trust's Constitution and the Standing Orders of the Board of Directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. 11 Follow-up discussion with governors 12:45 Page 3 Agenda links to the Board Assurance Framework (BAF) 15 July 2025 – Open Session Overview of the BAF Risk 1a: Lack of capacity to appropriately respond to emergency demand, manage the increasing waiting lists for elective demand, and provide timely diagnostics, that results in avoidable harm to patients. 1b: Due to the current challenges, we fail to provide patients and their families / carers with a high-quality experience of care and positive patient outcomes. 1c: We do not effectively plan for and implement infection prevention and control measures that reduce the number of hospital-acquired infections and limit the number of nosocomial outbreaks of infection. 2a: We do not take full advantage of our position as a leading University teaching hospital with a growing, reputable, and innovative research and development portfolio, attracting the best staff and efficiently delivering the best possible treatments and care for our patients. 3a: We are unable to meet current and planned service requirements due to the unavailability of staff to fulfil key roles. 3b: We fail to develop a diverse, compassionate, and inclusive workforce, providing a more positive staff experience for all staff. 3c: We fail to create a sustainable and innovative education and development response to meet the current and future workforce needs identified in the Trust’s longer-term workforce plan. 4a: We do not implement effective models to deliver integrated and networked care, resulting in sub-optimal patient experience and outcomes, increased numbers of admissions and increases in patients’ length of stay. 5a: We are unable to deliver a financial breakeven position, resulting in: inability to move out of the NHS England Recovery Support Programme, NHS England imposing additional controls/undertakings, and a reducing cash balance impacting the Trust’s ability to invest in line with its capital plan, estates/digital strategies, and in transformation initiatives. 5b: We do not adequately maintain, improve and develop our estate to deliver our clinical services and increase capacity. 5c: Our digital technology or infrastructure fails to the extent that it impacts our ability to deliver care effectively and safely within the organisation, 5d: We fail to prioritise green initiatives to deliver a trajectory that will reduce our direct and indirect carbon footprint by 80% by 2028-2032 (compared with a 1990 baseline) and reach net zero direct carbon emissions by 2040 and net zero indirect carbon emissions by 2045. Agenda links to the BAF No Item Linked BAF risk(s) 5.6 Performance KPI Report for Month 2 5.8 Finance Report for Month 2 5.9 ICS Finance Report for Month 2 5.10 People Report for Month 2 5.11 Freedom to Speak Up Report 5.12 Infection Prevention and Control 2024-25 Annual Report 5.13 Guardian of Safe Working Hours Quarterly Report 6.1 Corporate Objectives 2025-26 Quarter 1 Review 6.2 Research and Development Plan 2025-26 1a, 1b, 1c 5a 5a 3a, 3b, 3c 3b 1c 3b All 2a Appetite (Category) Minimal (Safety) Current risk rating 4x5 20 Cautious (Experience) Minimal (Safety) 4x4 16 4x4 16 Open (Technology & Innovation) 3x4 12 Open (workforce) Open (workforce) Open (workforce) 4x5 20 4x3 12 4x4 16 Cautious (Effectiveness) 3x3 9 Cautious (Finance) 4x5 20 Target risk rating 4 x 2 Apr 6 27 3 x 2 Apr 6 27 2 x 3 Apr 6 27 3 x 2 Mar 6 27 4 x 3 Mar 12 30 4 x 2 Mar 8 30 3 x 2 Mar 6 29 3 x 2 Dec 6 25 3 x 3 Apr 9 30 Cautious (Effectiveness) Open (Technology & Innovation) Open (Technology & Innovation) 4x5 20 3x4 12 2x4 8 4 x 2 Apr 8 30 3 x 2 Apr 6 27 2 x 2 Dec 4 27 Does this item facilitate movement towards or away from the intended target risk score and appetite? Towards Away Neither x x x x x x x x x Minutes Trust Board – Open Session Date 13/05/2025 Time 9:00 – 13:00 Location Conference Room, Heartbeat/Microsoft Teams Chair Jenni Douglas-Todd (JD-T) Present Dave Bennett, NED (DB) Gail Byrne, Chief Nursing Officer (GB) Jenni Douglas-Todd, Chair (JD-T) Diana Eccles, NED (DE) David French, Chief Executive Officer (DAF) Paul Grundy, Chief Medical Officer (PG) Steve Harris, Chief People Officer (SH) Jane Harwood, NED/Senior Independent Director (JH) Ian Howard, Chief Financial Officer (IH) Duncan Linning-Karp, Interim Chief Operating Officer (DL-K) David Liverseidge, NED (DL) Tim Peachey, NED (TP) In attendance Martin De Sousa, Director of Strategy and Partnerships (MDeS) Craig Machell, Associate Director of Corporate Affairs and Company Secretary (CM) Ceri Connor, Director of OD and Inclusion (CC) (item 5.11) Lauren Anderson, Corporate Governance and Risk Manager (LA) (item 6.2) Diana Hulbert, Guardian of Safe working Hours and Emergency Department Consultant (DH) (item 5.12) Kelly Kent, Head of Strategy and Partnerships (KK) (item 6.1) Jenny Milner, Associate Director of Patient Experience (JM) (item 5.13) Natasha Watts, Deputy Chief Nursing Officer (NW) (item 5.13) Helena Blake, Head of Clinical Quality Assurance (shadowing G Byrne) Raquel Domene Luque, Interim Lead Matron, Ophthalmology (shadowing G Byrne) 1 governor (observing) 6 members of staff (observing) 3 members of the public (observing) Apologies Keith Evans, Deputy Chair and NED (KE) Alison Tattersall, NED (AT) 1. Chair’s Welcome, Apologies and Declarations of Interest The Chair welcomed attendees to the meeting. There were no interests to declare in the business to be transacted at the meeting. It was noted that apologies had been received from Keith Evans and Alison Tattersall. 