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Florence FAQs_v1.0

Description: Florence FAQ’s Introduction During the 2023 MHRA inspection UHS received a ﬁnding and some advice regarding working electroni
Url: /Media/Southampton-Clinical-Research/Downloads/Florence-FAQs-v1.0.pdf

CH003 SOP regimen validation full

Description: Standard Operating Procedure Validation of Chemotherapy Protocols in ARIA (Wessex) (SOP:CH003) 1. Objective 1.1 The purpose of this standard operatin
Url: /Media/UHS-website-2019/Docs/Chemotherapy-SOPs1/Validation/CH003-SOP-regimen-validation-full.pdf

SOP validation dose banding Aria ver1

Description: Central South Coast Cancer Network Standard Operating Procedure Validation of CSCCN Dose Banding in Aria (SOP:CH004) 1. Objective 1.1
Url: /Media/UHS-website-2019/Docs/Chemotherapy-SOPs1/Validation/SOPvalidationdosebandingAriaver1.pdf

Papers Trust Board - 13 January 2026

Description: Date Time Location Chair Apologies Agenda Trust Board – Open Session 13/01/2026 9:00 - 13:00 Conference Room, Heartbeat Education
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Trust-governance-and-corporate-docs/2026-Trust-documents/Papers-Trust-Board-13-January-2026.pdf

Handling concerns and complaints policy

Description: Handling Complaints Policy, Version 13.0 Trust reference PET003 Version number 13.0 Description Policy to explain how University Hospital Southampton implements the framework for the NHS Complaints (England) Regulations 2009. It clarifies what people should expect when then complain, in accordance with Parliamentary and Health Service Ombudsman’s complaint standards. Level and type of document Target audience Trust-wide corporate policy – controlled document. Staff, patients, relatives, and carers. Author(s) (names and job titles) Policy sponsor Shona Small, Complaints Manager Jenny Milner, Associate Director of Patient Experience This is a controlled document. Whilst this document may be printed, the electronic version posted on Staffnet is the controlled copy. Any printed copies of this document are not controlled. As a controlled document, this document should not be saved onto local or network drives but should always be accessed from Staffnet. All documents must remain watermarked as ‘draft’ until they have been approved by the Expert Group. 1 Date Version control Author(s) Version Approval created committee 6.9.2024 Shona Small 6.9.2024 Experience of care committee Date of approval 10/7/24 Date next review due 10/7/27 Key changes made to document To bring in line with Ombudsman’s new complaint standard terminology. PET003 Handling Complaints Policy version 13. Issued 10.7.24 Page 1 2 Index 1 Version control ............................................................................................................... 1 2 Index.............................................................................................................................. 2 3 Introduction .................................................................................................................... 2 4 Quick References .......................................................................................................... 3 5 Scope and purpose ........................................................................................................ 3 6 Definitions ...................................................................................................................... 4 7 Details of policy.............................................................................................................. 5 8 Roles and responsibilities ............................................................................................ 15 9 Communication and training plans ............................................................................... 15 11 Document review...................................................................................................... 16 12 Process for monitoring compliance ........................................................................... 16 13 Appendices .............................................................................................................. 17 • Appendix A ................................................................................................................. 17 • Appendix B................................................................................................................. 18 • Appendix C................................................................................................................. 18 • Appendix D................................................................................................................. 21 • Appendix E ................................................................................................................. 22 • Appendix F ................................................................................................................. 23 • Appendix G................................................................................................................. 24 • Appendix H................................................................................................................. 31 • Appendix I .................................................................................................................. 33 • Appendix J ................................................................................................................. 34 • Appendix K - Audit tool to monitor policy compliance ............................................. 35 • Appendix L ................................................................................................................. 36 14 References ............................................................................................................... 36 3 Introduction The purpose of this policy is to explain how University Hospital Southampton NHS Foundation Trust (UHS) implements the statutory legal framework for the local authority, social services and National Health Service Complaints (England) Regulations 2009, and how the Trust meets the requirements of the NHS Constitution. The policy makes clear what people should expect when they complain (NHS Constitution) and supports a culture of openness, honesty and transparency (duty of candour). Trust practice is informed by the Parliamentary and Health Services Ombudsman (PHSO) Complaint Standards and Principles of Remedy, including the Scale of Injustice. The policy deals with the handling of concerns and complaints (regarding Trust services, buildings or the environment) received from patients, patient’s relatives, carers, visitors and other service users. In most circumstances the quickest and most effective way of resolving a concern or complaint is to deal with the issues when they arise or as soon as possible after this (early resolution). PET003 Handling Complaints Policy version 13. Issued 10.7.24 Page 2 In circumstances where early resolution is not possible, this policy describes the processes in place to ensure that complaints are handled efficiently and investigated thoroughly. Patient and Family Relations (P&FR) are responsible for the overall management of complaints. P&FR combines the patient advice and liaison service (PALS) and the complaint handling functions, to provide a flexible approach to resolving complaints. The policy promotes the use of people’s experience of care to improve quality. By listening to people about their experience of healthcare, the Trust can resolve mistakes faster, learn new ways to improve the quality and safety of services, and prevent the same problem from happening again in the future. The reporting and monitoring of trends, themes and lessons learnt is undertaken through divisional governance structures, quality committee and the quality governance steering group and is used to ensure compliance with commissioner, regulatory and good practice requirements. The Trust is committed to providing safe, effective and high-quality services. However, it is recognised that things can occasionally go wrong. When complaints are raised, the Trust has a responsibility to acknowledge the complaint, put things right as quickly as possible, prevent reoccurrence and identify service improvements. Written information regarding how the Trust deals with complaints will be made available in all departments, the main reception, patient support services, the Trust website and through the local Integrated Care Bureau (ICB), The Advocacy People and other patient forums. 4 Quick References None 5 Scope and purpose The purpose of the policy is to: • Outline the Trust policy on handling complaints • Describe the procedure followed to respond to complaints • Confirm the roles and responsibility associated with this process • Provide staff with guidance on how to respond to a complaint • Describe how this policy links to the National Complaint Handling Framework o Promotes a learning and improvement culture o Positively seeks feedback o Is thorough and fair o Gives a fair and accountable decision The aim is to explain how UHS implements the statutory legal framework for the local authority social services and NHS Complaints (England) Regulations 2009, meets the requirements of the NHS Constitution and duty of candour, and ensures compliance with commissioners, regulatory and good practice requirements. The aims and outcomes of this policy promote early, local and prompt resolution involving the complainant in deciding how their complaints are handled. Likewise, good complaint handling and continuous learning is endorsed throughout the policy, promoting improvements in the quality and safety of services at UHS and facilitating positive patient experiences. PET003 Handling Complaints Policy version 13. Issued 10.7.24 Page 3 Aims • To listen, to acknowledge mistakes, explain what went wrong and to consider prompt, appropriate and proportionate remedy to put things right. • To provide a consistent approach to the timely and efficient handling of complaints and establish an agreed plan with the complainant with an emphasis on early resolution, sharing learning and improving our services. • To ensure organisational openness and an approach that is conciliatory and fair to people both using and delivering services. • To respect the individual’s right to confidentiality and treat all users of this policy with respect and courtesy. Outcomes • The policy and procedure will, as far as is reasonably practical, be easy to understand, accessible, publicised in ways that will reach all service users and include information about support and advocacy services, if relevant. • All staff will receive an appropriate level of training to enable them to respond positively to complaints, and endeavour to resolve issues quickly. • The Trust will ensure that service users and carers can raise a complaint without their care, treatment or relationship with staff being compromised. • Investigations will be thorough, fair, responsive and appropriate to the seriousness of the complaint. They will also be conducted within the timescales agreed with the complainant. • The format of the response to the complaint will be agreed with the complainant. This may be verbal, by phone or at a meeting, or written, by email or letter. • The Trust will strive to resolve all complaints locally, while reminding people of their right to take the matter to the Parliamentary and Health Service Ombudsman if they are not satisfied. • Within divisions and care groups, local leadership and accountability will facilitate early resolution and ensure complaints are responded to promptly and used to initiate actions and opportunities for service and staff improvement. • Divisional governance structures will be used to ensure organisational learning from complaints and the sharing of best practice. 6 Definitions Please see Appendix A for flow chart. For the purpose of this policy, the following definition will apply: Term Everyday Conversations Early Resolution Definition Defined as every-day issues that with help can be resolved there and then (within 24 hours), without the person becoming dissatisfied and wanting to make a complaint. Defined as a more straightforward complaint that can be resolved fairly quickly (within 10 days), e.g., appointment issues, staff attitude, services not provided to expected standards. PET003 Handling Complaints Policy version 13. Issued 10.7.24 Page 4 Closer Look Defined as an expression of dissatisfaction, or a perceived grievance or injustice, that needs a closer look. Timescale for resolution is agreed with the complainant. 7 Details of policy 7.0 Details of complaints process – refer to Appendix B for process overview. 7.1 Making a complaint Service users and the public who contact P&FR to make a complaint will receive appropriate assistance from the Trust to enable them to understand the procedure and, if required, will be signposted to complaint advocacy. 7.1.1 How to make a complaint – Stage 1 Information on how to raise a concern or make a complaint can be found on both our internal and external webpages. Complaints may be made about any matter reasonably connected with the exercise of the functions of the Trust, both clinical and non-clinical. They can be made verbally, in person or via telephone, or in writing either in a letter or electronically. A complaint may be raised with any member of Trust staff, P&FR (PALS or complaints team) or the chief executive. Alternatively, the complainant may choose to address their complaint to their local commissioner, NHS England, a member of parliament or another third party, such a health advocate. 7.1.2 Who may make a complaint – Stage 1 Complaints may be made by a patient, their representative, or any persons who are affected by or likely to be affected by the action, omission or decision of the Trust. This includes family, carers, advocates, care home/nursing homes, MPs, Integrated Care Bureau (ICB) and NHS England. When complaints are made by persons other than the complainant, the need for consent will be assessed. In the above circumstances where the Trust does not intend to consider a complaint, the complainant will be notified of the reasons for this decision in writing. Complainants will be made aware of independent complaints advocacy for help and support to make a complaint. Other specialist advocacy agencies covering areas such as mental health, learning disabilities, elderly or disadvantaged groups, and independent mental capacity advocacy (IMCA) are also available for general support. Details are available from PALS and the complaints team. 7.1.3 Consent if the complainant is not the patient – Stage 1 In cases where a patient’s representative makes a complaint, consent will be obtained from the patient, or person legally responsible for the patient, for permission to access their health records for the purpose of the investigation, where required, and to release the details of the investigation to the representative. If the patient is unable to act for themselves, the nominated first contact, or an individual who holds Power of Attorney (POA) for Health and Welfare can make a complaint on the patient’s behalf and will be able to provide consent for this to be investigated and the details released PET003 Handling Complaints Policy version 13. Issued 10.7.24 Page 5 to them. If the complainant is not the patient’s nominated first contact or does not hold POA, we will inform the complainant that the nominated first contact, or POA holder needs to confirm they are happy for the outcome of the investigation to be shared with another party. If the patient has died, the Trust will respect any known wishes that had been expressed by the patient. This includes sharing the outcome of an investigation with parties who are not the nominated first contact or POA holder, but in these circumstances, we will contact the nominated first contact, or POA holder to ensure they are happy for the details to be shared. In circumstances where a complaint is made by a third party when the patient has not authorised the complainant to act on their behalf, this does not preclude the Trust from undertaking a full and thorough investigation into the concerns raised. Specifically, if the complaint raises concerns about patient safety or the conduct of staff, the relevant Trust policies will be evoked. Without consent, a response to the third party will be limited and the reasons for this explained to the complainant. 7.1.4 Complaints relating to Private Patient Services For complaints relating to private patient services at UHS, the patient should refer to the private patient policy, which includes the private patient complaint’s procedure for patients wishing to raise a concern regarding their private treatment at the Trust. 7.1.5 Complaints excluded from the scope of this policy The Trust is not required to consider the complaint in the following circumstances. However, the Trust will consider each case individually and, as soon as reasonably practicable, notify the complainant in writing of its decision and the reason for the decision. a) A complaint made by a responsible body (local authority, NHS body, primary care provider or independent provider who provides care under arrangements made with an NHS body). b) A complaint by an employee of a local authority or NHS body about any matter relating to that employment. c) A complaint which has been investigated previously or either has been or is currently being investigated by the Parliamentary and Health Service Ombudsman. d) A complaint arising out of the alleged failure to comply with a request for information under the Data Protection Act 2018, or a request for information under the Freedom of Information Act 2000. Please refer to the UHS information governance policy. e) Complaints about private treatment provided in the Trust. However, any complaint made about the Trust’s staff or facilities relating to care in their private bed will be investigated under this policy. f) Lost property claims, which are investigated and handled directly by the care group manager. However, any claim for lost property made as part of a complaint will be dealt with under this policy. g) Complaints concerning incidents or events which occurred over 12 months from the date the complaint is submitted. These are seen as out of time in the NHS complaints process – see 3.2.8. PET003 Handling Complaints Policy version 13. Issued 10.7.24 Page 6 7.2 Specific considerations when dealing with complaints 7.2.1 Complaints involving a vulnerable adult or child protection Where it is known that the complaint involves a vulnerable adult or child, the executive lead for child protection or vulnerable adults will be informed. The name nurse for safeguarding children or adults (as appropriate) will be consulted and contribute to the decision as to the most appropriate route of investigation agreed. This may not be the complaints procedure. The named nurse will support with advice on additional notifications and communication with the complainant. 7.2.2 Complaints that include a Patient Safety Incident Investigation (PSII) If the content of the complaint is only about the ‘event’, the patient safety team (PST) will lead and co-ordinate the PSIRF investigation, explain duty of candour and respond to the complainant. If there are matters that need to be investigated outside of PSIRF, agreement will be made between the PST and the complaints team about which elements of the investigation will not be covered by PSIRF and will need to be investigated through the complaints process. In these circumstances, the PST will notify P&FR of appropriate timescales for completion and release of their investigation. P&FR will then agree the timescale for the final complaint response with the complainant and will usually continue to be the main point of contact for the complainant. This is dependent on the nature of the incident and sometimes different arrangements are agreed at the patient safety case review meeting. If there is a need for a dual approach to the investigation, this will be explained to the complainant. Usually, a written response to the whole complaint (i.e., including both investigations) will be offered, explaining the extended period of time required for the Trust to respond. Where a written response is required, this will be produced by the P&FR with support from the PST. Where the investigation has uncovered significant failings in care and treatment, oversight of this process will be provided by the head of P&FR working in partnership with legal services, head of patient safety and Trust medical lead for complaints as appropriate. The complainant will also be offered the opportunity to meet with Trust staff to discuss the findings of the PSII and provide opportunity for Trust staff to respond to any outstanding queries. Alternatively, the complainant may choose to receive the outcome of the two investigations in separate written responses. 