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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 - 13 January 2026

Description: Date Time Location Chair Apologies Agenda Trust Board – Open Session 13/01/2026 9:00 - 13:00 Conference Room, Heartbeat Education Centre Jenni Douglas-Todd Diana Eccles 1 Chair’s Welcome, Apologies and Declarations of Interest 9:00 Note apologies for absence, and to hear any declarations of interest relating to any item on the Agenda. 2 Patient Story The patient story provides an opportunity for the Board to reflect on the experiences of patients and staff within the Trust and understand what the Trust could do better. 3 Minutes of Previous Meeting held on 11 November 2025 9:15 Approve the minutes of the previous meeting held on 11 November 2025 4 Matters Arising and Summary of Agreed Actions To discuss any matters arising from the minutes, and to agree on the status of any actions assigned at the previous meeting. 5 QUALITY, PERFORMANCE and FINANCE Quality includes: clinical effectiveness, patient safety, and patient experience 5.1 Briefing from the Chair of the Finance, Investment & Cash Committee 9:20 David Liverseidge, Chair 5.2 Briefing from the Chair of the People and Organisational Development 9:30 Committee Jane Harwood, Chair 5.3 Briefing from the Chair of the Quality Committee 9:40 including Maternity and Neonatal Safety 2025-26 Quarter 2 Report Tim Peachey, Chair 5.4 Chief Executive Officer's Report 9:50 Receive and note the report Sponsor: David French, Chief Executive Officer 5.5 Performance KPI Report for Month 8 10:20 Review and discuss the report Sponsor: Andy Hyett, Chief Operating Officer 5.6 11:00 5.7 11:15 5.8 11:25 5.9 11:30 5.10 11:45 5.11 11:55 5.12 12:05 5.13 12:15 6 6.1 12:25 7 12:35 8 Break Finance Report for Month 8 Review and discuss the report Sponsor: Ian Howard, Chief Financial Officer ICB System Report for Month 8 Receive and discuss the report Sponsor: Ian Howard, Chief Financial Officer People Report for Month 8 Review and discuss the report Sponsor: Steve Harris, Chief People Officer Learning from Deaths 2025-26 Quarter 2 Report Review and discuss the report Sponsor: Paul Grundy, Chief Medical Officer Attendee: Jenny Milner, Associate Director of Patient Experience Infection Prevention and Control 2025-26 Quarter 2 Report Review and discuss the report Sponsor: Natasha Watts, Acting Chief Nursing Officer Attendees: Julian Sutton, Clinical Lead, Department of Infection/Julie Brooks, Deputy Director of Infection Prevention and Control Medicines Management Annual Report 2024-25 Receive and discuss the report Sponsor: Paul Grundy, Chief Medical Officer Attendee: James Allen, Chief Pharmacist Annual Ward Staffing Nursing Establishment Review 2025 Discuss and approve the review Sponsor: Natasha Watts, Acting Chief Nursing Officer CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL Annual Assurance for the NHS England Core Standards for Emergency Preparedness, Resilience and Response (EPRR) Review and discuss the report Sponsor: Andy Hyett, Chief Operating Officer Attendee: John Mcgonigle, Emergency Planning & Resilience Manager Any other business Raise any relevant or urgent matters that are not on the agenda Note the date of the next meeting: 10 March 2026 Page 2 9 Resolution regarding the Press, Public and Others Sponsor: Jenni Douglas-Todd, Trust Chair To agree, as permitted by the National Health Service Act 2006 (as amended), the Trust's Constitution and the Standing Orders of the Board of Directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. 10 Follow-up discussion with governors 12:45 Page 3 Agenda links to the Board Assurance Framework (BAF) 13 January 2026 – Open Session Overview of the BAF Risk 1a: Lack of capacity to appropriately respond to emergency demand, manage the increasing waiting lists for elective demand, and provide timely diagnostics, that results in avoidable harm to patients. 1b: Due to the current challenges, we fail to provide patients and their families / carers with a high-quality experience of care and positive patient outcomes. 1c: We do not effectively plan for and implement infection prevention and control measures that reduce the number of hospital-acquired infections and limit the number of nosocomial outbreaks of infection. 2a: We do not take full advantage of our position as a leading University teaching hospital with a growing, reputable, and innovative research and development portfolio, attracting the best staff and efficiently delivering the best possible treatments and care for our patients. 3a: We are unable to meet current and planned service requirements due to the unavailability of staff to fulfil key roles. 3b: We fail to develop a diverse, compassionate, and inclusive workforce, providing a more positive staff experience for all staff. 3c: We fail to create a sustainable and innovative education and development response to meet the current and future workforce needs identified in the Trust’s longer-term workforce plan. 4a: We do not implement effective models to deliver integrated and networked care, resulting in sub-optimal patient experience and outcomes, increased numbers of admissions and increases in patients’ length of stay. 5a: We are unable to deliver a financial breakeven position, resulting in: inability to move out of the NHS England Recovery Support Programme, NHS England imposing additional controls/undertakings, and a reducing cash balance impacting the Trust’s ability to invest in line with its capital plan, estates/digital strategies, and in transformation initiatives. 5b: We do not adequately maintain, improve and develop our estate to deliver our clinical services and increase capacity. 5c: Our digital technology or infrastructure fails to the extent that it impacts our ability to deliver care effectively and safely within the organisation, 5d: We fail to prioritise green initiatives to deliver a trajectory that will reduce our direct and indirect carbon footprint by 80% by 2028-2032 (compared with a 1990 baseline) and reach net zero direct carbon emissions by 2040 and net zero indirect carbon emissions by 2045. Agenda links to the BAF No Item Linked BAF risk(s) 5.5 Performance KPI Report for Month 8 5.7 Finance Report for Month 8 5.8 ICB System Report for Month 8 5.9 People Report for Month 8 5.10 Learning from Deaths 2025-26 Quarter 2 Report 5.11 Infection Prevention and Control 2025-26 Quarter 2 Report 5.12 Medicines Management Annual Report 2024-25 5.13 Annual Ward Staffing Nursing Establishment Review 2025 6.1 Annual Assurance for the NHS England Core Standards for Emergency Preparedness, Resilience and Response (EPRR) 1a, 1b, 1c 5a 5a 3a, 3b, 3c 1b 1c 1b 1b, 3a 1b Appetite (Category) Minimal (Safety) Current risk rating 4x5 20 Cautious (Experience) Minimal (Safety) 4x4 16 4x4 16 Open (Technology & Innovation) 3x4 12 Open (workforce) Open (workforce) Open (workforce) 4x5 20 4x3 12 4x4 16 Cautious (Effectiveness) 3x3 9 Cautious (Finance) 5x5 25 Target risk rating 4 x 2 Apr 6 27 3 x 2 Apr 6 27 2 x 3 Apr 6 27 3 x 2 Mar 6 27 4 x 3 Mar 12 30 4 x 2 Mar 8 30 3 x 2 Mar 6 29 3 x 2 Dec 6 25 3 x 3 Apr 9 30 Cautious (Effectiveness) Open (Technology & Innovation) Open (Technology & Innovation) 4x5 20 3x4 12 2x4 8 4 x 2 Apr 8 30 3 x 2 Apr 6 27 2 x 2 Dec 4 27 Does this item facilitate movement towards or away from the intended target risk score and appetite? Towards Away Neither x x x x x x x x x Minutes Trust Board – Open Session Date 11/11/2025 Time 9:00 – 13:00 Location Conference Room, Heartbeat Education Centre Chair Jenni Douglas-Todd (JD-T) Present Diana Eccles, NED (DE) Keith Evans, Deputy Chair and NED (KE) David French, Chief Executive Officer (DAF) Paul Grundy, Chief Medical Officer (PG) Steve Harris, Chief People Officer (SH) Jane Harwood, NED/Senior Independent Director (JH) Ian Howard, Chief Financial Officer (IH) Andy Hyett, Chief Operating Officer (AH) David Liverseidge, NED (DL) Tim Peachey, NED (TP) Alison Tattersall, NED (AT) Natasha Watts, Acting Chief Nursing Officer (NW) In attendance Craig Machell, Associate Director of Corporate Affairs and Company Secretary (CM) Lauren Anderson, Corporate Governance and Risk Manager (LA) (item 6.2) Martin de Sousa, Director of Strategy and Partnerships (MdS) (item 6.1) Lucinda Hood, Head of Medical Directorate (LH) (item 5.13) Diana Hulbert, Guardian of Safe Working Hours and Emergency Department Consultant (DH) (item 5.12) Vickie Purdie, Head of Patient Safety (VP) (item 7.3) Kate Pryde, Clinical Director for Improvement and Clinical Effectiveness (KP) (item 5.13) Scott Spencer, Health and Safety Advisor (SS) (item 7.3) 4 governors (observing) 2 members of staff (observing) 1. Chair’s Welcome, Apologies and Declarations of Interest The Chair welcomed attendees to the meeting. There were no interests to declare in the business to be transacted at the meeting. It was noted that no apologies had been received. The Chair provided an overview of meetings she had held and events that she had attended since the previous Board meeting. 2. Patient Story Item deferred to the next meeting. 3. Minutes of the Previous Meeting held on 9 September 2025 The draft minutes tabled to the meeting were agreed to be an accurate record of the meeting held on 9 September 2025, subject to a minor correction at 5.10. Page 1 4. Matters Arising and Summary of Agreed Actions The matters arising and actions were noted. • Actions 1281, 1283 and 1284 were closed. • Action 1282 was to be addressed through item 5.6 below. • In respect of action 1285, the Quality Committee would monitor progress on complaints response times. 5. QUALITY, PERFORMANCE and FINANCE 5.1 Briefing from the Chair of the Audit and Risk Committee Keith Evans was invited to present the Committee Chair’s Report in respect of the meeting held on 13 October 2025, the content of which was noted. It was further noted that: • In terms of the internal audit reports, which had been received by the committee, whilst there were a number of points for the Trust to address, no areas of significant concern had been identified. • There was a focus on ‘imposter fraud’ whereby individuals who had turned up to carry out a shift were not who they claimed to be. Whilst there had been no reported incidents at the Trust, the Trust had implemented controls at the ward level, which would be subject to testing during 2025/26. 5.2 Briefing from the Chair of the Finance, Investment & Cash Committee David Liverseidge was invited to present the Committee Chair’s Reports in respect of the meetings held on 22 September and 3 November 2025, the contents of which were noted. It was further noted that: • In September 2025, the Trust had reported that it was in line with its Financial Recovery Plan. Of the £110m Cost Improvement Programme (CIP) target, 76% had been fully developed. • The committee had reviewed the Finance Report for Month 6 (item 5.8), noting that the Trust had reported an in-month deficit of £5.4m, which was in line with the Financial Recovery Plan. • The committee had expressed concern that 17% of the CIP target was not fully developed and that the Trust was £2.5m off-track in terms of delivery of the target at Month 6. • Whilst progress had been made in terms of addressing patients with no criteria to reside and mental health patients, this remained an area of concern. • The committee considered the NHS England Medium Term Planning Framework, noting that the first submission by the Trust was due prior to Christmas 2025. 5.3 Briefing from the Chair of the People and Organisational Development Committee Jane Harwood was invited to present the Committee Chair’s Reports in respect of the meetings held on 22 September and 3 November 2025, the contents of which were noted. It was further noted that: • There continued to be little improvement in terms of the number of patients with no criteria to reside or mental health patients, which impacted staffing numbers. • The Trust was adopting a harder line in respect of its approach to violence and aggression, which included a greater willingness to exclude individuals. • The current participation rate in the Staff Survey was lower than the national average, which was likely indicative of staff morale and engagement. Page 2 • The Trust’s workforce numbers remained above plan, with limited options available to address this issue, especially in the absence of funding for restructuring costs. 5.4 Briefing from the Chair of the Quality Committee Tim Peachey was invited to present the Committee Chair’s Report in respect of the meeting held on 13 October 2025, the content of which was noted. It was further noted that: • The committee received an update in respect of mental health patients, noting that although there were significant issues in the Emergency Department, the whole pathway for these patients remained a problem. • The committee carried out a six-monthly review of the Trust’s progress against its Quality Priorities, noting that good progress had been made on four of the six priorities and two were slightly behind. 