Browse site A to Z

Search results

Go To Advanced Search

MP000 028 Cellular pathology user handbook v24

Description: University Hospital Southampton NHS Foundation Trust PATHOLOGY DIRECTORATE Cellular Pathology (Management) MP 000 028 Revision
Url: /Media/UHS-website-2019/Docs/Services/Pathology/Cell-path/MP000-028-Cellular-pathology-user-handbook-v24.pdf

Community diagnostic centre - referral for lung function testing - respiratory physiology service

Description: Community Diagnostic Centre (CDC) Referral for Lung Function Testing – Respiratory Physiology Service * Referrals must be sent via the e-Referrals System (e-RS). Please attach this form, as well as any other relevant information/documents. * Referrals will not be accepted unless this form is fully completed and attached. * Patients will be discharged back to their GP, if they fail to attend to their appointment. Do NOT Refer * Patients under 18 years old - we are an adult service only. * Patients who have undergone a laryngectomy and/or with a tracheostomy. Contraindications to Lung Function Testing * Active untreated TB * Aortic or Cerebral Aneurysm >6 cm * Untreated pulmonary embolism * Eye, Brain, Abdominal, Thoracic or Vascular Surgery * Unstable Angina and/or Recent MI * Recent Pneumothorax Urgent Referrals We will aim to fast-track requests for individuals who are on a 2WW pathway, pregnant or waiting a surgical procedure. Patient Details Patient Name: Date of Birth: NHS Number: Registered GP Name of Referring GP: Date of Referral: Do you consider this referral to be urgent? (see criteria above) Yes ☐ No ☐ Is this referral part of the SHIFT-AIR early & accurate diagnosis programme? (Eligible sites - Southampton Central PCN, Woolston & Townhill PCN, Sea City PCN, Raymond Road & Brook House Lane surgeries) Yes ☐ No ☐ Brief description of symptoms and main concerns: Click or tap here to enter text. Pulmonary Function Testing (please select below as required): ☐ Fractional Exhaled Nitric Oxide (FeNO) ☐ Spirometry ☐ Bronchodilator Response ☐ By ticking this box, you are prescribing either 4 puffs (400 µg) of Salbutamol via a Volumatic spacer OR 2.5ml Salbutamol via a nebuliser, in order to assess this patient’s bronchodilator response. The test will NOT be performed, if this box is not ticked. Is the patient able to attend outpatient appointments? Yes ☐ No ☐ Does the patient require hospital transport? Yes ☐ No ☐ Is the patient ambulant? Yes ☐ No ☐ Details: Does the patient require an interpreter? Yes ☐ No ☐ If yes, what language: Does the patient have any infectious diseases? Yes ☐ No ☐ Details:
Url: /Media/UHS-website-2019/Docs/Services/Respiratory/Community-diagnostic-centre-referral-for-lung-function-testing-respiratory-physiology-service.docx