7.2.3 Complaints that are relating to Overseas Visitors If a patient considers that they have been charged incorrectly, they should raise this with the Overseas Visitor Manager (OVM) in the first instance to discuss on what basis they have been found to be chargeable and whether the provision of further documentary evidence is required. Where there continues to be a disagreement about how the Charging Regulations have been applied to a particular patient, the patient may want to seek the services of PALS. Where a patient is unhappy with the healthcare they have received, they or someone on their behalf and with their consent, can use the NHS complaints procedure as set out in this policy. The OVMs will ensure that the chargeable patients are aware of the complaint’s procedure. Complaints regarding charging will be fairly heard by an impartial person who is independent of the overseas visitors charging operation within the Trust. 7.2.4 Clinical negligence, personal injury or another claim. PET003 Handling Complaints Policy version 13. Issued 10.7.24 Page 7 If the complainant indicates a clear intention to bring legal proceedings for clinical negligence, personal injury or other claim, the use of the complaint’s procedure is not necessarily precluded. The complaints team will discuss the nature of the complaint with the litigation and insurance services department or Trust solicitor, if required), to determine whether the progression of the complaint might prejudice subsequent legal or judicial action. If there is no legal reason why the complaint should not be investigated, the complaints team will continue to investigate the complaint in accordance with Trust policy. In cases where there are legal reasons why a complaint should not be dealt with under this policy, the complaint investigation will cease. The complainant will be advised of this fact and requested to ask their legal representative to contact the claims department. The complaints team can continue to investigate any issues raised within the complaint that are not part of the claim. 7.2.5 Disciplinary or professional investigation or investigation of a criminal offence Cases regarding professional conduct where a complaint is found to be justified may require an internal disciplinary investigation to be undertaken. Such an investigation may result in the involvement of one of the professional regulatory bodies and/or police/counter fraud team depending on the nature of the allegations. Appropriate action will be taken in accordance with the Trust disciplinary procedure. In such circumstances, the complainant will be informed that a disciplinary investigation will be undertaken but that they have no right to be informed of the outcome of the investigation. Any other issues raised in the complaint which do not form part of the disciplinary or criminal investigation may continue to be dealt with under the complaints policy. 7.2.6 Coroner’s inquest In complaints involving a death that is referred to the coroner, the PST will lead and co-ordinate the investigation. This ensures clear lines of communication and investigation for clinicians and families. The complaints team will advise the family that their concerns will be investigated by the PST in preparation for the inquest hearing and that HM coroner’s office (HMCO) will endeavour to include all concerns raised. Any separate issues can be investigated by the complaints team under the NHS complaint regulations. 7.2.7 Allegations of fraud or corruption Any complaint concerning possible allegations of fraud and corruption is passed immediately to the NHS counter fraud service for action. 7.2.8 Media interest In cases where a complainant has contacted, or expresses their intention to contact, the media, the head of communications will be informed and will take appropriate action regarding Trust communication and media management. 7.2.9 Time limit for making a complaint Normally a complaint should be made within 12 months of the date on which the matter occurred, or 12 months of the date on which the matter came to the notice of the complainant. PET003 Handling Complaints Policy version 13. Issued 10.7.24 Page 8 Where a complaint is made after this time, the complaint may be investigated if the complainant had good reasons for not making the complaint within the above time limits and where, given the time lapse, it is still possible to investigate the complaint effectively and efficiently. In circumstances when a complaint is not being investigated on this basis, the complainant will be informed of the reason for that decision and advised that they may still ask the Parliamentary and Health Service Ombudsman to consider their complaint. 7.2.10 Handling of joint complaints between organisations In cases where a complaint involves more than one NHS provider, commissioner, local authority or third-party independent provider, and the complainant so wishes, the Trust will work with the other relevant organisations in seeking resolution. There is a jointly agreed protocol for the ‘Handling of NHS Inter-organisational Complaints in Hampshire and the Isle of Wight’, (Appendix C). This provides a framework for the handling of joint complaints between organisations, clarifies roles and responsibilities of organisations, enhances inter-organisation co-operation and reduces confusion for service users. The lead organisation will provide a single response on behalf of all organisations involved, ensuring that the complainant receives a seamless, effective service. The procedure for dealing with multi-agency complaints involving third party independent providers can be found at Appendix D. 7.3.11 Complaints received from nursing and care homes on behalf of their residents See Appendix E 7.3.12 Harassment and vexatious/intractable complainants Harassment Violence, racial, sexual or verbal harassment towards staff will not be tolerated; neither will language that is of a personal, abusive or threatening nature, either written or verbal. If staff should encounter this behaviour, they should seek support from their line manager and complete an adverse event form (AER). Where appropriate, the complainant will be informed in writing that their behaviour is unacceptable. Please see the UHS eliminating bullying and harassment policy. Abuse will be reported to the police. In the event that the complainant has harassed or threatened staff dealing with their complaint, all personal contact with the complainant will be discontinued. The complaint thereafter can only be pursued through written communication. Vexatious or intractable complainants In a minority of cases, people pursue their complaints in a way that can either impede the investigation of their complaint or can have a significant resource issue for the Trust and cause undue stress for staff. Unfortunately, despite patience and sympathy there are times when there is nothing further that can reasonably be done to assist them to rectify a real or perceived problem. PET003 Handling Complaints Policy version 13. Issued 10.7.24 Page 9 Judgement and discretion must be used when considering potential persistent, habitual or vexatious complainants. The criteria and procedure can be found at Appendix F and authorisation of vexatious status will be made by the head of P&FR. 7.3 Responding to complaints of patients, their relatives or carers 7.3.1 Local resolution Early resolution is the first line of investigation and response to a complaint and is undertaken within the Trust. Local resolution enables the Trust to provide the quickest opportunity for a full and thorough investigation and respond with the emphasis on a positive outcome rather than the process. The local resolution response will: • Acknowledge failures. • Apologise. • Quickly put things right when they have gone wrong. • Use the opportunity to improve services. Complaints are often raised directly to the staff involved. This is often frontline staff in wards, clinics or reception. All Trust staff, as a means of improving service provision, will welcome the complainant’s concerns or complaint positively. In most circumstances, the quickest and most effective way of resolving a complaint is to deal with the issues when they arise or as soon as possible after this (early local resolution). Upon raising a complaint, the complainant will be listened to, treated courteously and have their confidentiality assured. Discussions should include seeking an understanding of how they would like their complaint managed and what outcomes they are seeking. Every opportunity should be taken to resolve complaints at the outset and deescalate the complaint. If the staff member approached is unable to deal with the issue, they will refer the matter to a more senior member of staff on duty at the time, such as ward sister, matron, head of department or site manager. A complainant may simply require an apology, explanation, clarification of a misunderstanding or remedial action to be taken and therefore should not be automatically referred to P&FR, unless this is the complainant’s wish. 7.3.2 Early resolution All complaints are first assessed by our PALS team. If possible, they will agree with the complainant to investigate to achieve early resolution, in a sooner timescale. The PALS team will investigate via the NHS complaints process and provide a written response. 7.3.3 Taking a closer look If it is not possible to achieve early resolution, the complaint is passed to the complaints team to take a closer look. PET003 Handling Complaints Policy version 13. Issued 10.7.24 Page 10 • 7.3.3 Complaint assessment and acknowledgement On receipt of a complaint in the PALS or complaints team the first responsibility is to ensure that the patient’s immediate health needs are being met; ideally this will occur within 24 hours. In cases where a complaint that is being investigated under the NHS Complaint Regulations is received verbally, a transcript of the concerns should be made and sent to the complainant for agreement before the start of the investigation. The nature, complexity and seriousness of the complaint are assessed and graded using the complaint assessment tool (Appendix G). Any immediate actions are undertaken which may include, but are not restricted to, contact with Trust directors or divisional leads, PST, claims, communications, child protection, vulnerable adults, infection prevention and human resources. An assessment will also be made as to the requirement for consent to be sought before any investigation can proceed. Complaints are acknowledged within three working days, and this includes details of advocacy services and ‘Raising a concern or complaint’ (previously ‘Have your say’) leaflet detailing the Trust’s complaint process. Complaints received via email out of hours will receive an automated acknowledgement of receipt of email. The complaint handler will establish a relationship, offer an apology or empathy, clarify issues for investigation and seek to understand what resolution looks like for the complainant. They will also discuss and agree the management of the complaint, including any opportunity for early resolution, the timescales and the method of response. 7.3.4 Complaint investigation planning The nature and grade of the complaint will influence the level of investigation and the level of notification or cascade throughout the organisation. This is based on the complexity and severity score of the complaint (minimum, minor, moderate, major or severe) and the primary focus or professional group who are the subject of the complaint (medical, nursing, allied professionals, managerial or administrative). Higher graded complaints require prompt action, more robust investigations and may require the involvement of investigation contributors: • external to the division but internal to the organisation • external to the organisation The complaint handler will assess the complaint and plan the scope and approach to the investigation. This includes identifying the key staff required to contribute to the investigation (complaint investigation contributors). Where the contributors are adversely commented upon in the complaint, care is taken to ensure they are informed of the complaint by the complaint lead or line manager to ensure they receive support throughout the process. The complaint lead (CL) can add an additional level of scrutiny and modify or validate the complaint investigation plan prior to the start of the investigation, usually within three days. Staff directly involved in the complaint will not be allocated the role of complaint lead. 7.3.5 Complaint investigation Complaints will be thoroughly investigated in a manner appropriate to resolving the issues speedily and efficiently within the agreed timeframe. The complaint handler remains responsible for keeping the complainant up to date with the progress of the investigation and negotiates any necessary extensions to the agreed timeframe. PET003 Handling Complaints Policy version 13. Issued 10.7.24 Page 11 For all complaints assessed as ‘severe’, if appropriate, and where possible a scoping meeting will be held by the PST to identify any immediate actions and to support investigation planning. This meeting may be virtual or face-to-face, involving the complaint lead, complaint handler and care group clinical lead or matron. The complaint lead will oversee the quality and timeliness of the investigation and validate the conclusions, outcome and actions agreed for inclusion in the complaint response. On completion of the investigation the complaint handler will review the complaint investigation to ensure that it has been thorough and addresses all the issues raised by the complainant. The complaint lead will support the complaint handler to scrutinise the findings, draw conclusions, agree the complaint outcome and consider whether there is evidence of service failure or maladministration. The compliant lead will also ensure that a robust action plan is formulated to cover all upheld elements of the complaint. 7.3.6 Complaint Response When responding to a complaint staff will give a clear, balanced account of what happened based on the established facts. Staff will be open and honest when things have gone wrong and where improvements can be made. All complaints will receive a fair and honest response. The complainant may prefer to receive this via letter, email, at a meeting or as a telephone call. The latter will usually be followed up in writing or via email. The response will address all issues raised, provide a full explanation, an apology as appropriate, any decisions regarding remedy and any actions that have or are planned to be undertaken to put the matter right. Details will also be given of what actions should be taken should the complainant believe the response has not adequately answered the issues raised. Where possible, the response will be in a format suitable for the complainant, such as large font or translation into another language. The complaint handler is responsible for producing a draft response for validation by the complaint lead once all contributors have had the opportunity to comment. The written response may take the form of a complaint response letter or a letter of apology, together with a separate investigation report or recorded audio disc. A final internal quality assurance check is undertaken before sending the response letter to the CEO or delegated deputy for signing and sending out by registered mail or secure email. A main complaint category is identified with the complainant, and this is used to determine the status of the complaint on closure by the complaint handler. Where the main category is found to be upheld, the complaint is recorded as upheld. If the main category is not upheld but some or all of the remaining categories are upheld, the complaint is closed as partially upheld. 7.3.7 Remedy If a complaint is upheld or partially upheld, the Trust will decide whether the maladministration or service failure has caused an injustice (Health Service Ombudsman’s Principles of Remedy). The Trust should, as far as is possible, put the individual back into the position they would have been in if the maladministration or service failure had not occurred. If that is not possible, the Trust should compensate appropriately. PET003 Handling Complaints Policy version 13. Issued 10.7.24 Page 12 The Trust will consider suitable and proportionate financial and non-financial remedies for the complainant and, where appropriate, for others who have suffered the same injustice. An appropriate remedy may be an apology, an explanation or remedial action. Financial compensation will not be appropriate in every case but should be considered. Appropriate and proportionate financial remedy will be considered by the CGM (budget holder for the service complained about) and complaint handler in the first instance. If an agreement cannot be reached, the head of P&FR will review, make comparisons to similar cases and reach agreement for any financial remedy with the director of nursing and, where appropriate, the key internal stakeholders involved. This provides consistency in evaluating the amount of financial remedy that is fair, reasonable and proportionate to the injustice suffered. On agreement with the CGM, any financial remedy is then offered to the complainant explaining the amount, why this has been offered and who to contact to accept the offer. The governance framework includes monitoring of the decision-making processes and recording payments of financial remedy offered to complainants. This will be reported quarterly to the patient experience and engagement steering group. This policy does not relate to medico-legal claims for compensation which will be dealt with through the legal services department in conjunction with the NHSLA. 7.3.8 Re-investigation of a complaint – Stage 2 In cases where the complainant is not satisfied with the Trust response, the complaint will be re-opened, also called Stage 2. This may be because the complainant considers the initial investigation to be inadequate, incomplete or unsatisfactory, or the complainant believes that their issues have not been addressed, fully understood or new questions have been raised. The complaint will be reassessed and the issues that remain unresolved for the complainant will need to be clarified and a new complaint investigation plan agreed. The same investigative procedure will be followed. However, the Trust can decline a Stage 2 investigation if the team feel that there is nothing more to investigate, add or clarify, and believe that the Stage 1 investigation is complete. Independent advice or a second opinion may be considered on the element of the complaint that has been re-opened for investigation. Meeting with the complainant is encouraged to aid resolution of the complaint. In some circumstances, and in agreement with all parties, conciliation or mediation could also be considered. If early resolution has been completely exhausted and the complainant still remains dissatisfied, the complainant is informed of their right to go to the PHSO. 7.3.9 Stage 3: Parliamentary and Health Service Ombudsman (PHSO) & The Independent Sector Adjudication Service (ISCAS) PHSO: In cases where the Trust has been unable to resolve a complaint to the complainant’s satisfaction, the complainant has the right to refer their complaint to the PHSO for independent review. The PHSO is independent of the NHS and is appointed by the government and will undertake an independent investigation into complaints where it is considered that the Trust has not acted properly, fairly or has provided a poor service. PET003 Handling Complaints Policy version 13. Issued 10.7.24 Page 13 The Trust will fully comply with all PHSO requests for information. As appropriate, divisional management teams and directors will be notified by P&FR of any complaint that is being investigated by the PHSO, or any recommendations made by them. The PHSO can be contacted at: www.ombudsman.org.uk Parliamentary and Health Service Ombudsman Millbank Tower 30 Millbank Westminster London SE1P 4QP Telephone: 0345 015 4033 ISCAS: Is a scheme that provides independent adjudication on complaints about independent healthcare providers. ISCAS CEDR, 3rd Floor 100 St Paul’s Churchyard London EC4M 8BU www.iscas.cedr.com Telephone: 0207 7536 6091 7.4 Confidentiality and record keeping 7.4.1 Confidentiality and ensuring patients, their relatives and carers are not treated differently as a result of raising a concern or complaint Information about complaints and all the people involved is strictly confidential, in accordance with Caldicott principles. Information is only disclosed to those with a demonstrable need to know or a legal right to access those records under the Data Protection Act 2018. All data will be processed in accordance with Trust policy. Complaints will not be filed on health records but maintained in a separate case file subject to the need to record any information that is strictly relevant to their health record. Complaints must not affect the patient’s/complainant’s treatment and the complainant must not be discriminated against. Any identified discrimination will be reported to HR and managed as per Trust policies. 