A A AText only | Accessibility | Privacy and cookies

Browse site A to Z

Search results

Go To Simple Search

Gender pay gap report 2023

Description
Gender Pay Gap. Our Gender Pay Gap at a Glance Snapshot from 31st March 2023 Our mean average gender pay gap at UHS has reduced by 6.4% since 2017. The Context This is the 7th year of reporting our Gender Pay Gap (GPG). We continue to work hard to support the development of our people in their chosen roles, and have been committed to work on our recruitment processes to ensure they are fair, inclusive and transparent. Our Gender Pay Gap is decreasing, and over the last 6 years we have seen a reduction of 6.4%. Our data highlights a difference in the gender pay gap dependant on the role. As last year, we have analysed the data so we can see the differences between those who are on Agenda for Change contracts, those who are on Medical, Dental and VSM contracts, as this helps us identify where to focus our efforts. It is important to note that sex and gender are terms that are often used interchangeably but they are in fact two different concepts. The World Health Organisation describes sex as characteristics that are biologically defined and identified at birth, whereas gender is based on socially constructed features and is a personal, internal perception of oneself. It is sex that is protected under the Equality Act 2010. We recognise that an individual can identify as more than male or female, but as the GPG mandates the use of male and female as comparators, it therefore may not be representative of everyone at UHS. 26.04% 73.96% 21.72% (£5.31 p/h) Our Workforce Our Mean Gender Pay Gap People who identify as female make up the majority of our workforce This is an average of the difference between the female and male hourly rate of salary. This has decreased from 23.33% the year before. 12.05% (£2.36 p/h) Our Median Gender Pay Gap This is the middle value of the difference between the female and male. This has increased slightly from 11.42% the year before. Full time staff 64.43% of staff are full time Of our full time staff 33.36% identify as male 66.64% identify as female Part time staff 35.57% of staff are part time Of our part time staff 10.63% identify as male 89.37% Identify as female Gender Pay Gap. Our Gender Pay Gap by Quartile Snapshot from 31st March 2023 61.92% 38.08% 77.93% 22.07% Upper Quartile Upper Middle 78.00% 22.00% 77.97% 22.03% Lower Middle Lower Quartile The proportions of male and female full-pay relevant employees across the different pay bands. Gender pay reporting aims to show the difference in average pay and bonus payments between male and female staff. *Bonus payments are Clinical Excellence Awards or Clinical Impact Awards. Our Mean Bonus Pay Gap 31.26% The difference between the mean bonus pay between males and females is weighted in favour of males. (For those eligible) Our Median Bonus Pay Gap 33.33% The difference between the median bonus pay paid to males and females is weighted in favour of males. (For those eligible) Gender Pay Gap. Our Workforce in detail White Staff 70.59% LGBTQIA+ Staff 3.78% Currently we do not formally report on the sexual orientation of staff in relation to GPG, but our existing data shows that Black and Under represented Ethnic Staff 26.72% Of this staff group 21.95% identify as male and 78.05% 3.78% of staff identify as either Bisexual, Gay, Lesbian or other sexual orientation identify as female Of this group 33.44% identify as male and 66.56% identify as female Staff with a long-term health condition or disability Of this group 79.81% identify as female and 20.19% identify as male 11.57% Intersectionality We know that gender pay gap is about more than just gender. When we analyse our data we consider the diversity of our workforce. The gender pay gap can also be impacted by protected characteristics and wider intersectionality. On the next page we will look at the gender pay gap using different staff groups such as those on Agenda for Change contracts, Medical and Dental as well as Trust Board. Gender Pay Gap. Through the lens of Agenda for Change Agenda for Change When we analyse the pay for those on Agenda for Change (AfC) contracts we see there is a much smaller pay gap between men and women of 0.58%, which equates to a difference of £0.10. This is a small increase on last year (0.48%, £0.08). The mean gender pay gap for AfC staff favours males in bands 1, 8c and 8d (some of the lowest and highest earning bands). It is important to note that NHS terms and conditions determine the pay structure for those on Agenda for Change contracts. The Job Evaluation system matches job roles to nationally agreed profiles and pay bands. Pay increases in each band are determined by the length of service, and pay rises occur when an individual reaches a "pay step". When the top of the pay band is reached, there are no further rises in that pay band. Fact: Nurses make up the majority of the AfC clinical workforce at UHS. Entry level is Band 5, accounting for the larger proportion of females in Band 5 and 6. Historically we have seen more females than males in this profession although this is changing! Mean GPG Gender by AfC band Differen Band Female Male % Gap ce 1 £12.33 £12.81 £0.47 3.69% 2 £12.20 £12.08 -£0.12 -1.02% 3 £11.89 £11.68 -£0.21 -1.77% 4 £13.36 £12.99 -£0.37 -2.85% 5 £17.30 £17.01 -£0.29 -1.71% 6 £19.99 £19.37 -£0.63 -3.23% 7 £23.46 £22.66 -£0.81 -3.57% 8a £25.66 £25.68 £0.01 0.06% 8b £30.36 £29.29 -£1.07 -3.66% 8c £35.05 £36.25 £1.20 3.32% 8d £42.00 £42.80 £0.81 1.88% 9 £51.76 £50.14 -£1.62 -3.22% All AfC Staff £17.37 £17.47 £0.10 0.58% Band 1 2 3 4 5 6 7 8a 8b 8c 8d 9 Female Head Count 10 1486 1083 820 2084 1736 1077 355 109 53 18 6 Male Head Count 16 471 199 234 536 391 257 128 56 24 18 11 We continue to notice a steady decline in our AfC gender pay gap. However, female representation in the senior levels of our organisation still needs to be improved (Band 9 and above). On the next page we will look at the gender pay gap between our Medical & Dental staff. Gender Pay Gap. Our mean average gender Looking at Medical and Dental Staff Mean GPG Gender by Medical Grade pay gap for medical and Medical and Dental T&C's Medical Grade FY1 Female Male Difference %Gap £15.69 £15.59 -£0.11 -0.68% Medical Grade FY1 Female Male Head count Head count 40 31 dental staff has reduced by 2% since 2022. FY2 £18.44 £18.56 £0.12 0.65% FY2 46 The Medical and Dental (M&D) Terms and Conditions ST1/2 £22.69 £22.32 -£0.37 -1.65% ST1/2 170 work in a similar way to AfC, by providing a framework ST3+ £29.77 £29.39 -£0.38 -1.28% designed to deliver the principle of equal pay. ST3+ 270 In 2016, the national contract for medical staff in SAS £35.56 £39.01 £3.46 8.86% training (Junior Doctors) was re-negotiated. Our trust SAS 50 fellows are included alongside their equivalent in- Consultants £51.77 £54.84 £3.07 5.60% training colleagues. All Medical Consultants 337 £35.65 £39.89 £4.25 10.64% Our M&D staff analysis, shows a move in the right Staff direction with a gender pay difference of 10.64%, a decrease from 12.63% in 2022. The History The data in the tables show how the pay gap varies across the grades, the largest gap appears between Specialty Doctors and Consultants. These numbers include the fellows as well as deanery trainees. In 2024... UHS signed the sexual safety in the workplace charter and will progress projects in specific areas to challenge existing behaviours that may be unfavourable for women Historically, males have dominated the Consultant workforce. This is largely due to less females being recruited as students to medical school, as well as societal factors such as females traditionally having taken career breaks, or been carers and this has led to more female doctors working less than full time to balance family life and child care. For some this has resulted in barriers to progression. However, things are changing. The introduction of policies around maternity and paternity leave, and more inclusive working practices has brought more flexibility around family life and career choices. 58 134 280 29 494 Our Reality There is general recognition that the medical profession still has some way to go to be truly inclusive. The historical context, and legacy working conditions, as we are seeing take a long time to change. This impacts on our ability to make progress at pace in order to decrease the gender pay gap within Medical and Dental Consultant body. However, this will change as more women progress in the profession. Gender Pay Gap. Meaningful changes for Medical and Dental Staff So What? We are not content with reviewing the GPG data each year and hoping that things will change with time. Our "Always Improving" value is the driver for all our priorities and actions. We plan to review each increment pay scale so we can use this data to identify any further actions to improve the GPG. UHS remain committed to the positive interventions introduced over the past 12 months with the aim of improving the GPG over time in line with the UHS Inclusion and Belonging strategy. Looking ahead for 2024 Ideas from our Women's Network Dedicated positive action programmes for leadership and development Mentoring and coaching for Local responses to staff survey female consultants results where female experience is less Deliver the principles of than for male the Sexual Safety in the Workplace Charter Support and mentorship for Clinical Excellence Award applications Women's Network continue to champion GPG activity and empower women of UHS Gender Pay Gap. The Trust Board The Exec Gender Pay Gap From the top Pay for those on Executive contracts is not subject to national banding but is subject to annual review and approval by the Trust Remuneration & Appointments Committee. It is important to note that Exec pay is also inclusive of CIA's and CEA's which does impact the Gender Pay Gap. Salaries are determined by a range of factors including nationally benchmarked NHS pay rates set out by NHS Improvement (the NHS Trusts performance and governance regulator), job evaluation and market forces analysis. We do not include our Non-Executive Directors in our analysis due to the nature of their employment terms with UHS. These are not employees of the Trust and are not required to be included in the reporting analysis. There are 6 members on the Trust Board, with a mean pay gap of 8.66% (median 9.53%). Mean Median Female Hourly Rate £87.81 £87.81 Male Hourly Rate £96.13 £97.06 Difference £8.32 £9.25 %Gap 8.66% 9.53% The Plan Females remain under represented in our very senior roles. However, we have invested in the development of our future leaders and our inclusive working practices; early indications suggest we are beginning to see this change. We want females to experience a "level playing field" and we are committed to removing potential barriers for females in very senior roles. Our Executive team remain committed to improvements as set out in our People Strategy, and the work programmes which will deliver our Inclusion and Belonging Strategy. Gender Pay Gap. Our commitment to Equality, Diversity and Inclusion Our ambition Our aim is to be the recognised employer and educator of choice in the South and to empower all staff to recognise their full potential. As part of our commitment to creating a culture of inclusion and belonging; we strive to provide equal opportunities, eliminate discrimination and foster good relations in our activities as an employer, service provider and partner in line with the Public Sector Equality Duty. The Trust-wide measures we are taking are set out in more detail in our Inclusion and Belonging Strategy.
Url
/Media/UHS-website-2019/Docs/About-the-Trust/Equality-reports/Gender-pay-gap-report-2023.pdf