Papers Trust Board - 11 November 2025

Description: Date Time Location Chair Agenda Trust Board – Open Session 11/11/2025 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 (item deferred) 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 9 September 2025 Approve the minutes of the previous meeting held on 9 September 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 9:05 Keith Evans, Chair 5.2 Briefing from the Chair of the Finance, Investment & Cash Committee 9:10 David Liverseidge, Chair 5.3 Briefing from the Chair of the People and Organisational Development 9:15 Committee Jane Harwood, Chair 5.4 Briefing from the Chair of the Quality Committee 9:20 Tim Peachey, Chair 5.5 Chief Executive Officer's Report 9:25 Receive and note the report Sponsor: David French, Chief Executive Officer 5.6 Performance KPI Report for Month 6 10:00 Review and discuss the report Sponsor: Andy Hyett, Chief Operating Officer 5.7 Break 10:40 5.8 Finance Report for Month 6 10:55 Review and discuss the report Sponsor: Ian Howard, Chief Financial Officer 5.9 ICB System Report for Month 6 11:05 Receive and discuss the report Sponsor: Ian Howard, Chief Financial Officer 5.10 11:10 People Report for Month 6 Review and discuss the report Sponsor: Steve Harris, Chief People Officer 5.11 NHSE Audit and review of 'Developing Workforce Safeguards' including 11:20 UHS Self-Assessment Return Review and approve the self-assessment return Sponsor: Natasha Watts, Acting Chief Nursing Officer 5.12 11:30 Guardian of Safe Working Hours Quarterly Report and Update on 10-Point Plan Review and discuss the report and update Sponsor: Paul Grundy, Chief Medical Officer Attendee: Diana Hulbert, Guardian of Safe Working Hours and Emergency Department Consultant 5.13 Annual Clinical Outcomes Summary Report 11:45 Review and discuss the report Sponsor: Paul Grundy, Chief Medical Officer Attendees: Lucinda Hood, Head of Medical Directorate/Kate Pryde, Clinical Director for Improvement and Clinical Effectiveness 6 STRATEGY and BUSINESS PLANNING 6.1 Corporate Objectives 2025-26 Quarter 2 Review 11:55 Review and feedback on the corporate objectives Sponsor: David French, Chief Executive Officer Attendee: Martin de Sousa, Director of Strategy and Partnerships 6.2 Board Assurance Framework (BAF) Update 12:05 Review and discuss the update Sponsor: Natasha Watts, Acting Chief Nursing Officer Attendees: Craig Machell, Associate Director of Corporate Affairs and Company Secretary/Lauren Anderson, Corporate Governance and Risk Manager Page 2 7 CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Feedback from the Council of Governors' (CoG) meeting 28 October 2025 12:15 (Oral) Sponsor: Jenni Douglas-Todd, Trust Chair 7.2 Register of Seals and Chair's Actions Report 12:25 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 7.3 Health and Safety Services Annual Report 2024-25 12:30 Receive and discuss Sponsor: Natasha Watts, Acting Chief Nursing Officer Attendees: Vickie Purdie, Head of Patient Safety/Scott Spencer, Health and Safety Adviser 8 Any other business 12:40 Raise any relevant or urgent matters that are not on the agenda 9 Note the date of the next meeting: 13 January 2026 10 Items circulated to the Board for reading 12:45 10.1 South Central Regional Research Delivery Network (SC RRDN) 2025-26 Q2 Performance Report Note the report Sponsor: Paul Grundy, Chief Medical Officer 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 3 Agenda links to the Board Assurance Framework (BAF) 11 November 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 6 5.8 Finance Report for Month 6 5.9 ICB System Report for Month 6 5.10 People Report for Month 6 5.11 Workforce Safeguards Self-Assessment 5.12 Guardian of Safe Working Hours Quarterly Report 5.13 Clinical Outcomes Summary Report 1a, 1b, 1c 5a 5a 3a, 3b, 3c 1a, 3a 3a, 3b 1a, 1b Appetite (Category) Minimal (Safety) Current risk rating 4x5 20 Cautious (Experience) Minimal (Safety) 4x4 16 4x4 16 Open (Technology & Innovation) 3x4 12 Open (workforce) Open (workforce) Open (workforce) 4x5 20 4x3 12 4x4 16 Cautious (Effectiveness) 3x3 9 Cautious (Finance) 5x5 25 Target risk rating 4 x 2 Apr 6 27 3 x 2 Apr 6 27 2 x 3 Apr 6 27 3 x 2 Mar 6 27 4 x 3 Mar 12 30 4 x 2 Mar 8 30 3 x 2 Mar 6 29 3 x 2 Dec 6 25 3 x 3 Apr 9 30 Cautious (Effectiveness) Open (Technology & Innovation) Open (Technology & Innovation) 4x5 20 3x4 12 2x4 8 4 x 2 Apr 8 30 3 x 2 Apr 6 27 2 x 2 Dec 4 27 Does this item facilitate movement towards or away from the intended target risk score and appetite? Towards Away Neither x x x x x x x Minutes Trust Board – Open Session Date 09/09/2025 Time 9:00 – 13:00 Location Conference Room, Heartbeat/Microsoft Teams Chair Jenni Douglas-Todd (JD-T) Present Diana Eccles, NED (DE) Keith Evans, Deputy Chair and NED (KE) Paul Grundy, Chief Medical Officer (PG) Steve Harris, Chief People Officer (SH) Jane Harwood, NED/Senior Independent Director (JH) Ian Howard, Chief Financial Officer (IH) Andy Hyett, Chief Operating Officer (AH) David Liverseidge, NED (DL) Alison Tattersall, NED (AT) In attendance Craig Machell, Associate Director of Corporate Affairs and Company Secretary (CM) Lauren Anderson, Corporate Governance and Risk Manager (LA) (item 6.1) Danielle Honey, Named Nurse for Safeguarding Children (DH) (item 5.14) Lucinda Hood, Head of Medical Directorate (LH) (item 5.15) Duncan Linning-Karp, Deputy Chief Operating Officer (DL-K) (item 5.6) Corinne Miller, Named Nurse for Safeguarding Adults (CMi) (item 5.14) Jenny Milner, Associate Director of Patient Experience (JM) (items 5.11-5.12) 1 member of the public (item 2) 30 members of staff (observing) 6 members of the public (observing) Apologies Gail Byrne, Chief Nursing Officer (GB) David French, Chief Executive Officer (DAF) Tim Peachey, NED (TP) 1. Chair’s Welcome, Apologies and Declarations of Interest The Chair welcomed attendees to the meeting. There were no interests to declare in the business to be transacted at the meeting. It was noted that apologies had been received from Gail Byrne, David French and Tim Peachey. The Chair provided an overview of meetings she had held and events that she had attended since the previous Board meeting. 2. Patient Story Aelwen Emmett, a volunteer at the Trust and former patient was invited to present her experience, focusing particularly on her work to improve the standard of food offered to patients. 3. Minutes of the Previous Meeting held on 15 July 2025 The draft minutes tabled to the meeting were agreed to be an accurate record of the meeting held on 15 July 2025. Page 1 4. Matters Arising and Summary of Agreed Actions The matters arising and actions were noted. In respect of action 1246, it was noted that virtual outpatient appointments had now been built into the Trust’s programme. Furthermore, meetings were to be held with commissioners and the cancer network to improve the quality of referrals. It was noted that action 1246 could be closed. 5. QUALITY, PERFORMANCE and FINANCE 5.1 Briefing from the Chair of the Finance and Investment Committee David Liverseidge was invited to present the Committee Chair’s Reports in respect of the meetings held on 21 July and 2 September 2025, the content of which was noted. It was further noted that: • In July 2025, the Trust had reported that it was £1.1m adverse to its plan, but that the underlying trajectory was improving. • The committee received an update from Wessex NHS Procurement Limited, noting that the company was on track in terms of its Cost Improvement Programme target. • The committee had received an update in respect of both the proposed Hampshire and Isle of Wight elective hub and a possible Urgent Treatment Centre at Southampton. • The committee reviewed the Finance Report for Month 4 (item 5.8), noting that the Trust had reported a year-to-date deficit of £19.5m, which was £5.8m adverse to plan. Key drivers for the Trust’s financial position included the lack of improvement in the number of patients having no criteria to reside and mental health patients, the continued difference between funded and actual activity under block contracts, lower than anticipated income, and higher than planned workforce numbers. • The Trust was ahead of its plan on Cost Improvement Programme delivery. • The committee reviewed the Trust’s proposed Financial Recovery Plan and noted the need to ensure that the long-term impact of decisions needed to be taken into account. • The committee reviewed the Trust’s cash position and noted that cash support would be required in the Autumn and that the committee would be amending its terms of reference to expand its role in terms of cash monitoring and oversight. • The committee reviewed the Board Assurance Framework risks within its remit, noting that Risk 5a had increased to 25 due to the risk associated with the Trust’s cash position (item 6.1). 5.2 Briefing from the Chair of the People and Organisational Development Committee Jane Harwood was invited to present the Committee Chair’s Reports in respect of the meetings held on 21 July and 1 September 2025, the content of which was noted. It was further noted that: • The committee reviewed the People Report for Month 4 (item 5.10), noting that there continued to be significant demands on the Trust’s workforce, especially due to the number of patients having no criteria to reside and patients with a primary mental health need. Whilst the Trust’s substantive workforce had reduced, there had been an increase in the number of temporary staff resulting in the Trust reporting that it was 55 whole-time- equivalents above its plan. Page 2 • The committee considered the impact of the recruitment controls on the administrative and clerical workforce and the potential for shortages in these areas causing issues elsewhere. • The committee received an update in respect of the Mutually Agreed Resignation Scheme (MARS), noting that 65 applications had been approved. • The committee received an update on the recruitment of newly qualified nurses, noting that the Trust had pre-empted the announcement of a ‘guarantee’ by the Secretary of State. • The committee reviewed the workforce related elements of the Trust’s Financial Recovery Plan, noting the challenges in delivering what was required and the Trust’s reliance on improvements in patients having no criteria to reside and mental health patients. • The committee reviewed its terms of reference, proposing to make only minor changes (item 7.2). 5.3 Briefing from the Chair of the Quality Committee Diana Eccles was invited to present the Committee Chair’s Report in respect of the meeting held on 18 August 2025, the content of which was noted. It was further noted that: • The committee considered the proposal to revise enhanced rates paid to temporary staff in certain areas to remove the enhancement and bring rates into line with Agenda for Change rates. The committee noted the impact on staff and the concerns expressed by staff members. However, it was further noted that the enhancements were not intended to be permanent. • The committee received the Experience of Care report and noted a continuation in the trend observed during Quarter 4 of staff attitudes featuring as a reason for complaint. It was considered likely that this was indicative of the pressures on staff. • The committee reviewed the Maternity and Neonatal Safety 2025-26 Quarter 1 Report, noting that an action plan was in place in respect of the Maternity Triage Line to address some shortcomings identified in the process. • The committee received the Learning from Deaths 2025-26 Quarter 1 Report (item 5.11), noting that the Trust was one of only 11 trusts out of 119 with a lower-than-expected death rate during the period. • The committee reviewed the Safeguarding Annual Report 2024-25 and Strategy 2025-26 (item 5.14), noting that activity levels remained consistent with prior years, but the complexity of cases had increased. 5.4 Chief Executive Officer’s Report Paul Grundy was invited to present the Chief Executive Officer’s Report, the content of which was noted. It was further noted that: • The NHS league tables for 2025 had been published on 9 September 2025. The Trust had ranked 48th out of 134 and had been placed in segment 3 of the NHS Oversight Framework due to the effect of the ‘financial override’. The Trust was temporarily in segment 5 due to being in the Recovery Support Programme. • Trusts were required to submit self-assessments for the Provider Capability Assessment during October 2025. This would inform decisions relating to which organisations to place in the Performance Improvement Programme. • Resident doctors undertook strike action between 25 and 30 July 2025. Approximately one-third of those eligible at the Trust took part in the industrial action and the Trust had performed well in terms of mitigating the impact on activity. Page 3 • The Royal College of Nursing had published results of its analysis of violence and aggression against nursing staff in emergency departments, noting that the number of incidents had increased from 2,093 in 2019 to 4,054 in 2024. • NHS England had published a series of urgent and emergency care improvement guides to assist organisations with managing the winter period. • A number of changes to the organisation of local councils in Hampshire and Southampton were proposed as part of national plans to create unitary councils in place of existing county and district/borough councils. 