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UHS AR 23-24 Final

Description: 2023/24 Incorporating the quality account University Hospital Southampton NHS Foundation Trust Annual Report and Accounts 2023/24 Presented to Parliament pursuant to Schedule 7, paragraph 25(4)(a) of the National Health Service Act 2006 © 2024 University Hospital Southampton NHS Foundation Trust Contents Welcome from our chair and chief executive 6 Overview and performance 8 Performance report 9 Overview 10 Accountability report 37 Directors’ report 38 Remuneration report 62 Staff report 75 Annual governance statement 95 Quality account 111 Statement on quality from the chief executive 112 Priorities for improvement and statements of assurance from the board 115 Other information 180 Annual accounts 207 Statement from the chief financial officer 208 Auditor’s report 210 Foreword to the accounts 217 Statement of Comprehensive Income 218 Statement of Financial Position 219 Statement of Changes in Taxpayers’ Equity 220 Statement of Cash Flows 221 Notes to the accounts 222 5 Welcome from the Chair and Chief Executive Officer This has been another busy and undoubtedly challenging year across the NHS and UK health and social care system, and much of what has impacted the national picture has been reflected in the operational focuses and patient and people priorities for University Hospital Southampton NHS Foundation Trust (‘UHS’ or the ‘Trust’) over the last year. Meeting and continuing to overcome the challenges we have faced has required an organisation-wide team effort, and looking back at the successes we feel incredibly proud of the achievements of our 13,000 staff. Particular highlights include: • In the top ten in the country (7th) against government targets for elective recovery performance with 118% of activity compared with 2019. • Top-quartile performance against most performance metrics compared to similar sized teaching hospitals, including Emergency Department access, long-waiting patients on Referral to Treatment pathways, Diagnostics and Cancer performance. • Significant investment in new capacity through building new wards and theatres and refurbishing existing areas of the hospital. • Delivery of our highest ever Cost Improvement Programme saving. These achievements place us among the best performing trusts in England in several areas and are even more remarkable against a backdrop of continued periods of industrial action and increasing demand for our services, with many people coming to us with higher levels of acuity than ever before. The Trust’s performance in terms of elective recovery places it as one of the best-performing trusts in England and demonstrates the impact of the Trust’s decision to invest in additional capacity in prior years by building new wards and theatres. The Trust’s Emergency Department performance in respect of its four-hour waiting target at the end of March 2024 has attracted additional capital funding as part of an incentive scheme. Some of this funding will be used to increase the department’s same-day emergency care capacity during 2024/25. From a financial perspective, balancing the complexities of today’s challenges alongside the need to protect and ensure the long-term stability and quality of our service provision, has required the Board to take a number of considered and crucial efficiency improvement actions this year. Whilst challenging, the Trust has seen significant progress in delivering on both its forecasted finance position for 2023/24 and productivity targets. Achieving long-term financial stability is key to us continuing to invest in much needed upgrades and improvements to the parts of our estate that are ageing, and to developing new state-of-the-art facilities and infrastructure that increases our capabilities and capacity into the future. In the last year parts of the hospital have been transformed, with the opening of new wards, theatres and a skybridge to link the estate. Construction of a sterile services and aseptics facility has begun at Adanac Park and the expansion of our neonatal department, where we treat and care for some of our most vulnerable babies and their families, is underway. The development of a new aseptic facility at Adanac Park will have capacity to serve other hospitals within the region and is a significant opportunity for improved system-wide working. 6 We have also worked with our people to design spaces where they can rest, relax and recharge - including a new wellbeing hub and rooftop garden on the Princess Anne Hospital site. In addition, 40 staff rooms across the site have been refurbished thanks to funding from Southampton Hospitals Charity. During the year, the Trust worked to establish the Southampton Hospitals Charity as a separate charitable company to improve its ability to both raise and spend funds. This process completed on 1 April 2024. Work was carried out to refurbish a children’s ward during the year in partnership with the charity. Our people are our greatest asset, and we are pleased to see improvements from the annual staff survey in several areas - such as how people can work more flexibly, access to learning and development and improved satisfaction in support from line managers. We recognise the pressures and demands that come with working in this environment and will continue to ensure everyone working here feels heard, encouraged and supported when raising concerns. At UHS, every opportunity is taken to recognise and celebrate the incredible things our people do here every day, including the return of our in-person annual awards ceremony, monthly staff recognition events and the first ever ‘We Are UHS Week’. These occasions are an important reminder that, even when faced with challenges, there is so much to be proud of and celebrate across the whole Trust. Working together, both within the Trust and across organisational boundaries, remains one of our core values. The partnership between UHS and the University of Southampton is as strong as it has ever been, with more than 250,000 individuals having now taken part in research studies in Southampton. As the lead partner member for Acute Hospital Services on the Hampshire and Isle of Wight Integrated Care Board, we are proactively working with other trusts and healthcare providers in the region to improve the health of the community we serve. In addition, the Trust has continued to work in partnership with other providers across the system to build a shared elective orthopaedic hub in Winchester. It is anticipated that the health and social care system will continue to be a challenging environment in 2024/25. We recognise that many of the big challenges we face can only be solved in partnership with wider local partners, and we are committed to actively playing our part in delivering system-wide solutions. Equally, we will continue to focus on improving whatever is within our internal control, and to work collaboratively with our people to ensure our patients’ experience, safety and outcomes remain central to our decision-making and the actions of everyone at UHS. Jenni Douglas-Todd Chair 19 July 2024 David French Chief Executive Officer 19 July 2024 7 PERFORMANCE REPORT Performance report Introduction from the Chief Executive Officer As with 2022/23, this was another challenging year with continued increasing demand for the Trust’s resources and the need to balance this with the need to deliver quality patient care and at the same time maintain a sustainable financial position. Demand for non-elective care continued to increase with an average of 375 attendances per day to our main Emergency Department. In addition, the number of patients on the 18-week Referral to Treatment pathway rose to 58,000. Patients having no clinical criteria to reside in hospital, but unable to be discharged due to the lack of funded care in a more suitable location, posed and continues to pose a significant challenge for the Trust. The number of patients within this category was as high as 270 at times and was consistently higher throughout the year when compared to 2022/23. Despite this the Trust continued to perform well when compared to other comparable organisations, achieving some of the best Emergency Department and elective recovery fund performance in England. The Trust’s financial position continued to be difficult, which required some difficult decisions in respect of spending controls and controls on recruitment. The Trust focused in particular on controlling spending on temporary and agency staff, but in view of the overall workforce numbers compared to the 2023/24 plan, further controls were implemented in respect of substantive recruitment. Due to the additional controls and the Trust’s best delivery to date on its Cost Improvement Programme (£63.4m), the Trust achieved an end of year deficit of £4.5m, compared to the deficit of £26m anticipated in its 2023/24 plan. 9 Overview About the Trust Our services University Hospital Southampton NHS Foundation Trust is one of the largest acute teaching trusts in England with a turnover of more than £1.3 billion in 2023/24. It is based on the coast in south east England and provides services to over 1.9 million people living in Southampton and south Hampshire and specialist services, including neurosciences, respiratory medicine, cancer care, cardiovascular, obstetrics and specialist children’s services, to nearly four million people in central southern England and the Channel Islands. The Trust is also a designated major trauma centre, one of only two places in the south of England to offer adults and children full major trauma care provision. As a leading centre for teaching and research, the Trust has close working relationships with the University of Southampton, the Medical Research Council, National Institute for Health and Care Research (NIHR), Wellcome Trust and Cancer Research UK. The Trust is consistently one of the UK’s highest recruiting trusts of patients to clinical trials and one of the top nationally for research study volumes as ranked by the NIHR Clinical Research Network. Every year the Trust: treats around 155,000 inpatients and day patients, including about 70,000 emergency admissions sees over 750,000 people at outpatient appointments deals with around 150,000 cases in our emergency department The Trust provides most of its services from the following locations: • Southampton General Hospital – the Trust’s largest location, where a great number of specialist services are based alongside emergency and critical care and which includes Southampton Children’s Hospital. • Princess Anne Hospital – located across the road from Southampton General Hospital and providing maternity care and specialist care for women with medical problems during pregnancy and babies who need extra care around birth across the region. • Royal South Hants Hospital – although the Trust does not operate this site near the centre of Southampton it provides a smaller number of services from this location. • New Forest Birth Centre – located at Ashurst on the edge of the New Forest and run by experienced midwives and support staff it acts as a community midwifery hub. The services provided by the Trust are commissioned and paid for by the Hampshire and Isle of Wight Integrated Care System (ICS) and, in the case of more specialised services (such as treatments for rare conditions), by NHS England. Trust services are supported by clinical income, of which 54% is paid for by NHS England and 43% by integrated care boards, predominantly the Hampshire and Isle of Wight Integrated Care Board (ICB). These are provided under a standard NHS contract, which incorporates ongoing monitoring of the Trust and the quality of the services provided. 10 Our structure UHS gained foundation trust status on 1 October 2011. A foundation trust is a public benefit corporation providing NHS services in line with the core NHS principles: that care should be universal, comprehensive and free at the point of need. The Trust is licensed as a foundation trust to provide these services by NHS England and the healthcare services we provide are regulated by the Care Quality Commission. Since 1 July 2022, the Trust has been part of the Hampshire and Isle of Wight Integrated Care System when this was established through the Health and Social Care Act 2022. Each ICS has two statutory elements: an integrated care partnership (ICP) and an integrated care board. The ICP is a statutory committee jointly formed between the NHS integrated care board and all upper-tier local authorities that fall within the ICS area. The ICP brings together a broad alliance of partners concerned with improving the care, health and wellbeing of the population, with membership determined locally. The ICP is responsible for producing an integrated care strategy on how to meet the health and wellbeing needs of the population in the ICS area. The ICB is a statutory NHS organisation responsible for developing a plan for meeting the health needs of the population, managing the NHS budget and arranging for the provision of health services in the ICS area. The Trust has been a university teaching hospital since 1971. The diagram below provides an overview of the overall organisational structure of the Trust. Public and foundation trust members Council of Governors Board of Directors Executive Directors Division A Division B Division C Division D Surgery Critical Care Opthalmology Theatres and Anaesthetics Cancer Care Emergency Medicine Helicopter Emergency Medical Services Medicine and Medicine for Older People Pathology Specialist Medicine Women and Newborn Maternity Child Health Clinical Support Cardiovascular and Thoracic Neurosciences Trauma and Orthopaedics Radiology Trust Headquarters Division 11 Our values The Trust’s values describe how things are done at UHS and act as a guide to all staff working with colleagues to deliver high quality patient care and a great patient experience every day. These values are: Patients, their families and carers are at the heart of what we do. Their experience of our services will be our measure of success. Partnership between clinicians, patients and carers is critical to achieving our vision, both within hospital teams and extending across organisational boundaries in the NHS, social care and the third sector. We will ensure we are always improving services for patients through research, education, clinical effectiveness and quality improvement. We will continue to incorporate new ideas, technologies and create greater efficiencies in the services we provide. 12 Our strategy 2021-25 The Trust’s strategy was updated during 2020/21 to take account of everything its staff had experienced during the COVID-19 pandemic and what had been learnt from this. The vision for UHS is to become an organisation of world class people delivering world class care. The Trust’s strategy is organised around five themes and for each of these it describes a number of ambitions UHS aims to achieve by 2025. Theme Ambitions Outstanding patient outcomes, • We will monitor clinical outcomes, safety and experience of our experience and safety patients regularly to ensure they are amongst the best in the UK By 2025 we will strengthen our and the world. national reputation for outstanding • We will reduce harm, learning from all incidents through our patient outcomes, experience and proactive patient safety culture. safety, providing high quality care • We will ensure all patients and relatives have a positive experience and treatment across an extensive of our care, as a result of the environment created by our people range of services from foetal and our facilities. medicine, through all life stages and conditions, to end-of-life care. Pioneering research • We will recruit and enable people to deliver pioneering research in and innovation Southampton. We will continue to be a leading teaching hospital with a growing, reputable and innovative research and development portfolio • We will optimise access to clinical research studies for our patients. • We will enable innovation in everything we do, and ensure that ‘cutting edge’ investigations and treatments are delivered in Southampton. that attracts the best staff and efficiently delivers the best possible treatments and care for our patients. World class people • We will recruit and develop enough people with the right Supporting and nurturing our knowledge and skills to meet the needs of our patients. people through a culture that values • We will provide satisfying and fulfilling roles, growing our talent diversity and builds knowledge and through development and opportunity for progression. skills to ensure everyone reaches • We will empower our people, embracing diversity and embedding their full potential. We must provide compassion, inclusion and equity of opportunity. rewarding career paths within empowered, compassionate, and motivated teams. Integrated networks and collaboration We will deliver our services with partners through clinical networks, collaboration and integration across geographical and organisational boundaries. • We will work in partnership with key stakeholders across the Hampshire and Isle of Wight integrated care system. • We will strengthen our acute clinical networks across the region, centralising when necessary and supporting local care when appropriate. • We will foster local integration with primary and community care as well as mental health and social care services for seamless delivery across boundaries. • We will build on our successful partnership with University of Southampton (UoS), growing our reputation as a national leading university teaching hospital. 13 Theme Foundations for the future Making our enabling infrastructure (finance, digital, estate) fit for the future to support a leading university teaching hospital in the 21st century and recognising our responsibility as a major employer in the community of Southampton and our role in broader environmental sustainability. Ambitions • We will deliver best value to the taxpayer as a financially efficient and sustainable organisation. • We will support patient self-management and seamless care across organisational boundaries through our ambitious digital programme, including real time data reporting, to inform our care. • We will expand and improve our estate, increasing capacity where needed and providing modern facilities for our patients and our people. • We will strengthen our role in the community as an employer of choice, a partner in delivery of services to our population and by leading the Greener NHS agenda locally. During each year of the strategy the Trust sets out a more detailed series of objectives to achieve and progress towards the delivery of its ambitions. In 2023/24 these objectives included: Outstanding patient outcomes, experience and safety Pioneering research and innovation World class people Integrated networks and collaboration Foundations for the future • Increasing the number of reported Shared Decision-Making conversations. • Increasing the number of specialities reporting outcomes that matter to patients. • Rolling out the Patient Safety Incident Reporting Framework across the Trust. • Working with patients as partners to improve patient satisfaction. • Treating patients according to need but aiming for no patient to wait, other than through patient choice, more than 65 weeks for treatment. • Delivering national metrics for site set-up time to target for clinical research studies. • Improving the Trust’s position against peers. • Delivering year three of the Trust’s research and innovation investment plan. • Developing the five-year research and development strategy implementation plan and delivery of the first year. • Strengthening and broadening the partnership between the Trust and the University of Southampton. • Supporting delivery of the Trust’s workforce plan for 2023/24. • Reducing turnover and sickness absence rates. • Increasing overall participation in the NHS staff survey and maintaining overall staff engagement score. • Increasing the proportion of appraisals completed. • Delivering the first year objectives of the Inclusion and Belonging strategy. • Working in partnership with acute trusts to agree and implement the acute services strategy. • Producing and embedding an internal framework for network development. • Working with the local delivery system on vertical integration to reduce the number of patients without criteria to reside. • Working with system partners to open a surgical elective hub. • For the Trust to be seen as an ‘anchor institution’ in the local area. • Delivering the Trust’s financial plan for 2023/24. • Engaging the organisation in the challenge to manage demand so that capacity and demand are in equilibrium. • Delivery of the Always Improving strategy priorities. • Delivering the Trust’s capital programme in full. • Entering into a new energy performance contract and delivering the first year of the Public Sector Decarbonisation Scheme. Performance against these objectives was monitored and reported to the Trust’s Board on a quarterly basis. 14 At the end of 2023/24, the Trust had met the objectives set as follows: Corporate Ambition Outstanding patient outcomes, safety and experience Pioneering research and innovation World class people Integrated networks and collaboration Foundations for the future Totals Number of Objectives 5 5 5 5 5 25 Achieved in full 4 3 2 3 2 14 Partially achieved 1 2 2 1 3 9 Not achieved 0 0 1 1 0 2 Particular areas to highlight where the Trust has achieved strong delivery during the year include: • Delivery of quality priorities in Shared Decision-Making and the roll out of the Patient Safety Incident Response Framework. • Achieving the Trust’s 65-week waiter glide path. • Successful delivery of a number of research and development priorities, including work with the University of Southampton. • Maintaining sickness absence and turnover well below the targets set at the beginning of the year, and successfully delivering the first year of the Trust’s Inclusion and Belonging strategy. • Delivery of the Trust’s full available capital budget and completion of the first year of the Trust’s decarbonisation scheme. 15 Principal risks to our strategy and objectives The Board has identified and manages the principal risks to the delivery of its strategy and objectives through its board assurance framework. The principal risks to the delivery of its strategy and objectives identified by the Trust during 2023/24 were that: • There would be a lack of capacity to appropriately respond to emergency demand, manage the increasing waiting lists for elective demand, and provide timely diagnostics, that results in avoidable harm to patients. • Due to the current challenges, the Trust fails to provide patients and their families or carers with a highquality experience of care and positive patient outcomes. • The Trust would not effectively plan for and implement infection prevention and control measures that reduce the number of hospital-acquired infections and limit the number of nosocomial outbreaks of infection. • The Trust does not take full advantage of its position as a leading university teaching hospital with a growing, reputable and innovative research and development portfolio, attracting the best staff and efficiently delivering the best possible treatments and care for its patients. • The Trust is unable to meet current and planned service requirements due to unavailability of qualified staff to fulfil key roles. • The Trust fails to develop a diverse, compassionate and inclusive workforce, providing a more positive experience for all staff. • The Trust fails to create a sustainable and innovative education and development response to meet the current and future workforce needs identified in the Trust’s longer-term workforce plan. • The Trust does not implement effective models to deliver integrated and networked care, resulting in sub-optimal patient experience and outcomes, increased numbers of admissions and increases in patients’ length of stay. • The Trust is unable to deliver a financial breakeven position, resulting in: inability to move out of the NHS England Recovery Support Programme; NHS England imposing additional controls/undertakings; and a reducing cash balance, impacting the Trust’s ability to invest in line with its capital plan, estates and digital strategies and in transformation initiatives. • The Trust does not adequately maintain, improve and develop its estate to deliver its clinical services and increase capacity. • The Trust fails to introduce and implement new technology and expand the use of existing technology to transform its delivery of care through the funding and delivery of the digital strategy. • The Trust fails to prioritise green initiatives to deliver a trajectory that will reduce its direct and indirect carbon footprint by 80% by 2028-2032 (compared with a 1990 baseline) and reach net zero direct carbon emissions by 2040 and net zero indirect carbon emissions by 2045. During 2023/24, the Trust saw continued increased demand for its services, particularly in the Emergency Department In addition, the number of patients having no clinical criteria to reside in hospital, but unable to be discharged due to a lack of appropriate care packages was higher than anticipated and spiked during winter, which significantly impacted patient flow through the hospital and required the Trust to engage additional temporary staff. The number of patients in this category peaked at 270 during the winter. There were particular challenges in respect of those patients with a primary mental health care need who would be better cared for in a more suitable alternative setting. 