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2025 WRES report and action plan

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Workforce Race Equality Standard Annual Report 2025 1 Executive Summary WRES Data has been submitted by the Trust since 2015 and progr
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/Media/UHS-website-2019/Docs/About-the-Trust/Equality-reports/2025-wres-report-and-action-plan.pdf

Workforce Race Equality Standard annual report 2024

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Executive Summary WRES Data has been submitted by the Trust since 2015 and progress is reviewed
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/Media/UHS-website-2019/Docs/About-the-Trust/Equality-reports/UHS-WRES-report-2024.pdf

Papers Sept 2020 held in closed session due to Covid-19

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Date Time Location Chair Agenda - Trust Board Meeting 29/09/2020 9:00 - 16:00 Microsoft Teams Peter Hollins 1 Chair
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/Media/UHS-website-2019/Docs/About-the-Trust/Trust-governance-and-corporate-docs/2020/papers-sept-2020-held-in-closed-session-due-to-covid-19.pdf

WRES report and action plan 2023

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Workforce Race Equality Standard Annual Report 2023 1 Table of Contents Executive Summary.......................................................
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/Media/UHS-website-2019/Docs/About-the-Trust/Equality-reports/WRES-report-and-action-plan-2023.pdf

Papers CoG 16.07.2025

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Date Time Location Chair Agenda Council of Governors 16/07/2025 14:00 - 15:30 Conference Room, Heartbeat/Microsoft Teams Jenni Douglas-Todd 1 Chair’s Welcome and Opening Comments 14:00 2 Declarations of Interest 14:02 3 Minutes of Previous Meeting 14:03 Approve the minutes of the previous meeting held on 29 April 2025 4 Matters Arising/Summary of Agreed Actions 14:05 5 Strategy, Quality and Performance 5.1 Chief Executive Officer's Performance Report 14:10 Receive and note the report Sponsor: David French, Chief Executive Officer Attendee: Steve Harris, Chief People Officer 5.2 Operating Plan 14:30 Receive and note the report Sponsor: Ian Howard, Chief Financial Officer Attendees: Ian Howard, Chief Financial Officer and Andrew Asquith, Director of Planning and Productivity 5.3 Break 14:50 6 Governance 6.1 Review Terms of Reference - Council of Governors 15:00 Approve the proposed changes to the terms of reference Sponsor: Jenni Douglas-Todd, Trust Chair Attendees: Craig Machell, Associate Director of Corporate Affairs and Company Secretary and Karen Russell, Council of Governors' Business Manager 7 Membership Engagement and Governor Activity 7.1 Membership Engagement 15:05 Receive the report Sponsor: Jenni Douglas-Todd, Trust Chair 7.2 Governors' Nomination Committee Feedback 15:09 Chair: Jenni Douglas-Todd, Trust Chair 8 Review of Meeting 15:14 Review and feedback on the content of this meeting Sponsor: Jenni Douglas-Todd, Trust Chair 9 Any Other Business 15:19 Raise any relevant or urgent matters that are not on the agenda 10 Date of Next Meeting: 28 October 2025 15:29 Note the date of the next meeting Page 2 Minutes - Council of Governors (CoG) Open Session Date Time Location Chair Present 29 April 2025 14.00-15:50 Conference Room, Heartbeat Education Centre and Microsoft Teams Jenni Douglas-Todd, Trust Chair Jenni Douglas-Todd, Trust Chair Shirley Anderson, Elected, New Forest, Eastleigh and Test Valley Professor Cathy Barnes, Appointed, Solent University Patricia Crates, Elected, New Forest, Eastleigh and Test Valley Sandra Gidley, Elected, New Forest, Eastleigh and Test Valley Lesley Gilder, Elected, Southampton City Ben Grassby, Elected, Rest of England and Wales Sathish Harinarayanan, Elected, Medical Practitioners and Dental Staff Professor Sue Latter, Appointed, University of Southampton Brian Lovell, Elected, Rest of England and Wales Councillor Louise Parker-Jones, Appointed, Hampshire County Council Cat Rushworth, Elected, Isle of Wight Karen Smith-Baker, Elected, Health Professional and Health Scientist Staff Jake Smokcum, Elected, Nursing and Midwifery Staff Liz Taylor, Elected, Non-Clinical and Support Staff Mike Williams, Elected, New Forest, Eastleigh and Test Valley JDT SA CB PC SG LG BG SH SL BL LPJ CR KSB JS LT MW In attendance Pete Baker, Commercial and Enterprise Director (for item 5.5) PB Helena Blake, Head of Clinical Quality Assurance (for item 5.3) HB Gail Byrne, Chief Nursing Officer (for item 5.1 and 5.3) GB Sam Dolton, Events and Membership Officer SD Kelly Kent, Head of Strategy and Partnerships (for item 5.4) KK Karen Russell, Council of Governors’ Business Manager KR Apologies Theresa Airiemiokhale, Elected, Southampton City TA Katherine Barbour, Elected, Southampton City KB Linda Hebdige, Elected, Southampton City LH Councillor Pam Kenny, Appointed, Southampton City Council PK Jenny Lawrie, Elected, Southampton City JL Esther O’Sullivan, Elected, New Forest, Eastleigh and Test Valley EO 1 Chair’s Welcome and Opening Comments JDT welcomed everyone to the meeting, in particular CB who was attending for the first time. 2 Declarations of Interest There were no new declarations of interest relating to matters on the agenda. 1 3 Minutes of Previous Meeting The minutes of the meeting held on 29 January 2025 were approved as an accurate record of the meeting. 4 Matters Arising/Summary of Agreed Actions There was one item arising from the previous meeting on 29 January 2025 which had been completed. 5 Strategy, Quality and Performance 5.1 Chief Executive Officer’s Performance Report The Chair welcomed GB who joined the meeting to present the performance report on behalf of David French. GB highlighted the following: • Despite the economic challenges, the Trust continued to benchmark well for productivity measures including theatre utilisation and length of stay whilst recognising there remains an opportunity to go further. • For Quarter 4 the overall Friends and Family Test Trust average was 94% for patients rating their care as “Good” or “Very Good”. • The volume of patients with no criteria to reside remained above 200 per day which continued to place a barrier on the Trust’s bed availability. • The financial environment remained extremely challenging and a Financial Improvement Group had been set up as a sub-group of the Board of Directors (the Board) to consider cost saving initiatives. • Divisions had been asked to identify savings of 5% in clinical areas and 10% in non-clinical areas and Trust Headquarters. • GB and Paul Grundy (Chief Medical Officer) were also setting up a panel to review the Equality Impact Assessment and consider the impact on patient safety and staff. In response to questions raised by the CoG, GB advised: • With regard to Saturday waiting lists in urology, she understood they would be continuing. Agency usage was very low and there had been a £6m reduction. • In addition to bed availability being impacted by no criteria to reside, this was also affected by the number of patients with mental health issues. There was also a discussion about the use of virtual wards and how complex it can be. • With regard to the statistics regarding the proportion of patients attending ED when they should be seeking assistance elsewhere and the number which converted into inpatients, this information was not shown in the Performance Report. 