5.5 Chief Executive Officer’s Report David French was invited to present the Chief Executive Officer’s Report, the content of which was noted. It was further noted that: • NHS England had published the Medium Term Planning Framework, which was intended to encourage organisations to think beyond a 12-month time horizon and to progress the NHS 10-Year Plan. The Trust was expected to provide its first submission prior to Christmas 2025, but the detailed planning assumptions had yet to be received from NHS England. It was noted that a more detailed report on the Medium Term Planning Framework was to be received as part of the closed session of the meeting. • The Strategic Commissioning Framework had been published by NHS England, which provided welcome clarifications about the future role of integrated care boards. • The Trust had been placed into Tier 1 for both Urgent and Emergency Care and for Elective performance. There was a national expectation that trusts would have no patients waiting over 65 weeks for elective care by 21 December 2025. Where organisations had more than 100 such patients at the end of October 2025, they had been placed into Tier 1. The Trust was taking steps, including mutual aid, to attempt to address the number of long waiters, but there was insufficient capacity in the system. • Resident doctors were due to strike for a further five-day period commencing on 14 November 2025, having rejected the Government’s latest offer to resolve the ongoing dispute with the British Medical Association. • The Hampshire and Isle of Wight Integrated Care Board and NHS England South East Region had carried out a visit to the Trust’s paediatric hearing services in May 2025. The report, received in October 2025, had been positive about the service. • The Trust and the University of Southampton had been awarded £16.3m by the National Institute for Health and Care Research. The Trust was one of only four organisations out of 15 applications to receive an award. • The NHS Business Services Authority had announced the award of a £1.2bn contract to Infosys to deliver a new and enhanced workforce management system for the NHS to replace the existing Electronic Staff Record system. The 2030 target date for implementation was considered ambitious. Further details would be considered by the People and Organisational Development Committee when available. Page 3 5.6 Performance KPI Report for Month 6 Andy Hyett was invited to present the ‘spotlight’ report in respect of Diagnostics, the content of which was noted. It was further noted that: • Diagnostics performance was a key element of the pathway, as delays in diagnosis had a consequential impact on the overall length of pathways such as those for cancer and patients on a Referral To Treatment pathway. • Although there were some concerns with Diagnostics in the Trust, the Trust, generally, performed better than other organisations. The Board discussed the matters raised in the Diagnostics ‘spotlight’. This discussion is summarised below: • There had been a long-standing issue with waiting times for cystoscopy due to insufficient capacity. However, a plan was being developed to improve the situation, although it was considered appropriate that the plan should also address broader issues with urology as a whole. • There was concern regarding the availability of magnetic resonance imaging (MRI) scanners, particularly as two scanners were out-of-action. It was noted that the current set-up in terms of MRI scanners was not fit for the longer term and a strategy for the future needed to be developed. • There was a disparity between capacity and demand in respect of the neurophysiology service, as this service had previously relied on outsourcing. • Generally, activity was increasing, but overall performance appeared to be declining. There was also the additional financial challenge that Diagnostics was funded under a ‘block’ contract arrangement which did not fully take into account the demand for these services. • There were concerns about the electrical supply capacity at the Southampton General Hospital site and the ability of the Trust to expand its Diagnostic capacity with this limitation. It was considered that a better longer-term model would be for scanners at local community diagnostics centres. Actions Andy Hyett agreed to work on and present at either a future Board meeting or Trust Board Study Session the Trust’s longer-term strategy with respect to MRI scanners and imaging. Andy Hyett agreed to develop a longer-term plan for cystoscopy/urology and to report back to the Board during Quarter 4. Andy Hyett agreed to develop a long-term solution to the neurophysiology service. Andy Hyett was invited to present the Performance KPI Report for Month 6, the content of which was noted. It was further noted that: • The Trust’s Emergency Department had recorded performance of 67.6% against the four-hour standard during September 2025. The department remained busy with c.450 patients and 120 ambulance attendances per day. • There had been some initial performance impacts with the roll out of the MIYA system in the Emergency Department, but this appeared to have now been addressed with performance up to previous levels. • A number of initiatives were being introduced into the Emergency Department in order to improve performance. These included the layout of the service, pathway re-designs, having General Practitioners in the department, and arranging with non-urgent patients to attend at a scheduled time rather than waiting in the department. Page 4 • In October 2025, the Trust had recorded 363 patients waiting over 65 weeks on a Referral To Treatment pathway against a national target of no such patients by the end of December 2025. • The Trust was making use of the independent sector, weekend working, and was requesting capacity from other providers to address the number of patients waiting over 65 weeks. • The planned industrial action by resident doctors posed a challenge, noting that the national expectation was that trusts maintain 95% of their capacity during this period. It was noted that, in contrast to previous instances of industrial action, resident doctors were apparently less forthcoming in terms of whether they intended to participate in the industrial action. • The Trust continued to report one of the lowest Hospital Standardised Mortality Rates in England. • The Trust’s cancer performance, based on a BBC article, was 21 out of 121 trusts. It was noted that whilst the number of patients being referred on a cancer pathway had increased significantly, the number of patients diagnosed with cancer had not materially changed. • There appeared to have been an increase in the number of pressure ulcers and ‘red flag’ incidents. Work was ongoing to address the findings of the pressure ulcer audit which had been presented to the Quality Committee on 2 June 2025. • The number of patients having no criteria to reside and mental health patients remained high. Actions Andy Hyett agreed to clarify the basis of the calculation of the ‘Watch & Reserve antibiotics usage per 1,000 adms’ metric. 5.7 Break 5.8 Finance Report for Month 6 Ian Howard was invited to present the Finance Report for Month 6, the content of which was noted. It was further noted that: • The Trust had submitted its Financial Recovery Plan to NHS England in August 2025, which committed to an additional £23m improvement in the Trust’s financial position to deliver a full-year position of a £54.9m deficit. In the absence of these additional improvements, the Trust had been forecasting a year-end position of a £78m deficit. The revised target was subject to a number of assumptions, including the need for demand management and improvements in non-criteria to reside and mental health patient numbers. • There were a number of risks to the achievement of the Financial Recovery Plan, including whether there would be improvements in mental health and non-criteria to reside and/or steps taken to manage demand, high levels of activity, and whether it would be possible to reduce the workforce and close theatres. The need for the Trust to focus on achieving the 65-week wait target in particular could impact the Trust’s ability to close capacity. • The Trust had reported an in-month deficit of £5.4m (£30.8m year-to-date), which was in line with the trajectory set out in the Financial Recovery Plan. The Trust’s underlying deficit had seen some marginal improvement during the period. • The Trust’s cash position remains an area of significant concern. Cash requests had been made to NHS England, but the latest request for November 2025 had been rejected. It was therefore likely that the Trust would need to manage its supplier payments in accordance with its available cash. Page 5 5.9 ICS System Report for Month 6 Ian Howard was invited to present the ICS System Report for Month 6, the content of which was noted. It was further noted that: • The Hampshire and Isle of Wight Integrated Care System had reported a year- to-date deficit of £48m. • A significant improvement in the run-rate would be required for the system to be able to deliver its 2025/26 plan. • The system was one of the worst in England in terms of the number of beds occupied by patients having no criteria to reside with approximately 23% of beds being occupied by such patients compared with a national average of 12%. • The system was also below plan in terms of its targets for access to General Practitioners and targets relating to mental health patients. It was noted that the performance in these areas had a consequential impact on the Trust’s performance in areas such as urgent and emergency care performance. 5.10 People Report for Month 6 Steve Harris was invited to present the People Report for Month 6, the content of which was noted. It was further noted that: • The overall workforce fell by 73 whole-time-equivalents (WTE) during September 2025 and was reported as being 54 WTE above the Trust’s 2025/26 plan. The reduction in workforce had been driven through a combination of the impact of the recruitment controls, mutually agreed resignation scheme (MARS) leavers, and a significant drop in use of temporary staff during the month. • On 15 October 2025, the Trust had heard the collective grievance brought by the Royal College of Nursing in respect of the removal of enhanced NHS Professionals rates. It was decided not to reverse the decision in order to maintain equity with the rest of the workforce and consistency across other local providers. A number of actions had been agreed following the hearing. • Sickness rates had increased to 3.8%, although the Trust still benchmarked well against peers. • There were concerns about the potential impact of influenza during the winter period and therefore the Trust was taking a number of actions to promote vaccination of staff. The Trust was currently third in terms of uptake in the Region. • The level of participation in the national Staff Survey remained a challenge with only 32% of staff having completed the survey compared with a national average of 38%. It was considered likely that the recent difficult decisions taken and the impact on staff was impacting staff experience and engagement. • The People and Organisational Development Committee would be examining statutory and mandatory training levels together with the latest proposed national changes. Page 6 5.11 NHSE Audit and review of 'Developing Workforce Safeguards' including UHS Self-Assessment Return Natasha Watts was invited to present the NHS England audit and review of ‘Developing Workforce Safeguards’ (2018), including the Trust’s Self-Assessment Return, the content of which was noted. It was further noted that: • ‘Developing Workforce Safeguards’ was published in October 2018 and included a range of standards to assure safe staffing across the workforce. NHS England had initiated an audit, review and improvement plan amidst concern about a national reduction in compliance. • The Trust had submitted a self-assessment as part of this NHS England review. This assessment showed that the Trust continued to comply with the majority of the standards. • The audit exercise has been used as an opportunity to identify opportunities for improvement. Twelve recommendations have been developed, of which nine were assessed as ‘green’ and three as ‘amber’. 5.12 Guardian of Safe Working Hours Quarterly Report and Update on 10-Point Plan Diana Hulbert was invited to present the Guardian of Safe Working Hours Quarterly Report and Update on the 10-Point Plan, the content of which was noted. It was further noted that: • Resident doctors were due to strike for five days from 14 November 2025. This would be the thirteenth strike in recent years. It was noted that, in addition to pay, the dispute also concerned working conditions and the shortage of posts and consequent risk to resident doctors of unemployment. • The Trust had performed a self-assessment against the 10-Point Plan and it was noted that the majority of the plan’s contents had been considered by the Trust for some time. There were also a number of dependencies on the part of NHS England in areas such as lead employer models. • A national review of statutory and mandatory training was expected to enable portability of training records to facilitate staff moving between NHS organisations. • There had been significant improvements in respect of gaps in rotas. 5.13 Annual Clinical Outcomes Summary Luci Hood and Kate Pryde were invited to present the Annual Clinical Outcomes Summary Report, the content of which was noted. It was further noted that: • The paper provided an overview of the clinical outcomes reviewed by the Clinical Assurance Meeting for Effectiveness and Outcomes (CAMEO) over the 12-month period to September 2025. • The majority of specialities provide reports to CAMEO, although outcome data can be more difficult in some areas to capture than in others. • The outcomes reviewed by the CAMEO and outputs from this body were also influencing the development of the Trust’s clinical strategy. • The strains on the capacity of services posed a risk to clinical outcomes. Page 7 • There was potential that a ‘quality’ override could form part of the NHS Oversight Framework in the future, operating in a similar manner to the ‘financial’ override by limiting the segmentations available to an organisation. 6. STRATEGY and BUSINESS PLANNING 6.1 Corporate Objectives 2025-26 Quarter 2 Review Martin De Sousa was invited to present the review of Corporate Objectives 2025/26 for the second quarter, the content of which was noted. It was further noted that: • Of the 12 objectives agreed for 2025/26, six were rated ‘green’, four were ‘amber’ and two were ‘red’. • The ‘red’ rated risks were that relating to the Trust’s financial performance and that relating to the Trust’s achievement of its workforce plan for 2025/26. 6.2 Board Assurance Framework (BAF) Update Lauren Anderson was invited to present the Board Assurance Framework update, the content of which was noted. It was further noted that: • BDO had completed its audit of the Trust’s risk maturity and had presented its report to the Audit and Risk Committee on 13 October 2025. The audit had highlighted a number of strengths including the Board Assurance Framework, risk definition, and use of risk in decision-making. In terms of opportunities for improvement, the audit report suggested some improvements in articulation of operational risks and use of ‘SMART’ methodology for actions. • The Board Assurance Framework had been reviewed by relevant executive directors and committees since it was last presented to the Board. There had been no changes to the ratings or target dates. 7. CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Feedback from the Council of Governors’ (COG) Meeting 28 October 2025 The Chair presented a summary of the Council of Governors’ meeting held on 28 October 2025. It was noted that the meeting had considered the following matters: • Chief Executive Officer’s Performance Report • Governor attendance at Council of Governors’ meetings • Review of the Council of Governors’ Expenses Reimbursement Protocol • Appointment of Jane Harwood as Deputy Chair with effect from 1 October 2025 • Membership engagement • Feedback from the Governors’ Nomination Committee It was noted that the Trust’s work on violence and aggression received particular attention from the Governors. 