16 Performance overview The Trust monitors a broad range of key performance indicators within its departments, divisions, directorates and through Trust executive committees. On a monthly basis, the Board and executive committee receives a performance report containing a variety of indicators intended to provide assurance in respect of the Trust’s strategy and that the care provided is safe, caring, effective, responsive and well-led. This report also includes the Trust’s performance against the national targets set by NHS England. The performance reports include a ‘spotlight’ section, which provides more detailed analysis of a particular area. Typically, this is one of either the national targets or the Trust’s performance against the expectations set out in the NHS Constitution. The monthly performance report is also published on the Trust’s website. The Chief Executive Officer provides a regular report on performance to the Council of Governors, which includes a range of non-financial and financial performance information. Capacity The Trust continued to experience high demand for its services, especially in the Emergency Department, with average demand during the year being around 375 patients presenting per day in the main adult and children’s emergency department. In addition, the Trust experienced a significant impact on flow within the hospital due to a high number of patients having no clinical criteria to reside in hospital but unable to be discharged. This number was as high as 270 at times during winter: an increase of around 50 patients when compared to the prior year. The Trust also saw an increase in the number of referrals with the number of patients on a waiting list under the 18-week Referral to Treatment pathway rising from approximately 55,000 to 58,000 by the end of the year. In common with other trusts, the ongoing industrial action also impacted the Trust’s ability to provide urgent care and deliver on its elective recovery programme. Quality and compliance Despite the challenges, the Trust’s Emergency Department performance was one of the highest in England in March 2024, which resulted in additional capital funding being awarded. In addition, the Trust’s elective recovery performance was one of the best in England at 118% compared to 2019. The Trust continued to monitor the quality of care delivered throughout 2023/24 through a number of established quality assurance programmes. Clinical leaders monitored key quality, safety and patient experience indicators such as falls, pressure ulcers and venous thromboembolisms. Quality peer reviews were carried out, most significantly through Matron-led Quality Walkabouts every week in and out of hours focusing on the five key CQC questions – safe, effective, responsive, caring, and well-led. The Trust’s Clinical Accreditation Scheme builds on this intelligence, with clinical areas completing self-assessments of performance and review teams completing onsite visits. Patient representatives were included in these review teams. Learning was shared at the Clinical Leaders’ Group and via quarterly reports. The Trust was an active partner in a South-East accreditation network, offering advice and a steer to providers who are just setting up or looking to develop their own scheme, and extended that advice and support to other providers in England. 17 On 15 May 2023, the CQC inspected the maternity and midwifery service at Princess Anne Hospital as part of their national maternity inspection programme. The inspection report was published 11 August 2023, and the Trust retained its overall rating of ‘good’. This year UHS introduced its Fundamentals of Care (FOC) initiative. Whilst this is not a new concept, there were concerns that missed fundamental care had been amplified during the COVID- 19 pandemic. This initiative aims to empower and educate staff at all levels to ensure fundamental care is at the heart of what the Trust does. The Trust completed its transition to the Patient Safety Incident Response Framework (PSIRF) and collaborated with the ICB to develop a PSIRF plan and policy to underpin the change. The Trust implemented the requirements in respect of ‘Martha’s Rule’ where patients, relatives and carers have a legal right to a rapid review by a critical care outreach team during an acute deterioration episode in and out of hours. The Trust continued its focus on infection prevention and control, responding rapidly to rises in infection over the winter, and successfully flexing initiatives and innovations to achieve successful management in a responsive manner. The Trust progressed its Always Improving strategy and successfully supported the identification and implementation of further quality improvement projects. This included improvements across theatres, inpatient flow and outpatient programmes. During the year, average length of stay was reduced by 1.64%, day theatre cancellations were reduced by 200, and 42,350 patients were placed onto Patient Initiated Follow Up (PIFU) pathways. Further information can be found in the Quality Account. Partnerships The Trust works within the Hampshire and Isle of Wight Integrated Care System, and is an active member of a number of partner groups including the Acute Provider Collaborative Board and the Health and Wellbeing Board. The Trust develops and agrees its annual financial plans with the Integrated Care Board. The Trust is a member of a number of specific partnership groups for particular services, including the Central and South Genomics Medicine Service, the Children’s Hospital Alliance and the Southern Counties Pathology Network. The Trust works actively as a partner with other provider organisations around clinical networks, particularly with acute Trusts within the Integrated Care System and others closely located geographically. The Trust also links closely with the University of Southampton on a number of topics including research, commercial development and education and has a developed meeting structure to oversee this. 18 Workforce The Trust’s key areas of focus during 2023/24 were in respect of increasing the substantive workforce whilst also reducing reliance on bank and agency usage, and reducing staff turnover and sickness. Although the Trust was successful in recruiting to substantive posts, the expected reduction in reliance on bank and agency staff did not materialise, which meant that the Trust was 331 whole-time equivalents above its plan for 2023/24. The Trust was successful in reducing staff turnover from 13.5% in 2022/23 to 11.4%, achieving the local target of . Cancer Waiting Times - 2 Week Wait Performance Cancer Waiting Times - 2 Week Wait Performance 100% 90% 80% 70% 60% 50% 40% Apr-23 May-23 Jun-23 Jul-23 Aug-23 Sep-23 Oct-23 Nov-23 Dec-23 Jan-24 Feb-24 Mar-24 Performance % standard met The national target was for 96% of patients to commence treatment within 31 days of diagnosis. In March 2024, the Trust achieved 92% and performed in the range of 86%-94% throughout the year. The Trust has continued to make progress against the target for treatment of cancer within 62 days of an urgent GP referral, improving performance from 64% in April 2023 to 76% in March 2024 (NHS average: 69%). First definitive treatment for cancer within 31 days of a decision to treat % standard met Cancer waiting times 31 day RTT performanceUHS vs. NHSE average Cancer waiting times 31 day RTT performance UHS vs. NHSE average 96% 94% 92% 90% 88% 86% 84% 82% 80% 78% 76% Apr-23 May-23 Jun-2 3 Jul-2 3 Aug-23 Sep-2 3 Oct-23 Nov-2 3 Dec-23 Jan-24 Feb-2 4 Mar-24 Performance NHS Average 27 Treatment for Cancer within 62 days of an urgent GP referral to hospital Cancer Waiting Times 62 Day RTT Performance UHS vs NHSE Average Cancer Waiting Times 62 Day RTT Performance UHS vs NHSE Average % standard met 1 00% 80% 60% 40% 20% 0% Apr-23 May-23 Jun-23 Jul-23 Aug-23 Sep-23 Oct-23 Nov-23 Dec-23 Jan-24 Feb-24 Mar-24 Performance NHS Average 28 Quality priorities Priorities for improvement 2023/24 Last year the Trust continued its ambition to deliver the highest quality care shaped by a range of national, regional, local, and Trust-wide factors. During the year the Trust continued to experience unprecedented demand on its services, with flow, capacity, infection prevention and safety all presenting challenges. However, the Trust was confident in its ability to keep a focus on its quality priorities, and its teams worked hard to achieve their goals even in these difficult circumstances. Priorities are aligned to the three core dimensions of quality: • Patient experience – how patients experience the care they receive. • Patient safety – keeping patients safe from harm. • Clinical effectiveness – how successful is the care provided? Out of the six priories set, the Trust achieved five and partially achieved one. Overview of success Quality Priority One Improving care for people with learning disabilities and autistic (LDA) people across the Trust. Supporting staff delivering this care. Outcome against goals: achieved Key achievements: • LDA working group reestablished. • Development of an improvement plan using the NHS Learning Disability Improvement standards. • The LDA team has moved to the virtual enhanced care group in Division B where operational and governance support, leadership, and peer support/learning opportunities has been strengthened. • Sensory Boxes have been introduced for all clinical areas, funded by the Hampshire and Isle of Wight (HIOW) Integrated care board (ICB). These boxes include noise cancelling headphones, fidget toys, communication books and visual cards to support patients and wards. • Recruited additional Learning Disability Champions. • Established links with the parent carer forum (PCF) for the local area and are now attending regular events. A representative from the PCF sits on the LDA working group. The LDA team are working with the Trust lead for patient experience to develop this aspect of the LDA workplan over the next year. Quality Priority Two Supporting patients, service users and staff to overcome their tobacco dependence via a smoking cessation programme. Outcome against goals: achieved Key achievements: • Package of support available to patients who may be smokers and who need to be supported not to smoke during their treatment. • Fully trained team of tobacco advisors working in the hospital and an advisor working in the outpatient setting supporting the patients once they have returned home. • Devised the IT changes the Trust would like to implement to improve its service and referral process. • Recruited 30 smoke-free champions. • Successfully supported 1,131 patients with a self-confirmed quit rate of 45.6% at 28 days. • Supported 109 outpatients who have successfully achieved a 60% quit rate. • On track to achieve the goal to go smoke-free by April 2024 including the removal of smoking shelters. 29 Quality Priority Three Ensure carers are fully supported, involved, and valued across all our services by developing the carers support service across the Trust in partnership with Southampton Hospitals. Outcome against goals: partially achieved Key achievements: • Carers now have a more comprehensive package of concessions and vouchers to help support their cared-for person (e.g. free parking available onsite for blue badge owners is now available). • Listening events were held to put patients at the centre of transforming the way we deliver care is delivered, enabling their voices to improve the quality of care and outcomes for all. • Developed joint working with local partners (e.g. Children’s Society and No Limits to support young carers). Not yet achieved: • The ‘pathway to support, has not yet been developed. Work is ongoing to develop a new strategy. • A charity-funded carers’ support worker has not yet been appointed. • The carers’ training package has not yet been relaunched. Quality Priority Four Put patients at the centre of transforming the way care is delivered, enabling their voices to improve the quality of care and outcomes for all. Outcome against goals: achieved Key achievements: • Work has continued to work across corporate and divisional services to embed patients and carers into quality and service improvement, creating new patient groups (e.g. Mesh Support Group). • Successfully developed our engagement with various local communities, working to ensure that a range of care experiences are considered ( e.g. there is now a Gypsy, Roma, and Irish Traveller community health liaison officer to ensure that these communities are engaged with and brought into work to improve the inclusivity of our services). • Attending multiple public engagement opportunities (Young Carers’ Festival, Mela, University Freshers’ Fayres, Carers’ Listening Lunch, Hoglands Park Play Day, visits to local temples and ‘Love Where You Live’). • Youth and Young Adult Ambassador involvement has increased, including attendance toat meetings of the Council of Governors, and supporting hospital projects. • A Celebration of Carers Week and Volunteers Week were run. • The Trust has analysed its reported outcome measures to identify health inequalities in its services. This information has been used to set a new quality priority for 2024/25. • An SMS friends and family test text survey has been introduced to improve the response rate on patient feedback from the Emergency Department. In the first three months following the survey launch, responses increased from 24 to 424. 30 Quality Priority Five To develop the Trust’s clinical effectiveness process, connecting to the Trust’s Always Improving approach to measuring, understanding, and using outcomes to improve patient care. Outcome against goals: achieved Key achievements: • The Trust has developed its clinical effectiveness process across the Trust with involvement of informatics, governance and management teams, clinical effectiveness leads as well as reporting committees. • Patient representation onhas been included in the clinical assurance meeting for effectiveness and outcomes (CAMEO) to ensure conversations focus on what matters to patients. • The CAMEO template has been changed to focus discussions on areas the specialty is proud of (strong or improving outcomes), areas for improvement (poorly benchmarked or worsening outcomes) and planned actions. • The Trust encourages the use of run and/or statistical process control charts along with benchmarking where available. • Details of NICE and quality standards and national and regional reviews are included to cover breadth of clinical effectiveness. • How the clinical effectiveness team works has been reorganised, aligning each of them to each division giving a named link which helps to deepen understanding and improve links with governance and improvement activities locally. • Working with informatics to establish a core set of clinical outcome measures which are meaningful to patients, which can be reported centrally (starting with surgical specialities). • Starting to develop an education strategy and platform to support staff with a number of tools used in clinical effectiveness as well as clarity on where and how to record and evidence audit and service improvement. • A revised strategy has been drafted. Quality Priority Six Developing a culture where all clinical staff have a basic knowledge of diabetes. Outcome against goals: achieved Key achievements: • Launch of the ‘Start with the Diabasics’ Initiative, designed to help give diabetes visibility across UHS. • Delivered an extensive education programme to clinical staff across the professions and bands, including the introduction of some e-learning and a Diabasics introductory video has been shown at all trust staff inductions since July 2023. • Supported the development of 45 diabetes link nurses, resulting in all ward areas now having a named diabetes link nurse. • Improved triage for referrals. • Established processes for ‘lessons learned’. • Developed IT solutions to improvingimprove alerts and guidance. • A ‘Ketone Wednesdays’ initiative has been created in response to overuse of blood ketone testing (estimated waste cost of £100,000 per year). • The Trust’s lead diabetes specialist nurse and the Diabasics Initiative were both shortlisted for National Quality in the Care Diabetes Awards (October 2023). • The Diabasics Initiative was mentioned as a case study on the Diabetes UK charity website as an example of good practice that could be reproduced elsewhere. More information can be found about how the Trust delivered and measured its quality priorities, including feedback from patients and staff and improvement aims and quality priorities for 2024/25, in the Trust’s Quality Account for 2023/24. 31 Financial performance The Trust delivered a deficit of £4.5m from a revenue position of over £1.3bn, following receipt of £24.6m one-off cash support from NHS England. UHS started the year with an underlying deficit as a result of a number of cost pressures, notably demand for services being above block contract levels and the cost of national pay awards being above funded levels. The Trust has also continued to face a number of pressures, including high numbers of patients who no longer meet the criteria to reside in the hospital, and high demand for patients with a primary mental health need. In 2023/24, the Trust delivered a record savings level of £63.4m (5%) across a range of programmes. Trust operating income rose by £107m from the previous financial year, most notably funding the NHS pay award, as well as additional elective recovery funding. Trust operating expenses rose by £89m, incorporating funded inflationary costs as well as costs relating to the cost pressures outlined above. The Trust has also continued its reinvestment of surplus cash into infrastructure for the Trust, with capital investment of over £75m, including investment in new wards, theatres, decarbonisation, digital infrastructure, neonatal expansion and backlog maintenance. Trust cash and cash equivalents finished the year at £79m, a reduction of £24m from the previous year due to the operating loss and capital investment outlined above. Whilst liquidity remained strong in 2023/24 supported by NHS England cash support, the underlying financial deficit means it is likely to decline further in 2024/25. The Trust is continuing to monitor its cash position closely and is considering whether additional cash support may be required in 2024/25. Sustainability The Trust recognises that everyone has a part to play in responding to the climate crisis. In March 2022, the Trust agreed its own green plan in response to the challenge of the NHS becoming the world’s first health service to reach carbon net zero. Now in its third year, the plan identifies the Trust’s key areas of focus and its ambitions and has seen progress across all areas of the plan. The plan sets out the scale of the challenge, the Trust’s commitment to reducing the impact on the environment and the steps to be taken across the following categories: • Estates and facilities • Clinical and medicines • Digital transformation • Supply chain and procurement • Travel and transport • Waste and resources • Food and nutrition • Adaptation • Biodiversity • Wider sustainability The Trust continues to progress through its green plan and has completed the ‘Greener NHS’ reporting tool for several quarters, which has demonstrated good progress. In addition, the Trust is planning to launch its ‘Our Sustainable UHS’ app for staff, which will give tips on sustainability and create personalised travel plans, including identifying potential contacts for car sharing. In addition, the Trust is considering proposals to implement additional solar power, smart metering and expanding the use of LED lighting. 32 In 2022/23, the Trust was successful in bidding for £29.4m of funding through the Public Sector DeCarbonisation Fund, which will be used to fund green initiatives as part of the Trust’s capital programme. During the year the Trust successfully bid for £823k in National Energy Efficiency Funding which has been used to upgrade the lighting at Princess Anne Hospital. Social, community, anti-bribery and human rights issues The Trust recognises its responsibilities under the European Convention on Human Rights (included in the Human Rights Act 1998 in the UK). These rights include: • right to life • right not to be subjected to inhuman or degrading treatment or punishment • right to liberty and freedom • right to respect for privacy and family life. These are reflected in the duty, set out in the NHS Constitution, to each and every individual that the NHS serves, to respect their human rights and the individual’s right to be treated with dignity and respect. The Trust is committed to ensuring it fully takes into account all aspects of human rights in its work. An equality impact assessment is completed for each Trust policy. For patients, the Trust’s safeguarding policies protect and support the right to live in safety, free from abuse and neglect and other policies and standards are designed to optimise privacy and dignity in all aspects of patient care. Feedback from patients and the review of complaints, concerns, claims, incidents and audit help to monitor how the Trust is achieving these objectives. The Trust’s green plan, approved by the board of directors in March 2022, recognises the Trust’s broader role and responsibility to address the issues of climate change, air pollution, waste and environmental decline present to the city of Southampton and the impact that these issues have on the health and wellbeing of the local population served. Although the Modern Slavery Act 2015 does not apply to the Trust, its green plan sets out an ambition to stop modern slavery. The Trust is also committed to maintaining an honest and open culture within the Trust; ensuring all concerns involving potential fraud, bribery and corruption are identified and rigorously investigated. The Trust has a Fraud, Bribery and Corruption Policy, a Standards of Business Conduct Policy and a Raising Concerns (Whistleblowing) Policy. These apply to all staff and to individuals and organisations who act on behalf of UHS. Anti-bribery is part of the Trust’s work to counter fraud. This work is overseen by the Audit and Risk Committee, which receives regular reports from the local counter fraud specialist on the effectiveness of these policies through its monitoring and reviews, providing recommendations for improvement, as well as an annual report from the freedom to speak up guardian. You can read more about the work of the Audit and Risk Committee and the Trust’s approach to counter fraud in the Accountability Report. Events since the end of the financial year There have been no important events since the end of the financial year affecting the Trust. Overseas operations The Trust does not have any overseas operations. 33 Equality in service delivery NHS trusts have an essential role in tackling health inequalities, both as part of the services they provide, but also through work with the wider system. By working with those in integrated care systems, local authorities and third sector organisations, the Trust can have a significant impact on the health of the local population. The national focus on health inequalities is growing. This comes with new legal duties around reporting information and expectations to report on improvement programmes. In September 2023, a health inequalities steering group was initiated, under the leadership of the Chief Medical Officer, with representation from clinical, operational, transformation, patient experience, research, organisational development and culture, informatics, public health and the Integrated Care Board. The group focused on scoping future priorities aligned to national guidelines, contractual obligations and priorities, regional priorities, feedback from clinical teams and patients, understanding where action is already being taken, and what the data is showing. Overall, the group
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Annual-reports-and-quality-accounts/UHS-AR-23-24-Final.pdf