Gender Pay Gap Report 2025

Description
Gender Pay Gap. Our Gender Pay Gap at a Glance Snapshot from 31st March 2025 The Context This is the 8th year of reporting our Gender Pay Gap (GPG). We continue to work hard to support the development of our people in their chosen roles, and have been committed to work on our recruitment processes to ensure they are fair, inclusive and transparent. As an NHS Trust, we adhere to the national pay frameworks and policies. Our Gender Pay Gap has been decreasing year on year, however the mean pay gap has increased since 2024 by 1.25% to 21.75% in favour of Males. Analysis of this shows the increase isn’t driven by changes to base pay or hours worked but due to men being disproportionately represented in the highest paid roles, particularly senior medical roles. Even small increases in male representation here will materially widen the mean and median pay gap. The gap is being pulled towards the top of the distribution. A note about language: In April 2025, the UK Supreme Court gave judgement in the case of Scottish Women vs Scottish Government and clarified protections of Sex and Gender Reassignment under the Equality Act 2010. Whilst this report is known as the Gender Pay Gap, when Male and Female is referred to in this report, it is the biological sex they were born with, not their preferred or acquired gender. We recognise that an individual can identify as more than male or female, but as the GPG mandates the use of male and female as comparators, it therefore may not be representative of everyone at UHS. 25.98% 74.02% 21.75% (£6.17 p/h) Our Workforce Our Mean Gender Pay Gap People who identify as female make up the majority of our workforce This is an average of the difference between the female and male hourly rate of salary. This is a 1.25% increase from 2024 following a year on year decrease since reporting began. Full time staff 61.22% of staff are full time Of our full time staff 26.35% identify as male 73.65% identify as female 12.77% (£2.92 p/h) Our Median Gender Pay Gap This is the middle value of the difference between the female and male. Part time staff 38.78% of staff are part time Of our part time staff 25.39% identify as male 74.61% Identify as female Gender Pay Gap. Our Gender Pay Gap by Quartile Snapshot from 31st March 2025 Our Mean Bonus Pay Gap 31.03% The difference between the mean bonus pay between males and females is weighted in favour of males. (For those eligible) Our Median Bonus Pay Gap 61.78% 38.22% 78.33% 21.67% Upper Quartile Upper Middle 76.77% 23.23% 78.44% 21.56% Lower Middle Lower Quartile The proportions of male and female full-pay relevant employees across the different pay bands. When we analyse the data, pay gaps are not significant for males and female with Agenda for Change contracts. The gap is within our Medical and Dental workforce, specifically in additional awards/bonus pay. 26.83% The difference between the median bonus pay paid to males and females is weighted in favour of males. (For those eligible) A note about medical awards/bonus pay: Clinical Excellence Awards (CEAs) were awarded for clinical excellence by application up to 1 April 2024 when the process closed. The individuals who were awarded up to that date retain their CEA until the end of their contract at the same level originally awarded. CEAs have now been replaced by the National Clinical Impact Awards (NCIAs). Gender Pay Gap. Our Workforce in detail White British 63.57% LGBTQIA+ 3.72% Currently we do not formally report on the sexual orientation of staff in relation to GPG, but our existing data shows that Black, Asian or other global ethnicities Of this staff group 3.72% of staff identify as either Bisexual, Gay, Lesbian or other sexual orientation 33.86% 25.96% are male and 74.04% are female Of this group 36.98% are male and 63.02% are female Staff with a long-term health condition or disability 11.53% Of this group % are 83% female and 17% are male Note: Workforce percentages do not total 100% as “not stated or unspecified” are not included Pay gaps aren’t just about sex and gender We know that implications on pay and pay gaps is more than just related to a person’s sex. When we analyse our data we consider the diversity of our workforce as a whole. We also carry out ethnicity and disability pay gap analysis. Pay gaps can also be impacted intersectionality, by organisational structural issues, and bias. Gender Pay Gap. Looking closer at Medical and Dental Staff Mean GPG Gender by Medical Grade Our mean average gender pay gap for medical and Medical Grade Female Male Difference %Gap Medical Grade Female Male Head count Head count dental staff has reduced by Medical and Dental T&C's FY1 £19.26 £19.41 £0.15 0.77% FY1 51 35 FY2 £23.22 £23.10 -£0.12 -0.52% FY2 50 38 1.94% since 2022. The Medical and Dental (M&D) Terms and Conditions ST1/2 £28.29 £27.95 -£0.34 -1.22% ST1/2 186 work in a similar way to AfC, by providing a framework ST3+ £36.03 £35.94 -£0.09 -0.25% designed to deliver the principle of equal pay. ST3+ 327 In 2016, the national contract for medical staff in SAS £48.14 £51.04 £2.90 5.68% training (Junior Doctors) was re-negotiated. Our trust SAS 20 fellows are included alongside their equivalent in- Consultants £61.46 £64.47 £3.01 4.67% training colleagues. All Medical Consultants 354 £42.42 £47.50 £5.08 10.69% Our M&D staff analysis, shows a move in the right Staff direction with a gender pay difference of 10.69%, a decrease from 12.63% in 2022. The History The data in the tables show how the pay gap varies across the grades, the largest gap appears between Specialty Doctors and Consultants. These numbers Historically, males have dominated the Consultant workforce. This is largely due to less females being recruited as students to medical include the fellows as well as deanery trainees. school, as well as societal factors such as females traditionally having taken career breaks, or been In 2024... UHS signed the sexual safety in the workplace charter and will progress projects in specific areas to challenge existing behaviours that may be unfavourable for women carers and this has led to more female doctors working less than full time to balance family life and child care. For some this has resulted in barriers to progression. However, things are changing. The introduction of policies around maternity and paternity leave, and more inclusive working practices has brought more flexibility around family life and career choices. 156 300 9 495 Our Reality There is general recognition that the medical profession still has some way to go to be truly inclusive. The historical context, and legacy working conditions, as we are seeing take a long time to change. This impacts on our ability to make progress at pace in order to decrease the gender pay gap within Medical and Dental Consultant body. However, this will change as more women progress in the profession. Gender Pay Gap. Looking ahead for 2026 So What? At UHS, we remain committed to identifying gaps in pay exist, what might be causing them, and seeking ways to reduce or eliminate the gap. Our Always Improving value continues to drive our priorities and actions. We continue to implement the workstreams in our Inclusion and Belonging Strategy, specifically focussed on recuitment, talent, and eliminating bias from our organisational structures. Our Positive Action programmes are seeking to address any disparity in representation in the workforce, and in 2026 we are undertaking a succession planning and talent programme within our senior leadership cohort, which will identify the demographic of the current workforce and take action to address any disparity of representation, pay, or experience. Dedicated positive action programmes for leadership and development Mentoring and coaching for female Consultants Deliver the principles of the Sexual Safety in the Workplace Charter Local responses to staff survey results where female experience is less than for male Women's Network continue to champion and empower and support women Gender Pay Gap. Our commitment to Equality, Diversity and Inclusion Our ambition Our aim is to be the recognised employer and educator of choice in the South and to empower all staff to recognise their full potential. As part of our commitment to creating a culture of inclusion and belonging; we strive to provide equal opportunities, eliminate discrimination and foster good relations in our activities as an employer, service provider and partner in line with the Public Sector Equality Duty. The Trust-wide measures we are taking are set out in more detail in our Inclusion and Belonging Strategy.
Url
/Media/UHS-website-2019/Docs/gender-pay-gap-report-2025.pdf

