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Determining incapacity

Description: Five years ago, a judge's decision provided us with helpful guidance on how to diagnose incapacity.
Url: /HealthProfessionals/Clinical-law-updates/Determining-incapacity.aspx

Delusions erode capacity

Description: A recent case provides a rare explicit example of how delusions can be relevant in compromising a person's capacity.
Url: /HealthProfessionals/Clinical-law-updates/Delusions-erode-capacity.aspx

Papers Trust Board - 15 July 2025

Description: Agenda Trust Board – Open Session Date 15/07/2025 Time 9:00 - 13:00 Location Conference Room, Heartbeat Education Centre Chair
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Trust-governance-and-corporate-docs/2025-Trust-documents/Papers-Trust-Board-15-July-2025.pdf

Annual report 2021-2022

Description: 2021/22 Incorporating the quality report University Hospital Southampton NHS Foundation Trust Annual Report and Acco
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Annual-reports-and-quality-accounts/Annual-report-2021-2022.pdf

UHS AR 22-23-6

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

Description: QUALITY ACCOUNT 2021/22 Part 1: QStaUteAmeLnItToYn qAuaClitCy fOroUm NtheTchief executive 2021/22 1.1 Chief executive’s statement and welcome Welcome to the quality report for University Hospital Southampton NHS Foundation Trust (UHS) for 2020/21, which incorporates the quality accounts. 2020/21 has been a year of unprecedented change for healthcare, and as might be expected this year’s account has a strong focus on our ongoing r QUALITY ACCOUNT 2021/22 Part 1: Statement on quality from the chief executive 1.1 Chief executive’s statement and welcome Welcome to the 2021/22 quality account which I am pleased to present on behalf of University Hospital Southampton NHS Foundation Trust (UHS). 2021/22 has been another year of unprecedented challenge for healthcare, and this year’s quality account continues to have a strong focus on our ongoing response to the COVID-19 pandemic. It also includes information about how we are working to restore services for our patients as we move out of the pandemic. It demonstrates that despite the difficulties, we have supported each other and have never been distracted from our commitment to quality. The challenges of the last year may have been enormous, but there have also been some real positives from the experience. We are working differently and more collaboratively as a health and care system, developing integrated care and rapidly introducing major change across our services, which helps us to focus on and continue to develop the high quality of our services. As we recuperate and recover from the pandemic, we will be a team of people that together is stronger than ever before. The professionalism of the team and all those involved across UHS has been inspiring in the face of significant adversity. I am grateful for the care, compassion and kindness shown by all colleagues to our patients and to each other during the most difficult of years. This is a great platform from which to seize all the opportunities we have before us to continue improving the quality of our services and care. As we begin to move forward, the Trust faces another set of challenges as our services have inevitably been affected over the last couple of years. We remain hugely concerned about the national growth in waiting lists for diagnosis and treatment, and for the people who may not have come forward for vital tests or treatment due to the pandemic. We will continue to do everything possible to maximise the number of patients that we can safely treat, and to ensure that patients on our waiting lists are regularly risk assessed and seen according to clinical priority. We are building capacity as quickly as we can and are recruiting more staff so we can treat the patients who need us. I have no doubt that the staff at UHS will continue to keep their focus on the quality of the services and care we give to ensure everyone who comes to UHS will have the best possible experience as they work tirelessly to put patients first. Quality assurance has remained a cornerstone of our care despite this period of intense pressure. We have consolidated the work we started last year to embed a different approach to governance, reporting and assurance requirements, and our approach as an acute provider has continued to flex and adapt. We are hugely proud to be playing an important role in the national response to COVID-19, not only through the delivery of essential healthcare, but also through the many research programmes that are helping us globally to understand and better treat the virus, and as the lead provider for the delivery of the COVID-19 vaccine programme to our population. We are investing significantly in our research and development infrastructure to secure our future as leading-edge university teaching hospital. Equally, we are investing in other significant areas such as refurbishing the hospital, developing innovative digital solutions. We have also launched a sustainability initiative to make the hospital greener, recognising the influence it has on impacting the environment and population we serve. We aim to achieve carbon net zero, resulting in healthier lives for our community and people. 2 QUALITY ACCOUNT 2021/22 During 2021/22 the Board has been working on our strategy for the next five years, which sets out our ambition for our quality standards and what we want the hospital to be in 2025 for patients and staff. I’m excited to be the person leading UHS to achieve these ambitions, knowing success with be a collective effort. There is so much to do, but I know that working together we will overcome all the challenges because that is what the UHS family does. The pandemic has challenged us, but it has also driven change, and it has shown what we can do together with the people of our city and region. In spite of the immense pressures we continue to face, our patients are hugely appreciative and grateful for the outstanding quality of care and treatment they receive here at UHS. This is testament to the dedication and hard work of everyone in the UHS family. The information contained within this report has been subject to internal review and, to the best of my knowledge presents a true and accurate picture of the performance of the Trust. David French Chief Executive Officer 21 June 2022 3 QUALITY ACCOUNT 2021/22 1.2 Introduction to this report Each 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 and 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? This report tells you how well we did against the quality priorities and goals we set ourselves in each domain for 2021/22 (last year). It sets out the priorities we have agreed for 2022/23 (next year) and how we plan to achieve them. The quality account incorporates all the requirements of The National Health Service (Quality Accounts) Regulations 2010 (as amended) as well as additional reporting requirements. 4 QUALITY ACCOUNT 2021/22 Part 2: Priorities for improvement and statements of assurance from the board 2.1 Priorities for improvement This section provides a look back over the 2021/22 quality priorities at UHS and sets out our quality priorities for 2022/23. 2.1.1 Progress against 2021/22 priorities Last year we set our quality priorities to ensure we delivered the highest quality of care shaped by a range of national and regional factors as well as local and Trust‐wide considerations. We recognised the overriding issues of significant operational pressures being felt right across the health and social care system and the pressures associated with the second year of the COVID-19 pandemic. We acknowledged that many of the aims of our priorities could be disrupted by the ongoing pandemic and that we might need to be flexible in adapting the priorities in changing circumstances. We limited ourselves to four priorities in recognition of these pressures and to allow UHS to focus on responding to them. This year our retrospective review reflects how we addressed the four priorities in the context of our organisational response to the COVID-19 pandemic and the pressing need to work towards restoration of our services. Our challenge was to deliver the highest quality care in the context of these combined pressures. Overview of success Figure 1: Priority 1 PRIORITY 1 Introduction of Midwifery continuity of carer (MCoC) for women at risk of complications in pregnancy. Core Dimension: Patient safety, patient experience and clinical effectiveness Achieved Why was this a priority? We recognise that the relationship between care giver and receiver leads to better safety and outcomes for women and babies in our care. Being cared for and supported through their pregnancy by the same midwifery team helps ensure safer care based on a relationship of mutual trust and respect and offers a more positive and personal experience. Midwifery continuity of carer (MCoC) is a model of care that aims to limit the number of different healthcare professionals a woman sees during her pregnancy. Its aim is for the pregnant woman to receive intrapartum care from a midwife she has met previously during her current pregnancy, thereby providing greater continuity. 5 QUALITY ACCOUNT 2021/22 This approach was the single biggest request of women heard during the NHS England 2015 National Maternity Review ‘Better Births’. The model has proven beneficial clinical outcomes for women including: 16% less likely to lose their baby and 19% less likely to lose their baby before 24 weeks. 24% less likely to experience pre-term birth. 15% less likely to have regional anaesthesia (e.g., an epidural). 16% less likely to have an episiotomy. The model organises midwives into teams of eight or fewer. Each midwife aims to provide antenatal, labour and postnatal midwifery care to approximately 36 women per year (pro rata), with support from the wider team for out-of-hours care. The ‘Better Births’ report published in 2016 set out a clear recommendation that the NHS should work towards a shared ambition for the NHS in England of MCoC being the default model of care available to all pregnant women. To ensure equity in maternity health outcomes the report recommended that roll-out should be prioritised by March 2023 for those most likely to be at greater risk of complications in pregnancy and experience poorer outcomes. NHS England identified this group as woman from Black, Asian and minority ethnic (BAME) backgrounds, those who live in the most deprived decile (IMD-1/Indices of multiple deprivation-1) or those with increased vulnerability (e.g., poor perinatal mental health, history of substance misuse, history of domestic violence). What have we achieved in 2021/22? Our service was quick to adopt the model of MCoC. We used a variety of communication forums to engage our staff and patients, including involvement in national and local public MCoC events, staff team meetings, use of digital platforms, newsletters and dedicated time at midwifery study days for education and discussion. We rapidly established five MCoC teams with each team caring for their own caseload of women in the antenatal, labour and postnatal period. Three are ‘‘caseloading’’ teams meaning they care for their women in labour with an ‘’on call’’ commitment night and day and are based in the east, west and centre of Southampton. The remaining two teams are integrated teams who are available for women in labour when they are on a set shift for labour care and are based in the centre and west of the city. All our teams have a linked consultant obstetrician to ensure continuity of obstetric involvement, and a statement of purpose was agreed to describe the roles and responsibilities required to support the delivery of the model. Before the publication of the ‘Better Births’ report we had already identified the need for a focus on the needs of Black and Asian women and those living in IMD-1 areas. Following publication of the report we accelerated our work, and since July 2020 Black and Asian women and those living in IMD-1 areas have been included for care in our MCoC teams. NHS England Ambition target recommendations 2020/21 Percentage achieved by UHS 2021/22 35% of women will be booked to receive care in a continuity of carer team 41.7% 35% of Black, Asian and minority ethnic women booked to receive care in a 75% continuity of carer team 35% of women living in an IMD-1 area booked to receive continuity of carer 80% 6 QUALITY ACCOUNT 2021/22 How improvements are measured and monitored MCoC compliance is reviewed at monthly service delivery meetings, at bimonthly maternity safety champion peer review meetings and through the local maternity and neonatal system (LMNS) by analysing data on the regional maternity services dashboard. We monitor the data, which tracks our performance using key performance indicators (KPIs), and report performance and strategic plans to our quality committee and Trust Board. Our statement of purpose is reviewed every six months by the programme’s senior matron to ensure it is responsive and continues to be fit for purpose. We actively seek feedback from our patients and their families and from our staff. What our patients told us: ‘‘‘I was under X’s care from around 19 weeks into my pregnancy after moving to Southampton. She came to visit us at home on most occasions and stayed in regular contact throughout my pregnancy; she also came to visit us at home after I’d given birth too. This was invaluable throughout the pandemic and I felt really reassured having a familiar face throughout.’’ ‘’My midwife always instilled confidence in me and I felt able to contact her and other members of the team with any worries or concerns no matter how small. I’m extremely grateful for the care I received, Thank you.’’ ‘‘I had my third baby in August and due to my fear of hospitals and anything medical I opted for my first home birth. X from the homebirth team was incredible right from the moment she happened to appear (out of nowhere like a fairy godmother) into my midwife appointment just as I was saying I wanted a homebirth but was worried about it… she told me she would contact me to arrange a Zoom call where we could chat and she could answer all questions.’’ ‘’My midwife seemed to have this sixth sense where she could tell when I was anxious about something and all of a sudden was telling me it was all going to be okay. She continued my care at my home each time, which was the first time I’d had any pre-natal care at home and it made me so much more relaxed!’’ ‘’Even in the two weeks after birth if I needed anything for me or for the baby, I just had to call my midwife, and it would either go through to her or a homebirth midwife on call day or night.’’ ‘’I would like to say huge thanks to you and your team for the care you have provided. I am so glad that I was under your team. Your advice at each stage of pregnancy helped me to deliver a healthy baby.’’ ‘’You have always gone above and beyond to make me feel comfortable (as you were aware of my past history). Whenever I started panicking, you calmed me by your friendly support. You had clarified things by providing more information and clarity …. as we were not sure about the options we had.’’ ‘’You made sure that I will get full support from my consultant and GP where I needed. I cannot imagine my pregnancy journey without you.’’ ‘’I didn’t know them (the midwife team) earlier but they made me feel like they were my sisters.’’ ‘’I do not think you could have done more than what you did.’’ ‘’My overall experience is so positive with the support I got from your team.’’ 7 QUALITY ACCOUNT 2021/22 What our staff told us: ‘’Working in the team has been the most rewarding thing I have done during my time as a midwife.’’ ‘’The role is so varied day to day and the fluidity it allows encourages you to constantly learn new skills and broadens your outlook on what defines being a midwife.’’ ‘’I have supported families throughout their pregnancy, birth, postnatal period and beyond and because of the relationships you nurture with these families they trust you completely.’’ ‘’My self-confidence at work has grown massively and I now feel happy to facilitate birth at home, in a birth centre or on Labour Ward, wherever my woman wishes.’’ ‘’This has given me exposure to new experiences, which can feel challenging at times, but by having a supportive team around you, advice is never far away. Caseloading has meant I’ve been part of the woman’s wider support network and understand the challenges she may face during her day-to-day life. This enables strong working relationships with other members of the multi-disciplinary team working with the family, such as safeguarding teams/family nurses/health visitors/obstetric team/social workers and more.’’ ‘’You really are at the centre of that family, coordinating their care, to improve their outcomes and their experience whilst accessing maternity care.’’ Key areas identified of opportunities for further improvement Originally our aspirations for 2022/23 were to grow our teams to ensure we had enough resource to offer MCoC to all Black and Asian women and women living in IMD-1 areas. Two new integrated teams came online in January 2022, with plans to develop staff incentives to increase this during the year. We agreed to develop a MCoC team for those in IMD-2 and IMD-3 areas in the west Hampshire area where there are currently no IMD-1 areas. When COVID-19 restrictions relaxed, we had also planned to increase face-to-face engagement with the local maternity workforce and continue to engagement with and sharing good practice across the Southeast region. On 30 March 2022 the final report of the independent review of maternity services at The Shrewsbury and Telford Hospital NHS Trust (the Ockenden Report 2022) was published. The report recommended: ‘’All trusts must review and suspend, if necessary, the existing provision and further roll out of Midwifery Continuity of Carer (MCoC) unless they can demonstrate staffing meets safe minimum requirements on all shifts. This will preserve the safety of all pregnant women and families, which is currently compromised by the unprecedented pressures that MCoC models place on maternity services already under significant strain. The reinstatement of MCoC should be withheld until robust evidence is available to support its reintroduction.’’ Following this recommendation UHS has taken the decision to maintain current levels of provision but cease any further roll out. 8 QUALITY ACCOUNT 2021/22 Figure 2: Priority 2 PRIORITY 2 To support staff wellbeing and recovery Core Dimension: Patient safety and patient experience Achieved Why was this a priority? The health and wellbeing of our people and promoting a healthy work environment is one of our top priorities. Since the start of the pandemic we have focussed on what really makes a difference in supporting people to stay well and healthy and have continued to build on this work during 2021/22. During year we have actively listened to our staff and responded to their feedback by including more “in the moment” support, more regular morale initiatives and creating easier ways to access wellbeing support every day. We have become more flexible and responsive as the year has progressed, provided a range of support and options tailored to the needs of individuals. We have recognised that wellbeing is very personal, and everyone’s approach to promoting and sustaining their own wellness may be different. We appreciated many people were mentally and physically exhausted after the demands of responding to the pandemic. We recognised they would need time, space and support to develop resilience while the pandemic continued, and to recover as pressures eased. We saw that while the overall health and wellbeing scores in the NHS Staff Survey had improve significantly in 2020, the proportion of staff reporting work-related stress had also increased. What have we achieved in 2021/22? During the year we continued to introduce programmes, interventions and wider support offerings. The goal of our model is to ensure our staff can access the most appropriate support at the time and place that they need it. In 2021 we employed a staff wellbeing lead/programme manager and a wellbeing administrator as part of our organisational development (OD) team and tasked them with leading on the development and delivery of the wellbeing programme and interventions. A key area of growth and strength for staff wellbeing during the pandemic and beyond is the joined up working of the wellbeing, psychology, spiritual care, occupational health services and peer practitioner communities. During the early part of 2021 a series of interventions to support reflection and wellness were introduced aiming to provide safe spaces for people to talk, listen, be heard and give feedback on where things could be improved. The OD team worked alongside our psychologists to introduce a variety of different ways that people could be engaged. We invested in the training of peer practitioners called ‘safe space practitioners’ to be able to provide on-site, in the moment, interventions when people needed them. Strengthening that safe space practitioner peer network means we have trained more staff in safe space coaching and support techniques to enable people to access support when needed. The team are open to any suggestions of other areas where staff would find peer support valuable and to deliver thinking environments. 9 QUALITY ACCOUNT 2021/22 We also trained appreciative inquiry facilitators to work with staff in self-determined change to enable them to take a positive approach to their own wellbeing, appreciate the things that are going well and adopt a mindset of appreciation and hope. After a successful pilot in May 2021, we recruited over 100 wellbeing champions working all over the Trust across a range of professions and seniority. Wellbeing champions have been given training, tools and resources to lead on championing wellbeing in their areas. They offer signposting to support, monthly champion meetings sharing ideas and practice and regular updates on wellbeing. They are important links on the ground for the wellbeing team and have their own workplace champion pages on Staffnet (our intranet) for sharing information and mutual support. They carry out regular wellbeing walkabouts wearing pink scrubs to make them highly visible. They are often accompanied by our executive directors and senior clinical leaders who are also available to listen, support and generally help raise morale. In the latter part of 2021 as the COVID-19 pandemic continued, staff resilience was tested by challenges around increasing staff shortages and the ability for staff to take regular breaks away from clinical areas for rest. We recognised a need for boosting staff morale and devised a wellness and appreciation programme, which took refreshments out to staff including lunch grab bags, fruit boxes, hot drinks and wellbeing treats. To make it quicker and easier for staff to access wellbeing information we launched Windows onto Wellbeing (WoW), a one-stop page on Staffnet consisting of various wellbeing windows each outlining a variety of aspects of wellbeing information and available support, with links and resources. This is being supplemented by wellbeing leaflets with QR codes, posters and video information. A staff Facebook wellbeing page was set up, populated by the wellbeing team and any staff who wish to post. This shows the latest wellbeing information, support and training opportunities updated in real time as well as being a platform for inspirational quotes and for people to share wellbeing practice and thoughts. During 2021/22 we tried to ensure, where possible, that wellbeing was included as an automatic element of all our initiatives and ‘‘business as usual’’. Staff wellbeing was incorporated into many of our educational streams, with wellbeing awareness sessions being included in induction training, team study days and our UHS advocates study day. Team and personal wellbeing action plan templates have been created for use across the organisation, and when our chief nursing officer (CNO) introduced daily ward huddles (‘stop for support’) for our nursing teams, a key element was the opportunity to check on staff wellbeing and offer support. 10 QUALITY ACCOUNT 2021/22 Teaching on stress management and post-traumatic stress is delivered by various groups and individuals including the wellbeing programme manager, the OD team, the psychology team and the wellbeing team. Wellbeing conversation workshops have been offered with good uptake and more are being rolled out in 2022/23. Mindfulness and mindful self-compassion workshops were commissioned in 2021/22 and have proved popular. Other initiatives led by our wellbeing programme manager include our domestic abuse project which works with our partners Standing Together to support staff impacted by domestic abuse, our suicide prevention support advisory group, facilitating reflective practice guidance and a small working group which is supporting the patient safety incident response framework (PSIRF) agenda by exploring the impact of being involved in adverse incidents. We have an embedded peer support service to provide psychological support to our staff in the context of traumatic events at work. The service is modelled on an evidence-based approach using a trauma risk management (TRiM) methodology which helps to identify risks for people who may suffer poor mental health following traumatic experiences. Our TRiM practitioners support those who have experienced traumatic events and we have increased the number of our practitioners during 2021/22. UHS is part of a regional mental health first aid (MHFA) faculty which works in partnership across Hampshire and the Isle of Wight and is currently in the process of training peer practitioners as MHFA champions. Our ambition is that our practitioners will go on to participate in ‘train the trainer’ sessions, sharing training across the integrated care system (ICS). We also looked at ways to demonstrate how much we value our staff. We wanted to celebrate the hard work, commitment and dedication consistently shown in rising to the challenges of the pandemic. We have promoted our long service awards, which recognise continuous service to the Trust, and our retirement gift scheme, which rewards employees after completing 20 years or more service in the NHS. In December 2021, a festive card containing a gift token from the CEO and Chair was given to all substantive UHS staff in recognition and appreciation of every person’s effort and dedication to our patients and families during the year. We have asked our staff for feedback about our initiatives and used their insights to help shape ongoing work. We have developed a UHS Insights document which summarised how staff were feeling and how the feedback they have given will support people to move forward This is illustrated in the infographics below. 11 QUALITY ACCOUNT 2021/22 What our staff tell us: “It all means I can allow myself time, space and kindness to deal with the difficulties during/post [pandemic] knowing that others felt/are feeling the same way I am.’’ ‘’I really appreciate the way the hospital has prioritised staff wellbeing. It has made us feel as though we are a priority and really valued.’’ ‘’I have been impressed with how many different options there have been to help us all get through this and help us look after ourselves.’’ ‘’I’ve never known staff health be so important to the Trust, and it’s made a big difference to how I’ve coped.’’ “I don’t know if you ever get to hear how people you’ve seen through TRiM are getting on or not... so I thought I’d give you a little update. I’m back at work on week 2 of a phased return… I’m delighted to say that so far it seems to have worked wonders!’’ 12 QUALITY ACCOUNT 2021/22 ‘’The main reason for this email is to say thank you. You were pivotal in the whole journey ensuring I got on the right track to restore my head health early. Without you it’s highly likely I’d have probably gone back to work and have ended up in a much worse position and the whole process would have been a lot longer and arduous to get back to where I am today.” “Listening to other staff members’ struggles and realising that we are not on our own, we are part of a big team.” “Hearing the different stories but appreciating we were united in suffering, learning, confusion and hope has been helpful.” ‘’I can see senior leaders are human with the same insecurities as us; they’ve been in our shoes at some point.’’ ‘Listening to the situations that others have faced was a real reminder that we have had a shared experience which makes things feel easier. The honesty and openness of others was both enriching and humbling. I left feeling like my faith in humanity had been restored.’’ “I found that listening to others’ experiences was extremely valuable. Although I was obviously aware that we have ‘all been in this together’ it has at times felt quite lonely and difficult.” How improvements will be measured and monitored The decision-making, measurement, monitoring and governance of the wellbeing programme is managed by the healthy workplace and wellbeing group which reports into the UHS people board, and then into the people and OD committee. Membership includes representation from occupational health, psychology, spiritual care, peer practitioner groups, HR and health and safety teams and works to support the NHS health and wellbeing framework (2021/22). The people and OD committee reports into Trust Board. Key areas identified of opportunities for further improvement It is important to us that we continue to lead compassionately and inclusively, so our people are involved in decision-making, feel hopeful for the future and are confident in bringing their whole selves to work no matter who they are. We want the culture at UHS to reflect our commitment to prioritising the health and wellbeing of all staff so that it is a consideration in every decision we make. We are working to build confidence and trust in the vast array of support we have developed over the last two years, to drive uptake now awareness is high and to help people find effective help. Risk of burnout due to exhaustion remains a concern and efforts will be focussed in this area for 2022/23. We have identified temporary wellbeing hub space for staff while we wait for the new staff wellbeing building, which has been made possible with the funding from the proceeds of the auction of the donated Banksy ‘Game Changer’ artwork. This new building will house a gym, café and space for reflective groups to meet as well as being a base from which the wellbeing team will provide its support. In 2022/23 several UHS staff will taking part in the first regional diploma in health and wellbeing and a regional wellbeing festival is planned for July 2022, in which we will be taking an active lead. Our 2021/22 annual NHS staff survey results are positive with our scores relating to wellbeing being above the benchmark average. Contributing factors to wellbeing such as staff engagement, morale, staff experience in areas such as kindness and respect, feeling valued and trusted to do their job were all above the benchmark average. Our staff experience scored related to violence and aggression at work, bullying, and harassment have also improved and are close to the benchmark average. Our score relating to staff experiencing work-related stress has remained the same at 42%, which has not declined since 2017. We will continue to work towards improving our staff survey results during 2022/23. 13 QUALITY ACCOUNT 2021/22 Figure 3: Priority 3 PRIORITY 3 Managing risks to patients delayed for treatment and restoring elective programmes Core Dimension: Clinical effectiveness Partially achieved Why was this a priority? The pandemic had a significant impact on waiting times as elective activity reduced to focus on treating patients with COVID-19. In March 2020 only 29 patients were waiting over 52 weeks for treatment, but by March 2021 this had increased to 3,311 patients. These delays clearly have a significant impact on people’s quality of life and, at times, outcomes. During the first wave of the pandemic elective activity reduced substantially, with only 35% of April 2019 levels of activity taking place in April 2020. By 2021 there was a real imperative to move towards managing the pandemic while continuing to treat as many other patients as possible and making sure we communicated effectively with those waiting to help manage the uncertainty and to reduce the backlog where possible. What have we achieved in 2021/22? During the first year of the pandemic the Trust set up a clinical prioritisation process, led by the chief medical officer (CMO) that focused on prioritising all patients waiting for surgery to ensure we continued to treat people based on need and urgency. The Trust also implemented a clinical assurance framework (CAF), designed to measure and mitigate risks across the specialities as well as ensuring that resources (e.g., theatres) were allocated in line with anticipated levels of potential harm. During 2021/22 our hospitals continued to see significant levels of COVID-19 demand with the end of the first wave lasting into May 2021. From September 2021 the number of COVID-19 patients started to increase again, rising to approximately 100 in December 2021 before gradually decreasing. A further wave followed in March 2022, with over 100 COVID-19 patients being cared for in the Trust. Despite this, the Trust continued to see more elective patients in 2021/22 than in 2020/21: Figure 4: Number of elective patients seen April 2020-March 2022 This was despite more stringent and time-consuming infection control measures than prior to the pandemic and reducing theatre capacity to support intensive care staffing. At times, we had up to seven wards repurposed for caring for patients with COVID-19. 14 QUALITY ACCOUNT 2021/22 Cancer care We are proud to have maintained all our cancer services throughout the pandemic and believe that we continue to offer clinically effective services to patients. Despite the number of patients being treated for cancer increasing throughout 2021/22 due to a rise in referrals that occurred after each COVID-19 wave, we were able to respond to this increase. Figure 5: Cancer care patient tracking list July 2020- March 2022 When COVID-19 restrictions in England were relaxed, both in September 2021 and again in February 2022, we saw higher volumes of referrals and two week waits (2WW) performance for urgent referrals has been affected. This is mainly in the breast service with other tumour site performance being broadly maintained. We have seen a relatively stable level of 31-day performance (the target for at least 96% of patients to start a first treatment for a new primary cancer within 31 days of the decision to treat) and 62-day performance (the target that there is no more than 62 days wait between the date the hospital receives an urgent referral for suspected cancer and the start of treatment). We note that our 62-day performance shows us to be in line with other tertiary teaching hospitals, which illustrates that other hospitals are seeing similar challenges to UHS in relation to cancer. When benchmarking against similar trusts (other large teaching hospitals), we have continued to perform well, and we continue to prioritise cancer services to reduce the number of patients awaiting treatment, including reducing those waiting more than 62 days. Outpatient services At the start of the pandemic in 2020 we saw a seismic shift towards non-face-to-face outpatient appointments. The national aspiration was to maintain 25% of patients seen non-face-to-face in 2021/22. Figure 6: proportion of face to face and non-face to face appointments at UHS 15 QUALITY ACCOUNT 2021/22 Although the proportion of virtual appointments has naturally reduced compared to levels seen during the pandemic (as some clinics have reverted to a face-to-face service), we have continued to offer virtual outpatient appointments through 2021/22. We recognise that in some cases this provides a more convenient service for patients. We have also rolled out a patient texting programme, which provided an additional safety net. For the specialties with the highest number of long waiting patients we text patients to ask whether their symptoms have worsened and whether they need to speak to a clinician. If they confirm that they do need to speak to a clinician, an outpatient appointment is scheduled for them. We have also used technology to continue to offer virtual appointments where appropriate and are conducting approximately 30% of our appointments virtually. The Trust has maintained this as a target, and although we have returned to face-to-face appointments where necessary, virtual appointments continue to be a core part of our strategy with our outpatient clinical activity increased to achieve the target. Figure 7: Proportion of virtual appointments Diagnostics During 2021/22 UHS significantly increased the volume of diagnostic activity as the pandemic eased and services adjusted their ways of working, focussing on reducing the longest diagnostic waits first. Despite an increase in diagnostic referrals, the size of the diagnostic waiting list has been held steady, alongside an improved performance. Alongside community partners in Solent NHS