2. Patient Story Item postponed to the next meeting. 3. Minutes of the Previous Meeting held on 11 March 2025 The draft minutes tabled to the meeting were agreed to be an accurate record of the meeting held on 11 March 2025. Page 1 4. Matters Arising and Summary of Agreed Actions The matters arising and actions were noted. It was noted that action 1218 could be closed. 5. QUALITY, PERFORMANCE and FINANCE 5.1 Briefing from the Chair of the Audit and Risk Committee Ian Howard was invited to present the Committee Chair’s Report in respect of the meeting held on 17 March 2025, the content of which was noted. It was further noted that: • The committee considered the going concern assessment in respect of the 2024/25 annual accounts and agreed that it was appropriate that the accounts be prepared on a going concern basis. • The committee additionally noted that there had been no significant issues raised by the Trust’s external auditors. • The committee received a report on losses and special payments during 2024/25, noting that these payments generally related to lost patient property. • An update was received in respect of Information Governance. The Trust – in common with most others – was not expected to meet the standards set out in the Data Security and Protection Toolkit due to the introduction of the Cyber Assurance Framework as part of the Toolkit requirements. 5.2 Briefing from the Chair of the Finance and Investment Committee The chair of the Finance and Investment Committee was invited to present the Committee Chair’s Reports in respect of the meetings held on 24 March and 28 April 2025, the content of which was noted. It was further noted that: • The committee reviewed the Finance Report for Month 12 (item 5.8), noting that the Trust had achieved its forecast deficit of £7m for 2024/25 following the receipt of revenue support. Furthermore, the Trust had achieved £85.3m of Cost Improvement Programme delivery and Elective Recovery performance of 127%. Nonetheless, the Trust’s underlying deficit was circa £75m. • The Trust’s cash position remained challenging with the Trust likely to require revenue support during either the first or second quarters of 2025/26. • The committee reviewed the Trust’s proposed 2025/26 plan during March 2025 and noted that there were no material changes between the draft reviewed and that submitted on 23 April 2025. • The committee supported a proposal for the Trust to participate in the elective hub at Winchester. 5.3 Briefing from the Chair of the People and Organisational Development Committee The chair of the People and Organisational Development Committee was invited to present the Committee Chair’s Reports in respect of the meetings held on 24 March and 25 April 2025, the content of which was noted. It was further noted that: • The committee received a briefing in respect of the Staff Survey 2024 (item 5.11). • The committee reviewed the People Report for Month 12 (item 5.10), noting that the Trust had ended the year 373 whole-time-equivalents (WTE) above plan. This was largely due to the reductions in patients having no criteria to reside and mental health patients not materialising. In addition, there had been higher than normal use of bank staff in March 2025 and lower than anticipated staff turnover. Page 2 • An update in respect of the planned organisational restructuring, including regarding the Equality and Quality Impact Assessment process being developed. • It was considered likely that the delivery of the Trust’s 2025/26 workforce plan would necessitate additional workforce controls. It would be important to ensure that appropriate support was provided to staff in managing at a time of increased demand, financial pressures, and a reducing workforce. 