UPL gender pay gap report 2024

Description
Gender Pay Gap. Our Gender Pay Gap at a Glance Snapshot from 5th April 2024 The Context This is the first year of reporting our Gender Pay Gap (GPG). We continue to work hard to support the development of our people in their chosen roles, and have been committed to work on our recruitment processes to ensure they are fair, inclusive and transparent. Our Gender Pay Gap shows a -34.44% mean average difference, meaning that females are earning more than males at UPL. Our data highlights that on average females are earning £5.44 an hour more than their male counterparts. It is important to note that sex and gender are terms that are often used interchangeably but they are in fact two different concepts. The World Health Organisation describes sex as characteristics that are biologically defined and identified at birth, whereas gender is based on socially constructed features and is a personal, internal perception of oneself. It is sex that is protected under the Equality Act 2010. We recognise that an individual can identify as more than male or female, but as the GPG mandates the use of male and female as comparators, it therefore may not be representative of everyone at UPL. 27.27% 72.73% Our Workforce People who identify as female make up the majority of our workforce. -34.44% (-£5.44 p/h) Our Mean Gender Pay Gap This is an average of the difference between the female and male hourly rate of salary. Females in UPL are on average earning £5.44 an hour more than males. -14.46% (-£1.74 p/h) Our Median Gender Pay Gap Our Gender Pay Gap by Quartile Snapshot from 5th April 2024 This is the middle value of the difference between the female and male. As this is the first year that UPL are reporting their gender pay gap, the intention is to review the data and engage management teams/board with planning actions in response. 100% 0% 66.67% 33.33% Upper Quartile Upper Middle 33.33% 66.67% 100% 0% Lower Middle Lower Quartile The proportions of male and female full-pay relevant employees across the different pay bands. This is the first year that UPL have reported their gender pay gap. Our Mean Bonus Pay Gap -115.59% The difference between the mean bonus pay between males and females is weighted in favour of females. (For those eligible) Our Median Bonus Pay Gap -50.25% The difference between the median bonus pay paid to males and females is weighted in favour of females. (For those eligible)
Url
/Media/UHS-website-2019/Docs/About-the-Trust/Equality-reports/UPL-gender-pay-gap-report-2024.pdf

WPL gender pay gap report 2025

Description
Gender Pay Gap. Our Gender Pay Gap at a Glance Snapshot from 5th April 2025 This is the second year that WPL have reported their gender pay gap. The Context This is the second year of reporting our Gender Pay Gap (GPG). We continue to work hard to support the development of our people in their chosen roles, and have been committed to work on our recruitment processes to ensure they are fair, inclusive and transparent. Our Gender Pay Gap shows a 0.53% mean average difference, meaning that males are earning more than females at WPL. Our data highlights that on average males are earning 0.09p an hour more than their female counterparts. It is important to note that sex and gender are terms that are often used interchangeably but they are in fact two different concepts. The World Health Organisation describes sex as characteristics that are biologically defined and identified at birth, whereas gender is based on socially constructed features and is a personal, internal perception of oneself. It is sex that is protected under the Equality Act 2010. We recognise that an individual can identify as more than male or female, but as the GPG mandates the use of male and female as comparators, it therefore may not be representative of everyone at WPL. 61.23% 38.77% Our Workforce 0.53% (£0.09 p/h) Our Mean Gender Pay Gap This is an average of the difference People who identify as male between the female and male hourly make up the majority of our rate of salary. Males in WPL are on workforce. average earning 28p an hour more than females. Our Gender Pay Gap by Quartile Snapshot from 5th April 2025 -16.73% (-£2.19 p/h) Our Median Gender Pay Gap This is the middle value of the difference between the female and male. There are 98 employees at WPL As this is the second year that WPL are reporting their gender pay gap, the intention is to review the data and engage management teams/board with planning actions in response. 21.74% 78.26% 0% 100% Upper Quartile Upper Middle 46.67% 53.33% 45.83% 54.17% Lower Middle Lower Quartile The proportions of male and female full-pay relevant employees across the different pay bands.
Url
/Media/UHS-website-2019/Docs/wpl-gender-pay-gap-report-2025.pdf

UEL gender pay gap report 2025

Description
Gender Pay Gap. Our Gender Pay Gap at a Glance Snapshot from 5th April 2025 This is the second year that
Url
/Media/UHS-website-2019/Docs/About-the-Trust/Equality-reports/UEL-gender-pay-gap-report-2025.pdf

WPL gender pay gap report 2024

Description
Gender Pay Gap. Our Gender Pay Gap at a Glance Snapshot from 5th April 2024 This is the first year that
Url
/Media/UHS-website-2019/Docs/About-the-Trust/Equality-reports/WPL-gender-pay-gap-report-2024.pdf

UEL gender pay gap report 2024

Description
Gender Pay Gap. Our Gender Pay Gap at a Glance Snapshot from 5th April 2024 This is the first year that
Url
/Media/UHS-website-2019/Docs/About-the-Trust/Equality-reports/UEL-gender-pay-gap-report-2024.pdf

UPL gender pay gap report 2025

Description
Gender Pay Gap. Our Gender Pay Gap at a Glance Snapshot from 5th April 2025 UHS Pharmacy LTD is a subsidiary
Url
/Media/UHS-website-2019/Docs/upl-gender-pay-gap-report-2025.pdf

Gender pay gap report

Description
UHS's full gender pay gap report is now available to read.
Url
/AboutTheTrust/Newsandpublications/Latestnews/2018/March-2018/Gender-pay-gap-report.aspx