Back to school poster June 2020

Description: BACK TO SCHOOL With schools beginning to gradually reopen, it brings a period of change for young people, preparing to transition back to school life. Managing this transition effectively is important for maintaining their wellbeing. Children have already managed a range of changes and disruptions to their school life due to the outbreak of Coronavirus and it is important that these are considered and managed well during their transition back to school. This poster details a range of tips for supporting for children back to school, including helpful resources. Managing unexpected ending and transitions Communicate honestly- Encourage children to look to the future positively, promoting optimism and hope to manage worries. However, it is important to avoid making unrealistic promises about what the future will look like. Normalise worries and anxiety- It is important to remind children that it is normal to feel anxious or worried when activities end during times of change or uncertainty. Encourage children to talk about their worries and support them to engage in relaxation strategies to manage their anxiety (e.g. breathing exercises). Sustaining social support networks- The coronavirus pandemic means children are experiencing periods of transition without their usual social support systems. It is important to sustain social relationships with others to enable children to feel connected and supported. Schools can encourage this by arranging online social activities. Focusing on accomplishments rather than worries- It is helpful to frame an ending as a moment of transition and growth. Giving young people the opportunity to share and celebrate some of their achievements whilst on lockdown is a useful way to achieve this (e.g. recording positive moments, providing certificates). For those children moving onto a new school in September it may be usual to make and reflect on yearbook journals. Preparation- Preparation gives young people time to come to terms with change. Having supportive conversations at home about the transition and planning the new routine. Schools who are welcoming new students in September can support these children by providing virtual welcome packs. Using peer support models is also a further way to ease anxiety about transitions, enabling children to hear about others experiences (e.g. of moving up to secondary school). "Managing unexpected endings and transitions"-Anna Freud National Centre for Children and Families https://www.annafreud.org/media/11627/managing-unexpectedendings-transitions-may2020.pdf Choose health- Give your child the basics that they need (e.g. exercise, sleep) Work together- share ideas, enjoy achievements Ten tips for parents to help children cope with change Be wise- listen to your child, be interested, give boundaries Communicatee.g. keep talking, hugging, listening, smiling Get learning- Be involved and find out more (e.g. social media, what it is like to be young in the current world) Be calm- try to stay calm whilst your child is feeling distressed Have fun- Provide lots of light relief by doing fun activities together Be the anchor- In times of change you are comforting, routine, home Move on up- Encourage children's independence Look after yourself- Support yourself to best support your child https://youngminds.org.uk/media/2957/top-ten-tips-poster.pdf Managing anxiety following the pandemic Whilst many people are looking forward to the world transitioning back to a time closer to 'normal life', this period of uncertainty and the transition back to 'normality' and school can cause heightened anxiety in many young people. There are a range of tips and resources available to support young people with managing these anxieties. Supporting children Important not to and young people Acknowledge, validate assume how they will and discuss children's cope with reintergration- some may manage the change with little difficulty, others may struggle. Children may struggle to understand, express or communicate how they are feeling. There may be indicators instead in the way they behave (e.g. the way May be helpful to provide family based support if parents/carers are struggling with their own emotional wellbeing. questions and worries. Validation of worries helps children to develop coping strategies to deal with uncertainty and anxiety. they interact with others, sleep). Ensure to keep a supportive, consistent and empathetic approach to meet their needs. Predictability and consistency- helpful to send in advance Communication is essential between parent/carers and professionals working with or supporting a child. Regular meetings, telephone calls, or using communication books which document how the young person coped with isolation and Regular use of praise, validation, empathy, kindness and compassion help the child feel contained and supported. plans for reintegration and helpful to be transparent about any plans that remain subject to change. Children may benefit from whether there are ongoing worries practice in getting themselves that can be shared between adult back into a routine before caregivers can be helpful. school integration starts (e.g. With older children it is important to acknowledge and validate young getting up early in the morning and re-establishing a good bedtime routine). Where possible, some young people people's emotional (due to pre-existing needs or increased anxiety/emtoional coping difficulties) may require a flexible or phased reintegration back to school. Important to have conversations and agree plans as soon as possible and communicate them effectively. responses to GCSE's and A Levels being cancelled. Children with SEND and Autism Spectrum Condition: When communicating with young people with SEND and ASC around their anxieities/worries they may require additional use of communication aids such as communication systems (Widgits, Makaton, PECS) using visual Given children will have been Some children may feel worried about having missed work/fallen behind and may feel as if there is guides with symbols, images and easy read text (e.g. social stories) in order to aid two way communication. exposed to differing levels of information and have varied experiences around the pandemic; it may be helpful to have general school guidance and rules around language and information that is a lot of work to complete when they go back to school to catch up. Sharing proposed timetables and expectations of what young people will be doing is useful. Provide young people with access to self-soothe aids (materials, activities) at all times. May be helpful to schedule in times dedicated to self- soothe time within the day/ week. shared in playgrounds or class group settings. Supporting parents, carers and professionals Talk to your friends, families and colleagues about how you are feeling and ask for help if you are struggling or worried about the 'reintegration' back into 'normal life'. Take time to find your new routine- making plans and being organised can help when you feel you have to juggle multiple demands. Ensure you have regular opportunities for rest and downtime- be kind and compassionate towards yourself. Remember it's ok to struggle or feel overwhelmed at times. 'How to cope after Covid-19 and the pandemic' (Hampshire Child and Adolescent Mental Health Services) https://hampshirecamhs.nhs.uk/issue/coronavirus-help-support-and-advice/ - There are also a range services provided on this resource that can provide further emotional support Resources for supporting children and young people with worries and anxiety There are a range of resources available that can be used by young people to support their anxieties and worries during this period of reintegration. 'Going back to school- COVID19' Story- social story for young children about going back to school https://www.autismlittlelearners. com/2020/05/going-back-toschool-story.html ''Place2Be' resource pack- 'Find your Brave'- mental health resources for both primary and secondary school children. https://www.childrensmentalhealthwe ek.org.uk/schools-and-youth-groups/ 'The tale of going back to school (after the Covid-19 Lockdown)- a tale to positively prepare children for the transition back to school, by helping them understand how their school life will be different and most importantly, how it will remain familiar. https://www.talesofmebooks.com/products/th e-tale-of-going-back-to-school-after-the-covid- 19-lockdown SEA inclusion and safeguarding- 'The many problems of returning to school' blog- Blog post from Sara Alston (SEND and Safeguarding Consultant and Trainer) providing recommendations of how to support children with the transition back to school https://www.seainclusion.co.uk/post/the- many-problems-of-returning-to-school 'Mentally Healthy Schools'- qualityassured resources to help primary schools promote children’s mental health and wellbeing. https://www.mentallyhealthyschools. org.uk/ ''Child Brain Injury Trust'- tips and resources for supporting children with brain injuries with the transition back to school. https://childbraininjurytrust.org.uk/2020 /04/considerations-for-returning-toeducation-for-children-young-peoplewith-brain-injury-during-covid-19/ 'The Koala who could' book (Rachel Bright 2006)- feel good rhyming story portraying a positive message about facing up to change '“Angry, fed up, isolated”: Coronavirus and children’s mental health' (Anne Longfield- Children’s Commissioner for England')article about how the Coronavirus pandemic can affect children's mental health and recommendations/resources of how to support children. https://www.childrenscommissioner.gov.uk/2 020/04/03/angry-fed-up-isolated-coronavirus- and-childrens-mental-health/ 'Stem4- supporting teenage mental health'- Information and recommendations around supporting anxiety in teenagers. https://stem4.org.uk/anxiety/ STARS resources- range of resources for supporting children with Autism with the transition back to school and coping with the pandemic http://www.starsteam.org.uk/corona virus-resources
Url: /Media/UHS-website-2019/Docs/Services/Child-health/COVID-19/Back-to-school-poster-June-2020.pdf

WRES report and action plan 2023

Description: Workforce Race Equality Standard Annual Report 2023 1 Table of Contents Executive Summary.........................................................
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Equality-reports/WRES-report-and-action-plan-2023.pdf

Welcome to the TAVI clinic - patient information

Description: Information about transcatheter aortic valve implantation (TAVI) - a procedure to replace a faulty aortic (heart) valve via a thin plastic tube.
Url: /Media/UHS-website-2019/Patientinformation/Cardiovascular-and-thoracic/Welcome-to-the-TAVI-clinic-3352-PIL.pdf

Workforce Race Equality Standard Annual Report 2022

Description: Workforce Race Equality Standard - Annual Report 2022 Table of Contents Executive Summary 3 Introduction 5 WRES Data Submission 2022 6 Indicator
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Equality-reports/Workforce-Race-Equality-Standard-Annual-Report-2022.docx

