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Standing Financial Instructions

Description: These Standing Financial Instructions (SFIs) are issued for the regulation of the conduct of Trust members and officers in relation to
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Finance/StandingFinancialInstructions.pdf

Papers Trust Board - 29 November 2022

Description: Date Time Location Chair Agenda Trust Board – Open Session 29/11/2022 9:00 - 13:20 Conference Room, Heartbeat/Microsoft Teams
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Trust-governance-and-corporate-docs/2022-Trust-documents/Papers-Trust-Board-29-November-2022.pdf

Papers Trust Board - 15 July 2025

Description: Agenda Trust Board – Open Session Date 15/07/2025 Time 9:00 - 13:00 Location Conference Room, Heartbeat Education Centre Chair Jenni Douglas-Todd Apologies Alison Tattersall In attendance Lauren Anderson, Corporate Governance and Risk Manager (from 9:30) (shadowing Craig Machell) 1 Chair’s Welcome, Apologies and Declarations of Interest 9:00 Note apologies for absence, and to hear any declarations of interest relating to any item on the Agenda. 2 Patient Story The patient story provides an opportunity for the Board to reflect on the experiences of patients and staff within the Trust and understand what the Trust could do better. 3 Minutes of Previous Meeting held on 13 May 2025 9:15 Approve the minutes of the previous meeting held on 13 May 2025 4 Matters Arising and Summary of Agreed Actions To discuss any matters arising from the minutes, and to agree on the status of any actions assigned at the previous meeting. 5 QUALITY, PERFORMANCE and FINANCE Quality includes: clinical effectiveness, patient safety, and patient experience 5.1 Briefing from the Chair of the Audit and Risk Committee 9:20 Keith Evans, Chair 5.2 Briefing from the Chair of the Finance and Investment Committee 9:25 Dave Bennett, Chair 5.3 Briefing from the Chair of the People and Organisational Development 9:30 Committee Jane Harwood, Chair 5.4 Briefing from the Chair of the Quality Committee 9:35 Tim Peachey, Chair including Maternity and Neonatal Safety 2024-25 Quarter 4 Report and Maternity and Neonatal Workforce Report 5.5 Chief Executive Officer's Report 9:40 Receive and note the report Sponsor: David French, Chief Executive Officer 5.6 Performance KPI Report for Month 2 10:10 Review and discuss the report Sponsor: David French, Chief Executive Officer 5.7 Break 10:40 5.8 Finance Report for Month 2 10:55 Review and discuss the report Sponsor: Ian Howard, Chief Financial Officer 5.9 ICS Operational Delivery Report for Month 2 11:05 Receive and discuss the report Sponsor: Ian Howard, Chief Financial Officer 5.10 People Report for Month 2 11:10 Review and discuss the report Sponsor: Steve Harris, Chief People Officer 5.11 Freedom to Speak Up Report 11:20 Review and discuss the report Sponsor: Gail Byrne, Chief Nursing Officer Attendee: Christine Mbabazi, Equality & Inclusion Adviser/Freedom to Speak Up Guardian 5.12 Infection Prevention and Control 2024-25 Annual Report 11:30 Receive and discuss Sponsor: Gail Byrne, Chief Nursing Officer Attendees: Julian Sutton, Clinical Lead, Department of Infection/Julie Brooks, Deputy Director of Infection Prevention and Control 5.13 Guardian of Safe Working Hours Quarterly Report 11:40 Receive and discuss the report Sponsor: Paul Grundy, Chief Medical Officer 6 STRATEGY and BUSINESS PLANNING 6.1 Corporate Objectives 2025-26 Quarter 1 Review 11:50 Review and feedback on the corporate objectives Sponsor: David French, Chief Executive Officer Attendee: Martin De Sousa, Director of Strategy and Partnerships 6.2 Research and Development Plan 2025-26 12:00 Discuss and approve the plan Sponsor: Paul Grundy, Chief Medical Officer Attendees: Christopher Kipps, Clinical Director of R&D/Karen Underwood, Director of R&D/Laura Purandare, Deputy Director of R&D Page 2 6.3 Board Assurance Framework (BAF) Update and Risk Appetite Statement 12:10 Review and discuss the update. Review and ratify the risk appetite statement. Sponsor: Gail Byrne, Chief Nursing Officer Attendees: Craig Machell, Associate Director of Corporate Affairs and Company Secretary/Lauren Anderson, Corporate Governance and Risk Manager 7 CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Register of Seals and Chair's Actions Report 12:30 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 7.2 Review of Standing Financial Instructions 2025 12:35 Review and approve the SFIs Sponsor: Ian Howard, Chief Financial Officer Attendee: Phil Bunting, Director of Operational Finance 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: 9 September 2025 10 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. 11 Follow-up discussion with governors 12:45 Page 3 Agenda links to the Board Assurance Framework (BAF) 15 July 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 2 5.8 Finance Report for Month 2 5.9 ICS Finance Report for Month 2 5.10 People Report for Month 2 5.11 Freedom to Speak Up Report 5.12 Infection Prevention and Control 2024-25 Annual Report 5.13 Guardian of Safe Working Hours Quarterly Report 6.1 Corporate Objectives 2025-26 Quarter 1 Review 6.2 Research and Development Plan 2025-26 1a, 1b, 1c 5a 5a 3a, 3b, 3c 3b 1c 3b All 2a 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) 4x5 20 Target risk rating 4 x 2 Apr 6 27 3 x 2 Apr 6 27 2 x 3 Apr 6 27 3 x 2 Mar 6 27 4 x 3 Mar 12 30 4 x 2 Mar 8 30 3 x 2 Mar 6 29 3 x 2 Dec 6 25 3 x 3 Apr 9 30 Cautious (Effectiveness) Open (Technology & Innovation) Open (Technology & Innovation) 4x5 20 3x4 12 2x4 8 4 x 2 Apr 8 30 3 x 2 Apr 6 27 2 x 2 Dec 4 27 Does this item facilitate movement towards or away from the intended target risk score and appetite? Towards Away Neither x x x x x x x x x Minutes Trust Board – Open Session Date 13/05/2025 Time 9:00 – 13:00 Location Conference Room, Heartbeat/Microsoft Teams Chair Jenni Douglas-Todd (JD-T) Present Dave Bennett, NED (DB) Gail Byrne, Chief Nursing Officer (GB) Jenni Douglas-Todd, Chair (JD-T) Diana Eccles, NED (DE) David French, Chief Executive Officer (DAF) Paul Grundy, Chief Medical Officer (PG) Steve Harris, Chief People Officer (SH) Jane Harwood, NED/Senior Independent Director (JH) Ian Howard, Chief Financial Officer (IH) Duncan Linning-Karp, Interim Chief Operating Officer (DL-K) David Liverseidge, NED (DL) Tim Peachey, NED (TP) In attendance Martin De Sousa, Director of Strategy and Partnerships (MDeS) Craig Machell, Associate Director of Corporate Affairs and Company Secretary (CM) Ceri Connor, Director of OD and Inclusion (CC) (item 5.11) Lauren Anderson, Corporate Governance and Risk Manager (LA) (item 6.2) Diana Hulbert, Guardian of Safe working Hours and Emergency Department Consultant (DH) (item 5.12) Kelly Kent, Head of Strategy and Partnerships (KK) (item 6.1) Jenny Milner, Associate Director of Patient Experience (JM) (item 5.13) Natasha Watts, Deputy Chief Nursing Officer (NW) (item 5.13) Helena Blake, Head of Clinical Quality Assurance (shadowing G Byrne) Raquel Domene Luque, Interim Lead Matron, Ophthalmology (shadowing G Byrne) 1 governor (observing) 6 members of staff (observing) 3 members of the public (observing) Apologies Keith Evans, Deputy Chair and NED (KE) Alison Tattersall, NED (AT) 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 Keith Evans and Alison Tattersall. 2. Patient Story Item postponed to the next meeting. 3. Minutes of the Previous Meeting held on 11 March 2025 The draft minutes tabled to the meeting were agreed to be an accurate record of the meeting held on 11 March 2025. Page 1 4. Matters Arising and Summary of Agreed Actions The matters arising and actions were noted. It was noted that action 1218 could be closed. 5. QUALITY, PERFORMANCE and FINANCE 5.1 Briefing from the Chair of the Audit and Risk Committee Ian Howard was invited to present the Committee Chair’s Report in respect of the meeting held on 17 March 2025, the content of which was noted. It was further noted that: • The committee considered the going concern assessment in respect of the 2024/25 annual accounts and agreed that it was appropriate that the accounts be prepared on a going concern basis. • The committee additionally noted that there had been no significant issues raised by the Trust’s external auditors. • The committee received a report on losses and special payments during 2024/25, noting that these payments generally related to lost patient property. • An update was received in respect of Information Governance. The Trust – in common with most others – was not expected to meet the standards set out in the Data Security and Protection Toolkit due to the introduction of the Cyber Assurance Framework as part of the Toolkit requirements. 5.2 Briefing from the Chair of the Finance and Investment Committee The chair of the Finance and Investment Committee was invited to present the Committee Chair’s Reports in respect of the meetings held on 24 March and 28 April 2025, the content of which was noted. It was further noted that: • The committee reviewed the Finance Report for Month 12 (item 5.8), noting that the Trust had achieved its forecast deficit of £7m for 2024/25 following the receipt of revenue support. Furthermore, the Trust had achieved £85.3m of Cost Improvement Programme delivery and Elective Recovery performance of 127%. Nonetheless, the Trust’s underlying deficit was circa £75m. • The Trust’s cash position remained challenging with the Trust likely to require revenue support during either the first or second quarters of 2025/26. • The committee reviewed the Trust’s proposed 2025/26 plan during March 2025 and noted that there were no material changes between the draft reviewed and that submitted on 23 April 2025. • The committee supported a proposal for the Trust to participate in the elective hub at Winchester. 5.3 Briefing from the Chair of the People and Organisational Development Committee The chair of the People and Organisational Development Committee was invited to present the Committee Chair’s Reports in respect of the meetings held on 24 March and 25 April 2025, the content of which was noted. It was further noted that: • The committee received a briefing in respect of the Staff Survey 2024 (item 5.11). • The committee reviewed the People Report for Month 12 (item 5.10), noting that the Trust had ended the year 373 whole-time-equivalents (WTE) above plan. This was largely due to the reductions in patients having no criteria to reside and mental health patients not materialising. In addition, there had been higher than normal use of bank staff in March 2025 and lower than anticipated staff turnover. Page 2 • An update in respect of the planned organisational restructuring, including regarding the Equality and Quality Impact Assessment process being developed. • It was considered likely that the delivery of the Trust’s 2025/26 workforce plan would necessitate additional workforce controls. It would be important to ensure that appropriate support was provided to staff in managing at a time of increased demand, financial pressures, and a reducing workforce. 5.4 Briefing from the Chair of the Quality Committee The chair of the Quality Committee was invited to present the Committee Chair’s Report in respect of the meeting held on 17 March 2025, the content of which was noted. It was further noted that: • The committee reviewed the Trust’s quality indicators, which continued to indicate that the organisation was under pressure. • Following an incident at Derriford Hospital in Plymouth on 4 March 2022 whereby a member of the public had suffered fatal injuries due to the downwash from a landing helicopter, the Trust had commissioned a review of its own safety arrangements. It was noted that some additional safety measures would be required. • A visit by NHS South East Region to the Princess Anne Hospital in February 2025 had provided some positive feedback about the service. The Maternity and Neonatal Safety 2024/25 Quarter 3 Report was noted. It was further noted that: • The report had been reviewed by the Quality Committee at its meeting held on 17 March 2025. • The proportion of births via caesarean section remained high at over 40%, with late requests in particular placing additional pressure on theatre capacity. • Following successful recruitment of additional staff in late 2024, operational pressures had reduced substantially compared with the previous situation. • A never event relating to a missing swab was under investigation. • The Trust was currently over establishment in terms of its number of midwives and expected to be staffed above the requirement indicated by the anticipated birthrate for the area by the end of 2025/26. 