Papers Trust Board 27 May 2021

Description
Date Time Location Chair Agenda Trust Board – Open Session 27/05/2021 9:00 - 13:00 Microsoft Teams Peter Hollins 1 Chair’s Welcome, Apologies and Declarations of Interest 9:00 To note apologies for absence, and to hear any declarations of interest relating to any item on the Agenda. 2 Staff Story The patient or staff story provides an opportunity for the Board to reflect on the experiences of patients and staff within the Trust and understand what the Trust could do better. 3 Minutes of Previous Meeting held on 30 March 2021 9:15 4 Matters Arising and Summary of Agreed Actions To discuss any matters arising from the minutes, and to agree on the status of any actions assigned at the previous meeting. 5 QUALITY, PERFORMANCE and FINANCE Quality includes: clinical effectiveness, patient safety, and patient experience 5.1 Briefing from the Chair of the Charitable Funds Committee (Oral) 9:25 Dave Bennett, Chair 5.2 Briefing from the Chair of the Finance and Investment Committee (Oral) 9:30 Dave Bennett, Chair 5.3 Briefing from the Chair of the Quality Committee (Oral) 9:35 Tim Peachey, Chair 5.4 Chief Executive Officer's Update (Oral) 9:40 Sponsor: David French, Chief Executive Officer 5.5 Integrated Performance Report for Month 1 10:00 To review the Trust's performance as reported in the Integrated Performance Report Sponsor: David French, Chief Executive Officer 5.6 Equality and Diversity Update (WRES and WDES) 10:45 Sponsor: Steve Harris, Chief People Officer Attendee: Gemma Genco, Head of Equality, Diversity & Inclusivity 5.7 Gender Pay Gap Reporting 2020 11:05 Sponsor: Steve Harris, Chief People Officer Attendee: Kirsty Durrant, Strategic HR Projects Manager 5.8 Freedom to Speak Up Report 11:25 Sponsor: Gail Byrne, Chief Nursing Officer Attendee: Christine Mbabazi, Equality & Inclusion Adviser/Freedom to Speak Up Guardian 5.9 Finance Report for Month 1 11:45 Sponsor: Ian Howard, Interim Chief Financial Officer 6 STRATEGY and BUSINESS PLANNING 6.1 CRN: Wessex 2020/21 Annual Report and 2021/22 Annual Plan 11:55 Sponsor: Paul Grundy, Chief Medical Officer Attendees: Rebecca McKay, Chief Operating Officer, CRN: Wessex/Clare Rook, Deputy COO, CRN: Wessex 7 CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Register of Seals and Chair's Actions 12:15 In compliance with the Trust Standing Orders, Standing Financial Instructions, and the Scheme of Reservation and Delegation. Sponsor: Peter Hollins, Trust Chair 7.2 Emergency Planning and Business Continuity Annual Report 2020/21 12:20 Sponsor: Joe Teape, Chief Operating Officer 7.3 Charitable Funds Committee Terms of Reference 12:30 Sponsor: Peter Hollins, Trust Chair Attendee: Karen Flaherty, Associate Director of Corporate Affairs and Company Secretary 7.4 Trust Executive Committee Terms of Reference 12:35 Sponsor: David French, Chief Executive Officer Attendee: Karen Flaherty, Associate Director of Corporate Affairs and Company Secretary 8 Any Other Business 12:40 To raise any relevant or urgent matters that are not on the agenda 9 To note the date of the next meeting: 29 July 2021 Page 2 10 Resolution regarding the Press, Public and Others Sponsor: Peter Hollins, 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 3 Minutes of Previous Meeting held on 30 March 2021 1 Minutes TB 30 March 2021 OS Minutes Trust Board – Open Session Date Time Location Chair Present 30/03/2021 9:00 - 12:05 Microsoft Teams Peter Hollins (PH) Dave Bennett (DB), Non-Executive Director (NED) Gail Byrne (GB), Chief Nursing Officer Cyrus Cooper (CC), NED Keith Evans (KE), NED David French (DAF), Interim Chief Executive Officer Paul Grundy (PG), Interim Chief Medical Officer Steve Harris (SH), Chief People Officer Jane Harwood (JH), NED (until item 5.10) Ian Howard (IH), Interim Chief Financial Officer Tim Peachey (TP), NED and Senior Independent Director/Deputy Chair Joe Teape (JT), Chief Operating Officer In attendance Brenda Carter (BC), Assistant Director of People (for item 5.8) Ellen Copson (EC), Associate Professor of Medical Oncology, University of Southampton and Honorary Medical Oncology Consultant (for item 2) Kirsty Durrant (KD), Strategic HR Projects Manager (for item 5.8) Karen Flaherty (KF), Associate Director or Corporate Affairs and Company Secretary Sarah Herbert (SHe), Divisional Head of Nursing and Professions, Division B (for item 5.9) Sandra Hodgkyns (SHo), Head of Emergency Planning Response and Resilience/Security (for item 5.9) Stephanie Ramsey (SR), Director of Quality and Integration (Chief Quality Officer and Chief Nurse), NHS Southampton City CCG (for item 5.6) 3 governors (observing) 3 members of the public (observing) 5 members of staff (observing) 1 member of the public (for item 2) 1 Chair’s Welcome, Apologies and Declarations of Interest The Chairman welcomed all those attending to the meeting. The following declaration of interests for GB were reported to the Board: • Chair of the Directors of Nursing Group, University Hospital Association; • Chair of the Wessex Patient Safety Collaborative; and • Member of the Policy Board, NHS Employers. The Board also noted that DB was no longer a director of Davox Consulting Limited. 2 Patient Story The patient story was told by the husband of a patient who sadly died in early 2020 following treatment for cancer at the Trust. As a result of the treatment she had received at the Trust following a diagnosis in April 2017, her life had been extended by over three years. In terms of areas for improvement, better communication of his wife’s initial diagnosis would have helped her and her family to come to terms with the diagnosis more quickly. Following their arrival at hospital, they were being asked lots of questions and his wife was being sent for tests and scans without being given information about what concerns the clinicians had or potential diagnoses. The diagnosis was also delivered on the ward just prior to a visit from a relative and with better planning this could have been done more sensitively by providing a better environment in which to have the conversation and more time for his wife to absorb the information. Once his wife met the specialist team, including the specialist nurse, she felt more reassured and was given hope by the availability of different treatment options. The Trust’s appointment of a dedicated specialist nurse for his wife’s particular cancer shortly after her diagnosis made a huge difference. The specialist nurse was always present when his wife met the consultants and would check if there was anything he or his wife needed and provided practical advice and support, which meant that he and his wife were able to spend more time together. GB reiterated the importance of specialist nurses across different patient pathways and the Trust continued to invest in more specialist nurses. While acknowledging that there was a shortage of private spaces to speak with patients and their families, through its End of Life Care Steering Group the Trust had identified a number of rooms across the hospitals to enable clinicians to go somewhere private in situations like these. The cancer service also continued to adapt to changes in cancer care and the needs of patients, with patients now living longer. Maggie’s Southampton had recently opened at the Southampton General Hospital site to provide help and support for those living with cancer, although the services it offered were currently reduced as a result of the Covid-19 pandemic. The Board expressed its gratitude for sharing the story with such strength and dignity. 3 Minutes of Previous Meeting held on 28 January 2021 The minutes of the meeting held on 28 January 2021 were approved as an accurate record of that meeting. 4 Matters Arising and Summary of Agreed Actions The updates on the actions were noted. The action relating to cancelled appointments in ophthalmology (reference 354) had been followed up and could be closed, as could the actions relating to patients medically optimised for discharge (reference 351 and 393) and the Ockenden report (reference 395), which were included as items on the agenda later in the meeting. The action relating to patient nutrition (reference 394) would be reviewed at the next meeting of the Quality Committee, which would then report to the Board. The Board agreed that the actions relating to specialty outcomes (reference 350 and reference 326) should be combined, with the paper due to be presented to the Board at its meeting in April 2021. Page 2 5 QUALITY, PERFORMANCE and FINANCE 5.1 Briefing from the Chair of the Audit and Risk Committee KE updated the Board on the meeting of the Audit and Risk Committee held on 15 March 2021: • the external audit work had commenced and there were no issues to report at this early stage; • the internal auditors had reviewed referral to treatment (RTT) data quality and while data inaccuracies had been identified in the sample testing, these had not impacted on patients clinical treatment or on Trust’s the overall performance against the RTT target, and in most instances had resulted in the Trust overreporting on pathways; and • updates had been provided on progress against the recommendations in the board governance review and the ongoing review of the data security and protection toolkit. 5.2 Briefing from the Chair of the Finance and Investment Committee DB provided an overview of the Finance and Investment Committee meeting the previous day, highlighting: • that funding for the loss of other income and additional accruals of annual leave that staff had been unable to take due to the Covid-19 pandemic had been received; • the update on the planning process for 2021/22 following the publication of new national guidance that sought to achieve a balance between restoring services and reducing backlogs while supporting staff recovery; • the review of the most recent operational productivity dashboard, from which it had been difficult to draw any meaningful conclusions given the impact of the Trust’s response to the most recent wave of the Covid-19 pandemic in the previous months; and • the business case for the expansion of the outpatients area in ophthalmology, which would be considered by the Board later in the meeting. 