5.2 Annual Report and Quality Accounts Timetable 2024/25 NHS England had published the timetable for the 2024/25 annual report and accounts and associated guidance. The Trust was required to produce an annual report and accounts as well as a Quality Account. The Trust had decided to align the timetables of both the Quality Account and the annual report and accounts, and to incorporate these into the same document. The Quality Account was required to be published by 30 June 2025, whereas the annual report and accounts could not be published until after they had been laid before Parliament. Parliament’s summer recess was to commence on 21 July 2025. 2 The Trust had taken the decision to produce the annual report and accounts and the quality accounts on the same timetable as a single document. However, the quality account was to be published as a separate document by 30 June 2025. Once the annual report and accounts had been published, it would be presented at the next CoG meeting which would be prior to the Trust’s Annual General Meeting. 5.3 Draft Quality Account 2024/25 The chair welcomed HB to the meeting. GB provided the background to the quality account. HB advised that the quality account contained a number of mandated sections which were laid down by NHS England. There was to be a 30 day consultation period and any feedback would be taken into account in the final document. Governors were invited to provide feedback directly to HB by 13 May 2025. The following questions were raised: • It was not clear how quality management linked to the strategic objectives. HB agreed to add into the introduction to the quality account. • The narrative provided details of progress during the year, but year on year improvements were not included. • Were there set quality aspects which were measured and how did objectives map on to bigger quality metrics? GB advised that some aspects were always measured, these would be done vertically if one ward had issues and horizontally to look across wards, for example, in the case of pressure ulcers. HB agreed there may need to be a section regarding quality assurance processes and how it all links together. • Sue Latter questioned that not all the quality measures appeared to be measuring quality. GB answered and referred to the KPI report which goes to TB and JDT commented that it was interesting and wondered if Quality Committee could explore and work with her. GB then mentioned one of the things she was most proud of was leadership development but didn’t know how that could be quantified as a quality measure. JDT thanked GB and HB for attending. 5.4 Corporate Objectives The chair welcomed KK to the meeting. KK advised that this was the final year of the Trust’s current strategic plan which covered 2021-2025, and the future strategy was in the process of being developed. In view of the current financial challenges and growing demands on the Trust’s services, 12 corporate objectives had been created which were fewer than in previous years, to ensure they were fully focussed on the achievements required. In response to a question regarding achieving the previous year’s objectives, KK advised that progress reports were provided quarterly throughout the year. This year the plan was to publish ahead of the first quarter the anticipated milestones against each of the objectives. It was noted that it would be useful to see the planned achievements on one page, possibly with risk ratings and order of priority. 3 KK confirmed that with regard to the future strategy, there had been a period of engagement with staff and the public which would feed into it. JDT thanked KK for attending. 5.5 Non-NHS Activity One of the responsibilities of the CoG was to determine whether the Trust’s nonNHS activity would significantly interfere with its principal purpose, which was to provide goods and services for the health service in England, or the performance of its other functions. There was a clear legal requirement that the Trust must derive greater levels of income from its principal purpose, rather than its non-NHS income. It also enabled the CoG to monitor when it may need to specifically approve an increase in non-NHS income under other provisions of the National Health Service Act 2006. This would apply to proposals to increase by 5% or more the proportion of total income in any financial year attributable to activities other than the provision of goods and services for the purposes of the health service in England (including private work). In summary, the contribution arising from non-NHS activity in 2024-25 as a percentage of Trust income (baseline £1.47bn) equated to 2.1%, as per the UHS 2024/25 unaudited accounts. This was a slight increase from 1.8% as reported in 2023-24. In response to questions from governors, PB confirmed that: • He considered that staff having the opportunity (outside their NHS employment) to choose to earn additional income working in a private environment should be seen as beneficial to staff, and something that tended to be attractive to new staff considering joining an NHS Trust. This question was always one of the most important considerations as the Trust did not want to destabilise its workforce. Private healthcare providers typically had non-compete or no-poaching clauses and would invariably have different recruitment mechanisms to a local trust, for example, they would have their own national and international recruitment functions distributing staff to their sites around England. • It was uncommon for NHS Trusts to have the capability to create spin-out companies and he noted that this was far more routine in the University sector. For this reason, the Trust had worked very closely with the university spin-out team and emulated much of their guidance and processes. PB also noted that the Trust differed slightly in the allocation of equity (shares) in the new company than would typically be seen in the university sector. • There had been almost £7m worth of private patient activity performed at UHS over the previous 12 months. • The current income from private work was generated from within the existing SGH operational footprint and that NHS staff were not obliged to work in private healthcare provision. • With regard to the sheer size of the potential Southside A building, this had been informed by a formal Feasibility Study, conducted by an external architect/surveyor, and the area that the Trust had looked at was aligned with the UHS Estates Master Plan, which was the document that looked at how the SGH (and PAH) site could continue to develop. JDT thanked PB for attending. 