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Guidance for new grant holders_FINAL_Oct2019
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Guidance for new UHS* grant holders Congratulations, you’ve been awarded some research funding! Now what? What are the key things yo
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/Media/Southampton-Clinical-Research/Grants/Download/Guidance-for-new-grant-holders-FINAL-Oct2019.pdf
Guidance for new grant holders_FINAL_June2021
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Guidance for new UHS* grant holders Congratulations, you’ve been awarded some research funding! Now what? What are the key things yo
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/Media/Southampton-Clinical-Research/Grants/Download/Guidance-for-new-grant-holders-FINAL-June2021.pdf
Annual-report-2017-18
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ANNUAL REPORT AND ACCOUNTS 2017/18 incorporating the quality account 2017/18 Presented to Parliament pursuant to Schedule 7, paragraph 25 (4) (a) of the National Health Service Act 2006 University Hospital Southampton NHS Foundation Trust Annual report and accounts 2017/18 incorporating the quality account 2017/18 Presented to Parliament pursuant to Schedule 7, paragraph 25 (4) (a) of the National Health Service Act 2006 3 ©2018 University Hospital Southampton NHS Foundation Trust 4 TABLE OF CONTENTS Overview and performance report Statement from the chairman and chief executive 7 Statement of purpose and activities 8 History of UHS 8 Structure of executive team 9 Structure of our services 10 Our vision and values 11 Priorities, key issues and risks 12 Going concern disclosure 15 Performance report 15 Regulatory body ratings 22 Environmental matters 23 Social, community and human rights issues 24 Accountability report Directors’ report – the Trust Board 26 Well-led framework 32 Audit and risk committee 32 Disclosures 35 Council of Governors 43 Annual remuneration statement 52 Remuneration and appointments committee 55 Governors’ nomination committee 57 Staffing report 61 Responding to the staff annual attitude survey 66 Statement of chief executive’s responsibilities as the accounting officer 71 Annual governance statement 72 Review of economy, efficiency and effectiveness of the use of resources 79 Equality, diversity and inclusion 83 Environmental sustainability and climate change 85 Southampton Hospital Charity 89 Developments in informatics 90 Leading research into better care 90 Investing for the future 91 Quality account and report Chief executive’s welcome 139 Our approach to quality assurance 141 Our commitment to safety 142 Our commitment to staff 143 Our commitment to education and training 145 Our commitment to technology to support quality 146 Our commitment to the Care Quality Commission 147 Review of quality performance 149 Progress against 2017/18 priorities 157 Clinical research 149 Review of services 150 CQUIN payment framework 150 Data quality 151 Clinical audits and confidential enquiries 152 Seven day hospital services 153 Learning from deaths 154 Priorities for improvement 2018/19 175 Conclusion 191 Responses to our quality account 192 Statement of directors’ responsibilities 198 Independent auditor’s report 199 Appendix Appendix one Quality improvement framework 2018/19 203 Appendix two Quality performance data 204 Appendix three CQUIN data 211 Appendix four Clinical audit and confidential enquiries data 214 Appendix five Registration with the Care Quality Commission 216 Appendix six Glossary of acronyms 217 Annual accounts Statement from the chief financial officer 93 Foreward to the accounts 94 Independent auditor’s report 95 Financial statements 101 5 OVERVIEW AND PERFORMANCE REPORT OVERVIEW AND PERFORMANCE REPORT A word from the chairman and chief executive Staff at UHS achieved some amazing things in 2017/18, a year in which the Trust faced the huge challenge of continuing to deal with rapidly rising demand for our services at a time when, like many hospitals, we were already under great pressure. Perhaps the most obvious achievement was that the Care Quality Commission (CQC) rated UHS as good for the quality of care which it provides overall and outstanding for leadership. It is no coincidence that the results from our latest NHS staff survey were so positive. We were particularly pleased that our response rate had increased and that UHS staff rated us the fourth best nationally for staff recommending the hospital as a place to work or receive care. We are also the seventh best nationally for staff engagement and results show that our staff feel able to contribute fully towards improvements. However, it’s truly in times of adversity, such as that we experienced over the winter period, that you see teamwork and commitment shine through. On several occasions we supported our neighbouring hospitals by providing care to their patients. We were also immensely proud of the way our staff pulled together during the days of thick snow with many staying on site overnight to ensure we had enough staff to care for our patients. Others stayed to look after stranded patients who were unable to get home. Staff with 4x4 vehicles collected colleagues for work and drove patients home. It was a monumental and incredibly uplifting effort from all. Our staff have indeed continued to strive tirelessly to provide both the quality of care and the speed of access to treatment to which we aspire. We are confident that we have done the former but the rapid increase in patient numbers has at times made it difficult to achieve the latter. We are determined to improve our performance to achieve the standards our patients expect. We are encouraged by the terrific results we achieve in the NHS Friends and Family test, with patients overwhelmingly recommending UHS as a place to have their hospital care. As the result of achieving our financial target for 2016/17 we became eligible for additional national cash incentive payments, which meant that in 2017/18 we were able to commit to the biggest capital investment programme the Trust has ever seen. As part of this programme we were able to address some of the areas of our estate that were highlighted as requiring improvement in a previous CQC report. We are delighted to say that we have again delivered our financial target for 2017/18 and will as a result be able to sustain a high rate of investment in upgrading our hospitals. We have also recently been able to start work on a £5m project to build a new Children’s Emergency Department as the result of generous support from the public for Southampton Hospital Charity and our partnership with the Murray Parish Trust without which the project would have been impossible. It will transform the environment in which our young patients are treated. Sadly at the end of the year we waved goodbye to Fiona Dalton, our chief executive for the last four years, who took the opportunity of a lifetime to live and work in Vancouver where she will lead a major Canadian healthcare group. Fiona was a remarkable chief executive, both immensely liked and admired throughout UHS and she left with the goodwill and best wishes of everyone. Peter Hollins David French Chairman Interim chief executive officer 7 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 post-graduate 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 11,454 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 2017/18 was more than £810m. 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)). 8 OVERVIEW AND PERFORMANCE REPORT The way we’re structured Structure of the executive team Associate director of corporate affairs Amanda Lowe Constitution; Council of governors; legal services; insurance; risk management; policy management; freedom of information (FOI) general data protection regulations (GDPR) Chief executive (interim) David French Director of HR Steven Harris Employee relations; pay and reward; resourcing and temporary staffing; staff engagement; staff performance and appraisal; occupational health and wellbeing; childcare services Medical director Dr Derek Sandeman MD for research & development; clinical effectiveness; clinical practices and outcomes; professional regulation & standards; GP relationships Director of nursing & organisational development Gail Byrne Chief financial officer (interim) Paul Goddard Clinical governance & patient safety; education; patient experience; clinical practice & outcomes; professional regulation & standards; complaints/PALS; HR/workforce; voluntary services; fundraising Caldicott Guardian Financial management; financial strategy; investment & ROI; audit; procurement; capital programme management; estates; Commercial development Division A Surgery Cancer care Critical care & theatres Chief operating officer Caroline Marshall Major incident planning; security; communications Division B Division C Emergency medicine Women & newborn Specialist medicine/ ophthalmology Pathology Child health Support services Director of transformation & improvement Jane Hayward Division D Cardiovascular & thoracic Neurosciences Trauma & orthopaedics Cost improvement & transformation; information technology; information governance; core platform systems; informatics development; strategy; commissioning; business & capacity planning Senior Information Risk Owner (SIRO) Radiology 9 OVERVIEW AND PERFORMANCE REPORT Structure of our services Our services are split into five divisions and 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. Division A Surgery Cancer care Critical care Theatres Division B Emergency medicine Medicine for older people Pathology Specialist medicine and ophthalmology Genetics Division C Child health Women and newborn Support services Division D Cardiovascular and thoracic Neurosciences Trauma and orthopaedics Major trauma centre Radiology TRUST HQ Corporate affairs Communications Finance Human resources Informatics Patient support services Claims and litigation Cost improvement and transformation Estates and capital developments Research and development 10 OVERVIEW AND PERFORMANCE REPORT Our vision and values Our Forward 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: putting patien putting patien putting patien putting patien putting patien putting patien putting patien putting patien putting patien king together king together king together king together king together king together king together king together king together ts first ts firwsotr ts firwsotr wor ts first ts firwsotr ts firwsotr wor ts first ts firwsotr ts firwsotr wor always imparlwovaiynsg imparlwovaiynsg improving always imparlwovaiynsg imparlwovaiynsg improving always imparlwovaiynsg imparlwovaiynsg improving ts first ts first ts first wor wor wor putting patien putting patien putting patien king together king together king together always imparlwovaiynsg imparlwovaiynsg improving Patients and families will be at Our clinical teams will provide the heart of what we do and services to patients and are their experience within the crucial to our success. hospital, and their perception We have launched a leadership ofmtheeasTurruensgtop,aftwiesnuitlslcfbcnigreesptsaosti.euntrs fnigrsptatients first clsintrrikacintageltgomgyetahtnherkraianggtteoegmnetsehuernkrrintegstteoogaeumthresr are engaged in the day-to-day management and governance of the Trust. alw alw alw Our growing reputation in research and development and our approach to education and training will continue ays improtvoinagiyns icmoprropvionagrysaitmeprnoveinwg ideas, technologies and greater efficiencies in the services we provide tients first tients first tients first together together together mproving mproving mproving putti putting pa putti putting pa putti putting pa wo working wo working wo working always i always i always i 11 OVERVIEW AND PERFORMANCE REPORT Our priorities, key issues and risks Our top eight priorities 1 Promote and live our values. We will: • be clearer about the behaviours we expect from our staff • recruit, train and promote people who demonstrably share our values in everything they do 2 Improve safety, quality and productivity. We will: • Sign up to safety and deliver on our promises to patients as part of this campaign • Focus on improving outcomes by measuring and publishing clinical outcomes for all specialties • Focus on improving the whole patient experience, so that patients feel treated with compassion by all staff in every contact • Develop the concept of excellent administrative care, organising our services well so that the patient journey runs smoothly • Commit to productivity improvement across all areas • Develop innovative solutions that allow us to deliver services more efficiently while making better use of our capacity 3 Our staff and education mission. We will: • Attract the best staff by offering them a better deal and the best place to work • Continue to invest in education and training opportunities for our staff including leadership development • Ensure that our leaders and staff understand and deliver our equality and diversity agenda • Prioritise excellent communication that allows the voice of our staff to be heard and acted on • Focus on the staff of the future by developing our education and training capability for clinical and non-clinical staff • Work with our local education providers to offer excellent education opportunities and bring high calibre people into healthcare roles in our hospitals 4 Become a hospital without walls. We will: • Increase the number of patients we care for who are not inpatients within the hospital. Some of these will be cared for in another residential location or at home in partnership between ourselves and other organisations • Be clear about services where we wish to provide end-to-end integrated care, and those where we wish to work with partners to integrate care across organisations • Work with health and social care partners (public, private and third sector), where necessary using new organisational models, to ensure that patients are always cared for in the right setting • Work more closely with general practices and support innovation being led by primary care 12 OVERVIEW AND PERFORMANCE REPORT 5 Specialised services. We will: • Engage with commissioners to plan changes in service models according to national service specifications • Continue to plan and manage the ongoing drift of sub-specialist work particularly in paediatrics and complex surgical services • Maintain and develop the critical mass that is increasingly required to care for complex and specialist patients • Work with Salisbury NHS Foundation Trust, the University of Southampton and other partners to play our part in the genomic revolution, building on the Genomic Medicine Centre and seeking to become a Genomics Central Laboratory Hub for the region • Develop our clinical informatics ability to ensure that we can take advantage of new information available for the benefit of patients 6 Preventative care. We will: • Continue to expand our screening programmes as national policy and commissioning intentions develop • Take every opportunity to further support and improve the health of our staff • Ensure that our clinical translational research programme, much of which is directly relevant to health promotion, accelerates translation of research into benefit for the local population 7 Discovery. We will: • Develop a detailed plan to continue increasing the number of UHS patients who are offered access to clinical trials and maximise the impact of the research we undertake • Work with the University of Southampton to submit a strong bid for the next round of Biomedical Research Centre / Biomedical Research Unit funding opportunities • Support the University of Southampton to create an international centre for cancer immunology to accelerate the development of new immune therapies to treat cancer 8 All stages of life. We will: • Continue to expand our paediatric services in partnership with community and local acute paediatrics and develop the physical infrastructure of a modern children’s hospital as quickly as finances allow • Continue to improve transition and the care of teenagers and young adults • Develop elderly care services that are integrated across the acute and community sectors • Continue to develop our end of life care 13 OVERVIEW AND PERFORMANCE REPORT Key issues and risks 1 Failure to deliver national access targets, which impacts patient experience and patient safety. Whilst we are meeting some of the national constitutional standards in waiting times, we are not meeting them all. A number of actions have been taken in relation to improving responsiveness and working with local health and social care partners to reduce delayed transfers of care. The Trust will continue to work to reduce delayed transfers of care, as well as reviewing the efficiency of discharge processes during 2018/19. 2 Capacity and occupancy, which impacts on patient flow and the quality and timeliness of care. Operational risks have been identified across a number of services/specialties linking to issues around increasing referrals, system capacity and delayed transfers of care. We have mitigated this by implementing daily reviews to assess system capacity and escalation requirements aligning capacity plans with the wider system, developing plans to reduce length of stay with strong clinical leadership and oversight and working with local health and social care partners to reduce delayed transfers of care. 3 Staffing, both in terms of recruitment and retention. To mitigate this risk we will continue to focus on making UHS an attractive employer by: • developing band four posts and apprentices • leveraging the ‘Think UHS’ recruitment brand • continuing to recruit within Europe and further afield • working with universities to increase student nurses • enhancing medical overseas fellows posts • reviewing all junior doctor rotas in light of the new contract • using flexible and temporary staff when needed • creating different roles linked to our research agenda • reviewing training and education to enhance retention. 14 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. Monthly Trust Board Public meeting where executive directors present high level summary to chairman and non-executive directors. For further information see page 30. Audit and risk committee Strategy and finance committee Quality 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 on page 72. 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. 15 OVERVIEW AND PERFORMANCE REPORT Key performance indicators (KPIs) The Trust publishes a monthly Integrated KPI Board Report on its website which provides both the Board and the public with an overview of performance within the Trust. This report is constantly evolving as new areas of monitoring are developed and new areas of national focus become apparent. For 2017/18 the format of the monthly report followed the five key Care Quality Commission (CQC) questions: • Are we safe? • Are we effective? • Are we caring? • Are we responsive? • Are we well-led? The monthly report features the following sections: • Executive digest – update on the previous month’s performance written by the director of transformation and improvement. • Trust overview – the top KPIs identified by Trust Board, RAG-rates for the previous 13 months • Safe • Effective • Caring • Activity • Emergency department (ED) • Referral to treatment (RTT/18 weeks) • Cancer waiting times • Flow • Staffing (HR) • Education and training • Research and development • Estates This report also includes summary versions of quarterly reports submitted to TEC which go into greater detail about patient experience, patient safety, clinical effectiveness and outcomes, and infection prevention. In addition, a separate Finance Board Report is submitted to Trust Board on a monthly basis. The emergency department, Activity and Flow section have several KPI’s that are relevant to the key risk of delivering the national access target. Some of the KPI’s are: • Number of attendances • Time to initial assessment • Hospital red/black alerts • Delayed transfers of care • Non-elective length of stay The Activity and Flow section have several KPI’s that are relevant to the key risk of capacity and occupancy. Some of the KPI’s are: • Length of stay • New referrals • Number of attendances • Bed occupancy • Hospital red/black alerts The Staffing (HR) section has several KPI’s that are relevant to the key risk of Staffing. Some of the KPI’s 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 16 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 2017/18 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 now has a model hospital steering group which identifies potential improvement projects from the data and reports to transformation board. Detailed analysis and explanation of the development and performance of UHS Activity, capacity and occupancy Over the past three years we have seen significant increases in all types of activity. This is linked to demographic growth, new specialist techniques and services transferring from other providers including vascular services from Portsmouth. In addition, UHS now has responsibility for surgical services at Lymington. The graph and table below demonstrate this increase in activity. UHS growth in activity – 2015/16 to 2017/18 700,000 600,000 500,000 400,000 300,000 200,000 100,000 0 Inpatient spells (inc. day cases Outpatient appointments 2015/16 2016/17 2017/18 ED attendances (type one) Referrals Inpatient spells (inc. day cases Outpatient appointments ED attendances (type one) Referrals 2015/16 146,066 562,972 95,217 191,888 2016/17 155,780 596,621 99,493 204,840 2017/18 154,224 624,083 102,547 208,872 Increase 15/16 to 17/18 5.6% 10.9% 7.7% 8.9% 17 OVERVIEW AND PERFORMANCE REPORT Hospital alert status The hospital alert status is decided by the operations centre after assessing the bed and staffing position, and is recorded twice daily at the Trust bed meetings (though the status may change at any time). Black alert is the highest level of alert and is issued when there are no empty beds available across the Trust with no expected discharges, the emergency department is full, and if actions are not taken several ambulances are likely to be delayed for long periods of time, stopping them from responding to 999 calls (this is based on a national definition of escalation). Red alert is when the majority of the hospital is under significant operational pressure and is likely to include a mismatch between supply and demand of beds and/or there are no beds available, with patients waiting more than three hours in the emergency department, and patients with a clinical decision for admission but no bed identified for them to move to. The Trust will undertake a wide range of actions in response to this, including the opening of additional overnight beds (usually within day wards), the redistribution of staff or bed capacity to support areas under most pressure, Trust-wide communication to request a focus on actions which will enable patients to be discharged or the admission avoided and the potential review of less urgent elective operations to maintain bed availability for patients with more urgent needs. In 2015/16 a black alert was recorded seven times at the twice daily bed meetings. In 2016/17 this was increased to eleven and in 2017/18 this increased again to twenty. The chart below shows red and black alerts logged during 2017/18. 50 Number of AM and PM alerts 40 30 20 10 0 Mar 17 Apr 17 May 17 Jun 17 Jul 17 Aug 17 Sep 17 Oct 17 Nov 17 Dec 17 Jan 18 Feb 18 Mar 18 Red alerts Black alerts Contributing to this change has been an increase in length of stay (LoS) for elective patients linked to a more complex case mix and an increase in day cases. The chart below shows the total bed days attributable to delayed transfers of care at UHS in 2017/18. UHS delayed transfers of care 2017/18 Percentage of bed days lost 3,400 3,200 3,000 2,800 2,600 2,400 2,200 2,000 Mar 2017 April 2017 May 2017 June 2017 July 2017 Aug 2017 Sept 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Mar 2018 18 OVERVIEW AND PERFORMANCE REPORT Referral to treatment (18 weeks) performance National target: 92% of all patients on 18 week pathway and not yet treated should have waited 18 weeks or less at the end of the month (incomplete pathways target). How did we do? UHS met the target in quarter one of 2017/18 but did not meet the target for the rest of the year. Achievement of this target in 2017/18 should be set against a rise in patient referrals, which highlights the increased demands being placed on the Trust. We have identified a reporting issue at our satellite outpatient clinics in Salisbury and are investigating the impact on referral to treatment reporting. Emergency department (ED) performance There are three types of emergency departments: Type Type Type ONE TWO THREE 3 24 hour with full resuscitation facilities 3 Consultant-led 3 Designated accommodation for patients admitted via ED 3 Single specialty emergencies (eye or dental) 3 Consultant-led 3 Designated accommodation 3 Minor injuries/walk-in centres 3 Doctor or nurse-led 3 Can be routinely accessed without appointment 3 May be co-located within an ED or sited in the community We run all three types of departments and, in August 2017 we also took over the operation of Lymington Minor Injuries Unit and opened the Urgent Care Hub at Southampton General in October 2017. All three types are subject to the national target and are therefore reflected in our figures. National target: The constitutional standard remains at 95% but a national recovery trajectory was agreed as: Patients should be treated and either admitted or discharged within four hours of arrival 85% achievement target set for April 17 90% achievement target in or before September 2017 95% achievement target by March 2018. How did we do? December 2017 was an extremely challenging month for emergency patients for the whole Hampshire and Isle of Wight area. UHS saw an increase in patients admitted to the Trust with influenza and, alongside our own bed pressures, we took ambulance diverts from other hospitals in order to maintain patient safety across Hampshire. Our Trust received formal letters of thanks from local commissioners and providers for the part we played during this difficult period. 19 OVERVIEW AND PERFORMANCE REPORT The graph below shows our performance against the four hour target over the last year. National 4 hour access target – UHS performance 100% 95% 89.4% 90% 85% 80% 87.4% 86.7% 91.4% 89.5% 93.3% 91.9% 90.5% 87.1% 83.2% 82.1% 82.5% 75% April 2017 May 2017 June 2017 July 2017 Aug 2017 Sept 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Mar 2018 Cancer waiting times There are ten separate cancer waiting times measures (below) that the Trust reports to the Department of Health on a monthly basis, each of which can then be split into tumour site specific performance groups. In 2017/18 the Trust met six of these measures. Number Measures Achieved 1 a maximum one month (31-day) wait from the date a decision to treat (DTT) is made to the first definitive 8 treatment for all cancers 2 a maximum 31-day wait for subsequent treatment where the treatment is surgery 8 3 a maximum 31-day wait for subsequent treatment where the treatment is a course of radiotherapy 3 4 a maximum 31-day wait for subsequent treatment where the treatment is an anti-cancer drug regimen 3 5 a maximum two month (62-day) wait from urgent referral for suspected cancer to the first definitive 8 treatment for all cancers 6 a maximum 62-day wait from referral from an NHS cancer screening service to the first definitive treatment 3 for cancer 7 a maximum 62-day wait for the first definitive treatment following a consultant’s decision to upgrade the 3 priority of the patient (all cancers) 8 a maximum two-week wait to see a specialist for all patients referred with suspected cancer symptoms 3 9 a maximum two-week wait to see a specialist for all patients referred for investigation of breast symptoms, 8 even if cancer is not initially suspected 10 A maximum 31-day wait (urgent GP referral to treatment) for first treatment for rarer cancers 3 The number of patients referred under the two week wait urgent suspected cancer protocol seen within two weeks of their referral, rose by 5.2% in 2017/18. The chart overleaf shows the rise in demand for UHS cancer services over the past three years. 20 OVERVIEW AND PERFORMANCE REPORT UHS growth in cancer actvity – 2015/16 to 2017/18 20,000 18,000 16,000 14,000 12,000 10,000 8,000 6,000 4,000 2,000 0 Two week waits 62 day target patients 2015/16 2016/17 2017/18 31 day target patients For staffing performance, please refer to page 61. For financial performance please see page 93. David French Interim chief executive officer 24 May 2018 21 OVERVIEW AND PERFORMANCE REPORT 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 2017/18 the Trust was confirmed as being placed within segment ‘2’. This segmentation information is the Trust’s position as at 31 March 2018. 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. Area Financial sustainability Financial sustainability Financial sustainability Overall scoring Care Quality Commission ratings: Metric Capital service cover Liquidity Income and expenditure margin Distance from financial plan Agency spend Q1 Q2 Q3 Q4 2 2 2 1 2 2 1 1 1 1 1 1 1 1 2 1 1 1 1 1 1 1 1 1 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 Good Outstanding Requires improvement Outstanding 22 OVERVIEW AND PERFORMANCE REPORT The CQC inspected all key questions in four of the eight core services of surgery, critical care, end of life care and outpatient and diagnostic imaging and noted the Trust had a stable leadership team in place since their last inspection. The previous inspection in 2015 had found safety of medicine and maternity services, along with responsiveness of urgent and emergency care and children’s services ‘required improvement’. At the 2017 inspection the following observation was made: ‘At this inspection we saw significant improvement across the areas we inspected. There were improvements in surgery, critical care, end of life care and outpatients. Critical care is rated overall as ‘Outstanding’, with surgery, end of life care, and outpatients and diagnostic imaging as ‘Good’ overall. These services had been rated requires improvement in 2015. The improvements were in line with the trust’s improvement plan and had been assisted by the trust board and executive leadership team’ Professor Sir Mike Richards Chief Inspector of Hospitals 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, for example: • The Trust generates approximately 3,000 tonnes of waste yearly, half of which is clinical waste. If not properly treated this huge amount of waste can cause soil, water and air pollution depending on the disposal route. • Due to the large number of visitors and deliveries we attract every day, traffic congestion is regularly experienced on and around the site, which impacts the air quality around the hospital. We are committed to environmental sustainability and consider it as part of the business culture. We acknowledge that reducing waste and minimising the consumption of scarce resources is consistent with financial sustainability. Our sustainability disclosure section on page 85 provides greater detail on the steps we are taking to reduce our activities’ impact on the environment. 