7.2 Register of Seals and Chair’s Action Report The paper ‘Register of Seals and Chair’s Actions Report’ was presented to the meeting, the content of which was noted. Page 8 It was further noted that one further item had been sealed on 7 November: Deed of Guarantee between University Hospital Southampton NHS Foundation Trust (Guarantor) and CHG-Meridian UK Limited (Beneficiary) regarding the payment and due performance obligations of UHS Estates Limited (UEL) under the Guaranteed Contract and specifically the Stryker Power Tools delivered to UEL under the pre-contract open build period with CHG. Seal number 307 on 7 November 2025. Decision: The Board agreed to ratify the application of the Trust Seal to the documents listed in the ‘Register of Seals and Chair’s Actions Report’ and to the additional document referred to above. 7.3 Health and Safety Services Annual Report 2024-25 Spencer Scott was invited to present the Health and Safety Services Annual Report 2024/25, the content of which was noted. It was further noted that: • The number of incidents reportable pursuant to the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) had increased substantially to 68 such incidents compared to 39 in 2023/24. The majority of these incidents related to moving and handling or exposure to infectious diseases. • There was a concern that there had been a reduction in the number of health and safety related reports and escalations whilst at the same time the number of RIDDORs had increased. • Four areas of concern were highlighted: Entonox surveillance of maternity staff, display screen equipment compliance, the Southampton General Hospital loading bay, and workplace temperatures during the summer. 8. Any other business There was no other business. 9. Note the date of the next meeting: 13 January 2026 10. Items circulated to the Board for reading The item circulated to the Board for reading was noted. There being no further business, the meeting concluded. 11. Resolution regarding the Press, Public and Others Decision: The Board resolved that, as permitted by the National Health Service Act 2006 (as amended), the Trust’s Constitution and the Standing Orders of the board of directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. The meeting was adjourned. Page 9 List of action items Agenda item Assigned to Deadline Status Trust Board – Open Session 15/07/2025 - 5.11 Freedom to Speak Up Report 1267. Data Mbabazi, Christine 10/03/2026 Pending Explanation action item Christine Mbabazi to include data from other mechanisms for reporting concerns in future Freedom to Speak Up reports. Trust Board – Open Session 09/09/2025 - 8 Any other business 1286. Organ donation Machell, Craig 03/02/2026 Pending Explanation action item Craig Machell agreed to add organ donation to the agenda of a future Trust Board Study Session. Update: Scheduled for TBSS on 03/02/26. Trust Board – Open Session 11/11/2025 - 5.6 Performance KPI Report for Month 6 1293. MRI scanners and imaging Hyett, Andy 13/01/2026 Pending Explanation action item Andy Hyett agreed to work on and present at either a future Board meeting or Trust Board Study Session the Trust’s longer-term strategy with respect to MRI scanners and imaging. 1294. Cystopscopy/urology Hyett, Andy 13/01/2026 Pending Explanation action item Andy Hyett agreed to develop a longer-term plan for cystoscopy/urology and to report back to the Board during Quarter 4. Page 1 of 2 Agenda item Assigned to Deadline Status Trust Board – Open Session 11/11/2025 - 5.6 Performance KPI Report for Month 6 1295. Neurophysiology Hyett, Andy 13/01/2026 Pending Explanation action item Andy Hyett agreed to develop a long-term solution to the neurophysiology service. 1296. Watch & Reserve antibiotics usage Hyett, Andy 13/01/2026 Pending Explanation action item Andy Hyett agreed to clarify the basis of the calculation of the ‘Watch & Reserve antibiotics usage per 1,000 adms’ metric. Page 2 of 2 Agenda Item 5.1 i) Committee Chair’s Report to the Trust Board of Directors 13 January 2026 Committee: Finance, Investment and Cash Committee Meeting Date: 24 November 2025 Key Messages: Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) Any Other Matters: • The committee received an update in respect of the Trust’s commercial activities, noting that the Trust had robust systems in place to maximise cost recovery for private patient and overseas visitor income. The Trust’s private patient unit project continued to progress. The Trust was also seeking a partner to manage its parking provision. • The committee received the Finance Report for Month 7. The Trust had reported a £5.1m in-month deficit (£35.9m year-to-date), which was in line with the trajectory contained in the Financial Recovery Plan. The underlying deficit remained flat at £6.4m. Whilst there had been a slight reduction in the number of mental health patients, there were c.240 patients having no criteria to reside at any point during the period. There was an increased level of scrutiny in respect of non-pay expenditure. • The committee reviewed an update on the Trust’s measures for financial improvement, noting that the Trust was forecasting achievement of £85-95m against its target of £110m Cost Improvement Programme delivery for 2025/26. • The committee noted the Trust’s approach and the timelines associated with the Medium Term Planning submission. It was noted that the framework set ambitious financial and performance targets. • The committee received an update in respect of the Trust’s Theatre Experience Programme, noting that there had been a 3% increase in utilisation and a 3% reduction in cancellations. • The committee reviewed the Trust’s productivity, noting that the Trust’s productivity had fallen by 3.3% compared to the prior year due to high-cost growth. • The committee received an update in respect of the Trust’s cash position and forecast and supported a proposal to request further cash support for January 2026. • The committee received an update on Capital Planning for 2026/272029/30. It was noted that it was expected that the Trust would be allocated c.£40m per annum, although there were concerns about the impact of the Trust’s cash position and the ability of the Trust to meet this level of expenditure. N/A N/A Page 1 of 2 Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Limited Assurance Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. No Assurance There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Not Applicable Where assurance is not required and/or relevant. Risk Rating: Low Medium High Not Applicable Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda Item 5.1 ii) Committee Chair’s Report to the Trust Board of Directors 13 January 2026 Committee: Finance, Investment and Cash Committee Meeting Date: 15 December 2025 Key Messages: • • • • • • The committee received the Finance Report for Month 8 (see below). The committee discussed the Trust’s future transformation programmes, noting that the areas of focus would be: urgent and emergency care, elective care, and automation of administrative processes. The committee was assured that the programmes were felt to be suitably ‘bold and ambitious’ and were grounded in realistic opportunities, rather than ‘blue sky’ ideas. The committee reviewed the draft capital plan for 2026/27 – 2029/30, noting that the Trust had been allocated c.£40m of capital departmental expenditure limit (CDEL) per year. It was noted that the Trust’s cash position could place constraints on the Trust’s capital programme. The opportunity to secure funding from national programmes outside of CDEL should be pursued vigorously. The plan was to be discussed in a Trust Board Study Session prior to submission in February 2026. The committee reviewed, challenged and discussed the Trust’s medium-term plan ahead of the first submission to NHS England on 17 December 2025. The committee provided feedback in respect of the proposed submission noting that some of the assumptions within the 2025/26 plan had not materialised with regard to matters such as reductions in non-criteria to reside numbers and the committee sought assurance that learnings had been applied to the development of the medium-term plan submission. The committee was assured that such assumed reductions within the 2026/27 plan were based purely on actions which were deemed to be within the Trust’s control. The committee suggested some changes with regard to the plan, particularly around growth assumptions in the cost base, and agreed to recommend the revised plan to the Board for approval. It was noted that more detail and reviews would be required prior to the final submission date in February 2026. The committee received an update in respect of the Trust’s cash position and supported a proposal to make a further request for cash support from NHS England for January 2026. The Trust reviewed and supported a proposal for transforming the Southern Counties Pathology network. Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) 5.7 Finance Report for Month 8 Assurance Rating: Risk Rating: Substantial High • The Trust had reported an in-month deficit of £4.9m (£40m year-todate), which was consistent with the Trust’s Financial Recovery Plan. • November 2025 had been a challenging month due to costs associated with industrial action, patients with no criteria to reside and mental health patients. • The Trust had received c.£3m of income out of £6.1m for elective over-performance. • There had been a slight improvement in the Trust’s underlying deficit. Page 1 of 2 Any Other N/A Matters: Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Limited Assurance Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. No Assurance There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Not Applicable Where assurance is not required and/or relevant. Risk Rating: Low Medium High Not Applicable Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda Item 5.2 i) Committee Chair’s Report to the Trust Board of Directors 13 January 2026 Committee: People & Organisational Development Committee Meeting Date: 21 November 2025 Key Messages: • • • • The committee reviewed the People Report for Month 7 including progress against the workforce plan. During October 2025, the overall workforce grew by 14 whole-time-equivalents (WTE). Although the substantive workforce had reduced by 15 WTE, there had been lowerthan-expected turnover and increased temporary staffing usage due in part to high sickness levels. The Trust remained on track, however, with respect to its Financial Recovery Plan trajectory. There were concerns about the response rate to the Staff Survey, which was below the national average. The Trust’s vaccination campaign for staff had started well with the uptake rate for the flu vaccine amongst staff at 43%. The committee considered the outputs of the review by NHS England of statutory and mandatory training and the implications for UHS. It was noted that a revised framework would facilitate passporting of training between NHS organisations. The Trust was aligned to the Core Skills Training Framework across six out of eleven areas and ten out of eleven areas for the Utilising E-Learning for Health material. The committee received an update in respect of the Trust’s Inclusion and Belonging strategy. It was noted that resource constraints and the impact of the current financial and operational environment on staff morale had impacted progress towards achievement of the objectives set out in the strategy. The committee reviewed the People risks contained within the Trust’s Board Assurance Framework. Assurance: N/A (Reports/Papers reviewed by the Committee also appearing on the Board agenda) Any Other N/A Matters: Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Limited Assurance Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. Page 1 of 2 No Assurance Not Applicable Risk Rating: Low Medium High Not Applicable There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Where assurance is not required and/or relevant. Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda Item 5.2 ii) Committee Chair’s Report to the Trust Board of Directors 13 January 2026 Committee: People & Organisational Development Committee Meeting Date: 15 December 2025 Key Messages: Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) • The committee reviewed the People Report for Month 8 (see below) including progress against the workforce plan and Financial Recovery Plan. • The committee considered the workforce implications of the Trust’s medium term plan submission, noting that there were a number of national expectations and targets, such as those relating to sickness rates and elimination of agency spend. In addition, the committee noted the risks associated with the plan, including those where the Trust was reliant on progress with respect to non-criteria to reside and mental health numbers. • The committee received an update regarding the Trust’s Violence and Aggression workstream, noting that the Trust had adopted a revised approach to violence, aggression and abuse directed at staff with a greater willingness to take action against violent/abusive patients and members of the public. A violence and aggression board had been established to provide executive oversight and leadership, and the Trust’s policy was being revised. This work would be accompanied by a comprehensive communication plan for both staff and members of the public. • The committee reviewed the Trust’s progress against its objectives for Year 4 of its People Strategy. 5.9 People Report for Month 8 Assurance Rating: Risk Rating: Substantial High • The overall workforce fell during November 2025, with substantive numbers falling by 52 whole-time-equivalents (WTE). However, temporary staffing use had increased during the month due to increased sickness and operational pressures, which offset much of the reduction in substantive numbers. • The Trust was over its original plan by 214 WTE despite a decrease of nearly 400 WTE since 31 March 2025. In order to hit the Trust’s Financial Recovery Plan target, the overall workforce would need to fall by a further 137 WTE (including a 72 WTE reduction in temporary staffing) by the end of March 2026. • A forecast based on the previous year’s temporary staffing usage for the remaining months of the year indicated that the Trust would end the year approximately 500 WTE above the Trust’s 2025/26 plan. • The Trust had submitted a baseline assessment against the 10 Point Plan to improve Resident Doctors’ working lives in August 2025, which indicated that the Trust compared favourably against other organisations in the South East. The main issues concerned space available for doctors to work in and timeliness of reimbursement of course-related expenses. • The Trust was expected to meet a target of 95% of job plans having been signed off prior to 31 March 2026. At the start of December 2025, 55% of job plans had been signed off. Page 1 of 2 Any Other Matters: • Sickness absence had increased in November 2025 to 4.2% in month due to seasonal illnesses. • The staff survey closed on 28 November 2025. The completion rate for the staff survey had been lower t
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Trust-governance-and-corporate-docs/2026-Trust-documents/Papers-Trust-Board-13-January-2026.pdf