Records management policy

Description: Records Management Policy Date Issued: Review Date: Document Type: 9 May 2018 19 April 2021 Policy Version: 6 Contents Paragraph 1 2 3 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 4 5 6 7 8 9 Appendices Appendix A Appendix B Appendix C Executive Summary Introduction, Scope and Purpose Definitions Details of Procedure to be followed Regulatory and legal framework The Records Information Lifecycle Record Creation Handling and Using Records Record Closure and Retention Appraisal Disposal Additional Guidance on Specific Record Types Roles and Responsibilities Related Trust Policies Communication Plan Process for Monitoring Compliance/Effectiveness of this Policy Arrangements for Review of this Policy References Page 2 3 4 5 5 6 6 7 9 10 11 11 13 14 14 15 15 15 Page 17 21 22 Record Creation and Filing Procedures Medical Record Keeping Standards List of Record Types listed in NHS retention Schedule 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 26 Executive Summary 1. There is a need to manage Trust records efficiently and effectively to support day to day operational and business activity and meet certain legal requirements. As we create and collect increasing amounts of information about our patients, staff and business activities it is vital that are able to organise, securely store and retrieve this information when required. 2. As we manage the incremental change from traditional/paper based record keeping to electronic/ digital systems we encounter new challenges, however the key principles of records management outlined in this policy continue to apply to these new storage mediums. Where different or additional guidance is required this is provided. 3. This policy is structured to provide staff with guidance on managing records through their life cycle from creation to disposal. Adherence to this guidance will support all aspects of Trust business and help the Trust comply with its duties as a public body subject to the Public Records Act (1958) and the Freedom of information Act (2000). 4. The Records/Information Life Cycle describes a regime designed to ensure information is managed from the point that it is created to the point that it either destroyed or permanently preserved as being of historical or research interest. The cycle is illustrated in this diagram: 5. In summary this policy: Defines duties and responsibilities in regard to records management in the Trust Outlines the key legal obligations and statutory provisions that apply to records created and used within the Trust Provides a procedural Framework with guidance to encourage best practice in records management within the Trust Describes the `Information Life Cycle' and highlight best practice to be followed at each stage of the cycle from creation to disposal. Page 2 of 26 1. Introduction, Scope and Purpose 1.1 Introduction 1.1.1 Records Management is the process by which an organisation manages all the aspects of records whether internally or externally generated and in any format or media type, from their creation, all the way through to their lifecycle to their eventual disposal The Trust's records are its corporate memory, providing evidence of actions and decisions and representing a vital asset to support daily functions and operations. Records support policy formation and managerial decision-making, protect the interests of the Trust and the rights of patients, staff and members of the public. They support consistency, continuity, efficiency and productivity and help deliver services in consistent and equitable ways. Adherence to the guidance provided in this Policy will provide the Trust with a number of benefits including: better use of physical and server space; better use of staff time; improved control of valuable information resources; compliance with legislation and standards; and reduced costs. This document sets out a framework within which Trust records can be managed and controlled effectively, and at best value, commensurate with legal, operational and information needs. 1.1.2 1.1.3 1.1.4 1.2 Scope 1.2.1 This policy applies to Trust records held in any format including: Paper Photographs slides and other images Microform microfich and microfilm Audio and video tapes, cassettes CD ROM etc Computerised records Scanned records Text messages and social media Websites and intranet sites that provide key information to patients The majority of Trust members of staff will create records during the course of their day to day activity. Aspects of this policy will therefore apply to most members of staff, with specific responsibilities applying to department heads and managers for the management of local records created stored or held in their areas of responsibility. At the time of publication of this policy preparations are being made to ensure the Trusts compliance with the implementation of the European Union General Data Protection Regulation (GDPR) in May 2018. To date no direct impact on the records procedures outlined in this policy has been identified as a consequence of the introduction of GDPR. As these preparations progress any identified changes required to records management policy and procedure will be made. The Trust is also in the process of changing to a digital format of medical record recording and storage using the Onbase Electronic Document Management System (eDMS). An incremental roll out of the system to care groups has started but is at an early stage. 1.2.2 1.2.3 1.2.4 Page 3 of 26 1.2.5 1.2.6 This policy makes an occasional reference to this significant change and the key principles for records management outlined in this policy (storage, retention etc) still apply to the records created and stored in Onbase. As the incremental roll out of Onbase eDMS progresses and operational procedures are finalized this policy will be reviewed and the need for changes to be made or additional operational policies and procedures to be published will be agreed and implemented. 1.3 Purpose 1.3.1 The purpose of this policy is to: Define duties and responsibilities in regard to records management in the Trust Outline the key legal obligations and statutory provisions that apply to records created and used within the Trust Provide a procedural Framework with guidance to encourage best practice in records management within the Trust Describe the `Information Life Cycle' and highlight best practice to be followed at each stage of the cycle from creation to disposal. Definitions 2. Term Records Management Meaning Applied in this Policy A set of activities required for systematically controlling the creation, distribution, use, maintenance, and disposition of recorded information maintained as evidence of business activities and transactions. Record Information created, received and maintained as evidence and information by an organisation and person, in pursuance of legal obligations or in the transaction of business. (ISO Standard 154891:2016). General Data Protection European Union Directive which will replace the Data Protection Act Regulation (GDPR) (1998) in UK law, enforceable from 25th May 2018. Designed to harmonise data protection regulation across the European Union. Electronic Document A software program/system that manages the creation, storage and Management System control of documents electronically. (eDMS) Information Life Cycle A term that describes a controlled regime in which information is managed from the point that it is created to the point that it either destroyed or permanently preserved as being of historical or research interest. Public Authority An organisation within the categories listed in Schedule 1 to the Freedom of information Act defined as `a body that appears to be exercising functions of a public nature or who are providing, under contract with a public authority, any service whose provision is a function of that authority. The Trust is a Public Authority. Metadata Data that describes information about other data. e.g. author and creation date of a record are elements of its metadata. Record Classification Means by which a record keeping system arranges or organises Scheme records to enable appropriate management controls to be applied and support accurate retrieval of information. e.g. a filing index. Page 4 of 26 Public Records Administrative and departmental records belonging to Her Majesty, in the UK or elsewhere, in right of Her Majesty's Government, and in particular records of or held in any government department and records of offices, commissions or other bodies under HMG in the UK. (Public Records Act 1958). All Trust records are public records subject to the Public Records Act (1958) Data Subjects An individual who is the subject of personal data. Patient Administration Electronic system used to hold non clinical details about Trust System (PAS) patients (demographics, GP details, contacts etc). Electronic Clinical A module of the Trust PAS used to record the movement of patient Record Tracking (eCRT) Health Record Folders within UHS and partner organisations. Record closure The process followed to make a record inactive when it has ceased to be in active use other than for reference purposes. Record retention The process of keeping a record for a period of time for administrative, legal, fiscal, historical, or other purposes. Record appraisal The process of deciding what to do with a record when the business use has ceased. The outcome of record appraisal will be either: destroy/delete, retain for a further period or transfer to a Place of Deposit. The National Archives A non-ministerial department, and the official archive and publisher (TNA) for the UK Government, and for England and Wales. TNA publishes advice and guidance on information and records management. Place of Deposit (POD) Record Archive storage location appointed by the Secretary of State for Culture Media and Sport. Usually a public archive service provided by a Local Authority. Corporate Records Records of business processes such as accounting, procurement, staff management and estates maintenance. In NHS organisations this term covers all records that are not patient/care records. Permanent preservation A process followed to place a record in an archive storage location allowing public access to records of historical administrative or local importance. Record Disposal The destruction, deletion or transfer for permanent preservation of a closed record British Standard 10008- The British Standard that outlines best practice for the 2014 Evidential Weight implementation and operation of electronic information and Legal Admissibility management systems, including the storage and transfer of of Electronic Information information. Information Governance An umbrella term relating to the processes and systems used by organisations to manage the information they hold. In the context of the NHS, it specifically refers to the processes and procedures used to ensue confidentiality, security and accuracy of information. 3. Details of Procedures to be Followed 3.1 Regulatory and Legal Framework 3.1.1 Under the terms of the Public Record Act 1958 all records created in the Trust are regarded as public records. The act imposes a statutory duty on the Trust to make arrangements for the safe keeping and eventual disposal of records. The ownership and copyright of records created within Trust lies with the Trust and not the individual who has created them. Page 5 of 26 3.1.2 3.1.3 3.1.4 As a Public Authority subject to the Freedom of Information Act the Trust has a duty to follow the Code of Practice for Records Management published by the Lord Chancellor in accordance with section 46 of the FOIA. The code provides guidance to public authorities on keeping, managing and destroying records. The Data Protection Act sets in law how personal and sensitive information may be processed and largely influences the way we handle care records. Further guidance on the confidentiality aspects of record keeping is provided in the NHS Confidentiality Code of Practice and the Trust Data Protection and Confidentiality Policy. The Records Management Code of Practice for Health and Social Care 2016 provides records management guidance for NHS and Social Care organisations based on current legal requirements and professional best practice. The Trust is committed to following the guidance issued in the code of practice and the procedures outlined in this policy are largely based on the guidance included in this Code of Practice. 3.2 The Records Information Lifecycle 3.2.1 The records or information lifecycle is a term that describes a controlled regime in which information is managed from the point that it is created to the point that it either destroyed or permanently preserved as being of historical or research interest. The cycle is illustrated in figure 1 Figure 1. The Information Lifecycle 3.2.2 Procedural guidance associated with each stage of the cycle is included in subsequent sections 3.3 Record Creation 3.3.1 ISO 15489-1:2016 Information and Documentation � Records Management describes the characteristics of `Authoritative Records' as being authentic, reliable integral and useable. Table 1 below expands on these definitions. Page 6 of 26 Table 1. Record Characteristics Record Characteristic Authentic How to Evidence It is what it purports (claims) to be To have been created or sent by the person purported to have created or sent it and To have been created or sent at the time purported. Full and accurate record of the transaction/activity or fact Created close to the time of transaction/activity Created by individuals with direct knowledge of the facts or by instruments routinely involved in the transaction /activity. Complete and unaltered Protected against unauthorised alteration Alterations after creation can be identified as can the persons making the changes. Located, retrieved, presented and interpreted The context can be established through links to other records in the transaction/activity. Reliable Integrity Useable 3.3.2 3.3.3 3.3.4 3.3.5 By organising records in a file system or classification scheme elements of `Metadata' are associated with each record which helps maintain the characteristics described above. Metadata in its simplest form would identify the creator, creation date and subject of a record but can be expanded to include additional information such as destruction date, identifiers and accessibility. Classification schemes can be a simple arrangement of files and folders on a Network drive increasing in sophistication up to a full blown Electronic Document and Records Management System such as the Onbase edMS being introduced to store patient records in the Trust. All Trust records should be stored within an appropriate classification/filing system after creation. This will ensure they remain secure and accessible from the outset and be available to support Trust business activity. A more comprehensive guide for users covering the creation and filing of records is attached at Appendix 1. 3.4 Handling and Using Records 3.4.1 Record Keeping 3.4.1.1 When completing entries in or creating any form of records the following general guidance should be applied: Be factual, consistent and accurate Write clearly and in such a way that text cannot be erased Write in such a way that any alterations or additions are dated, timed and signed in such a way that the original entry can still be read. Page 7 of 26 3.4.1.2 Healthcare professionals may be subject to additional record keeping codes of practice set by their professional bodies. The Academy of Medical Royal Colleges has published a set of generic medical record keeping standards which are reproduced at Appendix 2. All entries in Trust care records should conform to these standards. 3.4.1.3 Rights granted to members of the public by the Freedom of Information Act and to patients and staff under the Data Protection Act can result in copies of corporate records being placed in the public domain and data subjects obtaining copies of records containing information about them. Providing record entries are factual and accurate and personal records do not include any unnecessary and/or derogatory comments record disclosure should not create any additional issues. 3.4.2 Confidentiality and Access 3.4.2.1 All Trust records are public records and thus are subject to a number of statutory provisions regarding confidentiality, access and disclosure. Patients entrust the NHS or allow it to gather sensitive information relating to their health and other matters as part of their seeking treatment. They do so in confidence and they have the legitimate expectation that staff will respect this trust. It is essential, if the legal requirements are to be met and the trust of patients is to be retained, that the NHS provides, and is seen to provide, a confidential service. 3.4.2.2 Specific guidance on patient confidentiality issues is provided in the Trust Data Protection and Confidentiality Policy. Further advice on all aspects of patient confidentiality and the application of the Data Protection Act (1998) on the way we handle records in the Trust can be obtained from the Trust Information Governance Manager. 3.4.2.3 The Data Protection Act (1998) makes provision in law for `data subjects' (e.g. patients and members of staff) to obtain copies of otherwise gain access to information held about them. The Trust Access to Records Policy covers this aspect of records management and further advice on the procedure can be obtained from the Trust Information Governance manager. 3.4.2.4 In 2000 the government introduced the Freedom of information Act providing members of the public with the general right of access to recorded information held by a wide range of bodies across the public sector. The effect of this legislation is to make it possible for people to obtain copies of a wide range of Trust records that in the past would have remained confidential. The Trust Freedom of Information Policy covers this aspect of records management and further advice on the procedure can be obtained from the Trust Information Governance manager. 3.4.3 Record Tracking 3.4.3.1 Ideally the movement and location of all records should be controlled to ensure that a record can be retrieved at any time and there is an auditable trail of record transactions. This is best achieved using some form of record tracking system to record the movement of records between locations. 3.4.3.2 It is the policy of the Trust that patient health record folders are tracked using the PAS record tracking component (electronic casenote record tracking e-CRT.) Users are provided with training to use e-CRT prior to being granted access to the system. 3.4.3.3 While electronic records do not require tracking as such, control must be exercised when hard copies are produced. If separate clinical casenotes are produced from electronic systems to form a filing system individual record movements should be tracked to aid retrieval and avoid loss of data. 3.4.3.4 For most areas, where movement of records is restricted, paper based systems may be employed, using registers or tracer cards to record the relevant information. Page 8 of 26 3.4.3.5 When making arrangements to move records which contain personal or sensitive information to destinations external to the Trust (including archive storage) consideration needs to be given to security and confidentiality and a means of dispatch chosen that affords an adequate level of security. (See Trust Data Protection Policy for further guidance.) 3.4.4 Record Storage 3.4.4.1 When not required for operational purposes records should be kept in a secure storage area. Records in current use should ideally be stored close to the point of use while records no longer in current use can be transferred to secondary or archive storage more remote from the operational area. 3.4.4.2 Records should be stored in an appropriate environment to ensure they remain fit for purpose during their expected period of retention. When evaluating the suitability of a location for record storage the following points should be considered: Environment. Is the location suitable for the type of material being stored? Is the area free from hazards that may cause the records to deteriorate or place at risk staff that may need to access the records? i.e. excessive dust, damp, restricted access. Security. Is the level of security offered by the location acceptable for the type of record being stored? Ease of Access. Can records be easily located and retrieved? Some restrictions on access may be acceptable for records that are not frequently recalled. Layout. Consideration should be given to the design of the storage location to ensure the most cost effective use is made of the space available. 3.4.4.3 External storage companies provide an alternative to local storage and in the short term can prove a cost effective alternative in areas where record storage space is at a premium. The Trust has negotiated a contract for external record storage with a Restore, a national provider with storage premises located a few miles East of Southampton. Advice on external storage options and alternative strategies such as archiving records to digital formats can be obtained from the Trust records manager. 3.4.4.4 A comprehensive record should be maintained of any records sent for commercial storage including a proposed date for review/destruction. A mechanism for reviewing these records for disposal should be developed and implemented to ensure records are not retained longer than necessary. 3.4.4.5 Digital information should be stored in such a way that throughout the lifecycle it can be recovered in an accessible format. Over time such changes as migration to new formats can cause links to other documents and embedded documents to fail to open impacting the integrity of the record. Any changes to the electronic storage systems used to hold Trust records should only take place after full consideration of the impact on the records held and successful testing of retrieval of transferred records from the new version/system. 3.5 Record Closure and Retention 3.5.1 A record should be closed when the business use for that record ceases. Following closure NHS records are subject to a minimum period of retention. The length of the retention period varies by record type and is based on legal and regulatory requirements and the assessed importance of and likely need to access the type of record. Certain types of corporate records (e.g. finance, meeting records etc) will follow annual cycles with existing records closed following year end and new records created for the new year (calendar or financial). 3.5.2 Page 9 of 26 3.5.3 3.5.4 3.5.5 3.5.6 3.5.7 3.5.8 3.5.9 Paper record folders should be clearly marked with the date of closure and planned review/disposal date. Closed records in electronic storage systems should hold this information as part of the record's metadata and/or the record moved to another area of the system reserved for closed records. For patient care records the recognised date of record `closure' is normally the date of the patient's last attendance for treatment. Where a patient has died subsequent to treatment at the Trust the retention period applicable to deceased patient records (8 years) may be applied from the date of death, if this results in a shorter retention period. Minimum retention periods for NHS and Social Care records are set out in Appendix 3 of the Code of Practice which can be accessed via this link: https://digital.nhs.uk/codes-of-practice-handling-information Periods of retention between 6 months and 20 years are listed for NHS record types organised by functional groups. A list of the NHS record types with minimum retention periods listed in the Code of practice is reproduced at Appendix 3. The majority of adult patient health records are subject to a minimum retention period of 8 years. Health records for Children, Obstetric records, mental health (including psychology) records, and records recording treatment for cancer are all subject to longer periods of retention. The period of retention is measured from the start of the calendar year following the record closure date. e.g. record closed 1 July 2017 subject to 5 year retention period. Period starts 1 Jan 2018 and ends 31 Dec 2022. The code of practice lists minimum periods of retention and in most cases it will be appropriate to destroy records immediately once the period has expired. Retention beyond the recommended period is permitted with good reason but if personal data is held `longer than necessary' the Trust may breach a provision of the Data Protection Act. The Public Records Act 1958 states no public record can be retained after closure for a period in excess of 20 years without permission from the Sec of State for culture Media and Sport. However, a legal exemption applies for individual NHS staff and patient records to meet the extended (20 years plus) periods of retention listed for these records in the Code of Practice. 3.6 Appraisal 3.6.1 When the minimum retention period for a record or set of records has passed it should be subject to an appraisal. The purpose of the appraisal process is to: Identify records of public interest worthy of permanent preservation by transfer to The National Archives or a local Place of Deposit. Identify records to be retained for a longer period To confirm that records not meeting above criteria should be deleted or destroyed. A small percentage of Trust records will meet the criteria for selection for permanent preservation. The preservation of a small subset of key records is designed to enable the public to understand the working of the Trust and the impact on the population it serves and to preserve information likely to have long term research value. The Code of Practice includes guidance on the records that should be considered for preservation in the schedule of minimum retention periods. The suggestions for consideration include Trust Board and other key committee papers, key policies and strategies and records of major building works. 3.6.2 3.6.3 Page 10 of 26 3.6.4 3.6.5 The process of selection of key corporate records for permanent preservation will be managed by the Trust Records manager and the Director of Corporate Affairs who will agree with the Trust's local Place of Deposit (POD), Southampton City Archives, which Trust records merit transfer. Clinical records are problematic to preserve permanently in an archive and due to confidentiality issues personal health records cannot normally be accessed by the public for considerable periods of time following transfer. This does not prevent appropriate sets of clinical records being considered for permanent preservation and the Code of Practice provides some specific guidance on this process. 3.7 Disposal 3.7.1 Following appraisal any records not selected for permanent preservation or a longer retention period should be disposed of. No information should be destroyed if it is the subject of a request under the DPA and/or FOIA or any other legal process, such as an inquest following a death. Paper records should be destroyed securely through a local process of cross cut shredding or using the Trust confidential waste disposal service or other similar secure disposal service. Destruction of digital information is more challenging. At present there are two ways of permanently destroying digital information and these are either: overwriting the media a sufficient number of times or the physical destruction of the media. Further advice about the destruction of digital records can be obtained from the Trust Informatics service. Where decisions are made to destroy/dispose of a series or bulk number of Trust records a record of the decision and the details of the records disposed of should be maintained. 3.7.2 3.7.3 3.7.4 3.8 Additional Guidance on Specific Record Types 3.8.1 E-Mail 3.8.1.1 Personal e-mail accounts tend to be structured according to personal preference and the data stored is not searchable and organised in a systematic way, making e-mail accounts unsuitable for record storage purposes. 3.8.1.2 E-mail accounts should not be used to file records on a permanent basis but should be regarded as transient storage areas for working documents. E-mails or documents distributed by e-mail that need to be retained as Trust records should be copied to the appropriate paper or electronic registered file system and the e-mail copy destroyed as soon as practicable. 3.8.1.3 Where email is declared as a record or as a component of a record, the entire email must be kept including attachments so the record remains integral - for example an email approving a business case must be saved with the business case file. Emails that are the sole record of an event or issue, for example an exchange between a clinician and a patient, should be copied in to the relevant clinical record rather than being simply deleted. 3.8.2 Scanned Records 3.8.2.1 Where paper records are scanned, the main consideration is that the information can perform the same function as the paper counterpart did, and like any evidence, scanned records can be challenged in a court. This is unlikely to be a problem provided it can be demonstrated that the scan is an authentic record and there are technical and organisational means to ensure the scanned records maintain their integrity, authenticity and usability as records, for the duration of the relevant retention period. Page 11 of 26 3.8.2.2 Complying with the standard, `BS 10008 Electronic Information Management Ensuring the authenticity and integrity of electronic information' provides one method of ensuring and demonstrating that electronic information remains authentic. The scanning of Trust patient records for inclusion in the Onbase eDMS patient record system is being carried out in accordance with this standard. 3.8.2.3 For smaller scale local record scanning projects compliance with the full scope of BS 1008 will not be the appropriate methodology. Methods that can be employed to ensure that scanned records can be considered authentic include: A written procedure outlining the process to scan, quality check and any destruction process for the paper record Evidence that the process has been followed An audit trail or secure system that can show that no alterations have been made to the record after the point they have been digitised Fix the scan into a file format that cannot be edited such as Portable Document Format (PDF). 3.8.2.4 Providing scanning is carried out to an acceptable standard with an element of quality assurance included in the process it is Trust policy and normal practice that original documents should be destroyed after scanning. This prevents issues with two versions of the same record existing (original and scanned) and maximises the benefits accruing from scanning paper records. 3.8.2.5 There may be some local exceptions to this practice with appropriate justification. 3.8.3 Staff Records 3.8.3.1 Staff records should hold sufficient information about a staff member for decisions to be made about employment matters. The nucleus of any staff file will be the paperwork collected through the recruitment process and this will be expanded over time with additional material added by line managers. 3.8.3.2 Upon termination of contract, records must be held up to and beyond the staff member's statutory retirement age. On contract termination line managers should return the employees file to HR department for retention until the employee's 75th birthday or 6 years after leaving whichever is the longer. To reduce the burden of storage a summary record may be prepared and held. 3.8.4 Records of non NHS Funded Patients 3.8.4.1 Records of individuals who are not NHS funded held in the Trust record keeping systems must be kept for the same minimum retention periods as other records outlined in this Code. The same levels of security and confidentiality will also apply. 3.8.5 Adopted Persons Health Records 3.8.5.1 The records of adopted persons can only be placed under a new last name when an adoption order has been granted. Before an adoption order is granted, an alias may be used, but more commonly the birth names are used. 3.8.5.2 Depending on the circumstances of the adoption there may be a need to protect from disclosure any information about a third party. Care must be exercised when disclosing records of adopted patients because of the heightened risk of accidental disclosure. 3.8.5.3 It is important that any new records, if created, contain sufficient information to allow for a continuity of care. At present the patients GP will initiate any change of NHS number or identity if it was considered appropriate to do so, following the adoption. The Trust would then make changes to its own records in line with that initiated by the patient's GP. Page 12 of 26 3.8.6 Health Records of Transgender Patients 3.8.6.1 Patients considering or undergoing gender identity change may ask for changes to their name they are known by to be made and in most cases the Trust will agree to such a request. 3.8.6.2 A patient can request that their gender be changed in a record by a statutory declaration, but this does not give them the same rights as those that can be made by the Gender Recognition Act 2004. 3.8.6.3 The formal legal process (as defined in the Gender Recognition Act 2004) is that a Gender Reassignment Certificate is issued by a Gender Reassignment Panel. At this time a new NHS number can be issued and a new record can be created, if it is the wish of the patient. 3.8.6.4 Except in a limited set of circumstances it is an offence under the gender recognition act to disclose without consent information that would identify that a person has undergone a gender identity change. 3.8.6.5 The key to the successful management of records in these circumstances is to discuss with the patient their choices and agree what they wish to happen in respect to their health record. If a new health record is being created there is a need to identify which records are moved into the new record and to discuss how to link any records held in any other institutions with the new record. 4. Roles and Responsibilities 4.1 Chief Executive 4.1.1 As accountable officer the Chief Executive is responsible for the overall leadership and management of the Trust and its performance in terms of service provision, financial and corporate viability, ensuring that the Trust meets all its quality and safety, statutory and service obligations and for working closely with other partner organisations. The CEO delegates aspects of this responsibility to relevant Executive Directors according to their organisational portfolios. 4.2 Director of Transformation and Improvement 4.2.1 The Director of Transformation and Improvement is the appointed Executive Director with responsibility for Information Governance including records management and is the Trust Senior Information Risk Owner (SIRO). The SIRO is responsible for managing information risk in the Trust and will implement and lead the NHS Information Governance risk assessment and management processes within the Trust and advise the Board on the effectiveness of information risk management. 4.2.2 4.3 Caldicott Guardian 4.3.1 The Trust Caldicott Guardian is the Director of Nursing who has a particular responsibility for reflecting patients' interests regarding the use of patient identifiable information. The Trust Caldicott Guardian is responsible for ensuring patient identifiable information is shared in an appropriate and secure manner. The duties and responsibilities of the Trust Caldicott Guardian are outlined in the Trust Confidentiality and Data protection Policy. 4.3.2 Page 13 of 26 4.4 Trust Records Manager 4.4.1 The Trust Records Manager is responsible for ensuring that this policy is implemented and that the records management system and associated processes are developed, co-ordinated and monitored. The Trust Records Manager is also responsible for the overall development and maintenance of health records management practices and promoting compliance with this policy in such a way as to ensure the easy, appropriate and timely retrieval of patient information. 4.4.2 4.5 Local Managers 4.5.1 The responsibility for local records management is devolved to divisional, care group and department heads whom retain overall responsibility for the management of records generated by their activities, i.e. for ensuring that records created within their unit are managed in a way which meets the aims of the Trust's records management policy and associated procedures. 4.6 Clinical Leads and Matrons 4.6.1 Clinical leads in all professions have a responsibility to ensure clinical staff they manage who contribute to patient health records are adequately trained in record keeping and are aware of and adhere to the standards for record keeping outlined in this policy. 4.7 All Staff 4.7.1 Members of Staff who create, receive and use records have records management responsibilities. In particular all staff must ensure that they keep appropriate records of their work in the Trust and manage those records in keeping with this policy and with any guidance subsequently produced. Staff who make entries in medical records should do so in accordance with the clinical record keeping standards published in this policy. In addition Royal Colleges and other professional bodies publish record keeping guidance for clinical staff and it is the responsibility of clinical staff to ensure they keep up to date with and adhere to relevant legislation, case law and national guidance. Related Trust Policies 4.7.2 5. 5.1 The following Trust policies overlap with or relate to matters covered in this policy Information Governance Policy Data Protection and Confidentiality Policy Freedom of Information Policy Access to Records Policy Subject Access Policy IM&T Security Policy Incident Management Policy Patient Information and Corporate Identity Policy Web Publishing Policy 6. Communication Plan Page 14 of 26 6.1 The publication of this updated policy will be highlighted to staff via an article on the news section of `Staffnet', the Trust intranet. The article will draw attention to the key changes made to the previous policy version. 6.2 A copy of this policy will be available for staff to access via the policies section of Staffnet and links to the policy will also be provided within the records management section of the Information Governance pages of Staffnet. 6.3 Elements of record training and procedure form part of the annual training for information governance (now known as data security training) which forms part of the Trusts annual mandatory training requirement. 7. Process for Monitoring Compliance and Effectiveness 7.1 The purpose of monitoring is to provide assurance that the agreed approach is being followed � this ensures we get things right for patients, use resources well and protect our reputation. Our monitoring will therefore be proportionate, achievable and deal with specifics that can be assessed or measured. Key aspects of the procedural document that will be monitored: What aspects of compliance with the document will be monitored Compliance with Record handling best Practice and guidance What will be reviewed to evidence this How and how often will this be done Detail sample size (if applicable) Who will coordinate and report findings (1) Which group or report will receive findings Incidents reported with record related cause codes Medical records procedures for retrieval and tracking Medical Record Keeping Standards Sample or record movements recorded on Trust PAS Entries in sample of Trust inpatient medical records Ongoing monitoring carried out by local governance leads and Trust Records Manager Quarterly audit carried out by Medical Records Manager Annual Audit as part of Trust Clinical Audit programme. N/A Local governance leads and Trust Records Manager Serious breaches will be reported to the Information Governance Steering Group 25 records per quarter Medical Records Manager Information Governance Steering Group 100 records plus Audit managed by Trust Clinical Audit Manager and local Divisional audit leads Clinical Effectiveness Steering Group Where monitoring identifies deficiencies actions plans will be developed to address them. 8. Arrangements for Review of the Policy 8.1 This policy will be subject to formal review three years after publication unless significant changes in legislation or NHS guidance dictate an earlier review. Minor updates will be made as and when required. Page 15 of 26 8.2 If as a result of the full adoption of GDPR legislation into UK law on the 25th May 2018 a further amendment to this policy is required then this will be carried out. See para 1.2.3 above. 9. References Public Records Act (1958) Freedom of Information Act (2000) Data Protection Act (1998) General Data Protection Regulation Records Management Code of Practice for Health and Social Care 2016 Academy of Medical Royal Colleges' Standards for the clinical structure and content of patient records Chancellor's Code of Practice on the management of records issued under section 46 of the Freedom of Information Act (2000). The National Archives BS 10008 Electronic Information Management - Ensuring the authenticity and integrity of electronic information Appendices A. B. C. Record Creation and Filing Procedures Medical Record Keeping Generic Standards Categories of Records listed in NHS Retention Schedule Page 16 of 26 Appendix A to Records Management Policy User Guide to Record Creation Introduction 1. This guide primarily covers records created for non care purposes as the procedure for creating and filing patient records is part of the training given to users of the Patient Administration System. The key principles apply to all records however. 2. Although most records in the Trust are created and stored electronically some paper based record keeping systems are still in use. Most of the guidance provided in this document can be applied to both forms of records but where this is not the case users will need to exercise judgment when applying the guidance. 3. Common types of documents such as letters, meeting minutes, Job Descriptions etc should be always be created using the Trust Word Templates set up for these document types. When creating documents staff should take note of the guidance about document style contained in the Trust Patient Information and Corporate Identity Policy available on the Trust Intranet. 4. All records created in the Trust should be included in a record keeping filing system and be given a unique title or name to identify it. When creating records users need to consider the need for privacy markings and version control. The guidance set out in the following sections addresses these requirements and provides guidance in their application. Record Filing Systems 5. Records created in both electronic or paper form should be organised in some form of registered fling system so they can be easily located when needed and documents of a similar or linked nature are kept together. Filing systems can be created and organised using a variety of methods. Probably the most common method is a simple alphanumeric system whereby records are grouped together in folders that are given unique names. The folders are then organised/ordered in alphanumeric fashion in draws/cabinets (paper records) or within Trust HQ/Divisional/Care Group hard Drives (electronic records) 6. When designing and developing filing systems the following points should be considered: a. b. c. Retain control and continuity by restricting the number of staff who can create new folders in the system. Organise folders and sub folders in a logical manner that will make sense to those who need to access records within them. e.g. organised by function or teams. Give each folder a clear title that describes the contents within. e.g. `MeetingsDiv Board2009', `ComplaintsPatients200804to200906. Avoid names like `General', `Miscellaneous' or personal titles like `Jane's Folder'. (See next section for more details on file names) Within folders records are normally filed in chronological order by date of creation or receipt. It is good practice to clearly stamp on the front or all documents received the date of receipt. Folders in hard copy filing systems should be marked with the date the folder was opened and when closed the date of closure. When files are closed the date when the folder should be reviewed prior to disposal (usually at the end of the minimum retention period) should be added. In electronic filing systems these pieces of information can often be added to the metadata for the folders created. d. e. Page 17 of 26 f. g. A regular programme of reviews should be established to consider the need for closure and disposal of records/folders. The frequency of these reviews will largely depend on the size and growth rate of the filing system. A summary of the responsibilities, organisation and conventions used for each filing system should be set out in a document that is made available to all those who access the system. Folder and File Naming/Referencing Conventions 4. Names for folders and documents should be kept as short as possible whilst also being meaningful. Long file names create long file paths and links which increase the likelihood of error and are more difficult to remember. Avoid using personal names and codes and abbreviations that are not commonly understood. e.g. use `H&SCtteeTOR.doc' in preference to `Health_&_Safety_Comittee_Terms of_Reference.doc' 5. When creating sub folders and files within electronic filing systems there is no need to include in the file name descriptive information already contained in the parent folder as this will already form part of the filename/file path. e.g. use: not: `/.../DivBoard/agenda20100210' `/.../DivBoard/DivBoardagenda20100210 6. Avoid using spaces and underscores in file names. Some software packages have difficulty recognising file names with spaces. Use capital letters to delimit words. e.g. use `AuditMeetingsAgendas.doc' in preference to `Audit_Meetings_Agendas.doc' 7. When using a number in a file name always give it as a two digit number so that when it is displayed in the file directory in alphanumeric order it will be ranked in the correct order. Organised alphanumerically `ab2' will be listed after `ab10'. e.g. V01, V02, V03 etc not V1, V2, V3. 8. If using a date in the file name always state the date `back to front' and use four digit years, two digit months and two digit days: YYYYMMDD or YYYYMM or YYYY or YYYYYYYY. Writing dates in this way will present the records in chronological order in the file list with the latest record at the end of the list. e.g. use `20100201agenda.doc' not `1Feb2010Agenda.doc' 9. The elements of the file name should be ordered in the most appropriate way to retrieve the record. If records are retrieved by date the date element should appear first, if retrieved according to description then this should appear first. e.g. `20100201agenda.doc' (date retrieval) or `agenda20100201' (subject retrieval). Protective Marking of Documents 10. The NHS has agreed a scheme of classification using two privacy markings; Page 18 of 26 a. NHS CONFIDENTIAL. This classification should be used for paper and electronic documents containing personal identifiable clinical or NHS staff information and other sensitive information the compromise of which could lead to serious consequences for the Trust. The marking should be included at the top centre of every page of the document and documents so marked should be held and transported securely at all times. (The term NHS CONFIDENTIAL should never be used on correspondence to a patient.) b. NHS RESTRICTED. This classification should be used to mark all other sensitive information. Documents marked NHS RESTRICTED may also be endorsed with a suitable descriptor indicating the reason for the classification. A list of these descriptors is shown in the table below. The marking should be included at the top centre of every page of the document and documents so marked should be kept in lockable containers. 11. When classifying documents regard should be paid to the requirements of the Freedom of Information Act 2000. Careful consideration should be given to classifying documents that would be normally be published or disclosed on request.. Protective markings should wherever possible only be applied to documents that would be exempt from disclosure. Table 1 Categories of NHS RESTRICTED Documents Category Appointments Barred Board Commercial Contracts For Publication Management Personal Policy Proceedings Definition Concerning actual or potential appointments not yet announced Statutory prohibition on disclosure exists or disclosure would constitute contempt of court. Documents considered by an organisation's Board of Directors, initially in private. Where disclosure would be likely to damage a third party commercial undertaking's processes or affairs Concerning tenders Where it is planned that the information will be published at a future date. Concerning policy and planning affecting the interests of a groups of staff Concerning matters personal to the sender or recipient Issues of approach or direction on which the organisation needs to take decision. Information the subject of or concerned in a legal
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Papers Trust Board - 30 January 2020