23 OVERVIEW AND PERFORMANCE REPORT 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. 24 FR STAND BODY ACCOUNTABILITY REPORT Directors’ report – the Trust Board Board member Name Title Fiona Dalton Chief executive (until March 2018) David French Interim chief executive (chief financial officer until March 2018) Gail Byrne Director of nursing and organisational development Jane Hayward Director of transformation and improvement Biography Declarations Fiona was appointed as chief executive in 2013. Prior to re-joining the Trust she held the combined position of deputy chief executive and chief operating officer at Great Ormond Street Hospital for Children. Fiona joined the NHS management training scheme after graduating from Oxford University with a degree in human sciences and began her career in hospital management at Oxford Radcliffe Hospitals NHS Trust in 1996. She then spent four years at UHS as director of strategy and business development before moving to Great Ormond Street Hospital. NHS representative on Office for the Strategic Co-ordination of Health Research (OSCHR) Board; Director, Southampton Commercial Estates Development Partnership (CEDP) Project Company Limited, a whollyowned subsidiary of UHSFT. David joined the Trust in February 2016 and led on finance, procurement, estates and commercial development until March 2018, when he became interim chief executive officer. 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. 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 wholly-owned subsidiary of UHSFT; Member of Solent Acute Alliance 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. Husband is a consultant surgeon in the Trust; Trustee of Naomi House Children’s Hospice (until 10 February Jane joined the Trust in 2000 as a clinical services manager for the cardiothoracic directorate after spending two years in Hertfordshire as director of performance and 11 years at Barts and the London Hospitals in various roles including planning, finance and commissioning. Jane has led on human resources, information management and technology, improvement and modernisation and has been chief operating officer. Jane joined the Trust Board in February 2008 and became director of transformation and improvement in January 2014. Director, UHS Estates Limited, a wholly-owned subsidiary of UHSFT; Father is mental health act manager, Southern Foundation Trust (voluntary position) (until 31 August 2017), member of assessment committee for Clinical Excellence Awards South and Public Health England (lay member) (until January 2018), a UHSFT simulated patient (voluntary position); Mother is a UHSFT simulated patient (voluntary position) Dr Derek Medical Sandeman director Dr Caroline Marshall Chief operating officer Derek was appointed to the Trust as a consultant physician in 1993 and went on to develop a regional endocrine service. Throughout his career he has had 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. Caroline joined the Trust in 1997 as a consultant hepatobiliary and neuroanaesthetist. She has held the posts of college tutor for the Royal College of Anaesthetists and UHS mentoring and coaching lead. In 2008, she became clinical service director for critical care, and then divisional clinical director for division A between 2010 and 2013. Caroline served as interim chief operating officer between January to December 2014, and was then appointed to the substantive post. Her portfolio includes the executive lead for cancer and the executive lead for major trauma. Director of UHS Pharmacy Limited, a wholly-owned subsidiary of UHSFT; Daughter-in-law employed at UHSFT as medical support to department of innovation (from January 2017 – December 2017) Daughter is in an administration role at UHS (from July 2017) 26 ACCOUNTABILITY REPORT Board member Name Title Biography Declarations Paul Goddard Interim chief financial officer (from April 2018) Paul joined the Trust in June 2007 as assistant director of finance and become the deputy director in December 2012. Paul has spent over 25 years in NHS finance having worked in many different organisations. A fellow of the Association of Chartered Certified Accountants, Paul became interim chief financial officer at UHS from April 2018. Serves as a director of the Trust’s wholly owned subsidiary company, UHS Pharmacy Limited. Sits on the Southampton Hospital Charity committee. Non-executive directors Peter Hollins Simon Porter Chair Senior independent director and deputy chair Peter graduated in chemistry from Hertford College, Oxford. Joining Imperial Chemical Industries in 1973, he undertook a series of increasingly senior roles in marketing and then general management. Following three years in the Netherlands as general manager of 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 nonexecutive director in 2010, became senior independent director and deputy chairman of UHS in 2014, and was appointed chair in April 2016. Partner in the Jubilee Film Partnership; Chair of CLIC Sargent Cancer Care for Children (a company limited by guarantee); Council member of University of Southampton Simon was born and educated in Southampton and then Oxford, graduating with a degree in modern languages (Italian and French). He is a qualified chartered accountant, having spent most of his career with the London office of Ernst & Young, where he specialised first in audit, then in transactions and finally risk management. He was a partner with Ernst & Young from 1994 to 2010. He joined the Trust Board on 1 January 2011 as a designate non-executive director and became non-executive director from 1 June 2011. He is chair of the audit and risk committee and a member of the strategy and finance committee. He also holds non-executive board positions in the social housing sector. Former partner in Ernst & Young LLP; Non-executive director and chair of audit committee, Radian Group; Non-executive director and chair of audit committee, Octavia Housing Dr Mike Sadler Non-executive director Mike joined UHS as a clinical non-executive director in September 2014, from a similar position at an NHS foundation trust providing mental health, learning disability and community services. He has chaired our quality committee since June 2016. He works as an advisor and consultant on health and social care services, recently advising on health reform in the Middle East, and in Ireland. He has been chair and technical adviser to the Diabetes Professional Care Conference since 2015, and also worked for the CQC as a specialist adviser in primary care. External clinical associate for PricewaterhouseCoopers; Member of the Advisory Board for xim (from 1 May) Mike graduated from Nottingham University, and was a GP principal in Hampshire before moving into public health medicine. Having achieved an MSc with distinction at the London School of Hygiene and Tropical Medicine, he joined Portsmouth and South East Hampshire Health Authority, holding the joint posts of deputy director of public health and medical adviser. He has since held a series of senior clinical leadership roles in national organisations in both the public and private sector, including as a chief operating officer at NHS Direct and Serco’s health division. His last full time role, up until July 2013 when he commenced his portfolio career, was as director of health and social care at West Sussex County Council. 27 ACCOUNTABILITY REPORT Board member Name Title Jenni Non-executive Douglas- director Todd Biography
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ANNUAL REPORT AND ACCOUNTS 2016/17 incorporating the quality account 2016/17 Presented to Parliament pursuant to Schedule 7, paragraph 25 (4) (a) of the National Health Service Act 2006 University Hospital Southampton NHS Foundation Trust Annual report and accounts 2016/17 incorporating the quality account 2016/17 Presented to Parliament pursuant to Schedule 7, paragraph 25 (4) (a) of the National Health Service Act 2006 3 ©2017 University Hospital Southampton NHS Foundation Trust TABLE OF CONTENTS Performance report Statement from the chief executive 7 Statement of purpose and activities 9 History of UHS 9 Key issues and risks 10 Going concern disclosure 10 Performance reporting 11 Regulatory body ratings 15 Environmental matters 16 Social, community and human rights issues 16 Accountability report Directors’ report 18 Introducing the Board of Directors 20 The people 21 Audit and risk committee 25 Disclosures 28 Council of Governors 32 Annual remuneration statement 39 Remuneration and appointments committee 42 Governors’ nomination committee 44 Staffing data 48 Responding to the staff annual attitude survey 50 Statement of chief executive’s responsibilities as the accounting officer 55 Annual governance statement 56 Review of economy, efficiency and effectiveness of the use of resources 62 Equality, diversity and inclusion 66 Southampton Hospital Charity 67 Developments in informatics 68 Leading research into better care 68 Investing for the future 69 Environmental sustainability and climate change 70 Quality account and report Chief executive’s welcome 119 Our approach to quality assurance 121 Our commitment to safety 122 Our commitment to staff 125 Our commitment to education and training 126 Our commitment to technology to support quality 127 Our commitment to the Care Quality Commission 129 Progress against 2016/17 priorities 127 Priorities for improvement 2017/18 141 Review of quality performance 152 Conclusion 155 Responses to our quality account 156 Statement of directors’ responsibilities 163 Independent auditor’s report 164 Appendices Appendix one: Patient Improvement Framework (PIF) priorities 2017/18 168 Appendix two: Definitions of pressure ulcer grading 169 Appendix three: Quality performance data 170 Appendix four: CQUINS data 177 Appendix five: Clinical audit and confidential enquiries data 179 Appendix six: Outcome measures data 190 Appendix seven: Registration with the Care Quality Commission 191 Appendix eight: Pulse KPIs 192 Appendix nine: Glossary of acronyms 195 Annual accounts Statement from the chief financial officer 75 Foreward to the accounts 76 Independent auditor’s report 77 Financial statements 81 5 Statement from the chief executive More patients than ever before were treated at University Hospital Southampton (UHS) during 2016/17. And despite seeing an extra 41,000 patients than the previous year, we have continued to maintain our patient satisfaction scores with more than 95% recommending UHS. This is just one of many outstanding achievements across our hospitals which we are proud to highlight in this annual report. Our ongoing challenge now is tackling the high numbers of patients who could be at home, but who lack support from either health or social care to move out of hospital. There has been some hard work done in this area and we’re already seeing signs of improvement. The latest Friends and Family Test results - the survey which all UHS staff are asked to complete - said that 92% of staff would recommend UHS as a place to be treated, and 77% would recommend it as a place to work. Both these figures are the highest we have ever achieved, and are much better than the national average. We have been able to invest heavily in improved and expanded facilities for patients and for research. For instance, work has started on the radiotherapy bunker which will house the new linear accelerators used to treat cancer patients and the new Cancer Immunology Centre is also progressing well. The ongoing investment into diagnostics – particularly radiology but also more specific schemes such as hysteroscopy – should help patients right across the hospital. We recently received national recognition as a “global digital exemplar”; an award which we anticipate will bring an additional £10 million of national money. Historically, we have spent very little on information technology but, despite this, much has been delivered.This extra national money will make a real difference to patient care through some large-scale informatics projects and will also improve the day to day IT equipment our staff have available to them. Our new main entrance, which opened last summer, now feels like it has been here forever but I think it is still worth remembering what an improvement it is on the old entrance, and that it was rebuilt without spending any NHS money. We have been successful in renewing our NHS research funding, through both our Biomedical Research Centre (BRC) and Clinical Research Facility (CRF). This was a tough competition, as we were competing against every other academic medical centre in the country, and the rules were clear that only “world class research” would be funded. So the Southampton research team (UHS and the University of Southampton), led by Rob Read for the BRC and Saul Faust for the CRF, should be very proud that we were successful, and that Southampton research will continue to help patients receive better care across the world. Children’s services are very important to us and thanks to a combination of NHS funds and very generous donations, we have been able to refurbish and expand Piam Brown (paediatric cancer) ward and our paediatric intensive care unit (PICU). Despite a challenging time for NHS finances, UHS had a successful financial year, ending it with a surplus of £20.4m. This has enabled us to plan increased investment in our estate, particularly for the most vulnerable patients such as refurbishment of high dependency and intensive care facilities for patients of all ages, and theatre and interventional radiology rooms. This means that we will continue to have the facilities to look after the sickest patients in Hampshire and beyond. 7 In 2016/17 we launched our children’s emergency department campaign, alongside the Murray Parish Trust. We’re now well on our way to raising the £2 million needed, which will be fund matched by the Government. We hope to start building this summer. So, while there have been considerable challenges meeting uplifts in demand and managing discharges, there has also been much to celebrate and we look forward to 2017/18. Fiona Dalton Chief executive 23 May 2017 8 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 post-graduate 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 10,500 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 2016/17 was more than £760m. 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)). 9 Key issues and risks 1. Failure to deliver national access targets, which impacts patient experience and patient safety. Whilst we are meeting some of the national constitutional standards in waiting times, we are not meeting them all. A number of actions have been taken in relation to improving responsiveness and working with local health and social care partners to reduce delayed transfers of care. The Trust will continue to work to reduce delayed transfers of care as well as reviewing the efficiency of discharge processes during 2017/18. 2. Capacity and occupancy, which impacts on patient flow and to the quality and timeliness of care. Operational risks have been identified across a number of services/specialties linking to issues around increasing referrals, system capacity and delayed transfers of care. We have mitigated this by implementing daily reviews to assess system capacity and escalation requirements aligning capacity plans with the wider system, developing plans to reduce length of stay with strong clinical leadership and oversight and working with local health and social care partners to reduce delayed transfers of care. 3. Staffing, both in terms of recruitment and retention. To mitigate this risk we will continue to focus on making UHS an attractive employer by: • continuing to recruit within Europe and further afield • working with universities to increase student nurses • developing band four posts and apprentices • leveraging the ‘Think UHS’ recruitment brand • enhancing medical overseas fellows posts • reviewing all junior doctor rotas in light of the new contract • using flexible and temporary staff when needed • creating different roles linked to our research agenda • reviewing training and education to enhance retention 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. 10 Performance reporting 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. This begins with the monthly Trust Board meeting where the executive directors of the Trust will present a high level summary to the chairman and non-executive directors, as well as providing greater detail on key performance changes, risks and issues. Below this are a number of executive sub-committees attended by a subset of executive and non-executive directors. These are the audit and risk committee, the strategy and finance committee, and the quality committee. These committees will review issues in greater depth, feeding back to Trust Board as appropriate. In addition, there are regular Trust Board study sessions which focus on specific individual issues with the entire Board present. The Trust executive committee (TEC) meets monthly and is made up of the executive board members and the divisional management teams. Performance and service issues are discussed in greater detail at this meeting. Finally, there are regular performance meetings between the operational management team (led by the chief operating officer) and the division and care group management teams. These meetings focus on the individual patient and service pathways and developing the detailed plans for improvement. Key performance indicators (KPIs) The Trust publishes a monthly Integrated KPI Board Report on its website which provides both the Board and the public with an overview of performance within the Trust. This report is constantly evolving as new areas of monitoring are developed and new areas of national focus become apparent. For the 2016/17 period the most notable development to the monthly report was a restructuring of the format in order to better align the reported metrics to five key Care Quality Commission questions: • Are we safe • Are we effective • Are we caring • Are we responsive • Are we well-led. The monthly report features the following sections: • Executive digest – a textual update on the previous month’s performance across the Trust written by the director of transformation and improvement. • Trust overview – the top KPIs identified by Trust Board, RAG-rates for the previous 13 months (see Appendix eight) • Performance • Activity • Capacity • Emergency department (ED) • Referral to Treatment (RTT/18 weeks) • Cancer waiting times • Finance • Patient experience • Patient safety • Outcomes • Staffing (HR) and estates • Education and training • Research and development 11 This report also includes summary versions of quarterly reports submitted to TEC which go into greater detail about patient experience, patient safety, clinical effectiveness and outcomes, and infection prevention. In addition, a separate Finance Board Report is submitted to Trust Board on a monthly basis. 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 2016/17 we have reviewed the National Model Hospital data published by Lord Carter’s team at NHS Improvement, this includes the Getting it Right First Time Reports. This data and ability to compare our performance has helped to highlight areas of excellent practice and areas where there is potential to improve. This data is reported regularly to the Transformation Board. Detailed analysis and explanation of the development and performance of UHS Over the past three years we have seen significant increases in all types of activity. Some of this is due to an increase in the range of specialist services we offer, becoming a major trauma centre and the building of the helipad, but much of it is due to the increased and aging population in Southampton and the surrounding area. The graphs below demonstrate this increase in activity. Growth iUnHaSctGivritoyw-t2h01in4/A15cttiovi2ty01-62/10714/15 to 2016/17 700,000 600,000 500,000 400,000 300,000 200,000 2014/15 2015/16 2016/17 100,000 - Inpatient Spells (inc Outpatient day cases) Appointments ED Attendances (type 1) Referrals 2014/15 Inpatient spells (inc day cases) 144,934 Outpatient appointments 536,949 ED attendance (type one and two) 94,376 Referrals 182,407 2015/16 146,066 562,972 95,217 191,888 2016/17 155,780 596,621 99,493 204,840 Increase 2014/15 to 2016/17 7.5% 11.1% 5.4% 12.3% 12 The hospital alert status is decided by the operations centre after assessing the bed and staffing position, and is recorded twice daily at the Trust bed meetings (though the status may change at any time). Black alert is the highest level of alert and is issued when there are no empty beds available across the Trust with no expected discharges, the emergency department is full, and several ambulances are likely to be delayed for long periods of time, stopping them from responding to 999 calls. In 2014/15 a black alert was recorded 91 times at the twice daily bed meetings. In 2015/16 this was reduced to seven. However, as result of the increasing demand for Trust services this increased to eleven in 2016/17. Contributing to this change has been the increase in Length of Stay (LoS) for elective patients and bed capacity being impacted upon by the increased number of patients requiring a complex package of care after their discharge. These patients can often have their discharges delayed while beds in community care homes are found and supporting community care packages are arranged. The chart below demonstrates the change in LoS for elective and non-elective (emergency) patients over the past three years. 2016/17 saw an increased focus on discharging patients earlier in the day and at the weekend. This will remain a major focus for the Trust in 2017/18. Each of the above metrics will have an impact on the Trust’s performance against the three primary nationally reported targets for Referral to Treatment (RTT, or 18 Weeks) performance, emergency department performance and cancer waiting times performance. Referral to Treatment (18 Weeks) performance Due to a change introduced by the Government in 2015 trusts are only required to achieve the Incomplete Pathways target: 1. Incomplete Pathways – 92% of all patients on 18 week pathway and not yet treated should have waited 18 weeks or less at the end of the month. UHS met the target in quarters one, two, and three of 2016/17. In quarter four the target was met in February and March but performance in January meant that the target was not met for the quarter as a whole. Achievement of this target in 2016/17 should be set against the aforementioned rise in patient referrals, which highlights the increased demands being placed on the Trust. It is only due to the increased efficiency shown by the Trust’s inpatient and outpatient services that it has been possible to meet these targets on an ongoing basis. This is an excellent result and goes against the national trend. 13 Emergency department (ED) performance We did not meet the national target of 95% of all ED attendances being treated and either admitted or discharged within four hours of arrival in any month in 2016/17, but we did achieve our nationally agreed trajectory target. This has been a challenging target nationwide with the winter period being the worst performance the NHS in England has ever recorded. There are three types of ED that can be included in these figures: Type one A consultant led 24-hour service with full resuscitation facilities and designated accommodation for the reception of accident and emergency patients. Type two A consultant led single specialty accident and emergency service (e.g. ophthalmology, dental) with designated accommodation for the reception of patients. Type three Other type of accident and emergency/minor injury unity (MIUs/Walk-in Centres, primarily designed for the receiving of accident and emergency patients. A type three department may be doctor led or nurse led. It may be co-located with a major ED or sited in the community. A defining characteristic of a service qualifying as a type three department is that it treats at least minor injuries and illnesses (sprains for example) and can be routinely accessed without appointment. UHS has type one and type two (ophthalmology) departments. The Trust also had a type three (MIU) department until July 2014. Due to the nature of the activity at the MIU, the transfer of this department to another provider reduced UHS performance against the four hour target by approximately 3%. When comparing performance over the long term, it is important to factor this change in. ED performance improved in quarters one, two, and three of 2016/17 compared to 2014/15 and in quarters one and two over 2015/16, despite the increases in activity. In quarter three performance decreased by 0.6% while activity increased by 1,795 attendances, a 7.5% rise. In quarter four performance was 1.2% better than in 2015/16 and matched 2014/15 performance. The graph below shows UHS performance against the four hour target over the past three years. 96.00% 94.00% 92.00% 90.00% 88.00% 86.00% 84.00% 82.00% 80.00% 78.00% 76.00% Year-On-Year ED Performance by Quarter Q1 Q2 Q3 Q4 2014/15 2015/16 2016/17 14 Cancer waiting times There are ten separate cancer waiting times measures that the Trust reports to the Department of Health on a monthly basis, each of which can then be split into tumour site specific performance groups. In 2016/17 the Trust met all but one of these measures. The performance against the targets should be set against the significant rise in activity seen on the cancer pathways. The number of patients referred under the ‘two week wait urgent suspected cancer protocol’ that were seen within two weeks of their referral, rose by 1,058 (6.9%) in 2016/17. The chart below shows the rise in demand for UHS services over the past three years. 18,000 16,000 14,000 12,000 10,000 8,000 6,000 4,000 2,000 - UHS Growth in Cancer Activity - 2014/15 to 2016/17 2014/15 2015/16 2016/17 Two Week Waits 62-Day Target Patients 31-Day Target Patients 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. The Single Oversight Framework applied from quarter three of 2016/17. Prior to this, Monitor’s Risk Assessment Framework (RAF) was in place. Information for the prior year and first two quarters relating to the RAF has not been presented as the basis of accountability was different. This is in line with NHS Improvement’s guidance for annual reports. Segmentation During quarter four of 2016/17 the Trust was placed within segment ‘2’ This segmentation information is the Trust’s position as at 31 March 2017. Current segmentation information for NHS trusts and foundation trusts is published on the NHS Improvement website. 15 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. Area Financial sustainability Financial efficiency Financial controls Overall scoring Metric Capital service capacity Liquidity Income and expenditure margin Distance from financial plan Agency spend 2016/17 Q3 score 2 2 1 1 1 1 2016/17 Q4 score 2 2 1 1 1 1 The Care Quality Commission (CQC) gave us an overall rating of ‘requires improvement’ as at December 2014. You can see further details on page 128 of the quality account or in full by visiting www.uhs.nhs.uk or www.cqc.org.uk. The CQC returned in January 2017 to conduct a follow up inspection. We are currently awaiting their full report. Environmental matters A number of projects were undertaken in 2016/17 to reduce our impact on the environment. We have replaced a significant proportion of our external lighting and much of our internal lighting with LED technology. A number of ventilation systems have been upgraded to enable heat recovery and we have launched an awareness programme to help staff work in more environmentally sustainable ways. In addition to these developments we have implemented a range of measures to ensure that we are using energy more efficiently. For example, we now review and ensure the efficiency of high energy consumption equipment. More information can be found within the environmental sustainability and climate change section of this report. Social, community 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. 16 Directors’ report Composition of the Board The Board is currently comprised as follows: Non-executive directors: Peter Hollins chair Simon Porter senior independent director/deputy chair Professor Iain Cameron Lynne Lockyer Dr David Price Dr Mike Sadler Jenni Douglas Todd Executive directors: Fiona Dalton Gail Byrne Jane Hayward Dr Derek Sandeman Dr Caroline Marshall David French chief executive director of nursing and organisational development director of transformation and improvement medical director chief operating officer chief financial officer Each director confirms that at the time the annual report and accounts is approved: • so far as the director is aware, there is no relevant audit information of which the NHS foundation trust’s auditor is unaware • the director has taken all the steps they ought to have taken as director in order to make themselves aware of any relevant audit information and to establish that the NHS foundation trust’s auditor is aware of that information. 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. Trust Board declarations of interest Peter Hollins Partner in the Jubilee Film Partnership; Chair of CLIC Sargent Cancer Care for Children (a company limited by guarantee); Council Member of University of Southampton. Iain Cameron Dean, Faculty of Medicine and Member, University Executive Board, University of Southampton; Board Member, Wessex Academic Health Sciences Network; Director (Chair), Medical Schools Council (until 1 July 2016); Director, Medical Schools Council Assessment (until 1 July 2016); Director, UK CAT (Clinical Aptitude Test) (until 1 July 2016); Trustee, Wessex Medical Trust; Joint Chair, University Hospital Southampton/University of Southampton Joint Research Strategy Board; Joint Chair, National Institute for Health Research (NIHR) Biomedical Research Centre (BRC) Southampton Executive Board. Simon Porter Former Partner in Ernst & Young LLP; Non-executive Director and Chair of Audit Committee, Radian Group; Non-executive Director and Chair of Audit Committee, Octavia Housing. 