Going home from E1 Ocean ward - patient information

Description: This booklet explains how to prepare for your child going home following a stay on E1 Ocean ward.
Url: /Media/UHS-website-2019/Patientinformation/Childhealth/Going-home-from-E1-Ocean-ward-1265-PIL.pdf

A la carte menu

Description: DESSERTS & DRINKS DESSERTS HOT DESSERTS All served with custard or ice cream MON: Lemon Sponge ED V TUE: Syrup Sponge ED V WED: Apple Crumble ED V THU: Pineapple Sponge ED V FRI: Somerset Cake ED V SAT: Jam Sponge ED V SUN: Rhubarb Crumble ED V DAILY: Rice Pudding ♥ EC V COLD DESSERTS Fresh Fruit ♥ V EC option available Thick & Creamy Yogurt EC V Peaches in Light Syrup ♥ EC V Low Fat or Natural Yogurt ♥ EC V Jam Doughnut V Ice Cream EC V Chocolate Dessert Chocolate Brownie Pot EC V ED V Cheese & Crackers Caramel Sundae V EC V Ice cream also served with fruit DRINKS Coffee Decaf available Tea Decaf available Fruit or Herbal Tea Milk Hot Chocolate Squash or Malted Drink Non-dairy milk options are available on request. Drinks will be offered to you with your meals and throughout the day. Breakfast Lunch Supper 08:00 – 09:00 12:00 – 14:00 17:00 – 19:00 YOUR WARD HOST TEAM The team are here to help you during your stay, please make them aware of any special requirements. Your lunch order will be taken after breakfast and your supper order after your lunch. You can request your meal portion in small, medium or large. HOW DID WE DO? Your feedback is important to us, please scan the QR code and complete our patient satisfaction survey. Alternatively your Ward Host can complete the survey with you. CARBOHYDRATE INFORMATION This information is available if required for the management of your diabetes treatment, please speak to your Ward Host who can provide you a copy. ADDITIONAL MENUS We have the following alternative menus available: Allergen Free Vegan Gluten Free Low Potassium Low Fibre Kosher Level 4 Pureed World Food & Halal Level 6 Soft & Bite-Sized MISSED A MEAL? Speak to your Ward Host or Nurse and they will arrange a hot meal or snack box for you. ALLERGEN INFORMATION If you have a food allergy or intolerance, please advise your Nurse on admission and always inform your Ward Host before you place a meal order. Allergen Free menu available. FISH BONES Although every care has been taken to remove fish bones from our fish dishes, some may remain. Therefore, please take care when consuming fish dishes. Please speak with your Ward Host or nursing staff if you have any concerns. Inpatient Dining A LA CARTE A LA CARTE 15 BREAKFAST & SNACKS Select any four of these: CEREALS BREAD OR TOAST Branflakes Cornflakes Porridge EC Rice Krispies Weetabix EC Various milk options available including non-dairy. White Wholemeal Available with butter or sunflower spread and a selection of jams, marmalade, honey and marmite. Bread is EC. YOGURT FRESH FRUIT Thick & Creamy EC Various options Low Fat ♥ EC available, including ♥ EC. Natural ♥ EC Various flavours available. All options are V. Fruit Juice (apple or orange) and hot drinks are served with your breakfast. SNACKS Biscuits V Cake Slice V Crisps V Fresh Fruit ♥ V Malt Loaf ♥ V Yogurt EC V EC options available. A selection of snacks are served with your mid-morning and midafternoon drink. LUNCH & SUPPER STARTERS Soup ED EC Bread Roll V served with butter or sunflower spread V Apple or Orange Juice ♥ V LUNCH MAIN MEALS Vegetable Curry ♥ V Cauliflower Cheese EC V Potato Topped Chicken Pie ED EC Roast Chicken Breast in Gravy ♥ Sausage Roll ED Beef Bolognaise with Pasta ♥ EC SUPPER MAIN MEALS Penne Pasta in Tomato & Basil Sauce ♥ EC V Macaroni Cheese ED EC V Chicken Curry ♥ EC Fishcakes ♥ EC Sausages in Onion Gravy Cottage Pie ♥ EC SALAD Egg ♥ V Tuna ♥ Chicken ♥ Ham Salad base of lettuce, sweetcorn, carrots, cucumber, tomatoes + your topping choice OMELETTE Plain Omelette ♥ EC V Cheese Omelette ♥ EC V JACKET POTATOES Plain Potato ♥V Cheddar Cheese ED V Baked Beans ♥V Tuna Mayonnaise ♥ ED Served with your choice of fillings, butter V or sunflower spread V SANDWICHES Egg Mayonnaise Tuna Mayonnaise ED EC V ED EC Cheese ED V Chicken ♥ British Ham ♥ EC Ham & Cheese ED Available on white or wholemeal bread. Option of side salad V or pickle V to your sandwich Please choose one starter + one main meal from either the daily specials, main meals, omelettes, jacket potatoes, sandwiches or salads + accompaniments + one dessert DAILY SPECIALS MONDAY Vegetable Lasagne ED EC V Tuna Pasta Bake ♥ Vegetable of the day: Sweetcorn ♥ V TUESDAY Creamy Vegetable Cheese Bake EC V Shepherd’s Pie EC Vegetable of the day: Peas ♥ V WEDNESDAY Cauliflower & Broccoli Pasta V Corned Beef Hash ED EC Vegetable of the day: Carrots ♥ EC V THURSDAY Potato, Cheese & Leek Bake ED V Pork Meatballs in Tomato & Herb Sauce ♥ EC Vegetable of the day: Green Beans ♥ V FRIDAY Vegan Sausage Roll ED V Battered Haddock Vegetable of the day: Mushy Peas EC V SATURDAY Bean Chilli ♥ V Chicken Korma ♥ EC Vegetable of the day: Sweetcorn ♥ V SUNDAY Vegetable Cottage Pie ♥ EC V Roast Pork in Gravy ♥ Vegetable of the day: Brussel Sprouts ♥ EC V ACCOMPANIMENTS POTATOES & RICE choose one option Boiled Potatoes ♥ EC V Mashed Potato ED EC V Jacket Potato ♥ V Roast Potatoes ED V White Rice ♥ EC V Chips ED V VEGETABLES choose up to two options Baked Beans ♥ EC V Mashed Root Vegetables ♥ EC V Mixed Vegetables ♥V Vegetable of the day ♥ V SIDES as desired Bread Roll V Coleslaw ED V Pickle V Side Salad ♥ V A selection of dressings, condiments, and butter or sunflower spread are available Codes used in this menu ED Energy Dense: more nourishing than those coded ♥ as they contain more calories and/or protein. Suitable for patients with a reduced appetite. ♥ Healthy Options: contain moderate amounts of fat, sugar and salt. Suitable as part of a healthy balanced diet and for patients with diabetes. EC Easy to Chew: tender, easier to cut and eat food options. Suitable for patients who have difficulty coping with firm foods (e.g. patients who have no teeth, loose dentures or sore mouth) or patients with swallowing difficulties. Refer to our modified texture menus if you need a Level 4 or Level 6 meal. V Vegetarian: free from meat, poultry, fish and all products derived from these. Suitable for vegetarians that consume milk, eggs and their products. Vegan menu available. Spicy: some patients may find this spicy.
Url: /Media/UHS-website-2019/Patientinformation/Patient-menus/A-la-carte-menu.pdf