5.3 Briefing from the Chair of the Quality Committee TP provided an update on the meeting of the Quality Committee held on 15 March 2021 focusing on the following areas: • the increase in waiting times for diagnostics and plans to recover performance, with a review of patient harm to be completed once patients who had waited longer than six weeks had been seen; • the review of a ‘never event’ relating to a retained swab including the recommendations for a number of sensible actions that had already been implemented; • the latest update on experience of care including the Trust’s accreditation as a Veteran Aware NHS trust; • the recommendations for reporting on maternity safety following the Ockenden review of maternity services at Shrewsbury and Telford Hospital NHS Trust, which would be considered by the Board later in the meeting; • the urgent investigation of aspergillus infections in the intensive care unit to establish whether there was a link to an earlier leak in a pipe above the ceiling in that area; • the latest report on clinical outcomes, with the Board to receive a full Page 3 report at its meeting in April 2021; and • the review of the committee’s effectiveness. 5.4 Chief Executive Officer’s Update The Trust had taken part in the national day of reflection and one minute’s silence on 23 March 2021 to commemorate the anniversary of the first national lockdown due to the Covid-19 pandemic. This had given staff an opportunity to pause and reflect on the loss of life over the previous year, including patients and staff. There were currently 20 patients in the hospital who had tested positive for Covid-19, three of which were in intensive care. An average of three or four patients with Covid-19 were being admitted daily, which highlighted the importance of continuing to follow the rules as lockdown measures were eased. Staff were being encouraged to take annual leave and wellbeing conversations were taking place with every member of staff. Second doses of the Covid-19 vaccine were being administered to Trust staff and staff at health and social care partners. 92% of frontline staff and 90% of all staff had received at least one dose of the vaccine, including 88% of BAME (Black and Minority Ethnic) staff. Staff who had not yet received the vaccination were being contacted individually to understand the reasons for this and provide additional information where appropriate. As well as planning for the recovery of services in the short term, the Trust was carrying out long-term modelling of future demand and capacity supported by external consultants and architects, which would form the basis of the Trust’s estates masterplan for the main hospital site. In advance of this work, the corporate objectives for 2021/22 would be presented to the Board at its meeting in April 2021. The Trust had performed exceptionally well in its recent external accreditation of endoscopy by the Joint Advisory Group on GI Endoscopy (JAG), providing one of the best submissions reviewed by JAG. Each of the executive directors provided an update in turn, covering the following areas: • reopening of theatres in Southampton General and Princess Anne Hospitals, replacing the current additional capacity in the independent sector from 1 April 2021; • four ‘Always Improving’ quality improvement projects relating to the emergency department (ED), discharge of patients medically optimised for discharge (MOFD), theatres and outpatients; • the launch of the ‘Always Improving’ strategy with staff in June 2021; • the review of patients who had been waiting for surgery, in particular those in priority level 2 (surgery that can be deferred for up to four weeks); • modelling of the potential impact on the waiting list of GP referrals returning to more normal levels and patients potentially presenting with more advanced disease than if they had seen their GP earlier; • the business intelligence programme to improve prospective as well as retrospective reporting; • allowing time for teams to readjust to working together as part of the recovery process with additional support from the Trust for those teams experiencing challenges; • plans to safely reopen the hospitals to visitors, particularly while the Page 4 Trust continued to admit patients with Covid-19; • re-energising the COVID ZERO campaign to ensure that the infection control measures continued to be followed rigorously even as the number of cases reduced, with a nosocomial infection the previous week acting as a timely reminder of the risk; • the successful renegotiation of the limit on expenditure (CDEL) for 2020/21 through which the Trust had been able to access additional capital and the negotiation of the allocation of CDEL across the integrated care system (ICS) for 2021/22; and • the current projects in development including theatres, the private patient unit, ophthalmology and the pathology laboratory information system. The Board noted that that the Trust would need to establish how it would balance the needs of those patients who had been waiting longest for treatment with the clinical prioritisation process already in place as it planned for the recovery of activity. 5.5 Integrated Performance Report for Month 11 The integrated performance report (IPR) for month 11 was noted. During February 2021 the direct impact of Covid-19 infections upon the Trust continued to be significant. There were 263 patients in the hospital with Covid19 at the start of February and 129 at the end of the month. The number of patients in intensive care reduced from 67 at the beginning of the month to 39 by the end of February. This compared to the first wave of Covid-19 pandemic, when the number of patients with Covid-19 in the hospital peaked at 173 and 38 in intensive care. This also had an impact on elective activity within the Trust, which was 42% of the level in February 2020. The Board discussed the following areas: Responsive • while the Trust’s ED was performing well comparatively, it was not meeting the performance target on the length of time patients spent in ED, despite attendances at 71% of the normal level; • this was principally due to patients presenting with mental health conditions and surges of high acuity patients, however, new junior doctors had also joined ED in February who were not used to the level of attendances; • leadership in ED was central to managing the department in these situations particularly the effective operation of the consultant of the day model to ensure that decisions regarding patients were made in a timely manner; • performance in ED had improved overall as 87% of patients were currently seen within four hours with an average daily attendance of 345 patients compared to 78% of patients two years ago when the average daily attendance was 350 patients; • to continue to improve performance and the flow of patients through ED the Trust was ensuring that specialties adhered to the one hour standard for referrals; • infection control measures remained in place, including respiratory assessment and rapid testing in ED and the acute medical unit, although it was difficult to establish whether this had a material impact on performance as ED had performed consistently well during the Page 5 period of the pandemic; • activity in ED had increased in March 2021 as lockdown restrictions had eased; • while the number of non-face-to-face outpatient appointments had increased following the first wave of the pandemic, some of these had not been full appointments but rather an opportunity to check in with patients; • the use of non-face-to face outpatient appointments varied by condition and specialty and was more appropriate for some of these than others, however, the Trust was seeking to learn from those clinicians who had used these types of appointment successfully as part of its quality improvement work in outpatients; • feedback from patients non-face-to face appointments had been positive on the basis that their care was continuing, however, limited work had been done to assess effectiveness in terms of the experience and outcome of these appointments; and • although cancer performance measures remained stable, both the Trust and the Wessex Cancer Alliance had performed well comparatively and ranked as second highest performing in their respective peer groups. Safe • • the unusually high number of medication incidents reported with moderate or severe harm in February and the actions taken in response to these; and ensuring that staff continued to report incidents, particularly as they returned to their normal areas of work following the pandemic. Caring • the number of overnight ward moves for non-clinical reasons given that most patient moves during this period would be related to patients admitted with Covid-19; • the percentage of patients with a disability or additional needs reporting that those needs were met had reduced and there were resource challenges in this area currently with a vacancy in one of the two adult learning disabilities nursing roles, although the recruitment process was underway; and • increasing the number of vulnerable women on a continuity of carer pathway given the benefit to all these women in terms of the quality of oversight in maternity. ACTIONS: (1) GB would review the non-clinical reasons for overnight ward moves and provide an overview to the Quality Committee. (2) The Quality Committee would review the resourcing required to increase the percentage of vulnerable women on a continuity of carer pathway and update the