18 Lynne Lockyer Board member/trustee of the Brendoncare Foundation. David Price Chair of RTL Materials Ltd; Chair of Telesoft Technologies Ltd; Chair of Optitune Plc; Chair of Symetrica Ltd; Member of Advisory Board, Silverstream Technologies BV; Treasurer, University of Southampton; Chair of Lontra Ltd (from 1 May 2016). Michael Sadler GP Specialist Advisor for the Care Quality Commission (until 31 May 2016); External Clinical Associate for PricewaterhouseCoopers. Jenni Douglas-Todd Managing Director, Diversa Consultancy Limited; Member of the Judicial Conduct Investigative Office; Non-Executive Director, Hampshire Cricket Board (from 2 May 2016). Fiona Dalton NHS representative on Office for the Strategic Co-ordination of Health Research (OSCHR) Board; Director, Southampton Commercial Estates Development Partnership (CEDP) Project Company Limited, a wholly-owned subsidiary of UHSFT. Gail Byrne Husband is a consultant surgeon in the Trust; Trustee of Naomi House Children’s Hospice. Caroline Marshall Nil. Jane Hayward Director, UHS Estates Limited, a wholly-owned subsidiary of UHSFT; Father is Mental Health Act Manager, Southern Health Foundation Trust (voluntary position), member of Assessment Committee for Clinical Excellence Awards South and Public Health England (lay member), a UHSFT Simulated Patient (voluntary position); Mother is a UHSFT Simulated Patient (voluntary position). Derek Sandeman Director of UHS Pharmacy Limited, a wholly-owned subsidiary of UHSFT. David French Non-executive director and chair of audit and risk committee, Sentinel Housing Association (renamed Vivid Housing Limited on 23 April 2017); Governor and chair of Audit Committee, South Wilts Grammar School for Girls (until 8 December 2016); Chair of Hampshire and Isle of Wight NHS Counter Fraud Board; Director, UHS Estates Limited, a wholly-owned subsidiary of UHSFT; Director, Southampton Commercial Estates Development Partnership (CEDP) Project Company Limited, a joint venture between UHS and Interserve Prime. Approved by the Trust Board 23 May 2017. Chief executive 23 May 2017 19 Introducing the Board of Directors Trust Board The Board is made up of the chair, six non-executive directors and six executive directors including the chief executive. Together they bring a wide range of skills and experience to the Trust, such that the board achieves balance and completeness at the highest level. The non-executive directors, including the chair, are people who live or work in the local area and have shown a genuine interest in helping to improve the health of local people. The non-executive directors are determined by the Board to be independent in both character and judgement. The chair, executive directors and non-executive directors have declared any business interests that they have. The Board is satisfied that no conflicts of interest are indicated in any external involvement. The register of Board members’ interests is updated at least annually and is maintained by the company secretary and associate director of corporate affairs. It is available for public inspection from the company secretary and associate director of corporate affairs. The ‘reservation of powers to the Board and delegation of powers policy’ sets out the business to be conducted by the Board, or by one of its committees. Any enquiries should be made to: company secretary and associate director of corporate affairs, Trust Headquarters, Mailpoint 18, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, SO16 6YD or telephone 023 8120 6829. Senior independent director The senior independent director role provides a channel through which foundation trust members and governors are able to express concerns, other than the normal route of the chair or chief executive. Appointments Non-executive directors are appointed via open advertisement in accordance with the ‘Appointment of a foundation trust non-executive director good practice guide’ procedure adopted by the Trust. The process is managed through the governors’ nomination committee, a sub-committee of the Council of Governors. This committee also determines the remuneration and terms and conditions of the non-executive directors. For further details on the appointment of non-executive directors please see page 42-43. Development of the Board The Board held monthly study sessions during 2016/17 where strategic issues, along with emerging issues, were discussed. Meetings of the Board The Board meets once a month in public. Additional private meetings with only the Board, and associated employees of the Trust making presentations to the Board in attendance, are held as required. Other committees of the Board include: remuneration and appointment committee; audit and risk committee, strategy and finance committee; quality committee and charitable funds committee. Generally the other committees of the Board meet monthly with the exception of the audit and risk committee, which meets five times a year and the appointments and remuneration committee which meets every other month. The frequency of the meetings is set out in each committee’s terms of reference. These terms of reference are reviewed at least annually. The performance of individual Board members is reviewed as set out on page 24 of this report. 20 Engagement with Council of Governors The Trust Board engages with the Council of Governors through the chair and senior independent director. Non-executive and executive directors engage with sub-groups of the council where these are related to their portfolios. Board members meet regularly with governors and have an open invitation to attend formal Council of Governor meetings. The people Non-executive directors Peter Hollins, chair Peter graduated in chemistry from Hertford College, Oxford. Joining Imperial Chemical Industries in 1973, he undertook a series of increasingly senior roles in marketing and then general management. Following three years in the Netherlands as general manager of 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 Nonexecutive director in 2010, became senior independent director and deputy chairman of UHS in 2014, and was appointed chair in April 2016. He has also been the chair of CLIC Sargent Cancer Care for Children and Young People, and a Council Member of Southampton University, since 2014 and 2016 respectively. Simon Porter, senior independent director and deputy chair Simon was born and educated in Southampton and then Oxford, graduating with a degree in modern languages (Italian and French). He is a qualified chartered accountant, having spent most of his career with the London office of Ernst & Young, where he specialised first in audit, then in transactions and finally risk management. He was a partner with Ernst & Young from 1994 to 2010. He joined the Trust Board on 1 January 2011 as a designate non-executive director and became non-executive director from 1 June 2011. He is chair of the audit and risk committee and a member of the strategy and finance committee. He also holds non-executive board positions in the social housing sector. Professor Iain Cameron Iain is professor of obstetrics and gynaecology and dean of the Faculty of Medicine at the University of Southampton. After graduating in medicine at the University of Edinburgh, he underwent postgraduate clinical and research training in Edinburgh, Melbourne and Cambridge. He held the regius chair of obstetrics and gynaecology at the University of Glasgow from 1993 and moved to Southampton in 1999. His main clinical and research interests are reproductive endocrinology and investigation of the impact of the maternal environment on early pregnancy. Iain was chair of Medical Schools Council from 2013-16 and is a member of the UK Clinical Research Collaboration board and the Wessex Academic Health Science Network board. He was appointed as a non-executive director of the MDDUS (Medical and Dental Defence Union Scotland) in April 2017. Lynne Lockyer Lynne’s background is in human resource management and strategic management. She became a nonexecutive director for Southampton and South West Hampshire in 1996 and the vice chair in 2000. She was chair of Eastleigh and Test Valley South PCT from its inception in 2002 until its disestablishment in 2006. She has taken many roles in the local health economy including being a member of Hampshire’s Local Area Agreement Board and nationally was a member of the NHS Confederation Council and the National NHS Leaders Steering Group. She was until recently a course director at the University of Portsmouth and is now an organisation development consultant. She is a trustee of the Brendoncare Foundation. 21 Dr David Price David is a former chief executive of a FTSE-250 company with broad experience within the electronics, chemical, aerospace, defence, marine, and nuclear industries. He has a successful track record of developing highly complex companies in international markets. He is currently non-executive chairman of Symetrica Ltd, Telesoft Technologies Ltd, RTL Materials Ltd, Lontra Ltd and Optitune Plc. He is treasurer of the University of Southampton and a member of the advisory board of Silverstream Technologies BV. David is a chartered engineer and chartered scientist. He has a degree in electronic engineering, a PhD from University College London and, in 2001 he was awarded an honorary doctorate by Cranfield University for his services to science and engineering. David was made a Commander of the Order of the British Empire (CBE) for his services to industry. Dr Mike Sadler Mike joined us as a clinical non-executive director in September 2014, from a similar position at an NHS Foundation Trust providing mental health, learning disability and community services. He has chaired our quality committee since June 2016. He works as an advisor and consultant on health and social care services, recently advising on health reform in the Middle East, and in Ireland. He has been chair and technical adviser to the Diabetes Professional Care Conference since 2015, and also worked for the CQC as a specialist adviser in primary care. Mike graduated from Nottingham University, and was a GP principal in Hampshire before moving into public health medicine. Having achieved an MSc with distinction at the London School of Hygiene and Tropical Medicine, he joined Portsmouth and South East Hampshire Health Authority, holding the joint posts of deputy director of public health and medical adviser. He has since held a series of senior clinical leadership roles in national organisations in both the public and private sector, including as a chief operating officer at NHS Direct and Serco’s health division. His last full time role, up until July 2013 when he commenced his portfolio career, was as director of health and social care at West Sussex County Council. Jenni Douglas-Todd 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 being 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. 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. Executive directors Fiona Dalton, chief executive Fiona was appointed as chief executive in 2013. Prior to re-joining the Trust she held the combined position of deputy chief executive and chief operating officer at Great Ormond Street Hospital for Children. Fiona joined the NHS management training scheme after graduating from Oxford University with a degree in human sciences and began her career in hospital management at Oxford Radcliffe Hospitals NHS Trust in 1996. She then spent four years at UHS as director of strategy and business development before moving to Great Ormond Street Hospital. 22 Gail Byrne, director of nursing and organisational development 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. Jane Hayward, director of transformation and improvement Jane joined the Trust in 2000 as a clinical services manager for the cardiothoracic directorate after spending two years in Hertfordshire as director of performance and 11 years at Barts and the London Hospitals in various roles including planning, finance and commissioning. Jane has led on human resources, information management and technology, improvement and modernisation and has been chief operating officer. Jane joined the Trust Board in February 2008 and became director of transformation and improvement in January 2014. Dr Derek Sandeman, medical director Derek was appointed to the Trust as a consultant physician in 1993 and went on to develop a regional endocrine service. Throughout his career he has had 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. Dr Caroline Marshall, chief operating officer Caroline joined the Trust in 1997 as a consultant hepatobiliary and neuroanaesthetist. She has held the posts of college tutor for the Royal College of Anaesthetists and UHS mentoring and coaching lead. In 2008, she became clinical service director for critical care, and then divisional clinical director for division A between 2010 and 2013. Caroline served as interim chief operating officer between January to December 2014, and was then appointed to the substantive post. Her portfolio includes the Executive lead for cancer and the executive lead for major trauma. David French, chief financial officer David joined the Trust in February 2016 and leads on finance, procurement, estates and commercial development. 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. Board effectiveness On the basis of the expertise and experience described above, the Trust is confident that the necessary range of knowledge and skills exists within the Board of Directors and that its balance, completeness and appropriateness to the requirements of the NHS Foundation Trust constitutes a high performing and effective Board. A register of interests of Board members is outlined within this report and is also available from the associate director of corporate affairs. The effectiveness of the Board of Directors meetings is reviewed at the end of each meeting. Effectiveness of Board sub-committees is monitored through monthly board reports and annual evaluation/review of the terms of reference and work programmes. Schedule of Decisions Reserved to the Board The NHS Foundation Trust Code of Governance requires that there should be a formal schedule of matters specifically reserved for decision by the Board. The Scheme of Delegation shows the ‘top level’ of delegation within the Trust. The Scheme should be read in conjunction with Trust’s Standing Financial Instructions and Standing Orders. A copy of the Schedule of Matters Reserved for the Board can be obtained from the associate director of corporate affairs. 23 Attendance at board meetings in 2016/17 Board member 12 28 24 Apr Apr May Extra Extra CS CS 26 May 20 Jun Extra CS 28 26 27 11 27 29 16 26 28 28 Jun Jul Sep Oct Oct Nov Dec Jan Feb Mar Extra CS CS only Peter Hollins chair 3 33 33 3 3 3 3 3 3 3 33 3 Simon Porter 3 non-executive director 33 3 telecon 3 333 3 telecon 3 3 3 33 3 Iain Cameron 3 non-executive director 35 35 5 3 3 3 3 3 3 33 5 Lynne Lockyer 3 33 55 non-executive director telecon 3 3 3 3 3 3 3 33 3 David Price 5 non-executive director 33 3 telecon 3 333 3 telecon OS only 3 3 5 33 3 Mike Sadler 3 non-executive director 33 3 telecon 3 333 5 telecon 3 3 3 33 5 OS OS only only Jenni Douglas-Todd 3 non-executive director 33 3 telecon 3 3 53 3 telecon OS only 3 3 3 53 3 Fiona Dalton Chief executive 3 33 33 3 3 3 3 3 3 3 33 3 David French 3 Chief financial officer 33 33 3 3 3 3 3 3 3 33 3 Derek Sandeman Medical director 5 33 33 3 3 3 3 3 3 3 33 3 Gail Byrne Director of nursing and organisational development 3 33 35 3 3 3 3 3 3 3 33 3 Caroline Marshall 3 Chief operating officer 33 33 3 3 3 5 5 5 5 33 5 Jane Hayward Director of transformation and improvement 3 35 33 333 3 telecon 3 3 3 33 3 Telecon = telephone conference OS only = open session only 24 Audit and assurance committee (until May 2016) Board member Peter Hollins NED chair Simon Porter non-executive director senior independent director and deputy chair Iain Cameron non-executive director Lynne Lockyer non-executive director David Price non-executive director Mike Sadler non-executive director May 2016 3 5 3 5 3 3 Audit and risk committee (formerly audit and assurance committee) (from June 2016) Board member Simon Porter non-executive director senior independent director and deputy chair David Price non-executive director Mike Sadler non-executive director David French Chief financial officer 18 Jul 3 3 3 3 17 Oct 3 16 Jan 3 20 Mar 3 3 3 5 3 3 3 3 3 3 Audit and risk committee The audit and risk committee (formerly known as the audit and assurance committee) is a non-executive committee of the Trust Board with delegated authority to review the establishment and maintenance of an effective system of integrated governance, risk management and financial and non-financial control, which supports the achievement of the Trust’s objectives. As part of the Trust’s on-going commitment to continuous improvement the role and responsibilities of the audit and risk committee were subject to in-year review and revision. The principle change arising from the review was the transfer of responsibilities with regards to ‘clinical quality assurance’ to the quality committee. Composition and meetings There are three non-executive director members of the committee. The committee is chaired by Simon Porter. Further information on the chair is available on pages 21. Executive directors attend by invitation, and there is a standing invitation to the chief financial officer. Other executive directors and staff with specialist expertise attend by invitation. The audit and risk committee met five times between May 2016 and March 2017 in relation to matters covered in this annual report. 25 Purpose and remit The committee purpose is the remit of a ‘traditional’ audit committee, including an oversight function in relation to financial reporting, systems of internal control, risk management, effective use of resources, appointment and effectiveness of external and internal auditors. Major topics considered by the committee
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Supplier representative procedure
Description
Procurement and supply chain and the commercial development team appreciate the role that companies play to assist the Trust in providing safe, effective and economic products and services to staff and patients in their care. The aim of this procedure is to put the relationship between the Trust and its suppliers on a sound and professional basis.
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BRC Research-imaging-proposal-form_v2 2025 FINAL
Description
BRC Research Imaging Proposal form The BRC Research Imaging Proposal form should be completed by the chief/principal investigator of any new research study requiring access to imaging resources at University Hospital Southampton. The BRC Imaging Research Panel (BRC IRP) will use this information to determine the availability of resource and provide advice on costings for imaging research. This form should be completed before a full submission to this pilot scheme is made, to enable accurate timings/costings for the MR imaging to be determined. For the BRC MRI pump-priming research project award, this form will provide imaging specific background information, to help assess the feasibility of the project, alongside the full award application form. Please complete both Part 1 and Part 2 (detailed application). If detailed information is not known then please complete as much as possible (especially for Part 2), submit the form and we will be in contact to assist with this. Part 1 – Expression of interest Study title: Short title: Research question / summary of imaging requirements: Investigator: Email: Are you acting in your capacity as a UHS or UoS principal investigator? Select one only. UHS (Trust) UoS (University) Principal grant admin (n/a for BRC pump priming scheme) UHS (Trust) UoS (University) Other Part 2 – Detailed application Proposed start date: Proposed end date: Number of subjects: Statistical advice sought? Please circle Yes / No Type of study: Part of a multi-centre trial? Please circle Yes / No Approvals required? Please state Imaging required Imaging protocol (state if new or existing and who this has been discussed with) Frequency/timing/routine? Hardware/software/data storage/archiving and image processing and image analysis requirements? 1. 2. 3. 4. New imaging protocols (including MRI sequences) should be discussed with the MRI Research Radiographer, MRI Physics and relevant Consultant Radiologist (if required). Existing imaging protocols should be confirmed with the MRI Research Radiographer and relevant MRI Superintendent Radiographer (including protocol name and version date). Please indicate if each imaging event is routine (i.e. part of clinical care), additional as part of this proposal, and whether this will continue once the trial has ended. Hardware/software/data storage and post-processing requirements, including image archiving, should be discussed with radiology/medical physics/UoS. Please sign electronically to indicate that you have read and agree with the attached Joint UHS and UoS Policy for imaging research in Southampton and BRC award terms and conditions Name: Signature: Date: Please submit to the RIMG (on behalf of the BRC) by emailing: Angela.Darekar@uhs.nhs.uk Joint UHS and UoS policy for imaging research in Southampton – BRC/MRI specific Version 2, December 2019, Research Imaging Management Group This Joint Policy applies to any academic activity, hereby referred to as “Project”, which involves imaging or imaging results at UHS, whether it is research, case report, case series, audit, service evaluation or other description not specifically mentioned here. Planning and costing research 1. For research only: please inform RIMG (by emailing Angela.Darekar@uhs.nhs.uk) of the research at least one month prior to grant/award application form submission by completing the attached form 2. Please discuss protocols with the appropriate radiographer/radiologist/medical physicist assigned to the project by the Radiology Research Coordinator. This will ensure that accurate costings (or equivalent hours of scanning time) can be provided. 3. When costing grant applications, the Radiology Research team will advise on costing attribution across institutions. Ethical approval 1. The appropriate Health Research Authority and institutional (UHS or UoS) approvals need to be in place before the Project starts. Bookings 1. Please provide as much notice as possible for research bookings (at least 48 hours), and appreciate that they cannot always be accommodated at short notice. If particular procedures/personnel are required for bookings, these should be discussed with the Radiology Research team before RIMG approval is granted. 2. Liaise with the research radiographers for bookings, copying in RadiologyResearch@uhs.nhs.uk and provide: Name, DoB, Address, GP details, hospital ID (if available) and patient’s study ID. 3. Please use either the radiology research referral form or electronic requesting. Please clearly indicate the project title in the request and indicate that this is a research scan. Overlap between research and clinical imaging 1. If requesting clinical imaging that will later be used for research purposes, please clarify this to the reporting radiologist on the request form. Appropriate funding and ethical approvals must be in place. Publication 1. If manuscripts arise from Projects which make use of imaging data reported by UHS radiologists or involving UHS medical physicists, co-authorship or acknowledgement of these individuals should be discussed with them at the point of manuscript preparation. 2. Please include both UHS and UoS as affiliations, unless none of the authors have a honorary or substantive connection with UoS, and no use was made of any UoS facility. Please abide by the “Joint Partnership Policy and Guidance on Pre-clinical and Clinical Research Publications” v2.6, jointly approved by UHS and UoS. 3. Acknowledge resources (staff, space or equipment) of a particular imaging unit or department if these have been used. 4. Please remember to acknowledge any sponsorship you have received. 5. Please acknowledge BRC support using wording in section 4.5 below 6. For grants, please include the grant number and source. 7. Please inform RIMG of publications arising from imaging performed at UHS. Incidental findings 1. It is the recommendation of the RIMG that the Research Ethics Committee approved protocol defines precise instructions on how to consent for and manage incidental findings. These should specify a named clinician who will be responsible for managing incidental findings (reported by the radiologist(s) associated with the study) including informing the subject, arranging follow up tests and liaising with the GP as necessary. In the absence of clarity in the study protocol of any aspect relating to incidental findings, the Royal College of Radiologists’ guidance (https://www.rcr.ac.uk/publication/management-incidental-findings-detected-during-research-imaging), will need to be adhered to. Data management 1. Please ensure that data uploads/transfers and archiving processes have been discussed with the relevant people within PACS/Radiology Research/Medical Physics (as appropriate) and have been funded accordingly (to be confirmed for the BRC MRI pump-priming scheme). 2. Please ensure that all data management is in compliance with the General Data Protection Regulation or its UK equivalent. The award will only be made available if you meet the following conditions: BRC award terms and conditions 1. The award is subject to the terms and conditions of the BRC4 Research Contract signed by the Department for Health and Social Care and University Hospital Southampton NHS Foundation Trust on 8th November 2022. Specific applicable BRC terms are set out in Schedule 1 attached to this award letter. 2. The BRC funding is subject to the terms and conditions detailed in the BRC Collaboration Agreement signed by University Hospital Southampton NHS Foundation Trust and the University of Southampton, dated 15th September 2023. 3. Any additional grant funding secured by the postholder as a result of the BRC funding will be considered as grant income to the BRC. As the successful applicant awarded funding you will be required to: * Provide the BRC Manager with progress reports as requested by them, including a report at least 1 month prior to award end, plus information required to meet reporting requirements for NIHR, such as dates of submission of external applications * Contribute to the relevant School/Faculty conference and seminar programmes and BRC and NIHR-related training and development events in accordance with NIHR guidance. * Include an acknowledgement of NIHR Southampton BRC support on all publications, posters and other outputs resulting from this award. Schedule 1 – Specific Applicable NIHR Southampton Biomedical Research Centre Terms 1 Definitions: 1.1 "Award” means the funding applied for in this application. 1.2 BRC Manager means the member of staff at UHS employed to have overall management responsibility for the BRC. 1.3 “BRC Research Contract” means the Biomedical Research Centre grant contract signed by University Hospital Southampton NHS Foundation Trust and the Department for Health and Social Care and which is incorporate by reference, to the Award Letter. 1.4 “Background IP” means any Intellectual Property in existence at the commencement of the Research or created, devised or generated other than in the performance of the Research and which is actually used in the performance of the Research. 1.5 “Confidential Information” means all information of a commercially sensitive nature including (but not limited to) specifications, drawings, circuit diagrams, tapes, discs and other computable readable media, documents, techniques and know-how which are disclosed by one Party to the other for use in or in connection with the BRC or any Research. 1.6 “Foreground IP” means any Intellectual Property (and/or property right in Samples) that is created, generated or developed (whether in whole or in part) during the course of and for the purpose of any part of the Research. 1.7 “Parties” means Awardee and University Hospital Southampton NHS Foundation Trust. 1.8 “Research” means the project undertaken supported by the Award. 1.9 “Research Data” means information or data that is collected, collated or generated in the performance of the Research and includes (but is not limited to) information or data that is presented or stored in searchable form. For the avoidance of doubt, Research Data: a) does not include, without limitation, information or data that has been analysed as part of the Research; b) does include, but is not limited to, images. 1.10 “Samples” means material (including but not limited to biological material, organisms and chemical compounds), specimens or extracts collected, obtained or generated (whether in whole or in part) during the course of and for the purpose of any part of the Research. 1.11 “UHS” means University Hospital Southampton NHS Foundation Trust. 2 Intellectual Property 2.1 Awardee shall promptly report all Foreground IP to UHS. 2.2 Each Party shall own the Research Data and Foreground IP generated by it under the BRC or Project and the terms of clauses 11, 16 and 17 of BRC Research Contract shall apply to the use, management and exploitation of Research Data and Foreground IP. 2.3 Nothing contained in the Award Letter related to this funding shall affect the absolute and unfettered rights of each Party in all inventions, discoveries and intellectual property contained in its Background IP. 2.4 Subject to the BRC Research Contract, each Awardee shall undertake and continue at its expense the timely prosecution and maintenance of all Foreground IP which is solely owned by Awardee. In the event that the Awardee is unable or unwilling to comply with its obligation under this Clause 2.4, UHS and Funder shall consider how best to deal with such Foreground IP and shall have the option to require an assignment of such Foreground IP to the other Party to enable prosecution and maintenance of such Foreground IP by that other Party at its own cost. In the event that any Party wishes to exploit commercially any Foreground IP assigned pursuant to this Clause 2.4 that Party shall pay to the assigning Party a royalty and/or other appropriate form of remuneration which is fair and reasonable taking into consideration the factors set out under Clause 3.3. 2.5 In the event that any of the Parties are jointly responsible for generating Research Data and/or Foreground IP such Research Data and/or Foreground IP shall be jointly owned by the Parties. Ownership in Foreground IP shall be in accordance with the inventive contribution made by each Party to the generation of such Foreground IP and ownership in Research Data shall be in accordance with the relative contributions of each Party to the generation of the Research Data. 2.6 Joint owners of Foreground IP shall agree between them on who shall be responsible for the timely prosecution and maintenance of all such Foreground IP and the Party that is nominated to be so responsible shall be entitled to charge the other joint owners with a percentage of the costs of so doing as agreed between the joint owners. In the absence of any agreement to the contrary between joint owners the costs shall be equally shared. 3 Exploitation of Intellectual Property 3.1 Each Party grants to the other Party a non-exclusive, royalty-free licence (without the right to sublicence) to: 3.1.1 use its Research Data and Foreground IP for their own non-commercial research and development purposes but not for the purposes of commercial exploitation; and 3.1.2 in the case of UHS to use University of Southampton Research Data and Foreground IP in clinical activities within UHS; 3.1.3 subject to any existing third party obligations, use its Background IP for the purpose of undertaking the BRC and to enable the use of the Foreground IP pursuant to Clause 3.1.1 and 3.1.2 but not for the purposes of commercial exploitation. 