The home nasogastric tube feeding programme - patient information

Description: This factsheet provides some initial information on nasogastric tube (NGT) feeding at home.
Url: /Media/UHS-website-2019/Patientinformation/Neonatal/The-home-nasogastric-tube-feeding-programme-2521-PIL.pdf

Southampton sarcoma service - patient information

Description: This factsheet explains what the Southampton sarcoma service is, what we offer and what to expect during a personalised care appointment.
Url: /Media/UHS-website-2019/Patientinformation/Cancercare/Southampton-sarcoma-service-3925-PIL.pdf

Quality account 24-25 final

Description: QUALITY ACCOUNT 2024/25 QUALITY ACCOUNT Contents Part 1: Statement on quality from the chief executive 1.1 Chief executive’s statement and welcome 3 Part 2: Priorities for improvement and statements of assurance from the Board 2. Introduction 5 2.1 Priorities for improvement 6 2.1.1 Progress against 2024/25 priorities 6 2.1.2 Quality Improvement Priorities - 2024/25: Final Reports 8 2.2 Priorities for improvement for 2025/26 28 2.3 Statements of assurance from the Board 47 2.3.1 Review of services 47 2.3.2 Participation in national clinical audits and confidential enquiries 47 2.3.3 Recruiting to research 52 2.3.4 Commissioning for Quality and Innovation (CQUIN) payment framework 52 2.3.5 Statements from the Care Quality Commission (CQC) 52 2.3.6 Payment by results 53 2.3.7 Data quality 54 2.3.8 Data Security and Protection Toolkit (DSPT) 54 2.4 Overview of Quality Performance 55 2.4.1 Single Oversight Framework 55 2.4.2 Reporting against core indicators for 2024/25 55 2.4.3 Learning from deaths 67 2.4.4 Seven-day hospital services 70 2.4.5 Freedom to Speak Up 72 2.4.6 Rota gaps 74 2.4.7 Duty of Candour 76 Part 3: Other information 3.1 Our commitment to safety 77 3.2 Our commitment to improving the experience of the people who use our services 81 3.3 Our commitment to improve the quality of our patients’ environment 83 3.4 Our commitment to sustainability and the environment 85 3.5 Our commitment to staff 89 3.6 Our commitment to education and training 91 3.7 Our commitment to clinical research 98 3.8 Our commitment to technology 102 3.9 Conclusion 103 Part 4: Appendices 104 2 QUALITY ACCOUNT Part 1: Statement on quality from the Chief Executive 1.1 Chief Executive’s statement and welcome I am pleased to present this year’s quality account, which reflects our ongoing commitment to delivering safe, effective and compassionate care for our patients. 2024/25 has been a challenging year for UHS and the wider NHS and social care system. We have navigated operational pressures, with increasing numbers of patients who are medically fit but do not have an onward care package in place to be discharged, alongside a rise in winter infections and a record number of attendances to our emergency department. In the face of these challenges, our teams have worked tirelessly to enhance patient outcomes, improve service accessibility and ensure that the care patients receive meets the highest standards. I want to recognise the hard work of our staff in ensuring safety, driving innovation, and adapting to changes. This report highlights successful initiatives that have improved patient care over the past year. It also provides an overview of our quality priorities for 2024/25 and sets out our quality improvement priorities for 2025/26. We are proud to have maintained our focus on quality and achieved most of our objectives, enhancing the experience for those who use our services. Patient experience is an important priority for UHS. In 2024/25 we have successfully recruited approximately 2,000 ‘involved patients’, which will ensure that we co-design our services with those who use them, keeping our focus on our Trust values of patients first, working together and always improving. 2025/26 promises to be an exciting year for patient experience, with the development of the Patient and Family Support Hub, which will integrate voluntary services and ensure equitable access to support services for all. Our long-standing commitment to delivering safe, high-quality care is underpinned by the Fundamentals of Care programme - eight care commitments that patients, families and carers can expect from their care at UHS and these statements have been written in conjunction with patients, relatives and staff. In 2024/25 the programme has made significant progress in embedding Fundamentals of Care into our organisational culture. This has been achieved through developing understanding with newly registered professionals in our preceptorship programme, support worker development opportunities and the ongoing empowerment of staff through leadership development. In 2024/25, we have continued to strengthen our internal quality assurance programmes by aligning the clinical accreditation scheme with the CQC single assessment methodology. We are collaborating with other internal programmes - such as infection control, Patient-Led Assessments of the Care 3 QUALITY ACCOUNT Environment (PLACE) and friends and family feedback - to triangulate data and enhance oversight of key quality metrics, including patient safety, effectiveness, patient experience, and outcomes. This approach provides us with valuable intelligence to help us uphold our Trust values. 2024/25 marked one year of Patient Safety Incident Response Framework (PSIRF) implementation at UHS which has helped develop ‘just and learning’ culture across the organisation. Safety awareness has increased through our education programmes that have achieved good attendance and feedback. This coming year we will continue to build on the work that has been undertaken as part of implementation of the national safety standards for invasive procedures (NATSSIPS) 2. We continue to collaborate with our partners and develop our work as an integral organisation in the integrated health and social care system, building on trusted relationships across organisational boundaries are essential in improving health outcomes for our whole population. I want to recognise the amazing dedication of our staff in maintaining the safety of both colleagues and patients, fostering innovation, and adapting to evolving circumstances. Throughout this year, our teams across all services have strengthened their collaboration with our partners. As we continue to advance towards an integrated health and social care system, these trusted relationships are proving essential in our ability to respond effectively. To the best of my knowledge, the information contained in this document accurately reflects our performance, provides a true account of the quality of the health care services we provide, and where we have succeeded and exceed in delivery on our plans. David French Chief Executive Officer 26 June 2025 4 QUALITY ACCOUNT Part 2: Priorities for improvement and statements of assurance from the Board 2. Introduction Despite it being an extremely challenging year and unprecedented demand in the emergency department during 2024/25, the Trust maintained a strong focus on quality assurance. This was undertaken through established programmes and clinical leadership oversight of key safety and patient experience indicators, including falls, pressure ulcers, and venous thromboembolisms. The Fundamentals of Care initiative continued to be embedded, supported by high-quality peer reviews and weekly matron-led quality walkabouts aligned with CQC domains. The clinical accreditation scheme (CAS) was enhanced with updated documentation reflecting learning from themed walkabouts and aligned with national frameworks. A new governance framework for mortality and morbidity meetings was introduced to improve learning dissemination and escalation. The Trust also opened a Patient and Family Support Hub (P&FSH), advanced volunteer recruitment through a system-wide passporting approach, and began implementing NatSSIPs 2. In response to rising violence against staff, de-escalation training was rolled out, leading to a reduction in physical restraint and violence incidents. The Trust’s commitment to continuous improvement was demonstrated through training over 1,000 staff, outperforming NHS averages in improvement metrics, and achieving measurable service enhancements, including a 5.25% reduction in average length of stay, increased theatre throughput, and expanded use of patient initiated follow up pathways. Every year all NHS hospitals in England must prepare and publish an annual report for the public about the quality of their services. This is called the quality account and makes us at UHS more accountable to our patients and the public which helps drive improvement in the quality of our services. Quality in healthcare is made up of three core dimensions: Patient experience - how patients experience the care they receive Patient safety - keeping patients safe from harm Clinical effectiveness - how successful is the care we provide? 5 QUALITY ACCOUNT The quality account incorporates all the requirements of The National Health Service (Quality Accounts) Regulations 2010 (as amended) as well as additional reporting requirements. This includes: • How well we did against the quality priorities and goals we set ourselves for 2024/25 (last year). • It sets out the priorities we have agreed for 2025/26 (next year), and how we plan to achieve them. • The information we are required by law to provide so that people can see how the quality of our services compares to those provided by other NHS trusts. Additional information about our progress and achievements in key areas of quality delivery. Stakeholder and external assurance statements, including statements from our Council of Governors, Hampshire and Isle of Wight Integrated Care Board and Southampton County Council’s Health Overview and Scrutiny Committee. 2.1 Priorities for improvement This section reflects on the 2024/25 quality improvement priorities at UHS and outlines our quality improvement priorities for 2025/26. 2.1.1 Progress against 2024/25 priorities Last year, we upheld our commitment to delivering the highest standard of care, influenced by various national, regional, local, and trust-wide factors. Throughout the year, we encountered unprecedented demand on our services, contending with challenges related to operational, capacity, patient flow, infection prevention, and safety. Despite these difficulties, we were confident in our ability to maintain our focus on quality priorities. Our teams worked diligently to achieve their goals under these challenging circumstances. We are proud to present our accomplishments and how our successes have continued to enhance the quality of services we provide to those who rely on us. 6 QUALITY ACCOUNT Overview of success Core dimension Patient experience Patient safety Clinical effectiveness Quality priority Progress Exploring the provision of a support centre for people using our services. Creating a behaviour framework behind our values, bringing them to life to improve our patient and staff experience. Volunteering - a new focus. Achieved On hold Achieved Acuity and deteriorating patients: continuing to improve how we keep patients safe from harm. We will ensure that Fundamentals of Care (FoC) are provided to all our patients in collaboration with our patients, their family, and their carers. Improving our morbidity and mortality (M&M) meetings. Achieved Achieved Achieved Develop the Trust’s approach to reducing the impact of health inequalities (HIs). Help develop a UHS quality management system approach. Achieved Achieved 7 QUALITY ACCOUNT 2.1.2 Quality Improvement Priorities - 2024/25: Final Reports Quality Improvement Priority One: Exploring the provision of a support centre for people using our services (year one) Why was this a priority? UHS is a regional centre for many disease types, but we recognise there is inequality in provision of support facilities in the Trust for all our patients and their friends and families regardless of their clinical conditions. While cancer patients have access to designated centres such as The Maggie’s Centre and Macmillan facilities, other disease types have no comparable options despite often having enhanced needs. Patients who are nearing the end of their life are frequently spending their final days in bays with other patients as side rooms are prioritised for isolation purposes, and there are few areas available that can accommodate a hospital bed for patients to have time with their family away from their clinical setting. Apart from the UHS Patient Support Hub, there are no designated spaces that are accessible for patients, families, or carers, often resulting in staff offices and education rooms being inappropriately repurposed to meet their needs. Growing feedback from complaints and Friends and Family Test (FFT) responses emphasis our inability to provide patients, carers and their families access to spaces for respite and support. In addition, a recent UHS carers survey indicated that while we recognise that being a carer can sometimes be demanding both physically and emotionally, there are no designated areas for them to have their own personal needs met. Creating a bespoke support facility at UHS would help to address these needs and would be the first facility of its kind in an acute trust in England. What have we achieved? Estate has been identified. Work has started to repurpose the underutilised Macmillan Centre into a generic non-disease specific Patient and Family Support Hub. This agreement made through the Trust Investment Group was to end the current agreement with the Macmillan charity and to approach Southampton Hospitals Charity to support a refurbishment and further investment into the hub (for example funding a carers shower provision). Key areas identified for further development • Major grant request submitted to Southampton Hospitals Charity due to go to Charity Trustee Board in March 2025. • Recruitment of a band 7 mnager role (appointed in January 2025 and starting 31 March 2025); • Rebranding and merging (of current Patient Support Hub) started in February 2025. 