4 6 Governance 6.1 Governor Attendance at Council of Governors’ Meetings Under the Trust’s constitution (paragraph 2.1 of Annex 5) if a governor failed to attend two successive meetings of the council of governors, his or her tenure of office was to be immediately terminated by the council of governors (CoG) unless the CoG was satisfied that: • the absences were due to reasonable cause; and • he/she would be able to attend meetings of the CoG within such a period as the CoG considers reasonable. Following the recent review, there was one governor who had failed to attend two successive ordinary meetings of the CoG. Reasons for non-attendance were provided and were due to reasonable causes. In order to ensure that the CoG considered the situation when a governor fails to attend two successive ordinary meetings of the CoG, the process was for the Chair or Company Secretary to contact the governor to understand the reasons for this if these had not already been provided. The Chair or Company Secretary would then provide confirmation to the CoG as to whether this was due to reasonable causes and of the governor’s ability to attend future meetings. This would also help to identify any steps that the Trust could take to facilitate attendance. Decision: The CoG confirmed that it was satisfied that the process had been followed correctly to confirm that the failure of one current governor to attend two successive meetings of the CoG was due to reasonable causes and that they would be able to attend future meetings within a reasonable period. 6.2 Council of Governors’ Elections 2025 KR advised that a number of vacancies would arise within the council of governors on 1 October 2025 as current governors reached the end of their term of office: • Southampton City public constituency - five vacancies • New Forest, Eastleigh and Test Valley public constituency - three vacancies • Isle of Wight public constituency - one vacancy • Non-clinical and support staff class - one vacancy • Nursing and midwifery staff class - one vacancy The Trust’s constitution required vacancies arising on the council of governors due to the expiry of a term of office to be filled by an election conducted in accordance with the model election rules, as published by NHS Providers in August 2014. The elections were to be conducted by Civica Election Services on behalf of the Trust. Governors reaching the end of their first term of office were eligible to stand for reelection. However, two of the Southampton City governors, KB and TA, were reaching the end of their second term of office (a total of six years) which was the maximum allowed under the Trust’s constitution. The proposed timetable and arrangements for the elections to the CoG in 2025 were noted. 5 6.3 Appointment to the Governors’ Nomination Committee A vacancy had arisen on the Governors’ Nomination Committee (GNC) as Helen Eggleton had stood down on leaving her employment with HIOW ICB on 30 November 2024. Governors had been asked to express an interest if they were willing to join the GNC. Esther O’Sullivan had expressed an interest in taking on this additional role. The CoG was responsible for appointing the members of the GNC and had decided by a unanimous vote to approve her appointment. The CoG was asked to formally note the appointment of Esther O’Sullivan to the GNC. 7 Membership Engagement and Governor Activity 7.1 Membership Engagement SD introduced the Membership Engagement report. He advised that the communications team, in common with other teams within the Trust, were looking to identify cost savings. A colleague in the communications team had recently left the Trust under the Mutually Agreed Resignation Scheme which had placed a further strain on resources and therefore additional key priorities had been distributed across the team. SD had taken on an additional responsibility to assist the children’s hospital with social media. In addition, the publication of the Trust’s annual report and accounts which had previously been outsourced would now be produced in house by SD. In view of this, the communications team would not be able to lead any community events during 2025 but would advise governors if any other departments at UHS or other trusts would be having any involvement so they could provide support. Membership engagement in the previous quarter had been light and this would continue. A Community Care Engagement Event was to be held on Thursday, 1 May which had been communicated to governors and members, and all were welcome to attend. SD would continue to work with KR to promote the CoG elections for 2025. MW asked if the weekly update was only provided to governors and whether this could this be reduced to fortnightly to save resource. SD confirmed that this was the case, but he was happy to continue to prepare this on a weekly basis as it was not very time consuming. There was a discussion regarding how governors could provide support to promote membership of the Trust on day-to-day basis, and the benefits of becoming a member. It was confirmed that there was a statutory requirement for foundation trusts to have a trust membership in place. 7.2 Governors’ Nomination Committee Feedback Governors had received feedback from the Chair and NED appraisals, and an update regarding NED recruitment. 6 8 Review of Meeting Governors felt it had been an interesting meeting with a good mix of presenters. The walkabouts of the hospital earlier in the day had also been informative and worthwhile. 9 Any Other Business LT commented that sound in the conference room was quite poor. JDT noted that all meeting attendees could take responsibility for projecting their voices during discussions but agreed to investigate whether anything could be done to improve the situation. 10 Date of Next Meeting The next meeting of the CoG would be held on 16 July 2025. 7 Agenda item Council of Governors 29/04/2025 9 Any Other Business 1250 Sound in the Heartbeat Conference Room Assigned to Jenni Douglas-Todd Deadline Status 16/07/2025 Pending Explanation action item LT commented that sound in the conference room was quite poor. JDT noted that all meeting attendees could take responsibility for projecting their voices during discussions but agreed to investigate whether anything could be done to improve the situation. An update will be provided at the meeting on 16 July 2025. Item 5.1 Report to the Council of Governors - 16 July 2025 Title: Chief Executive Officer’s Performance Report Sponsor: David French, Chief Executive Officer Author: Sam Dale, Associate Director of Data and Analytics Purpose (type an ‘x’ in the appropriate box(es)) (Re)Assurance Approval Ratification Information x Strategic Theme (type an ‘x’ in the appropriate box(es)) Outstanding patient Pioneering research World class people outcomes, safety and innovation and experience Integrated networks and collaboration Foundations for the future x x x Executive Summary: Information about Trust performance supports the Council of Governors in their role. This report is intended to inform the Council of Governors about aspects of the Trust’s performance. Contents: The Chief Executive Officer’s Performance Report is attached. Risk(s): N/A Equality Impact Consideration: N/A UHS Council of Governors July 2025 Chief Executive’s Performance Report 1. Purpose and Context The purpose of this report is to summarise the Trust’s performance against a range of key indicators. This report covers data from the period March to May 2025. The period reflects the transition out of winter pressures and into a new financial year with its associated targets, bother operationally and financially. Whilst both present significant challenges for the organisation, UHS is focussed on maintaining strong performance across all areas whilst committing to the national requirement to maintain financial balance. Notable features of the period include: • As at May 25, the trust is in line with the financial