Description: Date Time Location Chair Apologies Agenda Trust Board – Open Session 30/01/2020 9:00 - 11:45 Conference Room, Heartbeat Edu
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Engaging for increased research participation - full report

Description: Engaging for increased research participation Public and healthcare professionals' perceptions For further information contact: Chris Stock Head of R&D communications and strategy University Hospital Southampton NHS Foundation Trust T: 07795506319 / E: christopher.stock@uhs.nhs.uk Ben Hickman Research director Alterline Research T: 01616050862 / E: ben.hickman@alterline.co.uk This report presents independent research funded in part by the National Institute for Health Research (NIHR) Clinical Research Network: Wessex. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health. Contents 1. Executive summary 1.1. Headline findings and recommendations 1.1.1.People are positive about research and participation 1.1.2. The critical conversations are not happening 1.1.3 Healthcare professionals perceive major barriers to involvement 1.1.4 The public need information, of immediate relevance to their health 1.1.5 Time and fitting participation into life is a concern 2. Introduction and Methodology 2.1. Introduction 2.2. Key objectives 2.3. This report 2.4. Method 3. Review of the literature 3.1. General background 3.2. Why do people take part in clinical research? 3.3. What stops people from taking part in clinical research? 3.4. Why do people take part, or not take part, in related activities? 3.5. Summary 4. Likelihood to participate in clinical research 4.1. The public view clinical research as important 4.1.1. Demographic Differences 4.2. Few people have been asked to take part in clinical research 4.3. Likelihood to participate 4.3.1. Demographic differences 4.4. Likelihood to participate in various types of research 5. Motivations for taking part 5.1. Why do other people take part in clinical research? 5.2. What would motivate you to take part? 5.2.1. Demographic differences 5.3. Exploring motivations in more depth 6. Barriers to taking part 6.1. Why don't other people take part? 6.2. What stops you from taking part? 6.2.1. Demographic differences 6.3. Exploring barriers in more depth 6.4. What do people mean by the `risks' involved? 6.5. How are people forming opinions about risk? 6.6. What might reassure people? 7. The experience of taking part in clinical research 7.1.What motivated people to take part? 7.2. Would people recommend the experience? 7.3. Why would people recommend the experience? 7.4. Why would people not recommend the experience? 7.5. Knowing someone who has taken part 7.6. Why would people be more likely to take part, knowing someone who has? 7.7. Why would people be less likely to take part, having known someone who has? 4 4 4 4 4 4 5 6 6 6 7 7 8 8 9 9 10 11 12 12 12 14 15 15 16 18 18 18 19 19 22 22 22 24 24 26 27 28 29 29 29 29 31 31 31 32 Engaging for increased research participation ? key findings and recommendations 2 8. Knowledge and information 8.1. Level of understanding of clinical research 8.1.1. Demographic differences 8.2. Seeking information 8.3. What information would you need? 8.4. Media coverage 9. Healthcare professionals' perceptions of clinical research 9.1. What do healthcare professionals think of clinical research? 9.2. Who do they think are getting involved in research? 10. Motivations for getting involved in clinical research 10.1. What motivates healthcare professionals to get involved? 11. Barriers to getting involved in clinical research 11.1. What stops healthcare professionals from getting involved? 12. Research opportunities 12.1. Approaching healthcare professionals 12.2. Why are healthcare professionals approaching patients? 12.3. Why are healthcare professionals not approaching patients? 13. Availability of information 13.1. Awareness of clinical research 13.2. Finding information about clinical research 14. The future 14.1.What would make you more likely to get involved in research in the future? 14.2.What would make you more likely to get speak to patients the future? 15. Conclusions and recommendations 15.1. People are positive about research and participation 15.2. The critical conversations are not happening 15.2.1. Recommendation 1 15.3. Healthcare professionals perceive major barriers to involvement 15.3.1. Recommendation 2 15.4. The public need information, of immediate relevance to their health 15.4.1. Recommendation 3 15.5.Time and fitting participation into life is a concern 15.5.1. Recommendation 4 Appendix 1 ? Public survey demographics 33 33 33 34 34 35 37 37 38 39 39 41 41 43 43 44 44 45 45 46 47 47 48 49 49 49 49 49 49 50 50 50 51 52 Engaging for increased research participation ? key findings and recommendations 3 1. Executive summary See section 15 for summary findings and specific recommendations for increasing clinical research participation. 1.1.1 People are positive about research and participation The Wessex population views research in the NHS positively and a large proportion are open to participating: 90% of respondents think that it is important for the NHS to support research into new treatments, whilst 47% think it likely they would be willing to participate in clinical trials in the future. Those that have participated have positive perceptions, and they will likely have a significant influence on others' future participation: 80% of people who have taken part in clinical research would recommend taking part to a friend or family member, whilst around half (44%) of people who know someone who has taken part in clinical research said that they are more likely to participate now because of their experience. 1.1.2 The critical conversations are not happening Only 15% have had clinical research discussed with them by a healthcare professional in their lifetime, whilst only 5% of those who have seen healthcare professional in the last 12 months had clinical research discussed with them. Recommendation 1: Communications supporting participation in interventional trials should be focussed on enabling effective clinical conversations, with a reduced emphasis on broad public awareness approaches. 1.1.3 Healthcare professionals perceive major barriers to involvement The healthcare professionals interviewed were broadly positive about research; however they cite workload, time and lack of local trial information as constraints on discussion of research with patients. Better trial information was also identified as something that would increase the likelihood of discussing trial options with patients. Clinicians self-segregate themselves into `researchers' (an academically orientated minority) and `practitioners', with the latter positive about the benefits of clinical research and open to research referrals/facilitation but unlikely to have direct involvement in, or lead their own, research. Direct involvement in research by clinicians is limited by lack of programmed/sanctioned time within work plans, perceptions of excessive bureaucracy and lack of support. Recommendation 2: Local Clinical Research Networks, local research infrastructure and Trusts' senior leadership should support NHS clinicians' engagement with local clinical trials, and to explore management and education interventions to make communication with patients about trials a routine part of all NHS consultations. 1.1.4 The public need information, of immediate relevance to their health Public participation motivations centred on potential benefits to one's own health or that of close friends and family, whilst perceived risk of harm and receiving the `unknown' alongside concerns over time commitments and time off work were the biggest barriers to participation. Only 9% of respondents reported that they felt they understood clinical research very well, with this group the least likely to agree that risk was a significant barrier to participation. Generic online searches, condition-specific online sources of information and healthcare professionals were the primary sources of information, with a high degree of trust in the information provided by professionals. Recommendation 3: Public communications and engagement should have a greater emphasis on informing and empowering people at the point of care or enquiry, to enable discussion of trials with clinicians. Engaging for increased research participation ? key findings and recommendations 4 1.1.5 Time and fitting participation into life is a concern Concerns over time commitments needed to participate in studies, including taking time out of work and fitting such activity into daily/family life were significant barriers to participation. Recommendation 4: Changes to clinical research delivery to improve convenience and flexibility for participants, alongside interventions that lower the practical threshold to participation should be investigated and evaluated. Engaging for increased research participation ? key findings and recommendations 5 2. Introduction and Methodology 2.1 Introduction The partnership between University Hospital Southampton NHS Foundation Trust (UHS) and the University of Southampton enables clinical-academics to perform clinical research through quality assured support, facilities and resources embedded at the heart of a major teaching hospital trust. This partnership hosts, and participates in the National Institute for Health Research Clinical Research Network Wessex (NIHR CRN:Wessex), one of 15 regional CRNs that coordinate and support clinical trial activity across the UK on behalf of the NIHR. Participation in clinical research by the public, patients and clinicians is essential to advancing medicine and care, and access to such trials is a right conferred to patients under the NHS constitution1. Because of this, recruitment to trials is the primary measure by which NIHR manages performance of CRNs and their member organisations. Rapid, complete recruitment to open trials remains challenging for Trusts and CRNs nationwide, indicating a significant issue relating to public and patient engagement with trial treatment options and research participation. Against this background UHS, with match-funding from NIHR CRN:Wessex, commissioned Alterline Research Ltd. to conduct a programme of market research to better understand the perceptions, motivations and barriers to participation in clinical research across the region. This research is intended to inform more effective communication and engagement aimed at increasing participation, primarily focussed on interventional clinical research. 2.2 Key objectives The research was conducted with three audiences: ? The public (18 years and older across all demographics and geographies) ? Primary care professionals including GPs and community nurses across the region. ? Hospital clinical staff including consultants, nurses, midwives and allied health professionals across the region's trusts. The research outputs are intended to provide an evidence base to help: ? ? ? ? Shape and inform effective engagement strategies with these audiences Build an evaluation framework against which engagement can be assessed and developed for greater efficacy Ensure coherence and commonality in engagement approaches and messages across Wessex Provide a reference point and baseline data for long-term tracking and evaluation. 2.3 This report This report details findings of the research with the public and healthcare professionals, exploring their attitudes towards clinical research, their likelihood to participate and the drivers and barriers to increasing participation and recommending actions for increasing research participation. > > > 1 NHS Constitution, 2013 http://www.nhs.uk/choiceintheNHS/Rightsandpledges/NHSConstitution/Documents/2013/the-nhs-constitution-forengland-2013.pdf Engaging for increased research participation ? key findings and recommendations 6 2.4 Method Review of literature and pilot A review of the existing literature was conducted to help inform the design of research materials including the quantitative and qualitative questionnaires. Quantitative questionnaire development A questionnaire comprising predominantly closed questions and a small number of open-ends was developed in partnership with the Trust. Quantitative public survey by telephone In total 1101 interviews were completed by telephone using specialist computer assisted telephone interviewing (CATI) software and an automated dialler system. The interview sample for the telephone survey was sourced from a specialist data provider using relevant postcodes. In order to ensure a representative survey sample of the Wessex population interview completions were monitored by key demographics such as gender, age and location. See appendix one for details of the demographic sample. Public depth survey Following the quantitative survey, key emerging themes were used develop a qualitative, in-depth survey which was administered by telephone. In total, 30 people took part in in-depth interviews including a mix of men and women, different ages and geographies. Clinician depth survey To explore perceptions, motivations and barriers of clinicians, an in-depth survey was designed and administered by telephone. In total, 25 healthcare professionals took part in the survey, including 6 GPs, 10 nurses, and 9 hospital consultants. Analysis The quantitative survey data was exported to SPSS (Statistical Packages for Social Sciences) where it was quality checked. Frequencies and cross-tabulations exploring differences between respondents were produced and key questions were charted and included in this report. Demographic differences have been included in this report following the application of tests of statistical significance. Open-ended data was themed, with key verbatim quotes pulled out and included in the report. The in-depth interviews were audio recorded and transcriptions were made. Key themes were identified from the focus group transcripts and representative verbatim quotes have been pulled out and included in the report. Engaging for increased research participation ? key findings and recommendations 7 3. Review of the literature 3.1 General background Clinical research is central to advancing medicine, developing and evaluating medications, treatments, and practices. The purpose of this review is to examine perceptions of clinical research, willingness to participate and motivations and barriers to taking part. As the research in the area is limited, it will also look at motivations and barriers to taking part in related, voluntary activities (i.e. giving blood and organ donation) in order to identify any commonalities. Generally, reports in the literature show support for clinical research to be high. The Wellcome Trust notes that 95% of adults and 93% of 13-18 year olds think that medical research should be supported2. Further 88% of those surveyed by the National Institutes of Health3 in the USA think that clinical trials are important for advancing knowledge about treating disease. A 2011 UK national survey of 990 adults by IPSOS-MORI, commissioned by the Association of Medical Research Charities, reported similarly strong public support for research with 97% believing the NHS should support research into new treatments, whilst 93% wanted their local NHS to be encouraged or required to support research. These figures are corroborated by a 2014 national survey of 3,000 adults commissioned by the National Institute for Health research, indicating that 95% of people said it was important to them that the NHS carries out clinical research4.5. Reported willingness to participate in research is also strong. In a monitor of people's views on science and research, 60% said they would be willing to take part in clinical trials6. 72% of those polled in the 2011 AMRC survey would want to be offered opportunities to be involved in trials of new medicines or treatments if they suffered from a health condition that affects their day-to-day life; 80% would consider allowing a researcher confidential access to their medical records, and 88% would be happy to be asked to talk to researchers about their family history or give a sample of their blood for laboratory testing. 89% of people surveyed in the 2014 NIHR national survey would be willing to take part in clinical research if they were diagnosed with a medical condition or disease, with only 3% saying they would not consider it at all5. Comis et al7 report that, in relation to cancer trials, 32% of adults would be willing to take part and 38% would potentially be interested, but would hold some reservations. Further, willingness to participate is not static and much depends on the nature of the trial. For example, 74% of people would be willing to allow access to their medical records, whereas only 30% would be willing to test a new drug2. These figures showing positive perception and willingness to participate are however in stark contrast to reported and actual participation rates. In two monitors by the Wellcome Trust, lifetime participation varied from 10%6 to 23%2, whilst a further 10% of people have a family member who has taken part6. These findings support National Institute for Health Research official figures indicating that annual recruitment to clinical trials in the English NHS stands at 0.94% of the English population (2013-14 figures)8, with CRN Wessex reporting recruitment of 1.15% of the regional population in the same period9. > > > Butt, S., Clery, E., Abeywardana, V., Phillips, M. (National Centre for Social Research). Wellcome Trust Monitor 1. London: Wellcome Trust; 2010 National Institutes of Health, National Cancer Institute. (1997). Results from Quarterly Omnibus Survey: Clinical Trials Questions-April 22, 1997. Bethesda: National Cancer Institute. 4 IPSOS-MORI / Association of Medical research Cahrities J11-02572 Public support for research in the NHS, http://www.ipsos-mori.com/ researchpublications/researcharchive/2811/Public-support-for-research-in-the-NHS.aspx 5 National Institute for Health Research, 2014, http://www.crn.nihr.ac.uk/blog/news/nine-out-of-ten-people-would-be-willing-to-take-part-inclinical-research/ 6 Clemence, M., Gilby, N., Shah, J., Swiecicka, J., Warren, D. (2013). Wellcome Trust Monitor Wave 2: Tracking public views on science, biomedical research and science education. London: Wellcome Trust. 7 Comis, R.L., Miller, J.D., Aldige, C.R., Krebs, L. and Stoval, E. (2003). Attitudes toward participation in cancer clinical trials. Journal of Clinical Oncology. 21: 830-835. 2 3 Engaging for increased research participation ? key findings and recommendations 8 3.2 Why do people take part in clinical research? By far, the most reported reason for taking part in clinical research in the literature was a sense of altruism and helping others. Mattson et al10, found that 65% of participants took part for altruistic reasons. Rosenbaum et al11 noted that 46% of people who participated in clinical research reported altruism as the reasons for doing so. Of those people, just under half (45%) provided an altruistic reason as their only motivation. Those who gave altruistic reasons were more likely to have higher levels of social support, have a college education, and were less likely to say they had a disability. Specifically in cancer trials, altruism is often reported as a reason for taking part12. Jenkins et al13 report that 23% of those who consented to take part in clinical research did so because others would benefit from their participation. Many people also said that they took part because of healthcare professionals. Some report that this was because of a recommendation from their doctor3 and others report that it was through the doctor's influence that they decided to take part14. Jenkins et al13 looked solely at people who had decided to take part after being asked by their doctor. Of those who were asked, 72% decided to take part, of which 21% said it was because they trust their doctor. Further, it is apparent that some people also take part in clinical research because of the benefit that it will have to them. Such motivations include a hoping that there will be a therapeutic benefit or because there is no other treatment available12. Further, in Mattson et al10 74% of participants for aspirin and beta-blocker trials said they were motivated by non-altruistic motivations. These motivations included better medical monitoring and reassurance, physical improvement and preventions of further illness. 3.3 What stops people from taking part in clinical research? A concern about side effects and risks present a significant barrier to participation in the literature. Looking into cancer trials, a fear of making the cancer worse presented a significant barrier when being asked to participate15. Further, when testing a new drug, 93% of those with concerns in the Wellcome Trust study said they were worried about the possible risk to their own health from participating2. As with many factors, concerns about the side effects and risks of a trial are not stable across all groups. Basche et al16 spoke to seniors who were asked to participate in cancer trials. They found that those ages 65?75 were more likely to participate in the trial when the side effects were likely, than those aged over 75. Further, many studies report that issues related to the time commitment of clinical research and logistical difficulties also present a significant constraint on participation. A quarter of people asked about their attitudes to participation in clinical research said that they did not have the time to participate17. Further, a third of people in Basche et al16 said that they were concerned about the time commitment and other issues, such as getting to the trial facility. Many other barriers have been reported in the literature. These include: a dislike of randomisation13 and the potential to be in a placebo group; lack of knowledge of both the processes involved in clinical research19 and the trials that are available18, and a lack of trust in medical research19. > > > NIHR Clinical Research Network Annual Report 2013/14 http://www.crn.nihr.ac.uk/wp-content/uploads/About%20the%20CRN/13_14%20Annual%20Performance%20Report_PUBLIC_FV.pdf 9 CRN Wessex Performance Report May2014, www.odp.nihr.ac.uk/default.htm 10 Mattson, M.E., Curb, J.D., and McArdle, R. (1985). Participation in a clinical trial: The patients' point of view. Controlled Clinical Trials. 6: 156-167 11 Rosenbaum, J.R., Wells, C.K., Viscoli, C.M., Brass, L.M., Kernan, W.N., and Horwitz, R.I. (2005). Altruism as a reason for participation in clinical trials was independently associated with adherence. Journal of Clinical Epidemiology. 58: 1109-1114. 12 National Institutes of Health, National Cancer Institute, Working Group on Enhancing Recruitment to Early Phase Cancer Clinical Trials. (2004). Enhancing Recruitment to Early Phase Cancer Clinical Trials: Literature Review. Bethesda: National Cancer Institute. 13 Jenkins, V. and Fallowfield, L. (2000). Reasons for accepting or declining to participate in randomised clinical trials for cancer therapy. British Journal of Cancer. 82(11): 1783-1788. 14 Chu, S.H., Jeong, S.H., Kim, E.J., Park, M.S., Park, K., Nam, M., Shim, J.Y., and Yoon, Y. (2012). The views of patients and healthy volunteers on participation in clinical trials: An exploratory survey study. Contemporary Clinical Trial. 33: 611-619 15 Solomon, M.J., Pager, C.K., Young, J.M., Roberts, R., and Butow, P. (2003). Patient entry into randomized controlled trials of colorectal cancer treatment: Factors influencing participation. Surgery. 133(6): 608-613. 16 Basche, M., Baron, A.E., Eckhardt, S.G., Balducci, L., Persky, M., Levin, A., Jackson, N., Zeng, C., Brna, P., and Steiner, J.F. (2008). Barriers to enrollement of elderly adults in early-phase cancer clinical trials. American Society of Clinical Oncology. 4(4): 162-168 8 Engaging for increased research participation ? key findings and recommendations 9 Although little literature looks into healthcare professionals' motivations regarding clinical research, several have looked at the barriers to getting involved. The research suggests that concerns for patients represent significant barriers to participation. In in-depth interviews with clinicians in South-west England, clinicians suggested that concerns for individual patients and respect for patients' preferences for different treatments prevented them from approaching patients and getting involved20. Further, concern for patients and a worry about the impact on the doctor-patient relationship was shown to be a significant barrier in Ross et al's meta-analysis21. 3.4 Why do people take part, or not take part, in related activities? Many reasons, both similar and dissimilar to those expressed above, are noted in the literature that motivate blood and organ donation. Coad et al22 found that those who knew someone who had donated or received an organ were more likely to agree with donating an organ to a family member or friend. Further, Wildman and Hollingsworth23 note that those who have donated blood before are more likely to donate again. Further, Cohen and Hoffner24 note that self-interest explains motivations to become an organ donor. 