Trust and Southern Health NHS Foundation Trust, the Trust successfully bid for phase one funding to develop a community diagnostic hub. The main hub will be based at the Royal South Hants Hospital (RSH), with other targeted diagnostics being delivered in Lymington New Forest Hospital and Hythe Hospital. These hubs will support a one-stop approach for conditions, delivering tests closer to home and releasing acute diagnostic capacity for the support of inpatients and complex patients. In late 2021 the Trust completed a Trust-wide patient-led waiting list validation of all patients waiting 33 weeks or longer. Discussions as to how best to continue this as part of a rolling programme rather than a standalone exercise are ongoing. The Trust worked with third party supplier partners to survey patients by text message or email linked to a secure portal, backed up by paper letters where patient details for digital contact were not available. This saved administrative time, as well as generating a far higher response than traditional methods of validating waiting lists. The purpose of this initiative was to reassure every patient and confirm if patients were ready to attend (and ask them to indicate a timescale if not), as well as indicate whether COVID-19 concerns were a factor in their wish to delay. We also wanted to know if patients’ circumstances had changed, to offer the opportunity of contact with the Trust about their specific circumstances and offer practical and holistic services from the patient support hub. 16 QUALITY ACCOUNT 2021/22 As well as following up patients whose responses did not match their clinical status, or whose responses flagged concern, all patients requesting contact were followed up by care group administrative and/or clinical teams. Referral to treatment (RTT) During 2021/22 UHS has had to continue to manage the impact of COVID-19 on patients on the elective waiting list. We are conscious that some patients have waited a long time from referral to treatment. As referrals have increased post-lockdown ( peaking in Summer 2021) , the total number of patients waiting has grown. However, we have reduced and held steady the total number of patients waiting over 52 weeks through 2021/22 Figure 8: RTT Patient treatment list Figure 9 : Patients waiting over 52+ weeks for treatment In 2021/22 we noted a small, but growing, cohort of patients who had waited more than 104 weeks for treatment due to pressures and constraints associated with the pandemic. This grew from 13 in March 2021, peaking at 171 in December 2021. Throughout 2021/22, our operational teams developed clear plans to address these longest waiters. At the end of March 2022, besides patients who had requested delay of their treatment, we only had five patients who had waited more than 104 weeks for their treatment. Actions to increase capacity and treat these patients include use of the independent sector for specific cohorts of patients (e.g., in the ear, nose and throat (ENT) service) and additional weekend capacity through waiting list initiatives (e.g., Urology ‘super weekends’). 17 QUALITY ACCOUNT 2021/22 We have continued to make good progress against our target and, when we remove the patients who are choosing to wait, we are ahead of the plan. While patients wait for surgery, we have continued to assess them using the CAF, where patients are clinically reviewed based on their previous clinical priority. We use a rating system where priority is given to patients most likely to deteriorate clinically, with P1 being the highest and P4 the lowest risk. Triage takes account of vital signs, pre-hospital clinical course, mechanism of injury and other medical conditions and is a dynamic process and patients are reassessed frequently (e.g., P2 patients every eight weeks, P3 patients every three months, P4 patients every six months). Based on this clinical review patients may be invited for an outpatient review. What our patients tell us: ‘’I was very worried about not getting my surgery because of the pandemic, but the hospital was good at keeping in touch so I felt I knew what was going on’’ ‘’The news was so bad my dad didn’t want to go to the hospital for his tests because he thought the people with covid should have the beds, but he was phoned and the lady was really good at reassuring him that he was important too so he had his tests’’ ‘’I was going to wait until the pandemic was over to have my operation, but they got in touch and said they could do it and got me in and did it anyway and I was so pleased’’ ‘’Not having to go to the hospital for my outpatient appointment was so much easier. No parking problems, and the doctor was just as good as if I’d been there. I hope this carries on‘’ ‘’I was so scared my cancer treatment was going to be stopped, but they sent me to another hospital to have it. I’ve read in the papers about people not getting their treatment, so I am so relieved my hospital could still do it’’. How improvements will be measured and monitored We have a robust reporting processes monitoring this activity which runs from care group and divisional governance and operational reporting through our Trust executive committee (TEC), quality committee and Trust Board. We work closely with our chief operating officer (COO) and executive team to maintain a constant focus. Key areas identified of opportunities for further improvement We will continue to work to restore elective activity and reduce waits during 2022/23. 18 QUALITY ACCOUNT 2021/22 Figure 11: Priority 4 PRIORITY 4 Reducing healthcare associated infection (HCAI) Core Dimension: Patient safety Achieved Why was this a priority? Healthcare associated infections (HCAIs) are among the most significant causes of morbidity and mortality in healthcare settings. We know prevention of HCAIs is central to providing safe and high- quality healthcare, good patient experience and maintaining safety. It also improves length of stay and helps with our financial and operational management. According to the World Health Organisation (WHO), HCAIs are common with an estimated 1.4 million affected at any given time and prevalence varying in the developed world from 5.1% to 11.6%. The most recent point prevalence survey of HCAIs in acute hospitals in England (2016), reported the prevalence of HCAIs as 6.6%, and a tertiary care hospital like UHS will be at risk from high levels as it treats many vulnerable patients needing complex support and procedures. In addition, antimicrobial resistance (AMR) has also been identified by the WHO as one of the top ten major threats to public health. Indiscriminate use of antibiotics in health and farming has led to significant challenges of multi-drug resistant bacteria in certain parts of the world. No new classes of antibiotics have been discovered since 1980, and we are facing the possibility of a world where antibiotics may no longer be effective. The UK five-year national action plan for tackling antimicrobial resistance (2019-2024) outlines key actions for focusing on infection prevention and control (IPC) and addressing AMR. Consequently, AMR and IPC are important for any healthcare organisation, and a system-wide approach to promoting and monitoring the judicious use of antimicrobials to preserve their future effectiveness is essential. At UHS we have a dedicated infection prevention team (IPT) committed to supporting the organisation in preventing and reducing HCAIs. The team is made up of a diverse set of professionals with significant experience in infection control, with leadership and oversight from the CNO and director of infection prevention and control. The team drives improvements in patient outcomes by supporting reductions in HCAIs. What have we achieved in 2021/22? Unsurprisingly the COVID-19 pandemic has remained a key area of focus for UHS in 2021/22, with a continued emphasis on preventing transmission of infection while supporting the recovery and restoration of services. In-hospital transmission of COVID-19 Throughout 2021/22 our COVID ZERO campaigns promoting safety across the workforce and services throughout the pandemic (wash, walk, wear, test and fresh air), and our follow-up #DontGoViral 2021 campaigns continued to be prioritised. Our COVID ZERO campaign has earned award-winning recognition for ‘Best crisis comms’ at the 2022 PRWeek UK Corporate, City & Public Affairs Awards. 19 QUALITY ACCOUNT 2021/22 What have we achieved in 2021/22? Strategies to prevent and reduce the risk of in-hospital transmission of COVID-19 have remained a priority and have been subject to ongoing review, with actions and improvements taken to reduce the ongoing risk of hospital onset infection and outbreaks. The figure below shows the trend of hospital-onset cases of COVID-19 from April 2021 to March 2022 and follows similar trends as the local and national prevalence of COVID-19. Figure 10: Cases of Hospital onset COVID-19*. *Classified as “hospital onset-definite hospital acquired” (HO. dHA) when the first positive test is at least 15 days following admission and “hospital onset-probable hospital acquired” when a first positive specimen occurred on days eight to 14 (HO. pHA) following admission Where cases of hospital acquired infection have occurred, they have been investigated using a root cause analysis (RCA) investigation process either as individual case reviews or part of a wider outbreak investigation. Hospital outbreaks of COVID-19 are robustly managed by the IPT using a formal incident/ outbreak management process and reported in the national outbreak management system with ongoing monitoring until 28 days following the last confirmed case. Learning from individual case investigations or outbreaks is shared promptly across the Trust and used to inform ongoing IPC actions and strategies. Clostridioides difficile (C. diff) UHS has seen wide fluctuations in the monthly number of C. diff cases with evidence of cases rising a few months after a major wave of COVID-19 infections. Reasons for the increase are not clear, but are likely to be multifactorial, and possibly related to the use of high-risk antibiotics during the first waves of the pandemic. This increase is being reported nationally with increases in rates of both community onset and hospital onset cases according to UK Health Security Agency (UKHSA) surveillance data. 20 QUALITY ACCOUNT 2021/22 Figure 11: Trends in hospital acquired C. diff * *Is classified into community-onset (COHA) and Hospital onset (HOHA) depending on identification of C. diff in community or hospital respectively. MRSA In 2021/22, UHS recorded cases of hospital acquired MRSA bloodstream infection as illustrated in the figure below. Figure 12: Number of patients who acquired MRSA (non-bloodstream infection) during their hospital stay The downward trend is representative of the trend that has been seen over the last few years. 21 QUALITY ACCOUNT 2021/22 Blood stream infections (BSI) All BSI cases are reviewed by the IPT to identify contributing factors or gaps in practice which may have contributed to infection occurring. They are investigated in detail to identify any learning that may drive improvements. Overall our reviews have noted that cases are complex with multiple risk factors for infection. A proportion of cases of BSI are assessed as unavoidable, but where infection is thought to have been preventable (e.g., occurred because of the presence of an invasive device such as an intravenous line or urinary catheter), this is followed up with appropriate investigation to identify emerging trends/themes, organisational learning and targeted improvement actions. The NHS Standard Contract 2021/22 includes quality requirements for NHS trusts and NHS foundation trusts to minimise rates of defined Gram-negative bloodstream infections to threshold levels set by NHS England and NHS Improvement. This includes klebsiella species, pseudomonas and E-coli. Monitoring of MSSA bloodstream infections is also undertaken. Hospital BSIs are defined as those that occur after the first 48 hours of admission (post 48-hour BSI). Figure 13: The number of cases of hospital acquired E coli BSI Figure 14 : The number of cases of hospital acquired klebsiella BSI 22 QUALITY ACCOUNT 2021/22 Figure 15 : The number of cases of hospital acquired pseudomonas BSI Figure 16 : The number of cases of hospital acquired MSSA BSI Vigorous focus and attention to IPC strategies targeted at reducing the risk of hospital transmission of COVID-19 has been central to our ongoing response to the pandemic, whilst at the same time focusing on restoring operational activity. Despite the challenges, UHS has one of the lowest rates of MRSA BSI in the country, and hospital-acquired COVID-19 infection is lower than in comparable hospitals. The health, safety and wellbeing of our patients, communities and staff has remained a priority,
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Annual-reports-and-quality-accounts/UHS-AR-21-22-Quality-Account.pdf

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Description: 2024/25 Incorporating the quality account University Hospital Southampton NHS Foundation Trust Annual Report and Accounts 2024/25 Presented to Parliament pursuant to Schedule 7, paragraph 25(4)(a) of the National Health Service Act 2006 © 2025 University Hospital Southampton NHS Foundation Trust Contents Welcome from our Chair and Chief Executive 7 Performance report 9 Introduction from the Chief Executive 10 Overview 11 Principal risks to our strategy and objectives 16 Performance overview 17 Performance analysis 22 Quality priorities 29 Financial performance 33 Sustainability 33 Social, community, anti-bribery and human rights issues 34 Events since the end of the financial year 35 Overseas operations 35 Equality in service delivery 35 Going concern 41 Accountability report 42 Directors’ report 43 Remuneration report 69 Staff report 82 Counter fraud 98 Code of governance for NHS provider trusts 98 NHS System Oversight Framework 99 Statement of the chief executive officer’s responsibilities as the accounting officer of UHS 100 Annual Governance Statement 102 Scope of responsibility 102 The purpose of the system of internal control 102 Risk management and control within the Trust 102 Review of economy, efficiency and effectiveness of the use of resources 116 Quality account 119 Part 1: Statement on quality from the Chief Executive 120 Part 2: Priorities for improvement and statements of assurance from the Board 122 Part 3: Other information 194 5 Annual accounts 241 Statement from the Chief Financial Officer 242 Auditor’s report including certificate 244 Foreword to the accounts 251 Statement of Comprehensive Income 252 Statement of Financial Position 253 Statement of Changes in Taxpayers’ Equity 254 Statement of Cash Flows 256 Notes to the accounts 257 6 Welcome from the Chair and Chief Executive Officer University Hospital Southampton NHS Foundation Trust (‘UHS’ or the ‘Trust’) has experienced another challenging year, with increased demand for the Trust’s services, a more restrictive financial environment, and changes in terms of the organisation of the NHS in England. Despite the challenges faced by the Trust during 2024/25, we can feel incredibly proud of the achievements of our 13,000 staff, who went above and beyond to deliver for our patients and the communities we serve. Particular highlights include: • In the top 15 in the country against government targets for elective recovery performance with 127% of activity compared with 2019/20. • Top-quartile performance against most performance metrics compared to similar sized teaching hospitals, including long-waiting patients on referral to treatment pathways, diagnostics and cancer performance. • Delivery of £85.3m of savings through our cost improvement programme – the highest ever amount by the Trust. We continue to be one of the best performing trusts in England in many areas. The Trust’s elective recovery performance places it as one of the best performing trusts in England. As a result, we have seen the number of long-waiting patients fall to one patient waiting over 78 weeks and to 21 patients waiting over 65 weeks – in many instances these delays were due to a national lack of corneal transplant tissue. This is despite an increase in the number of patients being referred to the Trust for treatment. Our performance against key cancer metrics has seen an improvement in commencing treatment of cancer within 62 days to 81% by March 2025, against the NHS England average for 2024/25 of 70.5%. Similarly, the Trust performed in the range of 88%-96% during the year against the target of patients commencing treatment within 31 days of diagnosis. There has been significant demand for non-elective care throughout the year, which has placed significant demands on the Trust’s emergency department. There were frequently more than 400 attendances per day and the Trust saw an average of 13,100 patients per month (2023/24: 12,700). As a result of this increased demand, coupled with issues with flow through the hospital and a high incidence of seasonal illnesses during the winter, UHS’s performance against the four-hour emergency department target has steadily declined over the course of 2024/25. The Trust also recorded a lower than expected death rate via the Summary Hospital-level Mortality Indicator (SHMI) and was one of 12 trusts in England out of 119 with lower than expected death outcomes. The Trust reported a deficit of £7m at year-end, which represents a significant achievement given the financial pressures we have experienced, such as significant demand for services above block contract levels, pay award pressures, and inflation. The Trust also saw its productivity improve during the year and delivered its highest ever performance under its cost improvement programme. 