5.5 Performance KPI Report for Month 4 Andy Hyett was invited to present the Performance KPI Report for Month 4, the content of which was noted. It was further noted that: • The Trust had reported an increase in the number of patients waiting over 52, 65 and 78 weeks alongside an increase in the overall waiting list. The Trust had entered Tier 2 escalation for Referral To Treatment performance. • The Trust had been placed in Tier 1 escalation due to the gap between its current Emergency Department performance and its performance plan for 2025/26. However, indicative data for August and September 2025 showed improved performance. • Work was ongoing to improve flow with task and finish groups established to review the discharge process and to implement rapid improvements. • The number of patients having no criteria to reside and those with a primary mental health need remained high. A workshop had been set up with Hampshire and Isle of Wight Healthcare NHS Foundation Trust in respect of mental health patients. • Steps were being undertaken to reduce the number of inappropriate attendances in the Emergency Department with patients potentially redirected to other areas. However, an Urgent Treatment Centre would be key to alleviating pressure on the Emergency Department in the longer term. The Board discussed the Trust’s performance against national standards. This discussion is summarised below: • Performance against the 62-day standard for cancer waiting times was an area of focus to ensure more consistent performance. • Work was ongoing to extend shared decision-making in order to involve patients in decisions about their care and treatment, noting however that this was more of a challenge with inpatients. • There was a challenge in terms of managing the demand for patients requiring diagnostic services. It was noted that there had been issues with availability of equipment over the summer period. It was acknowledged that diagnostics performance also impacted other areas such as cancer and Emergency Department metrics. • The percentage of over 65s attending the Emergency Department was expected to be a key metric to monitor over the winter period. Actions Andy Hyett agreed to look at the roll out of Pharmacy First. Andy Hyett agreed to carry out a deep-dive into Diagnostics to be either provided as a ‘Spotlight’ in the Performance KPI Report or via a Trust Board Study Session. Page 4 5.6 UHS Operating Plan 2025-26 and Board Assurance Statement Andy Hyett was invited to present the Operating Plan 2025-26 and Board Assurance Statement, the content of which was noted. It was further noted that: • The Operating Plan provided a summary of plans from October 2025 to September 2026, sitting alongside other key policies such as those relating to infection prevention control, major incidents, and influenza. • The Operating Plan would also serve as the Trust’s winter plan, which was recognised as a period of increased pressure. The Board discussed the proposed Operating Plan for 2025/26, this discussion is summarised below: • It was considered likely that, even with delivery of the demand management schemes being led by the Integrated Care Board (ICB), there would be a gap between demand and capacity over the winter period in particular. Therefore, further interventions to improve discharge rates and to reduce the number of patients having no criteria to reside would be necessary. In addition, the Trust would be required to make potentially difficult decisions in respect of prioritisation of patients and possible cancellation of elective procedures. • Concerns were expressed in relation to the trend of low uptakes of seasonal vaccinations, such as that against influenza, which had been seen since the COVID-19 pandemic. This situation would likely create further challenges due to patients with seasonal illnesses requiring additional infection prevention control measures. Furthermore, low uptake by staff members would likely result in increased rates of staff sickness and, accordingly, reduced capacity and/or increased expenditure on temporary staffing. • It was understood that there was a NHS campaign to encourage staff in particular to be vaccinated against influenza, and that plans were in place for senior leaders to visibly support this campaign through being vaccinated. • The Board challenged whether the Trust could meet the targets set out in the Operating Plan given the financial and other pressures currently experienced. • It was additionally noted that the Trust was reliant on external support and delivery of external demand management programmes led by the ICB in order to be able to meet the performance targets, especially in terms of management of the number of patients having no criteria to reside and those with a primary mental health need. • Furthermore, the Trust’s financial position was such that it was required to produce a financial recovery plan, which would require additional financial savings to be made. • It was agreed that the Board should fully consider whether to approve the Operating Plan once it had considered the Trust’s financial recovery plan in the Closed Session of the meeting. [Note: the matters below forming part of item 5.6 were discussed following the approval of the Trust’s financial recovery plan in the Closed Session.] Noting that the Board had discussed and supported the Trust’s financial recovery plan, subject to certain caveats, the Board again discussed the proposed Operating Plan for 2025/26. This discussion is summarised below: • The Trust’s financial recovery plan would need to be supported by NHS England and would also need to deliver in order for the Trust to be able to meet the performance targets set out in the Operating Plan. • The Trust continued to have significant dependence on third parties, especially other providers, the Integrated Care Board, and local authorities, to be able to successfully reduce the number of patients having no criteria to Page 5 reside or number of mental health patients. Without these reductions, the Trust would face significant capacity constraints, which would impact its performance, especially during periods of high demand. Decision Noting the discussions in the Closed Session in respect of the financial recovery plan, and having reviewed the proposed Operating Plan 2025-26 and accompanying Board Assurance Statement, the Board approved the Operating Plan 2025-26 and its submission, subject to the following: • delivery of system-wide programmes to manage demand and reduce numbers of non-criteria to reside and mental health patients, • appropriate support being provided by third parties, including local providers, the Integrated Care Board, and local authorities, especially in terms of supporting discharges and managing numbers of non-criteria to reside and mental health patients, and • support from NHS England for and delivery of the Trust’s financial recovery plan. In addition, the Board authorised the Chair and Chief Executive Officer to sign the Board Assurance Statement. 5.7 Break 5.8 Finance Report for Month 4 Ian Howard was invited to present the Finance Report for Month 4, the content of which was noted. It was further noted that: • The Trust had reported an in-month deficit of £6.8m (£4.8m above plan), although the underlying deficit was showing improvement, reducing to £6.6m. However, this trajectory was not sufficient to deliver the plan. • The Trust was carrying out approximately £2.5m of unfunded activity per month. In order to tackle some of this amount, the Trust had conducted negotiations with other providers and systems to address underfunding on contracts. • There were concerns about whether the Trust’s elective over-performance during the first half of the year would be fully funded. Whilst agreement had been reached in respect of funding three months of over-performance, it was not clear whether this would be replicated in the future. • The Trust would be seeking an activity management plan, which would detail which activities to cease to perform on the basis that the Trust continuing to over-perform against agreed funded activity levels was financially unsustainable and that it was not reasonable that the Trust should be criticised for falling performance in areas such as waiting lists as it sought to manage its finances. • The Trust’s cash position remained an area of concern with cash support to be requested from NHS England. • There appeared to be an emerging risk of slippage against the Trust’s capital programme, which was to be discussed at the Finance and Investment Committee. 5.9 ICS Operational Delivery Report for Month 4 Ian Howard was invited to present the ICS Operational Delivery Report for Month 4, the content of which was noted. It was further noted that: • The Trust was the only organisation within the system currently reporting being off plan. However, there were indicators from other providers with Page 6 significant risks being highlighted about organisations’ abilities to meet their 2025/26 plans. • There was an error in the report in respect of the Trust’s workforce numbers. A correction to the report had been requested. • The Hampshire and Isle of Wight ICS plan was for a breakeven position at the end of 2025/26. However, this was reliant on receipt of £60m of deficit support funding from NHS England, which was at risk because the Trust was no longer reporting being on plan. 5.10 People Report for Month 4 It was noted that two questions had been received from members of the public prior to the meeting (see Annex A), both of which related to the decision to remove the enhancement from NHS Professionals rates paid to staff in certain areas of the Trust such as in Theatres and in the Emergency Department. It was further noted that: • A discussion had also been held with staff prior to the Board meeting, at which a number of other questions had been raised. In particular, staff had expressed concerns about their feeling valued by the organisation. • The reasoning behind the decision to remove the enhancement previously paid on temporary staffing rates was explained as being to provide consistency with other staffing groups and with other providers by aligning rates paid with Agenda for Change rates. This change was part of a package of measures to improve the financial position of the Trust. • The decision to remove the enhancement was supported by an Equality and Quality Impact Assessment as part of the Trust’s process for making decisions of this nature. [Post meeting note: Following the meeting, the Royal College of Nursing, on behalf of its members in the affected areas, submitted a collective dispute. The questions raised in advance of the meeting, together with other related points, were to be addressed as part of the collective dispute process.] Steve Harris was invited to present the People Report for Month 4, the content of which was noted. It was further noted that: • The Trust’s plan for 2025/26 was for a reduction in whole-time-equivalents (WTE) by 765. Whilst the Trust had reduced the size of its workforce, it was still 55 WTE off-plan. • The Trust had reduced the number of divisions from four to three and had implemented recruitment controls whereby only 70% of clinical posts would be recruited to and a prohibition on recruitment to non-clinical posts. • The Trust had also carried out a Mutually Agreed Resignation Scheme (MARS) and had made some redundancies in discrete areas. It was noted, however, that there was a lack of funding for severance payments, which limited the Trust’s options with respect to steps it could take to reduce its workforce. • Temporary staffing was a particular area of focus, both in terms of numbers of temporary staff but also in terms of the cost paid for such staff. This aligned with the work of the South East temporary staffing collaborative which aimed to reduce the price of temporary labour in both bank and agency. Page 7 • Despite its challenges during 2025/26, the Trust had proactively offered roles to newly-qualified nurses ahead of the Secretary of State’s announcement of a ‘graduate guarantee’ on the basis that, from a strategic perspective, the Trust needed to take into account its future workforce requirements. Action Steve Harris and Andy Hyett agreed to respond to the questions and points raised at the meeting held with staff in respect of the NHS Professionals rates matter. 5.11 Learning from Deaths 2025-26 Quarter 1 Report Jenny Milner was invited to present the Learning from Deaths 2025/26 Quarter 1 Report, the content of which was noted. It was further noted that: • The Trust’s summary hospital-level mortality indicator (SHMI) score continued its downward trajectory and was the lowest value recorded since 2018. As such, the Trust was one of only 11 trusts nationally to achieve a lower-thanexpected mortality rate. • Work was ongoing to disseminate lessons from end-of-life care and an additional module for the Ulysses system had been purchased to facilitate data capture and standardisation for Morbidity and Mortality meetings. Action Jenny Milner was to provide further information to the Board in respect of why the Trust’s SHMI score remained low. 5.12 Annual Complaints Report 2024-25 Jenny Milner was invited to present the Annual Complaints Report 2024/25, the content of which was noted. It was further noted that: • The report provided details of complaints received between 1 April 2024 and 31 March 2025 and was the first full year of reporting against the new standard introduced by the Parliamentary and Health Service Ombudsman (PHSO). • Complaints activity had increased by 40% and the Trust was not currently meeting response targets. • The Trust benchmarked higher than others in terms of complaints not upheld. The Board discussed the Trust’s approach to complaints handling and, in particular, whether the Trust was an outlier in terms of the number of complaints not upheld. The Board challenged whether complaints deemed as ‘not upheld’ ought, in some instances, to be considered ‘partially upheld’. Consideration should therefore be given to reviewing the Trust’s complaints against PHSO referrals and outcomes. Action Jenny Milner was to provide further information regarding how the Trust was planning to meet complaints response times. Page 8 5.13 Medical Appraisal and Revalidation Annual Report including Board Statement of Compliance Paul Grundy was invited to present the Medical Appraisal and Revalidation Annual Report, the content of which was noted. It was further noted that: • The framework published by NHS England was designed to allow the Trust to provide assurance that its professional standards processes meet the relevant statutory requirements and support quality improvement. • Feedback in respect of the appraisals process had been largely positive. • Appraisal compliance rates had continued to rise across the year with a current average of 88.8%. • The Board was required to approve a Statement of Compliance confirming that the Trust was compliant with the Medical Profession (Responsible Officers) Regulations 2010 (as amended). Decision Having considered the Medical Appraisal and Revalidation Annual Report tabled to the meeting, the Board authorised the Chair or Chief Executive Officer to sign the Statement of Compliance. 