5.5 Chief Executive Officer’s Report David French was invited to present the Chief Executive Officer’s Report, the content of which was noted. It was further noted that: • Significant reorganisations of NHS England and integrated care boards (ICBs) had been announced. NHS England was to be abolished, and certain functions merged into the Department of Health and Social Care. Integrated care boards were expected to have to reduce their costs by 50%. • A ‘model’ integrated care board blueprint had been published, which appeared to imply that a significant proportion of ICB functions could be redistributed to providers. • It was expected that the number of ICBs would reduce to 25-30, with each serving populations of c.2m. In Hampshire, ICB and local authority boundaries were expected to align, which was considered to be beneficial. • The British Social Attitudes Survey 2024 showed the lowest satisfaction rating for the NHS since the survey began. • The Spring Statement and subsequent messaging indicated that there would not be additional funding during 2025/26. • The Trust continued to face significant pressure due to patients having no criteria to reside. Historically, there were typically around 100 such patients at Page 3 any one time, whereas 281 had been reported on 13 May 2025. This was the equivalent of six wards. • The Trust faced significant financial pressure during 2025/26 with a lower financial settlement than expected. In order to meet its plans, the Trust would be required to deliver c.£110m of Cost Improvement Programmes, reductions of 5% in divisions and 10% in Trust Headquarters, coupled with clinical and non-clinical recruitment controls. The Trust continued to experience high demand for services, especially in the Emergency Department. • It was important to protect the frontline and assist the organisation with managing at such a time. 5.6 Performance KPI Report for Month 12 Duncan Linning-Karp was invited to present the Performance KPI Report for Month 12, the content of which was noted. It was further noted that: • The Trust continued to face significant challenges in terms of its Emergency Department performance, with only 57.2% of patients spending less than four hours in the main Emergency Department. An external review was to take place. • There had been a four-month trajectory of increasing numbers of falls. Whether there was any correlation between the increasing number of falls and number of patients having no criteria to reside was being investigated. • The Trust continued to report strong Elective Recovery performance, although the size of the Trust’s waiting list continued to increase. There was some concern as to whether the financial pressures were impacting elective performance and waiting times. • There had been a decrease in the number of virtual outpatient appointments. • Ten never events had been reported as of the end of March 2025. The Trust expected regulatory scrutiny as a result. • The metrics reported in respect of research and development were being reevaluated. Duncan Linning-Karp was invited to present the spotlight on the Mental Health Patient Cohort, the content of which was noted. It was further noted that: • Regular reports on mental health patients were provided to the Quality Committee. • During 2024, there were 347 patients with a decision to admit to a mental health bed whilst at UHS (2023: 303), of these only 13.2% were transferred within the expected 12 hours (2023: 18.5%). During the first quarter of 2025, there had been 92 such patients. If the numbers remained consistent for the rest of 2025, a growth rate of 6% was expected. • In terms of patients brought to the Emergency Department as a hospital-based place of safety detained under section 136 of the Mental Health Act 1983, only 22% of patients brought to the Trust had a physical need, whereas the remaining patients were brought to the Emergency Department due to the lack of an available facility. • There were insufficient beds available at mental health providers, who were also impacted by delayed discharges. • The enhanced care required by mental health patients placed significant demand on the Trust’s resources. The situation appeared to be worsening with around 100 patients at any one time, of which around 10 were acute. • The Trust has met with the Integrated Care Board and mental health provider to push for a working group to address the issue that care for mental health patients at the Trust cost significantly more than the cost for looking after Page 4 patients at a dedicated facility due to the need to engage specialist agency staff. Actions Duncan Linning-Karp agreed to investigate why the number of virtual outpatients appointments had reduced. Gail Byrne agreed to examine the trend in respect of the friends and family test negative score for inpatients. 5.7 Break 5.8 Finance Report for Month 12 Ian Howard was invited to present the Finance Report for Month 12, the content of which was noted. It was further noted that: • The Trust had delivered its forecast £7m deficit at year end. This had been achieved through a combination of additional Cost Improvement Programme (CIP) delivery and additional revenue support • Whilst the Trust had delivered £85.3m of CIP, a significant proportion of this was non-recurrent. The Trust continued to record an underlying deficit of £6- 7m per month. • The Trust had £17m in cash, below its usual minimum holding of £30m. The Trust continued to closely monitor and manage its cash position, but it was likely that support would be required in the first quarter. • During 2024/25, the Trust had carried out £34m of unpaid for activity, particularly in terms of Emergency Department, non-elective and outpatient follow ups. There were, however, limited opportunities to reduce this activity due to quality impacts . 5.9 ICB Finance Report for Month 12 Ian Howard was invited the present the ICB Finance Report for Month 12, the content of which was noted. It was further noted that: • The Hampshire and Isle of Wight Integrated Care System had achieved a breakeven position for 2024/25. It was noted that this represented a significant achievement given that the system was reporting a cumulative deficit of £80m at Month 5. • The system-wide transformation programmes had had a lower-than-expected impact on the Trust. 5.10 People Report for Month 12 Steve Harris was invited to present the People Report for Month 12, the content of which was noted. It was further noted that: • At year end the Trust was 373 WTE above its 2024/25 plan. There had been a significant increase in use of bank staff in March 2025 due to annual leave and the number of mental health patients. The size of the substantive workforce had, however, reduced, albeit at a lower level than expected. • The formal consultation in respect of the organisational changes had been commenced with the unions. The Trust would be moving from four to three divisions and reducing its workforce. • The Trust had announced its intention to reduce the size of its workforce by 780 WTE (c.6%). This was to be achieved via a combination of natural Page 5 attrition and vacancy control and through a Mutually Agreed Resignation Scheme. • There were a number of risks to achievement of the Trust’s 2025/26 workforce plan, including: quality and safety risks (mitigated through Equality and Quality Impact Assessment); a lower-than-expected turnover rate due to a lack of opportunities elsewhere; the Trust’s cash position; and delivery of non-criteria to reside and mental health patient reductions. • The Trust had released a statement to staff and was awaiting guidance in respect of the recent Supreme Court ruling regarding the definition of a woman under the Equality Act 2010. 5.11 UHS Staff Survey Results 2024 Report Steve Harris was invited to present the UHS Staff Survey Results 2024 Report, the content of which was noted. It was further noted that: • The results of the Staff Survey had been discussed in detail by the People and Organisational Development Committee on 24 March 2025 and at a Trust Board Study Session held on 1 April 2025. • The Trust benchmarked well in certain areas, such as recommendation as a place to work and in terms of views of line management. However, the response rate was lower than in previous years and violence and aggression and civility and dignity scores remained areas of concern. The Board discussed the results of the Staff Survey and agreed that the Trust should focus its efforts on violence and aggression and on helping staff to manage change. It was noted that there was a strong correlation between line manager engagement and the survey response rate. 5.12 Guardian of Safe Working Hours Quarterly Report Diana Hulbert was invited to present the Guardian of Safe Working Hours Quarterly Report, the content of which was noted. It was further noted that: • There was to be a change in the exception reporting process from September 2025. The Trust was considering how best to manage these changes. • The financial constraints during 2025/26 would potentially impact the locum fill rate. • The Trust’s estate remained an issue, but work was ongoing, including consideration of re-purposing existing spaces. • Concerns had been expressed from some seeking consultant posts about the impact of the organisational changes on these opportunities. • The duration of handovers continued to result in breaches of working hour limits. 5.13 Learning from Deaths 2024-25 Quarter 3 and 4 Reports Jenny Milner was invited to present the Learning from Deaths Report, the content of which was noted. It was further noted that: • The Trust’s expected death rate remained lower than the national average, with the Trust ranked 12 out of 119. Page 6 • Further improvements in terms of the sharing of learning from Mortality and Morbidity meetings were required. Consideration was been given to using the Ulysses tool. • The Trust’s medical examiner service had reviewed more than 1,000 deaths since inception. 6. STRATEGY and BUSINESS PLANNING 6.1 Corporate Objectives 2024-25 Quarter 4 Review Martin de Sousa and Kelly Kent were invited to present the Corporate Objectives 2024/25 Quarter 4 Review, the content of which was noted. It was further noted that: • The Trust had delivered 50% of its annual objectives for 2024/25 and 37.5% of objectives had been partially achieved or had incurred minor delays. Two objectives remained ‘red’. • Particular areas to highlight included progress on long-waiters, patient experience, turnover/sickness of staff, and capital scheme delivery. The Trust had also been successful in slowing the rate by which the waiting list grew and in delivering Cost Improvement Programmes. • Areas of concern included the financial position, patients with no criteria to reside, and staff experience. • The Trust was in control of the delivery of some of the objectives, but full delivery of others was outside of the Trust’s control. 