5.4 Briefing from the Chair of the Quality Committee The chair of the Quality Committee was invited to present the Committee Chair’s Report in respect of the meeting held on 17 March 2025, the content of which was noted. It was further noted that: • The committee reviewed the Trust’s quality indicators, which continued to indicate that the organisation was under pressure. • Following an incident at Derriford Hospital in Plymouth on 4 March 2022 whereby a member of the public had suffered fatal injuries due to the downwash from a landing helicopter, the Trust had commissioned a review of its own safety arrangements. It was noted that some additional safety measures would be required. • A visit by NHS South East Region to the Princess Anne Hospital in February 2025 had provided some positive feedback about the service. The Maternity and Neonatal Safety 2024/25 Quarter 3 Report was noted. It was further noted that: • The report had been reviewed by the Quality Committee at its meeting held on 17 March 2025. • The proportion of births via caesarean section remained high at over 40%, with late requests in particular placing additional pressure on theatre capacity. • Following successful recruitment of additional staff in late 2024, operational pressures had reduced substantially compared with the previous situation. • A never event relating to a missing swab was under investigation. • The Trust was currently over establishment in terms of its number of midwives and expected to be staffed above the requirement indicated by the anticipated birthrate for the area by the end of 2025/26. 5.5 Chief Executive Officer’s Report David French was invited to present the Chief Executive Officer’s Report, the content of which was noted. It was further noted that: • Significant reorganisations of NHS England and integrated care boards (ICBs) had been announced. NHS England was to be abolished, and certain functions merged into the Department of Health and Social Care. Integrated care boards were expected to have to reduce their costs by 50%. • A ‘model’ integrated care board blueprint had been published, which appeared to imply that a significant proportion of ICB functions could be redistributed to providers. • It was expected that the number of ICBs would reduce to 25-30, with each serving populations of c.2m. In Hampshire, ICB and local authority boundaries were expected to align, which was considered to be beneficial. • The British Social Attitudes Survey 2024 showed the lowest satisfaction rating for the NHS since the survey began. • The Spring Statement and subsequent messaging indicated that there would not be additional funding during 2025/26. • The Trust continued to face significant pressure due to patients having no criteria to reside. Historically, there were typically around 100 such patients at Page 3 any one time, whereas 281 had been reported on 13 May 2025. This was the equivalent of six wards. • The Trust faced significant financial pressure during 2025/26 with a lower financial settlement than expected. In order to meet its plans, the Trust would be required to deliver c.£110m of Cost Improvement Programmes, reductions of 5% in divisions and 10% in Trust Headquarters, coupled with clinical and non-clinical recruitment controls. The Trust continued to experience high demand for services, especially in the Emergency Department. • It was important to protect the frontline and assist the organisation with managing at such a time. 5.6 Performance KPI Report for Month 12 Duncan Linning-Karp was invited to present the Performance KPI Report for Month 12, the content of which was noted. It was further noted that: • The Trust continued to face significant challenges in terms of its Emergency Department performance, with only 57.2% of patients spending less than four hours in the main Emergency Department. An external review was to take place. • There had been a four-month trajectory of increasing numbers of falls. Whether there was any correlation between the increasing number of falls and number of patients having no criteria to reside was being investigated. • The Trust continued to report strong Elective Recovery performance, although the size of the Trust’s waiting list continued to increase. There was some concern as to whether the financial pressures were impacting elective performance and waiting times. • There had been a decrease in the number of virtual outpatient appointments. • Ten never events had been reported as of the end of March 2025. The Trust expected regulatory scrutiny as a result. • The metrics reported in respect of research and development were being reevaluated. Duncan Linning-Karp was invited to present the spotlight on the Mental Health Patient Cohort, the content of which was noted. It was further noted that: • Regular reports on mental health patients were provided to the Quality Committee. • During 2024, there were 347 patients with a decision to admit to a mental health bed whilst at UHS (2023: 303), of these only 13.2% were transferred within the expected 12 hours (2023: 18.5%). During the first quarter of 2025, there had been 92 such patients. If the numbers remained consistent for the rest of 2025, a growth rate of 6% was expected. • In terms of patients brought to the Emergency Department as a hospital-based place of safety detained under section 136 of the Mental Health Act 1983, only 22% of patients brought to the Trust had a physical need, whereas the remaining patients were brought to the Emergency Department due to the lack of an available facility. • There were insufficient beds available at mental health providers, who were also impacted by delayed discharges. • The enhanced care required by mental health patients placed significant demand on the Trust’s resources. The situation appeared to be worsening with around 100 patients at any one time, of which around 10 were acute. • The Trust has met with the Integrated Care Board and mental health provider to push for a working group to address the issue that care for mental health patients at the Trust cost significantly more than the cost for looking after Page 4 patients at a dedicated facility due to the need to engage specialist agency staff. Actions Duncan Linning-Karp agreed to investigate why the number of virtual outpatients appointments had reduced. Gail Byrne agreed to examine the trend in respect of the friends and family test negative score for inpatients. 