5.14 Safeguarding Annual Report 2024-25 and Strategy 2025-26 Danielle Honey was invited to present the Safeguarding Annual Report 2024/25 and Strategy for 2025/26, the content of which was noted. It was further noted that: • The report summarised the activity of the Trust’s safeguarding service in 2024/25. It was noted that the service had contributed to reviews of 56 patients where a statutory review had been considered. • The number of referrals under section 42 of the Care Act 2014 caused by Southampton City Council had reduced following the implementation of the council’s new processes. This was not reflective of a reduction in the number of UHS referrals or the complexity of the referrals responded to. • There had been an increase in the number of open cases with Southampton City Council and there had been a 13% increase in the number of patients subject to Deprivation of Liberty Safeguards (DoLS) under the Mental Capacity Act 2005. • There had also been an increase in the number of scoping reviews compared to prior years, although fewer were progressing to formal reviews. • Following a survey of staff, work was underway to improve the visibility of the team and there was a focus on team wellbeing with support from the psychology team. • The situation in respect of expected changes in the role of integrated care boards was being monitored due to the potential for changes in the team’s scope and remit. Page 9 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: • All risks had been reviewed by the relevant executive directors since July 2025. • The revised risk appetites agreed by the Board in July 2025 were being embedded. • The rating of Risk 5a had increased from 20 to 25 due to the lack of agreement for cash support. However, once this agreement had been obtained and the Financial Recovery Plan was in place, it was expected that this risk would again reduce to 20. • An audit of the Trust’s risk management maturity by the Trust’s internal auditors was near to completion. 7. CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Feedback from the Council of Governors’ (COG) Meeting 16 July 2025 The Chair presented a summary of the Council of Governors’ meeting held on 16 July 2025. It was noted that the meeting had considered the following matters: • Chief Executive Officer’s Performance Report • The Trust’s 2025/26 Operating Plan • Council of Governors’ Terms of Reference • Membership Engagement • Feedback from the Governors’ Nomination Committee Furthermore, the Council of Governors approved the extension of the appointment of Tim Peachey as a non-executive director for a period of 12 months. 7.2 People and Organisational Development Committee Terms of Reference Craig Machell was invited to present the proposed changes to the People and Organisational Development Committee’s Terms of Reference, the content of which was noted. It was further noted that: • The People and Organisational Development Committee had reviewed its terms of reference at its meeting on 1 September 2025. • It was proposed to make only minor changes to remove reference to the Charitable Funds Committee, which no longer existed. Decision Having considered the proposed amendments to the People and Organisational Development Committee’s Terms of Reference, the Board approved the changes. Page 10 8. Any other business It was noted that it was organ donation week during 22-28 September 2025. Action Craig Machell agreed to add organ donation to the agenda of a future Trust Board Study Session. 9. Note the date of the next meeting: 11 November 2025 10. Items circulated to the Board for reading The item circulated to the Board for reading was noted. There being no further business, the meeting concluded. 11. Resolution regarding the Press, Public and Others Decision: The Board resolved that, as permitted by the National Health Service Act 2006 (as amended), the Trust’s Constitution and the Standing Orders of the board of directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. The meeting was adjourned. Page 11 Annex A Questions: 1. The Board has agreed a cut in bank pay rates for nursing staff, resulting in local staff being unlikely to maintain their bank roles in this organisation, (based on a survey of over 450 nurses within the affected areas). Currently these roles provide staffing in areas such as theatres and other specialised areas, the impact being these departments can use local skills and knowledge to provide seamless operational delivery. How can the board provide assurance that, a) this will not impact on safety for patients, and b) they truly value nurses for the professional skills they provide for this Trust. 2. Our Emergency Department has recently been placed under Tier 1 monitoring by NHS England, reflecting serious national concerns about safety and performance. The department is already regularly understaffed, with patient care frequently delayed as a result. In light of this, how can the Trust justify reducing NHSP pay rates for Emergency Department nurses — a decision that risks deterring skilled staff from covering shifts and further compromising patient safety and the delivery of safe, timely care? What specific steps will the Trust take to mitigate these risks to patients and staff if the changes go ahead? Page 12 List of action items Agenda item Assigned to Deadline Status Trust Board – Open Session 15/07/2025 - 5.11 Freedom to Speak Up Report 1267. Data Mbabazi, Christine Watts, Natasha 13/01/2026 Pending Explanation action item Christine Mbabazi to include data from other mechanisms for reporting concerns in future Freedom to Speak Up reports. Trust Board – Open Session 09/09/2025 - 5.5 Performance KPI Report for Month 4 1281. Pharmacy First Hyett, Andy 11/11/2025 Pending Explanation action item Andy Hyett agreed to look at the roll out of Pharmacy First. 1282. Diagnostics Hyett, Andy 11/11/2025 Pending Explanation action item Andy Hyett agreed to carry out a deep-dive into Diagnostics to be either provided as a ‘Spotlight’ in the Performance KPI Report or via a Trust Board Study Session. Trust Board – Open Session 09/09/2025 - 5.10 People Report for Month 4 1283. NHS Professionals rates Harris, Steve Hyett, Andy 11/11/2025 Pending Explanation action item Steve Harris and Andy Hyett agreed to respond to the questions and points raised at the meeting held with staff in respect of the NHS Professionals rates matter. Page 1 of 2 Agenda item Assigned to Deadline Status Trust Board – Open Session 09/09/2025 - 5.11 Learning from Deaths 2025-26 Quarter 1 Report 1284. SHMI score Milner, Jenny Watts, Natasha 11/11/2025 Pending Explanation action item Jenny Milner was to provide further information to the Board in respect of why the Trust’s SHMI score remained low. Trust Board – Open Session 09/09/2025 - 5.12 Annual Complaints Report 2024-25 1285. Response times Milner, Jenny Watts, Natasha 11/11/2025 Pending Explanation action item Jenny Milner was to provide further information regarding how the Trust was planning to meet complaints response times. Trust Board – Open Session 09/09/2025 - 8 Any other business 1286. Organ donation Machell, Craig 18/12/2025 Pending Explanation action item Craig Machell agreed to add organ donation to the agenda of a future Trust Board Study Session. Update: To be scheduled 18/12/25 or 03/02/26. Page 2 of 2 Agenda Item 5.1 Committee Chair’s Report to the Trust Board of Directors 11 November 2025 Committee: Audit & Risk Committee Meeting Date: 13 October 2025 Key Messages: • • • • • • • • • The committee reviewed and discussed the outputs of a ‘lessons learned’ activity following the late publication of the Trust’s annual report and accounts. It was noted that a number of actions had been agreed and that a trial run would be conducted at Month 9. The committee noted the proposal to tender for new valuers for 2025/26 and the review of the Modern Equivalent Asset estimation methodology that would be carried out during the year. The committee agreed with a proposal to write off historical debt from private (mostly overseas) patients on the basis that it was irrecoverable. There had been 68 waivers of competitive tendering during the first half of 2025/26, most of which related to continued service provision. It was noted that the submission as part of the National Cost Collection exercise had been completed in July 2025 and that the Trust was 7% more efficient than the average based on the data. An update was received in respect of Information Governance. The Trust’s Data Security and Protection Toolkit was now rated as ‘approaching standards’ and progress had been made in respect of the backlog in subject access requests. The committee received an update in respect of legal expenditure and claims during 2024/25. The committee reviewed the internal audit reports on the Data Security and Protection Toolkit, CQC Readiness, and risk maturity. The committee received an update on the progress of the Trust’s local counter-fraud team against the plan for 2025/26, noting that imposter fraud was an area of focus. 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 • The committee had last reviewed the BAF in March 2025, and there had been a definite increase in the level of risk with the ratings of four of the risks having increased since then. • Approximately 25% of the risks on the Trust’s operational risk register were rated ‘critical’ (i.e. 15 or above). • The internal audit of risk management had been positive and the Trust’s risk management framework was considered as being mature. 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 i) Committee Chair’s Report to the Trust Board of Directors 11 November 2025 Committee: Finance and Investment Committee Meeting Date: 22 September 2025 Key Messages: • • • • • • • • • The committee reviewed the Finance Report for Month 5. The Trust had reported an in-month deficit of £5.9m and £25.4m deficit year-todate. The in-month deficit was £4.2m above the original plan, but was in line with the trajectory in the Financial Recovery Plan. The Trust’s underlying deficit had continued to improve, reducing to £6.2m, although this improvement was not yet at the pace required. The main drivers of the variance to plan were variances in income compared with what had been expected during 2025/26 and variances in terms of pay costs. The Trust was expecting to be 95 whole-timeequivalents above plan at year end based on current assumptions. It was noted that the Trust had identified 100% of Cost Improvement Programme savings at Month 5 and 76% of schemes were fully developed. Approximately £37m of savings had been delivered between Months 1 and 5, although higher than anticipated levels of non-recurrent savings had been delivered. The committee reviewed the Trust’s capital forecast, noting that there was a risk of a shortfall against the Trust’s internal CDEL. An update was received regarding the Urgent and Emergency Care transformation programme. The committee received the annual assurance report from UHS Pharmacy Limited, noting the company’s performance during the year and the work being done to expand services internally and externally. The committee considered the Trust’s cash forecast for Month 5, noting that the Trust’s underlying deficit was steadily eroding the Trust’s cash balance. The Trust had introduced strict treasury management measures and had previously received advance payments from the ICB as a means to mitigate the cash position. However, it had been necessary to submit a request for revenue support from NHS England in September 2025 and further such applications would be required from November 2025 onwards. In order to increase the focus on and governance of cash-related matters, the committee reviewed its terms of reference to strengthen the cash-related provisions and agreed to recommend to the Board that the committee be re-constituted as the Finance, Investment and Cash Committee with an Operating Cash Group reporting into the committee. Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) N/A Any Other Matters: The revised terms of reference for the committee were reviewed and approved at the Board meeting held on 7 October 2025. 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 November 2025 Committee: Finance, Investment and Cash Committee Meeting Date: 3 November 2025 Key Messages: • • • • • • • • The committee reviewed the Finance Report for Month 6 (see below). The committee received an update in respect of the Trust’s performance against its Financial Recovery Plan, noting that progress had been made in terms of putting plans in place regarding patients with no criteria to reside and mental health patients. Good progress had also been made in respect of the ‘grip and control’ measures. At Month 6, the Trust remained on track with the Financial Recovery Plan. An overview of the recently published Medium Term Planning framework was provided. It was noted that the first submission of the Trust’s three-year plan was due before
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Trust-governance-and-corporate-docs/2025-Trust-documents/Papers-Trust-Board-11-November-2025.pdf