8 QUALITY ACCOUNT How will ongoing improvements be measured and monitored? Once the Patient and Family Support Hub is launched there will be a constant drive for patient and service user involvement, co-designing the space, there will be surveys on before and after, end of life quality of care will improve Progress metrics • Reduction in adverse event reporting that a patient died in an open bay. • Carers survey improvement. • P&FSH FFT results. Quality Improvement Two: Creating a behavior framework behind our values, bringing them to life to improve our staff and patient experience Creating a behaviour framework behind our Trust Values to bring them to life in our everyday work and interactions is still very much a priority. However, the work has been paused to ensure it aligns to the development of the new Trust strategy, both these pieces of work need to be produced side by side. It is anticipated the work on the behaviour framework will commence alongside the development of the overall Trust strategy and timelines for launch and embedding will move to 2025/26. 9 QUALITY ACCOUNT Quality Improvement Priority Three: Volunteering Why was this a priority? To value the contribution our volunteers make to our organisation, we wanted to improve the onboarding process to provide more guidance and support for our volunteer colleagues, and to work with them more closely to build in flexibility and be more creative in the kind of roles and support they could offer. What have we achieved? • We worked with our systems partners to complete a successful bid through Volunteering for Health (VfH) and have plans to develop a unified and standardised approach of volunteer recruitment using a passporting system. • Our key relationship is with the Hampshire and Isle of Wight Voluntary Community and Social Enterprise (VCSE) sector Health and Care Alliance (HIVCA) and it has allowed us to further explore a more system-wide approach, with a view to sharing resources, ideas, and opportunities both internally and outside the organisation on a regular basis. • We have worked with HIVCA and fostered a collaborative learning environment, aiming to streamline and standardise the volunteer onboarding processes over the coming year. • We have built upon current onboarding and training processes and are particularly developing the enhanced care training for our volunteers to support their awareness of working alongside patients who have mental health issues, dementia, delirium, learning disabilities and autism. • We are working with information governance leads to consider how the Trust’s internal policies can create equitable opportunities for a range of volunteers, to support them in accessing limited patient records, to allow them to document the interactions that they have with patients in support of the provision of collaborative holistic care. • We have begun to develop a new “ABC” approach to offering our volunteering roles, codesigning new roles for volunteers, and providing a flexible ‘responsive volunteering’ process that can support the organisational pressures as they arise and dovetailing the offer from our experience of care teams. • We have started to build relationships with the NHS care responder volunteer’s service looking at how they can enhance our existing offering provided by our responder volunteers. Key areas identified for further development • We have more scope to develop a more robust support process for volunteers during their placements through building better relationships between the volunteers and their clinical teams. • We will grow our volunteering hub space in spring 2025, to offer a more effective space for volunteers to access practical and welfare support from voluntary services, giving them a clear base and point of contact. • Working with HIVCA in the system-wide partnership, we will continue to explore the VfH funding and how it can develop the ‘passporting’ system for the volunteers across the network. • As our new Patient and Family Support Hub becomes established, we will work with the NHS responders and our existing responder volunteers to ensure a more extensive five to seven day/ week service (including evenings). 10 QUALITY ACCOUNT How will ongoing improvements be measured and monitored? The key metrics for measuring these outcomes will come from: • Our responder volunteer statistics through the Patient and Family Support Hub. • Our outcomes associated with the HIVCA partnership and the VfH bid i.e. progress with a passporting system including potential recruitment of a post to develop and establish this new system. Progress metrics • Year one funding from the VfH bid was received by the partnership to develop the partnership with the HIVCA support meetings every six to eight weeks. • The system-wide volunteer onboarding and passporting system has not yet been established but will continue to progress with the partnership. • We will have developed a responsive volunteer network, available five days a week with an established support system in place. • We are an open and inclusive recruiter of volunteers and monitor the equality, diversity and inclusivity of the volunteers we recruit, seeing a more diverse range of volunteers that begins to more accurately represent our local community. What our patients/relatives/carers tell us 11 QUALITY ACCOUNT 12 QUALITY ACCOUNT Quality Improvement Priority Four: Acuity and deteriorating patients: continuing to improve how we keep patients safe from harm ADULTS AND PAEDIATRICS Why was this a priority? The recognition, assessment, and escalation of a deteriorating patient either adult or child are a key element of our trust-wide patient safety and quality strategy with the aim of improving clinical outcomes for acutely ill patients. How rapidly we respond to patient deterioration both in and out of hours is a key determinant of patient and quality outcomes. What have we achieved? Five new starters have successfully completed their supernumerary period. The critical care outreach team (CCOT) resumed its 24/7 service on 16 December 2024. Recruitment for the final vacancies was completed in December 2024, with both new recruits scheduled to commence their roles by 31 March 2025. An education task and finish group has been established, which has conducted a gap analysis with all education leads and reviewed both internal and external training resources. Standards are currently under revision. The medical education and simulation team is testing the Acute Life-threatening Events-Recognition and Treatment (ALERT) course, which includes resident doctors and junior nurses. Initial feedback was presented to the deteriorating patient group on 25 September 2024. The Trust’s acute deterioration education day continues to review feedback and evaluations for study days. The acuity surveillance pilot was successful, and the CCOT is now formally implementing this initiative. Monthly acuity reports are generated at the Trust, division, care group, and ward levels, or through bespoke reporting. These reports incorporate various metrics, including National Early Warning Score 2 (NEWS2) and National Paediatric Early Warning Score (NPEWS) activations, Call 4 Concern activations, a 24-hour overview of NEWS2 activations, cardiac arrest calls, CCOT activations and reasons for referral, and unplanned admissions to the intensive care unit (ICU). Quarterly data on cardiac arrests, Treatment Escalation Plans (TEP), and Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) are presented to the resuscitation committee and the deteriorating patient group (DPG). Challenges persist in collecting robust sepsis data. UHS is participating in the national Martha’s Rule pilot programme, with Call 4 Concern implemented in March 2024 and all activations reported on Ulysses. A task and finish group has been established to explore patient wellness questions, which is a fixed agenda item at the DPG. The bi-monthly DPG has been established, with increasing medical engagement, and regular reports are submitted to the patient safety and quality committee (PSSG). Key areas identified for further development • Further roll out of Martha’s rule UHS-wide including Call 4 Concern. • Gain feedback from divisional governance teams regarding incidents to ensure learning is identified and appropriate action plans are devised and implemented. Collaboration with maternity and neonatal services. • Development of acuity dashboard. • Medium- and long-term service development commenced including workforce planning. 13 QUALITY ACCOUNT How will ongoing improvements be measured and monitored? • Bimonthly deteriorating patient group meetings to review current trends and themes, implementation of appropriate actions and evaluation of actions. • Biannual review of deteriorating patient group terms of reference. • Quarterly report to patient safety steering group. • Yearly assurance report – Trust quality committee. Progress metrics • Patient observation compliance data. • NEWS2 and NPEWS activations and data analysis. • Analysis of all unplanned admwissions to ICU from ward areas – adult and paediatric for themes to inform education and practice. • Adult and paediatric ICU stepdown data. • Adult critical care outreach team activity and outcome data. • Adult and paediatric cardiac arrest and outcomes data. • Adult TEP & DNACPR data. • Complaints and adverse event reports related to failure to rescue and failure to escalate. • Percentage of patients diagnosed with sepsis within the emergency department receiving appropriate antibiotics within one hour of sepsis diagnosis. • Analysis of adult and paediatric Call 4 Concern data, action plan developed, implemented, and adjusted in response to themes. • Analysis of patient/service user feedback on Call 4 Concern service. • Analysis of staff feedback on Call 4 Concern service. Volunteers and quality patient safety partners helped to promote the Call 4 Concern work 14 QUALITY ACCOUNT Quality Improvement Priority Five: Fundamentals of Care Why was this a priority? Patient Experience - Fundamentals of Care (FoC) was established as a priority in 2024/25 due to evidence that post COVID we had not yet returned to a less task-focussed and more patientfocussed level of care. The priority was developed to create a foundation and structure to tackle these care standards of care and to challenge practices, in response to patient and relative feedback. What have we achieved? Since commencing in late 2023 the following has been achieved: • We have established the FoC project board and this group continues to meet every three months to provide an overall project view, share successes and opportunities for learning, discuss the workstreams continuing under the eight standards and to escalate challenges through a formal governance structure (through quality committee and QGSG). • We have had one quality patient safety partner (QPSP) on the project board since conception. Subsequent events have involved two other QPSPs and have broadened the ‘patient voice’. • Each of the standards has a lead who oversees a multi-professional working group with clinical team representation. Some groups have chosen to pair due to links in their primary and secondary project drivers and actions. Matron involvement is driving the patient facing team involvement. • The project board is minuted, with an action tracker. The board is attended by the corporate nursing team and is supported by our deputy chief nurse, chaired by our head of patient experience. It is also supported by our chief nursing informatics officer, members of the transformation team and communications. • There is a FoC project manager in place who has worked with the transformation team to create a project plan in collaboration with workstream leads, a communications plan and drive forward key initiatives including business intelligence and the development of a clinical quality dashboard so we can measure the impact of the FoC. • Enhancing leadership and role modelling of the FoC has been a key focus through leadership in practice study days. These sessions, held three times annually, target leaders across the organisation to address and challenge behaviours related to the FoC. Incorporating the patient voice, these study days are grounded in real patient stories and involve the practical application of skills using simulated patients. 