3.2 The Parties will review and consider the optimum use of all Research Data and Foreground IP and agree which is the most suitable to effectively exploit or disseminate any Research Data and Foreground IP, subject to approval of the Funder. 3.3 In the event that any Party wishes to exploit commercially Foreground IP owned by the other Party, the owner of the Foreground IP shall grant to such Party a non-exclusive licence to use such Foreground IP for that purpose, subject to the agreement of appropriate terms in relation thereto, including a royalty and/or other appropriate form of remuneration which is fair and reasonable taking into consideration the respective financial and technical contributions of the Parties concerned to the development of the Foreground IP, the expenses incurred in securing intellectual property protection thereof and the costs of its commercial exploitation and any use of Background IP. 3.4 Should any of the Parties wish to exploit its own Foreground IP with a third party during the duration of the BRC, that Party must notify the other Party before approaching said third party, always provided that the disclosure of information required for such exploitation is subject to the obligations of confidentiality at least equivalent to those under Clause 11. Further any necessary notification to NIHR shall be made and their respective approval should be obtained or commercialisation agreement in place, if required, prior to exploitation. 3.5 In recognition of the Parties joint involvement with the BRC and the contribution to development of the Foreground IP a Party exploiting its own Foreground IP will provide a fair revenue share to the other Party. In the event any revenues are due to the Funder revenues shall first be distributed to the Funder prior to sharing between the Parties. 3.6 Subject to Clause 3.4 each Party agrees (where it is free and reasonably able to do so) to license on fair and reasonable terms its Foreground IP and Background IP that may be required to enable any other Party to exploit its own Foreground IP or Background IP, always subject to the obligations of confidentiality under Clause 5. 3.7 With regard to joint inventions, the Parties owning such inventions agree to co-operate fully in the protection of such joint inventions and each Party shall be entitled to make use of such joint inventions subject only to negotiating a licence in good faith from the other Party for its interest in such joint inventions on similar terms to those set out in clause 3.3. 3.8 The University shall grant to the Funder a non-exclusive, irrevocable, royalty-free, worldwide licence together with the right to grant sub-licences to health service bodies or others directly engaged in providing health care, permitting the Funder to use and publish 3.9 any information relating to the Research which is not Confidential Information of the University 3.9.1 any Foreground IP; 3.9.2 Research Data; 3.9.3 Reports; 3.9.4 arising know how; and, 3.9.5 conclusions arising from the Research 3.10 and in each case, the University acknowledges the Funder intends to exercise this right only where the Funder’s reasonable opinion the University is not appropriately managing, disseminating or using such items and in each case Funder is permitted to use or make available such items as it sees fit in support of: (i) the development, promotion or provision of health care that is not a commercial use; and/or (ii) for any other purpose that is not a commercial use. 4 Publication 4.1 Subject to the provisions of Clauses 2, 3 and 5 neither Party shall disclose or publish information or Foreground IP for the duration of the BRC and for 3 (three) years thereafter without the consent of the other Party , such consent, not to be unreasonably withheld or delayed. Further the Parties must seek to obtain all necessary consents from NIHR and any Collaborating Parties prior to publication. The obligation to seek consent of NIHR or continues after the end of the Research. 4.2 Subject to 4.1, the Parties shall be permitted to publish the Research Data of the BRC which they have undertaken in accordance with normal academic practice, subject always to the provisions of Clauses 8 and 5, and providing such disclosure does not jeopardise any application for Foreground IP protection by any Party. Request for such consent must be submitted together with the material proposed for publication to the BRC Manager. If any Party can reasonably demonstrate that such a disclosure contains material that would prejudice the value of any Background IP and/or Foreground IP, that Party shall inform the BRC Manager in writing within 28 days of that Party receiving a copy of the proposed publication and in that event the disclosure shall be amended so as to meet the objections of that Party or delayed to address their concerns. 4.3 Subject to the provisions of Clause 3 where in the opinion of UHS a proposed publication contains patentable or commercially sensitive subject matter which needs protection then the Party proposing to publish may be requested to refrain from doing so for a maximum of six 6 months in order to allow for application for patent protection in the name and at the cost of the relevant owner of the Foreground IP. The provisions of Clause 2 and 3 shall apply in respect of any licence to such Foreground IP. 4.4 Nothing contained in the Award Letter related to this funding shall prevent the submission of a thesis to examiners in accordance with the normal regulations of the Parties subject where appropriate to such examiners being bound by conditions of confidentiality in no less terms than those outlined in Clause 5 nor to the placing of such thesis in the library of the appropriate Research Party provided that access to such thesis shall only be available on conditions of confidentiality no less onerous than those contained in Clause 5 hereof. 4.5 The University shall ensure that all project investigators acknowledge in all theses, papers and other publications (including from non-BRC projects) that they receive support from the NIHR Southampton BRC, in accordance with BRC Research Contract. The form of words is: “[investigator initials] is supported by the National Institute for Health and Care Research through the NIHR Southampton Biomedical Research Centre”. 4.6 The Parties acknowledge that NIHR is entitled to publish the whole or any part of the Report. If the Parties wishes NIHR to delay such publication, it must submit a request in writing to the NIHR giving reasons for the requested delay which shall be considered in accordance with the NIHR’s Information for Authors’ Dual Publication Guidance and Embargo Policy as defined in the NIHR Contract and amended from time-to-time. 4.7 Neither Party shall use the other's name, crest, logo or registered image for any purpose without the express permission of the other Party. The Parties will agree treatment for referencing each others involvement in the BRC and joint branding for their activities subject to compliance with Clause 4.8 and the BRC Research Contract. 4.8 Neither Party shall issue any press release, public statement, or other media announcement related to the BRC or any Research Data or Foreground IP without the prior consent of the other Party and Funder, as applicable. 4.9 The Parties (in the case of the University via UHS must notify the Funder of any intention to issue a press release at least three (3) business days prior to any press release issued by it or on its behalf, directly related to the Research or Foreground IP, arising now how or Research Data or of matters arising from such Research. Awardee shall send one draft copy of the proposed press release to UHS at least five (5) business days before the date intended for release. For the avoidance of doubt this obligation shall continue in full force and effect following expiry of the Award letter 4.10 The Parties shall comply with guidance and advice from Funder on branding and publicity which may be issued from time to time including, but not limited to Funder’s guidance on the format for websites, press releases and use of social media, permitted use of the NIHR, BRC, NHS and Department of Health and Social Care brands, names and logos and ensuring all branding references to the BRC are prefixed with the term “NIHR”. 5 Confidentiality 5.1 The Parties hereto agree to use all reasonable endeavours to ensure that any Confidential Information disclosed or submitted in writing or any other tangible form to one Party (“Receiving Party”) by the other (“Disclosing Party”) shall be treated with the same care and discretion to avoid disclosure as the Receiving Party uses with its own similar information which it does not wish to disclose. Any information disclosed orally that is identified by the Disclosing Party as Confidential Information shall be treated the same as if it had been reduced to writing at the time of disclosure to the Receiving Party. 5.2 The Receiving Party shall not, during a period of seven (7) years after the termination of this Award Letter, use any such Confidential Information for any purpose other than the carrying out of its obligations under this Award funding or other than in accordance with the terms of this Award funding. 5.3 The undertaking in Clause 5.1 above shall not apply to Confidential Information: 5.3.1 which, at the time of disclosure, has already been published or is otherwise in the public domain other than through breach of the terms of this Award funding; 5.3.2 which, after disclosure to the Parties, is subsequently published or comes into the public domain by means other than an action or omission on the part of any of the Parties; 5.3.3 which a Party can demonstrate was known to him or subsequently independently developed by them; 5.3.4 lawfully acquired from third parties who had a right to disclose it with no obligations of confidentiality to any of the Parties; or 5.3.5 is required to be disclosed by applicable law or court order or by any Party's regulatory body, which is empowered by Statute or Statutory Instrument, but only to the extent of such disclosure and the Receiving Party shall notify the Disclosing Party promptly of any such request. 5.4 Staff and students and any agents, consultants or sub-contractors engaged to work on the BRC will be subject to the principles of confidentiality outlined in this Clause 5. 6 Term and Termination 6.1 The terms of this award shall come into force on the date when the Acceptance Statement is signed by the Awardee and remain in full force and effect until 31st March 2028 unless terminated earlier in accordance with the provisions of this Clause 6. 6.2 In the event that any Party shall commit any breach of or default in any terms or conditions of this Award funding, the other Party may serve written notice of such breach or default on the defaulting Party and in the event that such Party fails to remedy such default or breach within sixty (60) days after receipt of such written notice the other Party may, at their option and in addition to any other remedies which they may have at law or equity, terminate this Award funding by sending notice of termination in writing to the other Party. 6.3 If any Party (a) materially breaches any provisions of this Award funding ; or (b) passes a resolution for its winding-up; or if (c) a court of competent jurisdiction makes an order for that Party’s winding-up or dissolution; or makes an administration order in relation to that Party; or if any Party (e) appoints a receiver over, or an encumbrancer takes possession of or sells an asset of, that Party; or (f) makes an arrangement or composition with its creditors generally; or (g) makes an application to a court of competent jurisdiction for protection from its creditors generally; the other Party may terminate their involvement in the BRC. 6.4 In the event the BRC Research Contract terminates UHS may terminate this Award funding with immediate effect. 7 General 7.1 Each Party shall indemnify each of the other Parties, within the limits set out in this Clause 6, in respect of liability resulting from acts or omissions of itself, its employees or its students provided always that such indemnity shall not extend to claims for indirect or consequential loss or damages such as, but not limited to, loss of profit, revenue, contracts or the like. 7.2 Any amendments to this Award funding shall be valid only if made in writing and signed by authorised signatories of the Parties. 7.3 If any part or any provision of this Award funding shall to any extent prove invalid or unenforceable in law the remainder of such provision and all other provisions of this Award funding shall remain valid and enforceable to the fullest extent permissible by law, and such provision shall be deemed to be omitted from this Award funding to the extent of such invalidity or unenforceability. The remainder of this Award funding shall continue in full force and effect and the Parties shall negotiate in good faith to replace the invalid or unenforceable provision with a valid, legal and enforceable provision which has an effect as close as possible to the provision or terms being replaced. 7.4 No failure to exercise or delay in the exercise of any right or remedy which any Party may have under this Award funding or in connection with this Award funding shall operate as a waiver thereof, and nor shall any single or partial exercise of any such right or remedy prevent any further or other exercise thereof or of any other such right or remedy. 7.5 This Award funding including its Schedule supersedes all other agreements and understandings, whether written or oral, between the Parties about the BRC constitutes the entire agreement between the Parties regarding the BRC. 7.6 Except as otherwise expressly provided for herein, the Parties confirm that nothing in this Award funding shall confer or purport to confer on any third party any benefit or any right to enforce any term of this Award funding for the purposes of Contracts (Rights of Third Parties) Act 1999. 7.7 This Award funding shall be governed by and construed in accordance with English Law and each Party agrees to submit to the exclusive jurisdiction of the English Courts as regards any claim or matter arising under this Award funding. 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Papers Trust Board - 11 March 2025
Description
Date Time Location Chair Agenda Trust Board – Open Session 11/03/2025 9:00 - 13:00 Conference Room, Heartbeat Education Centre Jenni Douglas-Todd 1 Chair’s Welcome, Apologies and Declarations of Interest 9:00 Note apologies for absence, and to hear any declarations of interest relating to any item on the Agenda. 2 Patient Story The patient story provides an opportunity for the Board to reflect on the experiences of patients and staff within the Trust and understand what the Trust could do better. 3 Minutes of Previous Meeting held on 7 January 2025 9:15 Approve the minutes of the previous meeting held on 7 January 2025 4 Matters Arising and Summary of Agreed Actions To discuss any matters arising from the minutes, and to agree on the status of any actions assigned at the previous meeting. 5 QUALITY, PERFORMANCE and FINANCE Quality includes: clinical effectiveness, patient safety, and patient experience 5.1 Briefing from the Chair of the Audit and Risk Committee 9:20 Keith Evans, Chair 5.2 Briefing from the Chair of the Finance and Investment Committee 9:25 Dave Bennett, Chair 5.3 Briefing from the Chair of the People and Organisational Development 9:30 Committee Jane Harwood, Chair 5.4 Briefing from the Chair of the Quality Committee 9:35 Tim Peachey, Chair 5.5 Chief Executive Officer's Report 9:40 Receive and note the report Sponsor: David French, Chief Executive Officer 5.6 Performance KPI Report for Month 10 10:10 Review and discuss the report Sponsor: David French, Chief Executive Officer 5.7 Break 10:45 5.8 Finance Report for Month 10 11:00 Review and discuss the report Sponsor: Ian Howard, Chief Financial Officer 5.9 ICS Finance Report for Month 10 11:15 Receive and discuss the report Sponsor: Ian Howard, Chief Financial Officer 5.10 People Report for Month 10 11:20 Review and discuss the report Sponsor: Steve Harris, Chief People Officer 5.11 Mortuary Standards Compliance Update (Oral) 11:35 Sponsor: Gail Byrne, Chief Nursing Officer 6 STRATEGY and BUSINESS PLANNING 6.1 Corporate Objectives 2024-25 Quarter 3 Review 11:40 Review and feedback on the corporate objectives Sponsor: David French, Chief Executive Officer Attendees: Martin De Sousa, Director of Strategy and Partnerships/Kelly Kent, Head of Strategy and Partnerships 6.2 Board Assurance Framework (BAF) Update 11:50 Review and discuss the update Sponsor: Gail Byrne, Chief Nursing Officer Attendees: Craig Machell, Associate Director of Corporate Affairs and Company Secretary/Lauren Anderson, Corporate Governance and Risk Manager 7 CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Feedback from the Council of Governors' (CoG) meeting 29 January 2025 12:00 (Oral) Sponsor: Jenni Douglas-Todd, Trust Chair 7.2 Register of Seals and Chair's Actions Report 12:05 Receive and ratify In compliance with the Trust Standing Orders, Financial Instructions, and the Scheme of Reservation and Delegation. Sponsor: Jenni Douglas-Todd, Trust Chair Page 2 7.3 Audit and Risk Committee Terms of Reference 12:10 Review and approve the Terms of Reference Sponsor: Ian Howard, Chief Financial Officer Attendee: Craig Machell, Associate Director of Corporate Affairs and Company Secretary 7.4 Finance and Investment Committee Terms of Reference 12:15 Review and approve the Terms of Reference Sponsor: Dave Bennett, Committee Chair Attendee: Craig Machell, Associate Director of Corporate Affairs and Company Secretary 7.5 Quality Committee Terms of Reference 12:20 Review and approve the Terms of Reference Sponsors: Tim Peachey, Committee Chair Attendee: Craig Machell, Associate Director of Corporate Affairs and Company Secretary 7.6 Remuneration and Appointment Committee Terms of Reference 12:25 Review and approve the Terms of Reference Sponsor: Jenni Douglas-Todd, Trust Chair Attendee: Craig Machell, Associate Director of Corporate Affairs and Company Secretary 7.7 Trust Executive Committee Terms of Reference 12:30 Approve the proposed amendments to the Terms of Reference Sponsor: David French, Chief Executive Officer Attendee: Craig Machell, Associate Director of Corporate Affairs and Company Secretary 8 Any other business 12:35 Raise any relevant or urgent matters that are not on the agenda 9 Note the date of the next meeting: 13 May 2025 10 Items circulated to the Board for reading 29 January 2025 Message from Ian Howard re Update on legal dispute with BAM 10.1 South Central Regional Research Delivery Network (SC RRDN) 2024-25 Q3 Performance Report Note the report Sponsor: Paul Grundy, Chief Medical Officer Page 3 11 Resolution regarding the Press, Public and Others Sponsor: Jenni Douglas-Todd, Trust Chair To agree, as permitted by the National Health Service Act 2006 (as amended), the Trust's Constitution and the Standing Orders of the Board of Directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. 12 Follow-up discussion with governors 12:45 Page 4 Agenda links to the Board Assurance Framework (BAF) 11 March 2025 – Open Session Overview of the BAF Risk 1a: Lack of capacity to appropriately respond to emergency demand, manage the increasing waiting lists for elective demand, and provide timely diagnostics, that results in avoidable harm to patients. 1b: Due to the current challenges, we fail to provide patients and their families / carers with a high-quality experience of care and positive patient outcomes. 1c: We do not effectively plan for and implement infection prevention and control measures that reduce the number of hospital-acquired infections and limit the number of nosocomial outbreaks of infection. 2a: We do not take full advantage of our position as a leading University teaching hospital with a growing, reputable, and innovative research and development portfolio, attracting the best staff and efficiently delivering the best possible treatments and care for our patients. 3a: We are unable to meet current and planned service requirements due to the unavailability of staff to fulfil key roles. 3b: We fail to develop a diverse, compassionate, and inclusive workforce, providing a more positive staff experience for all staff. 3c: We fail to create a sustainable and innovative education and development response to meet the current and future workforce needs identified in the Trust’s longer-term workforce plan. 4a: We do not implement effective models to deliver integrated and networked care, resulting in sub-optimal patient experience and outcomes, increased numbers of admissions and increases in patients’ length of stay. 5a: We are unable to deliver a financial breakeven position, resulting in: inability to move out of the NHS England Recovery Support Programme, NHS England imposing additional controls/undertakings, and a reducing cash balance impacting the Trust’s ability to invest in line with its capital plan, estates/digital strategies, and in transformation initiatives. 5b: We do not adequately maintain, improve and develop our estate to deliver our clinical services and increase capacity. 5c: Our digital technology or infrastructure fails to the extent that it impacts our ability to deliver care effectively and safely within the organisation, 5d: We fail to prioritise green initiatives to deliver a trajectory that will reduce our direct and indirect carbon footprint by 80% by 2028-2032 (compared with a 1990 baseline) and reach net zero direct carbon emissions by 2040 and net zero indirect carbon emissions by 2045. Agenda links to the BAF No Item Linked BAF risk(s) 5.6 Performance KPI Report for Month 10 5.8 Finance Report for Month 10 5.9 ICS Finance Report for Month 10 5.10 People Report for Month 10 5.11 Mortuary Standards Compliance Update 5.11 Corporate Objectives 2024-5 Quarter 3 Review 1a, 1b, 1c 5a 5a 3a, 3b, 3c 1b All Appetite (Category) Minimal (Safety) Current risk rating 4x5 20 Cautious (Experience) Minimal (Safety) 3x3 9 4x4 16 Open (Technology & Innovation) 3x3 9 Open (workforce) Open (workforce) Open (workforce) 4x5 20 4x3 12 4x4 16 Cautious (Effectiveness) 3x3 9 Cautious (Finance) 4x5 20 Target risk rating 4 x 2 Apr 6 27 3 x 2 Mar 6 26 2 x 3 Apr 6 27 3 x 2 Dec 6 25 4 x 3 Mar 12 26 4 x 2 Mar 8 27 3 x 2 Mar 6 29 3 x 2 Dec 6 25 3 x 3 Apr 9 30 Cautious (Effectiveness) Open (Technology & Innovation) Open (Technology & Innovation) 4x5 20 3x4 12 2x3 6 4 x 2 Apr 8 30 3 x 2 Apr 6 27 2 x 2 Dec 4 27 Does this item facilitate movement towards or away from the intended target risk score and appetite? Towards Away Neither x x x x x x Minutes Trust Board – Open Session Date Time 07/01/2025 9:00 – 13:00 Location Chair Conference Room, Heartbeat/Microsoft Teams Jenni Douglas-Todd (JD-T) Present Dave Bennett, NED (DB) Gail Byrne, Chief Nursing Officer (GB) Jenni Douglas-Todd, Chair (JD-T) Diana Eccles, NED (DE) Keith Evans, Deputy Chair and NED (KE) David French, Chief Executive Officer (DAF) Paul Grundy, Chief Medical Officer (PG) Steve Harris, Chief People Officer (SH) Jane Harwood, NED/Senior Independent Director (JH) Ian Howard, Chief Financial Officer (IH) David Liverseidge, NED (DL) Tim Peachey, NED (TP) Joe Teape, Chief Operating Officer (JT) Alison Tattersall, NED (AT) In attendance Martin De Sousa, Director of Strategy and Partnerships (MDeS) Craig Machell, Associate Director of Corporate Affairs and Company Secretary (CM) James Allen, Chief Pharmacist (JA) (item 5.14) Lauren Anderson, Corporate Governance and Risk Manager (LA) (item 6.1) Julie Brooks, Deputy Director of Infection Prevention & Control (JB) (item 5.13) Rosemary Chable, Head of Nursing for Education, Practice and Staffing (RC) (item 5.15) Diana Hulbert, Guardian of Safe Working Hours and Emergency Department Consultant (DH) (item 5.11) Christine Mbabazi, Equality & Inclusion Adviser/Freedom to Speak Up Guardian (CMb) (item 5.10) John Mcgonigle, Emergency Planning & Resilience Manager (JMc) (item 7.1) Jenny Milner, Associate Director of Patient Experience (JM) (item 5.12) Danielle Sinclair, Deputy Emergency Planner (DS) (item 7.1) Julian Sutton, Lead Infection Control Director (JS) (item 5.13) Fatemeh Jenabi, Specialty Registrar (FJ) (shadowing JT) 1 member of the public (item 2) 6 governors (observing) 4 members of staff (observing) 1. Chair’s Welcome, Apologies and Declarations of Interest The Chair welcomed attendees to the meeting. There were no interests to declare in the business to be transacted at the meeting. The Board welcomed David Liverseidge, who had been appointed as an independent non-executive director with effect from 1 January 2025. Page 1 It was noted that Joe Teape had accepted an appointment as chief executive officer of Torbay and South Devon NHS Foundation Trust, and, accordingly Joe Teape would be leaving the Trust in February 2025. It was further noted that Jenni Douglas-Todd had been appointed as chair of the partnership between Portsmouth Hospitals University NHS Trust and Isle of Wight NHS Trust, commencing on 1 April 2025. 2. Patient Story Gillian Muir, one of the Trust’s ‘involved patients’, was invited to relate their experience of treatment for tongue and thyroid cancer in 2022. It was noted that: • Both the treatment received and staff were rated positively. However, the referral process was open to criticism. • In addition, it was considered that it would be beneficial to have a single point for information for patients as well as more information about self-help and on the patient journey. • The importance of the emotional aspect of treatment was noted as was the benefit of using patients to help other patients. Action Gail Byrne agreed to consider how the recommendations made in patient stories could be captured and action taken as a result. 3. Minutes of the Previous Meeting held on 5 November 2024 The draft minutes tabled to the meeting were agreed to be an accurate record of the meeting held on 5 November 2024. 4. Matters Arising and Summary of Agreed Actions It was noted that all actions were either closed or not yet due for completion. 5. QUALITY, PERFORMANCE and FINANCE 5.1 Briefing from the Chair of the Finance and Investment Committee The chair of the Finance and Investment Committee was invited to present the Committee Chair’s Reports in respect of the meetings held on 25 November and 16 December 2024, the content of which was noted. It was further noted that: • The Trust’s financial position remained challenging with additional cost pressures due to the pay awards and non-delivery of system-wide transformation programmes resulting in a year-to-date deficit of £18.2m. • There was a shortfall of £17m in respect of delivery of the Trust’s Cost Improvement Programme (CIP), largely due to non-delivery of system transformation programmes. • The Trust benchmarked well against comparator organisations in terms of its value-for-money and elective recovery delivery. • As at the end of November 2024, the Trust had carried out £21m in unfunded activity. • The Trust’s cash balance remained a concern, as it was being eroded by the Trust’s underlying monthly deficit and was expected to fall below the minimum required level in the first quarter of 2025/26. Page 2 5.2 Briefing from the Chair of the People and Organisational Development Committee The chair of the People and Organisational Development Committee was invited to present the Committee Chair’s Report in respect of the meeting held on 13 December 2024, the content of which was noted. It was further noted that: • As anticipated, the Trust’s workforce had grown slightly in November 2024. However, the main challenge to meeting the Trust’s 2024/25 plan remained the non-delivery of system-wide transformation programmes in mental health and non-criteria to reside, which the Trust had assumed would enable a reduction in its workforce by 218 whole-time-equivalents (WTE). • The committee received an update in respect of the ongoing industrial dispute with portering staff and in respect of the Band 2/3 pay dispute. • The committee reviewed the Board Assurance Framework and suggested that the rating of risk 3c should be increased to reflect the financial situation and uncertainty around the NHS long-term workforce plan (item 6.1). • Issues such as ongoing industrial disputes were impacting the Trust’s capacity to make progress on other areas such as organisational and cultural development and transformation. 5.3 Briefing from the Chair of the Quality Committee including Maternity and Neonatal Safety 2024-25 Quarter 2 Report The chair of the Quality Committee was invited to present the Committee Chair’s Report in respect of the meeting held on 25 November 2024, the content of which was noted. It was further noted that: • There had been seven ‘never events’ during 2024/25. • The committee had reviewed the Learning from Deaths 2024-25 Quarter 2 report (item 5.12), and it was noted that the risk rating attributable to this area in the Chair’s Report was aggregated. • The committee had reviewed the Infection Prevention and Control 2024-25 Quarter 2 report (item 5.13). • The committee had scrutinised the Maternity and Neonatal Safety 2024-25 Quarter 2 report in detail. 