Glasses for children - patient information

Description: This factsheet contains information about your child's glasses test appointment.
Url: /Media/UHS-website-2019/Patientinformation/Eyes/Childrens-eyes/Glasses-for-children-1775-PIL.pdf

Papers CoG 28.10.2025

Description: Date Time Location Chair Agenda - Council of Governors 28/10/2025 14:00 - 15:30 Heartbeat Conference Room/Microsoft Teams Jenni Douglas-Todd 1 Chair’s Welcome and Opening Comments 14:00 2 Declarations of Interest 14:05 3 Minutes of Previous Meeting 14:06 Approve the minutes of the previous meeting held on 16 July 2025. 4 Matters Arising/Summary of Agreed Actions 14:08 5 Strategy, Quality and Performance 5.1 Chief Executive Officer's Performance Report 14:09 Receive and note the report Sponsor: David French, Chief Executive Officer 6 Governance 6.1 Governor Attendance at Council of Governors' Meetings 14:29 Review governor attendance at Council of Governors' meetings Sponsor: Jenni Douglas-Todd, Trust Chair Attendees: Craig Machell: Associate Director of Corporate Affairs and Company Secretary and Karen Russell, Council of Governors' Business Manager 6.2 Review of Council of Governors' Expenses Reimbursement Protocol 14:34 Review the proposed changes to the Council of Governors' expenses reimbursement protocol Sponsor: Jenni Douglas-Todd, Trust Chair Attendees: Craig Machell, Associate Director of Corporate Affairs and Company Secretary and Karen Russell, Council of Governors' Business Manager 6.3 Appointment of Deputy Chair 14:39 Approve the appointment of Jane Harwood as Deputy Chair Sponsor: Jenni Douglas-Todd, Trust Chair 14:49 Break 7 Membership Engagement and Governor Activity 7.1 Membership Engagement 14:59 Receive the report Sponsor: Jenni Douglas-Todd, Trust Chair Attendee: Sam Dolton, Events and Membership Officer 7.2 Governors' Nomination Committee Feedback 15:09 Chair: Jenni Douglas-Todd, Trust Chair 8 Review of Meeting 15:14 Review and feedback on the content of this meeting Sponsor: Jenni Douglas-Todd, Trust Chair 9 Any Other Business 15:24 Raise any relevant or urgent matters that are not on the agenda 10 Date of Next Meeting: 29 January 2026 15:29 Note the date of the next meeting Page 2 Minutes - Council of Governors (CoG) Open Session Date Time Location Chair Present 16 July 2025 14.00-15.45 Conference Room, Heartbeat Education Centre and Microsoft Teams Jenni Douglas-Todd, Trust Chair Jenni Douglas-Todd, Trust Chair Theresa Airiemiokhale, Elected, Southampton City Shirley Anderson, Elected, New Forest, Eastleigh and Test Valley Patricia Crates, Elected, New Forest, Eastleigh and Test Valley Sandra Gidley, Elected, New Forest, Eastleigh and Test Valley Lesley Gilder, Elected, Southampton City Ben Grassby, Elected, Rest of England and Wales Professor Sue Latter, Appointed, University of Southampton Jenny Lawrie, Elected, Southampton City Brian Lovell, Elected, Rest of England and Wales Councillor Louise Parker-Jones, Appointed, Hampshire County Council Cat Rushworth, Elected, Isle of Wight Karen Smith-Baker, Elected, Health Professional and Health Scientist Staff Jake Smokcum, Elected, Nursing and Midwifery Staff Liz Taylor, Elected, Non-Clinical and Support Staff JDT TA SA PC SG LG BG SL JL BL LPJ CR KSB JS LT In attendance Andrew Asquith, Director of Planning and Productivity (for Item 5.2) AA Tracey Burt, Minutes TB Keith Evans, NED, Chair Audit and Risk Commitee KE Steve Harris, Chief People Officer (for Item 5.1) SHa Craig Machell, Associate Director of Corporate Affairs and CM Company Secretary Farhanah Miah, Associate Governor FM Neylia Mustafapour, Associate Governor NM Karen Russell, Council of Governors’ Business Manager KR David Watts, Corporate Affairs DW Apologies Professor Cathy Barnes, Appointed, Solent University CB Sathish Harinarayanan, Elected, Medical Practitioners and Dental SH Staff Linda Hebdige, Elected, Southampton City LH Councillor Pam Kenny, Appointed, Southampton City Council PK Esther O’Sullivan, Elected, New Forest, Eastleigh and Test Valley EO Mike Williams, Elected, New Forest, Eastleigh and Test Valley MW 1 Chair’s Welcome and Opening Comments JDT welcomed everyone to the meeting. She noted that several governors were coming to the end of their term of office and said that she would return to the matter later in the meeting. 1 2 Declarations of Interest There were no new declarations of interest relating to matters on the agenda. 3 Minutes of Previous Meeting The minutes of the meeting held on 29 April 2025 were approved as an accurate record of the meeting. 4 Matters Arising/Summary of Agreed Actions There were two items arising from the previous meeting on 29 April 2025: • the poor acoustics in the Heartbeat Suite conference room. JDT advised that she would update governors during Any Other Business. • JDT welcomed KE to the meeting to provide an update regarding the Annual Report and accounts. He advised that it contained three parts, the Annual Report, the Quality Account and detailed annual financial statements and he encouraged governors to read it. External auditors had been going through the document for quality control purposes but he did not expect any issues to be raised. CM advised that he hoped to issue the Annual Report and accounts by Friday 18 July. The final version, however, was now unlikely to be published until September, as it still had to be laid before Parliament, whose summer recess commenced on 21 July 2025. 5 Strategy, Quality and Performance 5.1 Chief Executive Officer’s Performance Report JDT welcomed SHa to the meeting, who said that he was attending on behalf of David French, CEO. He advised that the organisation was under a significant level of duress and he said that he had never known so many competing challenges. Much time was currently occupied by managing organisational change and the need to deliver the financial plan, whilst treating more patients than ever before, with a reduced workforce. At the end of Month 2 (May 2025) the Trust had been in line with the financial plan, with a deficit of £8m and the delivery of £12.5m of savings. Whilst the Trust benchmarked well across many areas, the Emergency Department (ED) continued to be a challenge, with more patients than ever attending. An external review of the department had been undertaken in June but it was proving difficult to move forward. The non-criteria to reside (NCTR) numbers had increased to peaks of 270 from an average of 220 and continued to have a negative impact on expenditure and patient flow across the organisation. Waiting lists were growing and SHa suggested that public patience was wearing thin, which meant that an increase in complaints was being seen. The hospital mortality rate, however, continued to show better than expected survival rates. SH advised that the Trust had one of the most challenging workforce plans it had ever had. It was looking to reduce the workforce by 6% and had set out a number of ways to achieve that goal, including some challenging recruitment controls. The divisional structure, which had been in place for around 15 years had now been changed to align more closely to national NHS priorities and to yield savings. The new structure, with three divisions instead of four, had gone live on 1st July 2025 and had mostly been achieved through natural attrition. Divisions had been asked to look for a 5% reduction in their pay costs and a 10% target 2 had been set for the Trust HQ function. Work was also being undertaken to reduce spending on bank staff. A Mutually Agreed Resignation Scheme (MARS), which was unique to UHS, had been launched and 222 applications had been received. Scrutiny of those applications was ongoing but it had been decided that 95 could not be allowed to resign and 14 were not eligible. Resident doctors, nationally, had turned down a 5.5% pay deal and had issued 14 days’ notice of industrial action, starting on 25 July 2025. Consultants and senior colleagues would, therefore, be required to provide cover by acting down. The Royal College of Nursing was also currently campaigning heavily regarding their pay and industrial action was possible. JDT thanked SHa for his report. 5.2 Operating Plan 2025 JDT welcomed AA, Director of Planning and Productivity, who said that he was attending on behalf of Ian Howard, Chief Financial Officer. He referred to the 2025-26 Annual Plan Summary presentation that had been circulated to governors and said that it was a difficult national landscape. He highlighted the following: • page 3 - when producing its annual plan, the Trust did not have an entirely free hand but had to work within the national NHS planning guidance/financial framework for 2025/26. That framework stated that: o all organisations must live within their means. o there was to be a significant reduction in staff numbers, particularly within corporate roles, bank and agency. o there must be a target to improve waiting times, e.g. a 5% improvement in the percentage of patients waiting more than 18 weeks from their referral to starting treatment. o there would be a new limit on the income available to support elective appointments and treatment. Money would no longer follow the patient and Trusts would receive no extra income if they treated/saw additional patients. • page 19 - despite all the adversity, reductions and cut-backs, the annual plan outlined a significant number of service developments/investments that were planned at UHS. These included the opening of an Urgent Treatment Centre at UHS. The following comments were made/questions raised: • given the current financial climate, whether there was likely to be any increase in research activity. AA advised that the Trust had a strong history of supporting research and he said that much of the treatment patients received had been informed by consultants leading research at UHS. • UHS was nowhere near the 5% improvement target that had been set by the NHS in relation to 18-week performance. BL queried whether the target was wrong or whether the Trust’s ambitions were too soft. AA acknowledged that it was a highly ambitious target but said that UHS was making improvements and it was right that Trusts should be striving to achieve it. • whether the Trust had to bid for national government money. AA advised that the money the organisation received for its annual running costs was set at the beginning of each financial year and there was very little (or no) opportunity to increase it during the year. SHa noted, however, that AA and his colleagues were adept at moving quickly to submit appropriate, high 3 quality bids, whenever national funding for specific service developments became available. • SA noted that there was an unprecedented challenge in relation to the people agenda, which was likely to impact staff survey results. SHa acknowledged that there was likely to be a deterioration in the results across the NHS and UHS would be looking to see whether its results were in line with that. He said that the Trust had always tried to be as transparent as possible with its staff and every two weeks there were Talk to David sessions that were open to all staff, to ask any questions they wanted to. • SA queried whether there was appropriate support for the most senior staff in the organisation. SHa advised that the executive team were very supportive of one another and that they were also well supported by the NEDs. • PC asked whether the Did Not Attend (DNA) rate impacted waiting lists. AA advised that it was around 6% but was reducing and varied between services. Also, clinics were often over-booked, so the time was generally used effectively. JDT thanked AA for attending. 6 Governance 6.1 Review Terms of Reference - Council of Governors JDT advised that the Terms of Reference had been reviewed and a small number of minor amendments proposed. It was noted that working groups had been removed but it was agreed that they could be re-instated in the future, if appropriate. The CoG approved the revised Terms of Reference. 7 Membership Engagement and Governor Activity 7.1 Membership Engagement JDT advised that Sam Dolton (SD), Events and Membership Officer, would no longer attend CoG in person but would still provide a report for the meetings. This was due to changes in the organisation, a reduction in Communication Team staff due to the MARS programme and a significant increase in SD’s workload. The following comments were made: • whether SD could, in future, attend to give his report as other staff did. • members who preferred to be contacted by post had received a written letter asking if they still wanted to be a postal member. If no response had been received, they had been removed from that list. • JDT expressed surprise that there were no members from the gypsy/traveller community and would discuss with SD. 7.2 Governors’ Nomination Committee Feedback JDT advised that the Governors’ Nomination Committee had met, informally, prior to the CoG meeting, so they could be updated regarding the NED vacancy. She advised that whilst it had been decided not to replace the NED who was leaving, the Trust had planned to recruit a replacement for Tim Peachey (TP), who had already been a NED for six years. However, at the stakeholder panel last week, it had been agreed that there was no one suitable to appoint, so the interviews had been stood down. The Trust had now engaged with the NHS regional team to try to extend TP’s term for another 12 months. If approved, at the start of the next calendar year the Trust would try again to recruit a suitable replacement. It was, however, well 4 known nationally that clinical NEDs were difficult to find, so it was possible that headhunters would be used. KE’s tenure as NED and Chair of the Audit and Risk Committee, would come to an end in January 2026 and it was hoped that the process to replace him would commence in September 2025. 8 Review of Meeting The following comments were made: • it had been an informative meeting and the NEDs had provided thorough answers to questions. • sound in the conference room continued to be poor. • several governors raised a concern regarding the incorrect pronunciation of BAME used by KE. JDT apologised to the governors and said that she would speak to KE. 9 Any Other Business • JDT noted that: o TA had reached the end of her second term as a governor. JDT thanked her for her contributions and wished her well for the future. o LH and EO had both come to the end of their first term and had decided not to stand again. JDT thanked them for their contributions to the CoG. o after two years as an Associate Governor, NM, was leaving and hoped to attend Reading University to study pharmacy. JDT wished her all the best with her exam results and future career. o PC, SG, LG, JL, CR, JS and LT were all reaching the end of their first term as governors and had the opportunity to stand again. Nominations would close at 5 p.m. on 30th July. • CR had offered to replace Katherine Barbour as the CoG representative on the Trust’s Sustainability Board. The CoG accepted her offer. • Southampton Pride would take place on 23/24 August and JDT thanked those governors who had already said they would attend. LT asked any other governors who were interested in attending, to let her know. • JDT advised that the cost of upgrading the sound equipment in the conference room had been considered but, in the current climate, was too high (around £5k). Other solutions therefore needed to be considered and she mentioned that a different seating arrangement at the last Trust Board had helped. • SL, who had joined the CoG meeting online, advised that volume had not been a problem but she had experienced some broadband issues. • JDT advised that in light of the financial challenges, the Trust had taken the decision not to provide refreshments for meetings, across the organisation. The CoG was keen to support the decision and agreed that they would, in future, bring their own lunch to meetings. They wanted, however, to retain the same timetable of sessions, as they valued the time together. • SG queried whether the CoG could have a briefing on the new NHS Plan and its implications for UHS. JDT advised that the detail of the plan was still being worked out but she was aware that all Trusts were to become Foundation Trusts by 2035 and there would no longer be a requirement to have a CoG. Given NHSE was hoping to develop an implementation plan by the autumn, she was hopeful governors would be able to have a fuller discussion at the next CoG. 10 Date of Next Meeting The next meeting of the CoG would be held on 28 October 2025. 