7.4.2 Record keeping A complete documentary record will be maintained for each complaint on the Ulysses database. This will include all written or verbal contacts with the complainant, staff involved in the investigative process and all actions taken in investigating the complaint. The complaint file is a confidential record. It will be stored securely and should be easily retrieved and understood in the event of further enquiry. In accordance with the UHS records management policy 2010, complaint files are kept and disposed of confidentially. Complaint files are retained for eight years. 7.5 Support for complainant and staff See Appendix H describing roles and responsibility of staff who can provide support. 7.3.6 Process by which the organisation aims to improve as a result of concerns and complaints being raised PET003 Handling Complaints Policy version 13. Issued 10.7.24 Page 14 Every complaint received should be regarded as an opportunity to learn and improve services. 7.6.1 Development of action plans P&FR will request a completed action report (Appendix I) from the complaint investigation contributors involved in all complaints that are upheld or partially upheld. In some cases, the actions required may already be completed and documented within the complaint response. In this situation the complaint lead should inform P&FR that a separate plan is not required, and this should be recorded on the complaints database. The complaint lead or divisional governance team is responsible for validating the action plan identified within the report. The divisional director of operations (DDO), or delegated person, is responsible for ensuring the action plans arising from concerns and complaints are completed within the agreed timescales and processes are in place for the action plan to be reviewed and monitored by the local governance groups. The DDO, or delegated, is supported by the divisional governance manager (DGM). 7.6.2 P&FR - support of learning The P&FR team will support divisional complaint information hubs, allowing real time information to be accessed by divisions and care groups as to number of complaints for each clinical area and identified key themes. Each division will have an identified lead within P&FR to support development of their individual approaches to learning and they will attend divisional and care group governance with the division. See Action Plan (Appendix I). 7.6.3 Complainant feedback The P&FR will ensure every complaint response is sent out with a patient satisfaction survey and the results are monitored, reported annually to QGSG and used to consider quality improvements. 8 Roles and responsibilities Roles and responsibilities See Appendix H describing roles and responsibilities of staff involved in resolving complaints. 9 Communication and training plans Communication plan This policy will be displayed on the Trust website and Staffnet and sent to divisional management teams to ensure dissemination throughout each division to all staff groups. An introduction to complaints is provided within the staff induction programme and further training is available via the Trust VLE portal in electronic format. Bespoke face-to-face training will be provided by the P&FR team on request to all staff groups. Monitoring of this policy by P&FR team will be used to identify areas where further training may be required. 10 Equality impact assessment (for all policies only) See Appendix L and J Equality and diversity are at the heart of our Trust values. Throughout the development of the policy, we give regard to the need to eliminate discrimination, harassment and victimisation, PET003 Handling Complaints Policy version 13. Issued 10.7.24 Page 15 to advance equality or opportunity, and to foster good relations between people who share a relevant protected characteristic (as cited in under the Equality Act 2010) and those who do not share it. As part of its development this Complaints policy and its impact on equality has been analysed and approved as being appropriate. The Policy & Guidance Team hold all equality impact assessments centrally. These are available upon request from Policy&Guidance@uhs.nhs.uk 11 Document review All Trust policies will be subject to a specific minimum review period of one year; we do not expect policies to be reviewed more frequently than annually unless changes in legislation occur or new evidence becomes available. The maximum review period for policies is every three years. The author of the policy will decide an appropriate frequency of review between these boundaries. Where a policy becomes subject to a partial review due to legislative or national guidance, but the majority of the content remains unchanged, the whole document will still need to be taken through the agreed process as described in this policy with highlighted changes. This Complaints policy will be reviewed in three years’ time in 2027. This policy will be reviewed every three years or earlier if any amendments to the NHS complaints regulations are made, or if any aspect of the policy is found to be inadequate. 12 Process for monitoring compliance The purpose of monitoring is to provide assurance that the agreed approach is being followed. This ensures that we get things right for patients, use resources well and protect our reputation. Our monitoring will therefore be proportionate, achievable and deal with specifics that can be assessed or measured. Key aspects of this policy will be monitored: Element to be monitored Lead (name/job title) Tool Frequency Reporting arrangements Compliance to NHS Complaints (England) Regulation 2009 and Parliamentary and Health Service Ombudsman’s Complaints Standards. Shona Small Measure against policies Every three years Reporting to Jenny Milner Where monitoring identifies deficiencies actions plans will be developed to address them. PET003 Handling Complaints Policy version 13. Issued 10.7.24 Page 16 13 Appendices • Appendix A Managing complaints Processing complaints in the PALS and complaints team. Complaint received into PALS & complaints team. The role of patient support officers (PSOs) and the complaint coordinator is to listen, understand concerns and risk assess situation. PSOs and/or administrator to register issue on Ulysses, consider whether consent is required, categorise concern and discuss with complainant how they would like the matter resolved. Low level to medium level of seriousness and can be resolved in 24 hours or up to 10 days Categorise as a COMPLAINT (Early Resolution) Managed by PALS manager and Patient Support Officers (PSO). • Identify actions needed. Provide feedback to care group if issues are for feedback only • Escalate any concerns to B6/B7/Matron/Consultant • Signpost to other teams/bodies where relevant, such as The Advocacy People • Investigate • Find resolution • Respond to complainant at the earliest opportunity and within 10 working days • Identify learning and share with care group Resolved – Yes • Record outcome and close case Resolved – No • Review whether complaint needs to be passed to the complaints team to take a closer look. Medium to high level of seriousness and requires investigation via the NHS complaints process. Categorise as a COMPLAINT (Taking a Closer Look) Managed by complaints team • Further risk assessment such as PST or safeguarding • Investigate in accordance with the complaints policy • Respond within agreed timescale with a Trust letter or hold complaint resolution meeting to share outcome of investigation • Identify learning and share with care group and divisional governance Resolved – Yes • Record outcome and close case on Ulysses. Resolved – No • Re-open case on Ulysses • Discuss and agree further actions or investigation plan with complainant • Respond within agreed timescale with a Trust letter or share outcome with complainant at resolution meeting Resolved – Yes • Record outcome and close case on Ulysses Resolved – No • Direct complainant to the Parliamentary and Health Service Ombudsman (PHSO) or litigation PET003 Handling Complaints Policy version 13. Issued 10.7.24 Page 17 • Appendix B Making a Complaint process There are different ways to make a complaint. It is usually easier to resolve concerns close to the time they occur by talking to the staff who are looking after you. This may be the ward manager, or matron for the department. They can discuss the things you are not happy with and will try to resolve them for you. If your concerns have not been resolved by talking to the department, you can contact the Patient Advice and Liaison Service (PALS). Their contact details are: Telephone: 023
Url: /Media/UHS-website-2019/Docs/Policies/Handling-concerns-and-complaints-policy.pdf

SOP validation favourite agents Aria ver1

Description: Central South Coast Cancer Network Standard Operating Procedure Validation of CSCCN Favourite Agents in Aria (SOP:CH006) 1. Objective 1.1
Url: /Media/UHS-website-2019/Docs/Chemotherapy-SOPs1/Validation/SOPvalidationfavouriteagentsAriaver1.pdf

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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Finance and Performance Reports 2023-24 Month 6 September 2023

Description: Report to the Trust Board of Directors Title: Agenda item: Sponsor: Author: Date: Purpose Finance Report 2023-24 Month 6 12.3 Ian Howard – Chief Financial Officer Philip Bunting – Director of Operational Finance David O’Sullivan – Assistant Director of Finance – Financial Performance 9 November 2023 Assurance or reassurance Approval Ratification Information X Issue to be addressed: Response to the issue: The finance report provides a monthly summary of the key financial information for the Trust. Finance and Investment Committee reviewed a detailed monthly finance report, including a review of forecast outturn and a spotlight on the capital and cash position. The full report is available to Trust Board members for background reading. The Committee agreed to highlight: M6 Financial Position UHS is reporting a deficit of £1.8m in September compared with a deficit plan of £2.3m. This is therefore £0.5m favourable to plan. The in-month position does however include nonrecurrent benefits relating to ERF (assumed to be non-recurrent at this stage), VAT reviews and additional back-dated income. YTD the deficit is £22.6m compared to a plan of £19m so £3.6m adverse to plan. The variance is due to the following three specific items: • Underfunded 22/23 non-consolidated pay award (Serco) - £1m. • 23/24 underfunded AfC pay award - £1m pressure YTD (£2m estimated for 23/24). This has reduced from the previous month as partial mitigations have been identified. • 23/24 underfunded medical pay award - £1.6m pressure YTD (£3.2m estimated for 23/24). This has also reduced in month as £1.4m of mitigations (full year calculation) have been identified mainly relating to education funding. ERF and Industrial Action ERF income of £1.2m is reported in month relating to a reassessment of prior period performance following the receipt of a further month of national data. The YTD position now includes £4.8m of ERF income with performance estimated at 114% against a revised target of 111%. Performance for September was 109% despite the significant challenge of managing industrial action which took place jointly for consultants and junior doctors. This covered a four-day period with three days of junior doctor strikes and two days of consultant strikes, one of which took place concurrently with junior doctors. Estimates value the loss of activity due to industrial action at £4.6m YTD as shown in the table below with a further £1.2m incurred in additional premium backfill costs. Page 1 of 31 Industrial Action Financial Impact Assessment (£m) Direct Cost Impact Estimated Loss of (Backfill less strike Month Income pay reductions) April 1.50 0.30 May 0.00 0.00 June 0.30 0.10 July 1.00 0.30 August 0.80 0.30 September 1.00 0.20 Total 4.60 1.20 Total Financial Impact 1.80 0.00 0.40 1.30 1.10 1.20 5.80 So far, the only adjustment to the ERF target relates to months up to April which reduced the annual target by 2%. Further announcements are expected in coming weeks although remain unconfirmed. We are however anticipating full relief for the impact of industrial action on the financial position of the Trust. Underlying Position The September reported position included several one-off items, as reported above. The Committee asked for the underlying position calculation to be reviewed, to included additional ERF income that would have been earned without industrial action, as well as adjusting for true non-recurrent savings only. This will be completed for M7, with the position expected to be in the region of £5m deficit per month. Deficit Drivers The underlying deficit continues to be driven by a number of underlying system pressures seen in 22/23, for which we have not been able to recover to date: • Non-pay inflation beyond funded levels • Impact of energy prices (with gas prices impacting UHS particularly hard) • High-cost drugs spend (previously pass-through) • Number of patients not meeting criteria to reside, impacting capacity (opening expensive “surge” capacity / bed capacity restricting elective activity) In 23/24, we are now seeing further pressures, notably: • Unfunded elements of pay awards - £0.4m per month. • The impact of industrial action is impacting our performance, both activity levels and capacity to deliver recurrent CIP. • Workforce pressures as substantive recruitment is not offset with temporary staffing reductions - £0.7m per month. • Covid testing funding reductions not immediately offset with cost reductions - £0.2m per month. • Mental health nursing pressures - £0.2m per month. • Tariff efficiency reductions not offset by recurrent CIP delivery - £0.7m per month. • Further growth in the number of patients not meeting the criteria to reside. These have been consistently at 200 with some weeks peaking at over 240. Unfunded additional activity is a further pressure for UHS where we are YTD providing activity above block funded level for free in the following areas: • £6.5m of outpatient follow up appointments • £3.8m of non-elective • £2.4m of other treatments UHS continues to target demand management within these areas shifting outpatients to patient initiated follow up protocols often via the My Medical Record platform. Page 2 of 31 Forecast Our submitted forecast to NHS England maintains delivery of a £26m deficit. This was underpinned by a £0.3m per month improvement to the financial position during 2023/24. The current YTD performance and run rate suggests it will be extremely challenging to achieve the planned position without additional funding due to industrial action costs. Finance Committee considered several potential forecasts, ranging from £26m deficit to £50m deficit, depending on the level of financial relief from industrial action and funding of pay-award pressures, as well as the level of H2 financial improvement being delivered. Due to the current funding uncertainty, it was recommended and agreed that the forecast remains at £26m until further clarity is received. Cost Improvement Plans Whilst £72m of CIP opportunities have been identified, the most-likely risk assessed position sits at £59m. Whilst we have made good progress with CIP performance, it is heavily supported by non-recurrent delivery that cannot be relied upon for underlying financial improvement. Capital A capital spotlight report highlighted that due to slippage and changes to funding, the Trust had a risk of under-spending against its CDEL target. However, we have identified £5.8m of schemes to bring-forward from the 2024/25 approved capital programme into 2023/24, mainly accelerating strategic maintenance schemes and medical equipment replacement. A further additional £1.3m of schemes have been prioritised as must-do schemes due to emerging risks (e.g., steam ducts propping). We are therefore slightly over-programmes, which is likely to be offset by further slippage risk and is within manageable levels. The risk of under-delivery has therefore been mitigated. The capital prioritisation process for 2024/25 and 2025/26 will soon commence using the multiyear programme already shared with finance and investment committee as a starting point. Planning 2024/25 The planning process for 2024/25 has been launched internally within the ICS in order to give an early indication of scale of financial challenge for the next financial year. Further updates will be provided at future finance and investment committees. Cash Spotlight The Committee considered a spotlight report into cash, which highlighted that cash has reduced from £105m to £68m in-year, driven largely by the Trust’s underlying deficit. The report highlighted the work of the finance team to maximise and safeguard the Trust’s cash position going forwards. A number of cash forecasts were considered, dependent on the underlying financial position of the Trust. However, it was anticipated the Trust would end the year with cash of circa £30m and may be required to request national cash support in either Q1 or Q2 of 2024/25. This is of course heavily dependent on income levels, industrial action relief and the impact of financial recovery measures across the ICB. Due to the scale of deterioration the Trust is rightfully ensuring future investment decisions show a cognisance of the scale of cash attrition to ensure projects can be completed and investments made responsibly with financing an important consideration. Page 3 of 31 Implications: • Financial implications of availability of funding to cover growth, cost pressures and new activity. • Organisational implications of remaining within statutory duties. Risks: (Top 3) of carrying out the change / or not: • Financial risk relating to the underlying run rate and projected potential deficit if the run rate continues. • Investment risk related to the above • Cash risk linked to volatility above • Inability to maximise CDEL (which cannot be carried forward) and the risk of a reducing internal CDEL allocation for 2024/25 due to the forecast deficit for 2023/24. Summary: Trust Board is asked to: Conclusion • Note the finance position. and/or • Note the update on capital. recommendation • Note the risk on the Trust’s cash position. Page 4 of 31 M6 Finance Report Page 5 of 31 Report to Trust Board October 2023 Ian Howard, CFO Philip Bunting, DOOF David O’Sullivan, Asst DOF Summary Page 6 of 31 2 Finance Dashboard Position (objective 5a) YTD vs. Plan Forecast Underlying Capital (objective 5d) YTD Forecast CIP (objective 5a) Identification Delivery Productivity (objective 5a) Page 7 of 31 3 Overall Position Page 8 of 31 4 Executive Summary In Month and Year to date Highlights: 1. In Month 6, UHS reported a deficit position of £1.8m which was £0.5m favourable to plan. YTD the deficit is now £ 22.6m which is £3.6m adverse to plan. The total plan for the year is £26m deficit which is currently forecast for delivery. The YTD shortfall to plan is a result of funding pressures relating to national pay awards for Agenda for Change and Medical staff. 2. The underlying position in September is a £6.1m deficit, which is in line with previous months run rates. This position exclu des the favourable impact of ERF overperformance within the overall trust position. 3. CIP delivery is reporting marginally behind plan YTD with £27.1m delivered vs plan of £27.8m. Of the value identified to date, £17.9m is non-recurrently delivered CIP. Annually, £71.7m of savings have been identified in plans, 104% of the trust target of £69m. A risk assessment of schemes has taken place which reduces the expected yield of schemes down to £59.1m - 86%. There is continued focus on savings identification and delivery to support financial recovery. 4. The themes seen in M6 were: 1. UHS is over its elective recovery target to the end of M6 at 114% / £4.8m favourable. Performance continues to be impacted by both industrial action and an increase in non-elective activity. Further changes to ERF targets are anticipated nationally but are not yet known. 2. Medical Pay Awards costs have been paid within the M6 position. This has resulted in a £1.8m pressure (above funded levels) YTD. The forecast annual impact of this is £3.2m. 3. Underlying drivers for the monthly financial deficit largely remain as per 22/23 including inflation, energy, drugs and incre ased volumes of patients not meeting the criteria to reside. 4. Upward workforce trends remain a risk with particular pressures around additional nursing spend related to providing safe car e for mental health patients and costs relating to cover for industrial action. 