6.2 Board Assurance Framework (BAF) Update Lauren Anderson was invited to present the Board Assurance Framework (BAF) Update, the content of which was noted. It was further noted that: • The BAF had been previously reviewed by the Board in March 2025, following which it had been reviewed by the relevant executive directors and committees. • None of the ratings of the risks had been amended. However, the target dates for three risks had been extended to reflect the challenges in achieving the target rating. • The Trust was holding a higher overall level of risk than had previously been the case. It was considered important to ensure that risks were managed across domains and not in silos. • The Trust was using its risk appetite to support decision-making such as in capital prioritisation and in terms of the decisions required to deliver its 2025/26 plans. • A risk appetite review had been scheduled at a future Trust Board Study Session on the basis that the current situation potentially necessitated changes in terms of the Trust’s stated risk appetite. Action The review of risk appetite was to be scheduled to take place at the Trust Board Study Session on 3 June 2025. Page 7 6.3 South Central Regional Research Delivery Network (SC RRDN) 2024-25 Annual Performance Review and 2025-26 Annual Plan Paul Grundy and Clare Rook were invited to present the South Central Regional and Research Delivery Network (SC RRDN) 2024/25 Annual Performance Review and the SC RRDN 2025/26 Annual Plan, the content of which was noted. It was further noted that: • During the year the organisation transitioned from the Clinical Research Network Wessex to the South Central Regional Research Delivery Network, whereby the Wessex and Thames Valley and Midlands Clinical Research Networks were integrated into a single entity. • In the Wessex region, 33,000 participants were recruited to over 500 studies during the first half of the year. A further 35,000 participants were recruited to over 800 studies during the second half of the year in the South Central region. • Commercial research remained a priority, with the South Central region benchmarking well in terms of recruitment. • In terms of the 2025/26 plan, the NHS 10-year plan was awaited, as this would likely impact the plan. It was currently intended that the network would focus on the National Institute for Health Research’s seven priorities. A stakeholder group was being convened to inform the SC RRDN’s direction of travel. 7. CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Feedback from the Council of Governos’ (CoG) meeting 29 April 2025 The Chair presented a summary of the Council of Governors’ meeting held on 29 April 2025. It was noted that the meeting had considered the following matters: • Chief Executive Officer’s Performance Report • Annual Report and Quality Account Timetable 2024/25 • Draft Quality Account • Corporate Objectives • Non-NHS Activity • Governor Attendance at Council of Governor meetings • Council of Governors’ Elections 2025 • Appointment to the Governors’ Nomination Committee • Membership Engagement and Governor activity • Chair’s and Non-Executive Directors’ appraisal outcomes 7.2 Register of Seals and Chair’s Actions Report The paper ‘Register of Seals and Chair’s Actions Report’ was presented to the meeting, the content of which was noted. It was further noted that, due to an issue with the electronic signature platform, a number of items were included in the report, which should have been included in previous reports. Decision: The Board agreed to ratify the application of the Trust Seal to the documents listed in the ‘Register of Seals and Chair’s Actions Report’. Page 8 8. Any other business Gail Byrne informed the Board that a joint targeted area inspection of the Trust’s Emergency Department and Maternity service by the Care Quality Commission (CQC), social services and the police was scheduled to take place on 20 May 2025, which would focus in particular on safeguarding of children. In addition, a routine Ionising Radiation (Medical Exposure) Regulations inspection was due to take place in June 2025. It was noted that the CQC had recently carried out unannounced inspections at Portsmouth Hospitals University NHS Trust and at South Central Ambulance Service NHS Foundation Trust. Accordingly, it appeared likely that the Trust should also expect an unannounced CQC visit, followed by a Well-Led review. It was noted that this was Dave Bennett’s last formal scheduled Board meeting, as his second three-year term was due to expire on 14 July 2025. The Board expressed its thanks to Dave Bennett. 9. Note the date of the next meeting: 15 July 2025 10. Resolution regarding the Press, Public and Others Decision: The Board resolved that, as permitted by the National Health Service Act 2006 (as amended), the Trust’s Constitution and the Standing Orders of the board of directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. The meeting was adjourned. Page 9 List of action items Agenda item Assigned to Deadline Trust Board – Open Session 13/05/2025 - 5.6 Performance KPI Report for Month 12 1246. Virtual outpatients appointments Linning-Karp, Duncan 15/07/2025 Explanation action item Duncan Linning-Karp agreed to investigate why the number of virtual outpatients appointments had reduced. 1247. Friends and family test Byrne, Gail 15/07/2025 Explanation action item Gail Byrne agreed to examine the trend in respect of the friends and family test negative score for inpatients. Trust Board – Open Session 13/05/2025 - 6.2 Board Assurance Framework (BAF) Update 1248. Risk appetite Byrne, Gail 03/06/2025 Explanation action item The review of risk appetite was to be scheduled to take place at the Trust Board Study Session on 3 June 2025. Status Pending Pending Completed Page 1 of 1 Agenda Item 5.1 Committee Chair’s Report to the Trust Board of Directors 15 July 2025 Committee: Audit & Risk Committee Meeting Date: 9 June 2025 Key Messages: • • • • • The committee considered the results of a review of historical private activity (pre-2022/23) which had not been invoiced by the Trust. It was noted that, of the £2.5m total, £1.6m had since been paid, but that £0.9m should be written off. It was further noted that this issue should not arise in future due to changes in contracting arrangements and improvements in processes. The committee noted an update in respect of the Trust’s submission as part of the annual National Cost Collection exercise. The committee received a report on waivers of competitive tendering between October 2024 and March 2025, noting that these represented c.£11m of activity over the period. The committee reviewed a draft of the Annual Report and Accounts for 2024/25. The committee noted that the external audit had not progressed as planned. The committee received the Quarter 4 Fraud, Bribery and Corruption Work Plan Update Report, noting that under the Counter-Fraud Functional Return that the Trust was green-rated. Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) 6.3 Board Assurance Framework (BAF) Update Assurance Rating: Risk Rating: Substantial N/A • There had been an increase in the number of critical risks recorded from 30-35 to c.50. Many of these risks related to staffing or capacity. • It was noted that some of this increase was driven by new risks being identified (or existing risks worsening), but that existing critical risks were not being closed due to insufficient resources. • In addition, following the Six Facet survey, there had been an improvement in the articulation of Estates-related risks, which was now reflected in the total number of operational risks. • The committee reviewed the Board Assurance Framework, noting that all risks had been reviewed by the relevant executive(s). 7.2 Review of Standing Assurance Rating: Risk Rating: Financial Instructions 2025-26 Substantial N/A • The committee reviewed the Trust’s Standing Financial Instructions, noting that changes were proposed to two areas: employee expenses and non-pay requisition limits. Any Other Matters: • The committee reviewed the Trust’s internal audit plan and agreed that a cyber security audit should be included as part of the plan. 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 15 July 2025 Committee: Finance and Investment Committee Meeting Date: 2 June 2025 Key Messages: Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) • The committee reviewed the Finance Report for Month 1. The Trust had reported a deficit of £4.4m in line with its plan whereby the Trust would move from a deficit to breakeven to surplus over the course of the year thereby achieving an overall breakeven position at year end. • The Trust’s underlying deficit was £7.2m in month. This was driven by patients having no criteria to reside, activity above block contract levels, and mental health patients. Use of bank staff had normalised when compared to Month 12, but there had been high drugs spend and lower than expected income which was under investigation. • The Trust was on track in terms of its Cost Improvement Programme (CIP). • The committee received an update in respect of the Trust’s cash position, noting that the Integrated Care Board had agreed to move scheduled payments to aid the Trust’s position. The Trust was forecasting a £7m negative balance in March 2026. • The committee reviewed the ‘Acute Drivers of Deficit’ report prepared by Deloitte, noting that many of the identified areas were long-term and/or structural issues. • The committee received an update on the Trust’s financial improvement programmes, noting that although c.£80m of the £110m CIP was currently viewed as ‘high risk’, this was expected to improve as schemes became more mature. • The committee noted the Trust’s response to a request to consider proposed workforce targets based on removing 50% of reported increases in corporate services expenditure since 2018/19. It was noted that the Trust expected to deliver this target through its existing plans. • The committee received an update in respect of the national and local contracting process, noting that most areas had now been agreed. The potential changes in Elective Recovery Funding posed a risk to the Trust. In addition, it was likely that £20-30m of activity would remain unfunded. N/A Any Other Matters: The committee received the Always Improving – Transformation End of Year Report, noting progress made. 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 15 July 2025 Committee: Finance and Investment Committee Meeting Date: 23 June 2025 Key Messages: • • • • • The committee reviewed the Finance Report for Month 2 (see below). The committee received an update in respect of the Trust’s cash position, noting that the position continued to deteriorate. It was further noted that discussions were underway with local providers, as some providers have cash whilst at the same time others risked running out. The committee received an update on the Urgent and Emergency Care Transformation Programme, noting that the Trust was targeting a reduction in length of stay by a further 5%. The committee noted an update from UHS Estates Limited and progress on a number of programmes. The committee considered a summary of the Spending Review presented by the Chancellor of the Exchequer on 11 June 2025. Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) 5.8 Finance Report for Month 2 Assurance Rating: Risk Rating: Substantial High • The Trust had recorded an in-month deficit of £3.8m, which was in line with its plan to reach a breakeven position by year end. • The Trust had achieved its planned Cost Improvement Programme delivery level, although much of this was due to non-recurrent savings, which creates a challenge later in the year. • The Trust’s underlying deficit remained at £7.2m, consistent with Month 1. • Income had been lower than expected with reductions in income from pathology and the Channel Islands. Non-pay costs for drugs and clinical supplies also remained a challenge. • The committee reviewed the Trust’s workforce trajectory for 2025/26, noting that even if all ‘red’ CIP schemes were to deliver, this would still result in a shortfall. 