5 List of action items Agenda item Assigned to Deadline Status Council of Governors 16/07/2025 7.1 Membership Engagement 1277 Presentation of the Membership Report at Council of Governors' Meetings Karen Russell 28/10/2025 Completed Explanation action item Due to a lack of resource in the Communications Team, Sam Dolton was no longer able to attend CoG on a regular basis. SG asked if it was possible for Sam to continue to attend just to present the quarterly membership report. Outcome Sam has kindly agreed to attend (either in person or via MS Teams) for the presentation of the membership report and to answer any questions which may arise. 1278 Trust Membership - Gypsy, Roma and Traveller (GRT) Community Jenni Douglas-Todd Karen Russell 28/10/2025 Completed Explanation action item JDT noted in the membership report that there were currently no members from the GRT community and advised that she would discuss with Sam Dolton. Outcome Sam has been reviewing the position regarding GRT members at other foundations trusts and will provide an update at the CoG meeting on 28 October 2025. Item 5.1 Report to the Council of Governors - 28 October 2025 Title: Chief Executive Officer’s Performance Report Sponsor: David French, Chief Executive Officer Author: Sam Dale, Associate Director of Data and Analytics Purpose (type an ‘x’ in the appropriate box(es)) (Re)Assurance Approval Ratification Information x Strategic Theme (type an ‘x’ in the appropriate box(es)) Outstanding patient Pioneering research World class people outcomes, safety and innovation and experience Integrated networks and collaboration Foundations for the future x x x Executive Summary: Information about Trust performance supports the Council of Governors in their role. This report is intended to inform the Council of Governors about aspects of the Trust’s performance. Contents: The Chief Executive Officer’s Performance Report is attached. Risk(s): N/A Equality Impact Consideration: N/A UHS Council of Governors October 2025 Chief Executive’s Performance Report 1. Purpose and Context The purpose of this report is to summarise the Trust’s performance against a range of key indicators. Where available, this report covers data from the period June to August 2025, noting that some performance data is reported further in arrears and therefore unavailable. Notable features of the quarter include: • The trust’s financial plan for 25/26 was breakeven including a savings target of £110m. In August, the trust reported a deficit of £25m which is £10m behind plan. The organisation has now submitted a financial recovery plan to NHS England to minimise the deficit through schemes of greater scale and pace. • The trust remains on target to spend its full capital allocation for 2025/26 ensuring continued investment in capacity, digital and infrastructure. • The trust’s overall waiting list has been increasing since the start of the financial year with several services impacted by increased demand. However, the waiting list remained stable between July and August (63,018 patients). • The percentage of patients waiting less than 18 weeks decreased to 62.0% for August 2025. The organisation is reporting an increase in the volume of long waiting patients (over 65 and 78 weeks) in certain surgical specialties but is exploring options to bring this back in line with national ambitions. • In August 2025 the ED department delivered a much improved four hour performance position of 68.7% and a reduction in average time in the department for admitted and nonadmitted patients. • The trust reported one never event across the reported period and five PSSIs (Patient Safety Incident Investigations). • The HSMR statistics have been refreshed for the July 2025 position and continue to reflect better than expected survival. • Despite the challenging environment facing all NHS staff, the latest pulse survey illustrates a 5.5% improvement for staff who recommend UHS as a place to work. 2. Safety Infection Control Clostridium Difficile infection MRSA Bacterium infection E.coli Target 78.0% June 2025 60.8% July 2025 61.0% August 2025 68.7% In August 2025 the ED department delivered a much improved four hour performance position of 68.7% and a reduction in average time in the department for admitted and non-admitted patients. The stronger August position reflects both a reduction in attendances in the month but also the early focus on action plans agreed internally and with the support of ECIST (Emergency Care Improvement Support Team) following a recent visit. The hospital continues to perform well against the 12 hour target averaging 2.1% of patients across this financial year. The hospital successfully transitioned to a new emergency department system (Miya) on 13 October. Whilst the implementation of a new digital system requires significant training and some disruption, Page 3 of 6 the rollout has been well managed and we look forward to the long term benefits for patient management and flow throughout the organisation. Referral to Treatment (RTT) % incomplete pathways within 18 weeks in month Total patients on a waiting list Target => 92% June 2025 64.1% 62,644 July 2025 63.4% 63,007 August 2025 62.0% 63,018 The overall waiting list across the trust remained steady at 63,018 patients for August 2025 which is an increase of just eleven patients since July 2025. However 18 week performance for August was 61.8% which is a reduction since July 2025 (63.4%). The trust reported thirty patients waiting over 78 weeks by the end of August 2025. The pressure area continues to be patients within the hospital’s skin service waiting for low priority surgery for benign conditions. Discussions are ongoing with the ICB and other trusts about pathway options for this cohort of long waiting patients. There were 188 patients waiting over 65 weeks predominantly within the surgery caregroup, but also within trauma and orthopaedics and gynaecology, where capacity has outstripped demand. The trust is meeting the regional team fortnightly to discuss action plans to address the waiting list position including providing speciality level support and expert insight for the most challenged areas. Cancer Target Faster Diagnosis - within 28 days > =77% 31 Day target - decision to treat to first definitive treatment 62 day target - urgent referral to first definitive treatment => 96% => 70% May 2025 78.0% 96.0% 77.5% June 2025 73.1% 96.0% 70.4% July 2025 80.0% 95.3% 78.0% The trust reported an improvement in July for performance against both national cancer metrics. 28 day faster diagnosis performance significantly increased to 80.0% for July (73.1% in June) moving the trust back in the top quartile compared to peer teaching hospitals. Similarly, performance for the 62 day standard improved to 78% for July 2025 ranking UHS 2nd against peer teaching hospitals. 5. Finance The financial environment remains extremely challenging for UHS. Our plan submission for 2025/26 targets breakeven delivery which is predicated on the achievement of £110m of savings. This represents 8% of turnover and would be a record achievement for UHS if delivered. The shape of the financial plan is one that requires month on month improvement with a deficit plan of £17m in the first half of the year offset by an equivalent surplus plan of £17m in the second half of the year. The financial architecture in 2025/26 also means a greater majority of the trust’s income is fixed (or capped) therefore savings are required to be achieved mainly via cost out schemes covering both pay and non pay. All areas were asked to explore workforce reductions (5% for clinical divisions and 10% for corporate areas) and a financial improvement group was established, chaired by the CEO, to help drive the pace of efficiency improvement in a mindful way. As at August (month 5) the trust is reporting a deficit of £25m which is £10m behind plan. The key deficit drivers are as follows: Page 4 of 6 1. The trust continues to ‘overtrade’ on block contracts with activity exceeding funded levels. Demand management continues to be a focus for the trust engaging with system partners to ensure only the most appropriate patients are admitted to UHS. 2. Non-criteria to reside numbers have increased to peaks of over 275 from an average of 215 in 2024/25. This is over 20% of the trust’s bed base and has a significant cost in addition to clinical risks of patient deconditioning and infection. This remains a focus of the inpatient flow programme. 3. Mental health patient demand has grown from previous years with patients often requiring enhanced levels of support at a premium cost to the trust. UHS continues to work with system providers on improvements for this patient group. Despite these pressures however the trust has continued to ensure value for money remains an organisational priority and is focused on transforming services under the three workstreams of theatre optimisation, outpatients and inpatient flow. There are positive signs of month-on-month improvement, but this has not been at the required pace to deliver the year-to-date plan. At the current run rate the scale of deficit would not be sustainable for the trust, or affordable for the NHS, and for this reason a financial recovery plan has been developed, signed off by the Trust Board, and submitted to NHS England. This targets greater scale and pace of financial improvement to try and minimise the deficit. Further to this the trust remains on target to spend its full capital allocation for 2025/26 totalling over £74m for which £44m is externally funded following successful grant/business case applications. This includes further investment in the emergency department of £8m. This continued investment in capacity, digital and infrastructure helps support continued ongoing financial sustainability and efficiency improvements. 6. Human Resources Indicator Staff recommend UHS as a place to work % Staff survey engagement score (out of 10) Q1 25/26 47.7% 6.39 Q2 25/26 53.2% 6.60 The Q2 trust survey results reflect the staff Pulse survey completed in July. The organisation is now focussed on the national NHS staff survey which continues until November. The pulse survey indicates improvements since quarter one in both the survey engagement scores and recommendation as a place to work since. Given the financial and operational pressures within the organisation, the trust has increased the number of platforms for senior leaders to engage with staff ensuring feedback is heard and changes well communicated. The trust is also providing additional support services for those managing change within their teams. Indicator Target Staff Turnover (internal target; rolling 12 month) <=13.6% June 2025 10.4% July 2025 10.9% August 2025 10.1% Sickness absence 12 month rolling (internal target) <=3.7% 3.9% 3.9% 3.8% Turnover: In August 2025, there was a total of 122 WTE leavers, 35 WTE more than July 2025 (87 WTE). Division A recorded the highest number of leavers (37 WTE). Within Division A, Nursing and Midwifery Registered Page 5 of 6 staff group had the highest number of leavers (16 WTE). Divisions C and B had the second and third highest number of leavers (35 and 28 WTE respectively); with the largest number of leavers for Division C being the Additional Clinical Services staff group (12 WTE), while in Division B Nursing and Midwifery Registered staff group accounted for 11 WTE leavers. Sickness: The current rolling sickness rate is 3.8% (as of August 2025), this is 0.1% above the 25/26 target (3.7%) and a reduction of 0.1% compared with both July 25 and June 2025 (both 3.9%). In-month sickness for August 2025 was 3.3%, a reduction of 0.22% from July 2025. Year-to-date sickness is 3.4% as of August 2025. Page 6 of 6 Item 6.1 Report to the Council of Governors - 28 October 2025 Title: Governor Attendance at Council of Governors’ Meetings Sponsor: Jenni Douglas-Todd, Trust Chair Author: Karen Russell, Council of Governors’ Business Manager Purpose (type an ‘x’ in the appropriate box(es)) (Re)Assurance Approval Ratification Information x Strategic Theme (type an ‘x’ in the appropriate box(es)) Outstanding patient Pioneering research World class people outcomes, safety and innovation and experience Integrated networks and collaboration Foundations for the future N/A N/A N/A N/A N/A Executive Summary: Under the Trust’s constitution (paragraph 2.1 of Annex 5) if a governor fails to attend two successive meetings of the council of governors, his or her tenure of office is to be immediately terminated by the council of governors (CoG) unless the CoG is satisfied that: • the absences were due to reasonable cause; and • he/she will be able to attend meetings of the CoG within such a period as the CoG considers reasonable. Following the recent review, there was one governor who had failed to attend two successive ordinary meetings of the CoG. Reasons for non-attendance were provided and were due to reasonable causes. In order to ensure that the CoG considers the situation when a governor fails to attend two successive ordinary meetings of the CoG, the process is for the Chair or Company Secretary contact the governor to understand the reasons for this if these have not already been provided. The Chair or Company Secretary would then provide confirmation to the CoG as to whether this was due to reasonable causes and the governor’s ability to attend future meetings. This would also help to identify any steps that the Trust could take to facilitate attendance. The CoG is asked to confirm that it is satisfied that the process has been followed correctly to confirm that the failure of one current governor to attend two successive meetings of the CoG was due to reasonable causes and that they would be able to attend future meetings within a reasonable period. Contents: N/A Risk(s): N/A Equality Impact Consideration: N/A Item 6.2 Report to the Council of Governors - 28 October 2025 Title: Review of Council of Governors’ Expenses Reimbursement Protocol Sponsor: Jenni Douglas-Todd, Trust Chair Author: Craig Machell, Associate Director of Corporate Affairs and Company Secretary and Karen Russell, Council of Governors’ Business Manager Purpose (type an ‘x’ in the appropriate box(es)) (Re)Assurance Approval Ratification Information x Strategic Theme (type an ‘x’ in the appropriate box(es)) Outstanding patient Pioneering research World class people outcomes, safety and innovation and experience Integrated networks and collaboration Foundations for the future N/A N/A N/A N/A N/A Executive Summary: The Council of Governors’ Expenses Reimbursement Protocol is required to be reviewed regularly and at least once every three years. Following review, the rates at which travelling and other expenses are paid to governors remain consistent with HM Revenue and Customs (HMRC) ‘approved amounts’ therefore no changes are required. However, a minor change to some of the wording which was unnecessary was identified. The Council of Governors is asked to approve the proposed changes to the Council of Governors expenses reimbursement protocol which are shown as tracked changes on the attached document. Contents: N/A Risk(s): N/A Equality Impact Consideration: N/A Council of Governors expenses reimbursement protocol, Trust reference Description Level and type of document Target audience List related documents/policies (do not include those listed as appendices) Author(s) (names and job titles) Document sponsor Version number 34 This document sets out the policy and procedure for the payment of travelling and other expenses to governors and the rates at which these will be paid Level 1: applicable across the Trust Standard operating procedure – controlled document Governors, Corporate affairs team Constitution Karen FlahertyCraig Machell, Associate Director of Corporate Affairs Trust Chair This is a controlled document. Whilst this document may be printed, the electronic version posted on Staffnet is the controlled copy. Any printed copies of this document are not controlled. As a controlled document, this document should not be saved onto local or network drives but should always be accessed from Staffnet. 