15 QUALITY ACCOUNT • As part of the patient hygiene working group, we have undertaken surveys using volunteer support, of patients and staff in the clinical decision unit (CDU), acute medical unit (AMU3), trauma assessment unit (TAU) and Macmillan acute oncology service (MAOS) in relation to their experiences of patient hygiene care and the impact of the trial patient hygiene packs. • Existing surveys, PALS interactions, complaints, adverse event reports (AER), Friends and Family Test (FFT) are followed up and reviewed by senior managers accordingly. These inform the FoC workstream through the head of patient experience. • Since conception, sharing the patient perspective and reflecting what patients would like to hear from us has been key. The posters around the organisation on our care commitments and resources on staffnet and the virtual learning environment (VLE) for staff, support this. These resources include: o Resources developed by each group to share during the monthly focussed trolley dashes. o Videos developed by staff for staff, to improve awareness of some key facts about each of the eight standards. Staff on Bassett ward engaging patients with dementia in crafting activities • Strong presence of the FoC throughout education as it has been mapped to the health care support worker (HCSW) induction, is included on preceptorship for all staff groups, has been presented to some university students at the University of Portsmouth and is embedded in lots of local training and development initiatives. The head of patient experience delivers many sessions across the organisation and beyond. Head of patient experience engaging with clinical staff in cardiovascular and thoracics on how to assess the FoC in their area 16 QUALITY ACCOUNT • The What Matters To Me (WMTM) project was trialled in some clinical areas from October 2024 (F7 and G7). Due to challenges in engaging the volunteer support to maintain this project it has temporarily been halted. The boards have an agreed template, agreed by a QPSP, and based upon feedback from staff and patients. The values of this project are echoed in local projects we have seen. • The FoC is being reviewed in conjunction with matron walkabout and the clinical accreditation scheme (CAS). Starting in February 2025, a new monthly focus is being established, with five core questions associated with a FoC standard and five specialist questions associated with that topic. This is forming past of ward benchmarking with a new self-assessment tool being implemented. Key areas identified for further development • Clinical representation in these working groups is to be re-established/built upon to support further engagement in the clinical areas/teams. • Continuing to establish links and support in child health, maternity and outpatients to ensure a bespoke but collaborative roll out of FoC. • To continue strong patient engagement and involvement, linking with involved patients where required with the support of our existing FFT results, the national inpatient and urgent and emergency (U&E) care surveys. • Resources to continue to grow to create a repository of information for staff and develop their knowledge around the FoC and to support each other in challenging behaviours and practices. • Employ interim project manager to maintain the project and support new ones whilst the current project manager is on maternity leave, focusing on establishing the dataset to evidence the FoC. • Strengthen the recruitment of volunteers for WMTM through the successful bid to Volunteering for Health (VfH) through the recruitment and investment in a volunteer coordinator, as part of a partnership with other organisations in Hampshire and Isle Of Wight (HIOW), including the charity sectors. • Successful implementation and evaluation of WMTM boards across key areas in organisation, with full volunteer support for the obtaining of photographs of the patients from themselves/ families to maintain that person-centred focus. How will ongoing improvements be measured and monitored? Improvements will be measured and monitored through FFT feedback, feedback from selfassessment tools and ongoing surveillance of the clinical quality dashboard. Progress metrics Reduction in clinical Iincidents: We’ve seen a decrease in the number and severity of incidents related to the FoC across inpatient settings. A key theme in early 2024 involved patients reporting being asked to urinate in incontinence pads. Six adverse event reports (AERs) were recorded in Q1, with none reported in Q3, indicating improvement. Reduction in complaints: While we don’t yet tag complaints specifically to FoC, we’ve observed a decline in ‘patient care’ complaints - from 14.67% in Q1 to 13.91% in Q3. We’re also exploring refinements in complaint categorisation to better align with FoC themes. 17 QUALITY ACCOUNT Increase in compliments: Patient and family feedback is gathered through various channels. For example, our urgent and emergency care survey showed an overall satisfaction score of 7.68/10. Improved oerformance against metrics: Throughout 2024, we’ve redesigned our improvement metrics in collaboration with clinical teams. These are now reflected in the clinical quality dashboard, supported by a comprehensive data dictionary developed by our project manager. 18 QUALITY ACCOUNT Quality Improvement Priority Six: Improving our morbidity and mortality (M&M) meetings Why was this a priority? The Patient Safety Incident Response Framework (PSIRF) sets out the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents. It supports our processes for learning and improving patient safety and clinical effectiveness and replaces the old serious incident framework. An important element of the PSIRF is the focus on strengthening the processes for local learning through M&M meetings. M&M meetings (or clinical review meetings) have a central function in supporting our services to achieve and maintain high standards of care. They allow us to review the quality of the care that is being provided to our patients and learn lessons from outcomes. They are multi-disciplinary meetings which provide a safe place for learning, for supporting comprehensive conversations and ensuring governance standards are met. They allow us to identify any opportunities for improvement and are an important opportunity for education. They also provide opportunities for senior staff to model appropriate professional behaviour and engage the significant expertise of clinicians at the point of care. There is also a growing trend in M&M meetings to identify how resilience within complex systems enables good outcomes in the face of the kind of challenges and uncertainties which we are experiencing, and which are inherent within healthcare delivery. What have we achieved? The medical advisor for patient safety is leading efforts on morbidity and mortality (M&M) meetings. A comprehensive framework for M&M meetings at UHS has been developed, establishing expectations for a safe learning environment that is multiprofessional and multi-disciplinary, with a systematic meeting structure and agenda focused on learning, governance integration, and patient-centred care. This framework is supported by a handbook, resources, and education for M&M leads. A dedicated Teams channel has been created to provide resources for M&M leads. An M&M workshop was held as part of the WHO Patient Safety Day on 12 September 2024, focusing on creating strong learning environments, maintaining patient centrality, and learning from palliative care. The workshop was attended by 20 M&M leads and governance representatives. Additionally, 20 M&M leads attended a study day on 23 January 2025, covering topics such as human factors and systems thinking, PSIRF, keeping the patient central, appreciative inquiry in M&M, creating strong learning environments, managing difficult behaviour, and expanding the scope of M&M beyond mortality. The study day was well received, and another is planned for early April. Regular meetings are held with M&M leads and the medical patient safety advisor to provide support and identify areas needing assistance. An electronic M&M recording system was developed and trialed to capture and evidence outcomes, but it is no longer supported by the Trust, prompting the investigation of alternatives. A clear escalation process from M&M meetings to the existing governance structure has been established, with actions recorded. M&M meeting outcomes are now a standing agenda item in governance meetings. 19 QUALITY ACCOUNT UHS - 6 key principles of M&M Safety A safe space for learning. A meeting atmosphere that is conductive to open discussion with a focus on ‘Just and Learning Culture’ and an emphasis on understanding the systems factors, not focusing on individuals. Multiprofessional and Multi-disciplinary Ensuring active participation across staff groups and different disciplines. Meeting Framework Systematic agenda selection process, structured meeting format and objective analysis of data, including consideration of systems factors, and human factors and ergonomics. Learning Focus Comprehesive discussions to generate actionable learning and system improvement. Using an appreciative inquiry approach to emphasise and learn from the every day, as well as where things can go wrong. Governance Hospital-wide system to record outcomes, lessons learned, and dissemination of recommendations to ensure action and learning. Supporting our integrated approach to quality across the organisation. Folow up to ensure actions are completed. Clear pathways for central reporting and escalation of concerns. Patient Centred Keeping the patient and the family central to the learning. Ensuring that the patient voice is heard when learning from events. Completing feedback and duty of candour to help build trust. Training as part of the WHO World Patient Safety Day: Discussing how to create psychological safety in meetings 20 QUALITY ACCOUNT Key areas identified for further development • Development of electronic recording process that can be used for all M&M meetings. • Need to develop stronger links and greater support from local governance. How will ongoing improvements be measured and monitored? Regular review of M&M meetings with the M&M leads to ensure that: • M&M meetings are represented by the multi-disciplinary. • Terms of reference are in place. • Incorporating mortality data. • Using a recording app (when available). • Outcomes are linked to actions and governance processes. Progress metrics The electronic recording system is not currently supported so we cannot measure this (and it makes it hard to audit actions and escalations as these would be audited via this). Survey of clinical staff (163 replies) and their view on M&M. Key findings: • 73% staff feel UHS views the meetings as important. • 75% that their department views these as important. • 60% that they are fit for purpose. • 75% that they make a difference to patient safety. • 80% agree that systems factors are considered. • 35% felt they were well supported by local governance. 