Board. Well-led • the impact of research activity on outcomes, more detail of which would be provided in the report on clinical outcomes at the meeting of the Board in April 2021. The Board’s review of the IPR, led by TP, would report to the Board in May 2021 with a candidate IPR. Page 6 5.6 Inpatient Flow - Medically Optimised for Discharge Update SR joined the meeting for this item. The Board noted the current performance against the process improvement trajectories and key performance indicators agreed by the system, system plans in the light of current performance and the Trust’s internal work programme for MOFD. The Board was interested to learn what the Trust could be doing differently or better in order to help improve performance as a system. The work to date had made a significant impact as the system responded to discharge an increased number of patients with more complex needs such as stroke patients, patients with challenging behaviours, patients requiring more intensive therapy and homeless patients. There was a specific issue with discharging to care homes at weekends and providing the necessary clinical support to these care homes to enable discharge. The main areas of focus for the Trust were to speed up processes and ensure patients MOFD were ready to be discharged earlier in the day as this would make it easier for services in the community to respond. While there was a target to get to 40-60 patients MOFD in hospital, no specific timescales had been set. ACTION: JT agreed to include a trajectory for MOFD patients in the regular reports to the Finance and Investment Committee. Funding was also likely to be an issue in the future as additional national funding provided during the Covid-19 pandemic to support the discharge of patients would be withdrawn at the end of June 2021. The Board recognised that system partners were aligned in their aim to address the delays in discharging patients MOFD and prevent potential patient harm as a result. However, the Board suggested a more holistic view of the issue would be beneficial when reviewing future resourcing, taking into account the revenue and capital implications and the consequences in terms of hospital capacity and addressing the current backlog of patients waiting for treatment. This analysis may identify where investment was needed to support discharge, including additional capacity, albeit that the ambition remained ‘home first’ when discharging patients in order to assess ongoing needs more accurately and reduce dependency. The meeting was adjourned briefly to allow for a break. 5.7 Ockenden Review of Maternity Services The Board noted the update on progress on the emerging findings and recommendations of the independent review of maternity services at the Shrewsbury and Telford Hospital NHS Trust released on 10 December 2020. The Trust had rated its progress against two of the recommendations as red, with no actions currently in place, and nine of the recommendations as amber, where actions were still in progress. Completion of these recommendations was dependent the Trust’s submission to NHS Resolution’s maternity incentive scheme which would be made by mid-July 2021 and therefore other trusts would be in a similar position. The Trust had received feedback on the information submitted to NHS England and NHS Improvement, which had been positive overall. A template had been designed to report to the Board and the local maternity Page 7 service (LMS) on maternity safety, which would incorporate a summary of serious incidents (SIs) and moderate harm incidents. This report would be submitted to the Board maternity safety champions and LMS on a monthly basis. The Board maternity safety champions would also meet with complainants before the referral of a complaint to the Parliamentary and Health Service Ombudsman. It was proposed that reporting to the Board on maternity safety issues including SIs and moderate harm incidents, the perinatal mortality report tool, early notification scheme, red flag incidents, staff concerns and evidence of listening to families including complaints would take place quarterly following review of the information by the Quality Committee. The frequency of reporting to the Board was in line with the recommendations in the Ockenden review although not with the guidance issued subsequently. The Board was keen to ensure it maintained a good understanding of the culture and patient experience in the maternity service given the impact of each on the quality of the service. Proposals to regularly survey staff would be considered later in the meeting. In addition the Board requested that the regular patient story should include maternity at least once annually. ACTION: KF to arrange a patient story from a patient using the maternity service at least once annually. DECISION: The Board agreed: • to receive a quarterly report on maternity safety issues; and • that all SIs and moderate harm incidents would be provided to the Board maternity safety champions and LMS. 5.8 UHS Staff Survey Results 2020 Report BC and KD joined the meeting for this item. The results of the NHS staff survey 2020 were noted by the Board. The survey had been completed by staff between September and November 2020. Overall the Trust’s results were at or above the acute trust average in nine out of ten themes. 77% of staff would recommend the Trust as a place to work and 87% of staff agreed that care of patients was the top priority for the Trust. Performance on health and wellbeing had significantly increased compared to 2019. However, the survey had also identified some areas for improvement. The areas with statistically significant decreases in performance compared to the 2019 staff survey results were: • Equality, diversity and inclusion; • Immediate managers; • Violence; and • Team working. In response to a question from a NED, it was clarified that only a small number of incidents of violence against staff from managers and colleagues reflected in the staff survey results were reported leading to an investigation. The reporting through the Trust’s Freedom to Speak Up processes had identified incidents involving microaggressions rather than acts of violence. Work was also ongoing to improve leadership skills within the organisation, which would set out expectations regarding values and behaviours. Over 1,000 free text comments had been submitted from staff as part of the survey and a national analysis of themes was being prepared, which would Page 8 provide further insight into how staff were feeling following the first wave of the pandemic. The Board supported more regular surveying of staff, particularly around the areas of improvement identified, recognising that things had changed since the survey was carried out six months ago and would continue to change. 5.9 Plan to Address Violence and Aggression against Staff SHe and SHo joined the meeting for this item. The Board noted the update on the progress made since the previous update in September 2020. This included closer working with Hampshire Constabulary, proposed changes to security arrangements, staff training and staff support. These plans aimed to reduce incidents of violence and aggression against staff and provide support to staff in the management of violence and aggression and following any incidents. The Board recognised that violence and aggression against staff would never be eliminated entirely as the Trust provided care to individuals with mental health issues, brain injuries, dementia and who lacked capacity who may find it difficult to control their behaviour. It was important, however, that violent and aggressive behaviour was challenged consistently when appropriate. The Board supported the approach to exclude violent and aggressive individuals from the Trust when they repeatedly displayed unacceptable behaviour that it was not possible to manage through de-escalation, anticipatory care planning and the challenging behaviour protocol. While not formally approving the funding for the plans set out in the paper, the Board noted the importance of investment in this area in order to support staff. A further update on progress would be provided in December 2021. 5.10 Finance Report for Month 11 The finance report for month 11 was noted. The following areas were highlighted: • the Trust has received the payments for the loss of other income, additional accruals of annual leave that staff had been unable to take due to the Covid-19 pandemic and the elective incentive scheme; • the Trust remained on track to achieve a breakeven position for 2020/21 as did the other trusts in the Hampshire and Isle of Wight ICS; and • the Trust’s balance sheet position remained strong, which placed the Trust in a good position to address likely pressures in 2021/22. 6 CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 6.1 Register of Seals and Chair's Actions for ratification DECISION: The Board ratified the application of the Trust seal and the Chair’s actions set out in the report. ACTION: IH would follow up on the Wessex Clinical Research Network and the assisted conception service items in the paper as these were not single tender actions required to be reported in accordance with the Trust’s Standing Financial Instructions. 