5.7 Break 5.8 Finance Report for Month 12 Ian Howard was invited to present the Finance Report for Month 12, the content of which was noted. It was further noted that: • The Trust had delivered its forecast £7m deficit at year end. This had been achieved through a combination of additional Cost Improvement Programme (CIP) delivery and additional revenue support • Whilst the Trust had delivered £85.3m of CIP, a significant proportion of this was non-recurrent. The Trust continued to record an underlying deficit of £6- 7m per month. • The Trust had £17m in cash, below its usual minimum holding of £30m. The Trust continued to closely monitor and manage its cash position, but it was likely that support would be required in the first quarter. • During 2024/25, the Trust had carried out £34m of unpaid for activity, particularly in terms of Emergency Department, non-elective and outpatient follow ups. There were, however, limited opportunities to reduce this activity due to quality impacts . 5.9 ICB Finance Report for Month 12 Ian Howard was invited the present the ICB Finance Report for Month 12, the content of which was noted. It was further noted that: • The Hampshire and Isle of Wight Integrated Care System had achieved a breakeven position for 2024/25. It was noted that this represented a significant achievement given that the system was reporting a cumulative deficit of £80m at Month 5. • The system-wide transformation programmes had had a lower-than-expected impact on the Trust. 5.10 People Report for Month 12 Steve Harris was invited to present the People Report for Month 12, the content of which was noted. It was further noted that: • At year end the Trust was 373 WTE above its 2024/25 plan. There had been a significant increase in use of bank staff in March 2025 due to annual leave and the number of mental health patients. The size of the substantive workforce had, however, reduced, albeit at a lower level than expected. • The formal consultation in respect of the organisational changes had been commenced with the unions. The Trust would be moving from four to three divisions and reducing its workforce. • The Trust had announced its intention to reduce the size of its workforce by 780 WTE (c.6%). This was to be achieved via a combination of natural Page 5 attrition and vacancy control and through a Mutually Agreed Resignation Scheme. • There were a number of risks to achievement of the Trust’s 2025/26 workforce plan, including: quality and safety risks (mitigated through Equality and Quality Impact Assessment); a lower-than-expected turnover rate due to a lack of opportunities elsewhere; the Trust’s cash position; and delivery of non-criteria to reside and mental health patient reductions. • The Trust had released a statement to staff and was awaiting guidance in respect of the recent Supreme Court ruling regarding the definition of a woman under the Equality Act 2010. 5.11 UHS Staff Survey Results 2024 Report Steve Harris was invited to present the UHS Staff Survey Results 2024 Report, the content of which was noted. It was further noted that: • The results of the Staff Survey had been discussed in detail by the People and Organisational Development Committee on 24 March 2025 and at a Trust Board Study Session held on 1 April 2025. • The Trust benchmarked well in certain areas, such as recommendation as a place to work and in terms of views of line management. However, the response rate was lower than in previous years and violence and aggression and civility and dignity scores remained areas of concern. The Board discussed the results of the Staff Survey and agreed that the Trust should focus its efforts on violence and aggression and on helping staff to manage change. It was noted that there was a strong correlation between line manager engagement and the survey response rate. 5.12 Guardian of Safe Working Hours Quarterly Report Diana Hulbert was invited to present the Guardian of Safe Working Hours Quarterly Report, the content of which was noted. It was further noted that: • There was to be a change in the exception reporting process from September 2025. The Trust was considering how best to manage these changes. • The financial constraints during 2025/26 would potentially impact the locum fill rate. • The Trust’s estate remained an issue, but work was ongoing, including consideration of re-purposing existing spaces. • Concerns had been expressed from some seeking consultant posts about the impact of the organisational changes on these opportunities. • The duration of handovers continued to result in breaches of working hour limits. 