40% said they would be willing to sign a blood donor card. Self-interest motivations were the most important predictor of willingness to sign the card, including pride and satisfaction with the decision, otherwise known as the `warm glow' feeling. A questionnaire of university students in Japan showed that being in good health, having time to donate, being given opportunity to donate and helping others were the most important motivations for those who both had given blood before and those who had not25. The same study also looked at barriers to taking part. These were very much the opposite of the motivators, and included having time to donate, not knowing when and where to donate and not being given the opportunity to donate were considered barriers to taking part25. Lack of knowing where to go and it not being in a convenient place was corroborated by a further study of American adults, as well as a fear of needles and pain26. 3.5 Summary In summary, although many people believe that clinical research is important and are willing to take part, this is not reflected in rates of participation. Reasons why people take part in clinical research include altruism, the influence of a healthcare professional and a benefit to themselves. Major barriers to participation include the risk to themselves and time commitments. Clinician barriers generally revolve around a concern for their patients. Significantly different motivators and barriers to taking part in related activities include knowing someone who has taken part, taking part before and knowing what opportunities were available. > > > Bevan, E.G., Chee, L.C., McGhee, S.M. and McInnes, G.T. (1993). Patients' attitudes to participation in clinical trails. British Journal of Clinical Pharmacology. 35(2): 204-207 18 Mills, E.J., Seely, D., Rachlis, B., Griffith, L., Wu, P., Wilson, K., Ellis, P., and Wright, J.R. (2006). Barriers to participation in clinical trials of cancer: a meta-analysis and systematic review of patient-reported factors. Lancet Oncol. 7: 141-148 19 Lovato, L.C. and Kristin, H. (1997). Recruitment for controlled clinical trials: Literature summary and annotate bibliography. Controlled Clinical Trials. 18: 328-357 20 Langley, C., Gray, S., Selley, S., Bowie, C., and Price, C. (2000). Clinicians' attitudes to recruitment to randomised trials in cancer care: A qualitative study. Journal of Health Services Research and Policy. 5(3): 164-169 21 Ross, S., Grant, A., Counsell, C., Gillespie, W., Russell, I., and Prescott, R. (1999). Barriers to participation in randomised controlled trials: A systematic review. J Clin Epidemiol. 52(12): 1143-1156 22 Coad, L., Carter, N., and Ling, J. (2013). Attitudes of young adults from the UK towards organ donation and transplantation. Transplantation Research. 2: 9-14 23 Wildman, J., and Hollingsworth, B. (2009). Blood donation and the nature of altruism. Journal of Health Economics. 28: 492-503 24 Cohen, E.L. and Hoffner, C. (2012). Gifts of giving: The role of empathy and perceived benefits to others and self in young adults' decisions to become organ donors. Journal of Health Psychology. 18(1): 128-138 25 Ngoma, A.M., Goto, A., Yamazaki, S., Machida, M., Kanno, T., Nollet, K.E., Ohto, H. and Yasumura, S. (2013) Barriers and motivators to blood donation among university students in Japan: Development of a measurement tool. Vox Sanguinis 105(3): 219-224 26 Adelbert, J.B., Schreiber, G.B., Hillyer, C.D., and Shaz, B.H. (2013). Blood donations motivators and barriers: A descriptive study of African American and white voters. Transfusion and Aphresis Science. 48(1): 87-93 17 Engaging for increased research participation ? key findings and recommendations 10 4. Likelihood to participate in clinical research 4.1 The public view clinical research as important To provide a background to people's perceptions of clinical research, we asked respondents to tell us how important they thought it was for the NHS to support research into new treatments. As figure 1 below shows, the overwhelming majority of people (90%) think that it is either important or very important. However, of those who responded to the survey, only 10% have actually taken part in clinical research. There is a clear gap between how important the area is seen to be, and how many people are taking part. Figure 1 g1 How important do you think it is, if at all, for the NHS to support research into new treatments for patients? Base: 1101 3% 6% 13% 77% Very unimportant g3 unimportant Neither important nor unimportant Important Very important 4.1.1 Demographic Differences Age Belief that supporting research is important is lowest in 18-24 year olds (73%). As people get older, they are more likely to believe that it is important, peaking at 96% for 75-84 year olds. Gender Females (95%) a more likely to say supporting research is important than males (85%). Educational attainment Those who have qualifications other than a degree are the most likely to view research as important (97%). Those who have no educational qualifications are least likely (80%). Employment status Students (90%), retired people (83%) and those who are employed (76%) are more likely to see clinical research as important, compared to those who are self-employed (69%), home-makers (67%), or gout of work and not looking for work (55%). 7 Dependents Those with dependents (96%) are more likely to view clinical research as important than those without dependents (90%). Health Those with good (80%) or very good health (80%) are more likely than those with fair (70%) or very bad (54%) to view research as very important. Previous participation Those who have participated in clinical research (99%) are more likely to say supporting research is important than those who have not (89%). g8 Knowing someone who has taken part Those who know someone who has taken part in clinical research (97%) are more likely to see supporting research as important, compared to those who don't (89%). > > > Engaging for increased research participation ? key findings and recommendations 11 g7 g7 4.2 Few people have been asked to take part in clinical research g8 g8 Importantly, of those surveyed, only 15% recalled a time when a healthcare professional had discussed involvement in clinical research with them. Further, of the 43% who had seen a healthcare professional in the last month, only 5% had clinical research discussed with them (Figure 2, below). Figure 2 Did the healthcare professional you saw discuss involvement in clinical research with you? Base: 367 5% Do you recall a time at any point in your life when a healthcare professional has discussed clinical research with you? 15% Base: 799 Yes No 95% Yes No 85% Increasing the number of conversations taking place between clinicians and their patients about clinical research is likely to increase the number of people who take part. In the in-depth interviews, people often said they reason they had not taken part before was because no-one had ever asked. "I just haven't been asked." "No-one's ever asked me." Further, previous research has shown that trust in healthcare professionals is high, with 72% of adults saying that they trust a medical professional to provide them with information about clinical research27. This was also seen in the in-depth interviews, where many respondents expressed a great deal of trust for their doctor. "So if they said `blardy blardy blah', would you take part? Then I probably would have done, because we gained that much trust." g1 "Yes I would trust them if they talked about clinical research because the consultant I've been under for four years now, my GP I've known for over 20 years now so they're people that I've known long enough to trust." 4.3 Likelihood to participate Although only 10% of people have taken part in clinical research, the results would show appetite for participation is higher than this. When respondents were asked if they would consider taking part in clinical research, just under half (47%) agreed that they would be likely or very likely to (Figure 3, below). Figure 3 How likely is it that you would be willing to participate in clinical research in the future? g3 Base: 1101 15% 16% 22% 31% 16% Very unlikely 27 unlikely Neither likely nor unlikely likely Very likely Butt, S., Clery, E., Abeywardana, V., Phillips, M. (National Centre for Social Research). Wellcome Trust Monitor 1. London: Wellcome Trust; 2010 g7 > > > 12 Engaging for increased research participation ? key findings and recommendations 4.3.1 Demographic differences The demographic differences below explore whether some people are more likely than others to participate. Characteristics of people who are more likely to participate include: ? ? ? ? ? ? ? ? ? Having previously participated (64%) or knowing someone who has (63%) Having a good understanding of clinical research (63%) Students (58%) and those unable to work (63%) Having a degree or equivalent level of education (58%) Registered organ donors (58%) People in very good health (57%) People who do regular volunteer work (55%) People who have given blood (54%) People aged 35-64 (52%). Age People aged 35-64 (52%) are most likely to agree that they would be willing to take part in clinical research, this decreases amongst 25-34s (48%), 16-24s (46%), 65-74s (49%) and in particular 75-84s (32%) and 85+ (12%). Understanding of clinical research Those who have a very good understanding of clinical research (63%) are the most likely to say they would take part in clinical research, followed by those that have some (54%), little (40%) or none (39%). Previous participation Those who have participated before (68%) are more likely to say they would be willing to take part than those who have not (45%). Knowing someone who has taken part People who know someone who has participated in clinical research (63%) are more likely to say that they are willing to take part than those who don't (44%). Educational attainment Those with a degree or a degree equivalent (58%) and those who have other qualifications (52%) are more likely than those with no qualifications (35%) to say they would take part. Employment status Students (66%), those who are unable to work (62%), and those who are employed for wages (52%) are more likely to say they are willing to take part than those who are those who are retired (37%) and out of work and looking (26%). Volunteers Those who give help as a volunteer to clubs or organisations weekly (55%), monthly (53%) or occasionally (54%) are more likely to say they are willing take part than those have volunteered in the last year (46%) and those who give unpaid help on an individual basis (36%). Giving blood People who have previously given blood (54%) are more likely to say they would participate than those who have not given blood (45%). Organ donors Those who are registered as organ donors (58%) are more likely to say they would participate than those who are not (42%). Health Those who have very good (57%), good (49%) and bad health (47%) are more likely to say they are would take part than those who have very fair (35%) or bad health (32%). > > > Engaging for increased research participation ? key findings and recommendations 13 4.4 Likelihood to participate in various types of research To expand on people's likelihood to take part, we asked people about different scenarios they would be willing to take part in. As shown in Figure 4 (below), the scenarios that might improve their own health or care are those in which people were most willing to participate . Likelihood to participate extends to 61% in the scenario where it may help prolong a respondents' own life, or where it is looking at new forms of care and exercise to regain movement after a knee injury. In contrast, the scenarios which people were least willing to take part reflected those which were at earlier stages of the research process. This may be because research into new medications or treatments is seen as riskier. Figure 4 How likely is it you would be willing to take part in clinical research if...? Base: 1101 The study might help prolong or improve your life because you have a condition, significant illness or injury The study is looking at a new form of care and exercises to regain movement after knee injury The study is observing how your condition, illness or injury develops or responds to current treatments, over time The study is looking at how the way care is given affects you and your health (e.g. care at home versus staying in hospital) The study is looking at a new medical device 9% 6% 9% 9% 9% 10% 8% 11% 12% 11% 11% 9% 9% 11% 12% 15% 17% 18% 24% 19% 22% 23% 21% 23% 24% 22% 22% 40% 42% 43% 44% 44% 39% 39% 40% 39% 21% 19% 17% 15% 14% 17% 12% 9% 10% The study is looking at a treatment at a very advanced stage of development The study is looking for healthy volunteers The study is looking at a new vaccination The study is looking at a new drug The study is looking at a treatment in the very early stages of development 11% 19% 25% 35% 10% Very unlikely Unlikely Neither likely nor unlikely Likely Very likely Engaging for increased research participation ? key findings and recommendations 14 5. Motivations for taking part 5.1 Why do other people take part in clinical research? In order to understand what motivates people to take part in clinical research, we asked respondents to tell us what they thought motivated other people to take part. The most commonly cited reasons were: ? Helping others/altruism ? A positive impact on their own health ? A personal interest in a particular disease/condition. 5.2 What would motivate you to take part? To look into motivations further, we asked people what would motivate them (rather than others) to take part in clinical research. When people are speaking about their own motivations, they tend to agree more with statements which are related to personal motivations, i.e. helping to improve their own, or a close relative's, health. However, altruistic motivations are still important, with 72% agreeing that they would be motivated by helping others. Respondents also indicated that other things would motivate them, beyond those factors seen earlier. Knowing that aftercare would be available (67%) and an interest in a particular disease (67%) are both seen as important to respondents. Just 32% of respondents said that money would motivate them to take part. Figure 5 To what extent do you agree or disagree that the following would motivate you to take part in a clinical trial? Base: 1101 g5 Supporting research into a condition a close family member suffers from A positive impact on my own health Getting access to the latest treatments for a condition I have Helping others by helping to find new treatments Knowing that there would be continued aftercare and follow-up A personal interest in a particular disease / condition I would find the process of being involved interesting Money / financial gain 6% 5% 12% 6% 5% 6% 5% 6% 7% 7% 6% 7% 8% 8% 10% 13% 15% 15% 19% 17% 22% 36% 42% 48% 44% 51% 45% 44% 47% 15% 35% 28% 30% 21% 22% 23% 14% 25% 7% 17% Strongly disagree Disagree g6 Neither agree nor disagree Agree Strongly agree > > > Engaging for increased research participation ? key findings and recommendations 15 5.2.1 Demographic differences Understanding of clinical research Those who have no understanding of clinical research (58%) are the least likely to agree that they would be motivated by getting the latest access to treatment for a condition they have. Age 35-44 year olds (76%) are more likely to agree that they would be motivated by helping others by finding new treatments than 16-24 (70%) and 25-34 (64%) year olds. 34-44 (86%), 44-54 (85%) and 55-64 (84%) years olds are more likely to agree that they would be motivated by a positive impact on their own health than 16-24 (64%), 25-34 (70%) and 75-84 (64%) year olds. 35-44 (77%), 45-54 (80%) and 55-64 (78%) year olds are more likely to agree that they would be motivated by getting access to the latest treatment for a condition they have than 16-24 (64%), 25-34 (67%), 75-84 (70%) and 85+ (53%) year olds. Gender Women (80%) are more likely than men (75%) to agree that supporting research into a condition a close family member suffers from would motivate them to take part. Educational attainment Those with a degree of degree equivalent and those with other qualifications are more likely than those who have no qualifications to say they are motivated by helping others by helping to find new treatments, a positive impact on their own health, getting access to the latest treatment for a condition they have and supporting research into a condition a close family member suffers from. Employment status Students (90%) are more likely to agree that they are motivated by helping others by helping to find new treatments than those who are employed (76%), self-employed (70%), retired (66%) and out of work and looking (50%). Employed persons (77%) are more likely to be motived by getting access to the latest treatment for a condition they have than those who are retired (71%). Students (96%) are more likely than any other group to strongly agree that they are motivated by supporting research into a condition a close family member suffers from. 5.3 Exploring motivations in more depth When exploring what would motivate people to take part some clear themes emerged from both the open survey questions and the in-depth interviews,. The key motivations are summarised below. It would have a positive impact on my own health Many felt that they would be motivated to participate because it may have a positive impact on their own health. "I've got a few health problems so I would like to take part to see if there any treatments or information in regards to arthritis that would help me" "I have arthritis - anything new to improve life or find a cure." "Finding a drug that helps me." "If anybody could help me with my lifestyle and my health, I'm in a lot of pain, I'm overweight, so that would help." Although some people who responded did not currently suffer from a condition, they suggested they would be motivated to take part if they did and it would help that condition. "I still think the key motivation for me to do it would be if there was something detrimental to my health or something for my health and well-being to improve my lifestyle." "Of course I would, if I had a condition that required treatment and was offered something that would alleviate that." > > > Engaging for increased research participation ? key findings and recommendations 16 Further, some suggested that they would take part as a last resort if nothing else would help their condition. "If I had something that was as of yet untreatable I'd give it a go, but otherwise no." "If I was in an unfortunate situation of having a life threatening illness then I tend to think you grasp at anything." Altruistic motivations and helping the people around me A willingness to help with clinical research relating to a condition that those close to them suffer from was evident in people's responses. "Because my mother has dementia." "In recent years a lot of people I know have suffered from cancer and arthritis." "I suppose its family history, we have had a run in with cancer so I suppose we would be interested in getting involved." "My son's diabetic, anything that would help." Respondents also suggested that they were motivated by a more general altruistic sense of helping others. "Because I want to help people." "If it helps give people a better life." "It's being out there trying to help somebody that is unable to help themselves." It will help advance medical science Some respondents expressed that they would be likely to take part because it may help improve medicine and medical science. "Because it is interesting and it helps the process of medical science." "I feel if people don't participate then science will not advance, for everyone's benefit." "It is important to help the development of medicine and if people aren't helping then there would be no progress and it wouldn't get anywhere." I would find it interesting Respondents said that they would be motivated to take part in various types of trials because they found it interesting. "I find that really quite interesting, I quite like a bit of psychology myself, I'd like to see what goes on in their heads to make it go one way or the other." "Yeah that's a fascinating thing, it's just so clever!" "I'm quite interested in exercise and diet." "Because it would be interesting to see how your health can be affected by those types of things." > > > Engaging for increased research participation ? key findings and recommendations 17 Because I've taken part before Those who had already taken part in clinical research suggested they would again because of their previous experience. "Previous experience in a clinical trial." "Already have been part of a clinical trial for cancer. So far it is a beneficial experience." "I have already taken part and thought it helped." "I have previously been part of a clinical trial and had a good experience." Money Earning money through participating was a clear motivation for a minority of people. "Depending on what the cash incentive was. I wouldn't participate in it if there was no financial gain because of the dangers behind it." "It would depend what it was in aid of and if it was for money." "If there was a large pay out I would take part." Engaging for increased research participation ? key findings and recommendations 18 6. Barriers to taking part 6.1 Why don't other people take part? We also looked into the barriers to taking part in clinical research. When asked what may stop other people from taking part, respondents mentioned: ? Being worried about the risks ? Lack of knowledge/information ? Lack of time to be involved. 6.2 What stops you from taking part? In order to explore this further, respondents were asked what would stop them personally (rather than others) from taking part. Respondents' answers reflected concerns about the risks involved in clinical research, a lack of knowledge and information, and practical issues with time and having to take time off work. When prompted, it was clear that there were other issues which concerned respondents. For some, the involvement of private drug companies (33%) and stories they have seen in the media (31%) would stop them from taking part in clinical research. Figure 6 To what extent do you agree or disagree that the following would stop you from taking part in a clinical trial? Base: 1101 g6 I'm worried about the risks g5 4% 11% 8% 7% 10% 12% 10% 20% 24% 28% 27% 32% 19% 19% 19% 28% 25% 42% 32% 35% 32% 25% 25% 19% 16% 32% 46% 14% 15% 14% 10% 6% 8% 6% 6% 5% 5% I might need to take time off work I don't have time to participate I don't know enough about clinical trials The involvement of a private drug company Stories I have seen in the media I wouldn't pass the medical screening test 37% 32% 44% 34% 20% 34% My family and friends would disapprove I'm not the type of person the NHS want to participate in clinical trials My religious or moral beliefs 18% 12% 25% 17% 16% 11% 5% Strongly disagree Disagree g9 Neither agree nor disagree Agree Strongly agree > > > Engaging for increased research participation ? key findings and recommendations 19 6.2.1 Demographic differences Understanding of clinical research Those who have a very good understanding (41%) are the least likely to agree they are worried about the risks, rising with some understanding (55%), little understanding (60%) and no understanding (62%). Those who have no (50%) or little understanding (48%) are more likely to agree that they don't have the time to take part than those with some (40%) or very good understanding (37%). Age Those aged 85+ (70%) are the most likely to say that not knowing enough about clinical research stops them from taking part. Those ages 75-84 (43%) and 85+ (59%) are the most likely to think that they are not the type of people the NHS want to take part. Gender Women (62%) are more likely to say that a worry about the risks would stop them from participating than men (52%). Women (48%) are also more likely to worry about needing time of work than men (43%). Educational attainment Those with no qualifications are least likely to agree that they are worried about the risks of participating (50%), that they don't have the time to participate (39%), and that they may need to take time off work (33%). However, this group are the most likely to agree (27%) that they are not the type of person the NHS wants to participate. Employment status Those who are unable to work are least likely to agre
Url: /Media/Southampton-Clinical-Research/Marketresearch/Engaging-for-increased-research-participation-full-report-v2.pdf