5. Surge capacity also remains open at times to support flow at times of peak bed pressure. Page 9 of 31 5 Overall Financial Position Income Clinical Income Pass-through Drugs & Devices Other Income Total Revenue Costs Pay - Substantive Pay - Bank Pay - Agency Drugs Pass-through Drugs & Devices Clinical Supplies Other non pay Total Operating Expenses Remove Depreciation and Amortisation Donated Income Profit/(Loss) from Operations (EBITDA) Add Less Non Operating Income Non Operating Expenditure Budget Full Year £000's Plan £000's Current Actual £000's Variance £000's Plan £000's Year to date Actual £000's Variance £000's 839,728 186,582 176,791 1,203,101 69,978 15,548 14,117 99,643 69,964 16,141 14,190 100,295 14 (592) (73) (652) 419,869 93,291 85,439 598,599 431,921 101,091 82,321 (12,052) (7,800) 3,118 615,333 (16,734) 630,404 43,631 15,070 35,928 186,582 67,008 225,801 1,204,424 38,037 (16,583) 20,131 2,166 (34,189) 52,521 3,876 1,287 2,994 15,548 5,793 18,749 100,769 3,128 (617) 1,385 181 (3,486) 55,136 4,189 1,092 3,223 16,141 1,497 18,764 100,041 3,024 (886) 2,392 391 (3,905) 2,615 313 (195) 228 592 (4,297) 15 (728) (104) (269) (1,007) (210) 419 313,401 23,667 8,254 17,966 93,291 35,797 114,749 607,124 18,972 (6,231) 4,216 1,086 (19,296) 331,885 24,948 6,751 16,529 101,091 31,589 115,700 628,493 18,383 (4,560) 663 2,585 (22,360) 18,484 1,281 (1,503) (1,436) 7,800 (4,208) 950 21,368 (589) 1,671 3,553 (1,499) 3,064 Net Surplus / (Deficit) incl Impairments & Donation Less Donated Income Less Profit on disposals Less Gain/ Loss on absorption Add back Donated Depreciation Add back Impairments Total Net Surplus / (Deficit) (11,892) (16,583) 0 0 2,475 0 (26,000) (1,920) (617) 0 0 204 0 (2,333) (1,122) (886) 0 0 178 0 (1,830) (798) (13,994) (19,112) 269 (6,231) (4,560) 0 0 0 0 0 0 26 1,225 1,041 0 0 0 (503) (19,000) (22,631) Page 10 of 31 5,118 (1,671) 0 0 184 0 3,631 UHS has submitted an annual plan position of £26m deficit for the 2023/24 financial year. In September a deficit position of £1.8m was reported, £0.5m favourable to plan. The YTD position of £22.6m deficit is £3.6m adverse to the planned deficit target of £19.0m. In Clinical Income ERF overperformance is reported at £4.8m YTD. This figure include an adjustment to April ERF baseline target at 2%. Future amendments are anticipated but have not been confirmed to date. The balance of the YTD favourable position on clinical income is as a result of pay award funding received above initial planning assumptions totalling £10.4m. Pay expenditure continues to exceed plan, due to pressures from the national pay awards, requirements for mental health nursing support, staffing of surge capacity areas, unfunded workforce growth in prior periods and lower than planned pay CIP Delivery. £10.4m of the pay variance is additional pay award funding offset within clinical income. Non pay categories (excluding pass through) are under plan YTD largely as a result of several nonrecurrent benefits taken in year. 6 Run Rates • The UHS run rate position has continued in M6 at a deficit of £1.8m which is lower than planned levels, however is the result of a number of non recurrent benefits released into the position. • The improved run rate trend in the second half of 2022/23 financial year was delivered by non recurrent means with the underlying position remaining challenging. This has continued into 2023/24. • Pressures continue across all expenditure and income types with notable challenges experienced in month detailed below. • Pay – Continued pressures as a result of national pay awards for AFC and medical staff, industrial action and mental health nurs ing. • Non Pay – Cost pressures relating to Energy increases and inflationary pressures on clinical supplies. Trends can be volatile du e to pass through drugs and devices which are not uniform each month. • Income – the run rate reduced in month following receipt of funding towards medical pay awards and ERF in M5. YTD ERF performance is reporting over plan by £4.8m / 114%. Page 11 of 31 7 Run Rates Page 12 of 31 8 Underlying Position / Risk Analysis Tbals The graph shows the underlying position for the Trust from April 2022 to present. This differs from the reported financial position as it has been adjusted for non recurrent items (one offs) to get a true picture of the run rate. Risk Variable Unidentified CIP Workforce Pressures CIP Delivery Risk Inflationary Pressure Unfunded Activity MH Nursing Covid Testing Criteria to Reside / Surge Capacity Energy Unfunded Pay Award Total Risk Mitigations Additional CIP ERF (Including IA adjustments) Stretch CIP Net Risk Risk @ Plan £m 15.8 0.0 18.2 8.0 0.0 0.0 0.0 0.0 0.0 0.0 42.0 (18.0) 0.0 0.0 Pag2e41.30of 31 Risk - current £m 0.0 8.4 9.9 0.0 2.5 2.3 1.2 1.2 2.1 6.2 33.8 0.0 (19.8) (7.5) 6.5 The average underlying position for 23/24 to date is £6.0m deficit. M6 figures showed a position of £6.1m. Due to the variability and unknown national picture on ERF (due to industrial action pressures), these figures have been excluded from underlying calculations. The decline since 2022/23 has primarily been driven by escalating pay award pressures, pressures related to activity, including the need for surge beds and impacts of strike actions in addition to the challenge of delivering efficiencies. A table outlining risks is also shown matching forecast scenario 2 on slide 12. 9 Key Variance Drivers Page 14 of 31 Key variance bridge A recurrent underlying deficit position was carried forward from the previous financial year of circa £4m per month. Trust plans were for month on month improvement reaching breakeven by financial year end. The graph to the left provides the following analysis: Stage 1) Items driving the Trust adverse position from planned £19.0m deficit to £22.6m reported YTD. Stage 2) Sets out non recurrent benefits to the position that bridge to the underlying deficit at M6 of £36.2m. ERF overperformance has also been removed from the underlying position. 10 Key Variance Drivers Page 15 of 31 Key variance pressures The following table sets out the key recurrent drivers that have resulted in adverse movements to plan in the underlying position during the 2023/24 financial year. - The yellow boxes represent pressures out of the organisations direct control and total £5.6m YTD of the adverse position to plan. - The red boxes identify pressures within the organisations control and total £11.6m YTD of the additional deficit to plan. - ERF overperformance has been removed from underlying position figures. These items require mitigation to deliver a breakeven underlying position moving forwards in addition to delivering the originally planned deficit reductions. 11 Forecasting / Forward View Page 16 of 31 The graphs provide forecast scenarios on a monthly and cumulative scenario for remainder of the financial year. 1) Delivery of plan. Resulting in a year end out turn deficit of £26m. 2) Original plan plus full impact of pay award pressures, receipt of industrial action support and £7.5m additional run rate efficiency improvement - £32.5m out turn. 3) Original plan plus full impact of pay award pressures, receipt of industrial action support, no further efficiency improvements - £40.0m out turn. 4) Original plan plus full impact of pay award pressures, no industrial action support or further efficiency improvements £50m out turn. 12 Cost Improvement Programme Page 17 of 31 UHS Total - £71.7m identified 104% of the total 23/24 requirement of £69m. Of the identified UHS total, £9.9m is Pay, £32.3m is Non-Pay, and £29.5m Income. Divisions and Directorates - £42.0m of CIP schemes identified. This represents 98% of the 23/24 target of £43.1m Central Schemes - £29.7m of CIP schemes identified. This represents 115% of the 23/24 target of £25.9m M 6 Trust YTD delivery is £27.1m. An increase in month of £6.3m. YTD delivery is below plan by £0.7m. Of the £27.1m delivered: £12.9m has been transacted by Divisions and Directorates £14.3m has been transacted through Central Schemes. £17.9m is non-recurrent. This includes £9.8m of non-recurrent Central Schemes. 13 Cost Improvement Programme • A risk assessment has been undertaken of the identified schemes to date in the table above. • The expected yield from plans is currently £59.1m, 86% of the 23/24 requirement • A significant reduction to total identification has taken place in month following review of the highest risk assessed items. Due to insufficient enabling plans and progress at ICS level, the £11.2m of system wide schemes based upon Carnall Farrar opportunity assessment for improved patient flow and reduction of non ‘criteria to reside’ occupancy have been removed. Page 18 of 31 14 Capital Page 19 of 31 Summary Position: Total capital expenditure (trust and external) YTD is £13.7m vs plan of £23.8m with a forecast outturn of £55.2m. To achieve the forecast position, £4.6m of expenditure has been agreed to be brought forward from 24/25 to replace slippage on 23/24 schemes. Trust Funded: To the end of M6, £12.2m has been spent on trust funded schemes against a YTD plan of £23.2m, with an annual forecast outturn of £47.7m Exte rnally Funded: To the end of September, £1.5m has been spent on externally funded schemes vs a YTD plan of £0.6m, with an annual forecast spend of £7.5m. 15 Capital Top 5 schemes by YTD Expenditure Value £000s Oncology Centre Ward Expansion Levels D&E Donated Estates Schemes Information Technology Programme Decarbonisation Schemes Strategic Maintenance Plan 6,235 2,262 2,178 4,500 2,124 Year to Date Actual 3,152 2,528 2,013 1,941 1,663 Variance 3,083 (266) 165 2,559 461 Plan 7,135 2,624 5,800 11,259 5,200 Forecast Actual 6,926 3,317 5,800 11,259 7,240 Variance 209 (693) 0 0 (2,040) • Spend on the wards expansion scheme remains high on a monthlybasis as the skyway link bridge element is constructed. • The Banksy funded staff welfare schemes (the welfare hub, PAH roof garden and staff room refurbishment) are complete • Informatics YTD expenditure has been incurred mainlyon staffing, core infrastructure and the ED & Flow contract. • The first milestone of the decarbonisation scheme has been reached meaning that £1.3m of costs are now due for payment. • Strategic Maintenance costs were high in month 6 at £1.1m, due to significant expenditure on the PAH substation (£0.6m) Top 5 Schemes by YTD Variance Year to Date Forecast £000s Plan Actual Variance Plan Actual Fit out of F Level Theatres (VE) 3,396 73 3,323 8,500 6,827 Oncology Centre Ward Expansion Levels D&E 6,235 3,152 3,083 7,135 6,926 Decarbonisation Schemes 4,500 1,941 2,559 11,259 11,259 Neonatal Expansion 2,283 287 1,996 10,030 7,917 CT Scanner 1,560 0 1,560 1,560 1,560 Variance 1,673 209 0 2,113 0 • Phase 3a of the F level theatres is now due to start in October and complete around Aug 24. • All works on the oncologyward expansion scheme (including the skywaylink bridge) will not be complete until Jan 24. • Decarbonisation scheme onlycommenced in August, but plans are in place to ensure the planned £11.3m of the grant are completed byMar 24. • Phase 1 of the neonatal expansion has commenced, and the scheme should complete in Jun 24. • The installation of the CT scanner will be later than originallyplannPeadgaen2d0woifll3th1erefore be accounted for Mar 24. 16 Statement of Financial Position 2022/23 M1 M2 M3 M4 M5 M6 MoM Statement of Financial Position YE Act Act Act Act Act Act Act Movement £m £m £m £m £m £m £m £m The September statement of financial position illustrates net assets of £566.6m which is £4.0m down on August. Fixed Assets Inventories Receivables Cash Payables Current Loan Current PFI and Leases 620,431 15,753 95,056 105,018 (229,641) (1,533) (12,580) 617,160 18,104 93,552 105,475 (237,019) (1,533) (12,202) 619,161 18,074 89,834 85,892 (218,352) (1,533) (12,153) 620,900 18,455 73,434 81,557 (202,499) (1,533) (11,347) 622,082 16,941 75,632 66,895 (195,495) (1,533) (11,228) 621,364 19,317 92,177 62,611 (212,574) (1,533) (10,705) 621,497 19,487 53,710 68,286 (184,559) (1,533) (10,272) 133 170 (38,467) 5,675 28,015 0 433 Net Assets 592,504 583,537 580,923 578,967 573,294 570,657 566,616 (4,041) Non Current Liabilities (24,624) (22,798) (22,759) (22,848) (21,545) (21,307) (21,426) (119) Non Current Loan (5,302) (5,302) (5,302) (4,802) (4,802) (4,802) (4,534) 268 Non Current PFI and Leases (108,576) (105,561) (107,100) (108,888) (107,948) (107,416) (104,644) 2,772 Total Assets Employed 454,002 449,876 445,762 442,429 438,999 437,132 436,012 (1,120) Public Dividend Capital Retained Earnings Revaluation Reserve 286,212 102,068 65,722 286,212 97,942 65,722 286,212 93,828 65,722 286,212 90,494 65,722 286,212 87,065 65,722 287,328 84,082 65,722 287,328 82,962 65,722 0 (1,120) 0 Total Taxpayers' Equity 454,002 449,876 445,762 442,428 438,999 437,132 436,012 (1,120) Page 21 of 31 Cash increased by £5.7m to £68.3m, following receipt of additional clinical and R&D income in month. The main movements in month were due to: - Receivables: Decreased by £38.5m following a reduction of £6.1m in accrued clinical income and £12.9m decrease in prepayments largely due to timings of M6 invoices paid in August. - Payables: Decreased by £28.0m in M6. This was due to £7.3m relating to medical and serco pay awards now paid, £4.9m decrease in PDC creditor as the half year payment was made in month. There were also entries that netted off between receivables and payables totalling £15m. 17 Cash and Payments Page 22 of 31 The cash balance increased by £5.7m to £68.3m in September. The reduction in year has been driven chiefly by the underlying deficit. In year volatility has however been influenced by: - The timing of pay award funding versus payments made to staff and HMRC/NHS Pensions Authority - Capital programme timings including slippage versus plan - Higher R&D receipts and VAT recovery The minimum cash holding position is set at £30m. Based on current trajectory, we are expected to reach this level by the end of the financial year in April 2024. There is on average a £5.5m cash outflow per the detailed inputs. This has moved out from December as per the M05 forecast due to maintaining the cash position in M06, which has been improved due to paying invoices as they fall due, rather than processed. Better Payment Practice Code (BPPC) performance in September is over the 95% target for both count and value. 18 Further Analysis of Position Page 23 of 31 19 Income / ERF The graph shows the ERF performance for 23/24 as well as a trend against plan for 22/23. In 23/24 the Trust has a target to achieve 111% (reduced from 113% following industrial action) of 19/20 activity for elective inpatients, outpatient first attendances and outpatient procedures. Delivery above this targeted level will generate additional funding for the Trust. ERF Performance (Target = 113%) Elective Spells Daycase Outpatients Firsts Outpatients Procedures Overall ERF Performance Excess Outpatient Follow Ups £'000s Excess Non Elective and ED £'000s Excess Other £'000s At the end of Month 6, ERF activity has been reported above plan to the value of £4.8m / 114%. Apr-23 May-23 Jun-23 108% 124% 100% 114% 108% 119% 115% 125% 112% 131% 133% 126% 118% 123% 110% £940 £1,388 £1,013 £34 £867 £1,709 £390 £536 £753 Jul-23 104% 112% 113% 133% 112% £894 -£4 £31 Aug-23 Sep-23 109% 90% 111% 115% 125% 125% 128% 125% 115% 109% £1,290 £1,010 £828 £322 -£65 £757 Oct-23 Nov-23 Dec-23 Jan-24 Page 24 of 31 Feb-24 Mar-24 Total 104% 113% 119% 127% 114% £6,535 £3,756 £2,402 No further decisions have been made to date on further national reductions to the ERF baseline following industrial action days between May and September. The table shows monthly achievement by POD type vs 19/20 baseline. Significant non ERF related activity is currently being provided by UHS above its block funded levels, totalling £12.7m. 20 Clinical Income - Elective Page 25 of 31 21 Clinical Income – Non Elective and Other Page 26 of 31 22 Staff Costs Pay Expenditure: • Pay costs have been normalised for the backdated impact of pay awards on the above graph (Payments made in M4 AFC and M6 Medical). • The normalised pay spend has increased by £0.6m between August and September. Of which £0.4m related to increased substantive costs and £0.2m for temporary staffing. • The main drivers of substantive cost increases in the month were: - ACP staff received pay arrears (backdated to April 23) of £0.25m following completion of a regrading exercise. - Increased Junior Doctor costs of circa £0.1m following an increase in WTE headcount in months 5 and 6. • Costs of staffing surge capacity in month totalled £0.11m, up from £0.07m in M5. Total spend YTD is now £0.59m. • Mental health temporary staffing costs remained flat in month at £0.67m. This sees a continued increase in average spend in the area compared with 22/23 values £0.40m and 23/24 average to date of £0.59m. Total spend YTD to the end of M6 is £3.56m. • Staffing WTE has increased by 84 WTE in month. This growth takes WTE actuals further away from planned values for the year. Page 27 of 31 23 Temporary Staffing Costs Page 28 of 31 Bank: Bank expenditure increased in month from £4.1m up to £4.2m. Increases have been experienced in: - Nursing up £72k - Admin staff up £72k Decrease of costs were experienced in: - Medical staff down £39k. - Scientific and Technical down £2k Age ncy: Agency costs increased in month by £0.1m up to £1.4m overall. Reductions were experienced in: - Nursing Staff down by £63k - Scientific and Technical down by £13k Increases were experienced across other staff groups: - Admin Staffing up by £158k - Medical Staff up £4k 24 Non-Pay Costs Non Pay Expenditure: • Other non pay has reduced in month back to expected levels following high costs in M5 relating to backdated inflation costs for Propco. • Non pass through drugs spend has increased in month by £0.8m overall. Increase were experienced within the care groups of Cancer, Specialist Medicine and Child Health. Costs are being investigated in collaboration with pharmacy to understand drivers and if pass through income may be available. • Clinical supplies costs have reduced in month by £4.0m, this is predominately due to non recurrent one-off benefits recognised in September. Page 29 of 31 25 CIP – Recurrent Pay Identification WTE and £ Re current Pay CIP: • The above table demonstrates the Pay CIP target for the organisation in 2023/24 based on WTE and £ values • On a WTE basis 61 WTE have been identified YTD, 16% of the 392 WTE target • On a £’s basis £3.2m have been identified YTD, 22% of the £14.6m target Page 30 of 31 26 Page 31 of 31 Report to the Trust Board of Directors Title: Agenda item: Sponsor: Author Date: Purpose Performance KPI Report 2023-24 Month 6 12.2 David French, Chief Executive Officer Sam Dale, Associate Director of Data and Analytics 9 November 2023 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 22 Report to Trust Board in October 2023 Performance KPI Board Report Covering up to September 2023 Sponsor – David French, Chief Executive Officer Author – Sam Dale, Associate Director of Data and Analytics Page 2 of 22 Report to Trust Board in October 2023 Report guide Chart type Cumulative Column Example 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 are 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 22 Report to Trust Board in October 2023 Introduction The Performance KPI Report is presented to the Trust Board each month. The report aims 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. This month, the following changes have been made to the report. • Data change: The medication errors data (metric 11) for August 2023 has been reduced from 4 to 3 cases as the severity for one case has been re- assessed and downgraded • Data Omission. The latest HSMR metrics reflect the July position as the latest statistics are yet to be published on the Healthcare Evaluation Data (HED) dashboards. Page 4 of 22 Report to Trust Board in October 2023 Summary This month the ‘Spotlight’ section contains an update on performance for RTT Waiting Times. The RTT spotlight highlights that: • Excluding a small cohort of corneal transplant patients impacted by national availability of tissue grafts, there are zero patients on the UHS RTT waiting list who have been waiting over 104 weeks for their elective treatment and three patients waiting over 78 weeks at the end of September. • The hospital targeted zero (non-corneal) patients waiting over 78 weeks by the end of October, however the extreme operational pressures experienced in the hospital at the end of October required a handful of complex but lower priority 78 week cases to be rescheduled into November. • The trust is in line with its submitted forecast which committed to having zero patients waiting over 65 weeks by March 2024. Performance against this target is being closely monitored and discussed with caregroups in weekly performance meetings. • A national Patient Initiated Digital Mutual Aid System (PIDMAS) will be launched imminently to understand how many patients on the waiting list would consider being treated at an alternative provider if deemed clinically appropriate. Areas of note in the appendix of performance metrics include: 1. We await the validated September position for Cancer waiting times, however August’s position reflects a further increase on two week wait performance (74.0%) putting UHS into the second quartile for this metric and the 62 day standard when compared to other Teaching Hospitals 2. The diagnostic waiting list continues to decrease every month within this financial year and now stands at 8,447 with 20% of patients waiting over six weeks. 3. Despite a decline in the number of category 2 pressure ulcers per 1000 bed days, both category 2 and 3 remain above the year to date target position. An ongoing campaign to increase awareness and enable staff to feel more confident with pressure ulcer prevention is underway and we are seeing a huge rise in the uptake of this education in the last quarter. 4. The percentage of births delivered by caesarean continue at the same increased rate. Whilst the department are implementing training and education strategies to ensure birth preference conversations happen early in the pathway, this will take time to reflect in the metrics. 