6.2 Board Assurance Framework (BAF) Update Assurance Rating: Risk Rating: Substantial N/A • Risks 5a, 5b and 5c have been updated, following discussions with the respective Executive Director(s). Any Other N/A Matters: Page 1 of 2 Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Limited Assurance Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. No Assurance There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Not Applicable Where assurance is not required and/or relevant. Risk Rating: Low Medium High Not Applicable Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda Item 5.3 Committee Chair’s Report to the Trust Board of Directors 15 July 2025 Committee: People and Organisational Development Committee Meeting Date: 25 June 2025 Key Messages: • The committee reviewed the People Report for Month 2 including progress on the Workforce Plan for 2025/26 (see below). • The committee noted that the plans for the Divisional restructure are now underway with the intention of implementing these on 01 July 2025. It is understood that whilst not all people plans have been finalised at a granular level, it is anticipated that most issues will be resolved through natural attrition and through the Mutually Agreed Resignation Scheme (MARS). • The MARS application window has now closed and there has been significant interest with 220+ applications submitted. These are currently being assessed for suitability and it is planned that the outcomes will be shared with applicants by 04 July 2025. Not all applications will be accepted as some posts cannot be surrendered, and the organisation cannot afford to accept them all. Whilst each resignation will represent a long-term saving there is a very real risk to in year cost pressures as all successful MARS applications will need to be funded locally, as there is no national funding to support this. • Additional recruitment controls also remain in place including a freeze on non-clinical recruitment, and a hold on 30% of clinical recruitment. • The committee noted that the scale of organisational change is significant and this is likely to be unsettling for staff. A number of support mechanisms have been implemented focussed on wellbeing, and this includes specific organisational change workshops targeted at leaders across the Trust to support them in supporting the wider workforce. The committee reflected that this is a positive step and that once the organisational restructure has completed, this should be used as a foundation for implementing change and leadership training as business as usual. • The committee received an update on the organisation’s education position and the current challenges and opportunities related to this. The committee acknowledged the significant risk to future workforce as a result of the current challenges across the NHS, in combination with the restricted and reduced funding streams which facilitate staff access to education and development. The committee noted the need to review education capacity again at UHS once the long-term workforce plan is published later in the year. Page 1 of 2 Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) Any Other Matters: 5.10 People Report for Month 12 Assurance Rating: Risk Rating: Substantial High • The Trust’s overall workforce grew by 19 WTE in May 2025 however it is still below the NHSE plan by 107 WTE. It was noted that turnover remains lower than average and it is suspected that this will be due to system wide recruitment controls limiting roles UHS staff may move into, in addition to a wider lack of opportunity in the jobs market as general employer confidence reduces. • Additionally, whilst both remain below plan, there has been an increase in temporary staffing bank and agency usage noting that April was a very low month. • The committee noted that the workforce plan is ambitious and sets out a reduction in headcount of c.750. All schemes to deliver this have been assessed for maturity and continue to be worked up, although even if it were to be assumed that all are followed through to completion, there is still a shortfall which needs to be addressed. Significant work has been undertaken to forward plan the trajectory. • It was noted that consideration had been given to the recruitment controls and whether these needed to be taken further, however as it will take several months to fully implement and see the benefit of those in place currently, this was decided against. The improvements in forecasting, and monthly review, will support this decision so that it can be reviewed again later in the year, probably September. • The committee discussed the need to track indicators related to people, money, performance and quality and consideration will be given to a balanced scorecard. • The committee received a further update in respect of the Band 2/3 pay dispute and in respect of the portering department. • The committee also received a series of updates on recent national letters to Trusts including a required review of job evaluation processes and analysis work on non-frontline nursing roles. Page 2 of 2 Agenda Item 5.4 Committee Chair’s Report to the Trust Board of Directors 15 July 2025 Committee: Quality Committee Meeting Date: 2 June 2025 Key Messages: Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) Any Other Matters: • It was n
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EDI Champion role descriptor_final 180924

Description: Job Title: NIHR Southampton BRC Equity Champion Salary: Clinical Academic 2PAs / non-Clinical Academics 0.2 WTE Department: Trust HQ, NIHR Southampton BRC Directly responsible to: Mike Grocott (BRC Director 2022-28) Internal Contacts: BRC Research Theme Leads; BRC Manager; Southampton Centre for Engagement, Research, and Impact (SCREI); Southampton Academy of Research (SoAR); UoS Athena Swan; UHS Deputy Director of Research & Development; Equality, Diversity & Inclusion (EDI) Project Manager and UHS Head of EDI – Working Together Team; Clinical Research Facility (CRF) and Wessex NIHR Applied Research Collaboration (ARC) Equity Champions. External Contacts: NIHR Head of EDI; NIHR EDI networks; External EDI leaders & facilitators; Regional Networks e.g. Wessex Experimental Medicine Network Role Purpose: “We believe an equitable environment is an innovative and fulfilling environment”. This role is critical to embedding an equitable culture within the BRC. This is core to our pursuit of excellence and in meeting the EDI aims of our university and hospital partners, and the NIHR. In this context, equity/EDI refers to all the statutorily recognised protected characteristics and other differences. The role holder will be expected to: • Act as the champion for equity (equality, diversity, inclusion & intersectionality) within the BRC. o Develop, implement, and monitor delivery of (working with the BRC leadership and SCREI teams) a BRC equity/EDI strategy. o Work closely with/within the UHS/UoS Centre for Research Engagement and Impact to drive that strategy. o Work closely with the EDI Patient and Public Involvement and Engagement (PPIE) Lead at UHS and contribute on a range of PPIE working groups and projects to support people with protected characteristics in coproduction with researchers, academics, external stakeholders, PPIE leads and patients and members of communities who contribute to our work. o Act as a vocal and visible expert-leader in research equity/EDI across the UHS/UoS partnership. o Collaborate with EDI leads within R&D, UHS and UoS as appropriate to share workstreams and also be cognisant of wider strategies. • Develop and implement solutions to complex equality, diversity, and inclusion challenges within the framework of relevant legislation. • Ensure the provision of a high standard of advice, support, and delivery across the BRC (in line with relevant UHS and UoS strategies). • Assist in the implementation of strategic policies, practices, and action plans and to have responsibility for their delivery. • Liaise closely with senior HR EDI colleagues to keep up to date on the latest legislation, thinking and practice in EDI matters. • Be proactive and keep abreast with developments in equality, diversity, inclusion & intersectionality across the UHS Trust and UoS in line with keeping up to date with local and national initiatives. The postholder will play a role in working with the EDI/equity function of the SCREI. That work will deliver activity and events developing awareness and behaviours supporting equality, diversity and inclusion across staff, researchers, students, research fellows, post-docs and others as relevant. Main Duties: 1. To provide outstanding leadership by example 2. To implement and monitor the equity/EDI strategy for Southampton NIHR BRC and to continue to develop this strategy. 3. To develop and implement advice and guidance for all relevant stakeholder groups (professional, student, PPIE and otherwise) with reference to relevant legislation and national guidance, working collaboratively with all key stakeholders. 4. Develop and implement initiatives and processes to enable investigators across the BRC to increase diversity of PPIE and participants in their research projects. 5. To be aware of, and contribute to, the NIHR agenda on equity/EDI and to successfully lead, submit and refine a fully developed Equality, Diversity and Inclusivity strategy. 6. To be cognisant of the University’s engagement with the equality agenda (currently Athena SWAN) along with other charters related to Gender, Race and Disability, and other protected characteristics across the UHS-UoS partnership, providing expert advice to the BRC. 7. To establish baseline data to monitor changes in the BRC workforce and the effectiveness of systems and processes implemented in driving culture change, using appropriate indicators. 8. To contribute to developing and delivering strategic EDI action plans across the BRC activities, including patient and public participation and engagement, and taking responsibility for key end results and ensuring that the plans support the BRC in line with the UHS-UoS overall strategy. 9. Contribute to BRC Review panels for Post-doctoral and PhD Fellowships, from an EDI perspective. 10. Devise, plan and implement seminars, conferences and other events to communicate equality, diversity and inclusion principles to staff, students and members of the community as appropriate. This may include close working with others e.g. the Manager for the Centre of Research, Impact and Engagement, PPI lead, SoAR and the Wessex Experimental Medicine Network. Person Specification Work Experience • Evidence of knowledge of the NIHR agenda on quality, diversity and inclusion within BRCs. • Understanding of equalities charter marks and frameworks. • Experience of making change happen by negotiating and implementing new policy/initiatives with a range of stakeholders, including those over whom they have no authority. • Experience of developing and implementing strategy/policy documents. • Experience of successfully chairing and facilitating meetings. • Experience of working with local and national networks. • Experience of recruiting and working with members of the public from underserved communities as partners in research • Experience of co-production in research • Knowledge and understanding of what Biomedical Research Centres, experimental medicine are NIHR infrastructure in general. Education/Qualifications • Hold a degree-level qualification or equivalent. • Substantial knowledge of current legislation and good practice in equality, diversity and inclusion, and its application within higher education. Understanding of Athena SWAN, Race Equality Charter Mark • An awareness of current political and social issues and how to handle challenges and barriers to minimise discrimination, exclusion, and inadequate/bad practice. Skills/Abilities • The ability to gain support in a professional, constructive, and non-confrontational manner. • A confident, collaborative and outcome focussed approach. • Experience of translating strategy into practical operational delivery. • Tenacity and resilience, able to respond positively to unexpected situations or barriers and develop solutions to complex issues. • Excellent communication, relationship building, mediation, persuading/negotiating and networking skills. • A passion for the work in the field of equality, diversity, and inclusion
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UHS AR 23-24 Final

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