Papers Trust Board - 25 July 2024

Description: Agenda Trust Board – Open Session Date 25/07/2024 Time 9:00 - 13:00 Location Anaesthetic Seminar Room (CE95/99), E Level, Centre Block, SGH/ Microsoft Teams Chair Jenni Douglas-Todd Apologies Gail Byrne (Natasha Watts to deputise) In attendance Kerrie Montoute, Head of Programmes, CDO Directorate at NHSE (shadowing Jenni Douglas-Todd) 1 9:00 2 3 9:15 4 5 5.1 9:20 5.2 9:25 5.3 9:30 5.4 9:35 5.4.1 Chair’s Welcome, Apologies and Declarations of Interest Note apologies for absence, and to hear any declarations of interest relating to any item on the Agenda. Patient Story The patient story provides an opportunity for the Board to reflect on the experiences of patients and staff within the Trust and understand what the Trust could do better. Minutes of Previous Meeting held on 6 June 2024 Approve the minutes of the previous meeting held on 6 June 2024 Matters Arising and Summary of Agreed Actions To discuss any matters arising from the minutes, and to agree on the status of any actions assigned at the previous meeting. QUALITY, PERFORMANCE and FINANCE Quality includes: clinical effectiveness, patient safety, and patient experience Briefing from the Chair of the Audit and Risk Committee (Oral) Keith Evans, Chair Briefing from the Chair of the Finance and Investment Committee (Oral) Dave Bennett, Chair Briefing from the Chair of the People and Organisational Development Committee (Oral) Jane Harwood, Chair Briefing from the Chair of the Quality Committee (Oral) Tim Peachey, Chair Maternity and Neonatal Safety 2024-25 Quarter 1 Report 5.5 Chief Executive Officer's Report 9:45 Receive and note the report Sponsor: David French, Chief Executive Officer 5.6 Performance KPI Report for Month 3 10:15 Review and discuss the report Sponsor: David French, Chief Executive Officer 5.7 Break 10:45 5.8 Finance Report for Month 3 11:00 Review and discuss the report Sponsor: Ian Howard, Chief Financial Officer 5.9 People Report for Month 3 11:15 Review and discuss the report Sponsor: Steve Harris, Chief People Officer 5.10 Annual Complaints Report 2023-24 11:30 Receive and discuss the report Sponsor: Gail Byrne, Chief Nursing Officer Attendee: Natasha Watts, Interim Deputy Chief Nursing Officer 6 STRATEGY and BUSINESS PLANNING 6.1 Corporate Objectives 2024-25 Quarter 1 Review 11:45 Review and feedback on the corporate objectives Sponsor: David French, Chief Executive Officer Attendees: Martin De Sousa, Director of Strategy and Partnerships/Kelly Kent, Head of Strategy and Partnerships 6.2 Research and Development Plan 2024-25 12:00 Discuss and approve the plan Sponsor: Paul Grundy, Chief Medical Officer Attendees: Karen Underwood, Director of R&D/Marie Nelson, R&D Head of Nursing and Health Professions 6.3 Board Assurance Framework (BAF) Update 12:20 Review and discuss the update Sponsor: Gail Byrne, Chief Nursing Officer Attendees: Craig Machell, Associate Director of Corporate Affairs and Company Secretary/Lauren Anderson, Corporate Governance and Risk Manager Page 2 7 CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Feedback from the Council of Governors' Meeting 24 July 2024 (Oral) 12:30 Sponsor: Jenni Douglas-Todd, Trust Chair 7.2 Register of Seals and Chair's Actions Report 12:35 Receive and ratify In compliance with the Trust Standing Orders, Financial Instructions, and the Scheme of Reservation and Delegation. Sponsor: Jenni Douglas-Todd, Trust Chair 8 Any other business 12:40 Raise any relevant or urgent matters that are not on the agenda 9 Note the date of the next meeting: 10 September 2024 10 Resolution regarding the Press, Public and Others Sponsor: Jenni Douglas-Todd, Trust Chair To agree, as permitted by the National Health Service Act 2006 (as amended), the Trust's Constitution and the Standing Orders of the Board of Directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. 11 Follow-up discussion with governors 12:45 Page 3 Minutes Trust Board – Open Session Date 06/06/2024 Time 9:00 – 13:00 Location Conference Room, Heartbeat/Microsoft Teams Chair Jenni Douglas-Todd (JD-T) Present Gail Byrne, Chief Nursing Officer (GB) Keith Evans, Deputy Chair and NED (KE) David French, Chief Executive Officer (DAF) Paul Grundy, Chief Medical Officer (PG) Steve Harris, Chief People Officer (SH) Jane Harwood, NED/Senior Independent Director (JH) Ian Howard, Chief Financial Officer (IH) Tim Peachey, NED (TP) (until 12:00) Joe Teape, Chief Operating Officer (JT) In attendance Craig Machell, Associate Director of Corporate Affairs and Company Secretary (CM) Lauren Anderson, Corporate Governance and Risk Manager (LA) (item 6.3) Christine Mbabazi, Equality & Inclusion Advisor/Freedom to Speak Up Guardian (CM) (item 5.12) Jenny Milner, Associate Director of Patient Experience (JM) (item 5.11) Suzy Pike, Divisional Director of Nursing/Professions, Division B (SP) (item 5.13) Clare Rook, Chief Operating Officer, CRN: Wessex (CR) (item 6.1) Julian Sutton, Interim Lead Infection Control Director (JS) (item 5.10) 1 member of the public (item 2) 5 governors (observing) 6 members of staff (observing) 2 members of the public (observing) Apologies Dave Bennett, NED (DB) Diana Eccles, NED (DE) Alison Tattersall, NED (AT) 1. Chair’s Welcome, Apologies and Declarations of Interest The Chair welcomed attendees to the meeting. There were no interests to declare in the business to be transacted at the meeting. It was noted that apologies had been received from Diana Eccles, Alison Tattersall and Dave Bennett. The Chair provided an overview of her activities since April 2024, including visits to hospital departments, meetings with peers and other key stakeholders. 2. Patient Story Hannah Pilka was invited to relate the story of her father, Karol Pilka, who died suddenly in hospital on 31 December 2023. The care and compassion shown by the nurse caring for Karol Pilka was highlighted. This greatly assisted the family with the grieving process. The Trust’s bereavement team was also praised. The Board noted the importance of care and compassion by the Trust’s staff. Page 1 3. Minutes of the Previous Meeting held on 28 March 2024 The draft minutes tabled to the meeting were agreed to be an accurate record of the meeting held on 28 March 2024. 4. Matters Arising and Summary of Agreed Actions It was noted there were no matters arising or overdue actions. 5. QUALITY, PERFORMANCE and FINANCE 5.1 Briefing from the Chair of the Audit and Risk Committee The chair of the Audit and Risk Committee was invited to provide an overview of the meeting held on 20 May 2024. It was noted that: • The committee reviewed the Trust’s National Cost Collection submission for 2023/24. • A report on waivers of competitive tendering was received, and it was noted that these were mostly due to urgent requirements or where there was only a single supplier. • The committee reviewed the Trust’s draft Annual Report and Accounts for 2023/24. • The draft internal audit report for 2023/24 was expected to provide a ‘clean’ opinion and there were no outstanding actions from previous audits. • The Trust received a ‘green’ assessment from the review against the Counter- Fraud Functional Standard. 5.2 Briefing from the Chair of the People and Organisational Development Committee The chair of the People and Organisational Development Committee was invited to provide an overview of the meeting held on 22 May 2024. It was noted that: • The committee reviewed the People Report for Month 1 (item 5.9) and noted that performance in this area was positive. • The additional workforce controls appeared to be working in terms of managing the size and composition of the Trust’s workforce. • The controls in respect of use of bank and agency staff also appeared to have had a significant effect. • The committee received an update on the Trust’s Inclusion and Belonging Strategy, noting that a number of initiatives were underway. • The committee reviewed progress against the objectives for year three of the Trust’s People strategy and expressed concern with the level of resource available to deliver these. 5.3 Briefing from the Chair of the Finance and Investment Committee The chair of the Finance and Investment Committee was invited to provide an overview of the meeting held on 3 June 2024. It was noted that: • The committee reviewed the Finance Report for Month 1 (item 5.7) and received an update in respect of the Trust’s annual plan for 2024/25. • The committee received an update on the Trust’s Cost Improvement Programme, noting that it had achieved £2.5m to date out of the £82m target. • UHS Estates was broadly on budget and was delivering and a positive report was also noted in respect of Wessex Procurement Limited. Page 2 5.4 Briefing from the Chair of the Quality Committee The chair of the Quality Committee was invited to provide an overview of the meeting held on 3 June 2024. It was noted that: • The committee noted an increase in the number of high-harm falls, which was a concern. • The committee also expressed concern at the resource demand posed by Inquests and post-mortems, particularly in terms of the number of witnesses now being called by Coroners. • The committee had reviewed a draft of the Trust’s Quality Account for 2023/24. • In reviewing the relative risk of mortality, it was noted that patients were 16% less likely to die at the Trust compared to the average mortality rate. • In terms of infection prevention and control, it was noted that this was at a higher rate than was acceptable, although there was a national issue in terms of infection prevention and control (item 5.10). 5.5 Chief Executive Officer’s Report David French was invited to present the Chief Executive Officer’s Report, the content of which was noted. It was further noted that: • It was the 80th anniversary of Operation Overlord, the Allied landings in Normandy. • The Infected Blood Inquiry had published its report on 20 May 2024. As a result of which, the UK Government has established a compensation scheme for those impacted. In addition, NHS England had commissioned an ongoing patient support service for those affected, and it was expected that the Trust would be one of the two providers in the region offering this service. • The Prime Minister had announced that a general election would be held on 4 July 2024. As a result, there were a number of implications for the Trust as a public body during the ‘pre-election period’. • Further industrial action by junior doctors was scheduled to take place between 27 June 2024 and 2 July 2024. The Trust was taking appropriate steps to manage this. • Paula Melhuish, Deputy Director of Estates and Capital Development, had received the Outstanding Service Award from the Health Estates and Facilities Management Association on 13 May 2024. • The Trust had been awarded additional capital funding due to its Emergency Department performance at the end of 2023/24. It was likely that some of this funding would be used to increase same-day emergency care capacity. • The Trust’s plan for 2024/25 had yet to be agreed in common with other trusts across NHS England. • Discussions were ongoing in respect of the Integrated Care Board’s transformation programmes, and it was noted that David French had been appointed to head the workforce transformation programme. 5.6 Performance KPI Report for Month 1 Joe Teape was invited to present the Performance KPI Report for Month 1, the content of which was noted. It was further noted that: • The data for March 2024 showed that the Trust was in the top-half or top- quarter in terms of its comparative performance. • There were 15 patients waiting longer than 78 weeks for a corneal transplant due to a lack of available materials beyond the Trust’s control. • Emergency Department performance had improved during May 2024 with use of surge capacity of only 14 per day (out of 50) and a reduction in the number Page 3 of patients with no criteria to reside of about 10%, although this was mostly due to the time of the year. • The Trust’s Diagnostics performance had been good over the period, with all but two areas achieving the 95% target. Recovery plans were in place for the areas not achieving the target and the Trust had informed trusts with cardiac magnetic resonance imaging capability that referrals would no longer be supported. • The Trust’s overall key performance indicators showed good or improving performance. However, there were concerns about the sustainability of this trajectory and some areas were vulnerable to loss of key personnel. • The Quality Committee was to carry out a deep-dive into falls and pressure ulcers, and a hydration trial to reduce the number of falls was being considered. The Board noted the reported ransomware attack against Synnovis on 3 June 2024, which had impacted trusts in London as well as the NHS Blood and Transplant service. It was noted that the Trust did use the supplier, but was unaffected by the incident. However, the impact on the NHS Blood and Transplant service would likely cause potential issues for the Trust in terms of the availability of blood and transplant services. Action: JT agreed to include Digital as an agenda item at a future Trust Board Study Session. 5.7 Finance Report for Month 1 Ian Howard was invited to present the Finance Report for Month 1, the content of which was noted. It was further noted that: • Planning for 2024/25 was still ongoing, and a further submission was to be made on 12 June 2024. As a result of the delays in the planning process, there was currently no formal reporting to NHS England. • The Trust had recorded a deficit of £3.8m during the month, which was in line with its current plan. • The Trust’s underlying deficit was between £4-4.5m per month. However, during month 1, this was nearer to £6m due to lower elective recovery performance during the period. 5.8 Break 5.9 People Report for Month 1 Steve Harris was invited to present the People Report for Month 1, the content of which was noted. It was further noted that: • There had been an overall reduction in whole-time equivalents during April 2024, with a reduction in bank and agency use. It was noted that 60-80 agency staff were related to patients with a mental health-related care need. • The Trust’s annual workforce plan had been submitted, but this was reliant on delivery by the Integrated Care System on a number of assumptions in terms of patients with no criteria to reside and provision of mental health care. • The Trust had received a silver award under the Defence Employer Recognition Scheme. Page 4 • The Trust was the second-lowest user of bank and agency staff in the southeast region. This represented a significant turnaround within a short period, although it was noted that there were some areas of fragility within the Trust. 5.10 Infection Prevention and Control 2023-24 Annual Report Julian Sutton was invited to present the Infection Prevention and Control 2023/24 Annual Report, the content of which was noted. It was further noted that: • There were a number of concerns stemming from application of ‘fundamentals of care’, such as a failure to apply risk reduction measures appropriately. • There had been seven cases of Methicillin-resistant Staphylococcus aureus (MRSA) during the year. • An update was provided in respect of the candida aureus outbreak, with approximately 70 patients colonised. • Rapid upper gastro-intestinal tract testing had resulted in benefits due to the speed of detecting infections and/or ruling them out quicker, thereby freeing up capacity. • An update was provided in respect of the incidence of measles since April 2024, which necessitated a significant amount of work to carry out contact tracing and to notify those potentially exposed. • There was a general increase in the infection rate nationally, and the Trust generally was in the middle in terms of its performance, dependent on the particular infection category. 5.11 Learning from Deaths 2023-24 Quarter 4 Report Jenny Milner and Paul Grundy were invited to present the Learning from Deaths report for Quarter 4, the content of which was noted. It was further noted that: • In line with a national trend, there had been an increase in the number of deaths during the fourth quarter. • A new application was being trialled to facilitate the sharing of the learnings from morbidity and mortality meetings. Work was also being carried out to standardise morbidity and mortality meetings, which would further facilitate the dissemination of learning. • Due to performance by the current provider below the standard expected, the Trust was tendering for a new supplier for baby funerals. • The Medical Examiner service was prepared for the changes due to be implemented nationally in September 2024 requiring the review of all deaths. • Based on the whole-year average, the Trust had the fifth-lowest mortality rate in England. • The Trust’s bereavement service had some constraints on resources, which was impacting out-of-hours and weekend support. 5.12 Freedom to Speak Up Report Christine Mbabazi was invited to present the Freedom to Speak Up Report, the content of which was noted. It was further noted that: • Between the period November 2023 – May 2024, the Trust had recorded 56 Freedom to Speak Up cases, compared to 44 during the same period in 2022/23. Page 5 • The reintroduction of face-to-face meetings following the COVID-19 pandemic had resulted in quicker resolution of issues. • The Trust was moving away from the term ‘whistleblowing’ owing to the possible negative connotations of the term, in favour of ‘speaking up’. • Investigations into cases raised via the Trust’s Freedom to Speak Up service always had involvement by an individual who was independent. • There was an issue with complaints found to be untrue where the complainant was anonymous and how to handle these cases, especially in terms of where an individual was subject to an unfounded allegation of wrongdoing. • The cases raised were similar in terms of the themes as the rest of the country. • Freedom to Speak Up should be a last resort, where possible, concerns should be dealt with at the local level. • Although most cases were resolved satisfactorily, communicating the outcome could be a challenge due to the need to preserve confidentiality in respect of matters such as disciplinary processes. • Support was provided to the Trust’s Freedom to Speak Up champions, including mental health/wellbeing support where appropriate. 5.13 Fuller Inquiry Report Suzi Pike was invited to present the Fuller Inquiry Report, the content of which was noted. It was further noted that in November 2021, an independent inquiry was established to investigate how an NHS estates member of staff was able to carry out inappropriate and unlawful actions in the mortuary of Maidstone and Tunbridge Wells NHS Trust, and how and why this activity went unnoticed for so long. The inquiry was split into two phases, and this report was to provide detail of the 17 recommendations arising from the inquiry’s phase one report and the Trust’s response to these. 6. STRATEGY and BUSINESS PLANNING 6.1 CRN Wessex 2023-24 Annual Performance Report Clare Rook and Paul Grundy were invited to present the CRN Wessex 2023/24 Annual Performance Report, the content of which was noted. It was further noted that: • The network was assessed against three high-level objectives concerning recruitment onto commercial and non-commercial studies and experience survey participation rates. • The network did not meet the objective in respect of open studies, but was close to the target for non-commercial studies. The network did achieve the experience survey participation objective. • The changes in the research network were expected to result in positive opportunities, although were consuming significant amounts of time managing the HR aspects of the transition. Page 6 6.2 Board Assurance Framework (BAF) Update Lauren Anderson was invited to present the Board Assurance Framework (BAF) update, the content of which was noted. It was further noted that: • The BAF had been reviewed and updated since it was last presented to the Board in March 2024. • The likelihood rating of the Estates risk (risk 5b) had increased, resulting in an increase from 16 to 20. • Work was being carried out to further embed the Trust’s risk appetite and to link the Trust’s operational risks with the BAF. This included consideration of the creation of an intermediate, division-level risk register in order to bridge the gap between the operational and BAF risks. 7. CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Feedback from the Council of Governors’ (CoG) Meeting 1 May 2024 The Chair provided an overview of the Council of Governors’ meeting held on 1 May 2024. It was noted that the Council of Governors had considered the following matters: • A report from the Chief Executive Officer • The Trust’s 2024/25 corporate objectives • Non-NHS activity • The annual report and quality account timetable • Terms of Reference • Governor vacancies and elections • Membership engagement 7.2 Register of Seals and Chair’s Actions Report The paper ‘Register of Seals and Chair’s Actions Report’ was presented to the meeting, the content of which was noted. Decision: The Board agreed to ratify the application of the Trust Seal to the documents listed in the ‘Register of Seals and Chair’s Actions Report’. 8. Any other business There was no other business. 9. Note the date of the next meeting: 25 July 2024 10. Resolution regarding the Press, Public and Others Decision: The Board resolved that, as permitted by the National Health Service Act 2006 (as amended), the Trust’s Constitution and the Standing Orders of the board of directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. The meeting was adjourned. Page 7 List of action items Agenda item Assigned to Deadline Status Trust Board – Open Session 28/03/2024 4.14 Guardian of Safe Working Hours Quarterly Report 1127. Junior Doctors Grundy, Paul Hulbert, Diana 24/10/2024 Pending Explanation action item Paul Grundy and Diana Hulbert agreed to include an item regarding junior doctors on a future Trust Board Study Session agenda. Update: Due to industrial action on 27 June, this item has been deferred to the next TBSS on 24/10/2024. Trust Board – Open Session 06/06/2024 5.6 Performance KPI Report for Month 1 1152. Digital Teape, Joe 24/10/2024 Explanation action item JT agreed to include Digital as an agenda item at a future Trust Board Study Session. Pending Update: This item is tentatively scheduled for TBSS on 24/10/2024. Page 1 of 1 Report to the Trust Board of Directors Title: Agenda item: Sponsor: Author: Date: Purpose: Issue to be addressed: Maternity & Neonatal (MatNeo) Safety Report 2024-25 Quarter 1 (Qtr.1) 5.4.1 Gail Byrne, Chief Nursing Officer Emma Northover, Director of Midwifery and Professional Lead for Neonatal Services Jess Bown, Quality & Safety Midwifery Matron Hannah Mallon, Quality & Safety Neonatal Matron Marie Cann, MatNeo Safety Lead 25 July 2024 Assurance or reassurance  Approval Ratification Information  This report constitutes the agreed Maternity & Neonatal (MatNeo) Services Qtr.1 safety report, provides a key overview of our services in, providing assurance to the members for the following: 1. Perinatal Quality Surveillance Qtr.1 (Appendix 1) 2. Serious Incidents (Appendix 2), Learning Slide (Appendix 2a) 3. Perinatal Mortality Review Tool (PMRT) (Appendix 3) 4. ATAIN Qtr.1 Report (Appendix 4) 5. Quality & Safety Shared Learning Slide (Appendix 5 MNSI QRM) 6. Culture Score Survey 7. MatNeo Service User Feedback (Appendix 6 CQC Maternity Survey Improvement plan/Birth trauma enquiry response) 8. MNVP Update 9. Trust Claims Scorecard 10. Midwifery Staffing Report 11. Maternity Safety Champions & Quad Team Update 12. NHSR (Maternity Incentive Scheme Year 6) NB 2, 6, 7, 8, 9 & 10 are reportable as per NHSR Year 6 NB Appendices 1-6 available in iBabs Documents. Response to the issue: 1. Perinatal Quality Surveillance – Maternity Neonatal Dashboard (Appendix 1) The Maternity & Neonatal Dashboard provides a perinatal quality surveillance overview of indicators for our services. The dashboard outcomes continue to be scrutinised by the Quality and Safety Team and reported to the MatNeo Safety Champions. The following section of the report will provide an update on the key indicators. The remaining red flags on the dashboard are ‘ongoing’, with no new concerns identified. As requirements change additional indictors will be added with recent changes including: • Late fetal losses (16+0-23+6) • Intrapartum stillbirths • PROMPT obstetric emergencies training (work in progress) • Newborn Life Support (NLS) (Data coming) • Maternity Day Assessment Unit (MDAU) Triage times. Page 1 of 9 1.1 % of Bookings by 9+6 weeks (NICE recommendation) Overall compliance for Qtr.1 was  31%. The action plan discussed in the previous report has been extended to continue for 3 months, taking us until the end of July 2024. This remains as a feature (Risk 815 Red 15) on the Risk Register until further notice. NB. As a result of the action and improvement plan mentioned above the number of bookings in May was 633, which is a significant increase from 448 in April. This increase should settle now that the backlog has been cleared. April 5.8% May 30% June 58% 1.2 Timeliness of testing KPI for sickle cell and Thalassemia screening Overall compliance for Qtr.1 was 36%. This surveillance indicator is set against a national benchmark and provides the indicator for the proportion of pregnant women and birthing people having had antenatal sickle cell and thalassemia screening for whom a screening result is available ≤10 weeks + 0 days gestation. This result enables prompt partner testing and the offer of prenatal diagnostic testing if required. The improvements seen in respect to compliance levels in screening have been as a direct result of the changes made to the booking processes. We anticipate further improvements to the screening data as service changes within the self-referral team become formalised. April 6.4% May 33% June 68% The action plan discussed in the previous report has been extended to continue for 3 months, taking us until the end of July 2024. This remains as a feature (Risk 37 Red 15) on the Risk Register until further notice. To note this indicator is intrinsically linked to the % of Bookings by 9+6 weeks and as this compliance increases so will screening compliance. 