plan, reporting a deficit of £8m and delivery of £12.5m of savings. • Significant increases in referrals beyond seasonality trends across several key specialties has resulted in further growth in the hospital’s waiting list which closed at 62,949 for May 2025. • The percentage of patients waiting less than 18 weeks increased to 64.4% which reflects the increase in referrals in the last 18 weeks, but also success in bringing waiting times down for several services. • Managing emergency department attendances and the subsequent flow of patients in and out of the hospital continue to be a highest priority. ED performance in May 2025 was 59% for the percentage of attendances who spent less than four hours in the department. • The trust reported an improvement in staff sickness rates. The 12-month rolling turnover rate remained steady at around 10.1% despite recent fluctuations linked to the introduction of a mutually agreed resignation scheme to support a pay expenditure reduction. • The hospital recognised a lower staff survey response rate linked to a change in survey provider. This will be remedied through wider staff communications in the next quarter • The hospital mortality rate continues to reflect better than expected survival. The organisation reported one never event across the three months and two PSIIs. 2. Safety Infection Control Clostridium Difficile infection MRSA Bacterium infection E.coli Target 78.0% March 2025 60.1% April 2025 63.6% May 2025 59.3% Attendances to the Emergency Department (ED) have remained high through this period, averaging 433 attendances per day across March, April and May. This, alongside ongoing flow challenges due to the number of patients no longer meeting the Criteria to Reside, means that UHS is facing a number of challenges in moving towards the national target. An external review completed by regional clinical leads for ED and AMU (acute medical unit) was undertaken at the end of June. Initial feedback gave some helpful areas for improvement. Full report is expected in July and will form the basis for our ongoing improvement work. One of the challenges we face is not having an on site urgent treatment centre, but that now has capital funding with plans to open in 2026. Page 3 of 6 Referral to Treatment (RTT) Target % incomplete pathways within 18 weeks in month => 92% Total patients on a waiting list March 2025 62.5% 61,686 April 2025 63.0% 62,310 May 2025 64.4% 62,949 The number of patients on the RTT waiting list continued to increase over the last three months despite signs of an overall NHS waiting list reduction reported nationally. The trust recognises the seasonal trend behind certain services each year, however there are also notable increases in Dermatology due to cessation of Tier 2 services in the community and a continual demand increase seen within Cardiology, Oral Surgery and Clinical Genetics. The trust is focussed on a series of interventions to reduce the waiting list which includes reductions to DNAs, improved theatre utilisation, management of referrals through expanded advice and guidance services and expansion of patient initiated follow-up services. Alongside this, the organisation constantly validates the waiting list to ensure patients’ conditions and pathway changes are well managed and appropriately reported. Cancer Target Faster Diagnosis - within 28 days 31 Day target - decision to treat to first definitive treatment 62 day target - urgent referral to first definitive treatment > =77% => 96% => 70% February 2025 84.4% 92.8% 72.1% March 2025 83.0% 93.8% 81.2% April 2025 81.8% 95.2% 75.4% The hospital continues to appropriately prioritise cancer patients and as a specialist teaching hospital accepts complex patients transferred from other providers during their cancer pathway. Cancer referrals remain high but we have maintained compliant performance on two of the three cancer standards, both also placing the Trust in the top quartile compared to peer teaching hospitals across the NHS. 5. Finance The financial environment remains extremely challenging for UHS. Our plan submission for 2025/26 targets breakeven delivery which is predicated on the achievement of £110m of savings. This represents 8% of turnover. The shape of the financial plan is one that requires month of month improvement with a deficit plan of £17m in the first half of the year offset by an equivalent surplus plan of £17m in the second half of the year. The financial architecture in 2025/26 means a greater majority of the trust’s income is fixed (or capped) therefore savings are required to be achieved mainly via cost out schemes covering both pay and non pay. All areas have been asked to explore workforce reductions and a newly formed financial improvement group has been established, chaired by the CEO, to help drive the pace of efficiency improvement in a mindful way. As at May the trust is on plan, reporting a deficit of £8m and delivery of £12.5m of savings. Some of this has however been underpinned by non-recurrent benefits that will therefore not reoccur in future months meaning the underlying challenge has been assessed at a c£14m deficit over April and May. A run rate at this trajectory would be unsustainable for the trust and therefore further energy is being Page 4 of 6 put into savings achievements. A MARS (mutually agreed resignation scheme) has been launched which should help support the delivery of sustainable workforce savings and detailed workforce trajectories have been developed. Continued efforts are being put into procurement, medicines optimisation, digital efficiencies and estates efficiencies to ensure maximum value for money for patients. Deficit drivers do however remain making the financial climate for sustainable improvement challenging. These are as follows: 1. Urgent and Emergency activity is in excess of block funding levels. This has meant surge capacity continues to be required and bed closure plans where length of stay reductions are achieved are often difficult to embed. 2. Non-criteria to reside numbers have increased to peaks of 270 from an average of 220. This is c20% of the trusts bed base and has a significant cost in addition to clinical risks of patient deconditioning and infection. This remains a focus of the inpatient flow programme. 3. Mental health patient demands continue at consistent levels from previous years with patients often requiring enhanced levels of support often at a significant cost premium to the trust. UHS continues to work with system providers on improvements for this patient group. Despite these pressures however the trust has continued to ensure value for money remains an organisational priority and is focused on transforming services under the three workstreams of theatre optimisation, outpatients and inpatient flow. Further to this the trust remains on target to spend its full capital allocation for 2025/26 totalling over £66m for which £36m is externally funded following successful business case applications. This includes further investment in the emergency department of £8m. This continued investment in capacity, digital and infrastructure helps support continued ongoing financial sustainability and efficiency improvements. 