5. The percentage of UHS women booked onto a continuity of carer pathway has remained below target throughout the year. The current CoC provision was affected by staffing and operational pressures over the summer. The majority of this has affected continuity around intrapartum care. The maternity service is trialling a different way to recruit into these teams by offering more flexible options for midwives to increase recruitment into these rewarding but very challenging roles. To give assurance the maternity service monitors and audits outcomes to ensure that groups most likely to be offered a CoC model are not showing as exceptions in our data or when clinically reviewing adverse o utcomes. Page 5 of 22 Report to Trust Board in October 2023 6. The decline in the September metric for Research and Development income reflects the cessation of the £20m COVBOOST grant which was previously contributing approximately £1m per month. The department also reprofiled Biomedical Research Centre funding from the National Institute of Health Research as it is expected to be deferred until 2024/25. Ambulance response time performance The latest unvalidated weekly data provided by the South Coast Ambulance Service (SCAS) shows that UHS does not significantly contribute to ambulance handover delays. In the week commencing 16th October 2023, our average handover time was 18 minutes 9 seconds across 801 emergency handovers, and 20 minutes 52 seconds across 45 urgent handovers. There were 44 handovers over 30 minutes, and 20 handovers taking over 60 minutes (the majority on 21 October) within the unvalidated data. Page 6 of 22 Report to Trust Board in October 2023 Spotlight Report Spotlight: Referral to Treatment Waiting Times The following information is based on the validated September 2023 submission, with operational insight based on the latest position for our long waiters. Overview In the 2023/24 NHS operational planning guidance, the priority for elective care was to eliminate waits of over 65 weeks by March 2024 (except where patients choose to wait longer or in specific specialties). In 2022/23, an equivalent priority was set for waits of over 78 weeks. To support and monitor Trust trajectories against the 2023/24 target, the national team have laid out additional in-year targets around patient pathway validation and outpatient referrals waiting for their first attendance. This is alongside the roll out of a national Patient Initiated Digital Mutual A id scheme (PIDMAS). This spotlight paper outlines the Trust’s current and forecast position against the national target, illustrates how we compare with our peer Trusts and explores some of the challenges, specialties and interventions which are influencing our position. Waiting Times Overview Graph 1 highlights the recent slowing down of the growth of the UHS PTL (patient treatment list) compared to the significant increases seen since January 2020. Graph 1 – RTT PTL volumes by waiting time The PTL was 59,253 at the end of September 2023, an increase of 5% since April 2023 (56,568). This compares to a PTL increase of 10% which seen across the equivalent period in 2022. It also highlights the waiting time cohort changes as we transition our focus from patients waiting over 78 weeks to the in-year target focussed on patients waiting over 65 weeks. Within the current PTL, there are 21 patients who have been waiting over 78 weeks and 349 who have been waiting over 65 weeks . In September 2022, the equivalent numbers were 286 (78 weeks) and 986 (65 weeks). Page 7 of 22 Report to Trust Board in October 2023 Spotlight Report Patients waiting over 78 and 104 weeks The only UHS patients waiting over 104 weeks in 23/24, are a small cohort of Ophthalmology patients (one in October) waiting for corneal transplants. This clinical situation is echoed across the country as the procedure is reliant on graft tissue being made available by the NHS Blood and Transfusion Centre. Excluding corneal patients, the Trust had three patients waiting over 78 weeks at the end of September. These patients have been within a handful of challenged specialties including Gynaecology, Urology and Paediatrics. In most cases, the required surgery is complex often requiring joint surgeons and was provisionally booked before 78 weeks. However, industrial action, clinical complications or managing a higher priority patient has required a cancellation. Any 78 week breaches have always been rebooked in the following month. We targeted zero (non corneal) patients waiting over 78 weeks by the end of October, however the very recent extreme pressures on our emergency services and elective capacity particularly within Trauma & Orthopaedics has inevitably impacted the planned surgery dates for a small cohort of long waiting patients, who have now been rescheduled for November. Patients waiting over 65 weeks At the end of September the Trust had 425 patients on the PTL who have been waiting over 65 weeks. As part of the Trust’s commitment to achieve the national target of zero 65 week waits by March’24, we submitted a glide which we are pro-actively monitoring every month. The performance team meet with each division to review individual patients who have not been booked against a target which we have stepped down from 78 weeks in April’23 to 65 weeks by December’23. This gives us clear line of sight against our glide, ensures services are pro-actively managing the appropriate cohorts and highlights consultants who need capacity plans or alternative pathway options to be explored. The Trust is currently in line with the 65 week glide submitted (see graph 4). Graph 2: Volume of patients waiting over 78 weeks by month Graph 3: Volume of patients waiting over 65 weeks by month Page 8 of 22 Report to Trust Board in October 2023 Spotlight Report 30,000 25,000 20,000 15,000 10,000 5,000 Apr/23 May/23 Jun/23 Jul/23 Aug/23 Sep/23 Oct/23 Nov/23 Dec/23 Jan/24 Feb/24 Mar/24 All Divisions Glide All Divisions Actual Graph 4: UHS 65 week performance glide and actual position Comparison with other Trusts In the latest available data (August’23) UHS places in the top quartile for the number of patients waiting over 65 weeks compared to other Teaching Hospital. This is illustrated in Graph 5. It should be noted that the metric is based on overall volume of patients rather than a percentage of the Trust’s overall PTL size which has not been made available. Graph 5: Teaching hospital comparator: patients waiting over 65 weeks Page 9 of 22 Report to Trust Board in October 2023 Spotlight Report Outpatient Referrals To support and gain assurance on our 65 week trajectories, the national team asked Trusts to ensure all patients who could breach 65 weeks by 31st March 2024, had their first outpatient appointment before the end of October 2023. Each service has therefore been working to ensure first outpatient appointments for this cohort are brought forward where necessary and appropriate. We envisage that a handful of specialties do not have the capacity to hit that target leaving approximately 800 patients unseen before 31st October, however, the majority of these patients have appointments in November with a small tail following soon after. The UHS glide against this target is shown in graph 6. The main challenged specialties are ENT, Paediatric Orthopaedics and Neurology. Volume of patients who will have breached 65 weeks by 31st March 24 and haven't had a first OP appointment 1000 800 600 400 200 0 Aug-23 Sep-23 Oct-23 Nov-23 Dec-23 Jan-24 Feb-24 Mar-24 UHS Graph 6: 65 week risk cohort waiting for a first OP appointment Patient Validation To ensure patient treatment lists are appropriately validated by hospitals, we have also been set a target of 90% of patients waiting over 12 weeks to have been validated by the end of October. This validation process ensures that patients are being reported on the appropriate waiting time and pathway and do still wish to proceed with their intended treatment, diagnostic or consultation. UHS employ both a central validation team and validation leads in each of the caregroups to support this process. This is now alongside our patient texting service which ensures appropriate contact is maintained with the patient and changes in need are understood. The Trust expects to achieve the 90% target through a combination of these approaches. PIDMAS The national team will imminently roll out a patient initiated digital mutual aid system. At the time of writing, the digital solution has been tested in a handful of pilot sites with an intended launch for all trusts at the end of October. The process is to enable patients to declare whether they would consider being offered to an alternative provider for their treatment. This will initially be offered to patients waiting over 40 weeks and will involve a text to a patient redirecting them to a digital platform where they can express their preference and how far they are willing to travel for treatment. This will then be reliant on clinical approval for suitability and another Trust declaring appropriate capacity. The process is being overseen by the I CB. Whilst the intention is to improve waiting times for patients, the solution is still in its infancy and not being used to influence the UHS forecast pos ition on long waiting patients. Page 10 of 22 Report to Trust Board in October 2023 Spotlight Report NHS Constitution - Standards for Access to services within waiting times The NHS Constitution* and the Handbook to the NHS Constitution** together set out a range of rights to which people are entitled, and pledges that the NHS is committed to achieve, including: The right to access certain services commissioned by NHS bodies within maximum waiting times, or for the NHS to take all reasonable steps to offer you a range of suitable alternative providers if this is not possible • Start your consultant-led treatment within a maximum of 18 weeks from referral for non-urgent conditions • Be seen by a cancer specialist within a maximum of 2 weeks from GP referral for urgent referrals where cancer is suspected The NHS pledges to provide convenient, easy access to services within the waiting times set out in the Handbook to the NHS Constitution • All patients should receive high-quality care without any unnecessary delay • Patients can expect to be treated at the right time and according to their clinical priority. Patients with urgent conditions, such as cancer, will be able to be seen and receive treatment more quickly The handbook lists 11 of the government pledges on waiting times that are relevant to UHS services, such pledges are monitore d within the organisation and by NHS commissioners and regulators. Performance against the NHS rights, and a range of the pledges, is summarised below. Further information is available within the Appendix to this report. * https://www.gov.uk/government/publications/the-nhs-constitution-for-england/the-nhs-constitution-for-england ** https://www.gov.uk/government/publications/supplements-to-the-nhs-constitution-for-england/the-handbook-to-the-nhs-constitution-for-england Page 11 of 22 Report to Trust Board in October 2023 NHS Constitution Monthly Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep target YTD 75% % Patients on an open 18 week pathway (within 18 weeks ) 31 UHSFT 65.1% 63.2% 4 5 6 5 5 5 5 5 4 4 4 4 5 4 ≥92% Teaching hospital average (& rank of 20) South East average (& rank of 17) 6 6 6 5 5 5 5 5 6 6 5 5 6 6 50% 63.7% % Patients following a GP referral for 100% suspected cancer seen by a specialist within 8 9 89.1% 10 13 17 14 13 15 17 17 17 16 16 16 2 weeks (Most recently externally reported 38 data, unless stated otherwise below) UHSFT Teaching hospital average (& rank of 20) 4 4 8 18 11 16 11 13 10 18 19 16 13 74.0% 10 South East average (& rank of 17) 55% ≥93% Cancer waiting times 62 day standard - 100% Urgent referral to first definitive treatment (Most recently externally reported data, 39 unless stated otherwise below) UHSFT 11 11 17 14 17 14 18 14 14 9 14 13 10 15 66.3% 63.7% Teaching hospital average (& rank of 19) South East average (& rank of 17) 4 40% 4 10 11 7 12 11 7 14 5 9 3 7 6 ≥85% 100% Patients spending less than 4hrs in ED - 58.6% (Type 1) 62.3% 7 5 4 9 12 9 8 8 12 28 UHSFT 7 4 5 7 6 6 ≥95% Teaching hospital average (& rank of 16) South East average (& rank of 16) 25% 4 3 4 4 4 4 3 3 3 5 7 5 5 5 7 40% 24.8% % of Patients waiting over 6 weeks for diagnostics 37 UHSFT Teaching Hospital average (& rank of 20) 9 9 11 11 11 12 12 12 8 10 7 7 7 8 7 9 20.0% 8 7 9 8 8 8 12 11 11 11 10 10 ≤1% South East Average (& rank of 18) 0% 70.8% 65.4% 62.2% 21.0% Page 12 of 22 Report to Trust Board in October 2023 Outstanding Patient Outcomes,Safety and Experience Appendix Outcomes 1 HSMR - UHS HSMR - SGH 2 HSMR - Crude Mortality Rate Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep 88.76 86.95 84.99 83.48 75 3.1% 2.9% 2.7% Monthly target ≤100 <3% YTD 82.7 2.6% YTD target ≤100 <3% 2.5
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Trust-governance-and-corporate-docs/2023-Trust-documents/Finance-and-Performance-Reports-2023-24-Month-6-September-2023.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 Jenni Douglas-Todd 1 Chair’s Welcome, Apologies and Declarations of Interest 9:00 Note apologies for absence, and to hear any declarations of interest relating to any item on the Agenda. 2 Staff Story The 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 Minutes of Previous Meeting held on 29 September 2022 9:20 Approve the minutes of the previous meeting held on 29 September 2022 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 Charitable Funds Committee (Oral) 9:30 Dave Bennett, Chair 5.2 Briefing from the Chair of the Finance and Investment Committee (Oral) 9:35 Jane Bailey, Chair 5.3 Briefing from the Chair of the Quality Committee (Oral) 9:40 Tim Peachey, Chair 5.4 Chief Executive Officer's Report 9:45 Receive and note the report Sponsor: David French, Chief Executive Officer 5.5 Integrated Performance Report for Month 7 10:05 Review and discuss the Trust's performance as reported in the Integrated Performance Report. Sponsor: David French, Chief Executive Officer 5.6 Finance Report for Month 7 10:35 Review and discuss the finance report Sponsor: Ian Howard, Chief Financial Officer 5.7 People Report for Month 7 10:45 Review and discuss the people report Sponsor: Steve Harris, Chief People Officer 6 Break 10:55 7 Infection Prevention and Control 2022-23 Q2 Report 11:05 Review and discuss the report Sponsor: Gail Byrne, Chief Nursing Officer Attendees: Julian Sutton, Interim Lead Infection Control Director/Julie Brooks, Head of Infection Prevention Unit 8 Medicines Management Annual Report 2021-22 11:15 Receive and discuss the report Sponsor: Paul Grundy, Chief Medical Officer Attendee: James Allen, Chief Pharmacist 9 Equality, Diversity and Inclusivity (EDI) Update including Workforce Race 11:25 Equality Standard (WRES) and Workforce Disability Equality Standard (WDES) Results 2022 Receive and discuss the reports Sponsor: Steve Harris, Chief People Officer Attendee: Ceri Connor, Director of OD and Inclusion 10 Annual Ward Staffing Nursing Establishment Review 11:35 Discuss and approve the review Sponsor: Gail Byrne, Chief Nursing Officer Attendee: Rosemary Chable, Head of Nursing for Education, Practice and Staffing 11 Guardian of Safe Working Hours Quarterly Report 11:45 Receive and discuss the report Sponsor: Paul Grundy, Chief Medical Officer Attendee: Diana Hulbert, Guardian of Safe Working Hours and Emergency Department Consultant 12 Learning from Deaths 2022/23 Quarter 2 Report 11:55 Review and discuss the report Sponsor: Paul Grundy, Chief Medical Officer Attendee: Ellis Banfield, Associate Director of Patient Experience 13 Freedom to Speak Up Report 12:05 Review and discuss the report Sponsor: Gail Byrne, Chief Nursing Officer Attendee: Christine Mbabazi, Equality & Inclusion Adviser/Freedom to Speak Up Guardian Page 2 14 Annual Assurance Process and Self-assessment against the NHS 12:15 England Core Standards for Emergency Preparedness, Resilience and Response (EPRR) Review and discuss the report Sponsor: Joe Teape, Chief Operating Officer Attendee: John Mcgonigle, Emergency Planning & Resilience Manager 15 STRATEGY and BUSINESS PLANNING 15.1 Board Assurance Framework (BAF) Update 12:25 Review and discuss the update Sponsor: Gail Byrne, Chief Nursing Officer Attendee: Craig Machell, Associate Director of Corporate Affairs and Company Secretary 16 CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 16.1 Register of Seals and Chair's Actions Report 12:35 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 16.2 Review of Standing Financial Instructions 2022-23 12:40 Review and approve the SFIs Sponsor: Ian Howard, Chief Financial Officer Attendee: Phil Bunting, Director of Operational Finance 16.3 Corporate Governance Update 12:50 Receive and discuss the update Sponsor: Gail Byrne, Chief Nursing Officer Attendee: Craig Machell, Associate Director of Corporate Affairs and Company Secretary 17 Any other business 13:00 Raise any relevant or urgent matters that are not on the agenda 18 Note the date of the next meeting: 31 January 2023 19 Items circulated to the Board for reading 19.1 CRN: Wessex 2022-23 Q2 Performance Report Note the report Sponsor: Paul Grundy, Chief Medical Officer Page 3 20 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. 21 Follow-up discussion with governors 13:05 Page 4 3 Minutes of Previous Meeting held on 29 September 2022 1 Draft Minutes TB 29 Sept 22 OS v2 Minutes Trust Board – Open Session Date Time Location Chair Present 29/09/2022 9:00 – 13:00 Microsoft Teams Jenni Douglas-Todd (JD-T) Jane Bailey (JB), Non-Executive Director (NED) Gail Byrne (GB), Chief Nursing Officer Cyrus Cooper (CC), NED (from item 5.4 part two) Jenni Douglas-Todd (JD-T), Chair Keith Evans (KE), NED David French (DAF), Chief Executive Officer Paul Grundy (PG), Chief Medical Officer Steve Harris (SH), Chief People Officer Jane Harwood (JH), NED Ian Howard (IH), Chief Financial Officer Tim Peachey (TP), NED Joe Teape (JT), Chief Operating Officer In attendance Jane Fisher, Head of Health and Safety Services (JF) (for item 7.3) Sarah Herbert, Deputy Chief Nursing Officer (SHe) (for item 5.7) Femi Macaulay (FM), Associate NED Corinne Miller, Named Nurse for Safeguarding Adults (CM) (for item 5.8) Karen McGarthy, Named Nurse for Safeguarding Children (KMcG) (for item 5.8) Christine McGrath (CMcG), Director of Strategy and Partnerships Helen Potton, Associate Director of Corporate Affairs and Company Secretary (Interim) (HP) Helen Ralph, Manager, Transformation Team (HR) (for item 6.1) Annabel Shawcroft, Clinical Programme Officer, Transformation Team (AS) (for item 6.1) Jason Teoh, Director of Data and Analytics (JTe) (for item 5.11) Diana Ward, Clinical Outcomes Manager (DW) (for item 5.10) One member of the public (observing) 3 governors (observing) 5 members of staff (observing) 1 members of the public (observing) Apologies Dave Bennett (DB), NED 1. Chair’s Welcome, Apologies and Declarations of Interest JD-T welcomed all those attending the meeting which was being held by Microsoft Teams. Apologies were received from DB. CC would be joining the meeting later. 2. Patient Story HP introduced the Patient Story which focused on the experience of a mother and daughter who had used the Trust’s services. Mum advised that during the pandemic, her daughter had been diagnosed with cancer in her abdomen at the age of nine years old. Page 1 Her daughter had surgery followed by nine rounds of chemotherapy at the Trust followed by radiotherapy in London. Whilst on maintenance chemotherapy her daughter had relapsed and sadly a decision was made that further treatment would not be beneficial. Her daughter’s response was to write a “bucket list”. Some of the items were for herself but some related to changes that she wanted for other people including wanting parents to be fed. Her daughter could not understand why, when she was asked what she wanted to eat, that this did not extend to her mum, when her mum was in the hospital supporting her. Her daughter had not wanted mum to leave to go and eat, and no one else could come to sit with her because of the COVID restrictions. Her daughter was scared and going through gruelling treatment and that made it very difficult for mum to leave her. In addition, her treatment had affected her smell, making her feel unwell which resulted in her mum eating in the ensuite toilet as there was nowhere else to sit and eat. After her daughter died, mum had been working on items from her daughter’s bucket list, with senior representatives of the NHS. Work focused on putting in place a national programme to feed parents, improve food for children and also the provision of play specialists. In terms of food, mum had been working with UHS’ Patient Support Hub since January. Initially snack and toiletry boxes were put into every parent room but now, every children’s ward across Portsmouth and Southampton, a total of 17 wards, received food and drink every week. A charity, Sophie’s Legacy, had been set up and a trial had started that provided parents with a £4 food voucher for the restaurant, which was in addition to the support provided by the Patient Support Hub. The initiative had been well received by parents. The hope is to roll this out across the Country as looking after parents was important to enable them to support the care of their children. JD-T thanked mum for sharing noting how devastating it must have been to lose her daughter and how amazing it was that she and her daughter had wanted to support others in this difficult time. GB also thanked mum for sharing the experience and the work that was being done in her daughter’s name, which was important to continue. DAF noted how extraordinary that at the age of nine her daughter was considering the future of others. DAF asked whether mum had good links with the hospital charity and SH confirmed that he would make contact to ensure that this happened. Action: SH JT noted the importance of good facilities being available including good quality, affordable food. It was important for the Board to look at this and also to look at the estate to ensure that there was appropriate spaces provided for parents. 