Description: Date Time Location Chair Apologies Agenda Trust Board – Open Session 30/01/2024 9:00 - 13:00 Conference Room, Heartbeat/Microsoft Teams Jenni Douglas-Todd Diana Eccles 1 Chair’s Welcome, Apologies and Declarations of Interest 9:00 Note apologies for absence, and to hear any declarations of interest relating to any item on the Agenda. 2 Patient Story The patient or staff story provides an opportunity for the Board to reflect on the experiences of patients and staff within the Trust and understand what the Trust could do better. 3 Break 9:15 4 Minutes of Previous Meeting held on 30 November 2023 9:25 Approve the minutes of the previous meeting held on 30 November 2023 5 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. 6 QUALITY, PERFORMANCE and FINANCE Quality includes: clinical effectiveness, patient safety, and patient experience 6.1 Briefing from the Chair of the Audit and Risk Committee (Oral) 9:35 Keith Evans, Chair 6.2 Briefing from the Chair of the Finance and Investment Committee (Oral) 9:40 Dave Bennett, Chair 6.3 Briefing from the Chair of the People and Organisational Development 9:45 Committee (Oral) Jane Harwood, Chair 6.4 Briefing from the Chair of the Quality Committee (Oral) 9:50 Tim Peachey, Chair 6.5 Chief Executive Officer's Report 9:55 Receive and note the report Sponsor: David French, Chief Executive Officer 6.6 Performance KPI Report for Month 9 10:25 Review and discuss the report Sponsor: David French, Chief Executive Officer 6.7 Finance Report for Month 9 10:55 Review and discuss the report Sponsor: Ian Howard, Chief Financial Officer 6.8 People Report for Month 9 11:15 Review and discuss the report Sponsor: Steve Harris, Chief People Officer 6.9 11:35 Break 6.10 Maternity Safety 2023-24 Quarter 3 Report 11:45 Review and discuss the report Sponsor: Gail Byrne, Chief Nursing Officer Attendees: Emma Northover, Director of Midwifery/Marie Cann, Maternity/Neonatal Safety Lead/Alison Millman, Safety & Quality Assurance Matron 7 STRATEGY and BUSINESS PLANNING 7.1 Corporate Objectives 2023-24 Quarter 3 Review 12:00 Review and feedback on the corporate objectives Sponsor: David French, Chief Executive Officer Attendees: Martin De Sousa, Director of Strategy and Partnerships/Kelly Kent, Head of Strategy and Partnerships 7.2 Board Assurance Framework (BAF) Update 12:10 Review and discuss the update Sponsor: Gail Byrne, Chief Nursing Officer Attendees: Craig Machell, Associate Director of Corporate Affairs and Company Secretary/Lauren Anderson, Corporate Governance and Risk Manager 8 CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 8.1 Register of Seals and Chair's Actions Report 12:20 Receive and ratify In compliance with the Trust Standing Orders, Financial Instructions, and the Scheme of Reservation and Delegation. Sponsor: Jenni Douglas-Todd, Trust Chair Page 2 8.2 Review of Standing Financial Instructions 2023-24 12:25 Review and approve the SFIs Sponsor: Ian Howard, Chief Financial Officer Attendee: Phil Bunting, Director of Operational Finance 8.3 Finance and Investment Committee Terms of Reference 12:30 Review and approve the Terms of Reference Sponsor: Dave Bennett, Committee Chair Attendee: Craig Machell, Associate Director of Corporate Affairs and Company Secretary 8.4 Quality Committee Terms of Reference 12:35 Review and approve the Terms of Reference Sponsors: Tim Peachey, Committee Chair Attendee: Craig Machell, Associate Director of Corporate Affairs and Company Secretary 9 Any other business 12:40 Raise any relevant or urgent matters that are not on the agenda 10 Note the date of the next meeting: 28 March 2024 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 Minutes Trust Board – Open Session Date Time 30/11/2023 9:00 – 13:00 Location Chair Present Microsoft Teams Jenni Douglas-Todd (JD-T) Dave Bennett, NED (DB) Gail Byrne, Chief Nursing Officer (GB) Keith Evans, Deputy Chair and NED (KE) David French, Chief Executive Officer (DAF) Paul Grundy, Chief Medical Officer (PG) Steve Harris, Chief People Officer (SH) Jane Harwood, NED/Senior Independent Director (JH) Duncan Linning-Karp, Deputy Chief Operating Officer (DL-K) (for J Teape) Ian Howard, Chief Financial Officer (IH) Femi Macaulay, Interim NED (FM) Tim Peachey, NED (TP) In attendance Martin De Sousa, Director of Strategy and Partnerships (MDeS) Craig Machell, Associate Director of Corporate Affairs and Company Secretary (CM) James Allen, Chief Pharmacist (JA) (item 5.12) Lauren Anderson, Corporate Governance and Risk Manager (LA) (item 6.2) Julie Brooks, Head of Infection Prevention Unit (JB) (item 5.13) Marie Cann, Maternity/Neonatal Safety Lead (MC) (item 5.9) Rosemary Chable, Head of Nursing for Education, Practice and Staffing (RC) (item 5.15) Diana Hulbert, Guardian of Safe Working Hours and Emergency Department Consultant (DH) (item 5.11) Christine Mbabazi, Equality & Inclusion Adviser/Freedom to Speak Up Guardian (CM) (item 5.15) John Mcgonigle, Emergency Planning & Resilience Manager (JM) (item 7.1) Alison Millman, Safety & Quality Assurance Matron (AM) (item 5.9) Jenny Milner, Associate Director of Patient Experience (JM) (item 5.10) Emma Northover, Director of Midwifery (EN) (item 5.9) Danielle Sinclair, Deputy Emergency Planner (DS) (item 7.1) Julian Sutton, Interim Lead Infection Control Director (JS) (item 5.13) 1 member of the public (item 2) 5 governors (observing) 1 member of staff (observing) 5 members of the public (observing) Apologies Diana Eccles, NED (DE) Joe Teape, Chief Operating Officer (JT) 1. Chair’s Welcome, Apologies and Declarations of Interest The Chair welcomed attendees to the meeting. Tim Peachey informed the Board that he now sits on the combined Portsmouth Hospitals University NHS Foundation Trust and Isle of Wight NHS Trust board, following the recent organisational changes. There were no further interests to declare in the business to be transacted at the meeting. Page 1 The Chair provided an overview of her activities since October 2023, including visits to hospital departments, meetings with peers and other key stakeholders. 2. Patient Story Karol Muir was invited to speak about her experience as a patient when she was diagnosed with neck and tongue cancer in early 2021. It was noted that: • Ms Muir’s experience was mixed with some poor experiences when given the diagnosis and by a staff member lacking compassion when addressing her claustrophobia. • In other instances, Ms Muir received a good service such as when a mask was being made for her radiotherapy and her experience on the acute oncology ward. • The Board acknowledged that kindness and compassion was very important. • The Board also noted that it was important to hear both good and bad aspects of patients’ experiences to enable the Trust to improve its services. 3. Minutes of the Previous Meeting held on 28 September 2023 The draft minutes tabled to the meeting were agreed to be an accurate record of the meeting held on 28 September 2023, subject to one minor amendment to item 5.2. 4. Matters Arising and Summary of Agreed Actions It was noted that all actions had either been completed or were not yet due. 5. QUALITY, PERFORMANCE and FINANCE 5.1 Briefing from the Chair of the Finance and Investment Committee The chair of the Finance and Investment Committee was invited to provide an overview of the meeting held on 27 November 2023. It was noted that: • The committee reviewed the Finance Report for Month 7 (item 5.5), much of which formed the basis of the Trust’s submission for the second half of 2023/24. • The committee examined the Trust’s capital re-prioritisation plans along with proposals for 2024/25 and 2025/26. • The Trust had identified £71.3m of Cost Improvement Programme schemes, which, when adjusted for risk, represented approximately £59m of savings. It was noted that the Trust was underweight in terms of recurrent savings. • The committee reviewed the Trust’s productivity on the basis of both the NHS methodology and a revised methodology, which took into account factors such as an appropriate rate of inflation. Under the NHS methodology, the NHS’s underperformance was 16% compared to 2019/20 and the Trust was 18% below that in 2019/20. However, under the revised model, the Trust was under-performing by only 6-7%. • The committee reviewed a proposal for an Integrated Care System-wide electronic patient record system. 5.2 Briefing from the Chair of the People and Organisational Development Committee The chair of the People and Organisational Development Committee was invited to provide an overview of the meeting held on 22 November 2023. It was noted that: • The committee reviewed the People Report for Month 7 (item 5.7). It was noted that the Trust’s substantive workforce continued to grow and whilst Page 2 agency use was under control, there had been an increase in use of bank staff, particularly due to demands in the Emergency Department, mental health nursing and staffing of surge areas. • It was noted that self-reporting of disabilities by staff and the rate of appraisals had both declined. • The initial indication in terms of the response rate to the staff survey showed a lower response rate than in previous years. 5.3 Briefing from the Chair of the Quality Committee The chair of the Quality Committee was invited to provide an overview of the meeting held on 27 November 2023. It was noted that: • The committee reviewed the Trust’s quality indicators and noted that the rate of falls and infections gave rise to concerns about the application of fundamentals of care principles. It was considered possible that the different focus during Covid-19 was a possible contributory factor. • The Trust had reported an increase in the number of complaints, although much of this increase was due to a change in the criteria of what was deemed to be a complaint. • The committee reviewed the results of the Experience of Care survey. Although the national picture had worsened, the Trust’s position remained essentially as before. • The Trust’s approach to end-of-life care was generally very good, although consideration needed to be given to the delivery of mandatory training to all staff. • In view of the general election due to take place before the end of 2024, it was considered likely that the Trust would receive an increased number of Freedom of Information Act requests. 5.4 Chief Executive Officer’s Report David French was invited to present the Chief Executive Officer’s Report, the content of which was noted. It was further noted that: • The Chancellor of the Exchequer had delivered his autumn statement on 22 November 2023, and although there were no specific announcements concerning the health and care sector, there was an expectation of increased public sector productivity. It was noted that the Government had previously announced £800m of additional winter funding for the NHS, although this was mostly repurposed existing funding. • A proposed pay settlement for senior doctors was expected to be voted on by British Medical Association members. • The Care Quality Commission had commenced a roll out of its new single assessment framework in the South region. • The public hearings for module 2 of the UK Covid-19 Inquiry had commenced on 3 October 2023. • The Trust had identified 181 cases of lung cancer through the Targeted Lung Health Check Programme. The financial impact of this programme was difficult to quantify, as it had led to a higher surgical workload, but reduced need for chemo- and radiotherapy. Other conditions had also been discovered through the screening programme. 