5.4 Chief Executive Officer’s Report David French was invited to present the Chief Executive Officer’s Report, the content of which was noted. It was further noted that: • There had been a water supply failure on 18 December 2024 due to a technical problem at a nearby water treatment works, which resulted in a loss of water for three days. Southern Water supplied the Trust with water via tankers during this period to ensure that soft (non-potable) water was available throughout the interruption. The Trust’s Estates team managed this incident well. • It had been a difficult start to 2025 with high Emergency Department attendance levels and ambulance volumes, exacerbated by the national prevalence of seasonal illnesses such as influenza, which impacted both patient and staff numbers. • In order to manage Emergency Department attendances as high as 450 patients per day, the Trust had been required to situate patients in other areas of the hospital, which placed additional logistical burdens on staff. • The high rates of attendance meant that the Trust was close to declaring a critical incident, noting that other local providers had already done so. • There were 263 patients having no criteria to reside awaiting discharge. Page 3 • The Government had made a number of announcements prior to Christmas in respect of possible reforms, including introduction of a league table for NHS providers. • In addition, the Government had announced its targets for the NHS, including a commitment that 92% of patients were seen within 18 weeks, which would likely pose a significant challenge, as currently only around 60% of patients were seen within this timeframe. There was also a possibility that a cap would be introduced on Elective Recovery Funding. • Based on discussions with NHS England, it was understood that the £22bn of additional funding announced in the Autumn Statement had already been allocated to address pay awards and other cost pressures, and accordingly 2025/26 would likely feel like a 1-2% decrease in terms of funding. The messaging from NHS England appeared to have also altered to one of providers doing what they could within the available funding envelope, rather than attempting to deliver against all targets whilst at the same time delivering a break-even financial position. • It was proposed to regulate NHS managers, and a consultation, closing on 18 February 2025, had been launched on 26 November 2024. It was agreed that any such regulation needed to be fair and equitable. • The Trust had opened a new state-of-the-art special care baby unit, designed to increase capacity and offer enhanced specialist care. 5.5 Performance KPI Report for Month 8 Joe Teape was invited to present the Performance KPI Report for Month 8, the content of which was noted. It was further noted that: • The Trust continued to perform well when compared to other equivalent organisations. • During November 2024, there had been an average of 450 patients per day attending the Emergency Department, and four-hour performance at Southampton General Hospital was 56.1%. • There had been improvements in cancer waiting times against the 28-day faster diagnosis and 31-day targets. • The Trust’s Referral To Treatment waiting list had reduced slightly, and the Trust’s performance against the 18-week target was top-quartile. • Between August and October 2024, the Trust’s performance against the six- week diagnostic standard was 87%, which although below the national target, was top-quartile. 5.6 Break 5.7 Finance Report for Month 8 Ian Howard was invited to present the Finance Report for Month 8, the content of which was noted. It was further noted that: • The Trust had reported a £5.7m in-month deficit (£18.2m year-to-date) and was £14.8m behind its 2024/25 plan. • The Trust had submitted its financial recovery plan to the Hampshire and Isle of Wight Integrated Care Board and was on track with this plan, with the exception of the pressures due to the pay award. • Based on the national month 7 productivity data, average national increased productivity was 1.7% whereas the Trust had recorded 4% during the same period. • The Trust’s cash position continued to deteriorate and there was a significant risk that additional cash support would be required in the fourth quarter. Page 4 • There was a risk that a cap would be applied to Elective Recovery funding in 2024/25 based on month 8 performance. 5.8 ICB Finance Report for Month 8 Ian Howard was invited to present the ICB Finance Report for Month 8, the content of which was noted. It was further noted that: • The Integrated Care System had reported a year-to-date deficit of £39.71m, compared to a planned year-to-date deficit of £10.23m. • £70m of cash support had been received and the ICS was forecasting achieving break-even at the end of the year. The Board discussed the ICB Finance Report for Month 8 and challenged the requests contained in the report in respect of the assurance to be given by Executive Directors regarding the system-wide transformation programmes. It was noted that whilst Executive Directors would be able to provide assurance regarding the Trust’s contribution, it would not be reasonable to expect them to provide assurance regarding matters outside their control. The Board additionally challenged the assertion that the Hampshire and Isle of Wight Integrated Care System would achieve break-even at the end of 2024/25, noting that there was no expectation that the system transformation programmes would deliver significant benefits in the final quarter. Actions Ian Howard agreed to coordinate a report to the Board in respect of the Trust’s contribution to the Hampshire and Isle of Wight Integrated Care System transformation programmes. The Chair and David French agreed to discuss the requests of the Board in the ICB Finance Reports with the Integrated Care Board’s chair. 5.9 People Report for Month 8 Steve Harris was invited to present the People Report for Month 8, the content of which was noted. It was further noted that: • The Trust was 77 whole-time-equivalents (WTE) above its 2024/25 plan and was projecting to be 186 WTE above plan at year end. The plan assumed a reduction of 218 WTE linked to improvements in mental health and patients having no criteria to reside through successful delivery of system-wide transformation programmes. These transformation programmes had yet to deliver any significant benefit. • An update was provided in respect of the industrial dispute with portering staff. It was noted that an ACAS-facilitated deal had been brokered and agreed with staff, although the mandate for strike action remained in force until May 2025. • An update was provided regarding the ongoing pay dispute relating to Band 2 and 3 staff. 5.10 Freedom to Speak Up Report The Freedom to Speak Up Report was tabled to the meeting, the content of which was noted. It was further noted that: • There had been 97 cases reported during 2024, most of which related to allegations of bullying or issues with team dynamics. Only one report related to a patient safety issue. Page 5 • It would be necessary to review responses to the staff survey regarding attitudes toward speaking up. • A ‘heatmap’ to triangulate safety, quality and wellbeing concerns was under consideration. The Board discussed the report and queried why staff felt unable to utilise line or senior management to resolve many of the issues reported via the Trust’s Freedom to Speak Up process. The importance of visibility on the part of the leadership team was noted. Actions Gail Byrne agreed to consider how Freedom to Speak Up can be used for its original purpose of raising concerns of safety. 5.11 Guardian of Safe Working Hours Quarterly Report Diana Hulbert was invited to present the Guardian of Safe Working Hours Quarterly Report, the content of which was noted. It was further noted that: • The vacancy rate for resident doctors was 9.16%, which was in line with previous years and low compared with peers. • There had been an average of 48 exception reports per month over the past 12 months. The most common reason had been due to working hours breaches and the majority had been in relation to F1 grades. • A lack of office space and lockers remained an issue. • The generation of a sense of belonging amongst resident doctors posed a challenge. • The session on resident doctors at the Trust Board Study Session in November 2024 was a welcome opportunity to speak to the Board about the lives of resident doctors. 5.12 Learning from Deaths 2024-25 Quarter 2 Report Jenny Milner was invited to present the Learning from Deaths 2024-25 Quarter 2 Report, the content of which was noted. It was further noted that: • The Trust’s relative mortality rate was lower than expected compared with national figures. The Trust was one of 12 other trusts (out of 119) in this position. • The Independent Medical Examiners Group had commenced work during the second quarter and was responsible for reviewing all deaths. • An electronic application was being developed to assist in disseminating the outputs from Mortality and Morbidity meetings. • There had been an increased number of reports of patients dying in bays rather than side-rooms, which correlated with complaints received. 5.13 Infection Prevention and Control 2024-25 Quarter 2 Report Julian Sutton and Julie Brooks were invited to present the Infection Prevention and Control 2024-25 Quarter 2 Report, the content of which was noted. It was further noted that: • In line with a more general national trend, the Trust was not expecting to meet its targets in respect of infection prevention and control. Page 6 • However, the Trust compared favourably with peers. • A hand-washing campaign had been carried out in October and November 2024. • Rates of clostridioides difficile were increasing both nationally and internationally. • The situation with regard to the candida auris outbreak appeared to be improving following the interventions made by the Trust. The screening arrangements would likely be required indefinitely and the maintaining of the fundamentals of care programme expectations was crucial to preventing future outbreaks. Action Gail Byrne agreed to include an item on infection prevention control at a future Trust Board Study Session to include details of an Australian study, point of care testing, and progress on the roll out of the Fundamentals of Care programme. 5.14 Annual Medicines Management 2023-24 Report James Allen was invited to present the Annual Medicines Management 2023-24 Report, the content of which was noted. It was further noted that: • During 2023/24, the Trust spent £219m on medicines, a four per cent increase compared to 2022/23. • Training continued successfully, although operational pressures had led to some challenges in this area. • The pharmacy team’s support to clinical trials had improved. • Improvements were required to the Trust’s estate to make it more suitable for the safe storage of medicines, especially given the increased volume and acuity of mental health in-patients and the resulting challenges in terms of security of patients’ medication. • The aseptic site at Adanac Park was expected to be ready in the coming months • Consideration was being given as to whether to stop prescribing over-thecounter medicines on discharge in order to accelerate the discharge process. 5.15 Annual Ward Staffing Nursing Establishment Review 2024 Gail Byrne was invited to present the Annual Ward Staffing Nursing Establishment Review 2024, the content of which was noted. It was further noted that: • It was a requirement from the National Quality Board that the Establishment Review be discussed by the Board in open session. • Out of the 37 recommendations which were made following the Francis inquiry in 2013, the Trust was compliant with 35. The areas of non-compliance related to the allocation of time for supervision time for statutory and mandatory training and in relation to equality, diversity and inclusion. Progress was being made in these areas, but further action was required to achieve full compliance. • The Trust was compliant with 37 out of 38 of the recommendations included in the NICE guideline on safe staffing for in-patient wards. An action plan was in place to address the single area of non-compliance. Page 7 • The Trust had conducted a robust six-monthly ward staffing review. Areas of challenge related to night shifts and the increasing number of patients with enhanced care needs. 6. STRATEGY and BUSINESS PLANNING 6.1 Board Assurance Framework (BAF) Update Lauren Anderson was invited to present the Board Assurance Framework Update, the content of which was noted. It was further noted that: • Five of the Trust’s risks were rated ‘critical’ and five were outside of appetite. • The rating of risk 5a had been increased from 15 to 20 due to the continuing financial pressures and the erosion of the Trust’s cash balance. • A new scoring matrix was being rolled out for the operational risk register and BAF risks. 7. CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Annual Assurance for the NHS England Core Standards for Emergency Preparedness, Resilience and Response (EPRR) John Mcgonigle was invited to present the Annual Assurance for the NHS England Core Standards for Emergency Preparedness, Resilience and Response, the content of which was noted. It was further noted that: • The Trust had reported full compliance in 60 out of 62 core standards as part of the self-assessment, with an overall assurance rating of ‘substantially compliant’. • The two key areas for improvement were in respect of lockdown procedures and the Trust’s approach to business continuity. • The Trust had also carried out a deep-dive into its cyber security arrangements. 7.2 Register of Seals and Chair’s Actions Report The paper ‘Register of Seals and Chair’s Actions Report’ was presented to the meeting, the content of which was noted. Decision: The Board agreed to ratify the application of the Trust Seal to the documents listed in the ‘Register of Seals and Chair’s Actions Report’. 8. Any other business The Board expressed its thanks to Joe Teape for his time as Chief Operating Officer, noting that this would be his last Board meeting at the Trust. 9. Note the date of the next meeting: 11 March 2025 Page 8 10. Resolution regarding the Press, Public and Others Decision: The Board resolved that, as permitted by the National Health Service Act 2006 (as amended), the Trust’s Constitution and the Standing Orders of the board of directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. The meeting was adjourned. Page 9 List of action items Agenda item Assigned to Deadline Status Trust Board – Open Session 25/07/2024 5.4 Briefing from the Chair of the Quality Committee (Oral) 1163. Impact of technology Machell, Craig 01/04/2025 Pending Explanation action item Craig Machell agreed to add an item covering the impact of technology over the next 5-10 years to a future Trust Board Study Session agenda. Update: Item tentatively scheduled for 01/04/2025 Study Session. Trust Board – Open Session 07/01/2025 2 Patient Story 1200. Recommendations Byrne, Gail 11/03/2025 Pending Explanation action item Gail Byrne agreed to consider how the recommendations made in patient stories could be captured and action taken as a result. Trust Board – Open Session 07/01/2025 5.8 ICB Finance Report for Month 8 1201. Transformation programmes Howard, Ian 11/03/2025 Pending Explanation action item Ian Howard agreed to coordinate a report to the Board in respect of the Trust’s contribution to the Hampshire and Isle of Wight Integrated Care System transformation programmes. Page 1 of 2 Agenda item Assigned to Deadline Status Trust Board – Open Session 07/01/2025 5.8 ICB Finance Report for Month 8 1202. ICB Finance Reports Douglas-Todd, Jenni French, David 11/03/2025 Pending Explanation action item The Chair and David French agreed to discuss the requests of the Board in the ICB Finance Reports with the Integrated Care Board’s chair. Trust Board – Open Session 07/01/2025 5.10 Freedom to Speak Up Report 1203. Raising concerns of safety Byrne, Gail 11/03/2025 Pending Explanation action item Gail Byrne agreed to consider how Freedom to Speak Up can be used for its original purpose of raising concerns of safety. Trust Board – Open Session 07/01/2025 5.13 Infection Prevention and Control 2024-25 Quarter 2 Report 1204. Trust Board Study Session Byrne, Gail 03/06/2025 Pending Explanation action item Gail Byrne agreed to include an item on infection prevention control at a future Trust Board Study Session to include details of an Australian study, point of care testing, and progress on the roll out of the Fundamentals of Care programme. Update: Item tentatively scheduled for TBSS on 3 June 2025. Page 2 of 2 Agenda item 5.1 Committee Chair’s Report to the Trust Board of Directors 11 March 2025 Committee: Audit & Risk Committee Meeting Date: 20 January 2025 Key Messages: • • • • • The committee considered the accounting policies and management judgements in respect of the 2024/25 annual accounts, noting that most of these were consistent with previous years. It was further noted that a full re-valuation was due to take place this year in respect of the Trust’s property, plant and equipment, a process which occurs every five years. The impact of IFRS16 was also noted. The committee reviewed the Trust’s compliance with the Code of Governance for NHS Provider Trusts, noting that the Trust was compliant in all areas or had appropriate explanations for areas of non-compliance, of which there were only a few. These had also been areas of non-compliance during 2023/24. The committee received a report on cyber risk, including recent trends and the steps that both the NHS and the Trust were taking to counter the threat posed. The committee received updates in respect of the internal audit programme, including the reports in respect of an audit of the Fit and Proper Persons framework and of Data Quality. An update was provided in respect of the work of the counter-fraud team, including an update on the work being undertaken to manage the risk impersonation fraud by those pretending to be agency/temporary staff. Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) 6.2 Board Assurance Framework (BAF) Update Assurance Rating: Risk Rating: Substantial N/A • All risks had been reviewed with the relevant executive director(s). • It was suggested that the BAF needed to more adequately reflect the Trust’s estate risk and the target date should be reconsidered. 7.3 Audit and Risk Committee Assurance Rating: Risk Rating: Terms of Reference Substantial N/A • The committee reviewed its Terms of Reference, proposing to only make minor changes. • The committee recommended that the Board approve the revised Terms of Reference. Any Other Matters: • The committee received an update in respect of the tenders for internal and external auditors. Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Page 1 of 2 Limited Assurance No Assurance Not Applicable Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Where assurance is not required and/or relevant. Risk Rating: Low Medium High Not Applicable Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda item 5.2 i) Committee Chair’s Report to the Trust Board of Directors 11 March 2025 Committee: Finance and Investment Committee Meeting Date: 27 January 2025 Key Messages: • • • • • • • • • • The committee reviewed the Finance Report for Month 9. The Trust’s financial position remained challenging with a £4.5m in-month and £22.7m year-to-date deficit recorded against a plan of £3.3m. Furthermore, the Trust’s cash position remained challenging. The underlying position had deteriorated during December 2024 due to lower than expected Elective Recovery income. In addition, there had been up to 500 Emergency Department attendances per day and circa 250 patients having no criteria to reside. The Trust was anticipating a year-end deficit of circa £35m once additional pay pressures had been taken into account. There were concerns that a cap would be applied to Elective Recovery funding based on month 8 figures. A significant proportion of the Trust’s undelivered Cost Improvement Programme related to non-delivery of system-wide transformation programmes. The Trust’s capital programme was £11.6m behind plan with £50.4m due to be spent during the remainder of the financial year. The committee received a report on the management of leases from an accounting perspective, noting that further work on reviewing leases was required. An update was received in respect of the annual planning and budgetsetting process, noting that no national planning guidance had yet been received. It was expected that 2025/26 would be challenging due to an anticipated real terms reduction in funding and possible cap on Elective Recovery funding. The committee received an update in respect of the Trust’s project to optimise operating services as part of the Always Improving programme, noting good progress being made in this area. The committee received an update in respect of Digital, noting the progress being made in respect of system developments and laptop upgrades as well as the latest position regarding the proposed system-wide Electronic Patient Record system and the planned go-live for the new Emergency Department system in April 2025. Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) 7.4 Finance and Investment Assurance Rating: Risk Rating: Committee Terms of Reference Substantial Low • The committee reviewed its Terms of Reference, proposing to only make minor changes. • The committee recommended that the Board approve the revised Terms of Reference. Any Other N/A Matters: Page 1 of 2 Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Limited Assurance Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. No Assurance There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Not Applicable Where assurance is not required and/or relevant. Risk Rating: Low Medium High Not Applicable Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda item 5.2 ii) Committee Chair’s Report to the Trust Board of Directors 11 March 2025 Committee: Finance and Investment Committee Meeting Date: 24 February 2025 Key Messages: • • • • • • • The committee considered a draft of the Trust’s annual plan submission to the Hampshire and Isle of Wight Integrated Care Board. The draft plan identified significant financial challenges continuing from the underlying financial pressures reported during 2024/25. The committee received an update in respect of the Trust’s inpatient flow programme, noting that whilst a 5% improvement in length of stay had been achieved, much of this had been offset by increased demand. The committee reviewed the Finance Report for Month 10 (see below). The committee received an update in respect of the Trust’s cash position, noting that it appeared likely that additional revenue support would be required in the first quarter of 2025/26. The committee received an update regarding the Trust’s 2024/25 Cost Improvement Programme. The Trust had identified £89.3m of schemes and forecast delivery of £76.3m of improvements. The committee received an update on the Trust’s decarbonisation programme, including on proposals for installing heat pumps, solar panels and renewing/replacing infrastructure. The committee noted an update in respect of UHS Estates Limited, including the risk associated with the management of endoscopy scopes and their replacement. Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) 5.8 Finance Report for Month 10 Assurance Rating: Risk Rating: Substantial High • The Trust’s underlying monthly deficit was c.£6.5m. There was a year-to-date deficit of £15.2m, £11.8m behind plan. • The Trust had reported a £7.5m surplus during the month due to oneoff items. • The Trust was forecasting an year-end deficit of £17.65m following work to agree a Hampshire and Isle of Wight Integrated Care System ‘landing plan’ for 2024/25. • The Trust’s capital programme was £12m behind plan, with £39.3m due to be spent during the remainder of 2024/25. 6.2 Board Assurance Framework (BAF) Update Assurance Rating: Risk Rating: Substantial N/A • Risks 5a, 5b and 5c have been updated, following discussions with the respective Executive Director(s). • It was proposed to extend the target date for risk 5a, but to include an interim target as at April 2026 between the current position and the ultimate objective of reducing this risk to 9. Any Other N/A Matters: Page 1 of 2 Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Limited Assurance Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. No Assurance There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Not Applicable Where assurance is not required and/or relevant. Risk Rating: Low Medium High Not Applicable Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda item 5.3 i) Committee Chair’s Report to the Trust Board of Directors 11 March 2025 Committee: People & Organisational Development Committee Meeting Date: 24 January 2025 Key Messages: • • • • • • • As forecast, the Trust’s workforce was seven whole-time-equivalents (WTE) above its plan at the end of December 2024. However, the total workforce had decreased by 90 WTE, owing to the impact of Christmas resulting in deferral of start dates until January 2025. It was forecast that the Trust would be 146 WTE above plan at the end of 2024/25, noting that the Trust had assumed a reduction of 220 WTE due to the impact of system-wide transformation programmes including Non-Criteria to Reside and mental health. The Trust was experiencing particularly high sickness levels due to the impact of seasonal illnesses. The committee received a presentation on the Trust’s internal leadership development programmes, including those relating to senior, operational, and emerging leaders as well as programmes targeted at under-represented groups. The committee received an update on staff health and wellbeing, noting that uptake for influenza and Covid-19 vaccinations was low at 50% and 30% respectively. The committee was updated on the status of the disputes with UNITE for Portering and with UNISON regarding Band 2 and Band 3 pay. The committee noted that the formal consultation in respect of transfer of staff to UHS Estates Limited had commenced. Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) Not applicable. Any Other Matters: The committee noted that an action plan had been agreed with the porters and that the team had moved from Estates, Facilities and Capital Development to the Site team. Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Limited Assurance Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. Page 1 of 2 No Assurance Not Applicable Risk Rating: Low Medium High Not Applicable There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Where assurance is not required and/or relevant. Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda item 5.3 ii) Committee Chair’s Report to the Trust Board of Directors 11 March 2025 Committee: People & Organisational Development Committee Meeting Date: 24 February 2025 Key Messages: • • • • The committee reviewed the People Report for Month 10 (see below). It was noted that January 2025 had been challenging, especially in terms of managing high levels of staff sickness due to seasonal illnesses as well as the impact of increased demand on the Trust’s services. Furthermore, the increasing number of patients requiring enhanced care placed further pressure on the Trust’s workforce numbers. It was expected that difficult decisions would be required to meet the financial and workforce expectations for 2025/26. As part of this, it would be necessary to ensure that quality indicators were monitored. In addition, the Trust will need to be focused on ensuring that staff still feel valued and supported to deliver the first class care they aspire to. This would
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BRC Research-imaging-proposal-form_v1 FINAL 10.12.2024
Description
BRC Research Imaging Proposal form The BRC Research Imaging Proposal form should be completed by the chief/principal investigator of any new research study requiring access to imaging resources at University Hospital Southampton. The BRC Imaging Research Panel (BRC IRP) will use this information to determine the availability of resource and provide advice on costings for imaging research. Ideally, this form should be completed before a submission for this pilot scheme is made, to enable accurate costings for the MR imaging to be estimated. For the BRC MRI pump-priming research project award, this form will provide imaging specific background information, to help assess the feasibility of the project, alongside the full award application form. Please complete both Part 1 and Part 2 (detailed application). If detailed information is not known then please complete as much as possible (especially for Part 2), submit the form and we will be in contact to assist with this. Part 1 – Expression of interest Study title: Short title: Research question / summary of imaging requirements: Investigator: Email: Are you acting in your capacity as a UHS or UoS principal investigator? Select one only. UHS (Trust) UoS (University) Principal grant admin (n/a for BRC pump priming scheme) UHS (Trust) UoS (University) Other Part 2 – Detailed application Proposed start date: Proposed end date: Number of subjects: Statistical advice sought? Please circle Yes / No Type of study: Part of a multi-centre trial? Please circle Yes / No Approvals required? Please state Imaging required Imaging protocol (state if new or existing and who this has been discussed with) Frequency/timing/routine? Hardware/software/data storage/archiving and image processing and image analysis requirements? 1. 2. 3. 4. New imaging protocols (including MRI sequences) should be discussed with the MRI Research Radiographer, MRI Physics and relevant Consultant Radiologist (if required). Existing imaging protocols should be confirmed with the MRI Research Radiographer and relevant MRI Superintendent Radiographer (including protocol name and version date). Please indicate if each imaging event is routine (i.e. part of clinical care), additional as part of this proposal, and whether this will continue once the trial has ended. Hardware/software/data storage and post-processing requirements, including image archiving, should be discussed with radiology/medical physics/UoS. Please sign electronically to indicate that you have read and agree with the attached Joint UHS and UoS Policy for imaging research in Southampton and BRC award terms and conditions Name: Signature: Date: Please submit to the RIMG (on behalf of the BRC) by emailing: Angela.Darekar@uhs.nhs.uk Joint UHS and UoS policy for imaging research in Southampton – BRC/MRI specific Version 2, December 2019, Research Imaging Management Group This Joint Policy applies to any academic activity, hereby referred to as “Project”, which involves imaging or imaging results at UHS, whether it is research, case report, case series, audit, service evaluation or other description not specifically mentioned here. Planning and costing research 1. For research only: please inform RIMG (by emailing Angela.Darekar@uhs.nhs.uk) of the research at least one month prior to grant/award application form submission by completing the attached form 2. Please discuss protocols with the appropriate radiographer/radiologist/medical physicist assigned to the project by the Radiology Research Coordinator. This will ensure that accurate costings (or equivalent hours of scanning time) can be provided. 3. When costing grant applications, the Radiology Research team will advise on costing attribution across institutions. Ethical approval 1. The appropriate Health Research Authority and institutional (UHS or UoS) approvals need to be in place before the Project starts. Bookings 1. Please provide as much notice as possible for research bookings (at least 48 hours), and appreciate that they cannot always be accommodated at short notice. If particular procedures/personnel are required for bookings, these should be discussed with the Radiology Research team before RIMG approval is granted. 2. Liaise with the research radiographers for bookings, copying in RadiologyResearch@uhs.nhs.uk and provide: Name, DoB, Address, GP details, hospital ID (if available) and patient’s study ID. 3. Please use either the radiology research referral form or electronic requesting. Please clearly indicate the project title in the request and indicate that this is a research scan. Overlap between research and clinical imaging 1. If requesting clinical imaging that will later be used for research purposes, please clarify this to the reporting radiologist on the request form. Appropriate funding and ethical approvals must be in place. Publication 1. If manuscripts arise from Projects which make use of imaging data reported by UHS radiologists or involving UHS medical physicists, co-authorship or acknowledgement of these individuals should be discussed with them at the point of manuscript preparation. 