7 Despite the introduction of strict controls in early 2024, the Trust exceeded its target for workforce numbers during 2024/25 by 373 whole-time-equivalents. However, a significant proportion of this number was due to assumed reductions in the number of staff required to manage patients with no clinical criteria to reside in the hospital and patients with a primary mental health need not materialising. Instead, the number of both categories of patient continued to rise during the year, placing additional strain on the Trust’s capacity and reducing flow through the hospital as patients are unable to move in a timely way from the emergency department, to wards and then to discharge due to lack of capacity. Higher levels of staff absence during the winter months coupled with high levels of seasonal illness and consequent demand on the emergency department also necessitated the opening and staffing of surge capacity. Indeed, demand on the emergency department was so great during the year that surge capacity was required even outside of the typically busier winter period. Our people remain our greatest asset. Without our staff, the Trust would not be able to deliver for the communities we serve. We were pleased to see the results from the 2024 Staff Survey, which placed UHS above the benchmarking group across all the key people themes. In particular, there have been improvements in relation to satisfaction with immediate managers, flexible working opportunities, and staff recommending UHS as a place to work. UHS has also continued with its staff room refurbishment programme and made significant improvements to the prayer facilities for Muslim staff, patients, students and community members in our chapel, all funded by Southampton Hospitals Charity. We expect 2025/26 to be even more challenging than 2024/25. The Trust has already had to take some difficult decisions in terms of its workforce numbers, prioritisation for capital expenditure, and services. We will be expected to continue to maintain quality of patient care and experience and to deliver the required levels of performance whilst at the same time having to make significant reductions in its expenditure to deliver a balanced budget. Many of the challenges faced by the Trust – in common with other providers – can only be addressed by working in partnership with wider local partners, such as other healthcare providers, local authorities and charities to deliver system-wide solutions. At the same time, we recognise that there is more that we can do internally to ensure that our internal processes deliver in the most effective and efficient manner. We would like to express our heartfelt thanks to our amazing staff, who have gone and continue to go above and beyond to put our patients first and deliver world class care. Jenni Douglas-Todd Chair David French Chief Executive Officer 8 PERFORMANCE REPORT OVERVIEW AND PERFORMANCE Performance report Introduction from the Chief Executive Officer This was another challenging year for the Trust, continuing the trend seen in previous years of increasing demand which must be balanced with the need to deliver quality patient care whilst maintaining a sustainable financial position. The Trust saw even higher demand for non-elective care than in recent years with attendances at the emergency department being as high as 400 per day and the Trust having to open and staff surge capacity for a significant proportion of the year, including outside of the typically more strained winter period. The trend of increasing numbers of patients having no clinical criteria to reside in hospital, but unable to be discharged due to a lack of funded care in a more appropriate venue, continued, as did the increasing number of patients presenting with a primary mental health need. This placed significant pressure on the Trust’s resources due to the impact on flow through the hospital and the need to engage additional members of staff to manage these patients – in some instances this requires as many as four members of staff, usually via a specialist agency, for each patient as well as, potentially, additional security resource. Despite the challenges, the Trust continued to perform well when compared to other comparable organisations, achieving some of the best elective recovery performance in England at 127% compared to 2019/20 levels. The Trust implemented spending and recruitment controls in early 2024, which it continued to operate under during 2024/25, in order to manage its difficult financial position. However, the Trust ended the year above its plan in terms of workforce numbers, although a significant proportion of this amount was due to the increasing number of patients having no criteria to reside and mental health patients. The Trust achieved its highest ever delivery on its cost improvement programme with £85.3m of savings, and achieved an overall end of year deficit of £7m. 10 OVERVIEW AND PERFORMANCE Overview About the Trust Our services University Hospital Southampton NHS Foundation Trust is one of the largest acute teaching trusts in England with a turnover of £1.5 billion in 2024/25. It is based on the coast in southeast England and provides services to people living in Southampton and south Hampshire and specialist services, including neurosciences, respiratory medicine, cancer care, cardiovascular, obstetrics and specialist children’s services, to nearly four million people in central southern England and the Channel Islands. The Trust is also a designated major trauma centre, one of only two places in the south of England to offer adults and children full major trauma care provision. As a leading centre for teaching and research, the Trust has close working relationships with the University of Southampton, the Medical Research Council, National Institute for Health and Care Research (NIHR), Wellcome Trust and Cancer Research UK. The Trust is consistently one of the UK’s highest recruiting trusts of patients to clinical trials and one of the top nationally for research study volumes as ranked by the NIHR Clinical Research Network. Every year the Trust: treats around 166,000 inpatients and day patients, including about 75,000 emergency admissions sees over 770,000 people at outpatient appointments deals with around 155,000 cases in its emergency department The Trust provides most of its services from the following locations: • Southampton General Hospital – the Trust’s largest location, where a great number of specialist services are based alongside emergency and critical care, and which includes Southampton Children’s Hospital. • Princess Anne Hospital – located across the road from Southampton General Hospital and providing maternity care and specialist care for women with medical problems during pregnancy and babies who need extra care around birth. • Royal South Hants Hospital – although the Trust does not operate this site near the centre of Southampton, it provides a smaller number of services from this location. • New Forest Birth Centre – located at Ashurst on the edge of the New Forest and run by experienced midwives and support staff, it acts as a community midwifery hub. • Lymington New Forest Hospital – a community hospital located in Lymington managed by Hampshire and Isle of Wight Healthcare NHS Foundation Trust. UHS manages surgical services at the hospital. The services provided by the Trust are commissioned and paid for by the Hampshire and Isle of Wight Integrated Care System (ICS) and, in the case of more specialised services (such as treatments for rare conditions), by NHS England. 11 OVERVIEW AND PERFORMANCE Trust services are supported by clinical income, of which 53% is paid for by NHS England and 44% by integrated care boards, predominantly the Hampshire and Isle of Wight Integrated Care Board (ICB). These are provided under a standard NHS contract, which incorporates ongoing monitoring of the Trust and the quality of the services provided. Our structure UHS gained foundation trust status on 1 October 2011. A foundation trust is a public benefit corporation providing NHS services in line with the core NHS principles: that care should be universal, comprehensive and free at the point of need. The Trust is licensed as a foundation trust to provide these services by NHS England and the healthcare services we provide are regulated by the Care Quality Commission. Since 1 July 2022, the Trust has been part of the Hampshire and Isle of Wight Integrated Care System when this was established through the Health and Social Care Act 2022. Each ICS has two statutory elements: an integrated care partnership (ICP) and an integrated care board. The ICP is a statutory committee jointly formed between the NHS integrated care board and all upper-tier local authorities that fall within the ICS area. The ICP brings together a broad alliance of partners concerned with improving the care, health, and wellbeing of the population, with membership determined locally. The ICP is responsible for producing an integrated care strategy on how to meet the health and wellbeing needs of the population in the ICS area. The ICB is a statutory NHS organisation responsible for developing a plan for meeting the health needs of the population, managing the NHS budget and arranging for the provision of health services in the ICS area. The Trust has been a university teaching hospital since 1971. The diagram below provides an overview of the overall organisational structure of the Trust. Public and foundation trust members Council of Governors Board of Directors Executive Directors Division A Surgery Critical Care Ophthalmology Theatres and Anaesthetics Division B Cancer Care Emergency Medicine Helicopter Emergency Medical Services Medicine and Medicine for Older People Pathology Specialist Medicine Division C Women and Newborn Maternity Child Health Clinical Support 12 Division D Cardiovascular and Thoracic Neurosciences Trauma and Orthopaedics Radiology Trust headquarters division OVERVIEW AND PERFORMANCE Our values The Trust’s values describe how things are done at UHS and act as a guide to all staff working with colleagues to deliver high quality patient care and a great patient experience every day. These values are: Patients, their families and carers are at the heart of what we do. Their experience of our services will be our measure of success. Partnership between clinicians, patients and carers is critical to achieving our vision, both within hospital teams and extending across organisational boundaries in the NHS, social care and the third sector. We will ensure we are always improving services for patients through research, education, clinical effectiveness and quality improvement. We will continue to incorporate new ideas, technologies and create greater efficiencies in the services we provide. 13 OVERVIEW AND PERFORMANCE Our strategy 2021-25 The Trust’s strategy was updated during 2020/21 to take account of everything its staff had experienced during the COVID-19 pandemic and what had been learnt from this. The vision for UHS is to become an organisation of world class people delivering world class care. The Trust’s strategy is organised around five themes and for each of these it describes a number of ambitions UHS aims to achieve by 2025. Theme Ambitions Outstanding patient outcomes, • experience and safety By 2025 we will strengthen our national reputation for outstanding • patient outcomes, experience and safety, providing high quality care • and treatment across an extensive range of services from foetal medicine, through all life stages and conditions, to end-of-life care. Pioneering research and • innovation We will continue to be a leading • teaching hospital with a growing, reputable and innovative research • and development portfolio that attracts the best staff and efficiently delivers the best possible treatments and care for our patients. World class people • Supporting and nurturing our people through a culture that values • diversity and builds knowledge and skills to ensure everyone reaches their full potential. We must provide • rewarding career paths within empowered, compassionate, and motivated teams. Integrated networks and • collaboration We will deliver our services with • partners through clinical networks, collaboration and integration across geographical and organisational • boundaries. • We will monitor clinical outcomes, safety and experience of our patients regularly to ensure they are amongst the best in the UK and the world. We will reduce harm, learning from all incidents through our proactive patient safety culture. We will ensure all patients and relatives have a positive experience of our care, as a result of the environment created by our people and our facilities. We will recruit and enable people to deliver pioneering research in Southampton. We will optimise access to clinical research studies for our patients. We will enable innovation in everything we do, and ensure that ‘cutting edge’ investigations and treatments are delivered in Southampton. We will recruit and develop enough people with the right knowledge and skills to meet the needs of our patients. We will provide satisfying and fulfilling roles, growing our talent through development and opportunity for progression. We will empower our people, embracing diversity and embedding compassion, inclusion and equity of opportunity. We will work in partnership with key stakeholders across the Hampshire and Isle of Wight integrated Care System. We will strengthen our acute clinical networks across the region, centralising when necessary and supporting local care when appropriate. We will foster local integration with primary and community care as well as mental health and social care services for seamless delivery across boundaries. We will build on our successful partnership with University of Southampton (UoS), growing our reputation as a national leading university teaching hospital. 14 OVERVIEW AND PERFORMANCE Foundations for the future • We will deliver best value to the taxpayer as a financially Making our enabling infrastructure efficient and sustainable organisation. (finance, digital, estate) fit for • We will support patient self-management and seamless the future to support a leading care across organisational boundaries through our university teaching hospital in the ambitious digital programme, including real time data 21st century and recognising our reporting, to inform our care. responsibility as a major employer • We will expand and improve our estate, increasing in the community of Southampton capacity where needed and providing modern facilities and our role in broader for our patients and our people. environmental sustainability. • We will strengthen our role in the community as an employer of choice, a partner in delivery of services to our population and by leading the Greener NHS agenda locally. During each year of the strategy the Trust sets out a more detailed series of objectives to achieve and progress towards the delivery of its ambitions. In 2024/25 these objectives included: Outstanding patient Establishing an integrated approach to quality management. outcomes, experience Treating patients according to need but aiming to meet the target of zero and safety 65-week waiters by the end of September 2024, and continued reduction of longer waiters. Reducing length of stay across elective and non-elective pathways. Improving patient experience and outcomes through continued implementation of the Fundamentals of Care programme. Pioneering research and innovation Delivering year four of the research and innovation investment plan. Delivering year two of the five-year research and development strategy implementation plan for research for impact. World class people Delivering a workforce plan for the Trust for 2024/25 which is safe, sustainable and affordable. Delivering targeted improvements in staff experience, engagement and culture. Sustaining turnover at less than 13% and maintaining sickness absence at under 4%. Integrated networks In partnership with acute trusts working directly with priority areas to and collaboration progress joint network strategies. Working with the local delivery system on vertical integration to reduce the number of patients without criteria to reside. Foundations for the future Delivering a stretching financial plan for 2024/25, including identifying what needs to be true to recover a sustainable financial position and exit the Recovery Support Programme. Engaging the organisation in the challenge to manage demand so that capacity and demand are in equilibrium. Delivering the aims of the 2024/25 transformation programmes and always improving strategic priorities. Delivering the prioritised 2024/25 capital programme and setting a prioritised capital programme for 2025/26. Completing year two of the Public Sector Decarbonisation Scheme. 15 OVERVIEW AND PERFORMANCE Performance against these objectives was monitored and reported to the Trust’s Board on a quarterly basis. At the end of 2024/25, the Trust had met the objectives set as follows: Corporate Ambition Number of Green Amber Red objectives Outstanding patient outcomes, 4 3 1 0 safety and experience Pioneering research and innovation 2 2 0 0 World class people 3 2 0 0 Integrated networks and collaboration 2 0 2 0 Foundations for the future 5 2 2 1 Totals 16 8 6 2 Note: Green: achieved in full Amber: partially achieved Red: not achieved Particular areas to highlight where the Trust has achieved strong delivery during the year include: • Reduction in the number of patients waiting over 65 weeks, with only 21 waiting over 65 weeks. • Reduction in the length of stay by 5.25% through successful delivery of the inpatient flow transformation programme. • Implementation of the Fundamentals of Care programme. • Successful delivery of year four of the research and innovation investment plan. • Reducing staff turnover to 10.1% at year end and achieving a staff absence rate below 4%. • Progress in developing the identified priority clinical networks. • Successful delivery of the Trust’s 2024/25 capital programme. Principal risks to our strategy and objectives The Board has identified and manages the principal risks to the delivery of its strategy and objectives through its board assurance framework. The principal risks to the delivery of its strategy and objectives identified by the Trust during 2024/25 were that: • There would be a lack of capacity to appropriately respond to emergency demand, manage the increasing waiting lists for elective demand, and provide timely diagnostics, that results in avoidable harm to patients. • Due to the current challenges, the Trust fails to provide patients and their families or carers with a high-quality experience of care and positive patient outcomes. • The Trust would not effectively plan for and implement infection prevention and control measures that reduce the number of hospital-acquired infections and limit the number of nosocomial outbreaks of infection. • The Trust does not take full advantage of its position as a leading university teaching hospital with a growing, reputable and innovative research and development portfolio, attracting the best 16 OVERVIEW AND PERFORMANCE staff and efficiently delivering the best possible treatments and care for its patients. • The Trust is unable to meet current and planned service requirements due to unavailability of staff to fulfil key roles. • The Trust fails to develop a diverse, compassionate and inclusive workforce, providing a more positive experience for all staff. • The Trust fails to create a sustainable and innovative education and development response to meet the current and future workforce needs identified in the Trust’s longer-term workforce plan. • The Trust does not implement effective models to deliver integrated and networked care, resulting in sub-optimal patient experience and outcomes, increased numbers of admissions and increases in patients’ length of stay. • The Trust is unable to deliver a financial breakeven position, resulting in: inability to move out of the NHS England Recovery Support Programme; NHS England imposing additional controls/ undertakings; and a reducing cash balance, impacting the Trust’s ability to invest in line with its capital plan, estates and digital strategies and in transformation initiatives. • The Trust does not adequately maintain, improve and develop its estate to deliver its clinical services and increase capacity. • The Trust fails to introduce and implement new technology and expand the use of existing technology to transform its delivery of care through the funding and delivery of the digital strategy. • The Trust fails to prioritise green initiatives to deliver a trajectory that will reduce its direct and indirect carbon footprint by 80% by 2028-2032 (compared with a 1990 baseline) and reach net zero direct carbon emissions by 2040 and net zero indirect carbon emissions by 2045. As in previous years, demand for services continued to increase, especially for emergency (nonelective) care. The winter months in particular saw both high levels of demand and above average levels of staff absence due to seasonal illnesses. The Trust consistently experienced high numbers of patients having no clinical criteria to reside in hospital, but who could not be discharged due to a lack of appropriate care packages. This results in a lack of flow through the hospital and also requires additional staff to be engaged due to the need to open surge capacity. In addition, the Trust continued to experience significant challenges from patients with a primary mental health care need for whom there were insufficient spaces available in a more suitable alternative setting. Performance overview The Trust monitors a broad range of key performance indicators within its departments, divisions, directorates and through Trust executive committees. On a monthly basis, the Board and executive committee receives a performance report containing a variety of indicators intended to provide assurance in respect of the Trust’s strategy and that the care provided is safe, caring, effective, responsive, and well-led. This report also includes the Trust’s performance against the national targets set by NHS England. The performance reports include a ‘spotlight’ section, which provides more detailed analysis of a particular area. Typically, this is one of either the national targets or the Trust’s performance against the expectations set out in the NHS Constitution. 