1 Date 28/04/22 Version control Author(s) Version created 3 Approval committee Board of Directors 28/10/2025 4 ? Date of Date next approval review due 28/04/2022 April 2025 28/10/2025 April 2028 Key changes made to document Updated rates at which travel expenses are paid and clarified policy in a number of areas. Minor changes to wording [Reference number]. Council of Governors expenses reimbursement protocol. Issued April 2022 Page 1 of 6 2 Index 1 Version control............................................................................................................................1 2 Index ...........................................................................................................................................2 3 Introduction .................................................................................................................................3 4 Scope..........................................................................................................................................3 5 Aim/purpose................................................................................................................................3 6 Training.......................................................................................................................................3 7 Travel..........................................................................................................................................3 8 Parking........................................................................................................................................4 9 Subsistence ................................................................................................................................4 10 Carers’ costs ...........................................................................................................................4 11 Completing expenses claim forms ..........................................................................................4 12 Roles and responsibilities .......................................................................................................5 13 Document review.....................................................................................................................5 14 Process for monitoring compliance .........................................................................................5 15 Appendices .............................................................................................................................6 16 References..............................................................................................................................6 [Reference number]. Council of Governors expenses reimbursement protocol. Issued April 2022 Page 2 of 6 3 Introduction The role of governor of a foundation trust is voluntary, and governors do not receive payment for this role. In accordance with paragraph 20 of the constitution of University Hospital Southampton NHS Foundation Trust (the Trust), the Trust should determine the rates at which travelling and other expenses are paid to governors. This document sets out the circumstances in which governors may be reimbursed for legitimate and necessary expenses incurred in the course of their duties as governors of the Trust. 4 Scope This policy and procedure applies to all governors. Where governors have been appointed by a partner organisation, in some cases that organisation may pay the expenses incurred by the appointed governor in performing the governor role in accordance with its own policies and procedures. 5 Aim/purpose Governors may incur expenses in carrying out their role. The expenses incurred will depend on each governor’s personal circumstances. All expenditure must be actually and necessarily incurred in carrying out the role and responsibilities of a governor. This will include travelling and other expenses for governors to attend council of governors’ meetings, board of directors’ meetings and committee or working group meetings as well as to any training or member events that the Trust requests governors to attend. The payment of expenses ensures that the Trust provides financial support to governors and they do not incur additional personal expenditure when performing their role. 6 Training The Trust has a duty to take steps to ensure that governors are equipped with the skills and knowledge they need to discharge their duties appropriately. Where training is not provided by the Trust, the Trust will be responsible for booking places on training courses, seminars and similar events for governors, therefore no Governor need incur any personal expense. Places at many external governor events are limited, so not all governors wishing to attend may be able to do so. Governors may identify and propose any suitable training opportunities they would like to attend to the Trust prior to such events taking place. Where approved by the Trust, the Trust will book places on these events. Any training, or similar events, booked directly by governors may not be funded by the Trust. 6 Travel Travel expenses will be paid at the rates set out below, which are the HM Revenue and Customs (HMRC) ‘approved amounts’, which do not require reporting or deductions for tax purposes. Governors should only claim for the return distance between their home and the Trust site or other venue or the distance travelled where this is less. When their journey starts from a location other than their home address and is further away than their home then this should be agreed with the Council of Governors’ Business Manager in advance. Public transport Cars and vans Paid on a like for like basis. Any claim must be supported by a valid ticket. Rail fares reimbursed at standard class only for advance purchase tickets. 45p per mile up to 10,000 miles and then 25p per mile thereafter. Governors are responsible for ensuring their private vehicles are appropriately insured. [Reference number]. Council of Governors expenses reimbursement protocol. Issued April 2022 Page 3 of 6 Passenger allowance Motorcycles Bikes Taxi Toll charges 5p per mile. This applies where a governor carries another governor in their own car or van. 24p per mile 20p per mile Taxis should only be used in exceptional circumstances where no other reasonable transport method is available or possible. Any claim must be supported by a valid taxi receipt issued by the driver. Any toll charges must be supported by a valid ticket/receipt. No driving penalties or fines will be reimbursed by the Trust. The Trust will not be responsible for any loss or damage to private vehicles or property or possessions. 7 Parking Redeemable tickets will be issued for you to use car park facilities at the Trust’s sites. Parking expenses incurred when attending meetings or events not held at Trust sites must be supported by a valid ticket/receipt. No traffic or parking fines will be reimbursed by the Trust. 8 Subsistence When away from the Trust sites and attending meetings that last more than five hours when meals are not provided, the Trust will reimburse governors subsistence claims in line with current staff allowances. The cost of any alcohol consumed, with or without meals, will not be reimbursed by the Trust and should not be claimed. Receipts for any expenditure will be required. Any potential claims for subsistence should be discussed with the Council of Governors’ Business Manager in advance. 9 Carers’ costs Governors may claim for reasonable carers’ costs for children under 16 and dependents, where there is medical or social services evidence that care is required and not already in place in order to attend meetings. Any potential claim for carers’ costs should be discussed with the Council of Governors’ Business Manager in advance. A receipt for the carers’ costs should be attached to the claim form. Expenses for carers’ costs will not be liable to deductions for tax and national insurance. I There is also some wording in brackets at the end of the carers costs section that should be removed as the actual costs would be paid provided that are not being paid/reimbursed by someone else. 10 Completing expenses claim forms The Trust will provide governors with an expenses claims form on request. Claim forms should be completed and returned to the Council of Governors’ Business Manager for authorisation as soon as possible after the expense has been incurred and no later than one month after the date on which the expenses were incurred. All claims (except mileage costs) should be supported by an itemised invoice or receipt. Claims, including invoices and receipts, received more than one month after the expenses were incurred could result in the claim not being paid depending on the reasons for this. In signing and dating the claim form, you are confirming: • that you actually and necessarily incurred the expense while carrying out your role as a governor; [Reference number]. Council of Governors expenses reimbursement protocol. Issued April 2022 Page 4 of 6 • that the journeys made were required for you to fulfil your duties and responsibilities as a governor; and • that you have not received any reimbursement from any other source for the expenses claimed. Claims will normally be reimbursed direct to the nominated bank or building society account by bank transfer. In order to ensure efficient reimbursement, the expenses claim form requests your bank details. This information will be held in the strictest confidence. 11 Roles and responsibilities Governors will be responsible for accurately completing expenses claims forms, retaining receipts and tickets to support any claim and submitting these to the Trust as soon as possible after the expense has been incurred and no later than one month of the date on which the expenses were incurred. The Council of Governors’ Business Manager will be responsible for making expenses claims forms available to governors, verifying that the claim relates to a meeting or event that governors were required or requested to attend and keeping accurate records of all claims submitted. The Associate Director of Corporate Affairs and Company Secretary will be responsible for making the final decision as to whether any claim should be accepted or accepted later than one month after the expenses were incurred. 12 Document review All Trust policies will be subject to a specific minimum review period of one year; we do not expect policies to be reviewed more frequently than annually unless changes in legislation occur or new evidence becomes available. The maximum review period for policies is every three years. The author of the policy will decide an appropriate frequency of review between these boundaries. Where a policy becomes subject to a partial review due to legislative or national guidance, but the majority of the content remains unchanged, the whole document will still need to be taken through the agreed process as described in this policy with highlighted changes. This Council of Governors reimbursement protocol will be reviewed every three years. 13 Process for monitoring compliance The purpose of monitoring is to provide assurance that the agreed approach is being followed. This ensures that we get things right for patients, use resources well and protect our reputation. Our monitoring will therefore be proportionate, achievable and deal with specifics that can be assessed or measured. Key aspects of this policy will be monitored: Element to be Total expenses incurred by all governors in each financial year as an monitored aggregate figure and comparative information from the previous year Lead (name/job title) Council of Governors’ Business Manager Tool Expenses claim forms and cost centre breakdown Frequency Annually Reporting This information is included in the Trust’s annual report and accounts arrangements Where monitoring identifies deficiencies actions plans will be developed to address them. [Reference number]. Council of Governors expenses reimbursement protocol. Issued April 2022 Page 5 of 6 14 Appendices Expenses claim form 15 References National Health Service Act 2006 [Reference number]. Council of Governors expenses reimbursement protocol. Issued April 2022 Page 6 of 6 Item 6.3 Report to the Council of Governors - 28 October 2025 Title: Appointment of Deputy Chair Sponsor: Jenni Douglas-Todd, Trust Chair Author: Karen Russell, Council of Governors’ Business Manager Purpose (type an ‘x’ in the appropriate box(es)) (Re)Assurance Approval Ratification Information x Strategic Theme (type an ‘x’ in the appropriate box(es)) Outstanding patient Pioneering research World class people outcomes, safety and innovation and experience Integrated networks and collaboration Foundations for the future N/A N/A N/A N/A N/A Executive Summary: In accordance with the paragraph 26.1 of the Trust’s constitution, the council of governors (CoG) is responsible for appointing the deputy chair. The current deputy chair, Keith Evans, will come to the end of his second term of office on 31 January 2026 therefore a new deputy chair needs to be appointed. It is usual practice for the Trust’s Chair to make a recommendation to the CoG as to who should be appointed to the role. Following discussion with non-executive directors, the Trust’s Chair would like to recommend to the CoG that Jane Harwood, non-executive director and senior independent director (SID), be appointed to the role of Deputy Chair. The NHS Code of Governance permits the same individual to serve as both the Deputy Chair and SID. The CoG is asked to approve the appointment of Jane Harwood as Deputy Chair with effect from 1 October 2025. Contents: N/A Risk(s): N/A Equality Impact Consideration: N/A 7.1 Report to the Council of Governors - 28 October 2025 Title: Membership Engagement Sponsor: Jenni Douglas-Todd, Trust Chair Author: Sam Dolton, events and membership officer Purpose (type an ‘x’ in the appropriate box(es)) (Re)Assurance Approval Ratification Information x Strategic Theme (type an ‘x’ in the appropriate box(es)) Outstanding patient Pioneering research World class people outcomes, safety and innovation and experience Integrated networks and collaboration Foundations for the future Executive Summary: This report aims to update the council on Trust membership and recent and planned engagement activities. Contents: Membership engagement report. Risk(s): This report is provided for the purpose of information. Equality Impact Consideration: N/A Overview of engagement Over the last three months we have continued to engage with our members. * All open rates as of 20 October 2025 Membership updates Our routine membership updates are split into two different formats: • A monthly newsletter to keep public members updated on what’s happening across the Trust and the ways they can get involved in various projects, with an edition produced in September. • A quarterly Connect digital magazine which mainly focuses on patient stories, UHS successes and individual/team achievements, with the autumn 2025 edition going out later in October. Update Type September 2025 Monthly update Date sent Sent to 17/09/2025 3,022 Bounces 64 Opens* 53% Other emails To mark Organ Donation Week in September we invited our public members to register their decision on the organ donation register. A link to the annual report and accounts 2024/25 was also sent to members in September. Email Register organ donation decision Annual report and accounts 2024/25 Date sent 22/09/2025 24/09/2025 Sent to 3,003 2,984 Bounces 65 65 Opens* 50% 47% Annual members’ meeting We held our annual members’ meeting in person on 8 October 2025. It included highlights of 2024/25 from the executive team, as well as a look at our current priorities, and a membership update from the lead governor. Following the presentation, there was a Q&A session with our executives covering a range of topics. Teams from across UHS took part in an exhibition showcasing their patient services and projects. In total 42 people attended the meeting (26 public members, 16 staff members), up from 17 last year. We have received 13 feedback forms: • 8 rating the event excellent • 4 good • 1 fair • 0 poor Positive feedback included: • “I thought David’s presentation was excellent. Pitched to the “layman” - not too medical, not too accounting.” • “It was a clear insight to both successes and challenges within the UHS. Very open and honest.” • “An excellent opportunity to understand the problems and to look at the possible solutions, given that there is an imbalance between supply and demand.” Suggestions for improvement: • “Microphones would have made hearing a lot easier.” • “Allow more time to be given to questions and to visit the range of stalls and the excellent We Are UHS display.” Public engagement on social Impressions = number of times a post has been displayed Engagement = number of likes, shares, comments We have been active across our social media channels, content with high engagement included: RSV protection for premature babies Earlier in October BBC News reported on the nationwide roll out of a new drug to protect premature babies from RSV this winter, following a successful trial at UHS. 124,076 impressions 9,378 en
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Governors/Papers-CoG-28.10.2025.pdf