21 QUALITY ACCOUNT Quality Improvement Priority Seven: Develop the Trust’s approach to reducing the impact of health inequalities (HIs) (year one) Why was this a priority? The causes of health inequalities are complex, but research has shown that the main drivers of health inequalities are social determinants; the environments people live in, access to employment and the kind of start they had in life. Inequalities are also driven by the ways in which health services are designed and delivered, and by the quality of clinical care received. The NHS plays an important role in both mitigating against the wider determinants and in reducing healthcare-based inequalities. As well as a moral and social responsibility, NHS trusts have a legal duty to consider health inequalities. A new requirement from NHS England asks that trusts describe the extent to which they have exercised its functions consistently with NHS England’s views set out in the statement on information on inequalities. Addressing health and care inequalities is a core focus of the CQC’s 2021 strategy. To reinforce this commitment, the CQC has outlined five equality objectives aimed at tackling disparities in health outcomes. They have made it clear that action will be taken where care falls short for particular groups. Providers are expected to proactively identify, engage with, and respond to individuals who face barriers to accessing care or experience poorer outcomes. These efforts will be reflected in the CQC’s assessment frameworks. Failure to address health inequalities also carries a significant financial burden for NHS trusts. Estimates suggest these disparities cost the NHS around £5.5 billion each year. Eliminating health inequalities could potentially reduce the volume of treatments provided by the NHS by up to 15%, easing pressure on services and resources. What have we achieved? Governance A health inequalities board has been convened, chaired by the chief medical officer and attended by representation across UHS, patient partners, public health teams from the local councils and the population health team within the integrated care board. The board has set some initial objectives. These will be delivered through five areas of focus, each with a dedicated sponsoring director and a detailed delivery plan. These areas of focus are: • Clinical priorities. • Data and measurement. • Enabling the organisation. • Communications and engagement. • Strategy and approach. Clinical priorities Three clinical priorities have been set, based on national guidance on services where there is greatest health inequalities impact. The public health leadership from the local councils and integrated care board were involved in this prioritisation to ensure that we chose areas with high prevalence locally, and where it was felt an acute trust can have greatest impact. Priorities set are tobacco dependency, hypertension and obesity. 22 QUALITY ACCOUNT Tobacco dependency In Southampton, smoking rates are higher than the national average. It is estimated that one in six Southampton deaths are attributable to smoking (JSNA, 2021). 70% of our lung cancer patients and 86% of our COPD patient deaths are directly attributable to smoking. People who smoke are 36% more likely to be admitted to hospital than non-smokers and have poorer treatment outcomes including reduced response to treatments, prolonged recovery and increased risk of complications, across many areas including surgery, cancer and cardiovascular disease (Royal College of Physicians, 2020). This leads to increased length of stay, higher rates of emergency department attendance and greater pressure upon outpatient clinics due to smoking-related comorbidities. We have been focusing on improving identification of those who have been admitted who smoke, increasing the delivery of very brief advice to all patients who smoke and increasing referral to tobacco dependency services on the ward for those who do not opt out. We’ve been reviewing our data to understand how we are supporting those most at risk of being impacted by health inequalities. Obesity In 2022 to 2023, 29.5% of adults in Southampton were estimated to be living with obesity, above the national average. Southampton has one of the highest childhood obesity rates in the county. There are a large number of conditions linked with obesity, including cardiovascular disease, hypertension and liver disease. There is a multi-disciplinary service provided at UHS for children which provides excellent outcomes, reversing clinical impacts such as hypertension and type two diabetes. This programme seeks to identify opportunities to collaborate with our system to prevent the increasing levels of childhood obesity, reflecting the national focus on left shift and prevention. Adult obesity services are in review across our system. Hypertension Hypertension is amongst the leading causes of death in Southampton and Hampshire. High blood pressure causes threat to life expectancy linked with stroke, vision loss, heart failure, heart attack, kidney disease/failure. Hypertension identification and control have both been a challenge across Hampshire and Isle of Wight. Although hypertension treatment is delivered in primary care, there are actions we are taking as a trust to support this important priority. This includes: • As the largest employer in the city we have the opportunity to improve health by supporting our staff. We are developing materials to support our staff to understand the importance of blood pressure monitoring and approach to accessing help with high blood pressure. We hope this knowledge will extend to families, communities and how we support our patients. • Support people to ‘wait well’ whilst on our waiting list, with improved guidance on controlling and monitoring blood pressure while waiting for surgery, reducing the number of cancelled procedures due to high blood pressure. • Consider how improved data sharing on blood pressure readings between UHS and GPs can support onward support for hypertension. 23 QUALITY ACCOUNT w Data and measurement Several positive steps have been taken in measuring and understanding health inequalities within our services. These have been: • Building new dashboard that enables us to assess whether access to our services in equitable related to IMD decile, age, gender and ethnicity. • Assessment of equitable delivery of smoking cessation services. • Assessing the acute impact of hypertension control. • Collaborating with the Integrated care board on producing the data required for national reporting guidelines. Enabling the organisation We wish to support staff across our organisation to understand health inequalities, to recognise them within services, to access to tools to enable service change and to have routes to escalate issues. We have appointed a health inequalities officer who will be a key link to support services to achieve this. We have begun developing training that will be available across the organisation. We have also established escalation routes for raising concerns related to health inequalities. Communications and engagement There have been a number of excellent case studies communicated during this year through existing communications channels such as the Connect magazine. HELIXR, a pioneering programme that supports vulnerable patients with chronic liver disease through the introduction of peer support workers, attracted news coverage and was featured on the BBC and ITV Meridian in March. We have been attending events across Southampton including Pride and the Black Business and Arts Festival to show our support and to connect with our communities. We’ve been reaching out to grow the number and diversity of our involved patients, aiming to reflect the diversity of our population in our feedback and helping us to better serve the needs of our community. Strategy and approach We have worked on establishing this approach to delivering health inequalities over the year, which is now seeing results in progress in all prioritised areas for improvement. We have taken discussions to our Trust Board to establish how we will move this important work forward in years to come. We have also reflected on how population health, prevention and health inequalities will feature in our developing updates to our trust and clinical strategies. Key areas identified for further development There are detailed delivery plans for all of our priority areas over the next year, which will enable us to keep driving towards our aims. Highlights from these plans include: • Designing and publishing health inequalities training for all staff. • Creating an internal staff campaign, recognising the impact of health inequalities within our people and providing advice. • Establishing a health inequalities operational group who receive escalations of health inequalities issues and assess trust-wide implications and support improvements. • Delivery of planned improvements within our three prioritised clinical specialties. • Connecting with our communities and engagement leads across our city, improving our insights into the local drivers of health inequalities and identifying improvement opportunities. • Reviewing our use of QEIAs for change and decision making. 24 QUALITY ACCOUNT • Development of Trust and clinical strategies with making impact on health inequalities included. • Making use of the data sets we have built to drive change within our services and measure our impact. How will ongoing improvements be measured and monitored? We have clear objectives against all priorities with delivery timelines. We will continue to assess our progress in delivering against these. The dashboards that have been built will enable us to measure change over time, demonstrating where we have been able to impact on the equality of access to services. We will continue to work with our patients to gain feedback on how well we have met their needs while under our care. Progress metrics During 2024/25, we significantly advanced data capabilities to measure health inequalities across UHS services. We now track outpatient and inpatient waiting lists, discharges, and emergency department performance by age, gender, ethnicity, and Index of Multiple Deprivation - enabling long-term impact assessment. Staff access to this data will also be monitored. While some planned measures were successfully implemented, others remain in progress and will continue into year two (2025/26) of this quality priority. As part of our hypertension programme, we aimed to reduce theatre cancellations and non-elective admissions. Pathway improvements are underway and will be implemented in 2025/26, supported by expanded data sources. Combined with the Hampshire and Isle of Wight Intergrated Care Board’s (HIOW ICB) cardiovascular disease (CVD)-focused ‘signature move’ in primary care, these efforts are expected to reduce non-elective admissions. HIOW ICB data for 2024/25 shows: • ~95 CVD-related ED attendances/month • ~420 non-elective admitted episodes of care/month • ~2,340 bed days/month Our tobacoo quit rates continue to be better than expected nationally. Throughout the year, the health inequalities board reviewed case studies from eight services, showcasing impactful improvement work. These have been documented to support organisational learning. 25 QUALITY ACCOUNT Quality Improvement Priority Eight: Develop a UHS quality management system approach (year one) Why was this a priority? In April 2023, NHS Improving Patient Care Together (IMPACT) was launched to support all NHS organisations, systems, and providers at every level (including NHS England) to have the skills and techniques to deliver continuous improvement. NHS IMPACT’s five components form the basis of all evidence-based improvement methods and underpin a systematic approach to continuous improvement: • Building a shared purpose and vision. • Investing in people and culture. • Developing leadership behaviours. • Building improvement capability and capacity. • Embedding improvement into management systems and processes. Taking a more integrated quality approach is also a key component of our ‘always improving’, clinical effectiveness and Trust strategies in support of our ‘outstanding patient outcomes, safety and experience’ strategic pillar. To establish our current position, the Trust undertook a self-assessment to gauge its organisational maturity against the IMPACT framework and identified ‘embedding improvement into management systems and processes’ as an area of opportunity to improve and employ best practice. It was also a recommendation from the Thirlwall Inquiry that organisations focus on their ability to triangulate different quality indicators to build
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Annual-reports-and-quality-accounts/quality-account-24-25-final1.pdf

Digital mole mapping - patient information

Description: This factsheet explains what digital mole mapping is, what it involves and what the potential benefits are.
Url: /Media/UHS-website-2019/Patientinformation/Skin/Digital-mole-mapping-2938-PIL.pdf

Gastroscopy and endoscopic full thickness resection (EFTR) aftercare advice - patient information

Description: This factsheet explains what to expect after having a gastroscopy and endoscopic full thickness resection (EFTR).
Url: /Media/UHS-website-2019/Patientinformation/Endoscopy/Gastroscopy-and-endoscopic-full-thickness-resection-EFTR-aftercare-advice-3773-PIL.pdf

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