5.5 Performance KPI Report for Month 7 Duncan Linning-Karp was invited to present the Performance KPI Report for Month 7, the content of which was noted. It was further noted that: • In terms of benchmarking against other trusts, the Trust was in the top quartile in all areas except one. Page 3 • There had been 23 breaches of the target for long-waiters. • The Trust was facing challenges in meeting the 31-day cancer treatment target due to increases in demand for radiotherapy and demand for prostate cancer treatment. The Board noted the spotlight on the Emergency Department. It was further noted that: • There had been a 17% increase in demand since 2019/20. • The Trust was targeting 76% of type 1 patients being seen within four hours, but this would be challenging and dependent on the General Practitioners (GPs) working at the Emergency Department and on a reduction in the number of patients with no criteria to reside. • The Trust was reviewing its processes to free up space and provide options to bypass the Emergency Department when individuals were referred by their GP. In addition, admission and discharge processes were also being reviewed. • It was noted that the GP ‘village’ in the Emergency Department would be insufficient on its own to reach the 76% target. • The biggest constraints in terms of performance were the speed of decisionmaking and the availability of beds. 5.6 Finance Report for Month 7 Ian Howard was invited to present the Finance Report for Month 7, the content of which was noted. It was further noted that: • The Trust had submitted to the Integrated Care Board its plans for the second half of the financial year, which anticipated a revised end-of-year deficit of £31.5m. • The Trust had a year-to-date deficit of £25m, although this was prior to receipt of anticipated additional funding for the costs of industrial action. • The Trust was consistently delivering above the ceilings agreed for services under ‘block’ contracts, which meant that the additional activity was unfunded. • The Trust’s Elective Recovery performance remained good, and the resultant funding received was £4.5m above the Trust’s plan. 5.7 People Report for Month 7 Steve Harris was invited to present the People Report for Month 7, the content of which was noted. It was further noted that: • The workforce grew by 93 whole-time equivalents during the month, and the total workforce was 270 over the plan submitted to NHS England. This increase was driven in particular by newly qualified nurses still within the supernumerary period, increased temporary staffing and a small increase in sickness absence. • Participation in the NHS staff survey was lower than that in previous years at around 40% compared to 55% during 2022/23. • Turnover and sickness rates remained lower than the Trust’s target levels. • There continued to be a high demand for mental health nursing staff, and it seemed likely that a system approach would be necessary to address this issue. 5.8 Break Page 4 5.9 Midwifery, Neonatal and Obstetric Anaesthetic Workforce Report Emma Northover, Marie Cann and Tim Peachey were invited to present the Midwifery, Neonatal and Obstetric Anaesthetic Workforce Report, the content of which was noted. It was further noted that: • Oversight of the midwifery, neonatal and obstetric workforce was a requirement of the NHS Resolution Maternity Incentive Scheme. It was noted that the obstetric element of the report would be provided at the next Board meeting on 19 December 2023. • The workforce faced a number of challenges, particularly in terms of recruiting to specialisms where there was a national shortage, and that activity in the service was unpredictable. • The Trust had in place a number of strategies to recruit staff and was also focusing on growing its own workforce in terms of skills where these were unobtainable in the market. • There were staff shortages in both maternity and neonatal teams. The maternity team was on a trajectory to fill its current vacancies and the shortages in the neonatal team were to be addressed through upskilling the Trust’s own workforce. • There had been a significant increase in the number of elective caesarean births, possibly driven by reduced confidence on the part of the public in maternity services due to recent media stories. • Due to the nature of the Trust’s services, it received a high number of high-risk patients, which placed further demands on its capacity. 5.10 Learning from Deaths 2023-24 Quarter 2 Report Jenny Milner was invited to present the Learning from Deaths Report for Quarter 2, the content of which was noted. It was further noted that: • In-patient deaths had fallen by 10% compared to the previous year, with deaths below the national average. • Five cases had been referred to internal morbidity and mortality meetings. • The Medical Examiner’s Office and Bereavement teams had been moved into the same structure in order to reduce administration and to also reduce the number of calls to families. 5.11 Guardian of Safe Working Hours Quarterly Report Diana Hulbert was invited to present the Guardian of Safe Working Hours Quarterly Report, the content of which was noted. It was further noted that: • The Trust had been fined for the first time since 2016 due to seven breaches of the maximum 13-hour shift length. There was considered to be a possible issue with the handover process, which resulted in the breaches of shift duration. • Suggestions had been sought from staff in order to improve the Trust’s processes. Page 5 5.12 Medicines Management Annual Report 2022-23 James Allen was invited to present the Medicines Management Annual Report for 2022/23, the content of which was noted. It was further noted that: • Over the course of the year, the Trust had improved its resilience in areas such as oncology pharmacy and had an increased focus on research. In addition, the aseptic site programme at Adanac Park was progressing. • The Trust was facing challenges in terms of its IT infrastructure and in filling clinical trials. • The next area of focus was to be on the storage of medicines. • There had been flooding in radio-pharmacology, but there had been minimal impact due to interventions undertaken and use of mutual aid. 5.13 Infection Prevention and Control 2023-24 Quarter 2 Report Julian Sutton and Julie Brooks were invited to present the Infection Prevention and Control Report for Quarter 2, the content of which was noted. It was further noted that: • The Trust continued to not meet the national standards for E-coli and C-Diff, although it compared reasonably well with comparator organisations. • Rapid gastro-intestinal testing continued to be of significant benefit in preventing norovirus outbreaks. • Respiratory testing time had increased, and the amount of time required for a person to be deemed a Covid-19 contact had been increased. • Approximately 50 patients had been impacted by a candida auris outbreak since March 2023. It was proving difficult to eradicate the source of the infections, and there was little understanding globally as yet of the pathogen. • The importance of adhering to fundamentals of care principles was emphasised, as there had been a number of preventable incidents due to poor hygiene practices. • The Hampshire and Isle of Wight Integrated Care Board was focusing on overprescribing of antibiotics, particularly by GPs. 5.14 Annual Ward Staffing Nursing Establishment Review 2023 Rosemary Chable and Gail Byrne were invited to present the Annual Ward Staffing Nursing Establishment Review 2023, the content of which was noted. It was further noted that: • It was a requirement for the Board to undertake a systematic ward staffing establishment review. • The Trust’s staffing levels were generally in line with expectations and staffing numbers have improved due to the Trust’s success in recruiting new staff. However, the influx of new, less experienced members of staff was placing pressure on more senior members of staff. When challenged on how staffing requirements were determined, it was noted that this assessment was based on analysis of data from multiple sources along with professional judgement. Page 6 5.15 Freedom to Speak Up Report Christine Mbabazi was invited to present the Freedom to Speak Up Report, the content of which was noted. It was further noted that: • Eighty-one cases had been raised in 2023/24. • Consideration was being given to publishing lessons learned from some of the Freedom to Speak Up cases on the staff intranet. • Additional support to line managers was also being examined such that staff were comfortable in approaching their managers, rather than utilising the Freedom to Speak Up process. • Some groups, such as junior doctors and some ethnic minorities, were generally less likely to engage with the Freedom to Speak Up process. • The Trust was recruiting more Freedom to Speak Up champions, especially from less engaged groups of staff. 6. STRATEGY and BUSINESS PLANNING 6.1 Board Assurance Framework (BAF) Update The Board Assurance Framework Update was noted. It was further noted that the Board Assurance Framework was due to be discussed in detail at the Trust Board Study Session scheduled to take place on 19 December 2023. 7. CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Annual Assurance for the NHS England Core Standards for Emergency Preparedness, Resilience and Response (EPRR) Duncan Linning-Karp and John Mcgonigle were invited to present the paper, ‘Emergency Preparedness, Resilience and Response Delivery Group (EPRR-DG) – Assurance Report’, the content of which was noted. It was further noted that: • The Trust’s preparedness had been assessed within ten domains, covering 62 core standards and multiple performance indicators within each. • The Trust was fully compliant with 60 of the 62 standards and was therefore ‘substantially compliant’. • The main area for improvement was in preparedness for a mass evacuation of the hospital. The Trust was working through a scenario for a full evacuation. • The Trust was also non-compliant in the area of a mass casualty scenario, as there had been new guidance released in this area. Work was ongoing to align with this new guidance. • Training in incident management had been delivered to senior leaders. 8. Any other business There was no other business. 9. Note the date of the next meeting: 30 January 2024 10. Items Circulated to the Board for reading The item circulated to the Board for reading was noted. Page 7 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 8 List of action items Agenda item Assigned to Deadline Status Trust Board – Open Session 28/09/2023 6.2 Health and Safety Annual Report 2022-23 1041. Violence and aggression update Byrne, Gail Harris, Steve Machell, Craig 29/02/2024 Pending Explanation action item Gail Byrne, Steve Harris and Craig Machell agreed to schedule a further update in respect of violence and aggression at a future Trust Board Study Session. Page 1 of 1 Report to the Trust Board of Directors Title: Agenda item: Sponsor: Date: Purpose: Issue to be addressed: Response to the issue: Chief Executive Officer’s Report 6.5 David French, Chief Executive Officer 30 January 2024 Assurance Approval or reassurance Ratification Information X My report this month covers updates on the following items: • Operational Update • National Audit Office qualification of DHSC accounts • External Recruitment Status • South Hampshire College Group • DHSC Consultation on New Nursing Spine Pay Points • NHS Providers Governance Survey 2023 • Intensive Care Society’s 2023 National Awards The response to each of these issues is covered in the report. Implications: Any implications of these issues are covered in the report. (Clinical, Organisational, Governance, Legal?) Summary: Conclusion The Board is asked to note the report. and/or recommendation Page 1 of 5 Operational Update January 2024 has been a very challenging month operationally for everyone within the Trust. Having safely navigated the period of industrial action by doctors in training between the 2nd and 8th January 2024, the Trust has experienced a period of heightened operational pressures which has seen record levels of patients within the hospital without criteria to reside (medically fit). These reached record levels on one day of 270 (over 25% of adult inpatient general acute bed base) coupled with significant infection outbreaks resulting in further wards closed (three at the time of writing) and closure of 23 bays across the wards. This in turn has caused a significant backlog of patients within the emergency department and has also sadly resulted in a significant increase in ambulance handover delays and queues within the adult emergency department footprint. The Trust has continued to manage these pressures as best as it can through hospital incident management arrangements and significant oversight of available beds and discharges daily. Unfortunately, the Trust has also had to cancel some elective operations due to