6. Human Resources Indicator Staff recommend UHS as a place to work % Staff survey engagement score (out of 10) Q4 24/25 66.4% 6.8 Q1 25/26 47.7% 6.39 We have changed provider for the quarterly pulse surveys and they are now provided by NHS England through the People Pulse. With the new provider, staff no longer receive a direct email inviting them to take part in the survey. With this change we only heard from 440 of our staff, in comparison to our usual 2000-4000 responses for the quarterly surveys. For quarter 2 we plan on sending out an all-staff email so staff are still receiving that direct communication about the survey. The People Pulse do a correlational analysis for us to show which core questions have the strongest relationship to employee engagement. In this survey, managers seeking to address the work challenges of staff had the highest correlation with engagement. Closely followed by managers seeking to understand work challenges and organisation proactively supporting health and wellbeing. This tells us what our biggest drivers of engagement have been and improving these will continue to increase the engagement of our staff. Page 5 of 6 Indicator Staff Turnover (internal target; rolling 12 month) Sickness absence 12-month rolling (internal target) Target 106 WTE reduction for UHS. ​ • reduce bank use by 20% and agency use by 30%. ​ Risks:​ • Delivering a net reduction in workforce will be challenging for UHS, especially in the context of (funded) clinical service expansions. It relies on length of stay and other productivity improvements, capacity closures, and implementation of organisational change processes. ​ 10 Workforce Plan Note: Includes Employed, Bank and Agency Whole Time Equivalents worked 11 Transformation Programme Our plan includes further improvements within our existing Transformation programmes. • In 25/26, we expect to translate the productivity benefits into capacity, staffing and expenditure reductions, whilst maintaining the numbers of appointments / treatments. • Increases in activity numbers and income are not appropriate due to NHS funding limits. • Our improvement programmes also seek to improve patient experience, reduce waiting times, and ensure that patients see the right service for their needs. Programme Urgent & Emergency Care Target cash-releasing financial benefit £6.2m Rationale The value of reducing average length of stay by 5% against our 24/25 baseline and using the released capacity to close escalation beds and ward beds. Elective Care: Optimising Operating Services Elective Care: Outpatients £1.5m £1.5m Filling 30% of the case gaps on elective operating lists with an additional patient by reducing cancellations, better scheduling and improved start times. This will require fewer theatre sessions to run to treat the same number of patients. Improvements in booking practices and digitisation will reduce outpatient administration, postage and paper costs. Patients will be more efficiently treated by seeing additional patients per clinic and providing more advice & guidance allow us to reduce the cost of delivering the funded level of outpatient activity. Note: The above Transformation programmes are enablers for divisional CIP delivery. 12 Transformation Programme: Patient Flow The patient flow programme is targeting a 5% reduction in length of stay in 25/26 having delivered a 5.4% reduction in 24/25. The 20,769 bed days released are expected to be realised by closing inpatient capacity with a cost benefit of £6.2m. Admission numbers are expected to remain consistent with 24/25. 13 Transformation Programme: Theatres UHS increased its average theatre utilisation performance by 1% in 24/25 to 78.2%. Consistent performance at 85% utilisation enabled by improvements in scheduling practices and late starts would enable a further 500 patients to be treated on our existing lists. Reducing the number of lists to keep activity consistent with the funded level is planned to yield a cost reduction of £1.5m. 14 Transformation Programme: Outpatients Improving our Did Not Attend (DNA) rate to upper quartile levels will enable us to see more patients within our outpatient clinics. This will enable us to save money by reducing the number of clinics provided whilst maintaining the same number of appointments. In addition, administration, postage and paper costs will be reduced through centralisation of admin staff, partial booking approaches and digital patient communication. A total cost benefit of £1.5m is anticipated. 15 NCTR Patients (‘non-Criteria to Reside’ in an acute hospital) The number of patients waiting in an acute hospital bed when they are fit to leave (but typically require care in the community arranged by other organisations) continues to be a concern. Our ICS does not currently have an agreed plan or target for improvement in 25/26. UHS colleagues are working with local health and social care partners to explore how improvements could be achieved. Those improvements that can be achieved within the hospital are being driven through our Urgent and Emergency Care Transformation Programme. 16 Mental Health Patients The numbers of patients receiving care for their mental health in acute hospital continues to be a concern, particularly as the acuity of these patients has increased as well as their enhanced need requirements. Whilst some patients have mental health together with physical health needs, many do not require the acute hospital and will receive more appropriate care when a mental health inpatient or outpatient service can be accessed. In addition to the impact on each patient, staffing for mental health needs / safety results in significant additional costs at UHS. Our ICS does not currently have an agreed plan or target for improvement in 25/26. UHS colleagues are working with local partners to explore how improvements could be achieved. 17 Quality and Performance Targets Measure National Target for 2025-26 A&E waits: ED patients waiting under 4 At least 78% in March 2026 hours A&E waits: ED patients waiting over 12 hours Elective waits: Incomplete Referral to Treatment pathways of 52 weeks or more Elective waits: Patients waiting no longer than 18 weeks for a first appointment Elective waits: Incomplete RTT pathways of less than 18 weeks Elective waits: 62-day cancer standard Reduce compared to 2024/25 Less than 1% At least 72%, with every trust delivering a minimum 5% improvement by March 2026 At least 65%, with every trust delivering a minimum 5% improvement by March 2026 75% by March 2026 UHS Plan for 2025-26 Complies with national priorities 70% for ED then 78% UHS alone Yes in March 2026 (assumes new UTC at SGH opens) 2% Yes 0.9% Yes 72% Yes 67% Yes 77% Yes Elective waits: 28-day cancer Faster 80% by March 2026 83% Yes Diagnosis Standard Quality: safety in maternity and Delivering the 12 key actions of the Continue planned delivery Yes neonatal services ‘Three year delivery plan’ 18 Service Developments / Investments 2025/26 Our annual plan includes a significant number of service developments / expansions, and investments in buildings / technology, that will deliver improvements for patients and staff alike. These include: Development / Investment Description Aseptic Pharmacy Mechanical Thrombectomy Community Diagnostic Centre HIOW Elective Hub – Winchester Urgent Treatment Centre Audiology Booths Salix Energy Works New building at Adanac Park, an improved and significantly expanded service for the aseptic production of medicines for