3. Minutes of the Previous Meeting held on 28 July 2022 The minutes of the meeting held on 28 July 2022 were approved as an accurate record of the meeting save for the following amendments: Page 2 • Page 3 – Correct spelling of Beachcroft • Page 3 – 5.3 third bullet – should read compliant not complaint. 4. Maters Arising and Summary of Agreed Actions Actions that were due had been completed. Action 763 – The complaint data was being compiled and would be sent out shortly. The remaining actions were not yet due but were being taken forward. 5. QUALITY, PERFORMANCE and FINANCE 5.1 Briefing from the Chair of the Audit and Risk Committee KE provided a briefing following the meeting on 12 September. The External Auditors had signed off their opinion on the financial statements with a clean opinion being given. From the Internal Auditors three reviews had been completed. The incident management review had focused on smaller incidents, noting that major incidents would normally be highlighted quickly. A large number had been tested and the conclusion was that the Trust needed to work on turning the reports around within the ten-day period. The Cyber Security review was one of significant assurance. However, the report highlighted that the Trust did not have formal documentation in terms of a Cyber Security Strategy and that not much training was provided for staff. Finally, in terms of General Data Protection Regulation (GDPR) and personal information, the Trust was required to have a “record of processing activities” (ROPA). The Trust undertook hundreds of activities but did not have a ROPA for every activity and the recommendation was to review and put in place an appropriate policy to enable a more general approach for wider coverage. The final review was stage 2 of how the Trust managed and governed IT projects. The report had focused on three areas: • The initial assessment of the benefits of the IT project which had been found to be thorough and well thought out and documented. • More guidance was recommended on how to evaluate benefits particularly in terms of non financial benefits including safety benefits. • There were very few post benefit assessments being completed which would help with learning. Plans were in place to put additional controls in place by March 2023 and a review would take place as part of their follow up procedures. JT reminded members that he had arranged for Cyber training for the Board and had agreed to provide further assurance around some of the arrangements and the Internal Audit was aligned to this. JT noted that staffing arrangements would need to be reviewed as currently there was only one colleague within the digital team that worked on cyber security issues. HP informed the Board that work was already underway in terms of the work around ROPAs. Action: JT Page 3 5.2 Briefing from the Chair of the Finance and Investment Committee JB provided an update from the last meeting noting that discussions had taken place around the current financial position and the operational plan, both of which were due to be discussed in the closed board meeting. There was significant challenge particularly around the deficit position but overall there was a really good grip on exactly where the Trust currently was, with appropriate decisions being made to reflect the balance between managing the financial position, whilst continuing to support our people and activity. A number of ongoing actions around productivity were being addressed together with a clearer view of the future cash position of the Trust. Finally, JB noted that Model Hospital data had been reviewed to enable the Trust to drive efficiencies compared to other hospitals and to facilitate learning. 5.3 Chief Executive Officer’s Report DAF noted that this was the first time that the Board had met since the death of Her Majesty Queen Elisabeth II and wanted to formally recognise the fantastic public service that she had given. The state funeral, which gave an additional bank holiday, provided the Trust with some challenging operational issues, with little guidance being provided in terms of what the best approach should be. Where staff were not involved in urgent or emergency care, such as within outpatients, electives and day case procedures, they were given the choice that if they wanted to work that would be gratefully received, but similarly if they wanted to take the day off to pay their respects, they were able to. Some staff wanted to work and others wanted to take the day. More than two thirds of the scheduled activity had been undertaken. DAF thanked all staff for all of their hard work and dedication. He also noted that: • The pilot of the care village had been very successful and would be discussed further in the next item. • Junior doctor pay rates had been quite challenging and was symptomatic of where the Trust was with many members of the workforce. The Royal College of Nursing (RCN) had notified the Trust of an intended ballot for strike action. Also, the British Medical Association (BMA) had published a rate card that they wanted trusts to pay, which was in many cases, significantly above current ratees. DAF noted that there were groups of staff who had indicated that they would not work for the Trust unless paid the new rates. It was a period of instability and people were understandably wanting to protect their income which was manifesting in the behaviours that we were seeing. • The HR team had been recognised by the Chartered Institute of Professional Management (CIPD), for a National awards which was a testament to the good work that SH and his team did. • The number of COVID positive cases was increasing with around 70 currently in the hospital. Mask wearing had been re-introduced in clinical areas in an attempt to limit the number of nosocomial transmissions. Care homes were not willing to accept patients with COVID which would impact potential discharges. In terms of staff Page 4 absence from COVID this was also increasing and staff were being encouraged to have both COVID and influenza vaccinations. • UHS was in the process of finalising an IT contract which, at first glance looked like it could be a replacement for our Emergency Department (ED) IT system. The initial contract was small but included from a strategic perspective, as the Trust had recognised the potential for having a longer-term development partner. UHS remained committed to its “Best of Breed” strategy but had been struggling to recruit and retain the people needed to develop the systems and this could be a step to delivering this by working together in partnership. Ultimately this could result in UHS not only being able to bring to develop our systems but also had the potential to bring to the market a number of our IT products that we had developed. • At the previous month’s board, the Trust had been aware of its segmentation under the Single Oversight Framework (SOF) review, but had omitted to formally advise the board. The Trust remained in segment 2, with 1 being good and 4 being bad. Trusts in segments 3 and 4 received more dedicated support and oversight. This was a vote of confidence from the regulators in the Trust despite the challenges it was facing. TP noted that the BMA pay card had received much criticism and should be resisted unless there was a proper negotiation about the rates. In terms of the IT partnership this was excellent news. PG noted that the Trust had been very clear through the Local Medical Councils (LMC), and individual conversations with teams, that the Trust would not be entering into negotiations about the BMA rates. It was growing as an issue but was an untenable position to hold in front of the rest of the workforce. Meetings were taking place with teams noting that it was not just about money. PG had been clear with his medical consultant colleagues that he was not able to recommend that consultants were paid as much in one day for an overtime operating list, which was greater than the amount some staff received in a month. In a cost-of-living crisis this was wrong. Many colleagues had understood this approach but there was still many who were very unhappy. JH congratulated SH for the award noting that this was a very difficult award to achieve, with tough competition, and that to achieve it during the pandemic was outstanding. Decision: The Board noted the report. 5.4 Integrated Performance Report for Month 5 (part one) JT noted the challenges that the Trust was currently under and in particular highlighted: • The previous day had been particularly tough with every space in the hospital full and lots of patients in the ED waiting for beds. This was replicated nationally with many organisations had declared critical incidents due to the pressures being faced. It was caused by increased numbers of COVID positive patients and a big spike in the number of delayed patients in the hospital which had hit 245 patients at the start of the week, with almost a quarter of the bed base who could be treated elsewhere. Page 5 • There was a record number of cancer referrals with the waiting list being the highest it had ever been. The Trust continued to deliver more diagnostic capacity than it had ever delivered but continued to struggle with capacity in view of the increased demand. This was a very difficult position alongside a time where staff morale was low and staff were tired due to the pressures over the last couple of years. • One of the two spotlights related to cancer and the Board had a study session the following week with a deep dive. Referrals had grown by about 25% per month from around 1600 two-week referrals to consistently above 2000 per month. The backlog of patients who had breached 62 days had gone up three-fold in the last two years from around 100 to 370 patients. The overall number of patients on the cancer pathway had also doubled in this period. This was challenging for a group of patients that the Trust wanted to prioritise in terms of access to services and care. • Across the Wessex Alliance footprint the backlog remained better than the rest of the Country but it was not where we would want to be in terms of cancer services. It was likely that our performance would dip as we started to treat those patients which would impact the 62 day target, despite the levels of activity and delivering relatively well in terms of our peer groups. • There were some excellent new pathways being developed including the dermatology dream pathway which would make a significant impact on the skin pathway once implemented. Work was also being done with the cancer allowance to map what we had, against what we needed to understand better the gaps. DAF noted that the cancer performance metrics were a measure of the patients that had been treated. Once you had a number of patients above the 62 days, if you did not treat them and let them remain on the waiting list. your measure would remain strong. However, this was not the right thing to do but once you had treated them this would impact that metric which was likely to be poor over the coming months. TP noted that the waiting had continued to get bigger which would suggest that either the Trust was not coping with the numbers coming through and people were therefore waiting longer and longer or that there was a higher rate of cancer in the population. Was this as a result of COVID reducing the body’s ability to fight small cancers that would normally disappear. JD-T also noted the highest number of referrals happening in August and wondered whether there was any national modelling being done around this. JT informed members that Professor Peter Johnson would be one of the presenters at the board study session and this would be a good opportunity to explore this. Anecdotally we appeared to be seeing more sicker patients who had a number of co-morbidities presenting as more complex patients and work was underway to investigate this further particularly from an inequality lens in terms of the demographics that were being referred on the two week wait referrals. PG noted that during COVID people tended to not present which was part of the reason for a backlog of presentations but that diagnosis appeared to also be increasing. Understanding why was not yet known and a discussion in the study session would be helpful to understand that particularly better. In terms of the appraisals spotlight SH noted: Page 6 • That a key element from the People Strategy was the Trust’s ability to provide meaningful progression for our staff. From the feedback given in the staff survey many staff believed that during the pandemic they had not received the development, training or the appraisal focus that they would have wanted. • Work to address that included a multi disciplinary team who had focused on refreshing the appraisal paperwork which had been well received. The team had a wide breadth of staff including clinical, operational and trade union representatives. Previously the number of appraisals carried out had been good but the quality had been low so training for appraisals had been reviewed to improve the quality of the appraisal discussion. Whilst the Trust was better than its peers, this simply highlighted that the NHS was not particularly good at appraisals. • A pilot had been implemented to better align appraisals with objective setting to enable them to cascade down to staff better which would conclude shortly and would feed into the process. JD-T noted that Division D consistently outperformed the other Divisions in terms of completed appraisals. In addition the staff survey showed that they were the only division that achieved a green in terms of an appraisal helping staff to undertake their job. This showed a correlation between the two and wondered what was the learning was. SH noted that Division D had historically had good rates of completion and had been involved in the refresh and had highlighted the need to focus at every level of the team. JH asked whether those within Division D had better promotion and development opportunities which could link back into the value of conducting a good appraisal. SH advised that there was nothing obvious but Division D had some good engagement scores overall but this could be looked at further. GB noted that the new appraisal paperwork had removed the need to consider how an individual contributed to the values of the organisation, and although the values were still referenced, questioned how through appraisal the behaviours and values continued to sit within the process. SH noted that the review of the values work was important and it would be good to look at how that could be brought back into the appraisal process to add value. Decision: The Board noted the report. 5.5 Finance Report for Month 5 IH presented the report and highlighted: • The Trust continued to focus on the underlying deficit, which for months 1 – 4 had been around £3m which had slightly worsened to £3,5m as energy costs started to grow. A deep dive had taken place at the Finance & Investment (F&I) Committee looking at some of the actions being undertaken and some of the future forecasts before the energy cap would come in and whether this would help or otherwise. There would still be a small increase in run rate into the latter half of the year which would deteriorate the Trust’s underlying position as we entered the winter months. • The key drivers were consistent. As well as energy prices, there were some drug costs pressures as we were on a block contract, cost associated with COVID including backfill of staff together with all of the operational pressures that had already been discussed. Page 7 • Cost Improvement Programme (CIP) performance had improved following the introduction of the Cost Savings Group. The Trust was currently achieving more than 80% identified which should increase going forward. In month delivery had also been strong. Everything was being done to try and improve the financial position but there were a number of pressures that were outside our control that would impact this. • Elective recovery framework performance had dipped in line with the operational pressures discussed, but UHS continued to achieve 106%, above the required 104%. UHS was in the top Trusts both in the region and nationally in terms of activity levels compared to 2019/20 levels. However, this was not resolving the waiting list issue that continued to grow. UHS continued to do well in terms of 2019/20 levels compared to other Trusts but this did create a financial pressure. • The Trust had reported a £12m deficit. The Hampshire and Isle of Wight deficit was £53m. This was an outlier within the region, and the region was an outlier nationally. This had resulted in the system becoming an outlier in terms of financial performance which might have adverse consequences going forward including upon the SOF rating. • The underlying deficit reduced the Trust’s cash balance and that may put pressure on our future capital investment programme. KE referred to the financial risks table and asked what the difference was between the original worst case of £57m and the forecast assessments which showed, best, intermediate and worst case? IH noted that the original worstcase scenario had been presented to the Board as part of the planning submissions, to show the range of possible financial outcomes with everything that was known at the time. The current best, intermediate and worst case were the current assessments. KE noted that UHS could not control COVID costs, energy costs and inflationary measures and that this would need Treasury to provide support. IH reminded members that nationally there was a drive to find efficiencies. It was likely that many Trusts would go into deficit this year but it was not clear what the response would be to that. KE commended the work on the CIP which was a fantastic achievement. He questioned whether the position could improve further with more CIP savings. IH advised that a target date of Month 6 had been agreed in terms of everything being identified 100% and the position might improve next month. IH noted that UHS was at 106% activity levels with the national average being around 94%. The 12% from the Elective Recovery Fund (ERF) would be worth about £20m to the Trust. If the Trust had undertaken less activity the Trust’s financial position would be a lot less stark but UHS continued to put patients first and try and balance performance, money and quality. In response to a question from JD-T IH confirmed that as of today and what was currently known, UHS could still achieve the best-case scenario. DAF suggested that in view of what had happened in markets over the recent days it was unlikely that the NHS would want to approach the Treasury. UHS should proceed on the basis that there would be no financial support being provided. In those circumstances the Board would need to consider at what point more significant interventions would need to be made. Page 8 5.6 People Report for Month 5 JD-T noted that this was a new report for the board. Previously the report had been presented to the Trust Executive Committee (TEC) and following discussion in that forum a decision was made that it should be presented to the open board for discussion. SH presented the report and noted that the version before the Board was the detailed report presented to TEC. Going forward a more streamlined report, with key highlights, would be developed for the Board discussion. SH highlighted: • Some of the key actions that had been taken in relation to recruitment and retention and also the cost-of-living crisis. There had been discussions at a previous closed board meeting around concerns in relation to the recruitment and retention of certain staff groups and some actions had been put in place to mitigate those concerns. • SH highlighted the challenges around Advanced Clinical Practitioners (ACPs) and pay rates. A few local organisations including GP practices were providing a differential rate of pay with a higher pay band. In the short term this was being addressed by a recruitment and retention premium to bridge the