lack of available beds despite all surge bed areas in the hospital being fully open. The Chief Nursing Officer has also implemented a number of enhanced infection prevention measures including wearing surgical masks in adult clinical areas and has also introduced temporary visitor restrictions to further limit the risk of spreading infection. Looking forward, the Trust continues to do all it can to respond to the current challenges and has invited the Emergency Care Intensive Support Team from NHS England to review its processes via an invited visit during January 2024. The Trust is also currently reframing its flow programme to focus on operational oversight. In addition, the Trust is rigorously eliminating all discharge delays within its control as well as continuing to work with community partners across health and social care to try and deal with the longer-term issues of capacity outside of the hospital. According to ‘Winter Watch’ published by NHS Providers, an overview of the situation in NHS England, during the week commencing 8 January 2024: • 93.3% of general and acute beds were occupied and 586 beds were closed due to diarrhoea and vomiting and norovirus. • A total of 90,294 patients arrived by ambulance, an increase of 25% compared to the previous year. • There was an average of 23,645 patients each day who no longer met the criteria to reside. Of these, over half (57.7%) remained in hospital. • An average of 49,039 staff were absent each day. National Audit Office qualification of DHSC accounts The NAO has qualified DHSC accounts for financial year 2022/23 due to the way in which the elective recovery fund (ERF) was administered. The Government established the ERF in 2022/23 to incentivise trusts to increase their activity after Covid-19. The money was paid to trusts and ICBs on the assumption targets would be met, but there were intended to be financial penalties if the activity goal (104% of 2019/20 baseline) was not met. However, the clawback mechanism was suspended over fears this would destabilise local systems, most of which were underperforming on their elective targets. As a result, local organisations were allowed to keep the funding, regardless of the number of patients they treated. Page 2 of 5 In their audit statement, NAO state “ERF was required to be ‘earned’ by integrated care systems hitting elective recovery targets. Where elective recovery targets were not met, the cash received by the department should have been returned to the consolidated fund.” NHSE’s 2022/23 accounts state: “The lower levels of elective activity were due to ongoing Covid19 pressures and longer lengths of stay, factors for which no additional funding had been provided. Therefore, we decided to allow providers to retain the elective funding to cover these costs, which the government has now deemed to be irregular.” UHS was one of only a handful of providers which achieved the ERF target of 104%; UHS achieved 108% whereas the average performance for the country was 97%. Of course, like all providers, UHS incurred the costs described in the NHS accounts for Covid-19 pressures and longer lengths of stay for which the ERF money was used to cover, but also incurred the costs of delivering additional elective activity which others did not. No income was received to cover the UHS cost of activity between 104% and the national average of 97%, whereas other providers were able to keep the money originally intended to fund the 104% target. We estimate the UHS cost of this 7% additional activity to be around £10m. The £10m cost of this activity has subsequently been ‘baked’ into the UHS baseline and is therefore a significant contributor to UHS’s current financial challenge and a strong headwind affecting the Trust’s ability to return to financial break-even. External Recruitment Status The Board is aware that following an update to the Trust’s forecasted headcount for 31 March 2024, additional recruitment controls were introduced on 22 December 2023 which remain in place. The executive team has been working through the detail of how the controls operate effectively but also with due regard to clinical quality and safety. One of the major challenges has been the dissonance between how it feels on the ground (busier than ever) and the explicit financial direction received from the Centre. This has been a fast-moving and dynamic situation and we will update the Board during the Board meeting on how we are navigating that challenge and how we are ensuring that clinical safety and quality is protected. South Hampshire College Group During January 2024, the Chief People Officer and Head of Education met the senior leadership team from the newly formed South Hampshire College Group (SHCG). This new organisation is the result of a merger between Eastleigh, Southampton City, and Fareham colleges, bringing together over 3,000 students across the area. The Trust will be working to create an overarching partnership with the group focused on growing vocational and entry-level opportunities for students into roles at the Trust (health-related, estates, business administration and digital). This supports the Trust’s People Strategy objectives of extending the diversity of our relationships with education providers to support a wider range of education to employment opportunities. It also supports the ambitions of the NHS long-term workforce plan, particularly around apprenticeship opportunities for non-graduate entry roles. SHCG can play an important role in the career promotion of the Trust, including working in partnership on industry placements. Senior leads from SHCG and the Trust will be meeting again in the Spring to take these activities forward. Department of Health and Social Care Consultation on New Nursing Spine Pay Points In May 2023, the government agreed a deal for the Agenda for Change (AfC) workforce through the NHS Staff Council. During negotiations, concerns were raised about how the AfC pay structure is affecting the career progression and professional development of nurses, and the direct impact that this is having on recruitment and retention. The Royal College of Nursing (RCN) Page 3 of 5 suggested that a separate pay spine for nursing staff could address these concerns. At present the same pay scales are used for all roles covered by Agenda for Change with banding (pay grade) determined through job evaluation. This call for evidence is being published to explore these specific concerns, to understand the benefits and challenges of a separate nursing pay spine, and to explore other potential approaches to addressing any issues identified. This exploration does not form part of the AfC deal that was agreed with the NHS Staff Council. The consultation is public and can be responded to as an individual (within or outside healthcare) or as an NHS organisation. The Trust will be participating in the consultation through evidence sessions being organised by NHS Employers and through its own written response. NHS Providers Governance Survey 2023 In September and October 2023, NHS Providers invited chairs, company secretaries and other corporate governance leads in NHS trusts and foundation trusts to complete a survey in relation to boards, their assurance committees and how trusts are developing in relation to the systems they are part of. The results of the survey were published on 15 December 2023. In summary: • 86% of respondents agreed or strongly agreed that the board has time to focus on key risks and issues, but the comments provided gave a clear sense that it can be challenging to prioritise and effectively cover everything. • Almost all respondents (99%) agreed or strongly agreed that the way the committees report to the board can provide it with assurance. • However, many respondents stated that space on agendas is under pressure, often attributing this to initiatives from the centre as well as new system and partnership-working related matters. This contributes to reduced bandwith for those producing and seeking to digest reporting and assurance information and putting pressure on the time available for effective discussion and scrutiny. • The pressures on executive directors were highlighted and there were concerns about too much detail coming through to boards and committees. • More than half of respondents (58%) said that their trust has associate non-executive directors, with the most common reason being developmental and to aid succession-planning. • Trusts’ experience in systems remains variable and whilst there has been some improvement, for the most part, the picture remains one of considerable variation. Of 36 comments in relation to this subject, 23 were critical of the way systems are working at present and a further eight said it was too soon to say. • Improvements were reported in relation to trust boards’ ability to influence the development of the systems they are part of, and in non-executive directors’ perceived confidence about their role and responsibilities in systems. • Only 20% of respondents expressed confidence about approaches to continuous improvement across systems and the lowest level of confidence was reported for how risk was managed across systems (12%, compared to 20% in the prior year). • 42% of respondents have a board member who is also a trust partner member on an Integrated Care Board, and chairs and governance leads were positive about the influence and access they felt having a board member in this role gave them. The full report can be read at: https://nhsproviders.org/resources/surveys/governance-surveyresults-2023 Page 4 of 5 Intensive Care Society’s 2023 National Awards The neuro-physiotherapy team, who work closely with the Trust’s Neuro Intensive Care Unit, were awarded ‘Team of the Year’ at the Intensive Care Society’s national awards. Footage of the award ceremony can be viewed at: https://www.youtube.com/watch?v=fHPem9G_JGo (watch from 9 minutes 35 seconds in). I would like to congratulate the team on this achievement. Page 5 of 5 Report to the Trust Board of Directors Title: Agenda item: Sponsor: Author Date: Purpose Performance KPI Report 2023-24 Month 9 6.6 David French, Chief Executive Officer Sam Dale, Associate Director of Data and Analytics 30 January 2024 Assurance or Approval reassurance Y Ratification Information Issue to be addressed: The report aims to provide assurance: • Regarding the successful implementation of our strategy • That the care we provide is safe, caring, effective, responsive, and well led Response to the issue: The Performance KPI Report reflects the current operating environment and is aligned with our strategy. Implications: This report covers a broad range of trust performance metrics. It is (Clinical, intended to assist the Board in assuring that the Trust meets Organisational, regulatory requirements and corporate objectives. Governance, Legal?) Risks: (Top 3) of carrying out the change / or not: This report is provided for the purpose of assurance. Summary: Conclusion and/or recommendation This report is provided for the purpose of assurance. Page 1 of 29 Report to Trust Board in January 2023 Performance KPI Board Report Covering up to December 2023 Sponsor – David French, Chief Executive Officer Author – Sam Dale, Associate Director of Data and Analytics Page 2 of 29 Report to Trust Board in January 2023 Report guide Chart type Example Cumulative Column Cumulative Column Year on Year Line Benchmarked Line & bar Benchmarked Control Chart Variance from Target Explanation A cumulative column chart is used to represent a total count of the variable and shows how the total count increases over time. This example shows quarterly updates. A cumulative year on year column chart is used to represent a total count of the variable throughout the year. The variable value is reset to zero at the start of the year because the target for the metric is yearly. The line benchmarked chart shows our performance compared to the average performance of a peer group. The number at the bottom of the chart shows where we are ranked in the group (1 would mean ranked 1st that month). The line shows our performance, and