intravenous infusion Further expansions to the capacity and hours covered by this specialist emergency treatment for suitable patients who have suffered a Stroke (Update – now impacted by changes to NHS Commissioner funding) Expansion of CDC at RSH to include an additional NHS CT and an MRI scanner by 2026, new Phlebotomy service in 2025 New UHS service jointly with HHFT, at Winchester, to undertake Orthopaedic Hip and Knee replacement procedures in two new operating theatres (from summer 2025) Construction will take place during 2025/26 with the aim of service commencement in March 2026 at SGH, adjacent to the existing ED Two replacement Audiology booths at the RSH, that will be suitable for children and patients with disabilities Improve energy efficiency and reduce carbon emissions in healthcare facilities, via the NHS Public Sector Decarbonisation Scheme funding 19 Item 6.1 Report to the Council of Governors - 16 July 2025 Title: Review Terms of Reference - Council of Governors Sponsor: Jenni Douglas-Todd, Trust Chair Author: Karen Russell, Council of Governors’ Business Manager Purpose (type an ‘x’ in the appropriate box(es)) (Re)Assurance Approval Ratification Information x Strategic Theme (type an ‘x’ in the appropriate box(es)) Outstanding patient Pioneering research World class people outcomes, safety and innovation and experience Integrated networks and collaboration Foundations for the future x Executive Summary: The terms of reference for the Council of Governors should be reviewed regularly, and at least once annually, to ensure that these reflect the purpose and activities of the Council of Governors. Following review, a few small changes are proposed to the Council of Governors’ terms of reference to reflect the current compliance arrangements, and one very minor grammatical change. The proposed changes are highlighted on the terms of reference document. The Council of Governors is asked to approve the revised terms of reference. Contents: Draft Council of Governors’ Terms of Reference Risk(s): N/A Equality Impact Consideration: N/A Council of Governors Terms of Reference Date Issued: 1 May 2024 16 July 2025 Review Date: April 20252026 Document Type: Terms of Reference Version: 78 Contents Paragraph 1 2 3 4 5 6 7 8 9 10 Role and Purpose Constitution Membership Attendance and Quorum Frequency of Meetings Conduct and Administration of Meetings Duties and Responsibilities Accountability and Reporting Review of Terms of Reference and Performance and Effectiveness References Appendices Appendix A Working Group and Reporting Structure Page 2 2 2 3 3 3 4 5 5 5 Page 6 Document Status This is a controlled document. Whilst this document may be printed, the electronic version posted on the intranet is the controlled copy. Any printed copies of this document are not controlled. As a controlled document, this document should not be saved onto local or network drives but should always be accessed from the intranet. Page 1 of 7 1. Role and Purpose 1.1 The general duties of the council of governors (CoG) of University Hospital Southampton NHS Foundation Trust (UHS or the Trust) are: 1.1.1 to hold the non-executive directors (NEDs) individually and collectively to account for the performance of the board of directors (the Trust Board); and 1.1.2 to represent the interests of the members of the Trust as a whole, and the interests of the public. 1.2 The duties and responsibilities of the CoG are more fully described in paragraph 7 below. 2. Constitution 2.1 The establishment and role of the CoG is derived from the National Health Service Act 2006 (as amended). The CoG is accountable to the members of the Trust and the public. 2.2 It is supported in its work by other committees and groups established by the CoG as shown in Appendix A. 2.3 The CoG is authorised to investigate any activity within its terms of reference. In carrying out its role the CoG is also authorised to seek reports and assurance from executive directors and managers. 2.4 The CoG is authorised to obtain external legal or other independent professional advice if it considers this necessary, taking into consideration any issues of confidentiality and the Trust’s standing financial instructions and supported by the Company Secretary. 3. Membership 3.1 The CoG comprises: 3.1.1 Public elected governors from the following areas: 3.1.1.1 Five from Southampton City 3.1.1.2 Five from New Forest Eastleigh and Test Valley 3.1.1.3 One from The Isle of Wight 3.1.1.4 Two from the Rest of England and Wales. 3.1.2 Staff elected governors, one from each of the following staff classes: 3.1.2.1 Medical practitioners and dental staff 3.1.2.2 Nursing and midwifery staff 3.1.2.3 Health professional and health scientist staff 3.1.2.4 Non clinical and support staff. 3.1.3 Appointed governors, one from each of: 3.1.3.1 Hampshire and Isle of Wight Integrated Care Board 3.1.3.2 Southampton City Council 3.1.3.3 Hampshire County Council 3.1.3.4 University of Southampton 3.1.3.5 Solent University. Page 2 of 7 3.2 The chair of the Trust (the Trust Chair) is the chair of the CoG. In the absence of the Trust Chair, the deputy chair appointed by the CoG (the Deputy Chair) will chair the meeting, or in their absence, another non-executive director. If there is no nonexecutive director present or available, the governors present will elect one of themselves to chair the meeting. 3.3 Only members of the CoG have the right to attend and vote at CoG meetings. However, the two Associate Governors will be invited to attend all meetings of the CoG. The Company Secretary and the Council of Governors’ Business Manager will also attend all meetings of the CoG. 3.4 Other individuals may be invited to attend for all or part of any meeting, as and when appropriate and necessary, particularly when the CoG is considering areas of risk or operation that are the responsibility of a particular executive director or manager. 4. Attendance and Quorum 4.1 Governors should aim to attend every meeting. Where a governor is unable to attend a meeting they should notify the Trust Chair or Council of Governors’ Business Manager in advance, providing a reason for their absence. 4.2 The quorum for a meeting will be one-third of the governors. A duly convened meeting of the CoG at which a quorum is present will be competent to exercise all or any of the authorities, powers and discretions vested in or exercisable by the CoG. 4.3 When an executive director or manager is unable to attend a meeting they should appoint a deputy to attend on their behalf. 5. Frequency of Meetings 5.1 The CoG will meet at least four times each year. 6. Conduct and Administration of Meetings 6.1 Meetings of the CoG will be convened by the Company Secretary at the request of the Trust Chair, or the Deputy Chair in their absence. 6.2 If the Trust Chair refuses to call a meeting after a requisition for that purpose, at least one-third of the governors may request the Trust Chair to convene a meeting in writing specifying the business to be transacted at the meeting. If the Trust Chair does not call a meeting within seven clear days after the receipt of the signed request, one-third or more of the governors may call a meeting for the purpose of conducting that business. 