17 OVERVIEW AND PERFORMANCE The monthly performance report is also published on the Trust’s website. The Chief Executive Officer provides a regular report on performance to the Council of Governors, which includes a range of non-financial and financial performance information. Capacity The Trust experienced high demand for its services, continuing the trend from previous years. Demand in the emergency department in particular was significant, with attendances growing by 3.2% compared to 2023/24. This situation has resulted in a gradual decline in the Trust’s performance against the target of 95% patients spending less than four hours in the main emergency department. The number of patients having no clinical criteria to reside continued to impact flow within the hospital. The number of patients having no clinical criteria to reside was frequently above 250 at any one time during the year. The Trust experienced an increase in the number of referrals with the number of patients on a waiting list under the 18-week referral to treatment pathway rising from approximately 59,000 to 62,000 by the end of the year. Quality and compliance The Trust’s elective recovery performance was one of the best in England at 127% compared to 2019/20. The Trust continued to monitor the quality of care delivered throughout 2024/25 through a number of established quality assurance programmes. Clinical leaders monitored key quality, safety and patient experience indicators such as falls, pressure ulcers and venous thromboembolisms. The roll out of the Trust’s Fundamentals of Care initiative continued. High-quality peer reviews were consistently conducted, with a key focus on weekly matron-led quality walkabouts – both during and outside of standard hours – centred around the five CQC domains: safe, effective, responsive, caring, and well-led. Additionally, focused matron walkabouts were introduced to address specific themes related to patient safety and Fundamentals of Care standards, such as medication safety and infection prevention. These initiatives have been instrumental in identifying areas for improvement and promoting the sharing of best practices across teams. The Trust’s clinical accreditation scheme (CAS) builds on this intelligence, with clinical areas completing self-assessments of performance and review teams completing on-site visits. The clinical areas were supported by the CAS team from an initial contact meeting and walkabout through to outcome panel. Patient representatives were included in these review teams. CAS paperwork was reviewed to reflect the learning points from themed Matron’s walkabouts, aligning it to the CQC single assessment framework and the UHS Fundamentals of Care programme to ensure a robust ward accreditation. Learning was shared at the clinical leaders’ group and via reports. 18 OVERVIEW AND PERFORMANCE A framework was developed to govern Mortality and Morbidity meetings at the Trust, setting expectations for the content and format of these meetings. In addition, further work was carried out to ensure that the output from these meetings was shared more widely and that there is a clear escalation process. The Trust opened a patient and family support hub, repurposing the Macmillan Centre into a generic non-disease specific facility. The Trust worked with system partners to develop a unified and standardised approach to volunteer recruitment using a passporting system. The Trust commenced its implementation of the National Safety Standards for Invasive Procedures 2 (NatSSIPs 2). Violence, abuse and aggression against staff continued to rise. The Trust took action over the course of the year to support its teams, including through roll out of de-escalation training. This has had a positive impact and has reduced the requirement for physical restraint and has reduced the number of incidences of physical violence against staff. However, the level of violence and aggression directed at staff by patients and other members of the public continues to be an area of concern for the Trust. The Trust continued to build its always improving culture and drive on quality improvement by training over 1,000 staff, remaining 3% above the NHS average for all improvement focussed staff survey questions and winning an award for patient involvement in improvement and safety. This enabled improvements across theatre, inpatient flow and outpatient programmes. In 2024/25, average length of stay was reduced by 5.25%, an additional 1,230 patients were treated in theatres, and 7% of patients were placed onto patient initiated follow up (PIFU) outpatient pathways. Partnerships Further information can be found in the quality account. The Trust works within the Hampshire and Isle of Wight Integrated Care System and is an active member of a number of partner groups including the Acute Provider Collaborative Board and the Health and Wellbeing Board. The Trust develops and agrees its annual financial plans with the Integrated Care Board. The Trust is a member of a number of specific partnership groups for particular services, including the Central and South Genomics Medicine Service, the Children’s Hospital Alliance and the Southern Counties Pathology Network. The Trust works actively as a partner with other provider organisations around clinical networks, particularly with acute Trusts within the Integrated Care System and others closely located geographically. The Trust also links closely with the University of Southampton on a number of topics including research, commercial development and education and has a developed meeting structure to oversee this. 19 OVERVIEW AND PERFORMANCE Workforce The Trust’s key area of focus during 2024/25 was to maintain a flat workforce level in order to meet the Trust’s 2024/25 workforce plan. In addition, the Trust sought to reduce reliance on bank and agency staff. The Trust ended the year above its workforce plan by 373 whole-timeequivalents. A significant proportion of the expected reduction in staff numbers had been linked to expected delivery of reductions in the number of patients having no criteria to reside and mental health patients through system-wide transformation programmes. However, these reductions did not materialise. In addition, due to the significant demand on the Trust’s services, it was necessary to open and staff surge capacity. This was exacerbated by high levels of staff absence due to illness during the winter months. The Trust was successful in reducing staff turnover to 10.1%, achieving the local target of 75% of staff in each area has received training, including neonatal medical team. • Trolley dashes. • Train the trainer. Progress metrics Audit of compliance: • Has it been undertaken for the appropriate babies? • Was the frequency of observation undertaken correctly? • Was the score accurately calculated? • Did escalation take place if required? • Was the response to escalation appropriate? 157 QUALITY ACCOUNT Quality Improvement Priority Four: Implementation of the National Safety Standards for Invasive Procedures (NatSSIPs) 2 at UHS Core dimension Patient safety Rationale of selection The new National Safety Standards for Invasive Procedures (NatSSIPs 2) represent the progression of the original NatSSIPs. The key aim to standardise, harmonise and educate (SHE) across organisations and procedural teams remains central to the NatSSIPs purpose. Critical changes include bolstered organisational standards and proportionate checks that recognise different levels of risk during major and minor invasive procedures, and the adaptions to processes that may be necessary in lifethreatening situations. This standardisation, harmonisation and education goals are set out in the table below. Standardise Harmonise Educate Organisational Sequential (‘The NatSSIPs Eight’) Safety behaviours, processs, policies, insight, involvement and performance measures across organisations and specialities. Expected behaviour, safety standards, checklists and format across invasive specialities. Across groups of hospitals. Across IT systems. Reduce variation across specialities. Commit to safety education, human factors expertise and systems thinking. Create a safety infrastructure, leadership understanding and training in cultural change. Teach and train in team behaviours, human factors, systems thinking learning / co-production with patients. Investigations into the increase of never events in 2023 and 2024 has identified that the majority of these had contributing factors related to stop points for safety. The key learning identified: Thematic analysis of never events Surgical mark not visible/clear Not listening to patient concerns Change in surgical plan and lack of documentaion Lack of time out if concerns are raised Lack of triangulated checks Ability to speak up concerns Swab, sharp and instrument count process Implant checks not triangulating patent details Inexperienced staff with lack of familiarity of processs Lack of induction training in stop points Distractions during stop point checks 158 QUALITY ACCOUNT All these factors will be addressed through NatSSIPs2 implementation. Safer invasive procedures is to be included as a local quality indicator by the ICB within the 2025/26 national contract. Key aims • Establish a NatSSIPs oversight committee. • Set up an invasive procedures committee. • Establish the following workstreams: o Audit of stops point for safety in theatres and for minor procedures in outpatient and ward areas o Multi-disciplinary safety walkabouts o VLE and induction workstream • Education: recruitment of medical education led to set up simulation-based MDT training. • Patient involvement. • NatSSIPs eight and communications. • Stop points for safety staff resources. Progress metrics • Increase in the completion of VLE stop points training. • Develop and implement a programme to deliver non-technical skills to the MDT. • All areas with a never event in the last two years have an up to date audit and action plan for compliance with NatSSIPs2. 159 QUALITY ACCOUNT Quality Improvement Priority Five: Fundamentals of Care Core dimension Patient safety Rationale of selection The term Fundamentals of Care (FoC) describes the eight standards that staff across the Trust have committed to in collaboration with the patient, to support the physical and emotional needs of patients’, relatives, and carers. This is not a new concept, it underpins the core values of what it means to be a healthcare professional, to truly ‘care’ and will build upon our achievements in year one. Operational challenges have led the workforce to become more task-focused and less personfocused, taking away from that personalised care experience but we are committed to changing that culture, following our Trust value, patients first. The FoC exemplifies how the interdisciplinary team connects and builds relationships with our patients, getting to know them and what matters to them as a person, not just as a patient, supporting and encouraging independence and rehabilitation from the beginning of their hospital stay. These activities are the essentials of our daily living such as personal hygiene, skin care, oral hygiene, toileting, eating and drinking, and mobilising. Communication is also essential and includes both listening and hearing patients, understanding what is important to them using communication tools they need, coming to shared decisions with patients about their care and recognising the diversity of our population, embracing accessibility for those with people with learning disabilities, sight/hearing loss or other disabilities, or if English may not be their primary language. In addition, the FoC encourages us as healthcare professionals to consider the whole person, support cultural, spiritual, mental health, emotional wellbeing and dignity needs of people we care for and those that matter to them. We know here at UHS that not everyone experiences this level of care, but we acknowledge the need to change the rhetoric from ‘we are busy’ to ‘we are never too busy to care’ empowering and educating our staff at all levels to challenge the ‘we have not got time’ rhetoric and ensure fundamental care is at the heart of what we do at UHS. Thus improving, patient care and experience. Key aims We will grow the multi-disciplinary engagement and involvement in workstreams that embrace the FoC and encourage person centred to care. We will continue to pursue the digitalisation of the Friends and Family Test (FFT), using this data and the national inpatient and urgent and emergency care survey as a baseline, while linking with involved patients where required with to encourage feedback on the FoC. We will listen to the voice of our patients, their relatives, and carers to make sure their stories and experiences are heard by our workforce to encourage the organisation wide change. We will ensure the FoC will has clear and measurable improvement metrics as part of a live clinical quality dashboard that will afford ward managers and senior leaders, the opportunity to monitor, review and report on to FoC in their areas. 160 QUALITY ACCOUNT We will embed the FoC into the matron walkabout and CAS processes, supported by consistent evaluation metrics that ask the patients about their experiences and encourage clinical areas to continually assess and evaluate the FoC in their areas through a self-assessment tool. We will enhance the availability of existing resources on our virtual learning environment (VLE) in collaboration with our patient partners for all staff groups and embed the FoC into training across the organisation, to improve the knowledge, skills and awareness ensuring the delivery of quality care. We will continue to test and evaluate the What Matters To Me project, growing our volunteer role to support staff in finding out what is important to the patient and using their personalised board to remind staff of the ‘person’ they are caring for. We will continue to establish project links in child health, maternity and outpatients to ensure a bespoke, but collaborative roll out of FoC, considering how these different care environments may impact care. Progress metrics • Patient hygiene: we will see an improvement in the number of patients who report having their personal care needs met, particularly within their first 24 hours coming through emergency admission routes. • Skin integrity: we will support the reduction in incidences of avoidable pressure ulcers across the organisation. • Communication: we see an increase in the number of people accessing our interpreting services and a reduction in complaints related to interpretation. • Pain: we will see an improvement in patients reporting that their pain was well controlled when coming through the emergency department. • Mouthcare: we will see a positive uptake in the implementation of the new mouthcare assessment tool and an improvement in patients reporting that their oral hygiene needs have been met. • Nutrition and hydration: we will see an increase in patients reporting they are being offered adequate food and drink provisions throughout their hospital stay, including access to equipment for those with conditions or disabilities that impact their ability to do so independently. • Bowel and bladder care: we will see improved assessment of bowel and bladder habits through increased documentation using the Inpatient Noting system. • Enhancing safe movement: we will support a reduction in the incidence of high harm falls and high harm falls that have preventable causes. • Infection prevention: we will see a reduction in nosocomial infections through increased hand hygiene standards and more effective cleaning of equipment. 