1.3 Booked onto Continuity of Carer (CoC) pathway The Maternity Continuity of Care Model (MCoC) is a key model that ensures all families, particularly those most vulnerable, have safer and improved outcomes. The outcomes are as follows: • Total booked onto a CoC pathway Current rate for Qtr.1 is 13%, within the target being > 35%. • Global Majority booked onto a CoC pathway Current rate for Qtr. 1 is 23%, which has increased from 14.7% in March, target being > 51%. This workstream has additional team lead oversight to ensure we are targeting those most at risk. April 24% May 22% June 22% Page 2 of 9 • Total booked who are living in IMD1 area booked onto a CoC pathway Current rate for Qtr. 1 is 65%, these women/birthing people are being identified early to ensure they are booked onto a CoC pathway and close oversight by the senior leadership team and NEST team leads. April 41% May 56.5% June 98% 1.4 Education and Training NHSR Year 6 - Safety Action 8 asks Trusts to evidence compliance of 90% for the 3 ‘in-house’ one day multi-professional training days. The Quality and Safety Team have close oversight working with the education leads to ensure progress is maintained for training and education. The need has been identified early and provision sought for additional training days, due to increased acuity operationally and staff being redeployed to work clinically, with the additional resources we are on track to meet compliance by 30 November 2024. 1.5 Neonatal Life Support (NLS) NHSR Year 6 – Safety Action 8 also asks Trusts for evidence of compliance of 90% for neonatal life support. This is included within PROMPT for Maternity Services but is taught separately within Neonatal Services. Targeted education is planned for Autumn 2024 to ensure compliance will be met by the end of the reporting period (November 2024). The process for providing the annual NLS updates within Neonatal Services is being reviewed to apportion it across the year, which includes having an allocated time within the doctor’s induction and adding to the rolling education rota. 2 Serious Incidents (SI) including Maternity and Newborn Safety Investigations (MNSI) and PMRT cases Appendix 2 provides assurance to the members that the appropriate reporting has taken place for Qtr.1. The report includes all new MNSI cases, of which there were 2, and any PSII cases. Also providing an update on all cases closed within the same timeframe, together with any thematic learning identified. Information will also be included which relates to new and closed perinatal mortality cases even where there are no patient safety care concerns for the service to continue to be transparent. 2.1 Appendix 2 also includes a summary of the Moderate incidents reported in April/May 2024 to date. There were 2 cases closed in Qtr.1 and the learning slides featured within the last report: • MNSI 029127 case closed Trust shared learning slide • MNSI 031668 case closed Trust shared learning slide. 2.2 Appendix 2a highlights the Iodine skin prep case learning slide which has been shared with the Local Maternity and Neonatal System (LMNS), case currently an ongoing PSII. 3 Perinatal Mortality Review Tool Report (PMRT) See Appendix 3 for a summary of Qtr.1 PMRT cases and learning. The MatNeo service can confirm that there is high level oversight of reported and processed cases to ensure reviews and feedback from and to families are captured within appropriate timeframes. Page 3 of 9 Case information is reviewed at a level where the service can look to identify any themes or vulnerable groups. Learning has been identified within the information and is shared with our LMNS. 4 ATAIN Qtr.1 Report For Qtr.1 2024/25, there were a total of 41 unexpected admissions. The process for reviewing term admissions has changed and the reasons for admission have also been amended slightly. However, poor perinatal adaptation continues to be the most common reason for admission. Appendix 4 provides a deep dive into Quarter 1 admissions. 5 Quality and Safety Shared Learning Our service continues to drive quality and ensure that safe care is provided to our families. Appendix 5 provides Committee members with an overview of the key learning from the Trust’s quarterly MNSI review meeting. 6 Perinatal Culture Score Survey The Trust is holding feedback sessions with the workforce, facilitated by Korn Ferry (the Score Survey provider), looking to obtain further narrative to support and inform the Change Team (improvement leads) to ensure meaningful results and a positive improvement. 7 MatNeo Service User Feedback 7.1 Friends & Family Overall, for Qtr.1 the Friends and Family feedback continues to be above Trust target at 32.0% with 89% recommending our service. This feedback is reviewed by the senior team and any thematic concerns are identified and improvements planned. 7.2 CQC Maternity Survey Action Plan Appendix 6 outlines the Maternity Improvement Plan following the 2023 CQC Women’s Experiences of Maternity Care Survey, combined with the themes identified in the recent Birth Trauma Enquiry report. Locally we have reviewed the results and have developed an action plan to address the findings. 8 Maternity & Neonatal Voices Partnership (MNVP) Chair Update The Hampshire and Isle of Wight ICB advertised the MNVP chair role on the 24 May 2024, with the closing date of 7 July 2024, subject to recruitment the Trust hopes to have a chair in place soon to support the MatNeo Service to ensure the patient voice is heard and service user engagement in shaping our MatNeo service. 9 Trust Claims Scorecard Qtr.1 Claims Scorecard will be reviewed by the Safety Champions and targeted interventions aimed at improving patient safety would be developed. This will come to the Quality Committee in August for noting as per NHSR Year 6 reporting requirements. Page 4 of 9 10 Midwifery Staffing Report 10.1 A clear breakdown of BirthRate Plus (BR+) or equivalent calculations to demonstrate how the required establishment has been calculated In line with national drivers for assurance in relation to safe staffing levels within maternity services, UHS Maternity Services currently utilise BirthRate Plus (BR+) as a system and framework for workforce planning and strategic decision making. The last assessment of UHS Maternity Services by BR+ in 2018 suggested an overall clinical establishment based on a midwife V birth ratio of 1:24, calculated against an annual birth rate of 5500 births. At the time, the required total establishment as calculated by BR+ to ensure safe staffing levels equated to 226.55 WTE which was inclusive of support staff contribution. UHS recently commissioned a revised BR+ review in March 2024. Whilst we await our final report, early indicators show our service to be operating in a staffing deficit, which indeed feels accurate on a day-to-day basis. Despite a lower birthrate in 23/24 of around 5000, the growing complexity of maternity calls for more input and midwifery care hours throughout pregnancies across the service, whilst also increasingly requiring wider MDT input. Birthrate Plus data shows that UHS continues to see a higher than average case mix with 77% of people falling within the highest acuity / care requirement categories compared to 68% in 2018. In July 2023, we saw a peak in this activity where 91% of women / birthing people delivered on our labour ward or in theatre. This rate has continued into 2024 with the average only falling to around 88% each month. Our normal birth rate has stabilised with an average of 45% however the rising trend we have seen over the last 12 months in caesarean section births, continues to be high and consistently account for over 40% of all births in our service. 10.2 In line with Midwifery staffing recommendations from Ockenden, Trust Boards must provide evidence of funded establishment being compliant with outcomes of BirthRate+ or equivalent calculations Over the last 3 years, UHS Maternity Services have at times been working with midwife V birth ratios that are more suggestive of 1:27. This has felt uncomfortable but with contingency frameworks in place, the service has remained safe. With a vacancy rate of 22.49 WTE currently for registered staff we are presently operating a 1:29 midwife V birth ratio. This situation is further compounded by short-term sickness, an increased national demand for education and training and a high maternity leave rate of 9%. This inevitably results in a workforce that is significantly overstretched carrying an overall headroom percentage of 31%. We have increased staff support in the clinical environment in addition to pastoral and psychological support to enhance retention of the workforce. We are pleased to say that with this initiative, we have retained 100% of our newly qualified preceptees who started with us in November 2023. UHS Maternity Services has a very detailed, robust escalation and contingency plan which is activated when the service is under pressure to maintain safety and improve maternal and neonatal outcomes. The leadership team, including the Director of Midwifery, commit to a high number of out of hours on calls to support the service when in escalation and when staffing does not match the acuity and activity across the acute clinical areas. Page 5 of 9 Whilst effective in bridging gaps for the most part, this is not a sustainable way of working and it is resulting in burnout across the midwifery leadership team. 10.3 Where Trusts are not compliant with a funded establishment based on BirthRate+ or equivalent calculations, Trust Board minutes must show the agreed plan, including timescale for achieving the appropriate uplift in funded establishment. The plan must include mitigation to cover any shortfalls In support of the BR+ acuity tool, UHS Maternity Services have developed a systematic process for workforce planning in the form of a monthly dashboard. This live data is reflective of total staff unavailability to include vacancy rates, sickness ratios, maternity leave, and study time, all of which is compared alongside the budgeted versus actual staffing establishment overall. The data recorded within the monthly dashboard is lifted directly from maternity Erostering and ESR systems. As such the staffing ratios are recorded in real time and will represent staffing levels in their most accurate form. The monthly dashboard not only records an accurate position for midwifery staffing at the current time but also offers a projected forecast for staff unavailability in the months going forward. This ensures and supports an ongoing process for rolling recruitment, involving both qualified and unqualified staff groups. Utilising the dashboard in this way will see the Maternity Service reduce the current vacancy rate down from a predicted 26.58WTE in October 2024 to fully recruited as per our current funded establishment by 1st February 2025, assuming that we are able to maintain engagement from all our new recruits. With national evidence directly linking reduced midwifery staffing levels and poor maternity and neonatal outcomes for families, recruitment to clinical maternity roles, both registered and unregistered has been supported by the Trust Board and prioritised at recruitment panels. With this support, Maternity Services have continued to recruit to vacant posts and following a successful newly qualified midwife recruitment drive, we are expecting 34WTE B5 midwives to join UHS Maternity Services on our preceptorship programme in November 2024. Recognising the level of support that our new colleagues will need, and to create a balanced skill mix across our workforce, we also have a rolling B6 recruitment process which is returning a steady stream of experienced B6 midwives also joining our service. 10.4 Midwifery red flag reporting – Evidencing compliance that all women / birthing people receive 1:1 midwifery care in active labour and the protected supernumerary status of the labour ward coordinator UHS Maternity Services record our staffing V acuity data every 4 hours across the intrapartum areas using the BR+ tool. Within our staffing template the labour ward coordinator is rostered and protected to maintain a supernumerary status at all times. This standard is achieved and maintained across the entirety of every shift, not just the start which is the reportable required standard. The skillset of this staff group is pertinent to the safe running of the labour ward, our most acute and high risk clinical area. The table below offers assurance to the Trust Board that UHS Maternity Services consistently meet this safety standard with no red flag events recorded for the whole of 2023 and to date in 2024. The labour ward coordinator team recognise the specialist nature of their role and reliably respond to cover unexpected vacant shifts. Across our operational Page 6 of 9 and leadership teams, we have staff who also hold the labour ward coordinator skillset as a dual or previous role which offers extra flexibility and redeployment options at times where a substitute coordinator may be required. At UHS, the labour ward coordinator does not take responsibility for any patients nor do they cover breaks for other members of staff enabling them to have continuous oversight of their clinical environment. Red Flag Report - Labour Ward (scheduled assessments only) Red Flag Red Flag Description 2023 total Jan Feb Mar Apr May Any occasion when 1 midwife is not able to provide continuous RF9 one-to-one care and 0 0000 0 support to a woman during established labour RF10 Labour ward coordinator not supernumerary status 0 0000 0 Red Flag Report - Broadlands (scheduled assessments only) Red Flag Red Flag Description 2023 total Jan Feb Mar Apr May Any occasion when 1 midwife is not able to provide continuous RF9 one-to-one care and 0 00 0 0 0 support to a woman during established labour Another red flag that is closely monitored and reportable to the Trust Board as a measure of good practice is the assurance that all women / birthing people receive 1:1 care in active labour across all birth environments. At UHS Maternity Services we respond quickly and effectively to the fast paced, unpredictable nature of intrapartum care and evoke our maternity escalation plan to source additional midwives for intrapartum care. Currently midwives are redeployed often to meet the needs of the service which can cause uncertainty and frustration for them at times. Morale and job satisfaction levels are low amongst midwives who are continuously called upon for support, however all would agree that safe care is the priority. It is only through this escalation that we continue to provide safe care to the women / birthing people accessing our service in the right place, at the right time and by the right people. If we cannot provide 1:1 care in active labour, UHS Maternity Services will declare the highest level of escalation, OPEL 4, and look to divert incoming people in labour to neighbouring Trusts across the region. Since the start of 2024, UHS Maternity Services have escalated to OPEL 4 on 23 occasions. Across the whole of 2023 OPEL 4 was declared 28 times. This is a significant and stark increase in service pressure that our Maternity Service Page 7 of 9 is experiencing with staffing and acuity accounting for the majority of cases. Whilst we report that we are compliant with providing 1:1 care in active labour and we are safe, we are seeing an increase in other reportable red flags such as delays in induction and being unable to facilitate birthplace choices. 10.5 Maternity Workforce Development – Next Steps/Way Forward Over the last year, an extensive listening exercise has taken place to help inform the future direction and structure of the Maternity Service workforce. To align with current service needs, and with staff wellbeing as a central focus, the Director of Midwifery and Midwifery Senior Leadership Team are reviewing the way the service is delivered with the potential of a workforce restructure. Ensuring that an appropriately skilled practitioner is available to meet service demands in the most responsive and efficient way remains pivotal in the success of this potential project. This will be pertinent to models and pathways of care provision, operating both in and out of the hospital setting, including homebirth and intrapartum services within our low-risk birth centres. Drivers around flexible working, retention and restorative practice will all underpin the direction and future of the way in which we work. In terms of strategic workforce planning, there is currently a significant focus around the issue of supply and demand for maternity staff, particularly registered midwives. Some options for workforce development see alternative training pathways for health care workers who previously may not have benefitted from such openings and include shortened midwifery conversion courses for registered nurses, return to practice midwifery courses, midwifery apprenticeship models and foundation programmes for aspiring maternity support workers. It is anticipated that by broadening the gateway into careers within maternity services, whilst allowing training and education to be both accessible and affordable, a wider audience of prospective candidates will be achieved. In these current times where maternity workforce tensions are so prominent, we recognise that succession planning is of prime importance, and therefore are busy creating new opportunities for staff upskilling and professional development. UHS Maternity Services are committed to investing in their people and as such have dedicated programmes for career development starting at band 2 and progressing to band 9. Our prime focus is to consider new ways in which we can future proof our maternity services going forward, whilst investing wholly in the health and wellbeing of our existing workforce. 11 Maternity & Neonatal Safety Champions & Quad Team Update Safety Champions Gail Byrne (Exec) Tim Peachey (Non-Exec) Victoria Puddy (Neonatal) Jillian Connor (Obstetric) Marie Cann (Midwifery) QUAD Bala Thyagarajan (Care Group Clinical Lead) Ganga Verma (Obstetric Clinical Lead) Hannah Kedzia (Care Group Manager) Marie Cann (Midwifery) The Safety Champions and Quad met on the 1 May 2024 for a joint meeting and safety walkabout of the service. There were no additional concerns or actions identified, just the ongoing challenges around staffing and estates recognised. Page 8 of 9 12 NHSR – Maternity Incentive Scheme year 6 The last Quality Committee report provided an exception report for the 10 safety actions. The Trust met with the LMNS on the 27 June 2024 for the first quarterly review meeting, to assess progress against the 10 safety actions, and the trajectory for complete submission is on track. The next review meeting is planned for August, to review progress, ahead of end of the reporting period on the 30 November 2024. Implications: (Clinical, Organisational, Governance, Legal?) The risk implications for the UHS Trust and MatNeo services sit within several frameworks including: • Reputational – Safety concerns can be raised by the public to both NHS Resolution and the CQC. • Financial – Compliance with NHS Resolution Maternity Safety Actions to meet all ten safety actions remains to be an expectation for maternity safety requirements. • Governance – Safety concerns can be escalated to the Care Quality Commission for their consideration and to NHS England, the NHS Improvement Regional Director, the Deputy Chief Midwifery Officer, the Regional Chief Midwife. • Safety - Non-compliance with requirements or recommendations would have a detrimental impact on the women and their families leading to increased poor outcomes and staff wellbeing. MNSI can raise concerns regarding the safety of MatNeo services and instigate reviews. Risks: (Top 3) of Top Risks: carrying out the • 788 (Red) Elective theatre capacity change / or not: • 258 (Red) Maternity staffing • 259 (Red) Capacity and demand in Maternity services • 260 (Red) MDAU • 262 (Red) Induction of Labour Summary: This Qtr.1 MatNeo services safety report provides an overview of the key safety Conclusion workstreams and aims to provide committee members with the actions and and/or mitigations in place to improve areas of significant concern. The report recommendation: encompasses the perinatal quality surveillance minimum requirements and aims to fulfil the reporting requirements for NHSR MIS year 6. The report will continue to be adapted and responsive to safety concerns or issues within our service providing assurance around safety improvements impacting our families, services and staff. The MatNeo dashboard provides the board with the Perinatal Quality Surveillance information and will continue to be refined to provide a platform for clear oversight of key outcomes and measures. We continue to work on ways to ensure the dashboard clearly highlights any action and improvement plans where areas of risk have been identified. The information provided is for assurance and reassurance, whilst meeting the requirements of NHSR Year 6, and highlights the safety improvement work and learning from all aspects of the services including serious incident and MNSI cases. We ask members to continue to support the MatNeo Services and provide monitoring and scrutiny as required. Page 9 of 9 Report to the Trust Board of Directors Title: Agenda item: Sponsor: Date: Purpose: Issue to be addressed: Response to the issue: Chief Executive Officer’s Report 5.5 David French, Chief Executive Officer 25 July 2024 Assurance Approval or reassurance Ratification Information X My report this month covers updates on the following items: • General Election • COVID-19 Inquiry • Forgotten Generation • Ligature Risk • Care Quality Commission • Haemophilia Treatment • LIMS system The response to each of these issues is covered in the report. Implications: Any implications of these issues are covered in the report. (Clinical, Organisational, Governance, Legal?) Summary: Conclusion The Board is asked to note the report. and/or recommendation Page 1 of 5 General Election On 4 July 2024, the UK’s general election result was a clear mandate for the Labour party, returning 412 Members of Parliament which represents a 174-seat majority. Labour’s manifesto commitments in terms of health included: • Using spare capacity in the independent sector to ensure that patients are diagnosed and treated more quickly. • Reform of the NHS to ensure that mental health is given the same attention and focus as physical health. • Modernising the Mental Health Act to address treatment of people with autism and learning difficulties, and racial inequalities perpetuated by the Act. • Implement professional standards and regulate NHS managers. • Set an explicit target to close the black and Asian mortality gap. • Implement the expert recommendations of the Cass Review, the independent review of gender identity services. • Ensure the publication of regular, independent workforce planning across he
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Trust-governance-and-corporate-docs/2024-Trust-documents/Papers-Trust-Board-25-July-2024.pdf

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/Microsof
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