5.13 Learning from Deaths 2024-25 Quarter 3 and 4 Reports Jenny Milner was invited to present the Learning from Deaths Report, the content of which was noted. It was further noted that: • The Trust’s expected death rate remained lower than the national average, with the Trust ranked 12 out of 119. Page 6 • Further improvements in terms of the sharing of learning from Mortality and Morbidity meetings were required. Consideration was been given to using the Ulysses tool. • The Trust’s medical examiner service had reviewed more than 1,000 deaths since inception. 6. STRATEGY and BUSINESS PLANNING 6.1 Corporate Objectives 2024-25 Quarter 4 Review Martin de Sousa and Kelly Kent were invited to present the Corporate Objectives 2024/25 Quarter 4 Review, the content of which was noted. It was further noted that: • The Trust had delivered 50% of its annual objectives for 2024/25 and 37.5% of objectives had been partially achieved or had incurred minor delays. Two objectives remained ‘red’. • Particular areas to highlight included progress on long-waiters, patient experience, turnover/sickness of staff, and capital scheme delivery. The Trust had also been successful in slowing the rate by which the waiting list grew and in delivering Cost Improvement Programmes. • Areas of concern included the financial position, patients with no criteria to reside, and staff experience. • The Trust was in control of the delivery of some of the objectives, but full delivery of others was outside of the Trust’s control. 6.2 Board Assurance Framework (BAF) Update Lauren Anderson was invited to present the Board Assurance Framework (BAF) Update, the content of which was noted. It was further noted that: • The BAF had been previously reviewed by the Board in March 2025, following which it had been reviewed by the relevant executive directors and committees. • None of the ratings of the risks had been amended. However, the target dates for three risks had been extended to reflect the challenges in achieving the target rating. • The Trust was holding a higher overall level of risk than had previously been the case. It was considered important to ensure that risks were managed across domains and not in silos. • The Trust was using its risk appetite to support decision-making such as in capital prioritisation and in terms of the decisions required to deliver its 2025/26 plans. • A risk appetite review had been scheduled at a future Trust Board Study Session on the basis that the current situation potentially necessitated changes in terms of the Trust’s stated risk appetite. Action The review of risk appetite was to be scheduled to take place at the Trust Board Study Session on 3 June 2025. Page 7 6.3 South Central Regional Research Delivery Network (SC RRDN) 2024-25 Annual Performance Review and 2025-26 Annual Plan Paul Grundy and Clare Rook were invited to present the South Central Regional and Research Delivery Network (SC RRDN) 2024/25 Annual Performance Review and the SC RRDN 2025/26 Annual Plan, the content of which was noted. It was further noted that: • During the year the organisation transitioned from the Clinical Research Network Wessex to the South Central Regional Research Delivery Network, whereby the Wessex and Thames Valley and Midlands Clinical Research Networks were integrated into a single entity. • In the Wessex region, 33,000 participants were recruited to over 500 studies during the first half of the year. A further 35,000 participants were recruited to over 800 studies during the second half of the year in the South Central region. • Commercial research remained a priority, with the South Central region benchmarking well in terms of recruitment. • In terms of the 2025/26 plan, the NHS 10-year plan was awaited, as this would likely impact the plan. It was currently intended that the network would focus on the National Institute for Health Research’s seven priorities. A stakeholder group was being convened to inform the SC RRDN’s direction of travel. 7. CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Feedback from the Council of Governos’ (CoG) meeting 29 April 2025 The Chair presented a summary of the Council of Governors’ meeting held on 29 April 2025. It was noted that the meeting had considered the following matters: • Chief Executive Officer’s Performance Report • Annual Report and Quality Account Timetable 2024/25 • Draft Quality Account • Corporate Objectives • Non-NHS Activity • Governor Attendance at Council of Governor meetings • Council of Governors’ Elections 2025 • Appointment to the Governors’ Nomination Committee • Membership Engagement and Governor activity • Chair’s and Non-Executive Directors’ appraisal outcomes 7.2 Register of Seals and Chair’s Actions Report The paper ‘Register of Seals and Chair’s Actions Report’ was presented to the meeting, the content of which was noted. It was further noted that, due to an issue with the electronic signature platform, a number of items were included in the report, which should have been included in previous reports. Decision: The Board agreed to ratify the application of the Trust Seal to the documents listed in the ‘Register of Seals and Chair’s Actions Report’. Page 8 8. Any other business Gail Byrne informed the Board that a joint targeted area inspection of the Trust’s Emergency Department and Maternity service by the Care Quality Commission (CQC), social services and the police was scheduled to take place on 20 May 2025, which would focus in particular on safeguarding of children. In addition, a routine Ionising Radiation (Medical Exposure) Regulations inspection was due to take place in June 2025. It was noted that the CQC had recently carried out unannounced inspections at Portsmouth Hospitals University NHS Trust and at South Central Ambulance Service NHS Foundation Trust. Accordingly, it appeared likely that the Trust should also expect an unannounced CQC visit, followed by a Well-Led review. It was noted that this was Dave Bennett’s last formal scheduled Board meeting, as his second three-year term was due to expire on 14 July 2025. The Board expressed its thanks to Dave Bennett. 9. Note the date of the next meeting: 15 July 2025 10. Resolution regarding the Press, Public and Others Decision: The Board resolved that, as permitted by the National Health Service Act 2006 (as amended), the Trust’s Constitution and the Standing Orders of the board of directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. The meeting was adjourned. Page 9 List of action items Agenda item Assigned to Deadline Trust Board – Open Session 13/05/2025 - 5.6 Performance KPI Report for Month 12 1246. Virtual outpatients appointments Linning-Karp, Duncan 15/07/2025 Explanation action item Duncan Linning-Karp agreed to investigate why the number of virtual outpatients appointments had reduced. 1247. Friends and family test Byrne, Gail 15/07/2025 Explanation action item Gail Byrne agreed to examine the trend in respect of the friends and family test negative score for inpatients. Trust Board – Open Session 13/05/2025 - 6.2 Board Assurance Framework (BAF) Update 1248. Risk appetite Byrne, Gail 03/06/2025 Explanation action item The review of risk appetite was to be scheduled to take place at the Trust Board Study Session on 3 June 2025. Status Pending Pending Completed Page 1 of 1 Agenda Item 5.1 Committee Chair’s Report to the Trust Board of Directors 15 July 2025 Committee: Audit & Risk Committee Meeting Date: 9 June 2025 Key Messages: • • • • • The committee considered the results of a review of historical private activity (pre-2022/23) which had not been invoiced by the Trust. It was noted that, of the £2.5m total, £1.6m had since been paid, but that £0.9m should be written off. It was further noted that this issue should not arise in future due to changes in contracting arrangements and improvements in processes. The committee noted an update in respect of the Trust’s submission as part of the annual National Cost Collection exercise. The committee received a report on waivers of competitive tendering between October 2024 and March 2025, noting that these represented c.£11m of activity over the period. The committee reviewed a draft of the Annual Report and Accounts for 2024/25. The committee noted that the external audit had not progressed as planned. The committee received the Quarter 4 Fraud, Bribery and Corruption Work Plan Update Report, noting that under the Counter-Fraud Functional Return that the Trust was green-rated. Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) 6.3 Board Assurance Framework (BAF) Update Assurance Rating: Risk Rating: Substantial N/A • There had been an increase in the number of critical risks recorded from 30-35 to c.50. Many of these risks related to staffing or capacity. • It was noted that some of this increase was driven by new risks being identified (or existing risks worsening), but that existing critical risks were not being closed due to insufficient resources. • In addition, following the Six Facet survey, there had been an improvement in the articulation of Estates-related risks, which was now reflected in the total number of operational risks. • The committee reviewed the Board Assurance Framework, noting that all risks had been reviewed by the relevant executive(s). 