Having a peripherally inserted central catheter (PICC) insertion - patient information

Description: This factsheet explains what a peripherally inserted central catheter (PICC) is and what the procedure to insert a PICC involves.
Url: /Media/UHS-website-2019/Patientinformation/Scansandx-rays/Having-a-peripherally-inserted-central-catheter-PICC-insertion-1922-PIL.pdf

Gentle low FODMAP diet - patient information

Description: This factsheet explains what FODMAPs are and what a gentle low FODMAP diet involves.
Url: /Media/UHS-website-2019/Patientinformation/Digestionandurinaryhealth/Gentle-low-FODMAP-diet-3924-PIL.pdf

Skin surgery under local anaesthetic - patient information

Description: This factsheet contains information about having skin surgery under local anaesthetic.
Url: /Media/UHS-website-2019/Patientinformation/Skin/Skin-surgery-under-local-anaesthetic-1757-PIL.pdf

Semaglutide for weight management in children - patient information

Description: This factsheet explains what semaglutide is, and what the potential benefits and risks of taking it are.
Url: /Media/UHS-website-2019/Patientinformation/Childhealth/Semaglutide-for-weight-management-in-children-3182-PIL.pdf

Liraglutide for weight management in children - patient information

Description: This factsheet explains what liraglutide is, and what the potential benefits and risks of taking it are.
Url: /Media/UHS-website-2019/Patientinformation/Childhealth/Liraglutide-for-weight-management-in-children-3181-PIL.pdf

311 to 320 of 772

Previous … 30 31 32 33 34 … Next

Browse site A to Z

Search results

MP000 028 Cellular pathology user handbook v24

Community diagnostic centre - referral for lung function testing - respiratory physiology service

Papers Trust Board - 11 November 2025

Glasses for children - patient information

Papers CoG 28.10.2025

Having a peripherally inserted central catheter (PICC) insertion - patient information

Gentle low FODMAP diet - patient information

Skin surgery under local anaesthetic - patient information

Semaglutide for weight management in children - patient information

Liraglutide for weight management in children - patient information

Site policies

Contact details

Useful links