the bar underneath represents the range of performance of benchmarked trusts (bottom = lowest performance, top = highest performance) A control chart shows movement of a variable in relation to its control limits (the 3 lines = Upper control limit, Mean and Lower control limit). When the value shows special variation (not expected) then it is highlighted green (leading to a good outcome) or red (leading to a bad outcome). Values are considered to show special variation if they -Go outside control limits -Have 6 points in a row above or below the mean, -Trend for 6 points, -Have 2 out of 3 points past 2/3 of the control limit, -Show a significant movement (greater than the average moving range). Variance from target charts is used to show how far away a variable is from its target each month. Green bars represent the value the metric is achieving better than target and the red bars represent the distance a metric is away from achieving its target. Page 3 of 29 Report to Trust Board in January 2023 Introduction The Performance KPI Report is presented to the Trust Board each month to provide assurance: • regarding the successful implementation of our strategy; and • that the care we provide is safe, caring, effective, responsive, and well led. The content of the report includes the following: • The ‘Spotlight’ section, to enable more detailed consideration of any topics that are of particular interest or concern. The selection of topics is informed by a rolling schedule, performance concerns, and requests from the Board. • An ‘NHS Constitution Standards’ section, summarising the standards and performance in relation to service waiting times; and • An ‘Appendix,’ with indicators presented monthly, aligned with the five themes within our strategy. Due to the earlier timing of the December 2023 Board, at the time of publishing last months’ report several of the validated IPR data points were not yet available but have now been updated within this report. • 31 - Patients on an open 18 week pathway (within 18 weeks) • 33 - Patients on an open 18 week pathway (within 52 weeks) • 34 - Patients on an open 18 week pathway (within 65 weeks) • 35 - Patients on an open 18 week pathway (within 78 weeks) • 35a - Patients on an open 18 week pathway (within 104 weeks) • 32 - Total number of patients on a waiting list (18 week referral to treatment pathway) • 36 - Patients waiting for diagnostics • 37 - % of patients waiting over 6 weeks for diagnostics Other changes of note within the report include: • 7 –MRSA bacteraemia: A correction in the November 2023 data, which was reported as 1 case, but on review has been changed to 2 cases. • 13 – Serious Incidents Requiring Investigation: As part of the move to the new Patient Safety Incident Response Framework (PSIRF) from October 2023, the metrics have removed the reporting of SIRIs, although Patient Safety Incident Investigations (PSII) are still being reported in this measure. • 38 – Cancer 2 Week Wait: In December 2023 NHS England stopped publishing 2 week wait data. Benchmark data is available for the period up until October 2023 for other hospitals. UHS will continue to publish our own performance against this metric. • 41 / 42 – Cancer 31 Day Performance / Cancer 31 Day Subsequent Treatment performance: From December 2023, NHS England measurement methodology changed, and published data from October 2023 onwards for 31 Day Cancer Performance combines both First and Subse quent treatment performance. As a result, metric 42 (Cancer 31 Day Subsequent Treatment) has been removed. Page 4 of 29 Report to Trust Board in January 2023 Summary This month’s spotlight covers Cancer performance. It highlights how UHS has seen improving levels of performance against the three new national cancer metrics, and the interventions that have been made to improve performance despite the ongoing challenges of increased demand. Detail is also provided by tumour site, outlining the specific challenges and actions taken by Care Groups to address performance. Areas of note in the appendix of performance metrics include: 1. As outlined within the Cancer spotlight, our increased focus on Cancer performance has led to significant improvements in 2 Week Wait performance (increasing to 88.9% in November 2023), UHS being in the top three teaching hospitals for 62 Day performance, and being the top teaching hospital for 28 Day Faster Diagnosis for the last three months – with an improvement in performance to 85.4%. 2. The Emergency Department (ED) four hour performance saw a small improvement in performance in December 2023 to 58.0%, although this remains below our H2 recovery ambitions. The GP programme has also led to some diversions away from the department which might otherwise have further improved performance. However, ED performance continues as a national issue, as illustrated by UHS remaining within the top quartile of teaching hospitals. 3. We have seen a further increase in the number of patients not meeting the Criteria to Reside in hospital which remains extremely high at an average of 203 patients through December 2023 – even though we would normally see a reduction over the Christmas period. 4. A positive ongoing reduction in the proportion of patients being readmitted within 28 days of discharge continues, with this standing at 10.6%. 5. There was a second consecutive month in the reduction of the waiting list to just over 58,000 patients. However, this remains significantly higher than pre-COVID, and there is often a softening of demand over the Christmas period. 6. We have also seen a continued reduction in the Diagnostic waiting list, which now stands at under 8,000 patients. The size of this waiting list is now broadly in line with pre-COVID levels, although the proportion of patients breaching the six week diagnostic standard is still higher. Ambulance response time performance The latest unvalidated weekly data is provided by the South Coast Ambulance Service (SCAS). Due to the significant challenges within the ED department, and the wider challenge with flow experienced in the trust since the New Year, we have seen an increase in handover times. In the week commencing 15 January 2024, our average handover time was 22 minutes 38 seconds across 675 emergency handovers, and 32 minutes 26 seconds across 35 urgent handovers. There were 73 handovers over 30 minutes, and 44 handovers taking over 60 minutes within the unvalidated data. Page 5 of 29 Report to Trust Board in January 2023 Spotlight Spotlight: Cancer performance 1. Introduction Cancer is a large basket of disparate diseases across every organ and tissue type of the body, unified by its biology in which abnormal cells divide without control and can invade nearby tissues. Cancer cells can also spread (metastasise) to other parts of the body. These cancerous diseases have very different treatments and prognoses. The other uniting factor underlying this name is that for many patients the word cancer generates significant anxiety and fear and recognising this, UHS works hard to provide the most streamlined service that we can offer to patients referred to our service. UHS is one of 12 regional cancer centres in the UK offering treatment for rare and complex cancers as well as children's cancer and brain cancer. We offer a wide range of treatments including novel therapies. UHS has historically benchmarked in the upper quartile, relative to our teaching hospital peers. We continue to perform well against the 28 day faster diagnosis and 62 day standards, but face challenges in meeting the 31 day standard. Recovery plans are in place focusing on the three key areas affecting this standard, radiotherapy, prostate surgery and skin (plastics). More d etail follows below. We continue to monitor cancer performance through regular performance meetings. However, there is an ongoing risk, with many tumour sites dependant on relatively few individuals to deliver, meaning that unexpected or unplanned absences can quickly affect performance. 2. Changes to Cancer Waiting Time Standards (CWT) In August 2023, NHS England received government approval to implement changes to the cancer waiting times standards from 1 October 2023. These changes were the outcome of a long term consultation which had the full support of NHS staff, patient groups and cancer. The proposed standards are in line with recommendations made by the Independent Cancer Taskforce in 2015 and the subsequent clinical review which was started in 2018. The three new standards (detailed below) are aligned to the requirements of modern cancer care, with a greater focus on outcomes and ensuring equitable access to care. The new treatment standards will measure waiting time for all patients regardless of their route into the system, rather than just those who were urgently referred by their GP. 1. The 28-day faster diagnosis standard (FDS). Patients with suspected cancer who are referred for urgent cancer checks from a GP, screening programme or other route should be diagnosed or have cancer ruled out within 28 days 2. A 62-day referral to treatment standard. Patients who have been referred for suspected cancer via any route and go on to receive a diagnosis should start treatment within 62 days of their referral. Page 6 of 29 Report to Trust Board in January 2023 Spotlight 3. A 31-day decision to treat to treatment standard. Patients, regardless of how they came to be diagnosed with cancer, should receive their treatment within a month of a decision to treat their cancer. These changes will still set the same high-performance bar for the same groups of patients as were covered by the previous standards and will increase the number and proportion of patients covered by the standards. They are designed to focus on two clear goals: achieving the fastest possible diagnosis, and for those who are diagnosed and require treatment, ensuring they receive treatment as quickly as possible. The new standards will also put all patients on a level playing field, regardless of the origin of their referral. Trusts do not need to make significant changes in terms of their data submissions – the only change of note in terms of overall process will be their reporting of performance against the 62-day standard to include patients who’ve entered cancer pathways via screening or consultant upgrades as well as those who were referred by their GP. In this paper, we explore early performance against the national targets in place for each of the new standards, UHS position compared to comparator Trusts and an exploration of the drivers and actions in place to improve performance for key tumour sites. 3. Cancer Referral Volumes At the start of the 2023 calendar year, the Trust experienced a 3000 period of significant volatility on cancer referrals which reached a five year high when 2,524 referrals were received in June 2023. 2500 2000 This high volume of referrals has remained since, but with some stabilisation of the monthly variance seen in the first half of the 1500 year. As expected, the festive period sees a reduction with 1000 December 2023 at 1,774. Despite this levelling off in recent 500 months, the referral volumes in 2023 averaged at 2,213 per month which overall is 7% higher than 2022 and 21% higher than 0 the 2021 calendar year. Ja n-22 Fe b -22 Ma r-22 Apr-22 Ma y-22 Jun-22 Jul -22 Aug-22 Se p -22 Oct-22 Nov-22 D e c-22 Ja n-23 Fe b -23 Ma r-23 Apr-23 Ma y-23 Jun-23 Jul -23 Aug-23 Se p -23 Oct-23 Nov-23 D e c-23 2022 2023 Graph 1: Cancer referral volumes by month Page 7 of 29 Report to Trust Board in January 2023 Spotlight 3,000 2,500 2,000 1,500 1,000 500 0 Jan Feb Mar Apr May Jun Jul Au g Sep Oct Nov Dec 2020 2021 2022 2023 Graph 2: Cancer Referrals – historic monthly comparison 4. Overall cancer waiting list (PTL) and patients waiting over 62 days (backlog) The overall waiting list size is heavily dependent on the number of two week wait referrals and the speed of seeing these patients, as the large majority of patients will leave the cancer waiting list at the point of being told that they don’t have cancer. Throughout
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