2. Please include both UHS and UoS as affiliations, unless none of the authors have a honorary or substantive connection with UoS, and no use was made of any UoS facility. Please abide by the “Joint Partnership Policy and Guidance on Pre-clinical and Clinical Research Publications” v2.6, jointly approved by UHS and UoS. 3. Acknowledge resources (staff, space or equipment) of a particular imaging unit or department if these have been used. 4. Please remember to acknowledge any sponsorship you have received. 5. Please acknowledge BRC support using wording in section 4.5 below 6. For grants, please include the grant number and source. 7. Please inform RIMG of publications arising from imaging performed at UHS. Incidental findings 1. It is the recommendation of the RIMG that the Research Ethics Committee approved protocol defines precise instructions on how to consent for and manage incidental findings. These should specify a named clinician who will be responsible for managing incidental findings (reported by the radiologist(s) associated with the study) including informing the subject, arranging follow up tests and liaising with the GP as necessary. In the absence of clarity in the study protocol of any aspect relating to incidental findings, the Royal College of Radiologists’ guidance (https://www.rcr.ac.uk/publication/management-incidental-findings-detected-during-research-imaging), will need to be adhered to. Data management 1. Please ensure that data uploads/transfers and archiving processes have been discussed with the relevant people within PACS/Radiology Research/Medical Physics (as appropriate) and have been funded accordingly (to be confirmed for the BRC MRI pump-priming scheme). 2. Please ensure that all data management is in compliance with the General Data Protection Regulation or its UK equivalent. The award will only be made available if you meet the following conditions: BRC award terms and conditions 1. The award is subject to the terms and conditions of the BRC4 Research Contract signed by the Department for Health and Social Care and University Hospital Southampton NHS Foundation Trust on 8th November 2022. Specific applicable BRC terms are set out in Schedule 1 attached to this award letter. 2. The BRC funding is subject to the terms and conditions detailed in the BRC Collaboration Agreement signed by University Hospital Southampton NHS Foundation Trust and the University of Southampton, dated 15th September 2023. 3. Any additional grant funding secured by the postholder as a result of the BRC funding will be considered as grant income to the BRC. As the successful applicant awarded funding you will be required to: * Provide the BRC Manager with progress reports as requested by them, including a report at least 1 month prior to award end, plus information required to meet reporting requirements for NIHR, such as dates of submission of external applications * Contribute to the relevant School/Faculty conference and seminar programmes and BRC and NIHR-related training and development events in accordance with NIHR guidance. * Include an acknowledgement of NIHR Southampton BRC support on all publications, posters and other outputs resulting from this award. Schedule 1 – Specific Applicable NIHR Southampton Biomedical Research Centre Terms 1 Definitions: 1.1 "Award” means the funding applied for in this application. 1.2 BRC Manager means the member of staff at UHS employed to have overall management responsibility for the BRC. 1.3 “BRC Research Contract” means the Biomedical Research Centre grant contract signed by University Hospital Southampton NHS Foundation Trust and the Department for Health and Social Care and which is incorporate by reference, to the Award Letter. 1.4 “Background IP” means any Intellectual Property in existence at the commencement of the Reseacrh or created, devised or generated other than in the performance of the Research and which is actually used in the performance of the Research. 1.5 “Confidential Information” means all information of a commercially sensitive nature including (but not limited to) specifications, drawings, circuit diagrams, tapes, discs and other computable readable media, documents, techniques and know-how which are disclosed by one Party to the other for use in or in connection with the BRC or any Research. 1.6 “Foreground IP” means any Intellectual Property (and/or property right in Samples) that is created, generated or developed (whether in whole or in part) during the course of and for the purpose of any part of the Research. 1.7 “Parties” means Awardee and University Hospital Southampton NHS Foundation Trust. 1.8 “Research” means the project undertaken supported by the Award. 1.9 “Research Data” means information or data that is collected, collated or generated in the performance of the Research and includes (but is not limited to) information or data that is presented or stored in searchable form. For the avoidance of doubt, Research Data: a) does not include, without limitation, information or data that has been analysed as part of the Research; b) does include, but is not limited to, images. 1.10 “Samples” means material (including but not limited to biological material, organisms and chemical compounds), specimens or extracts collected, obtained or generated (whether in whole or in part) during the course of and for the purpose of any part of the Research. 1.11 “UHS” means University Hospital Southampton NHS Foundation Trust. 2 Intellectual Property 2.1 Awardee shall promptly report all Foreground IP to UHS. 2.2 Each Party shall own the Research Data and Foreground IP generated by it under the BRC or Project and the terms of clauses 11, 16 and 17 of BRC Research Contract shall apply to the use, management and exploitation of Research Data and Foreground IP. 2.3 Nothing contained in the Award Letter related to this funding shall affect the absolute and unfettered rights of each Party in all inventions, discoveries and intellectual property contained in its Background IP. 2.4 Subject to the BRC Research Contract, each Awardee shall undertake and continue at its expense the timely prosecution and maintenance of all Foreground IP which is solely owned by Awardee. In the event that the Awardee is unable or unwilling to comply with its obligation under this Clause 2.4, UHS and Funder shall consider how best to deal with such Foreground IP and shall have the option to require an assignment of such Foreground IP to the other Party to enable prosecution and maintenance of such Foreground IP by that other Party at its own cost. In the event that any Party wishes to exploit commercially any Foreground IP assigned pursuant to this Clause 2.4 that Party shall pay to the assigning Party a royalty and/or other appropriate form of remuneration which is fair and reasonable taking into consideration the factors set out under Clause 3.3. 2.5 In the event that any of the Parties are jointly responsible for generating Research Data and/or Foreground IP such Research Data and/or Foreground IP shall be jointly owned by the Parties. Ownership in Foreground IP shall be in accordance with the inventive contribution made by each Party to the generation of such Foreground IP and ownership in Research Data shall be in accordance with the relative contributions of each Party to the generation of the Research Data. 2.6 Joint owners of Foreground IP shall agree between them on who shall be responsible for the timely prosecution and maintenance of all such Foreground IP and the Party that is nominated to be so responsible shall be entitled to charge the other joint owners with a percentage of the costs of so doing as agreed between the joint owners. In the absence of any agreement to the contrary between joint owners the costs shall be equally shared. 3 Exploitation of Intellectual Property 3.1 Each Party grants to the other Party a non-exclusive, royalty-free licence (without the right to sublicence) to: 3.1.1 use its Research Data and Foreground IP for their own non-commercial research and development purposes but not for the purposes of commercial exploitation; and 3.1.2 in the case of UHS to use University of Southampton Research Data and Foreground IP in clinical activities within UHS; 3.1.3 subject to any existing third party obligations, use its Background IP for the purpose of undertaking the BRC and to enable the use of the Foreground IP pursuant to Clause 3.1.1 and 3.1.2 but not for the purposes of commercial exploitation. 3.2 The Parties will review and consider the optimum use of all Research Data and Foreground IP and agree which is the most suitable to effectively exploit or disseminate any Research Data and Foreground IP, subject to approval of the Funder. 3.3 In the event that any Party wishes to exploit commercially Foreground IP owned by the other Party, the owner of the Foreground IP shall grant to such Party a non-exclusive licence to use such Foreground IP for that purpose, subject to the agreement of appropriate terms in relation thereto, including a royalty and/or other appropriate form of remuneration which is fair and reasonable taking into consideration the respective financial and technical contributions of the Parties concerned to the development of the Foreground IP, the expenses incurred in securing intellectual property protection thereof and the costs of its commercial exploitation and any use of Background IP. 3.4 Should any of the Parties wish to exploit its own Foreground IP with a third party during the duration of the BRC, that Party must notify the other Party before approaching said third party, always provided that the disclosure of information required for such exploitation is subject to the obligations of confidentiality at least equivalent to those under Clause 11. Further any necessary notification to NIHR shall be made and their respective approval should be obtained or commercialisation agreement in place, if required, prior to exploitation. 3.5 In recognition of the Parties joint involvement with the BRC and the contribution to development of the Foreground IP a Party exploiting its own Foreground IP will provide a fair revenue share to the other Party. In the event any revenues are due to the Funder revenues shall first be distributed to the Funder prior to sharing between the Parties. 3.6 Subject to Clause 3.4 each Party agrees (where it is free and reasonably able to do so) to license on fair and reasonable terms its Foreground IP and Background IP that may be required to enable any other Party to exploit its own Foreground IP or Background IP, always subject to the obligations of confidentiality under Clause 5. 3.7 With regard to joint inventions, the Parties owning such inventions agree to co-operate fully in the protection of such joint inventions and each Party shall be entitled to make use of such joint inventions subject only to negotiating a licence in good faith from the other Party for its interest in such joint inventions on similar terms to those set out in clause 3.3. 3.8 The University shall grant to the Funder a non-exclusive, irrevocable, royalty-free, worldwide licence together with the right to grant sub-licences to health service bodies or others directly engaged in providing health care, permitting the Funder to use and publish 3.9 any information relating to the Research which is not Confidential Information of the University 3.9.1 any Foreground IP; 3.9.2 Research Data; 3.9.3 Reports; 3.9.4 arising know how; and, 3.9.5 conclusions arising from the Research 3.10 and in each case, the University acknowledges the Funder intends to exercise this right only where the Funder’s reasonable opinion the University is not appropriately managing, disseminating or using such items and in each case Funder is permitted to use or make available such items as it sees fit in support of: (i) the development, promotion or provision of health care that is not a commercial use; and/or (ii) for any other purpose that is not a commercial use. 4 Publication 4.1 Subject to the provisions of Clauses 2, 3 and 5 neither Party shall disclose or publish information or Foreground IP for the duration of the BRC and for 3 (three) years thereafter without the consent of the other Party , such consent, not to be unreasonably withheld or delayed. Further the Parties must seek to obtain all necessary consents from NIHR and any Collaborating Parties prior to publication. The obligation to seek consent of NIHR or continues after the end of the Research. 4.2 Subject to 4.1, the Parties shall be permitted to publish the Research Data of the BRC which they have undertaken in accordance with normal academic practice, subject always to the provisions of Clauses 8 and 5, and providing such disclosure does not jeopardise any application for Foreground IP protection by any Party. Request for such consent must be submitted together with the material proposed for publication to the BRC Manager. If any Party can reasonably demonstrate that such a disclosure contains material that would prejudice the value of any Background IP and/or Foreground IP, that Party shall inform the BRC Manager in writing within 28 days of that Party receiving a copy of the proposed publication and in that event the disclosure shall be amended so as to meet the objections of that Party or delayed to address their concerns. 4.3 Subject to the provisions of Clause 3 where in the opinion of UHS a proposed publication contains patentable or commercially sensitive subject matter which needs protection then the Party proposing to publish may be requested to refrain from doing so for a maximum of six 6 months in order to allow for application for patent protection in the name and at the cost of the relevant owner of the Foreground IP. The provisions of Clause 2 and 3 shall apply in respect of any licence to such Foreground IP. 4.4 Nothing contained in the Award Letter related to this funding shall prevent the submission of a thesis to examiners in accordance with the normal regulations of the Parties subject where appropriate to such examiners being bound by conditions of confidentiality in no less terms than those outlined in Clause 5 nor to the placing of such thesis in the library of the appropriate Research Party provided that access to such thesis shall only be available on conditions of confidentiality no less onerous than those contained in Clause 5 hereof. 4.5 The University shall ensure that all project investigators acknowledge in all theses, papers and other publications (including from non-BRC projects) that they receive support from the NIHR Southampton BRC, in accordance with BRC Research Contract. The form of words is: “[investigator initials] is supported by the National Institute for Health and Care Research through the NIHR Southampton Biomedical Research Centre”. 4.6 The Parties acknowledge that NIHR is entitled to publish the whole or any part of the Report. If the Parties wishes NIHR to delay such publication, it must submit a request in writing to the NIHR giving reasons for the requested delay which shall be considered in accordance with the NIHR’s Information for Authors’ Dual Publication Guidance and Embargo Policy as defined in the NIHR Contract and amended from time-to-time. 4.7 Neither Party shall use the other's name, crest, logo or registered image for any purpose without the express permission of the other Party. The Parties will agree treatment for referencing each others involvement in the BRC and joint branding for their activities subject to compliance with Clause 4.8 and the BRC Research Contract. 4.8 Neither Party shall issue any press release, public statement, or other media announcement related to the BRC or any Research Data or Foreground IP without the prior consent of the other Party and Funder, as applicable. 4.9 The Parties (in the case of the University via UHS must notify the Funder of any intention to issue a press release at least three (3) business days prior to any press release issued by it or on its behalf, directly related to the Research or Foreground IP, arising now how or Research Data or of matters arising from such Research. Awardee shall send one draft copy of the proposed press release to UHS at least five (5) business days before the date intended for release. For the avoidance of doubt this obligation shall continue in full force and effect following expiry of the Award letter 4.10 The Parties shall comply with guidance and advice from Funder on branding and publicity which may be issued from time to time including, but not limited to Funder’s guidance on the format for websites, press releases and use of social media, permitted use of the NIHR, BRC, NHS and Department of Health and Social Care brands, names and logos and ensuring all branding references to the BRC are prefixed with the term “NIHR”. 5 Confidentiality 5.1 The Parties hereto agree to use all reasonable endeavours to ensure that any Confidential Information disclosed or submitted in writing or any other tangible form to one Party (“Receiving Party”) by the other (“Disclosing Party”) shall be treated with the same care and discretion to avoid disclosure as the Receiving Party uses with its own similar information which it does not wish to disclose. Any information disclosed orally that is identified by the Disclosing Party as Confidential Information shall be treated the same as if it had been reduced to writing at the time of disclosure to the Receiving Party. 5.2 The Receiving Party shall not, during a period of seven (7) years after the termination of this Award Letter, use any such Confidential Information for any purpose other than the carrying out of its obligations under this Award funding or other than in accordance with the terms of this Award funding. 5.3 The undertaking in Clause 5.1 above shall not apply to Confidential Information: 5.3.1 which, at the time of disclosure, has already been published or is otherwise in the public domain other than through breach of the terms of this Award funding; 5.3.2 which, after disclosure to the Parties, is subsequently published or comes into the public domain by means other than an action or omission on the part of any of the Parties; 5.3.3 which a Party can demonstrate was known to him or subsequently independently developed by them; 5.3.4 lawfully acquired from third parties who had a right to disclose it with no obligations of confidentiality to any of the Parties; or 5.3.5 is required to be disclosed by applicable law or court order or by any Party's regulatory body, which is empowered by Statute or Statutory Instrument, but only to the extent of such disclosure and the Receiving Party shall notify the Disclosing Party promptly of any such request. 5.4 Staff and students and any agents, consultants or sub-contractors engaged to work on the BRC will be subject to the principles of confidentiality outlined in this Clause 5. 6 Term and Termination 6.1 The terms of this award shall come into force on the date when the Acceptance Statement is signed by the Awardee and remain in full force and effect until 31st March 2028 unless terminated earlier in accordance with the provisions of this Clause 6. 6.2 In the event that any Party shall commit any breach of or default in any terms or conditions of this Award funding, the other Party may serve written notice of such breach or default on the defaulting Party and in the event that such Party fails to remedy such default or breach within sixty (60) days after receipt of such written notice the other Party may, at their option and in addition to any other remedies which they may have at law or equity, terminate this Award funding by sending notice of termination in writing to the other Party. 6.3 If any Party (a) materially breaches any provisions of this Award funding ; or (b) passes a resolution for its winding-up; or if (c) a court of competent jurisdiction makes an order for that Party’s winding-up or dissolution; or makes an administration order in relation to that Party; or if any Party (e) appoints a receiver over, or an encumbrancer takes possession of or sells an asset of, that Party; or (f) makes an arrangement or composition with its creditors generally; or (g) makes an application to a court of competent jurisdiction for protection from its creditors generally; the other Party may terminate their involvement in the BRC. 6.4 In the event the BRC Research Contract terminates UHS may terminate this Award funding with immediate effect. 7 General 7.1 Each Party shall indemnify each of the other Parties, within the limits set out in this Clause 6, in respect of liability resulting from acts or omissions of itself, its employees or its students provided always that such indemnity shall not extend to claims for indirect or consequential loss or damages such as, but not limited to, loss of profit, revenue, contracts or the like. 7.2 Any amendments to this Award funding shall be valid only if made in writing and signed by authorised signatories of the Parties. 7.3 If any part or any provision of this Award funding shall to any extent prove invalid or unenforceable in law the remainder of such provision and all other provisions of this Award funding shall remain valid and enforceable to the fullest extent permissible by law, and such provision shall be deemed to be omitted from this Award funding to the extent of such invalidity or unenforceability. The remainder of this Award funding shall continue in full force and effect and the Parties shall negotiate in good faith to replace the invalid or unenforceable provision with a valid, legal and enforceable provision which has an effect as close as possible to the provision or terms being replaced. 7.4 No failure to exercise or delay in the exercise of any right or remedy which any Party may have under this Award funding or in connection with this Award funding shall operate as a waiver thereof, and nor shall any single or partial exercise of any such right or remedy prevent any further or other exercise thereof or of any other such right or remedy. 7.5 This Award funding including its Schedule supersedes all other agreements and understandings, whether written or oral, between the Parties about the BRC constitutes the entire agreement between the Parties regarding the BRC. 7.6 Except as otherwise expressly provided for herein, the Parties confirm that nothing in this Award funding shall confer or purport to confer on any third party any benefit or any right to enforce any term of this Award funding for the purposes of Contracts (Rights of Third Parties) Act 1999. 7.7 This Award funding shall be governed by and construed in accordance with English Law and each Party agrees to submit to the exclusive jurisdiction of the English Courts as regards any claim or matter arising under this Award funding. 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BRC Research-imaging-proposal-form_v1 FINAL 10.12.2024
Description
BRC Research Imaging Proposal form The BRC Research Imaging Proposal form should be completed by the chief/principal investigator of any new research study requiring access to imaging resources at University Hospital Southampton. The BRC Imaging Research Panel (BRC IRP) will use this information to determine the availability of resource and provide advice on costings for imaging research. Ideally, this form should be completed before a submission for this pilot scheme is made, to enable accurate costings for the MR imaging to be estimated. For the BRC MRI pump-priming research project award, this form will provide imaging specific background information, to help assess the feasibility of the project, alongside the full award application form. Please complete both Part 1 and Part 2 (detailed application). If detailed information is not known then please complete as much as possible (especially for Part 2), submit the form and we will be in contact to assist with this. Part 1 – Expression of interest Study title: Short title: Research question / summary of imaging requirements: Investigator: Email: Are you acting in your capacity as a UHS or UoS principal investigator? Select one only. UHS (Trust) UoS (University) Principal grant admin (n/a for BRC pump priming scheme) UHS (Trust) UoS (University) Other Part 2 – Detailed application Proposed start date: Proposed end date: Number of subjects: Statistical advice sought? Please circle Yes / No Type of study: Part of a multi-centre trial? Please circle Yes / No Approvals required? Please state Imaging required Imaging protocol (state if new or existing and who this has been discussed with) Frequency/timing/routine? Hardware/software/data storage/archiving and image processing and image analysis requirements? 1. 2. 3. 4. New imaging protocols (including MRI sequences) should be discussed with the MRI Research Radiographer, MRI Physics and relevant Consultant Radiologist (if required). Existing imaging protocols should be confirmed with the MRI Research Radiographer and relevant MRI Superintendent Radiographer (including protocol name and version date). Please indicate if each imaging event is routine (i.e. part of clinical care), additional as part of this proposal, and whether this will continue once the trial has ended. Hardware/software/data storage and post-processing requirements, including image archiving, should be discussed with radiology/medical physics/UoS. Please sign electronically to indicate that you have read and agree with the attached Joint UHS and UoS Policy for imaging research in Southampton and BRC award terms and conditions Name: Signature: Date: Please submit to the RIMG (on behalf of the BRC) by emailing: Angela.Darekar@uhs.nhs.uk Joint UHS and UoS policy for imaging research in Southampton – BRC/MRI specific Version 2, December 2019, Research Imaging Management Group This Joint Policy applies to any academic activity, hereby referred to as “Project”, which involves imaging or imaging results at UHS, whether it is research, case report, case series, audit, service evaluation or other description not specifically mentioned here. Planning and costing research 1. For research only: please inform RIMG (by emailing Angela.Darekar@uhs.nhs.uk) of the research at least one month prior to grant/award application form submission by completing the attached form 2. Please discuss protocols with the appropriate radiographer/radiologist/medical physicist assigned to the project by the Radiology Research Coordinator. This will ensure that accurate costings (or equivalent hours of scanning time) can be provided. 3. When costing grant applications, the Radiology Research team will advise on costing attribution across institutions. Ethical approval 1. The appropriate Health Research Authority and institutional (UHS or UoS) approvals need to be in place before the Project starts. Bookings 1. Please provide as much notice as possible for research bookings (at least 48 hours), and appreciate that they cannot always be accommodated at short notice. If particular procedures/personnel are required for bookings, these should be discussed with the Radiology Research team before RIMG approval is granted. 2. Liaise with the research radiographers for bookings, copying in RadiologyResearch@uhs.nhs.uk and provide: Name, DoB, Address, GP details, hospital ID (if available) and patient’s study ID. 3. Please use either the radiology research referral form or electronic requesting. Please clearly indicate the project title in the request and indicate that this is a research scan. Overlap between research and clinical imaging 1. If requesting clinical imaging that will later be used for research purposes, please clarify this to the reporting radiologist on the request form. Appropriate funding and ethical approvals must be in place. Publication 1. If manuscripts arise from Projects which make use of imaging data reported by UHS radiologists or involving UHS medical physicists, co-authorship or acknowledgement of these individuals should be discussed with them at the point of manuscript preparation. 2. Please include both UHS and UoS as affiliations, unless none of the authors have a honorary or substantive connection with UoS, and no use was made of any UoS facility. Please abide by the “Joint Partnership Policy and Guidance on Pre-clinical and Clinical Research Publications” v2.6, jointly approved by UHS and UoS. 3. Acknowledge resources (staff, space or equipment) of a particular imaging unit or department if these have been used. 4. Please remember to acknowledge any sponsorship you have received. 5. Please acknowledge BRC support using wording in section 4.5 below 6. For grants, please include the grant number and source. 7. Please inform RIMG of publications arising from imaging performed at UHS. Incidental findings 1. It is the recommendation of the RIMG that the Research Ethics Committee approved protocol defines precise instructions on how to consent for and manage incidental findings. These should specify a named clinician who will be responsible for managing incidental findings (reported by the radiologist(s) associated with the study) including informing the subject, arranging follow up tests and liaising with the GP as necessary. In the absence of clarity in the study protocol of any aspect relating to incidental findings, the Royal College of Radiologists’ guidance (https://www.rcr.ac.uk/publication/management-incidental-findings-detected-during-research-imaging), will need to be adhered to. Data management 1. Please ensure that data uploads/transfers and archiving processes have been discussed with the relevant people within PACS/Radiology Research/Medical Physics (as appropriate) and have been funded accordingly (to be confirmed for the BRC MRI pump-priming scheme). 2. Please ensure that all data management is in compliance with the General Data Protection Regulation or its UK equivalent. The award will only be made available if you meet the following conditions: BRC award terms and conditions 1. The award is subject to the terms and conditions of the BRC4 Research Contract signed by the Department for Health and Social Care and University Hospital Southampton NHS Foundation Trust on 8th November 2022. Specific applicable BRC terms are set out in Schedule 1 attached to this award letter. 2. The BRC funding is subject to the terms and conditions detailed in the BRC Collaboration Agreement signed by University Hospital Southampton NHS Foundation Trust and the University of Southampton, dated 15th September 2023. 3. Any additional grant funding secured by the postholder as a result of the BRC funding will be considered as grant income to the BRC. As the successful applicant awarded funding you will be required to: * Provide the BRC Manager with progress reports as requested by them, including a report at least 1 month prior to award end, plus information required to meet reporting requirements for NIHR, such as dates of submission of external applications * Contribute to the relevant School/Faculty conference and seminar programmes and BRC and NIHR-related training and development events in accordance with NIHR guidance. * Include an acknowledgement of NIHR Southampton BRC support on all publications, posters and other outputs resulting from this award. Schedule 1 – Specific Applicable NIHR Southampton Biomedical Research Centre Terms 1 Definitions: 1.1 "Award” means the funding applied for in this application. 