7.2 Review of Standing Assurance Rating: Risk Rating: Financial Instructions 2025-26 Substantial N/A • The committee reviewed the Trust’s Standing Financial Instructions, noting that changes were proposed to two areas: employee expenses and non-pay requisition limits. Any Other Matters: • The committee reviewed the Trust’s internal audit plan and agreed that a cyber security audit should be included as part of the plan. Page 1 of 2 Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Limited Assurance Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. No Assurance There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Not Applicable Where assurance is not required and/or relevant. Risk Rating: Low Medium High Not Applicable Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda Item 5.2 i) Committee Chair’s Report to the Trust Board of Directors 15 July 2025 Committee: Finance and Investment Committee Meeting Date: 2 June 2025 Key Messages: Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) • The committee reviewed the Finance Report for Month 1. The Trust had reported a deficit of £4.4m in line with its plan whereby the Trust would move from a deficit to breakeven to surplus over the course of the year thereby achieving an overall breakeven position at year end. • The Trust’s underlying deficit was £7.2m in month. This was driven by patients having no criteria to reside, activity above block contract levels, and mental health patients. Use of bank staff had normalised when compared to Month 12, but there had been high drugs spend and lower than expected income which was under investigation. • The Trust was on track in terms of its Cost Improvement Programme (CIP). • The committee received an update in respect of the Trust’s cash position, noting that the Integrated Care Board had agreed to move scheduled payments to aid the Trust’s position. The Trust was forecasting a £7m negative balance in March 2026. • The committee reviewed the ‘Acute Drivers of Deficit’ report prepared by Deloitte, noting that many of the identified areas were long-term and/or structural issues. • The committee received an update on the Trust’s financial improvement programmes, noting that although c.£80m of the £110m CIP was currently viewed as ‘high risk’, this was expected to improve as schemes became more mature. • The committee noted the Trust’s response to a request to consider proposed workforce targets based on removing 50% of reported increases in corporate services expenditure since 2018/19. It was noted that the Trust expected to deliver this target through its existing plans. • The committee received an update in respect of the national and local contracting process, noting that most areas had now been agreed. The potential changes in Elective Recovery Funding posed a risk to the Trust. In addition, it was likely that £20-30m of activity would remain unfunded. N/A Any Other Matters: The committee received the Always Improving – Transformation End of Year Report, noting progress made. Page 1 of 2 Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Limited Assurance Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. No Assurance There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Not Applicable Where assurance is not required and/or relevant. Risk Rating: Low Medium High Not Applicable Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda Item 5.2 ii) Committee Chair’s Report to the Trust Board of Directors 15 July 2025 Committee: Finance and Investment Committee Meeting Date: 23 June 2025 Key Messages: • • • • • The committee reviewed the Finance Report for Month 2 (see below). The committee received an update in respect of the Trust’s cash position, noting that the position continued to deteriorate. It was further noted that discussions were underway with local providers, as some providers have cash whilst at the same time others risked running out. The committee received an update on the Urgent and Emergency Care Transformation Programme, noting that the Trust was targeting a reduction in length of stay by a further 5%. The committee noted an update from UHS Estates Limited and progress on a number of programmes. The committee considered a summary of the Spending Review presented by the Chancellor of the Exchequer on 11 June 2025. Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) 5.8 Finance Report for Month 2 Assurance Rating: Risk Rating: Substantial High • The Trust had recorded an in-month deficit of £3.8m, which was in line with its plan to reach a breakeven position by year end. • The Trust had achieved its planned Cost Improvement Programme delivery level, although much of this was due to non-recurrent savings, which creates a challenge later in the year. • The Trust’s underlying deficit remained at £7.2m, consistent with Month 1. • Income had been lower than expected with reductions in income from pathology and the Channel Islands. Non-pay costs for drugs and clinical supplies also remained a challenge. • The committee reviewed the Trust’s workforce trajectory for 2025/26, noting that even if all ‘red’ CIP schemes were to deliver, this would still result in a shortfall. 