6.3 The agenda of items to be discussed at the meeting will be agreed by the Trust Chair with support from the Company Secretary and the Council of Governors’ Business Manager. The agenda and supporting papers will be distributed to each member of the CoG and the regular attendees, no later than five days before the date of the meeting. Distribution of any papers after this deadline will require the agreement of the Trust Chair. 6.4 The Council of Governors’ Business Manager will minute the proceedings of all meetings of the CoG, including recording the names of those present and in attendance and any declarations of interest. 6.5 Draft minutes of CoG meetings and a separate record of the actions to be taken forward will be circulated promptly to all members of the CoG. Page 3 of 7 7. Duties and Responsibilities The CoG will have the following duties and responsibilities. 7.1 Holding the Non-Executive Directors to Account 7.1.1 hold the NEDs individually and collectively to account for the performance of the Trust Board; 7.2 Appointment of Chair, Non-Executive Directors, Chief Executive and External Auditor 7.2.1 7.2.2 7.2.3 7.2.4 7.2.5 7.2.6 7.2.7 7.2.8 7.2.9 approve the policies and procedures for the appointment and, where necessary, for the removal of the Trust Chair and NEDs; approve the appointment (or removal) of the Trust Chair; approve the appointment (or removal) of a non-executive director; approve the policies and procedures for the appraisal of the Trust Chair and NEDs; approve the policy for the composition of the NEDs; approve changes to the remuneration, allowances and other terms of office for the Trust Chair and NEDs; consider and, if appropriate, approve the appointment of the chief executive officer of the Trust as recommended by the Trust Chair and the NEDs; approve the criteria for appointing, re-appointing or removing the external auditor; approve the appointment or reappointment and the terms of engagement of the external auditor; 7.3 Constitution and Compliance 7.3.1 7.3.2 7.3.3 7.3.4 7.3.5 7.3.6 approve amendments to the constitution, recognising that any changes in respect of the powers, duties or role of the CoG will need to be approved at the next general meeting of members; approve the policy for the composition of the CoG; notify NHS England if the CoG is concerned that the Trust has breached, or is at risk of breaching, its licence conditions in the event that these concerns cannot be resolved through engagement with the Trust Board; receive the Trust’s annual report and accounts (including the quality accounts/report) and any report of the external auditor on them; decide whether a member is disqualified from membership or no longer eligible to be a member in the event of a dispute referred by the Company Secretary; consider any appeal by a member about entitlement to membership following a decision by the Company Secretary; 7.4 Governors 7.4.1 7.4.2 7.4.3 7.4.4 7.4.5 7.4.6 7.4.7 decide whether to appoint committees of the CoG to assist in the performance of its functions; approve the appointment of governors to any committees or working groups of the CoG or joint working groups with the Trust Board; approve the process for appointment or election to the role of lead governor and, as necessary, deputy lead governor; receive reports from the chairs of each committee or working group of the CoG on the discharge of the committee’s or working group’s duties; approve the removal from office of any governor in accordance with procedure set out in the constitution; approve jointly with the Trust Board the procedure for the resolution of disputes and concerns between the Trust Board and the CoG; decide whether or not to terminate the tenure of office of a governor for failure to attend meetings or to terminate a governor’s tenure of office for other reasons; Page 4 of 7 7.4.8 decide what action to take when a vacancy arises among the elected governors; 7.5 Strategy, Planning and Reorganisations 7.5.1 7.5.2 7.5.3 7.5.4 7.5.5 7.5.6 in response to requests from the Trust Board, provide feedback on the development of the annual operating plan and the strategic direction of the Trust; contribute to the development of stakeholder strategies, including membership engagement strategies; where the Trust’s forward plan contains a proposal that the Trust will carry on an activity other than the provision of goods and services for the purposes of the NHS in England, determine whether the CoG is satisfied that such activity will not interfere with this and notify the Trust Board of its determination; consider and, if appropriate, approve proposed increases to the amount of income derived from the provision of goods and services other than for the purpose of the NHS in England where such an increase is greater than 5% of the total income of the Trust in the relevant financial year; consider and, if appropriate, approve proposals from the Trust Board for mergers, acquisitions, separations and dissolutions (which will require the approval of more than half of the total number of governors); consider and, if appropriate, approve proposals for significant transactions in accordance with the constitution or such other transactions as the Trust Board may submit for the approval of the CoG from time to time (which will require the approval of more than half of governors voting at a quorate meeting of the CoG); 7.6 Representing Members and the Public 7.6.1 7.6.2 7.6.3 7.6.4 7.6.5 7.6.6 represent the interests of the members of the Trust as a whole and of the public; consider and, if appropriate, approve the membership engagement strategy; contribute to members’ and other stakeholders’ understanding of the work of the Trust in line with engagement strategies; seek the views of stakeholders, including members and the public and feed back relevant information to the Trust Board or to individual executive directors as appropriate; promote membership of the Trust and contribute to opportunities to recruit members in accordance with the membership engagement strategy; and report to members each year on the performance of the CoG. 8. Accountability and Reporting 8.1 The CoG will report to the membership at the Annual Members’ Meeting and on such other occasions as are arranged. 9. Review of Terms of Reference and Performance and Effectiveness 9.1 At least once a year the CoG will review its collective performance and effectiveness and its terms of reference. Any proposed changes to the terms of reference will be approved by the CoG. 10. References 10.1National Health Service Act 2006 10.2NHS Foundation Trust Code of GovernanceCode of Governance for NHS Provider Trusts 10.3Trust Constitution 10.4Standing Orders for the Practice and Procedure of the Council of Governors Page 5 of 7 Appendix A Council of Governors Governors' Nomination Committee Membership and Engagement Working Group Patient and Staff Experience Working Group Strategy and Finance Working Group Required by National Health Service Act 2006 or NHS Foundation Trust Code of Governance Code of Governance for NHS Provider Trusts Discretionary committee/group . Page 6 of 7 Council of Governors Terms of Reference Document Monitoring Information Approval Committee: Date of Approval: Responsible Committee: Council of Governors 1 May 202416 July 2025 Not applicable Version: 78 Monitoring (Se
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/Media/UHS-website-2019/Docs/About-the-Trust/Governors/Papers-CoG-16.07.2025.pdf