1.2 BRC Manager means the member of staff at UHS employed to have overall management responsibility for the BRC. 1.3 “BRC Research Contract” means the Biomedical Research Centre grant contract signed by University Hospital Southampton NHS Foundation Trust and the Department for Health and Social Care and which is incorporate by reference, to the Award Letter. 1.4 “Background IP” means any Intellectual Property in existence at the commencement of the Reseacrh or created, devised or generated other than in the performance of the Research and which is actually used in the performance of the Research. 1.5 “Confidential Information” means all information of a commercially sensitive nature including (but not limited to) specifications, drawings, circuit diagrams, tapes, discs and other computable readable media, documents, techniques and know-how which are disclosed by one Party to the other for use in or in connection with the BRC or any Research. 1.6 “Foreground IP” means any Intellectual Property (and/or property right in Samples) that is created, generated or developed (whether in whole or in part) during the course of and for the purpose of any part of the Research. 1.7 “Parties” means Awardee and University Hospital Southampton NHS Foundation Trust. 1.8 “Research” means the project undertaken supported by the Award. 1.9 “Research Data” means information or data that is collected, collated or generated in the performance of the Research and includes (but is not limited to) information or data that is presented or stored in searchable form. For the avoidance of doubt, Research Data: a) does not include, without limitation, information or data that has been analysed as part of the Research; b) does include, but is not limited to, images. 1.10 “Samples” means material (including but not limited to biological material, organisms and chemical compounds), specimens or extracts collected, obtained or generated (whether in whole or in part) during the course of and for the purpose of any part of the Research. 1.11 “UHS” means University Hospital Southampton NHS Foundation Trust. 2 Intellectual Property 2.1 Awardee shall promptly report all Foreground IP to UHS. 2.2 Each Party shall own the Research Data and Foreground IP generated by it under the BRC or Project and the terms of clauses 11, 16 and 17 of BRC Research Contract shall apply to the use, management and exploitation of Research Data and Foreground IP. 2.3 Nothing contained in the Award Letter related to this funding shall affect the absolute and unfettered rights of each Party in all inventions, discoveries and intellectual property contained in its Background IP. 2.4 Subject to the BRC Research Contract, each Awardee shall undertake and continue at its expense the timely prosecution and maintenance of all Foreground IP which is solely owned by Awardee. In the event that the Awardee is unable or unwilling to comply with its obligation under this Clause 2.4, UHS and Funder shall consider how best to deal with such Foreground IP and shall have the option to require an assignment of such Foreground IP to the other Party to enable prosecution and maintenance of such Foreground IP by that other Party at its own cost. In the event that any Party wishes to exploit commercially any Foreground IP assigned pursuant to this Clause 2.4 that Party shall pay to the assigning Party a royalty and/or other appropriate form of remuneration which is fair and reasonable taking into consideration the factors set out under Clause 3.3. 2.5 In the event that any of the Parties are jointly responsible for generating Research Data and/or Foreground IP such Research Data and/or Foreground IP shall be jointly owned by the Parties. Ownership in Foreground IP shall be in accordance with the inventive contribution made by each Party to the generation of such Foreground IP and ownership in Research Data shall be in accordance with the relative contributions of each Party to the generation of the Research Data. 2.6 Joint owners of Foreground IP shall agree between them on who shall be responsible for the timely prosecution and maintenance of all such Foreground IP and the Party that is nominated to be so responsible shall be entitled to charge the other joint owners with a percentage of the costs of so doing as agreed between the joint owners. In the absence of any agreement to the contrary between joint owners the costs shall be equally shared. 3 Exploitation of Intellectual Property 3.1 Each Party grants to the other Party a non-exclusive, royalty-free licence (without the right to sublicence) to: 3.1.1 use its Research Data and Foreground IP for their own non-commercial research and development purposes but not for the purposes of commercial exploitation; and 3.1.2 in the case of UHS to use University of Southampton Research Data and Foreground IP in clinical activities within UHS; 3.1.3 subject to any existing third party obligations, use its Background IP for the purpose of undertaking the BRC and to enable the use of the Foreground IP pursuant to Clause 3.1.1 and 3.1.2 but not for the purposes of commercial exploitation. 3.2 The Parties will review and consider the optimum use of all Research Data and Foreground IP and agree which is the most suitable to effectively exploit or disseminate any Research Data and Foreground IP, subject to approval of the Funder. 3.3 In the event that any Party wishes to exploit commercially Foreground IP owned by the other Party, the owner of the Foreground IP shall grant to such Party a non-exclusive licence to use such Foreground IP for that purpose, subject to the agreement of appropriate terms in relation thereto, including a royalty and/or other appropriate form of remuneration which is fair and reasonable taking into consideration the respective financial and technical contributions of the Parties concerned to the development of the Foreground IP, the expenses incurred in securing intellectual property protection thereof and the costs of its commercial exploitation and any use of Background IP. 3.4 Should any of the Parties wish to exploit its own Foreground IP with a third party during the duration of the BRC, that Party must notify the other Party before approaching said third party, always provided that the disclosure of information required for such exploitation is subject to the obligations of confidentiality at least equivalent to those under Clause 11. Further any necessary notification to NIHR shall be made and their respective approval should be obtained or commercialisation agreement in place, if required, prior to exploitation. 3.5 In recognition of the Parties joint involvement with the BRC and the contribution to development of the Foreground IP a Party exploiting its own Foreground IP will provide a fair revenue share to the other Party. In the event any revenues are due to the Funder revenues shall first be distributed to the Funder prior to sharing between the Parties. 3.6 Subject to Clause 3.4 each Party agrees (where it is free and reasonably able to do so) to license on fair and reasonable terms its Foreground IP and Background IP that may be required to enable any other Party to exploit its own Foreground IP or Background IP, always subject to the obligations of confidentiality under Clause 5. 3.7 With regard to joint inventions, the Parties owning such inventions agree to co-operate fully in the protection of such joint inventions and each Party shall be entitled to make use of such joint inventions subject only to negotiating a licence in good faith from the other Party for its interest in such joint inventions on similar terms to those set out in clause 3.3. 3.8 The University shall grant to the Funder a non-exclusive, irrevocable, royalty-free, worldwide licence together with the right to grant sub-licences to health service bodies or others directly engaged in providing health care, permitting the Funder to use and publish 3.9 any information relating to the Research which is not Confidential Information of the University 3.9.1 any Foreground IP; 3.9.2 Research Data; 3.9.3 Reports; 3.9.4 arising know how; and, 3.9.5 conclusions arising from the Research 3.10 and in each case, the University acknowledges the Funder intends to exercise this right only where the Funder’s reasonable opinion the University is not appropriately managing, disseminating or using such items and in each case Funder is permitted to use or make available such items as it sees fit in support of: (i) the development, promotion or provision of health care that is not a commercial use; and/or (ii) for any other purpose that is not a commercial use. 4 Publication 4.1 Subject to the provisions of Clauses 2, 3 and 5 neither Party shall disclose or publish information or Foreground IP for the duration of the BRC and for 3 (three) years thereafter without the consent of the other Party , such consent, not to be unreasonably withheld or delayed. Further the Parties must seek to obtain all necessary consents from NIHR and any Collaborating Parties prior to publication. The obligation to seek consent of NIHR or continues after the end of the Research. 4.2 Subject to 4.1, the Parties shall be permitted to publish the Research Data of the BRC which they have undertaken in accordance with normal academic practice, subject always to the provisions of Clauses 8 and 5, and providing such disclosure does not jeopardise any application for Foreground IP protection by any Party. Request for such consent must be submitted together with the material proposed for publication to the BRC Manager. If any Party can reasonably demonstrate that such a disclosure contains material that would prejudice the value of any Background IP and/or Foreground IP, that Party shall inform the BRC Manager in writing within 28 days of that Party receiving a copy of the proposed publication and in that event the disclosure shall be amended so as to meet the objections of that Party or delayed to address their concerns. 4.3 Subject to the provisions of Clause 3 where in the opinion of UHS a proposed publication contains patentable or commercially sensitive subject matter which needs protection then the Party proposing to publish may be requested to refrain from doing so for a maximum of six 6 months in order to allow for application for patent protection in the name and at the cost of the relevant owner of the Foreground IP. The provisions of Clause 2 and 3 shall apply in respect of any licence to such Foreground IP. 4.4 Nothing contained in the Award Letter related to this funding shall prevent the submission of a thesis to examiners in accordance with the normal regulations of the Parties subject where appropriate to such examiners being bound by conditions of confidentiality in no less terms than those outlined in Clause 5 nor to the placing of such thesis in the library of the appropriate Research Party provided that access to such thesis shall only be available on conditions of confidentiality no less onerous than those contained in Clause 5 hereof. 4.5 The University shall ensure that all project investigators acknowledge in all theses, papers and other publications (including from non-BRC projects) that they receive support from the NIHR Southampton BRC, in accordance with BRC Research Contract. The form of words is: “[investigator initials] is supported by the National Institute for Health and Care Research through the NIHR Southampton Biomedical Research Centre”. 4.6 The Parties acknowledge that NIHR is entitled to publish the whole or any part of the Report. If the Parties wishes NIHR to delay such publication, it must submit a request in writing to the NIHR giving reasons for the requested delay which shall be considered in accordance with the NIHR’s Information for Authors’ Dual Publication Guidance and Embargo Policy as defined in the NIHR Contract and amended from time-to-time. 4.7 Neither Party shall use the other's name, crest, logo or registered image for any purpose without the express permission of the other Party. The Parties will agree treatment for referencing each others involvement in the BRC and joint branding for their activities subject to compliance with Clause 4.8 and the BRC Research Contract. 4.8 Neither Party shall issue any press release, public statement, or other media announcement related to the BRC or any Research Data or Foreground IP without the prior consent of the other Party and Funder, as applicable. 4.9 The Parties (in the case of the University via UHS must notify the Funder of any intention to issue a press release at least three (3) business days prior to any press release issued by it or on its behalf, directly related to the Research or Foreground IP, arising now how or Research Data or of matters arising from such Research. Awardee shall send one draft copy of the proposed press release to UHS at least five (5) business days before the date intended for release. For the avoidance of doubt this obligation shall continue in full force and effect following expiry of the Award letter 4.10 The Parties shall comply with guidance and advice from Funder on branding and publicity which may be issued from time to time including, but not limited to Funder’s guidance on the format for websites, press releases and use of social media, permitted use of the NIHR, BRC, NHS and Department of Health and Social Care brands, names and logos and ensuring all branding references to the BRC are prefixed with the term “NIHR”. 5 Confidentiality 5.1 The Parties hereto agree to use all reasonable endeavours to ensure that any Confidential Information disclosed or submitted in writing or any other tangible form to one Party (“Receiving Party”) by the other (“Disclosing Party”) shall be treated with the same care and discretion to avoid disclosure as the Receiving Party uses with its own similar information which it does not wish to disclose. Any information disclosed orally that is identified by the Disclosing Party as Confidential Information shall be treated the same as if it had been reduced to writing at the time of disclosure to the Receiving Party. 5.2 The Receiving Party shall not, during a period of seven (7) years after the termination of this Award Letter, use any such Confidential Information for any purpose other than the carrying out of its obligations under this Award funding or other than in accordance with the terms of this Award funding. 5.3 The undertaking in Clause 5.1 above shall not apply to Confidential Information: 5.3.1 which, at the time of disclosure, has already been published or is otherwise in the public domain other than through breach of the terms of this Award funding; 5.3.2 which, after disclosure to the Parties, is subsequently published or comes into the public domain by means other than an action or omission on the part of any of the Parties; 5.3.3 which a Party can demonstrate was known to him or subsequently independently developed by them; 5.3.4 lawfully acquired from third parties who had a right to disclose it with no obligations of confidentiality to any of the Parties; or 5.3.5 is required to be disclosed by applicable law or court order or by any Party's regulatory body, which is empowered by Statute or Statutory Instrument, but only to the extent of such disclosure and the Receiving Party shall notify the Disclosing Party promptly of any such request. 5.4 Staff and students and any agents, consultants or sub-contractors engaged to work on the BRC will be subject to the principles of confidentiality outlined in this Clause 5. 6 Term and Termination 6.1 The terms of this award shall come into force on the date when the Acceptance Statement is signed by the Awardee and remain in full force and effect until 31st March 2028 unless terminated earlier in accordance with the provisions of this Clause 6. 6.2 In the event that any Party shall commit any breach of or default in any terms or conditions of this Award funding, the other Party may serve written notice of such breach or default on the defaulting Party and in the event that such Party fails to remedy such default or breach within sixty (60) days after receipt of such written notice the other Party may, at their option and in addition to any other remedies which they may have at law or equity, terminate this Award funding by sending notice of termination in writing to the other Party. 6.3 If any Party (a) materially breaches any provisions of this Award funding ; or (b) passes a resolution for its winding-up; or if (c) a court of competent jurisdiction makes an order for that Party’s winding-up or dissolution; or makes an administration order in relation to that Party; or if any Party (e) appoints a receiver over, or an encumbrancer takes possession of or sells an asset of, that Party; or (f) makes an arrangement or composition with its creditors generally; or (g) makes an application to a court of competent jurisdiction for protection from its creditors generally; the other Party may terminate their involvement in the BRC. 6.4 In the event the BRC Research Contract terminates UHS may terminate this Award funding with immediate effect. 7 General 7.1 Each Party shall indemnify each of the other Parties, within the limits set out in this Clause 6, in respect of liability resulting from acts or omissions of itself, its employees or its students provided always that such indemnity shall not extend to claims for indirect or consequential loss or damages such as, but not limited to, loss of profit, revenue, contracts or the like. 7.2 Any amendments to this Award funding shall be valid only if made in writing and signed by authorised signatories of the Parties. 7.3 If any part or any provision of this Award funding shall to any extent prove invalid or unenforceable in law the remainder of such provision and all other provisions of this Award funding shall remain valid and enforceable to the fullest extent permissible by law, and such provision shall be deemed to be omitted from this Award funding to the extent of such invalidity or unenforceability. The remainder of this Award funding shall continue in full force and effect and the Parties shall negotiate in good faith to replace the invalid or unenforceable provision with a valid, legal and enforceable provision which has an effect as close as possible to the provision or terms being replaced. 7.4 No failure to exercise or delay in the exercise of any right or remedy which any Party may have under this Award funding or in connection with this Award funding shall operate as a waiver thereof, and nor shall any single or partial exercise of any such right or remedy prevent any further or other exercise thereof or of any other such right or remedy. 7.5 This Award funding including its Schedule supersedes all other agreements and understandings, whether written or oral, between the Parties about the BRC constitutes the entire agreement between the Parties regarding the BRC. 7.6 Except as otherwise expressly provided for herein, the Parties confirm that nothing in this Award funding shall confer or purport to confer on any third party any benefit or any right to enforce any term of this Award funding for the purposes of Contracts (Rights of Third Parties) Act 1999. 7.7 This Award funding shall be governed by and construed in accordance with English Law and each Party agrees to submit to the exclusive jurisdiction of the English Courts as regards any claim or matter arising under this Award funding. 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Annual report 15-16
Description
University Hospital Southampton NHS Foundation Trust Annual report and accounts 2015/16 incorporating the quality account 2015/16 Presented to Parliament pursuant to Schedule 7, paragraph 25 (4) (a) of the National Health Service Act 2006 3 ©2016 University Hospital Southampton NHS Foundation Trust TABLE OF CONTENTS Performance report Statement from the chief executive 7 Statement of purpose and activities 8 History of UHS 8 Key issues and risks 9 Going concern disclosure 9 Performance reporting 10 Regulatory body ratings 14 Environmental matters 14 Social, community and human rights issues 15 Accountability report Directors’ report 17 Introducing the Board of Directors 20 The people 21 Audit and assurance committee 25 Disclosures 28 Council of Governors 33 Annual remuneration statement 40 Appointment and remuneration committee 43 Governors’ nomination committee 45 Staffing data 50 Regulatory ratings 57 Statement of chief executive’s responsibilities as the accounting officer 59 Annual governance statement 60 Voluntary disclosures 69 Quality account and report 2015/16 Chief executive’s welcome 121 Overview of University Hospital Southampton NHS Foundation Trust 122 Activity levels during 2015/16 122 Our 2015/16 priorities for improving quality 123 Our 2015/16 priorities for outcomes and clinical effectiveness 124 Our 2015/16 priorities for patient experience 126 Our 2015/16 priorities for patient safety 129 Never events 130 Our quality priorities for 2016/17 130 Participation in national clinical audits and confidential enquiries 131 Participation in clinical research 133 Data quality 133 Review of services 134 Registration with the Care Quality Commission (CQC) 136 Our standard core indicators of quality 139 Overview of performance 146 Further information about our Trust 150 Conclusion 153 Responses to our quality account 154 Statement of directors’ responsibilities 160 Independent auditor’s report 161 Annual accounts Statement from the chief financial officer 79 Foreward to the accounts 81 Independent auditor’s report 82 Financial statements 87 FTC summarisation schedules for UHS NHS Foundation Trust 118 Appendix Appendix A – pulse KPI’s 165 Appendix B – national clinical audit activity 166 Appendix C – local clinical audit activity 167 Appendix D – patient improvement framework 2016/17 175 Appendix E – glossary of acronyms 176 5 Statement from the chief executive 2015/16 has been a challenging year for University Hospital Southampton (UHS) but we are proud of the achievements we have made. In order to meet the needs of the population, we have seen 706,931 patients (total inpatients and outpatients), which is over 25,000 more patients than in the previous year. You’ll find a more detailed breakdown of activity on page 11. Overall, patients were happy with the care that we gave them, with 96%* likely to recommend UHS. We have worked hard to maintain and improve the quality of our services. In particular, we are pleased that our Hospital Standardised Mortality Rate (HSMR) is now below nationally expected levels. You can find more detail on this within the quality account section of this report. We are very aware that healthcare is a ‘risky business’ and that, internationally, healthcare is not as safe as it could be. In order to address this it is crucial that we encourage a safety conscious culture, including the reporting and analysis of all incidents and untoward events. In February 2016 the NHS published a ‘transparency league’ designed to assess how open and transparent NHS organisations are with regards to errors. We were pleased to be ranked as ‘good’ in this assessment. Patient waiting times is another important aspect of quality – whether that be waiting at home for a cancer diagnosis or elective surgery, or waiting in the emergency department for treatment or an inpatient bed. Throughout the year we met the national standards for cancer treatment, diagnostics and elective care, but we did not meet the four hour emergency access standard. We have, however, improved our performance compared to 2014/15, and we are committed to improving this performance in 2016/17. Feedback from our staff is important to us and is another important indicator of quality. The most recent staff Friends and Family Test indicated that 90% of our staff would recommend us as a place to be treated, and 76% as a place to work. Whilst we still have work to do, these figures are significantly better than the national average, and the highest that we have ever achieved. Other highlights of the year include being selected for two national initiatives: 1. to be one of the early implementers for the seven day service standards for emergency and inpatient services, and 2. to be one of the pilots for supporting staff health and wellbeing. Both of these initiatives are an important part of our journey towards becoming a higher quality provider of healthcare and an exemplary employer. Following extensive consultation, we also launched our new vision ‘Forward’ which can be found at www.uhs.nhs.uk/AboutTheTrust/Ourvision. Our Trust chair, John Trewby, left the Trust at the end of March 2016 when his second term of office came to an end. John has been an exceptional leader and over the last eight years he has steered UHS to achieve great things in some truly difficult circumstances. Under his leadership we achieved foundation status in 2011, developed as a clinical academic centre with a growing reputation for research, and have gained an outstanding reputation for the excellence and outcomes of our clinical services. I would like to take this opportunity to thank him for his commitment to UHS and welcome his successor, Peter Hollins, to the role. Finally, we continued to invest in our buildings and equipment. This included the creation of a new main entrance opened in May 2016, and ongoing major investment into radiological equipment. We also expanded our emergency department to create an ambulance assessment area and, in March 2016, chancellor George Osborne announced that the government will invest £2m in a new £4.8m children’s emergency and trauma department for our Southampton Children’s Hospital. Fiona Dalton Chief executive *figure based on April 2016 survey 7 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 650,000 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 more than three 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 post-graduate 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 10,500 people work at the Trust, making it one of the area’s biggest employers. We also benefit from the time of over 1,000 volunteers. Our turnover in 2015/16 was £693m. 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. Fourteen 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 regulator, Monitor. 8 Key issues and risks that could affect achievement of our objectives There are three key issues that could affect our ability to achieve our objectives, these are: 1. Failure to deliver the four hour emergency department target, which impacts both patient experience and safety. There is a recovery action plan in place which has been formally reviewed by our commissioners. The main focus for 2016/17 is working with partners to reduce delayed transfers in care, improving the numbers of discharges that occur before midday and improving processes for emergency patients between the ED and inpatient teams. 2. Capacity and occupancy, which impacts on patient flow and timeliness of care. Increased risk in 2016/17 through unplanned transfers in service by other local providers and support for emergency flows. We have mitigated this by minimising the bed closures refurbishment programme, focusing on seven day service, improving patient flow (such as home before lunch), developing a hospital without walls, investing in a capital programme to improve capacity (surgical robot, hybrid theatres and minor ops rooms) and reducing length of stay. 3. Staffing, plans are in place for both recruitment and retention. To mitigate this risk we will continue to focus on making UHS an attractive employer by: - continuing to recruit from overseas - working with universities to increase student nurses - developing band 4 posts and apprentices - rolling out a new, consistently branded, ‘Think UHS’ recruitment campaign - enhancing overseas fellows posts - reviewing all junior rotas in light of the new contract - using flexible and temporary staff when needed - creating different roles linked to our research agenda - reviewing training and education to enhance retention 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. 9 Performance reporting 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. This begins with the monthly Trust Board meeting where the executive directors of the Trust will present a high level summary to the chairman and non-executive directors, as well as providing greater detail on key performance changes, risks and issues. Below this are a number of executive sub-committees attended by a subset of executive and non-executive directors. These are the audit and assurance committee, the strategy and finance committee and the quality and performance committee. These committees will review performance and issues in greater depth, feeding back to Trust Board as appropriate. In addition, there are regular Trust Board study sessions which focus on specific individual issues with the entire Board present. The Trust executive committee (TEC) meets monthly and is made up of the executive board members and the divisional management teams. Performance and service issues are discussed with greater granularity at this meeting. Finally, there are regular performance meetings between the operational management team, led by the chief operating officer, and the division and care group management teams. These meetings focus on the individual patient and service pathways and developing the detailed plans for improvement. Key performance indicators (KPIs) The Trust publishes a monthly Integrated KPI Board Report on its website which provides both the Board and the public with an overview of performance within the Trust. This report is constantly evolving as new areas of monitoring are developed and new areas of national focus become apparent. The monthly report features the following sections: • Executive digest – a textual update on the previous month’s performance across the Trust written by the director of transformation and improvement • Pulse KPIs – the top KPIs identified by Trust Board, RAG-rates for the previous 13 months (see appendix A) • Performance • Activity • Capacity • Emergency department (ED) • Referral to Treatment (RTT, or 18 Weeks) • Cancer waiting times • Finance • Patient experience • Patient safety • Outcomes • Staffing (HR) and estates • Education and training • Research and development This report also includes summary versions of quarterly reports submitted to TEC which go into greater detail about patient experience, patient safety, clinical effectiveness and outcomes, and infection prevention In addition, a separate Finance Board Report is submitted to Trust Board on a monthly basis. 