161 QUALITY ACCOUNT Quality Improvement Priority Six: Develop the Trusts’ approach to reducing the impact of health inequalities (HIs) (year two) Core dimension Clinical effectiveness Rationale of selection Tackling health inequalities is a key priority for the NHS. At UHS we have been working to have an impact on health inequalities for several years. In 2024/25 we formalised these efforts with a governing board, chaired by our chief medical officer and with a clear programme of improvement based on recognised priorities. This formed the basis of our quality priority in 2024/25. This year’s quality priority is a continuation of the work that started in 2024/25. We intend to continue to grow our understanding and actions as an organisation, improving the equity of access, outcomes and experience of our services across our community. Key aims We are continuing our health inequalities board, with focus on five priorities: enabling our organisation, data and measurement, clinical service priorities, communication and engagement and strategy and approach. Each of these priorities have aligned directors to oversee improvement and a detailed delivery plan. Key priorities and expected outcomes from each of these are listed below: Enabling the organisation • Developing supporting structures: set up governance so that teams who identify health inequality related issues know where they can go for help, so that we can understand frequently arising challenges and notice when a problem raised might be affecting other of the hospital too. This will aid improvement, learning from issues identified and escalation of issues that cannot be resolved locally • Capability building: develop training for our staff to understand health inequalities, identify them within services and access tools to make improvement. • Delivery of the health inequalities officer role: grow knowledge of the health inequalities officer role across the organisation and utilise this role to share knowledge, training and support improvements. Data and measurement • Continue to develop our understanding of inequalities in access across outpatients and diagnostics, inpatients, theatres and the emergency department. • Enable the measurement of improvement in areas recognised as clinical priorities. • Enable completion of national reporting. Clinical priorities • Improve services and support for patients and staff with obesity (children and adults). • Improve identification and control of hypertension. • Improve services and support for patients and staff who smoke. 162 QUALITY ACCOUNT Communication and engagement • Adopt health inequalities into leadership and decision making. • Learning from our communities and our staff. • Communicating improvements internally and externally. • Staff support campaign. Strategy and approach • Overseeing and agreeing UHS approach and strategy for HIs. • Overseeing annual delivery against priorities. • Aligning programme resource. • Maintaining collaborative working with public health and Integrated care board teams and other local healthcare providers. • Keeping up to date with national recommendations and expectations, sharing this knowledge with our organisation. • Overseeing trust-wide improvement and health inequalities maturity. Progress metrics • Increasing numbers of staff trained. • Numbers of health inequalities issues reported (expected to increase through understanding before reducing due to improvement work). • Case studies shared of successful improvement projects. • Increased involvement and collaboration with patients and public on improvement. • Increased use of QEIA templates in decision making. • Demonstration of improved access to care for obesity, tobacco dependency and hypertension. 163 QUALITY ACCOUNT 2.3 Statements of assurance from the Board This section includes mandatory statements about the quality of services that we provide relating to the financial year 2024/25. This information is common to all quality accounts and can be used to compare our performance with that of other organisations. The statements are designed to provide assurance that the board of directors has reviewed and engaged in crosscutting initiatives which link strongly to quality improvement. 2.3.1 Review of services During 2024/25 UHS provided and/or sub-contracted 118 relevant health services (from total Trust activity by specialty cumulative 2024/25 contractual report). UHS has reviewed all the data available to them on the quality of care in all these relevant health services. The income generated by the relevant health services reviewed in 2024/25 represents 100% of the total income generated from the provision of relevant health services by UHS for 2024/25. 2.3.2 Participation in national clinical audits and confidential enquiries The UHS clinical audit programme was developed in support of the Trust’s vision by putting patients first, working together and always improving. This leads on to a specific strategy for clinical outcomes, to ensure robust and measurable processes are in place to plan locally and participate strategically. Healthcare Quality Improvement Partnership (HQIP) produces a National Clinical Audit & Enquiries Directory which identifies those national audits which are included in the NHS England Quality Account List 2024/25, those audits which are part of National Clinical Audit and Patient Outcomes Programme (NCAPOP). NCAPOP audits are commissioned and managed on behalf of NHS England by HQIP. These collect and analyse data supplied by local clinicians to provide a national picture of care standards for that specific condition. On a local level, NCAPOP audits provide local trusts with individual benchmarked reports on their compliance and performance, feeding back comparative findings to help participants identify necessary improvements for patients. The audits listed on the NCAPOP are ‘must-do’ national audits. The quality accounts national clinical audit list includes audits which we regard as ‘best practice’ to participate in (in addition to those from the NCAPOP) and for that reason we always include these in our corporate audit plans as a priority where they are relevant to our Trust. UHS has a strong history for completing clinical audits. The clinical effectiveness team has a robust approach to governing and supporting the completion. We’ve opened discussions with senior clinical leadership within Hampshire and Isle of Wight Integrated Care Board regarding the current challenges with contributing to and using the outputs of national audits. Benchmarked data resulting from national audits provides strong guidance on areas of excellence and improvement, however completion can be challenging in its compl
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Annual-report-and-quality-account-2019-20

Description: ANNUAL REPORT AND ACCOUNTS 2019/20 Incorporating the quality account 2019/20 Page 2 University Hospital Southampton NHS Foundation Trust Annual report and accounts 2019/20 incorporating the quality account 2019/20 Presented to Parliament pursuant to Schedule 7, paragraph 25 (4) (a) of the National Health Service Act 2006 Page 4 ©2020 University Hospital Southampton NHS Foundation Trust Page 5 TABLE OF CONTENTS Overview and performance report Welcome from our chair A word from the chief executive Overview of the Trust Statement of purpose and activities History of UHS Our executive team structure Structure of our services Our vision and values Our priorities, key issues and risks Voluntary disclosures Equality, diversity and inclusion 92 8 9 Environmental sustainability and climate chan ge 95 Quality account 10 Chief executive welcome 101 10 11 Annual accounts 12 Statement from the Chief financial officer 183 13 Independent Auditors report 185 14 Foreword to accounts 192 Performance report Going concern disclosure 16 Reporting structure 16 Key performance indicators 18 How we monitor performance 19 Overview of performance of UHS 18 Regulatory body ratings 19 Environmental matters 23 Social, community, anti-bribery and human rights issues 23 Accountability report Members of the Trust Board 25 Trust Board purpose and structure 30 Board meeting attendance record 2018/19 31 Well-led framework 32 Finance and investment committee 34 Quality committee 33 Audit and risk committee 35 External auditors 36 Governance code 36 Performance evaluation of Trust Board and its committees 36 Remuneration 36 Countering fraud and corruption 37 Independence of external auditor 37 Internal audit service 37 Better payment practice code 37 Statement as to the disclosures to auditors 38 Disclosures 38 Income disclosures 38 Governance disclosures 38 Approach to quality governance 38 Council of Governors 41 Annual remuneration statement 51 Remuneration and appointments committee 54 Governors’ nomination committee 57 Staffing report 61 Staff survey results 65 Trade union facility time 68 Statement of chief executive’s responsibilities as the accounting officer 72 Annual governance statement 73 Page 6 OVERVIEW AND PERFORMANCE REPORT Page 7 OVERVIEW AND PERFORMANCE REPORT Welcome from our chair 2019/20 was another challenging year for University Hospital Southampton NHS Foundation Trust (UHS). Demand for our services continued to rise rapidly, partly because of the ageing of the population we are here to serve and partly because of challenges in the external environment, but also because of our ability to offer exciting innovations for a range of conditions. As a result, we were not always able to offer treatment as rapidly as we wished. A major challenge towards the end of the year was the need to prepare the Trust for the COVID-19 pandemic, resulting in the need to re-engineer services on an unprecedented scale. The response of UHS staff to these challenges has, from start to finish, been magnificent. We saw major innovation in improved patient pathways to accommodate rising demand, and the creativity of colleagues in readying the Trust for COVID-19 was truly breath-taking in its scope and energy. UHS has had a long record of effective financial management. By constantly seeking operational innovation and better value for money in procurement, the Trust has been able to generate the funds necessary to make a number of capital investments which will provide huge patient benefit in future. There has been rapid progress in our major project to refurbish and extend our general intensive care unit. Our £2.2m investment in our new urology unit was completed this year; it will transform our patients’ experiences. We have continued wherever possible to work with partners and we are delighted that work on the £5m Maggie’s Centre has started. Quite apart from the need to navigate our way through the COVID-19 crisis and into the world beyond it, the Trust needs to prepare to play its full role in the Hampshire and Isle of Wight healthcare system as it develops in a way consistent with the NHS Long Term Plan. The responsibility for this falls of course to the Trust Board and I believe that even after having had more change on the Board this year than for some time, we continue to have a strong and committed leadership team. Following the retirement of Caroline Marshall, our long-serving chief operating officer, in September 2019 we welcomed Joe Teape into the position. Joe had not been at the Trust long before we were thrust into the COVID-19 pandemic and got to grips with it impressively rapidly. During the year we said farewell to three non-executive directors (NEDs); Catherine Mason who left us to become chair of Solent Healthcare, Mike Sadler our clinical NED and Simon Porter. After a series of rigorous selection processes, we were delighted to welcome Dave Bennett, Dr Tim Peachey and Keith Evans as replacements. Simon had been both deputy chair and senior independent director (SID) and on his departure Jenni Douglas-Todd succeeded him in both roles. The work of the Board is supported, stimulated and, quite correctly, challenged by the Council of Governors (COG) whose enthusiasm is of huge value to the proper governance of UHS. All of the elections to the COG were competitive, in some cases by a multiplicity of candidates. Unfortunately, one of those vacancies resulted from the death of Edward Osmond. Although Edward had only recently been elected as a governor, he had shown huge commitment to the role and I am sure would have gone on to make a major contribution to UHS. We welcomed nine new governors and one new young governor. I look forward to working with them and all the other governors as we move through and beyond the COVID-19 world. Peter Hollins Chair Page 8 OVERVIEW AND PERFORMANCE REPORT A word from the chief executive My first full year as chief executive officer of UHS has been exciting, inspiring, and extremely rewarding but not, as you would expect, without a considerable degree of challenge! The pressures on the NHS have been well publicised as we strive to provide the highest possible standard of care at a time when demand for our services escalates rapidly. At the same time, at UHS we need to play our full part in working out how we shape and deliver the health and care provision for our community into the future. During the year we have done a great deal of work on how we turn our vision for the Trust, world-class care for everyone, into what happens on the front line every day. While the vision may be new it is built firmly on our long-standing values; patients first, working together, and always improving, which together describe who we are as an organisation. These values were central to the development of our new clinical and corporate strategy which sets out an exciting future for UHS over the coming decade. It includes how we will deliver the safest care, delivering the best outcomes, as well as how we will focus on improving the health of our population, supporting both health and wellbeing. The values also provided the basis for our CQC rating of ‘Good’ awarded during the year as were some other fantastic accolades. These included a prestigious British Medical Journal award for improving care for older patients with the development of our frailty unit and activity hub. Our women’s and maternity care at the Princess Anne Hospital was named as being among the best in the world. In addition, we adopted prehabilitation for cancer patients, a pioneering service. There are countless other examples of innovation which have sprung from the creativity and innovative spirit at UHS. Some of these have involved better outcomes for patients, some an improved patient experience and others simply lower the cost of doing things, liberating money which we can then invest in improving other services. I’d like to thank every one of our staff for creating the spirit of UHS which means that the extraordinary happens every day. The world of health and social care is changing dramatically and we continue to be integral to the Hampshire and Isle of Wight Sustainability and Transformation Partnership (STP). UHS will have a leading part to play in ensuring that, with our partners, we forge a pattern for the provision of healthcare across the local system and beyond, delivering the highest possible standards of care on an enduring basis. As we entered 2020, we began preparing to face COVID-19, the largest pandemic we have seen. Some areas of the hospital are truly unrecognisable as we have adapted to the fight against this virus. The loss of life as a result of COVID-19 has been utterly devastating and it has, I am sure, touched us all personally. It has also challenged the health and wellbeing of all our staff, but particularly our frontline staff, in a unique way. I am not sure whether I am prouder of the spirit with which our staff have responded to the challenge or of the fact that they made us by common consent one of the best prepared trusts in the country. Finally, I’d like to recognise the acts of kindness I see throughout the Trust on a daily basis. It is one of the things that has struck me the most as I have got to know this organisation and the people within it. I watch how they support one another through challenging times, how they support patients and visitors in their own time and in work time, and how they go above and beyond every day for the people they’re caring for. Every day they make me hugely privileged to lead this amazing organisation. Paula Head Chief executive officer Page 9 OVERVIEW AND PERFORMANCE REPORT Overview of the Trust Statement of purpose and activities UHS is a large teaching hospital located on the south coast of England. We have a tripartite mission to provide clinical care, educate current and future healthcare professionals, and undertake research to improve healthcare for the future. Our clinical care encompasses local acute and elective care for 680,000 people who live in Southampton, the New Forest, Eastleigh and Test Valley. We also provide care for the residents of the Isle of Wight for many services. As the major university hospital on the south coast, UHS provides the full range of tertiary medical and surgical specialities (with the exception of transplantation, renal services and burns) to over 3.7 million people in central southern England and the Channel Islands. UHS is a centre of excellence for training the doctors, nurses and other healthcare professionals of the future. We work with the University of Southampton and Solent University to educate and develop staff at all levels, including a large apprenticeship programme, undergraduate and postgraduate education. Our role in research, developed in active partnership with the University of Southampton, is to contribute to the development of treatments for tomorrow’s patients. This work distinguishes us as a hospital that works at the leading edge of healthcare developments in the NHS and internationally. In particular we have nationally-leading research into cancer, respiratory disease, nutrition, cardiovascular disease, bone and joint conditions and complex immune system problems. We are one of the largest recruiters of patients into clinical trials in the country. Over 12,000 people work at the Trust, making it one of the area’s biggest employers. We also benefit from the contributions of over 1,000 volunteers. Our turnover in 2019/20 was £912m. History of UHS The Trust has its origins in the 1900s when the Shirley Warren Poor Law Infirmary was built on the site of what is now Southampton General Hospital. In the early half of the century, the site began to expand, including the opening of the school of nursing and the creation of the Wessex Neurological Unit. In 1971 a new medical school was opened in Southampton and the 1970s and 1980s saw a significant building programme encompassing the current footprint of Southampton General Hospital, Princess Anne Hospital and Countess Mountbatten House. During the 1990s, services were increasingly centralised at the general hospital, with the eye hospital and cancer services being relocated from elsewhere in the city. The Wellcome Trust funded a clinical research facility at the hospital in 2001 and this unit remains the foundation for much