6.2 Board Assurance Framework (BAF) Update Assurance Rating: Risk Rating: Substantial N/A • Risks 5a, 5b and 5c have been updated, following discussions with the respective Executive Director(s). Any Other N/A Matters: Page 1 of 2 Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Limited Assurance Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. No Assurance There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Not Applicable Where assurance is not required and/or relevant. Risk Rating: Low Medium High Not Applicable Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda Item 5.3 Committee Chair’s Report to the Trust Board of Directors 15 July 2025 Committee: People and Organisational Development Committee Meeting Date: 25 June 2025 Key Messages: • The committee reviewed the People Report for Month 2 including progress on the Workforce Plan for 2025/26 (see below). • The committee noted that the plans for the Divisional restructure are now underway with the intention of implementing these on 01 July 2025. It is understood that whilst not all people plans have been finalised at a granular level, it is anticipated that most issues will be resolved through natural attrition and through the Mutually Agreed Resignation Scheme (MARS). • The MARS application window has now closed and there has been significant interest with 220+ applications submitted. These are currently being assessed for suitability and it is planned that the outcomes will be shared with applicants by 04 July 2025. Not all applications will be accepted as some posts cannot be surrendered, and the organisation cannot afford to accept them all. Whilst each resignation will represent a long-term saving there is a very real risk to in year cost pressures as all successful MARS applications will need to be funded locally, as there is no national funding to support this. • Additional recruitment controls also remain in place including a freeze on non-clinical recruitment, and a hold on 30% of clinical recruitment. • The committee noted that the scale of organisational change is significant and this is likely to be unsettling for staff. A number of support mechanisms have been implemented focussed on wellbeing, and this includes specific organisational change workshops targeted at leaders across the Trust to support them in supporting the wider workforce. The committee reflected that this is a positive step and that once the organisational restructure has completed, this should be used as a foundation for implementing change and leadership training as business as usual. • The committee received an update on the organisation’s education position and the current challenges and opportunities related to this. The committee acknowledged the significant risk to future workforce as a result of the current challenges across the NHS, in combination with the restricted and reduced funding streams which facilitate staff access to education and development. The committee noted the need to review education capacity again at UHS once the long-term workforce plan is published later in the year. Page 1 of 2 Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) Any Other Matters: 5.10 People Report for Month 12 Assurance Rating: Risk Rating: Substantial High • The Trust’s overall workforce grew by 19 WTE in May 2025 however it is still below the NHSE plan by 107 WTE. It was noted that turnover remains lower than average and it is suspected that this will be due to system wide recruitment controls limiting roles UHS staff may move into, in addition to a wider lack of opportunity in the jobs market as general employer confidence reduces. • Additionally, whilst both remain below plan, there has been an increase in temporary staffing bank and agency usage noting that April was a very low month. • The committee noted that the workforce plan is ambitious and sets out a reduction in headcount of c.750. All schemes to deliver this have been assessed for maturity and continue to be worked up, although even if it were to be assumed that all are followed through to completion, there is still a shortfall which needs to be addressed. Significant work has been undertaken to forward plan the trajectory. • It was noted that consideration had been given to the recruitment controls and whether these needed to be taken further, however as it will take several months to fully implement and see the benefit of those in place currently, this was decided against. The improvements in forecasting, and monthly review, will support this decision so that it can be reviewed again later in the year, probably September. • The committee discussed the need to track indicators related to people, money, performance and quality and consideration will be given to a balanced scorecard. • The committee received a further update in respect of the Band 2/3 pay dispute and in respect of the portering department. • The committee also received a series of updates on recent national letters to Trusts including a required review of job evaluation processes and analysis work on non-frontline nursing roles. Page 2 of 2 Agenda Item 5.4 Committee Chair’s Report to the Trust Board of Directors 15 July 2025 Committee: Quality Committee Meeting Date: 2 June 2025 Key Messages: Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) Any Other Matters: • It was n
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