6.2 Amendment to Constitution for CCG Merger With effect from 1 April 2021, the individual Clinical Commissioning Groups Page 9 (CCGs) within Hampshire and the Isle of Wight were to merge to create a new NHS Hampshire, Southampton and Isle of Wight CCG. The Council of Governors (CoG) included an appointed governor from each of NHS Southampton City CCG and NHS West Hampshire CCG and as a result of the merger these two organisations would cease to exist. It was proposed that the Trust should reflect the merger in the composition of the CoG, by amending the composition of the CoG in Annex 3 of the Trust’s constitution to remove the Appointed Governor from each of NHS Southampton City CCG and NHS West Hampshire CCG and include an Appointed Governor from NHS Hampshire, Southampton and Isle of Wight CCG in their place. A separate review of the composition of the CoG would be undertaken as part of the annual review of the Trust’s constitution to ensure that the overall composition of the CoG remains representative and reflected the changes to NHS governance structures. DECISION: The Board approved the amendment to the Trust’s constitution with effect from 1 April 2021, subject to the approval of the CoG at its meeting on 31 March 2021. 7 Any Other Business There was no other business. 8 To note the date of the next meeting: 27 May 2021 9 Resolution regarding the Press, Public and Others DECISION: The Board resolved that, as permitted by the National Health Service Act 2006 (as amended), the Trust's Constitution and the Standing Orders for the Practice and Procedure of the Board of Directors, 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 10 4 Matters Arising and Summary of Agreed Actions 1 List of Action Items List of action items Agenda item Assigned to Deadline Status Trust Board – Open Session 30/03/2021 5.5 Integrated Performance Report for Month 11 426. Caring - overnight ward moves Byrne, Gail Peachey, Tim 27/05/2021 Pending Explanation action item GB would review the non-clinical reasons for overnight ward moves and provide an overview to the Quality Committee. 427. Caring - vulnerable women Byrne, Gail Peachey, Tim 27/05/2021 Pending Explanation action item The Quality Committee would review the resourcing required to increase the percentage of vulnerable women on a continuity of carer pathway and update the Board. Trust Board – Open Session 30/03/2021 5.6 Inpatient Flow - Medically Optimised for Discharge Update 428. Trajectory for MOFD patients Teape, Joe 27/05/2021 Pending Explanation action item JT agreed to include a trajectory for MOFD patients in the regular reports to the Finance and Investment Committee. Trust Board – Open Session 30/03/2021 5.7 Ockenden Review of Maternity Services 429. Patient story Flaherty, Karen 31/03/2022 Pending Explanation action item KF to arrange a patient story from a patient using the maternity service at least once annually. Page 1 of 2 Agenda item Assigned to Deadline Status Trust Board – Open Session 30/03/2021 6.1 Register of Seals and Chair's Actions for ratification 430. Follow up Howard, Ian 27/05/2021 Pending Explanation action item IH would follow up on the Wessex Clinical Research Network and the assisted conception service items in the paper as these were not single tender actions required to be reported in accordance with the Trust’s Standing Financial Instructions. Page 2 of 2 Report to the Trust Board of Directors Title: Agenda item: Sponsor: Date: Purpose Issue to be addressed: Integrated Performance Report 2021/22 Month 1 5.5 David French, Chief Executive Officer 27 May 2021 Assurance Approval or reassurance Y Ratification Information This report is intended to support the Trust Board in assuring that: • the care we provide is safe, caring, effective, responsive and well led in the context of the COVID-19 pandemic • at the same time we continue our journey toward our vision of World Class Care for Everyone. Response to the issue: The Integrated Performance Report reflects the current operating environment and is aligned with the Care Quality Commission Key Lines of Enquiry. Implications: This report covers a broad range of trust services and activities. It is (Clinical, Organisational, intended to assist the Board in assuring that the Trust meets regulatory Governance, Legal?) requirements and corporate objectives. Risks: (Top 3) of carrying This report is provided for the purpose of assurance. out the change / or not: Summary: Conclusion This report is provided for the purpose of assurance. and/or recommendation Page 1 of 1 Integrated KPI Board Report covering up to April 2021 Sponsor - Andrew Asquith, Director of Planning, Performance and Productivity, andrew.asquith@uhs.nhs.uk Chart Type Cumulative Column Example Cumulative Column Year on Year Line Benchmarked Line & bar Benchmarked Control Chart 100% 0% 66.8% Variance from Target Report Guide Explanation A cumulative column chart is used to represent a total count of the variable and shows how the total count increases over time. This example shows quarterly updates. A cumulative year on year column chart is used to represent a total count of the variable throughout the year. The variable value is reset to zero at the start of the year because the target for the metric is yearly. The line benchmarked chart shows our performance compared to the average performance of a peer group. The number at the bottom of the chart shows where we are ranked in the group (1 would mean ranked 1st that month). 66.49% The line shows our performance and the bar underneath represents the range of performance of benchmarked trusts (bottom = lowest performance, top = highest performance) A control chart shows movement of a variable in relation to its control limits (the 3 lines = Upper control limit, Mean and Lower control limit). When the value shows special variation (not expected) then it is highlighted green (leading to a good outcome) or red (leading to a bad outcome). Values are considered to show special variation if they -Go outside control limits -Have 6 points in a row above or below the mean, -Trend for 6 points, -Have 2 out of 3 points past 2/3 of the control limit, -Show a significant movement (greater than the average moving range). Variance from target charts are used to show how far away a variable is from its target each month. Green bars represent the value the metric is achieving better than target and the red bars represent the distance a metric is away from achieving its target. 2 Report to Trust Board in May 2021 Introduction The Integrated Performance Report is presented to the Trust Board each month. The report aims to: • Provide assurance that the care we provide is safe, caring, effective, responsive and well led in the context of the COVID-19 pandemic • Ensure that at the same time we continue our journey toward our vision of World Class Care for Everyone. We adjust / add to these indicators – informing the Board and keeping a comparative narrative – as the situation changes as we work through these unusual circumstances. The structure of the report is currently being reviewed in order that it can better reflect the ambitions within ‘Our Strategy 2025’, and to support the strategic discussions of the Board. April 2021 Summary During April the direct impact of COVID-19 infections upon the Trust reduced further. Patients with a confirmed COVID-19 diagnosis during their admission: • Started the month at 48 (11 of which were in intensive care / high care) • Finished the month at 24 (5 of which were in intensive care / high care) The phased resumption of the elective admissions continued within NHS facilities, and the additional access to independent sector theatres and beds that had been secured by NHS England during the pandemic terminated at the end March. 3 Report to Trust Board in May 2021 Key aspects of performance for consideration this month include: • The total number of patients on the RTT waiting list increased by over 1,000 patients to 37,613 in April. There are over 3,000 patients waiting over 52 weeks for treatment and over 500 patients waiting over 78 weeks. Our benchmarking confirms that we are continuing to perform well in comparison to our peer group. • The crude mortality rate and Hospital Standardised Mortality Ratio (HSMR) both increased significantly in January (though HSMR remained significantly better than would be expected on average in the NHS). Patient details have been requested in order that the recorded diagnosis can be checked as a first step in investigation. It may be relevant that January saw a peak in COVID-19 occupancy. • UHS 62 day performance (RE 23) improved to 86.5% (better than our local target and the national target applying to the majority of 62 day pathways). UHS was the best performing trust amongst our 10 ‘peer’ teaching hospitals in March. 4 Report to Trust Board in May 2021 RESPONSIVE • Emergency Department timeliness deteriorated slightly to 87% (RE 9) whilst remaining 3rd best amongst 8 benchmark trusts. Attendance numbers increased further to the highest levels since the COVID-19 pandemic started (RE 8). • Elective spell volumes (excluding daycases, at SGH/PAH only) (RE 13) recovered further, yet remained below those in Autumn 2020. Two SGH theatres are currently closed due to building works and are due to reopen in June. • The total number of patients on the RTT waiting list increased by over 1,000 patients this month. The cohort of patients who have waited over 52 weeks (RE 16) reduced by over 300 patients, whilst those waiting over 78 weeks (RE 17) increased by over 100 patients. We remain concerned by this situation and are focussed on improving the situation as soon as possible for our patients. Our benchmarking (in a group of 20 Teaching hospitals) confirms that we are continuing to perform well in comparison to our peer group. • Cancer performance measures for March indicate continued improvement in performance: o UHS 62 day performance (RE 23) improved to 86.5% (better than our local target and the national target applying to the majority of 62 day pathways). UHS was the best performing trust amongst our 10 ‘peer’ teaching hospitals again this month. o 31 day performance (RE 24) was maintained above the target at 97.6%. 