of the Trust’s groundbreaking medical research. In the last decade, development has continued with the opening of the North Wing Cardiac Centre in 2006, the creation of a major trauma centre with on-site helipad and the opening in 2014 of Ronald McDonald House for the relatives of sick children. Organisationally, Southampton University Hospitals Trust was formed in 1993, creating a single management board for acute services in Southampton. Eighteen years later, University Hospital Southampton NHS Foundation Trust (UHS) was formed (1 October 2011) when Southampton University Hospitals NHS Trust was licensed as a foundation trust by the then regulator, Monitor (now known as NHS Improvement (NHSI)). Page 10 OVERVIEW AND PERFORMANCE REPORT Our executive team structure Executive team structure as at 31/03/2020 Page 11 OVERVIEW AND PERFORMANCE REPORT Structure of our services Our organisation is split into five areas, with our clinical services grouped into four divisions. Within each division there are care groups. Each division, with the exception of Trust headquarters, is led by a divisional management team consisting of: • divisional clinical director (DCD) • divisional director of operations (DDO) • divisional head of nursing/professions (DHN) • divisional research and development lead • divisional finance manager • divisional planning and business development (or strategy) manager • divisional education lead • division HR business partner • divisional governance manager (DGM) The diagram below outlines the five divisions and care groups/services within each. Each care group has a clinical lead, care group manager and matron/s for specific services as a minimum. Page 12 OVERVIEW AND PERFORMANCE REPORT Our vision and values Our vision outlines who we are and what we stand for, as well as describing the current challenges we face and our priorities for the future. It also provides an in-depth review of our three Trust values, which are summarised below: Patients first Patients and families will be at the heart of what we do and their experience within the hospital, and their perception of the Trust, will be our measure of success. Working together Our clinical teams will provide services to patients and are crucial to our success. We have launched a leadership strategy that ensures our clinical management teams are engaged in the day-today management and governance of the Trust. Always improving Our growing reputation in research and development and our approach to education and training will continue to incorporate new ideas, technologies and greater efficiencies in the services we provide Page 13 OVERVIEW AND PERFORMANCE REPORT Our priorities, key issues and risks Our goals 1. Improving patient journeys (system focus, integration) We will: • Write a strategic plan for integrated ‘front door; services to address capacity and demand mismatch and enable flow • Secure influence in primary care by establishing the hospital’s role in supporting primary care networks • Promote value-based healthcare, particularly: Introduce ‘advanced decision making’ • Redesign services to provide timely safe care and meet constitutional access trajectories • Deliver priorities relevant to UHS in the first year of the long-term plan including commissioning and long-term changes 2. Delivering value-based health and care We will: • Deliver the Trust financial plan and maximise any national funding • Prepare UHS for the new NHS financial regime • Deliver the Trust Quality Improvement plan to improve safety/experience and outcomes • Build capability for change by embedding quality improvement, innovation and transformation at a leadership level • Deliver the Cost Improvement Plan (CIP) without compromising on quality 3. Supporting health lives (prevention, wellbeing inequalities, outcomes and experience) We will: • Improve staff health and wellbeing • Improve population health, maximising the impact of UHS touch points • Develop an early warning tool to identify any deterioration in quality 4. Building an expert and inclusive workforce (diversity, engagement, leadership) We will: • Close the staffing supply gap in priority groups/services to provide high quality and timely care • Manage overall workforce cost to meet CIP challenge • Measure improvement in staff engagement by increasing participation in staff survey • Increase representation of diverse groups in leadership and decision making • Improve the staff engagement score 5. Being agile in meeting people’s needs (organisational elegance/design/flexibility) We will: • Reset organisational structure as necessary, responding to changes outlined in the NHS long-term plan • Leverage digital capability to support patient empowerment and self-care • Measure staff user satisfaction with the Trust IT systems and use this to support the digital strategy • Be agile in flexing resources, responding to fluctuating demand • Secure strategic influence by establishing UHS role in the transition from STP to ICS 6. Leading edge research, education and innovation (research and outcomes) We will: • Identify the capacity constraints to expand research and plan to address • Identify priority areas without a research base and set strategy • Improve quality and breadth of education and training programme Page 14 OVERVIEW AND PERFORMANCE REPORT The novel coronavirus (COVID-19) will continue to have a significant impact on public health, morbidity and mortality if adequate prevention and control is not in place. The Trust put rapid and robust arrangements in place early on to prepare for the potential surge in COVID-19 patients. As the government now announces the easing of the lockdown restrictions, the COVID-19 challenge continues to unfold and still represents a very significant future risk to the organization. Our response and mitigations will continue to evolve through 2020/21. Further details on our response to the COVID-19 challenge are in included in the Annual Governance Statement on page 73.. Key issues and risks 1. Inability to develop partnerships and redesign services innovatively renders the Trust unable to meet the expectations of the NHS long-term plan, our strategic plan, and sustainable elective and non-elective pathways. UHS continues to actively develop partnerships across the region and work within the Integrated Care System whilst promoting value-based healthcare and delivering priorities relevant to UHS in the first year of the longterm plan. 2. Failure to deliver regulatory requirements results in license breach and loss of local control with an enforced change in leadership, impacting on Goals 1 to 6. UHS continues to monitor progress against NHSI Performance framework at committee and Board level and build capability for change by embedding quality improvement, innovation and transformation at a leadership level. 3. Failure to achieve financial targets results in a shortfall in cash required to deliver the capital programme. A robust cost improvement programme is in place, continuously monitored through governance processes with a focus on delivery of the Trust’s financial plan. 4. Reduced access to resources compromises the quality of services. We will implement the Trust Quality Improvement plan to improve safety/ experience and outcomes. 5. Capacity and capability gaps in the workforce lead to an inability to provide safe and timely care. To mitigate this risk, we will continue to develop initiatives to improve staff health and wellbeing with proactive recruitment and retention initiatives in place. Staff engagement is monitored through staff survey and leadership and development training in place. 6. Lack of inclusion and diversity results in the failure to get the best from every individual. UHS has an equality, diversity and inclusion strategy, with established Trust networks and inclusive talent management programmes. Page 15 OVERVIEW AND PERFORMANCE REPORT Performance report Going concern disclosure After making enquiries, the directors have a reasonable expectation that the Trust has adequate resources to continue in operational existence for the foreseeable future. For this reason, they continue to adopt the going concern basis in preparing the accounts. Reporting structure As a large NHS university hospital foundation trust, UHS monitors performance within individual teams throughout the year with feedback processes in place to escalate issues to more senior management teams. At a corporate level we have an established executive reporting structure. Page 16 OVERVIEW AND PERFORMANCE REPORT Monthly Trust Board Public meeting where executive directors present high level summary to chairman and non-executive directors. Audit andrisk committee Finance and Investment committee Quality Committee People & Organisational Development Committee Trust executive committee (TEC) Review performance/issues/risks in greater depth For further detail on role of these committees please refer to the annual governance statement section. Trust Board study sessions Trust Board members meet to focus on a specific issue. Performance meetings Operational management team (led by chief operating officer) and division and care group management teams focus on individual patient and service pathways to develop improvement plans. Page 17 OVERVIEW AND PERFORMANCE REPORT Key performance indicators (KPIs) The Trust publishes a monthly integrated KPI Board report on our website which provides both the Board and the public with an overview of our performance. This report is constantly evolving as new areas of monitoring are developed and new areas of national focus become apparent. The format of the monthly report follows our six strategic goals: • Improve patient journeys • Value-based health and care • Healthy lives • An expert and inclusive workforce • Being agile in meeting people’s needs • Leading edge research, education and innovation The monthly report features the following sections: • Overview – Aggregation of commentary supporting all sections of the report • Safe • Effective • Caring • Activity • Emergency access • Referral to treatment and diagnostics • Cancer waiting times • Flow • Staffing • Research and development • Estates • Digital This report also includes summary versions of quarterly reports submitted to the Trust executive committee, which go into greater detail about patient experience, patient safety, clinical effectiveness outcomes, and infection prevention. In addition, a separate finance Board report is submitted to Trust Board on a monthly basis. The Emergency Access, Activity and Flow section has several KPIs that are relevant to the key risk of delivering the national access target. Some of the KPIs are: • Number of attendances • Time to initial assessment • Delayed transfers of care • Non-elective length of stay The Activity and Flow sections have several KPIs that are relevant to the key risk of capacity and occupancy. Some of the KPIs are: • Length of stay • New referrals • Number of attendances • Bed occupancy The Staffing (HR) section has several KPIs that are relevant to the key risk of Staffing. Some of the KPIs are: • Staff turnover • Nursing vacancies • Friends and Family Test – percentage of staff who recommend UHS as a place to work You can see full copies of the monthly report by visiting www.uhs.nhs.uk Page 18 OVERVIEW AND PERFORMANCE REPORT How we monitor performance In addition to reviewing the data submitted to the Trust Board in these papers, we have a suite of tools available to compare UHS performance to that of comparable trusts around the country. Depending on the measures being monitored, UHS has a number of peer groups to benchmark against, including other local providers, major trauma centres and university hospital teaching trusts. Each NHS trust will service a different size and type of population and will offer a slightly different range of services so it is important to understand that this benchmarking provides an initial indication of performance rather than an absolute guide to our position nationally. In 2020/21 we continue to review the National Model Hospital data as it is published from NHS Improvement. The data and ability to compare our performance has helped to highlight areas of excellent practice and areas where there is potential to improve. The Trust is engaging with the model hospital team and has a member of staff on the ‘model hospital ambassador program’, as well as reviewing areas highlighted as having potential opportunities alongside finance and operational teams. Overview of performance Improving patient journeys 2019/20 was a challenging year in which we made only modest progress against some objectives to ‘Improve Patient Journeys’, and deteriorated in performance against others. • Inpatient length of stay remained stable but didn’t reduce as significantly as we had intended. The percentage of bed days used due to ‘Delayed Transfers of Care’ to other settings increased to nearly twice the national target. This, combined with growth in non-elective admissions (2.8% YTD excluding M12), resulted in occupancy rates which often exceeded our target, and an increase in patients cared for as ‘outliers’ away from their own speciality wards. • Emergency Access Performance (patients spending less than four hours in the emergency department) remained below both the national and local targets, though performance did show modest improvement during the year. There has been a further substantial increase in the volume of emergency department attendances. • The number of ‘elective’ patients waiting for treatment, the percentage of patients waiting within 18 weeks, and also the waiting time for first outpatient appointments, deteriorated significantly during the year. This has, in part, been impacted upon by reduced availability of clinical capacity due to staff concerns about the impact of new pension/tax regulations. There are, however, good indications that service changes are being implemented to increase consultation capacity in an efficient way as we had aimed to. There has been a substantial increase in consultations provided through ‘non-face-to-face’ routes, and a small decrease in the number of more traditional face-to-face consultations. • Urgent GP referrals for suspected cancer seen within two weeks saw a substantial and sustained improvement compared to the previous year, exceeding that target. • Performance against treatment within 62 days measures also demonstrated modest improvement during the year. Significant improvement in cancer performance continues to be required in order for UHS to deliver the national targets for timeliness of treatment. Page 19 OVERVIEW AND PERFORMANCE REPORT Delivering value-based healthcare • Complaints about UHS care have remained low, with the percentage of complaints ‘closed’ within 35 days above target for the first 11 months of 2019/2020. • Pleasingly, the availability of nursing care to our inpatients (expressed as care hours per patient per day) has increased progressively through the year from 8.6 to 8.9. An active overseas nursing recruitment and induction process has supplemented domestic recruitment and training. • The Trust has formed a 50/50 joint venture company with Hampshire Hospitals NHS Foundation Trust called Wessex NHS Procurement Limited (WPL). From 1 December 2019, WPL is providing procurement, supply chain and materials management services to the Trust. The objectives of this innovative partnership include the consolidation of supplies purchases for both Trusts (combined revenue £1.4bn) to leverage better prices from suppliers and increased productivity through the elimination of previously duplicated procurement activity. Supporting healthy lives • There was very good performance on the Hospital Standardised Mortality Ratio. The standard is 100 and we are consistently below this (83 in December, results are reported nationally retrospectively). This measure includes all patients in England with the same condition and compares those who have died with those that have survived. Being below 100 is a strong indicator of good care. • We continue to receive feedback, which is largely positive, through the national ‘Friends and Family’ survey for both our inpatient and maternity care. • The Board monitors a range of quality indicators. Of these, exceeding the target number of patients infected with clostridium difficile by six is of some concern, we are pleased that the number of severe/moderate medication errors has been maintained well below our target level, and following an increase in the number of Serious Incidents Requiring Investigation (SIRI) that were reported to Board in the early part of the year both the number of SIRIs has reduced and the timeliness of investigation has significantly improved. • Staff sickness levels were on target through the summer months, but significantly in excess of this through the winter months. As a whole, this is a cause for some concern. Building an expert and inclusive workforce • Very pleasingly, nursing vacancies were reduced significantly during the year, from 18% to 15%. Though still a challenge, this supports increases in the treatment capacity we can make available in the Trust, in our ability to open additional bed capacity to reduce our inpatient occupancy rates, and increases the care hours provided per patient per day. • Turnover rates have been in excess of our target throughout the year and there has also been a reduction in the percentage of staff who would recommend UHS as a place to work, though we remain above our target of 76%. The percentage of non-medical appraisals taking place within 12 months remains below target and is declining. • We have made steady progress this year towards our target of 15% of staff at Band 7 and above being from Black and Minority Ethnic backgrounds by 2023 (above 9% in March 2020). Being agile in meeting people’s needs • 2019/2020 has seen further progress in the implementation of digital tools that enable patients and clinicians to review and discuss patient specific clinical information in new ways, for example, large increases in usage of ‘My Medical Record’ and ‘digi-rounds’, modest further progress in electronic requesting and acknowledgement of tests, and stable usage of other tools. Page 20 OVERVIEW AND PERFORMANCE REPORT Leading edge research, education and innovation • The majority of recruitment targets have been achieved during 2019/20. • In Q4 UHS ranked 13th for contract commercial study recruitment, which is the same position achieved in the previous year and thus did not achieve our target of Top 10, with a constraint on pharmacy research capacity being a contributing factor. • The proportion of commercial studies closing in the 2019/20 financial year on time and to recruitment target ended the year below the 