10 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 serve 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. We will build on this knowledge by meeting and working with other trusts around the country and the world in order to share learning and build the best patient pathways and most efficient uses of resources possible. Detailed analysis and explanation of the development and performance of UHS Over the past four years we have seen significant increases in all types of activity. Some of this is due to an increase in the range of specialist services we offer, becoming a major trauma centre and the building of the helipad, but much of it is due to the increased and aging population in Southampton and the surrounding area. The graphs below demonstrate this increase in activity. UHS Growth in Activity - 2012/13 to 2015/16 600000 500000 400000 300000 200000 100000 2012/13 2013/14 2014/15 2015/16 0 Inpatient Spells (inc day cases) Outpatient Appointments ED Attendances (type 1) Referrals 2012/13 Inpatient spells (inc day cases 133,712 Outpatient appointments 447,122 ED attendance (type 1 & 2) 115,917 Referrals 165,597 2013/14 138,868 493,471 115,660 181,761 2014/15 144,934 536,949 111,297 182,402 2015/16 145,524 561,407 113,569 190,170 Increase 2012/13 to 2015/16 8.8% 25.6% -2.0& 14.8% In order to manage these increasing pressures we have focused our attention on the flow through the hospital. Our adult midday bed occupancy decreased by 4.3% in 2015/16 (to the end of February) compared to the same period in 2014/15, allowing the Trust greater flexibility when dealing with periods of high demand. This is reflected in the reduction in the number of red and black alerts issued in 2015/16. 11 The hospital alert status is decided by the operations centre after assessing the bed and staffing position, and is recorded twice daily at the Trust bed meetings (though the status may change at any time). Black alert is the highest level of alert and is issued when there are no empty beds available across the Trust with no expected discharges, the emergency department is full, and several ambulances are likely to be delayed for long periods of time, stopping them from responding to 999 calls. In 2014/15 a black alert was recorded 91 times at the twice daily bed meetings. In 2015/16 this was reduced to seven. A central pillar of this change has been the stabilisation of Length of Stay (LoS) despite the increased number of patients requiring a complex package of care after their discharge. These patients can often have their discharges delayed while beds in community care homes are found and supporting community care packages are arranged. The chart below demonstrates the change in LoS for elective and non-elective (emergency) patients over the past four years. Rolling 12-Month Average Length of Stay - Elective and Non-Elective 6.50 6.00 5.50 5.00 4.50 4.00 3.50 R-12 Non-Elective LoS R-12 Elective LoS 3.00 2015/16 saw an increased focus on discharging patients earlier in the day and at the weekend. This will remain a major focus for the Trust in 2016/17. Each of the above metrics will have an impact on the Trust’s performance against the three primary nationally reported targets for Referral to Treatment (RTT, or 18 Weeks) performance, emergency department performance and cancer waiting times performance. Referral to Treatment (18 Weeks) performance At the start of 2015/16 there were three targets the Trust was responsible for delivering: 1. Incomplete Pathways – 92% of all patients on an 18 week pathway and not yet treated should have waited 18 weeks or less at the end of the month. 2. Admitted Stops – 90% of all patients requiring an inpatient treatment should receive this treatment within 18 weeks of referral. 3. Non-Admitted Stops – 95% of all patients either receiving treatment in an outpatient setting or discharged without requiring treatment should have their pathway stopped within 18 weeks of referral. The government announced that, from July 2015 onwards, only the achievement of the Incomplete Pathways target would be required. This change allowed trusts to treat greater numbers of long-waiting patients each month. UHS met all three targets in quarter 1 of 2015/16 and continued to meet the Incomplete Pathways target throughout the rest of the year. 12 This continuing good performance should be set against the aforementioned rise in patient referrals, which highlights the increased demands being placed on the Trust. It is only due to the increased efficiency shown by the Trust’s inpatient and outpatient services that it has been possible to meet these targets on an ongoing basis. Emergency department (ED) performance We have failed to meet the national target of 95% of all ED attendances being treated and either admitted or discharged within four hours of arrival in any month in 2015/16. However, this has been a challenging target nationwide with the winter period providing the worst performance the NHS in England has ever recorded. Against this, the year on year improvement seen at UHS is good progress. There are three types of ED that can be included in these figures: Type 1 A consultant led 24-hour service with full resuscitation facilities and designated accommodation for the reception of accident and emergency patients. Type 2 A consultant led single specialty accident and emergency service (e.g. ophthalmology, dental) with designated accommodation for the reception of patients. Type 3 Other type of A&E/minor injury units (MIUs)/Walk-in Centres, primarily designed for the receiving of accident and emergency patients. A type 3 department may be doctor led or nurse led. It may be co-located with a major ED or sited in the community. A defining characteristic of a service qualifying as a type 3 department is that it treats at least minor injuries and illnesses (sprains for example) and can be routinely accessed without appointment. UHS has a type 1 and a type 2 (ophthalmology) department. The Trust also had a type 3 (MIU) department until July 2014. Due to the nature of the activity at the MIU, the transfer of this department to another provider reduced UHS performance against the four hour target by approximately 3%. When comparing performance over the long term, it is important to factor this change in. ED performance reduced fractionally in quarters 1 and 2 of 2015/16 compared to 2014/15, despite the loss of the MIU activity. In quarter 3, when the comparative activity was the same, performance improved by 4.7%. This was due in part to the improvements in hospital flow outlined earlier, and also linked to improvements in the operational performance of the department itself. While performance fell by 1.2% in quarter 4 of 2015/16 compared to the same time the previous year, this must be set against an increase in activity of over 3,000 additional ED attendances (12.1%). The graph below shows UHS performance against the four hour target over the past four years. Year-On-Year ED Performance by Quarter 98.00% 96.00% 94.00% 92.00% 90.00% 88.00% 86.00% 84.00% Cancer waiting times 82.00% 80.00% 78.00% 76.00% Q1 Q2 Q3 Q4 2012/13 2013/14 2014/15 2015/16 13 There are 10 separate cancer waiting times measures that the Trust reports to the Department of Health on a monthly basis, each of which can then be split into tumour site specific performance groups. In 2015/16 (to the end of February) the Trust met all 10 of these measures, an improvement on 2014/15 when one target was failed. This performance against the targets should be set against the significant rise in activity seen on the cancer pathways. The three central targets are the percentage of two week wait urgent suspected cancer patients seen within two weeks of their referral, which saw a rise in demand of 13% in 2015/16, the percentage of these patients diagnosed with cancer treated within 62-days of their referral (for which demand increased by 20.1%) and the number of all patients treated within 31 days of an agreed treatment plan being put in place (for which demand rose by 14.2%). The chart below shows the rise in demand for UHS cancer services over the past five years. 18,000 16,000 14,000 12,000 10,000 8,000 6,000 4,000 2,000 - UHS Growth in Activity - 2012/13 to 2015/16 Two Week Waits 62-Day Target Patients 31-Day Target Patients 2011/12 2012/13 2013/14 2014/15 2015/16* * 2015/16 data covers April to February only These targets are a leading priority for the Trust and will be the focus of in depth work in 2016/17, especially given the ongoing increases in demand for these services. Regulatory body ratings In the last quarter of 2015/16 Monitor rated UHS ‘2’ for our financial sustainability risk rating (1 being the most serious risk and 4 the lowest risk) and ‘green’ for our governance risk rating, which means that no governance concern is evident and no formal investigation is being undertaken. More details can be found on page 57. The Care Quality Commission (CQC) gave us an overall rating of ‘requires improvement’ as at December 2014. You can see the full report by visiting www.uhs.nhs.uk or www.cqc.org.uk. Environmental matters A number of projects were undertaken in 2015/16 to reduce our impact on the environment. We installed a large anaerobic digester which will provide renewable energy by naturally breaking down waste and turning it into fuel. We have also replaced one of our combined heat and power engines so that we can generate more of our own electricity on site and get the benefit of free heating that is a by-product of running a large gas engine. 14 In conjunction with these two developments we have implemented a range of measures to ensure that we are using energy more efficiently. For example, we are now ensuring that large water pumps are only running when needed and we are in the process of replacing old fluorescent lighting with more efficient LED systems. More information can be found within the environmental sustainability and climate change section of this report. Social, community 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. 15 Directors’ report Composition of the Board The Board is currently comprised as follows: Non-executive directors: Peter Hollins, chair Simon Porter, senior independent director Professor Iain Cameron Lynne Lockyer Dr David Price Dr Mike Sadler Jenni Douglas Todd Executive directors: Fiona Dalton, chief executive Gail Byrne, director of nursing and organisational development Jane Hayward, director of transformation and improvement Dr Derek Sandeman, medical director Dr Caroline Marshall, chief operating officer David French, chief financial officer Name John Trewby Lena Samuels Judy Gillow Dr Michael Marsh Mike Murphy Alastair Matthews Gail Byrne Dr Derek Sandeman Position Chairman Non-executive director Director of nursing and organisational development Medical director Director of strategy Director of finance and deputy chief executive Director of nursing and organisational development Medical director Paul Goddard Acting director of finance David French Chief financial officer Note Left the organisation on 31 March 2016 Left the organisation on 29 February 2016 Left the organisation on 30 September 2015 Left the organisation on 31 May 2015 Left the organisation on 31 December 2015 Left the organisation on 1 November 2015 Commenced from within the organisation on 1 October 2015 Commenced from within the organisation on 1 June 2015 Acting director from 23 October 2015 to 2 February 2016 Joined the organisation on 3 February 2016 It should be noted that the size of the Board has been reduced to seven non-executive directors (including the chair) and six executive directors. This decision was agreed by our appointments and remuneration committee on 25 August 2015. Each director confirms that at the time the annual report and accounts is approved: • so far as the director is aware, there is no relevant audit information of which the NHS foundation trust’s auditor is unaware • the director has taken all the steps they ought to have taken as director in order to make themselves aware of any relevant audit information and to establish that the NHS foundation trust’s auditor is aware of that information. 17 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. Trust Board declarations of interest John Trewby Council member University of Southampton; chair Exelis Defence Ltd; associate of Group 4 Securicor. Peter Hollins Partner in the Jubilee Film Partnership; chair of CLIC Sargent Cancer Care for Children (a company limited by guarantee). Lena Samuels Shareholder and director, 37 Patshull Road NW5 Limited; magistrate of Southampton Bench; member of staff at BBC; shareholder and director of Wessex Creative Media Ltd; chair of Pylewell Park Cricket Club; trustee Cultural Development Trust; prospective Labour Party parliamentary candidate for the New Forest West constituency (until 7 May 2015); communications and development specialist advisor for the Hampshire Cultural Trust (from 4 May 2015) Iain Cameron Dean of Faculty of Medicine and Member of University Executive Board, University of Southampton; board member of Wessex Academic Health Science Network; director (chair) of Medical Schools Council; director of Medical Schools Council Assessment; director of UK Clinical Aptitude Test; trustee of Wessex Medical Trust; joint chair of University Hospital Southampton/University of Southampton Joint Research Strategy Board; joint chair, National Institute for Health Research (NIHR) Biomedical Research Centre (BRC) Southampton Executive Board. Simon Porter Independent member of audit committee Amicus Horizon (until 21 October 2015); Former partner in Ernst & Young LLP; non-executive director and chair of audit committee, Radian Group; non-executive director and chair of audit committee, Octavia Housing. Lynne Lockyer Board member/trustee of the Brendoncare Foundation. David Price Public member of Network Rail Ltd (until 30 June 2015); chair of RTL Materials Ltd; chair of Telesoft Technologies Ltd; chair of Optitune Plc; chair of Symetrica Ltd; member of Advisory Board, Silverstream Technologies BV; treasurer, University of Southampton. Michael Sadler GP specialist advisor for the Care Quality Commission; external clinical associate for PricewaterhouseCoopers. Fiona Dalton Trustee of Gingerbread, the national charity for one-parent families (until 31 December 2015). Judy Gillow Trustee of Naomi House Children’s Hospice, Winchester (until 31 August 2015); trustee of Enham House Disability Charity, Andover. Gail Byrne Husband is a consultant surgeon in the Trust; trustee of Naomi House Children’s Hospice (from 1 January 2016). 18 Caroline Marshall Nothing to declare Jane Hayward Father is mental health act manager, Southern Foundation Trust (voluntary position), member of Mental Health Act Committee, Southern Foundation Trust (voluntary position), member of Assessment Committee for Clinical Excellence Awards (lay member), a UHS Simulated Patient (voluntary position), Lay member on Medical School undergraduate interview panels (until 31 December 2015); Mother is a UHS Simulated Patient (voluntary position). Michael Marsh Married to Sarah Marsh, who works within Specialised Commissioning of NHS Commissioning Board; selfemployed Medico Legal Expert on ad hoc basis independently to solicitors, Medical Defence Union (MDU) and NHS Litigation Authority. Derek Sandeman Nothing to declare. Alastair Matthews Non-executive director of NHS Innovations South East Ltd. Paul Goddard Partner works for the Trust as projects officer within the contracting department and previously PA to the director of research and development. David French Non-executive director and chair of audit and risk committee, Sentinel Housing Association; governor and chair of audit committee, South Wilts Grammar School for Girls; chair of Hampshire & Isle of Wight NHS Counter Fraud Board. Mike Murphy Parent governor, Mountbatten School, Romsey. 19 Introducing the Board of Directors Trust Board The Board is made up of the chair, six non-executive directors and six executive directors including the chief executive. Together they bring a wide range of skills and experience to the Trust, such that the board achieves balance and completeness at the highest level. The non-executive directors, including the chair, are people who live or work in the local area and have shown a genuine interest in helping to improve the health of local people. The non-executive directors are determined by the Board to be independent in both character and judgement. The chair, executive directors and non-executive directors have declared any business interests that they have. The Board is satisfied that no conflicts of interest are indicated in any external involvement. The register of Board members’ interests is updated at least annually and is maintained by the company secretary and associate director of corporate affairs. It is available for public inspection from the company secretary and associate director of corporate affairs. The ‘reservation of powers to the Board and delegation of powers policy’ sets out the business to be conducted by the Board, or by one of its committees. Any enquiries should be made to: company secretary and associate director of corporate affairs, Trust Headquarters, Mailpoint 18, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, SO16 6YD or telephone 023 8120 6829. Senior independent director The role of senior independent director has been established and, until 31 March 2016, was held by Peter Hollins, a non-executive director. The senior independent director role provides a channel through which foundation trust members and governors are able to express concerns, other than the normal route of the chair or chief executive. Appointments Non-executive directors are appointed via open advertisement in accordance with the ‘Appointment of a foundation trust non-executive director good practice guide’ procedure adopted by the Trust. The process is managed through the governors’ nomination committee, a sub-committee of the Council of Governors. This committee also determines the remuneration and terms and conditions of the non-executive directors. For further details on the appointment of non-executive directors please see page 45. Development of the Board The Board held monthly study sessions during 2015/16 where strategic issues, along with emerging issues, were discussed. Meetings of the Board The Board meets once a month in public. Additional private meetings with only the board, and associated employees of the Trust making presentations to the board in attendance, are held as required. Other committees of the Board include: appointment and remuneration committee; audit and assurance committee, strategy and finance committee; quality and performance committee and charitable funds committee. Generally the other committees of the board meet monthly with the exception of the audit and assurance committee, which meets five times a year and the appointments and remuneration committee which meets every other month. The frequency of the meetings is set out in each committee’s terms of reference. These terms of reference are reviewed at least annually. 20 The performance of individual Board members is reviewed as set out on page 44 of this report. Engagement with Council of Governors The Trust Board engages with the Council of Governors through the chair and senior independent director. Non-executive and executive directors engage with sub-groups of the council where these are related to their portfolios. Board members meet regularly with governors and have an open invitation to attend formal Council of Governor meetings. The people Non-executive directors John Trewby, chair to 31 March 2016 John joined the Trust on 1 April 2008, bringing with him a wealth of leadership experience after a distinguished career in the Navy where he rose to the rank of rear admiral and became the first chief executive of the Naval Bases and Supply Agency. After 36 years in the Navy, John joined the defence company British Aerospace (latterly BAE Systems) where he was their chief naval advisor for eight years. He is an associate of Group4Securicor and chair of Exelis Defence Ltd. He is a fellow of the Royal Academy of Engineering; sitting on its proactive membership committee and in 2009 chaired a study into “ICT for the UK’s Future”. He is currently chairing a study on wind turbines. He is a council member of the University of Southampton. Professor Iain Cameron Iain Cameron is a professor of obstetrics and gynaecology and dean of the Faculty of Medicine at the University of Southampton. After graduating in medicine at the University of Edinburgh, he underwent postgraduate clinical and research training in Edinburgh, Melbourne and Cambridge. He held the regius chair of obstetrics and gynaecology at the University of Glasgow from 1993 and moved to Southampton in 1999. His main clinical and research interests are reproductive endocrinology and investigation of the impact of the maternal environment on early pregnancy. Iain is chair of the Medical Schools Council; a member of the UK Clinical Research Collaboration board; the National Institute for Health Research advisory board; the Health Education England medical advisory group; and the Wessex Academic Health Science Network delivery board. Peter Hollins Peter Hollins graduated in chemistry from Hertford College, Oxford. Joining Imperial Chemical Industries in 1973, he undertook a series of increasingly senior roles in marketing and then general management. Following three years in the Netherlands as general manager of 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. Lynne Lockyer Lynne’s background is in human resource management and strategic management. She became a nonexecutive director for Southampton and South West Hampshire in 1996 and the vice chair in 2000. She was chair of Eastleigh and Test Valley South PCT from its inception in 2002 until its disestablishment in 2006. She has taken many roles in the local health economy including being a member of Hampshire’s Local Area Agreement Board and nationally was a member of the NHS Confederation Council and the National NHS Leaders Steering Group. She was until recently a course director at the University of Portsmouth and is now an organisation development consultant. She is a trustee of the Brendoncare Foundation. 21 Simon Porter Simon was born and educated in Southampton and then Oxford, graduating with a degree in modern languages (Italian and French). He is a qualified chartered accountant, having spent most of his career with the London office of Ernst & Young, where he specialised first in audit, then in transactions and finally management. He was a partner with Ernst & Young from 1994 to 2010. He joined the Trust Board on 1 January 2011 as a designate non-executive director and became non-executive director and co-chair of the audit and assurance committee from 1 June 2011. He has chaired the quality and performance committee since it was established in January 2014. He also holds non-executive board positions in the social housing sector. Dr David Price David is a former chief executive of a FTSE-250 company with broad experience within the electronics, chemical, aerospace, defence, marine, and nuclear industries. He has a successful track record of developing highly complex companies in international markets. He is currently non-executive chairman of Symetrica Ltd, Telesoft Technologies Ltd, RTL Materials Ltd and Optitune Plc. He is treasurer of the University of Southampton and a member of the advisory board of Silverstream Technologies BV. David is a chartered engineer and chartered scientist. He has a degree in electronic engineering, a PhD from University College London and, in 2001, he was awarded an honorary doctorate by Cranfield University for his services to science and engineering. David was made a Commander of the Order of the British Empire (CBE) for his services to industry. Dr Mike Sadler Mike joined us as a clinical non-executive director in September 2014, from a similar position at an NHS Foundation Trust providing mental health, learning disability and community services. He works for the CQC as a specialist adviser in primary care and works as an advisor and consultant on health and social care services. Mike was a GP principal in Hampshire before moving into public health medicine. Having achieved an MSc with distinction at the London School of Hygiene and Tropical Medicine, he joined Portsmouth and South East Hampshire Health Authority, holding the joint posts of deputy director of public health and medical adviser. He has since held a series of senior clinical leadership roles in national organisations in both the public and private sector, including as a chief operating officer at NHS Direct and Serco’s health division. His last full time role, up until July 2013 when he commenced his portfolio career, was as director of health and social care at West Sussex County Council. Jenni Douglas Todd – appointed 1 April 2016 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 head hunted into the civil service, at the Home Office, where she spent four years before being 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. 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. 22 Executive directors Fiona Dalton, chief executive Fiona was appointed as chief executive in 2013. Prior to re-joining the Trust she held the combined position of deputy chief executive and chief operating officer at Great Ormond Street Hospital for Children. Fiona joined the NHS management training scheme after graduating from Oxford University with a degree in human sciences and began her career in hospital management at Oxford Radcliffe Hospitals NHS Trust in 1996. She then spent four years at UHS as director of strategy and business development before moving to Great Ormond Street Hospital. Gail Byrne, director of nursing and organisational development 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. Jane Hayward, director of transformation and improvement Jane joined the Trust in 2000 as a clinical services manager for the cardiothoracic directorate after spending two years in Hertfordshire as director of performance and 11 years at Barts and the London Hospitals in various roles including planning, finance and commissioning. Jane has led on human resources, information management and technology, improvement and modernisation and has been chief operating officer. Jane joined the Trust Board in February 2008 and became director of transformation and improvement in January 2014. Dr Derek Sandeman, medical director Dr Derek Sandeman was appointed to the Trust as a consultant physician in 1993 and went on to develop a regional endocrine service. Throughout his career he has had 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. Dr Caroline Marshall, chief operating officer Caroline joined the Trust in 1997 as a consultant hepatobiliary and neuroanaesthetist. She has held the posts of college tutor for the Royal College of Anaesthetists and UHS mentoring and coaching lead. In 2008, she became clinical service director for critical care before holding the position of divisional clinical director between 2010 and 2013. Caroline served as interim chief operating officer before being appointed in December 2014. David French, chief financial officer David joined the Trust in February 2016 and leads on finance, estates and commercial development. 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 Sentinel Housing Association, a Hampshire-based social housing provider. Board effectiveness On the basis of the expertise and experience described above, the Trust is confident that the necessary range of knowledge and skills exists within the Board of Directors and that its balance, completeness and appropriateness to the requirements of the NHS Foundation Trust constitutes a high performing and effective Board. The chairman has held no other significant commitments during 2015/16. A register of interests of Board members is outlined within this report and is also available from the associate director 23 of corporate affairs. The effectiveness of the Board of Directors meetings is reviewed at the end of each meeting. Effectiveness of Board sub-committees are monitored through monthly board reports and annual evaluation/review of the terms of reference and work programmes. Schedule of Decisions Reserved to the Board The NHS Foundation Trust Code of Governance requires that there should be a formal schedule of matters specifically reserved for decision by the Board. The Scheme of Delegation shows the ‘top level’ of delegation within the Trust. The Scheme should be read in conjunction with Trust’s Standing Financial Instructions and Standing Orders. A copy of the Schedule of Matters Reserved for the Board can be obtained from the associate director of corporate affairs. Attendance at board meetings in 2015/16 Board Apr member 28 John Trewby chair 3 Peter Hollins SID & 3 deputy chair Iain Cameron NED 5 Lena Samuels NED 3 Simon Porter NED 3 Lynne Lockyer NED 3 David Price NED 3 Mike Sadler NED 3 Fiona Dalton CEO 3 Alastair Matthews finance 3 director and deputy CEO (until 1/11/15) Paul Goddard acting director of finance (from 24/10/15 until 2/2/16) David French chief financial officer (from 3/2/16) Michael Marsh medical 3 director (until 31/5/15) Derek Sandeman medical director (from 8/10/15 previously interim from 1/6/15) Judy Gillow director of 3 nursing and organisational development (until 30/9/15) Gail Byrne director of nursing and organisational development (from 1/10/15) Caroline Marshall chief 3 operating officer Jane Hayward director 3 of transformation and improvement Mike Murphy director 5 of strategy and business development May 26 May Jun Jul Extra 28 30 28 CS only 3 3 3 3 3 3 3 3 Sept Oct Nov Dec 18 Jan 29 29 24 CS only 28 3 3 3 3 3 3 3 3 3 3 3 telecon 3 3 3 3 3 5 3 3 5 3 3 5 3 3 5 5 5 3 telecon 3 3 3 3 3 3 3 3 5 3 3 3 3 3 3 3 3 3 telecon 3 3 3 3 3 3 3 3 3 telecon 3 3 3 3 3 3 3 5 3 3 3 3 3 3 3 3 3 3 3 3 3 3 5 (CS only) n/a 3 3 3 3 n/a n/a 5 5 n/a 5 5 3 3 3 3 3 n/a 3 3 3 3 3 n/a 3 3 3 3 n/a 5 3 3 3 5 3 5 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 5 Feb Mar 23 31 3 3 3 3 3 3 5 n/a 3 5 3 3 3 5 3 3 3 3 n/a 3 3 3 3 3 3 3 3 3 5 n/a 24 Audit and assurance committee attendance 2015/16 Board member Simon Porter NED and co-chair Iain Cameron NED and co-chair Peter Hollins NED senior independent director/ deputy chair Lena Samuels NED Lynne Lockyer NED David Price NED Mike Sadler NED Alastair Matthews finance director and deputy CEO (until 1/11/15) Paul Goddard acting director of finance (from 24/10/15 until 2/2/16) David French chief financial officer (from 3/2/16) Michael Marsh medical director (until 31/5/15) Derek Sandeman medical director (from 8/10/15 previously interim from 1/6/15) Judy Gillow director of nursing and organisational development (until 30/9/15) Gail Byrne director of nursing and organisational development (from 1/10/15) May 18 3 3 3 3 3 3 3 3 3 n/a 5 July 20 3 3 3 3 3 3 3 5 n/a 5 3 n/a Oct 19 3 3 3 3 5 3 3 3 n/a 3 3 Jan 18 3 3 3 Mar 21 3 3 3 3 n/a 3 3 3 3 5 3 n/a 3 n/a 3 n/a 3 3 n/a 3 3 Audit and assurance committee Introduction The audit and assurance committee is a non-executive committee of the Trust Board with delegated authority to review the estab
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Last updated: 14 September 2019
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