gap, together with conducting a workforce review that would seek to understand the banding and whether there was a need for a permanent band change. However, it would be important to consider the possible impact on the change to other bands across the Trust and manage that appropriately. • UHS continued to undertake Health Care Assistant (HCA) recruitment well, but the challenge was retention. There were good pathways in place but work was needed to strengthen landing boards and increase the support available in the hubs and implement some band 2 to band 3 progression roles for those who did not want to utilise the nursing apprenticeship route. • Demand on the recruitment team had significantly increased with a 25% increase of requested support. Some additional resource had been agreed to support them both within the organisation but also to increase engagement outside of the organisation. • In terms of cost of living, SH had been undertaking a lot of work with partners across the Trust including trade unions and listening to staff voices. There were a number of elements that were not under the Trust’s control including the national pay award and the rising energy crisis so the approach being taking was to take a balanced and fair approach. A number of things would be implemented which would be highlighted to all staff. A substantial discount was being negotiated in the restaurant to help people to eat a broad range of foods at competitive prices. The cycle to work scheme was being expanded, and there was some targeted support for those with high mileage within the organisation. For the 200 or so families who used the nursery the price was being rolled back to April this year. • The Trust already has a range of general support which would be expanded to make sure that we were targeting the right people. Through a partnership with the ICS we were linking up with the Citizens Advice Bureau to provide really high quality financial advice to our staff. We were focusing on crisis, and working with the Charity, had set up a hardship fund of £20,000 which would be distributed to the most challenging cases where staff had been identified as a particular Page 9 hardship case they would be able to eat free at the restaurant. Arrangements had also been made with a local charity to provide vouchers and food parcels. Discussion had taken place as to whether a food bank should be set up on site which logistically would have been difficult, so the decision to work with the charity was agreed to be the best approach to deliver that service for us. • Discussions had taken place at the Trust Executive Committee (TEC) who had fully supported the measures noting the impact on the nonrecurrent spend. KE suggested that this was a very sensible, targeted group of things to support our people. However, asked if the cost of £2.3m was currently included in the financial reports. IH advised that it was not included although some of the nonrecurrent elements had a funding source so would not hit the underlying position. In terms of annual leave buy out there were accruals from previous years. However, there were some recurrent costs. The measures were targeted, proportionate and in line with the Trust’s values for the current pressures being faced and if the Trust did not do anything it would likely increase costs or consequences elsewhere. DAF noted that the report was the same as presented to the TEC at which there had been a more detailed conversation. It would be helpful to understand which areas of the report were more relevant and appropriate for the Board conversation which could be discussed at the next People and OD POD) Committee meeting. Action: SH. JH supported the proposals within the paper and noted that they had also been presented to the People and OD Committee (POD). POD would be tracking the progress of each of the initiatives to ensure that they were delivering as anticipated. JH asked if the Trust had looked at what others were doing to ensure that we were doing everything possible for our staff. SH confirmed that discussions had taken place locally and that the Trust was one of the first to implement the range of measures which were similar to those of others. Nationally, there had been a push to have a collective response, noting that the NHS employed 1.5m people and that there would be national support that would be available shortly. TP noted the importance of having a people report at the Board and whilst the contents were good suggested that they could be presented in a more accessible way. FM also noted the importance of the report and discussion but wondered what staff morale was. If the finance, performance and people report were considered as a whole it was clear that staff were facing a lot of pressure and there was insufficient staff due to high turnover. The volume of patients was increasing which meant that the staff that the Trust did have, had to work harder and longer with pay that was not great and a cost-of-living crisis to deal with. This must have an impact on staff morale and was there also an impact on patient care? SH noted that morale was challenged which was recognised in the executive updates. The Trust undertook a quarterly staff survey alongside the current national annual staff survey and those results have been included within the report. The recent results discussed motivation, engagement and advocacy in Page 10 the organisation and UHS scores were still consistently in the top 10 of the NHS. However, the entirety of that engagement score was deteriorating. Morale was challenged and how that impacted on care was discussed in other forums. GB chaired the Quality Governance Steering Group (QGSG) which fed into the Quality Committee and focused on quality whether that be from the engagement of our staff or other challenges. GB suggested that it was a mixed picture. People enjoyed working as a team and we can see them pull together and work as a team through the challenges. There were a number of different pockets in the organisation who believed that they were in a worst situation following the pandemic and it was important to move out of that space and recognise this as a whole. In terms of quality, it was important to retain a close focus on quality and in some other Trusts they were starting to experience a significant challenge with regards to their quality indicators. At UHS there were some potential early indications that were being closely monitored. Without a doubt staffing levels, and the way in which we looked at the wards, impacted on patient experience and outcome. JD-T noted that one of the proposals was for staff to be able to sell back annual leave and being able to easily access the bank but if this was considered in the wider context, we had staff who were tired and not able to take leave as they had sold it, and were looking to work extra hours on the bank. How did the Trust manage and balance this? How should we look at the overarching risks for the workforce, and consequently patient care and performance, and what were the things that we needed to do to balance that. It would be helpful if the report could address some of those challenges to help the Board’s understanding. In addition JD-T asked NEDs to feedback what they would want to see within the report to enable an effective discussion. Action: SH and All NEDs JH asked about exit surveys and wondered if there was any information from them that could support our approach. SH advised that approximately 30% of staff completed exit surveys which needed to be increased. Pay for the lower paid staff had become an issue. SH reminded members that he chaired the ICS people officers group and that group had been looking at how collectively they could support retention and were looking to purchase better exit surveys for the system pulling together their collective buying power. Decision: The Board noted the report. 5.4 Integrated Performance Report for Month 5 (part two) Having noted the previous discussions under items 5.5 and 5.6 JD-T suggested that a discussion on the remaining of the IPR would be helpful and the following questions and comments were made: • JB noted that on pages 31 and 35, F1 – F5 this suggested that in terms of digital we believed that this was going to transform our efficiencies but it was not clear what the metrics indicated nor were some of them very high. PG suggested that there was an amazing resource in my medical record which we were not really making the most of. Work was needed to raise awareness with both patients and clinicians. Having used it as a patient it had been really helpful and enabled him to go paperless. JT noted that there was a business case that was overdue Page 11 for my medical record around how we industrialised it across the Trust which should provide some huge benefits and would bring a timeline back as to when this would happen. Action: JT JT noted that there was some big digital change happening with the rolling out of speech recognition and some E tools. In addition it would be helpful to look at the indicators to understand whether they were the right ones and review them as part of the digital updates which could be discussed at F&I. Action: JT The Board discussed the importance of giving people an overwhelming reason to access my medical record noting that the NHS App had initially been used for COVID vaccinations but could now enable people to order prescriptions and book appointments. JD-T noted the Serious Incident reports and the number of harm falls which looked higher than previously and wondered in terms of the pressures we were seeing and the issues around workforce should the Board be concerned about this? GB advised that it had recently been falls awareness week. There had been a number of successful programmes in the Trust including bay watch, but with reduced staffing numbers that had became a challenge and some more deliberate high impact actions were needed to reduce those falls. A deep dive into this would be brought to a future meeting. Action: GB GB confirmed that COVID numbers were rising. There were 66 patients with COVID some of whom were both asymptomatic and symptomatic. 5.7 Break The break took place prior to the Safeguarding Annual Report. 5.8 Safeguarding Annual Report 2021-22 and Strategy 2022-25 JDT suggested that the strategy should be discussed first noting that both had been discussed at the Quality Committee. KMcG presented the strategy which had previously been presented to the Trust Board two years ago before Covid. The strategy had been reviewed and updated in line with new legislation and aligned to UHS values and now included maternity services. Some of the strategy linked to children and adult reviews and making safeguarding personal together with our partners and developing stronger links within maternity, the emergency department and the wider hospital. Joining this up with the domestic abuse strategy and ensuring that we were always improving particularly around training and education including level 3 requirements. In terms of the Annual Report from a children’s perspective there were three main highlights: Page 12 • A significant increase, from 3700 to 6004, in the number of information sharing forms (ICF) which come through the ED where a child may possibly be at risk. In particular numbers had increased in the number of children presenting with mental health problems, particularly the 0 – 4 age group. This had been discussed at the Health Safeguarding Looked After Children Partnership who were looking at the 0 – 19 service provision which had changed significantly with COVID and a possible pattern of children of parents accessing through ED rather than going via their GP. • In terms of mental health, for any child who presented in the ED with a mental health condition an ICF would be completed. The number of presentations remained high. Alongside this the number of deliberate harm incidents had risen from 676 to 898, drugs and alcohol referrals had risen as had assaults over the preceding year. • Level 3 safeguarding training was at about 61%. There were two main reasons for this which was capacity and demand for the service and also a change of reporting requirements impacting just over 2000 staff. Training was on the Integrated Care Board (ICB) Risk Register as it was a wider system issue. In terms of the Annual Report for adults CM highlighted the following: • A 31% increase in safeguarding activity from the previous year with a 162% increase in Section 42 inquiries. This was due to a number of reasons including the impact of COVID including the removal of social distancing rules. • A 35% increase in the number of allegations made against people in a position of trust which was something that was being seen across other local provider organisations. These were highly sensitive cases and required significant safeguarding oversight and management alongside collaboration with HR colleagues and the relevant clinical areas, which had a significant impact on the team. • The creation of a new Mental Capacity Act (MCA), Deprivation of Liberty (DoL) and Liberty Protection Safeguards (LPS) team who supported people over the age of 16. Both locally and nationally this was one of the first teams that had been established. The team had worked to embed MCA as every day business which was key to the preparation for when LPS become law later next year or early the following year. • In terms of Learning Disability and Autism there was a lack of local provision which had been acknowledged by the ICS and work was underway in relation to service review and what this needed to look like going forward. GB thanked the team noting how hard they worked to safeguard vulnerable adults and children. GB referenced the Panorama programme that had aired the previous night in terms of a number of safeguarding issues against a Mental Health Trust. Whilst often allegations against staff were not grounded they were taken very seriously and investigated thoroughly. JB noted the 35% increase against staff and wanted to understand what the outcomes of the investigations were and whether they were justified and whether allegations were being made against different groups. CM advised that one of the key areas of allegations focused on restraint and that the level Page 13 of restraint applied was disproportionate. These would always be reviewed. Security staff worked in pairs and wore body cameras which would always be reviewed. There had not been any cases recently where that had proved to be an issue. Although there had been a big increase the total number of cases was 38 so not large numbers. The previous year there had been 23 cases. CC questioned what element of this sat within the Trust and what sat with the ICS? SH noted the importance of remembering the broader picture. Nationally there had been a rise of safeguarding incidents, but it was important to remember that our workforce formed part of that population and had struggled with lockdown and were experiencing hardship. JD-T noted the need for a system approach to manage the increased mental health demand. However, safeguarding was a key focus for the Care Quality Commission (CQC) inspections post COVID, and a local provider had recently been deemed to be inadequate due to safeguarding issues and was an issue for UHS to pay particular attention to. KMcG noted that through legislation children had the Local Area Designated Officer (LADO) which was lacking in adults, which provided a really strong link with that external partner. TP noted that there had been a detailed presentation on this in the Quality Committee. This was a national trend in increased safeguarding problems. Whatever pressure we are put under it was important not to let our safeguarding procedures slip and it needed to be protected to ensure that it worked well. Decision: The Board received the report. 5.9 Medical Appraisal and Revalidation Annual Report including Board Statement of Compliance PG presented the report which was a statement of compliance with the medical regulations and had a robust and strong process in place. PG noted that a new appraisal system had been introduced which had been well received and enabled the ability for medical staff to collect all of their appraisal information within one system instead of the previous three systems. This was beneficial for not only staff but also for those managing the process as it provided real time feedback and information both from a quality assurance perspective but also would enable better management of the process and improve appraisal rates in the future. JD-T asked whether the doctor appraisal information was included within the IPR information that the Board received and SH confirmed that it was reported separately but included in the report and currently stood at 76.7%. CC suggested that the system was good but asked whether everyone was using it. PG confirmed that the system was a mandatory one and would be the only system going forward in the future. In terms of how many staff had undertaken the process this was a little ahead of the rest of the staff. However, the system enabled us to keep better track as people would need to have completed four appraisals within the previous five years to go forward with revalidation which provided a good incentive to keep on top of this. Page 14 JD-T asked for Board members to confirm that they approved the statement of compliance. Decision: The Board noted the report and approved the statement of compliance. 5.10 Clinical Outcomes Summary PG introduced the comprehensive summary noting that the clinical lead who had ran the service for a number of years, had now left UHS and a process of recruitment was currently underway which would provide an opportunity to refresh and review. DW presented the paper and focused on the outcome programme which was unique to UHS, with 64 services out of 86 reporting their outcomes. A total of 484 outcomes had been reported all of which had been reviewed by TP via the Quality Committee. There was a thriving clinical audit programme in place. The outcomes reported per care group covered a large proportion of patients and dealt with both national and international work. In particular DW highlighted: • The Research and Development (R&D) team and the work that they had undertaken internationally on the COVID booster trial. • The Bone Marrow Transparent unit. • Maternity and the nest support teams who focused on women who may need additional support because of serious mental illness, or they were from socially challenging situations, or were non-English speaking, addiction, were homeless or were suffering from domestic abuse and other difficult situations. 12% of patients that were being seen in maternity required nest care. KE asked why 18 services were not reported and DW advised that it was because they did not have the mechanisms in place to know what their outcomes were and work was underway to support them to develop those processes. KE asked whether any of the reds within the report were really poor and JD-T noted that the data used was for 2020 and did not understand why it was so out of date. TP advised that data was provided from national audits was often two years behind, because there was a year of collection, a year of analysis and then it would be published. Within his experience he had never come across a hospital that had measured nearly 500 clinical outcomes let alone p
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Annual report 20-21