Papers Trust Board 27 May 2021

Description
Date Time Location Chair Agenda Trust Board – Open Session 27/05/2021 9:00 - 13:00 Microsoft Teams Peter Hollins 1
Url
/Media/UHS-website-2019/Docs/About-the-Trust/Trust-governance-and-corporate-docs/2021-Trust-document/TB-papers/Papers-Trust-Board-27-May-2021.pdf

Altruism in stem cell donation

Description
Mr Wheeler considers whether a person without capacity can be a stem cell donor.
Url
/HealthProfessionals/Clinical-law-updates/Altruism-in-stem-cell-donation.aspx

Annual ward staffing review January 2025

Description
[5.15] Report to the Trust Board of Directors, 7th January 2025 Title: Ward Staffing Nursing Establishment Review Jul
Url
/Media/UHS-website-2019/Docs/About-the-Trust/performance/TB-6-monthly-staffing-review-report.pdf

Papers Trust Board - 7 January 2025

Description
Date Time Location Chair Observing Agenda Trust Board – Open Session 07/01/2025 9:00 - 13:00 Conference Room, Heartbeat/Microsoft
Url
/Media/UHS-website-2019/Docs/About-the-Trust/Trust-governance-and-corporate-docs/2025-Trust-documents/Papers-Trust-Board-7-January-2025.pdf

Approaches to the best interests of adults and children differ

Description
Mr Wheeler considers the differences between determining best interests for an adult and a child.
Url
/HealthProfessionals/Clinical-law-updates/Approaches-to-best-interests-of-adults-and-children-differ.aspx
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