5 Report to Trust Board in May 2021 RESPONSIVE RE1 Non-elective Spells (discharged, including CDU) Non Elective LOS RE2-L Rolling 12 months (Solid) Monthly (Dashed) Number of inpatients that were RE3 medically optimised for discharge (monthly average) Monthly Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr target 6,800 6,292 4,000 7.5 6.0 4,128 6.49 - 5.45 - 4.5 250 76 0 122 - Longer LOS Census average RE4-N (Patients with LOS > =21days) 203.38 160.86 118.33 73 145 - RE5-l RE6 RE7 Adult midday bed occupancy Last minute cancelled operations not readmitted within 28 days Last minute cancelled operations 100% 98.2% 84.6% 71.1% 82.6% 40% 55 40 0 150 5 0 79.0% 90-95% - 6 35 - 6 Report to Trust Board in May 2021 RESPONSIVE Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr QTD 12,000 10663 RE8 Total ED Attendances - 5735 5,000 RE9-N Patients spending less than 4hrs in ED SGH Main ED (Type 1 and UCH) 92% 84% Major Trauma Centres (Type 1) 76% 90.2% 87.2% 81.30% 87.2% Rank of 8-> RE10-N Patients spending less than 4hrs in ED UHS Total (includes SGH all types) - 532533422111233 92.22% 85.5% 78.82% 91.1% 91.1% 88.0% 88.0% Q target - 95% 95% RE11-N Total time Total spent in ED - Percentiles UHS RE12 27,000 Accepted Referrals (excluding -initiated by consultant responsible) 0 RE13 2,000 Elective spells (excluding daycase, onsite SGH/PAH only) 0 90th, 4:00 Mean, 2:45 8,013 446 90th, 4:59 - - Mean, 3:04 19,100 - - 1,438 - - 7 Report to Trust Board in May 2021 RESPONSIVE Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan 100% % Patients on an open 18 week pathway 66.8% RE14-N (within 18 weeks ) with teaching hospital min-max range and rank (of 20) 18 12 14 14 7 6 7 7 10 10 10 9 30% 38,000 Total number of patients on a waiting RE15-N list (18 week referral to treatment 33106 pathway) 30,000 Patients on an open 18 week pathway 9,000 RE16-N (waiting 52 weeks+ ) with teaching hospital min-max range and rank (of 20) 0 15 154 13 13 13 11 11 11 10 9 6 6 6 1000 RE17 Patients on an open 18 week pathway (waiting 78 weeks+ ) 500 0 0 65,000 RE18 Face to face outpatient attendances 40,105 Feb Mar Apr 66.5% 9 8 37613 3108 5 4 553 34,415 Target > =92% - 0 65,000 RE19 Non-face to face outpatient attendances 15,703 0 RE19 - Latest month is awaiting approx ~3k outpatient attendances to be reported 18,748 - RE20-N Average weeks waited for first outpatient appointment 12.00 10.47 8.89 10.3 7.00 7.30 8.5 - 8 Report to Trust Board in May 2021 7.00 7.30 RESPONSIVE Target Patients to Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar /Apr recover target QTD 11,000 9563 RE21-N Patients waiting for diagnostics - 4317 4,000 80% % of Patients waiting over 6 weeks for RE22-N diagnostics with teaching hospital min- 45.2% 27.2% 90% N = 7 L= L=> 0 of 197 80% 85% 69.1% UHS Total ………………….Rank(of 10)-> 6 5 3 1 1 1 1 1 5 7 4 2 1 1 0.5 31 day cancer wait performance RE24-N (Latest data held by UHS, Combined measure – First and Subsequent Treatments of Cancer) 97.1% 93.2% 89.4% 92.2% 97.6% N=> 96% N=0 of 948 97.41% RE25-N Snapshot of waits > 104 days (from referral on a 62 day pathway) 36 27 29 25 11 17 9 11 25 24 17 13 16 22 - - - RE26-N 28 Day Faster Diagnosis 100% 70% 82.7% 87.5% => 75 % - 84.16% 9 Report to Trust Board in May 2021 RESPONSIVE RE27 My Medical Record - UHS patient logins Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr Monthly target 20,000 18,182 10,000 5,566 - 0 2,500 RE28 Number of Estates Help desk requests 900 and percentage completed on time 100% 85% 997 89.6% 1,592 - 84.7% > 85% 50% Elective inpatient activity - % of same month pre COVID-19 100% RE29 UHS Corporate peer average ------------------------------Rank--> 20% Non-elective inpatient activity - % of same month pre COVID-19 100% RE30 UHS Corporate peer average ------------------------------Rank--> 50% 1st outpatient attendances - % of same month pre COVID-19 100% RE31 UHS Corporate peer average ------------------------------Rank--> 30% Follow up outpatient attendances - 110% % of same month pre COVID-19 RE32 UHS Corporate peer average ------------------------------Rank--> 50% RE29-32 corporate peers group size = 7 90.4% 85.1% 35.23% 3 2 2 2 2 2 1 1 4 4 2 95.0% 66.6% 95.42% 534422232254 96.2% 51.7% 93.77% 47.20%2 2 2 2 2 2 2 2 2 2 2 3 70.3% 108.9% 102.8% - 63.6% 6 3 2 2 1 1 2 2 1 1 4 5 QTD - 86.2% - 10 Report to Trust Board in May 2021 SAFE • Only a single case of probable hospital associated COVID-19 acquisition > 7 days occurred in April (SA 6). • Our measure related to pressure ulcers was amended this month to distinguish between category 2 and 3 ulcers, regardless of level of ‘harm’ (SA 7/8). Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr Target YTD SA1-N Cumulative Clostridium difficile 2 SA2 MRSA bacteraemia 0 100 SA3 Clinical cleaning scores for very high risk areas 95 100 SA4 Serco cleaning scores for very high risk areas 95 Healthcare-acquired COVID 35 SA5 infection: COVID-positive sample taken > 14days after admission (validated) 0 Probable hospital-associated 80 SA6 COVID infection: COVID-positive sample taken > 7 days and 95% - 93.4% YTD target 95% 12 Report to Trust Board in May 2021 CARING • Inpatient feedback (CA 1) continues to be good and significantly better than target. • Maternity patient negative feedback (CA 2) continues to be worse than target; 6.6% compared to the target of =70% 41.5% 65.6% 14 Report to Trust Board in May 2021 0% CARING Monthly Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr target Total vulnerable women (living 100% CA8 within 10% most deprived decile) booked onto a continuity of carer 40.0% pathway 0% 100% % Patients reporting being CA9 involved in decisions about care and treatment 50% 86.0% 85.0% > =90% CA10 100% % Patients reporting finding somebody to talk to about worries and fears 50% 97.0% % Patients with a disability/ 100% additional needs reporting those 81.0% CA11 needs/adjustments were met (total number questioned included at chart base) 30 165 39 50% 57 153 215 133 164 174 178 240 77 CA11 - Performance is a scored metric with a "Yes" response scoring 1, "Yes, to some extent" receiving 0.5 score and other responses scoring 0. Overnight ward moves with a 100 CA12 reason marked as non-clinical (excludes moves from admitting 75.58 44.08 10 wards with LOS =90% 89.0% > =90% 63 110 289 29 - 10.8 - 15 Report to Trust Board in May 2021 EFFECTIVE • The crude mortality rate (EF 4) and Hospital Standardised Mortality Ratio (HSMR) (EF 3), both increased significantly in January (though HSMR remained significantly better than would be expected on average in the NHS). More deaths than ‘expected’ are reported in General Medicine, Respiratory Medicine and Medicine for Older People, with a primary diagnosis of ‘viral infection’. Information for 97 patients has been requested in order that the recorded diagnosis can be checked as a first step in investigation. • Measures relating to patients screened for smoking and harmful alcohol consumption (EF 5), with those found to smoke and given brief advice or a medication offer (EF 7), stalled in their recovery following the COVID-19 peak in January and are currently slightly below target. EF1-L Cumulative Specialities with Outcome Measures Developed EF2 Developed Outcomes RAG ratings EF3-N HSMR - UHS HSMR - SGH EF4 HSMR - Crude Mortality Rate Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr 53 54 56 56 57 255 260 285 305 332 100% 75% 80% 81% 79% 77% 76% 50% 85 82.2 81.5 75 3.5% 3.0% 2.5% Monthly target +1 - 80% EF6-N % patients screened & found to 100% have either moderate or high alcohol dependence given advice or referral 80% 96.7% 95.7% > 90% 100% % patients screened & found to EF7-N smoke given brief advice or a medication offer 60% 83.6% 88.9% > 90% 17 Report to Trust Board in May 2021 WELL LED • Non-medical appraisal rates (WL 2) have continued their modest rate of recovery to 81%, but still remain significantly below the target of 92%. • Overall sickness absence (WL 6) reduced to 3%, which is within target, whilst COVID-19 related absence (WL 7) reduced to 1% of employed time during the month of April. WL1-L Substantive Staff - Turnover Monthly Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr Target 13.63% 12.92% 12.22% 13.4% 12.3% 92% 95.0% 3.4% 12.4% =76% WL9-N Response rate of - staff recommend UHS 60% as a place to work: UHS Quarterly staff FFT National NHS Staff Survey 20% 50.0% 30% 11% WL10-L % of Band 7+ staff who are Black and Minority Ethnic 9.2% 10.0% 15% by 2023 7% WL11 14% % of Band 7+ Staff who have declared a disability or long term health condition 13.3% 13.6% - 12% WL12- QI training programme, and reporting, is currently temporarily suspended as team members support urgent change programmes as part of our Covid 19 response and recovery WL12-L Statutory & Mandatory Training Achieving Target 7 7 7 6 6 6 6 6 6 6 6 6 6 6 6 - 5 5 5 6 6 6 6 6 6 6 6 6 6 6 6 100 WL13-L Number of Apprenticeship Starts 44 49 59 23 - 0 19 Report to Trust Board in May 2021 0 WELL LED Monthly Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr target WL14-L Comparative CRN Recruitment Performance by clinical specialty 56% 52% 28% 36% 40% > =70.0% WL15-L Comparative CRN Recruitment Performance - weighted WL16-L Comparative CRN Recruitment - contract commercial WL17-L Proportion of studies closing in FY on time and to recruitment target non-commercial WL18 NIHR CRF & BRC cumulative quarterly publications 2 5 13 88% 13 50% 600 137 120 0 2 17 43% 246 261 7 7 45% 424 329 Top 5 8 2 Top 10 42% 452 562 > =80% 20 Report to Trust Board in May 2021 Changes and Corrections Section Responsive Safe Safe Caring Caring KPI KPI Name Type RE29-32 Activity metrics - % of same month pre COVID-19, UHS and corporate peer average change SA7 Pressure ulcers category 2 per 1000 bed days change SA8 Pressure ulcers category 3 and above per 1000 bed days change CA11 % Patients with a disability/ additional needs reporting those needs/adjustments were met correction (total number questioned included at
Url
/Media/UHS-website-2019/Docs/About-the-Trust/Trust-governance-and-corporate-docs/2021-Trust-document/TB-papers/Papers-Trust-Board-27-May-2021.pdf
1 to 10 of 134
Previous 1 2 3 4 5 … Next