80% target at 68%, though the year-end target for the proportion of non-commercial studies closing on time and to recruitment target was exceeded at 88% compared to 80% target. Details of UHS performance can be found in the Integrated Performance report which is available in the Trust Board papers section of our website www.uhs.nhs.uk. UHS performance is scrutinised by the Board on a monthly basis. Paula Head, chief executive officer 22 June 2020 Regulatory body ratings Single Oversight Framework NHS Improvement’s Single Oversight Framework provides the framework for overseeing providers and identifying potential support needs. The framework looks at five themes: 1. Quality of care 2. Finance and use of resources 3. Operational performance 4. Strategic change 5. Leadership and improvement capability (well-led) Based on information from these themes, providers are segmented from one to four where ‘4’ reflects providers receiving the most support, and ‘1’ reflects providers with maximum autonomy. A foundation trust will only be in segments three or four where it has been found to be in breach or suspected breach of its licence. Segmentation During 2019/20 the Trust was confirmed as being placed within segment ‘2’. This segmentation information is the Trust’s position as at 31 March 2020. Current segmentation information for NHS trusts and foundation trusts is published on the NHS Improvement website. Finance and use of resources The finance and use of resources theme is based on the scoring of five measures from ‘1’ to ‘4’, where ‘1’ reflects the strongest performance. These scores are then weighted to give an overall score. Given that finance and use of resources is only one of the five themes feeding into the Single Oversight Framework, the segmentation of the Trust disclosed above might not be the same as the overall finance score here. The Trust was on track to deliver a use of resources score of ‘2’. However, as a direct result of COVID-19 our staff were unable to take their full complement of annual leave. The Trust was required Page 21 OVERVIEW AND PERFORMANCE REPORT to allow for this additional cost, which was an unfunded cost pressure allowable by NHS Improvement. This had the impact of moving the distance from financial plan score to a ‘4’ and subsequently the overall use of resources score to a ‘3’. Area Financial sustainability Financial sustainability Financial sustainability Overall scoring Metric Capital service cover Liquidity Income and expenditure margin Distance from financial plan Agency spend Q1 Q2 Q3 Q4 Year 3 3 2 2 2 1 1 1 1 1 3 1 1 1 1 1 1 2 4 4 1 1 1 1 1 2 1 2 3 3 Care Quality Commission ratings: Overall rating for this trust Are services at this trust safe? Are services at this trust effective? Are services at this trust caring? Are services at this trust responsive? Are services at this trust well-led? Good Requires improvement Outstanding Good Requires improvement Good In December 2018, the CQC inspected four core services; urgent and emergency care, medicine, maternity and outpatients. It also looked at management and leadership, and effective and efficient use of resources. The CQC report (published on the 17 April 2019) rated the Trust as ‘good’ overall and ‘outstanding’ for providing effective services. All sites and services across the organisation are now rated as ‘good’ in the effective and caring domains, with Southampton General Hospital rated as ‘outstanding’ in these areas. The Well-Led section of this report provides further details of the inspectors’ findings. “Our inspectors found a strong patient-centred culture with staff committed to keeping their people safe, and encouraging them to be independent. Patients’ needs came first and staff worked hard to deliver the best possible care with compassion and respect. Inspectors saw many areas of outstanding practice, with care delivered by compassionate and knowledgeable staff. Several teams led by example with a continuous focus on quality improvement. The Trust did face some challenges especially with the ageing estates. Some patient environments were showing significant signs of wear and tear – but again staff were doing their utmost to deliver compassionate care”. Dr Nigel Acheson Deputy chief inspector of hospitals (South) Page 22 OVERVIEW AND PERFORMANCE REPORT Environmental matters We recognise that the Trust’s business has an impact on the environment. As a large hospital, we undertake a wide range of activities and use a large amount of resources. We are committed to environmental sustainability and consider it as part of the business culture. We continue to invest in energy saving initiatives and staff awareness campaigns that focus on promoting sustainability. We acknowledge that reducing waste and minimising the consumption of scarce resources is consistent with financial sustainability. Our sustainability disclosure section on pages 86 and 95 provides greater detail on the steps we are taking to reduce our activities’ impact on the environment. Social, community, anti-bribery and human rights issues We recognise our responsibilities under the European Convention on Human Rights (included in the Human Rights Act 1998 in the UK), which are relevant to health and social care. These rights include the: • right to life • right not to be subjected to torture, inhuman or degrading treatment or punishment • right to liberty • right to respect for private and family life The Trust is committed to ensuring it fully takes into account all aspects of human rights in our work. At University Hospital Southampton we value our reputation for top quality care and financial probity and conduct our business in an ethical manner. The Bribery Act 2010 was introduced to make it easier to tackle the issue of bribery which is a damaging practice. Bribery can be defined as ‘giving someone a financial or other advantage to encourage them to perform their duties improperly or reward them for having done so’. To limit our exposure to bribery we have in place an Anti-Fraud, Bribery and Corruption Policy, a Standards of Business Conduct Policy and a Freedom to Speak Up (formerly Raising Concerns) Policy. These apply to all staff and to individuals and organisations who act on behalf of UHS. We also employ a local counter-fraud specialist who will investigate, as appropriate, any allegations of fraud, bribery or corruption. The success of our anti-bribery approach depends on our staff playing their part in helping to detect and eradicate bribery. Therefore, we encourage staff, service users and others associated with UHS to report any suspicions of bribery and we will rigorously investigate any allegations. In addition, we hold a register of interest for directors, staff, and governors, and ask staff not to accept gifts or hospitality that will compromise them or the Trust. The Board of Directors carries out its business in an open and transparent way. We are committed to the prevention of bribery as well as to combating fraud, and expect the organisations we work with to do the same. Doing business in this way enables us to reassure our patients, members and stakeholders that public funds are properly safeguarded. There are no important events since the year end affecting the Foundation Trust. No political donations have been made. The Trust has no overseas branches. Page 23 OVERVIEW AND PERFORMANCE REPORT Page 24 ACCOUNTABILITY REPORT Members of the Trust Board Board member Name Title Paula Head Chief executive officer David French Deputy chief executive officer and chief financial officer Gail Byrne Director of nursing and organisational development Biography Paula joined the Trust as chief executive in September 2018, having been chief executive at the Royal Surrey County NHS Foundation Trust in Guildford and before that at Sussex Community NHS Foundation Trust. She began her career as a pharmacist working in the community, in hospitals and at health authorities before moving into general management and her first board position at Kingston Hospital. Since then she has spent time on the boards of commissioners and providers, including director of transformation at Frimley Park Hospital NHS FT. Paula lives in Hampshire and has a daughter studying medicine at the University of Southampton. David joined the Trust in February 2016 and served as interim chief executive officer from April to September 2018. He read Economics and Social Policy at the University of London before joining ICI plc, where he qualified as a chartered management accountant. David has extensive healthcare experience from the pharmaceutical industry, mostly Eli Lilly and Company where he held many commercial and financial roles in the UK and overseas. He joined the NHS in 2010 as chief financial officer of Hampshire Hospitals NHS Foundation Trust. He also serves as a non-executive director for Vivid Housing Limited, a social housing provider across Hampshire and the Solent. Gail joined the Trust in 2010 as deputy director of nursing and head of patient safety. Prior to this, she has worked at the Strategic Health Authority as head of patient safety, and director of clinical services at Portsmouth Hospital. Gail has also worked in Brisbane, Australia as a hospital Macmillan nurse, and as general manager of a special purpose vehicle company for the private finance initiative at South Manchester Hospitals. Declarations Daughter is a medical student at University of Southampton; Member of Hampshire & Isle of Wight Sustainability and Transformation Partnership Executive Delivery Group Non-executive director and chair of audit and risk committee, Vivid Housing Limited; Director, UHS Estates Limited, a wholly-owned subsidiary of UHSFT; Director, Southampton Commercial Estates Development Partnership (CEDP) Project Company Limited, a joint-venture company owned 50/50 by UHSFT and Prime plc; Member of Hampshire & Isle of Wight Counter Fraud Board; Member of Hampshire & Isle of Wight Sustainability and Transformation Partnership Capital Planning Panel; Director of Wessex NHS Procurement Limited (WPL), a joint venture company owned 50/50 by UHSFT and Hampshire Hospitals NHS Foundation Trust (from December 2019) Husband is a consultant surgeon at UHS; Daughter is a midwife at UHS (from March 2019) Dr Derek Sandeman Joe Teape Medical director Chief operating officer Derek was appointed to the Trust as a consultant physician in 1993 and went on to develop a regional Director of UHS Pharmacy Limited, endocrine service. Throughout his career he has had a wholly-owned subsidiary of extensive clinical leadership experience, most recently serving eight years as clinical director. Derek’s leadership roles have also included programme director for postgraduate education and the Wessex Endocrine Royal College representative. He has a strong history of wider system engagement, working collaboratively with partners to improve systems resilience and pathways. UHSFT; Member of Hampshire & Isle of Wight Sustainability and Transformation Partnership Clinical Executive Group Joe joined the Trust as chief operating officer in December Nil 2019. Previously he was deputy chief executive and director of operations of a large health board in Wales which managed integrated services across three counties including four district general hospitals as well as mental health, learning disability and community services. Prior to this, Joe worked in director roles across finance and strategy within provider acute trusts across the south west of England. Joe is passionate about providing leadership and support for all staff, whatever their profession, and contributing to excellent patient care. He is committed to open and ongoing engagement with the general public and often uses social media to engage with colleagues and with those who have an interest in healthcare. Page 25 ACCOUNTABILITY REPORT Non-executive directors Name Title Peter Hollins Chair Dr Tim Peachey Non-executive director David Bennett Non-executive director Biography Declarations Peter graduated in chemistry from Hertford College, Chair of CLIC Sargent Cancer Care Oxford. Joining Imperial Chemical Industries in 1973, for Children (a company limited by he undertook a series of increasingly senior roles in guarantee) (until December 2019); marketing and then general management. Following Council member of University of three years in the Netherlands as general manager of Southampton ICI Resins BV, he was appointed in 1992 as chief operating officer of EVC in Brussels – a joint venture between ICI and Enichem of Italy. He played a key role in the flotation of the company in 1994, returning in 1998 to the UK as chief executive officer of British Energy where he remained until 2001. From 2001, he held various chairmanships and non- executive directorships. In 2003, he decided to return to an executive role as chief executive of the British Heart Foundation in which post he remained until retirement in March 2013. He joined Southampton University Hospital Trust as a non- executive director in 2010, became senior independent director and deputy chairman of UHS in 2014, and was appointed chair in April 2016. Tim qualified as a doctor from Kings College Hospital Director, TP Medcon Ltd; Clinical School of Medicine in 1983. For nearly 20 years, he Safety Officer, Block Solutions Ltd; worked as a consultant anaesthetist at the Royal Free Non-executive director and Quality Hospital in London, specialising in pancreatic cancer Committee chair, Isle of Wight NHS surgery, liver surgery and liver transplantation. He also Trust developed an interest in medical leadership and management and has held positions such as clinical director, divisional director and medical director at the Royal Free. In 2012, Tim moved into full-time management as chief executive of Barnet and Chase Farm Hospitals NHS Trust until its acquisition by the Royal Free. He then worked as the London associate medical director at the NHS Trust Development Authority before moving to Barts Health NHS Trust as improvement director and subsequently became deputy chief executive. Tim now holds two NHS non-executive posts. In addition to his role at University Hospital Southampton, Tim also serves on the board for Isle of Wight NHS Trust as deputy chair. He is a practicing mediator specialising in the healthcare sector. He also consults for companies in the medical information technology industry. Dave graduated in chemistry from the University of Director, Davox Consulting Limited; Southampton before entering management consulting, Non-executive director, Faculty of becoming a partner in Accenture’s strategy practice. Leadership and Medical In 2003 he joined Exel Logistics (later bought by DHL), Management (from November managing the company’s healthcare business across 2019); Director Royal College of Europe and the Middle East. During this time, he General Practitioners (RCGP) established NHS Supply Chain, a UK organisation Enterprises Ltd and RGCP responsible for procuring and delivering medical Conferences Ltd (from November consumables for the NHS in England, as well as sourcing 2019) capital equipment. Dave joined the board of Cable & Wireless as sales director in 2008. He later set up his own strategy consulting practice serving the healthcare sector, completing numerous projects in the UK and the US. Dave has also served as a non-executive director at The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust between 2009 and 2016. He chaired the Trust’s quality committee. Page 26 ACCOUNTABILITY REPORT Board member Name Title Jenni DouglasTodd Senior independent director/deputy chair (from 01/02/2020) Biography Jenni is a former chief executive of Hampshire Police Authority and the office of the Hampshire police and crime commissioner. After beginning her career in the probation service, she was headhunted into the civil service, at the Home Office, where she spent four years before becoming director of policy and research for the Independent Police Complaints Commission. In the latter role she was responsible for establishing governance of the new police complaints system. She then spent two and a half years as a resident twinning adviser for the UK, based in Turkey to help set up a law enforcement complaints system before taking up the role of chief executive of the county’s police authority. During her three years in the post, she supported the authority in developing effective governance processes to increase accountability and transparency. She also helped the organisation deliver cost-savings whilst still improving performance and developing closer working relations with neighbouring forces. Declarations Independent chair, Dorset Integrated Care System. Managing director, Diversa Consultancy Limited; Member of the Judicial Conduct Investigative Office; Nonexecutive director, Hampshire Cricket Board; Trustee, NACRO; Member of English Cricket Board’s Regulatory Committee. Professor Non-executive Cyrus director Cooper In 2012, she became chief executive and monitoring officer for the Hampshire police and crime commissioner, where she led the development of the office’s vision, mission, values and organisational strategy. She took on the role of investigating committee chair for the General Dental Council in 2014 and, in April that year, founded the Diversa Consultancy, which supports organisations with changes in business, culture and behaviour. She is also a member of the Judicial Conduct Investigating Office, a public appointment. Cyrus Cooper is professor of rheumatology and director of the MRC Lifecourse Epidemiology Unit. He’s also vicedean of the faculty of medicine at the University of Southampton and professor of epidemiology at the Nuffield Department of Orthopaedics (rheumatology and musculoskeletal sciences, University of Oxford). He leads an internationally competitive programme of research into the epidemiology of musculoskeletal disorders, most notably osteoporosis. His key research contributions have been: • discovery of the developmental influences which contribute to the risk of osteoporosis and hip fracture in late adulthood • demonstration that maternal vitamin D insufficiency is associated with sub-optimal bone mineral accrual in childhood • characterisation of the definition and incidence rates of vertebral fractures • leadership of large pragmatic randomised controlled trials of calcium and vitamin D supplementation in the elderly as immediate preventative strategies against hip fracture. Director and professor of rheumatology, Medical Research Council (MRC) Lifecourse Epidemiology Unit; Vice-D
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Annual-reports-and-quality-accounts/annual-report-and-quality-account-2019-202.pdf

UHS AR 23-24 Final

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