Description: 2020/21 Incorporating the quality report University Hospital Southampton NHS Foundation Trust Annual Report and Accounts 2020/21 Presented to Parliament pursuant to Schedule 7, paragraph 25(4)(a) of the National Health Service Act 2006 © 2021 University Hospital Southampton NHS Foundation Trust Table of contents Welcome from our chair and chief executive 6 Overview and performance 8 Performance report 9 Overview 10 Accountability report 29 Directors’ report 30 Remuneration report 53 Staff report 65 NHS Foundation Trust Code of Governance 81 NHS Oversight Framework 81 Annual governance statement 84 Quality report 95 Statement on quality from the chief executive 96 Priorities for improvement and statements of assurance from the board 99 Other information 153 Annual accounts 180 Statement from the chief financial officer 181 Auditor’s report 182 Foreword to the accounts 188 Statement of Comprehensive Income 189 Statement of Financial Position 190 Statement of Changes in Taxpayers’ Equity 191 Statement of Cash Flows 192 Notes to the accounts 193 5 Welcome from our chair and chief executive 2020/21 was undoubtedly the most challenging year in the history of the NHS, and we have felt the impact of the COVID-19 pandemic here at University Hospital Southampton NHS Foundation Trust (UHS) in full. Responding to this has meant there isn’t a single part of our organisation that hasn’t changed in some way over the last year and we have all had to adapt to a rapidly changing environment. Our staff have been unwavering in their dedication, hard work and commitment to keeping our hospitals running, our patients cared for, and their colleagues supported. Every single member of the UHS family has played their part. The loss of life from COVID-19 has been devastating, and at UHS we stand shoulder-to-shoulder with everyone affected by this tragedy, including the families of staff members whom we lost. We must recognise the incredible work of Southampton Hospital Charity, which has funded boost boxes, wellness rooms, a helpline and so much more to support staff at a time when their wellbeing is more important than ever. As the nationwide vaccination programme continues to offer hope of life more like pre-pandemic times, we are proud to have been at the forefront of these efforts - from being part of early research for the Oxford-AstraZeneca vaccine, to the opening of one of the largest vaccination hubs in the region on our site in December 2020. We will continue to play a key role in vaccination development by leading the world’s first clinical trial into the effectiveness of COVID-19 booster vaccines, as well as taking part in a study involving pregnant people. Our response to COVID-19 has prompted innovation and new ways of working across the Trust, to the benefit of patient experience. At the start of the pandemic we faced real challenges of capacity and increases in waiting times, which led to us working with Spire Southampton so cancer treatment and surgery could continue for patients at highest risk. We also increased the number of outpatient attendances which took place by telephone or video call, and our patient support hub was set up to provide a single point of support for patients who had been advised to shield. We are immensely proud of the record of the Trust during the pandemic, exemplified by the number of patients we were able to take into our care from well outside the local area. The Trust is in a strong financial position as a result of careful spending and efficiencies, which has allowed us to invest significantly in upgrading our estate. These improvements have seen the opening of the general intensive care unit, and the new cancer ward, which was built in just six months. These formed part of overall capital expenditure of £80 million during the year. The last year has seen us say goodbye to two members of our executive leadership team. Paula Head left the chief executive officer role in November to join the national response to COVID-19, before becoming a senior fellow at The King’s Fund. Derek Sandeman moved on from being our chief medical officer to take the same position at the Hampshire and Isle of Wight Integrated Care System. We are grateful to both for their efforts on the Trust leadership team during the most challenging of years. One of our non-executive directors, Jenni Douglas-Todd, also left the Trust to take on the important role of director of equality and inclusion with NHS England and NHS Improvement. 6 Looking ahead to the future, UHS will play a key role in the Hampshire and Isle of Wight Integrated Care System. Our commitment is to deliver services with partners through clinical networks, collaboration and integration across geographical and organisational boundaries for seamless patient care. We as a Trust board are looking forward to implementing our own five year strategy, which sets out ambitions for what we want the hospital to be in 2025, for both patients and staff. Our focus will always be on enabling world class people to deliver world class care. Peter Hollins David French Chair Chief Executive Officer 7 OVERVIEW AND PERFORMANCE Performance report Introduction from our chief executive Over the last year, the way in which the Trust has worked and performance it has achieved, has been transformed by the COVID-19 pandemic. • UHS saw a number of large surges in demand for inpatient care, and for intensive respiratory support in particular, due to COVID-19 infection rates. Our capacity to deliver intensive care had to be increased, and many of our staff moved from other services such as our elective theatres in order to meet this need for care. • We have introduced and continue to maintain a number of changes to reduce the risk of COVID-19 being transmitted, or adversely affecting patient outcomes, within the Trust. Changes have included the wearing of additional personal protective equipment by our staff (especially when caring for patients who might have COVID-19 or undertaking higher risk procedures), reducing the number of patients coming to our outpatient departments and increasing the number of telephone and video consultations, separating elective and emergency patients within our departments and regular testing of our staff and all patients on or prior to their admission to hospital for treatment. • Public concerns about safety, government restrictions and the efforts of community services actually contributed to reductions in the total number of patients who sought hospital care this year. • Treatment plans have been modified by a number of services, in partnership with patients, to reduce the risk posed by COVID-19 to those patients. This was often appropriate in those circumstances in which the normal treatment would significantly reduce the patient’s own resistance to infections. Our performance has, in many cases, been strongly influenced by these profound changes. We have responded well to the need to provide the most urgent care, and the adverse impacts on elective care have been slightly less than the average across the NHS. However, we remain very concerned by the significant increase in the numbers of patients waiting longer than they should for elective care. It will take concerted and sustained action within both the Trust and the wider NHS in order to return elective performance to levels achieved before the pandemic whilst also continuing to meet urgent care needs as the restrictions that have been implemented within our society are progressively relaxed. 9 Overview About the Trust Our services University Hospital Southampton NHS Foundation Trust is one of the largest acute teaching trusts in England with a turnover of more than £1 billion in 2020/21. 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 more than 3.7 million people in central southern England and the Channel Islands. The Trust is also a designated major trauma centre, one of only two places in the south of England to offer adults and children full major trauma care provision. As a leading centre for teaching and research, the Trust has close working relationships with the University of Southampton, the Medical Research Council, National Institute for Health Research (NIHR), Wellcome Trust and Cancer Research UK. UHS is consistently one of the UK’s highest recruiting trusts of patients to clinical trials and in the top ten nationally for research study volume as ranked by the NIHR Clinical Research Network. 12,000 Every year over staff at UHS: treat around 160,000 inpatients and day patients, including about 75,000 emergency admissions see over 650,000 people at outpatient appointments deal with around 150,000 cases in our emergency department deliver more than 100 outpatient clinics across the south of England, keeping services local for patients The Trust provides most of its services from the following locations: • Southampton General Hospital – the Trust’s largest location, where a great number of specialist services are based alongside emergency and critical care and which includes Southampton Children’s Hospital. • Princess Anne Hospital – located across the road from Southampton General Hospital and providing maternity care and specialist care for women with medical problems during pregnancy and babies who need extra care around birth across the region. • Royal South Hants Hospital – although the Trust does not operate this site near the centre of Southampton it provides a smaller number of services from this location. • New Forest Birth Centre – located at Ashurst on the edge of the New Forest and run by experienced midwives and support staff it offers a safe, ‘home away from home’ environment for women having a healthy pregnancy and expecting a straightforward birth. The services provided by the Trust are commissioned and paid for by local clinical commissioning groups (CCGs) and, in the case of more specialised services (such as treatments for rare conditions), by NHS England. Over 50% of UHS services are paid for by CCGs and approximately 48% by NHS England. We provide these 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 Monitor (the independent regulator, now part of NHS England and NHS Improvement) and the healthcare services we provide are regulated by the Care Quality Commission. Being a foundation trust has enabled greater local accountability and greater financial freedom and has supported the delivery of the Trust’s mission and strategy over a number of years. The diagram below provides an overview of the overall organisational structure of the Trust. Public and foundation trust members Council of Governors Board of Directors Executive Directors Division A Surgery Critical Care Opthalmology Theatres and Anaesthetics Division B Division C 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 Division D Trust Headquarters Division Cardiovascular and Thoracic Neurosciences Trauma and Orthopaedics Radiology Corporate Affairs Communications Estates, Facilities and Capital Development Finance Human Resources Informatics Patient Support Services Procurement and Supply Transformation and Improvement (‘Always Improving’) Research and Development Strategy and Business Development 11 The Trust is also part of an integrated care system in Hampshire and the Isle of Wight, which is a partnership of NHS and local government organisations working together to improve the health and wellbeing of the population across Hampshire and the Isle of Wight. Our values Our values describe how we do things at UHS and act as a guide to all staff working with colleagues to deliver high quality patient care and a great patient experience every day. Our values are: Patients, their families and carers are at the heart of what we do. Their experience of our services will be our measure of success. Partnership between clinicians, patients and carers is critical to achieving our vision, both within hospital teams and extending across organisational boundaries in the NHS, social care and the third sector. We will ensure we are always improving services for patients through research, education, clinical effectiveness and quality improvement. We will continue to incorporate new ideas, technologies and create greater efficiencies in the services we provide. 12 Our strategy 2021-25 The Trust’s strategy was updated during 2020/2021 to take account of everything our staff had experienced during the COVID-19 pandemic and what we had learnt from this. The vision for UHS is to continue on its journey to become an organisation of world class people delivering world class care. Our strategy is organised around five themes and for each of these describes a number ambitions we aim to achieve by 2025. Theme Ambitions Outstanding patient outcomes, • We will monitor clinical outcomes, safety and experience of our experience and safety patients regularly to ensure they are amongst the best in the UK By 2025 we will strengthen our and the world. national reputation for outstanding • We will reduce harm, learning from all incidents through our patient outcomes, experience and proactive patient safety culture. safety, providing high quality care • We will ensure all patients and relatives have a positive experience and treatment across an extensive of our care, as a result of the environment created by our people range of services from foetal and our facilities. medicine, through all life stages and conditions, to end-of-life care. Pioneering research • We will recruit and enable people to deliver pioneering research and innovation in 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 tax payer 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 will set out a more detailed series of objectives to achieve and progress towards the delivery of its ambitions. In 2020/21 these objectives included: • Recovery, restoration and improvement of clinical services • Implementing the ‘Always Improving’ strategy • Restoring a full research portfolio • Continuing our focus on staff wellbeing including the long-term effects of coronavirus (long COVID) • Working in partnership with the newly established integrated care system • Creating a sustainable financial infrastructure • Making our corporate infrastructure (digital, estate) fit for the future to support a leading university teaching hospital in the 21st century, including an estates masterplan. Performance against these objectives will be monitored and reported to the Trust’s board of directors on a quarterly basis. Principal risks to our strategy and objectives The board of directors 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 2020/21 were that: • it would be unable to form effective partnerships that achieve networked care for patients; • it could not develop the estate in line with the ambitions set out in the strategy; • it would fail to restore and increase capacity following the COVID-19 pandemic to meet waiting times for elective care and cancer care needs; • it would fail to introduce and implement new technology for the transformation of care; • it would be unable to retain, recruit, develop and train a diverse and inclusive workforce necessary to meet the strategic goals; • it could not develop a sustainable model within the new financial regime that preserves quality care; • it would fail to provide vulnerable service users with timely and high quality and appropriate care; • it would not reach the ambition of outstanding compliance and quality standards; • it could not sufficiently engage with key stakeholders and system partners to support effective interventions and maintain the health of the local population; • it would be unable to respond to the needs of the NHS in order to deliver our strategy; • it would fail to capitalise on its relationship with the universities in Southampton and other health education providers in line with our strategy; • it would not develop innovative education and training approaches. 14 While the COVID-19 pandemic presented the Trust with new risks as it introduced more stringent infection control processes, stopped certain types of activity and responded quickly to care for large numbers of seriously ill patients who had tested positive for COVID-19, it also prompted innovation across a wide range of areas. However the ongoing impact of the pandemic on both our staff, patients who have had COVID-19 and patients who have waited longer than expected for treatment as a result, added to the risks facing the Trust. National targets for performance have not been amended as a result of the pandemic, although the national plan has focussed on the recovery of activity levels as the first stage in a restoration of elective services. Capacity – The initial and subsequent waves of the COVID-19 pandemic have led to increases in the waiting times for patients and the number of patients waiting more than 52 and 78 weeks has increased significantly. While the Trust was able to recover capacity quickly between waves of the pandemic, its ability to reduce the overall waiting list and the length of time patients are waiting for treatment remains one of the key risks for the Trust. This may be compounded by the reduction in the number of referrals from GPs during the pandemic, leading to a potential future increase in the number of patients being referred as people visit their GPs for the first time with more advanced disease. During the pandemic the Trust utilised the support available from the independent sector to continue cancer treatment and surgery for those patients at highest risk. It also increased the number of outpatient attendances which took place by telephone or video call. The Trust developed a clinical assurance framework during the year to better assess the risk of harm to patients as a result of delays in treatment and this has been utilised in decision-making around the allocation of resources to those areas where there is the greatest risk of potential harm to patients. In addition to opening additional capacity during 2020/21 (described in the Estates section below), the Trust also committed expenditure and commenced construction works in 2020/21 in order to be in a position to open an additional endoscopy room and four further operating theatres during 2021/22 and prepared plans for a significant expansion in ophthalmology outpatient capacity. These initiatives will contribute to improvements in elective waiting times that needed following the pandemic. Quality and compliance – The Trust continued to monitor the quality of care delivered throughout 2020/21. During the COVID-19 pandemic the primary focus became infection prevention and control, with the launch of a successful COVID ZERO campaign that saw the Trust reduce the transmission of the virus in hospital (nosocomial transmission). The Trust also achieved its annual target for reduction in Clostridium Difficile infections, however, there was one MRSA Bacteraemia during March 2021, the only such event in 2020/21. The Trust continued to develop its proactive patient safety culture during 2020/21 with changes to the way in which patient safety incidents are investigated and the approval of its Always Improving strategy, which will be launched in 2021. Reporting and investigation of incidents continued during 2020/21. Partnerships – During 2020/21, the Trust and its partners worked together very effectively to discharge patients safely and provide ongoing support to patients who had tested positive for COVID-19, to ensure patients requiring urgent cancer treatment and surgery were able to continue their treatment in the independent sector and to develop a COVID-19 saliva testing pilot with the University of Southampton and local authorities. Work to respond to the COVID-19 pandemic, however, meant that as a system we were unable to progress the Hampshire and Isle of Wight strategic plan delivery at the pace we would have wanted or had set out to achieve, particularly the development of networks. Nonetheless the application for Hampshire and Isle of Wight to become an integrated care system was approved with effect from 1 April 2021. 15 Existing networks continued to develop and improve. The Trust also became the Wessex Cancer Surgical Hub during 2020 as a result of a national initiative with the aim of maximising the number of patients receiving curative surgery. Both the Wessex Cancer Alliance and the Trust ended the year as the second highest performing among their respective peers for cancer treatment. Workforce – While additional staff were recruited to specifically assist the Trust during the pandemic, the Trust continued to recruit nurses from overseas during 2020/21 meaning that the number of vacancies has reduced compared to the position prior to the pandemic. Changes to recruitment processes were approved in 2020/21 to improve the fairness, transparency and quality of these. The Trust also continued to work with its staff networks and specific focus groups to increase diversity in leadership roles. While workforce capacity continues to be one of the biggest challenges faced by the Trust, during 2020/21 our main focus has been on supporting our staff to respond to the COVID-19 pandemic and providing both the tools and time to help staff recovery. We are incredibly proud of the way that staff responded to the pandemic and continue to recognise this in whatever ways we can, however, we also want to ensure that staff continue to be able to contribute to patient care at their best and want to stay and develop with the Trust. Technology was also used at levels not previously achieved to continue to deliver training to staff and enable staff to work from home where possible, ensuring a safer environment for patients and staff in the hospitals. Estate – The Trust continued to invest in and develop its estate during 2020/21 including the opening a new general intensive care unit (GICU), a new operating theatre and a new cancer care ward, built in just six months. These were part of £80 million of capital expenditure in 2020/21. The Trust has also established a programme to reduce backlog maintenance in addition to continuing to add to and improve the environment in which services are provided to patients and the working environment for staff. Innovation and technology – There have been exceptional levels of achievement in relation to COVID-19 related research activity, including in partnership with the universities. You can read more about these from page 167 of the quality report. The board of directors also supported the funding of an expansion of research and innovation activity to allow the continued delivery of the Trust’s ambitions to innovate and improve and transform its services. Sustainable financial model – The Trust achieved its forecast breakeven position in 2020/21. Income was more predictable in 2020/21 as block contract arrangements were put in place in response to the COVID-19 pandemic and ensured that costs were covered. The Trust continues to maintain a strong cash position and to implement improvements and efficiency savings, allowing it to continue to invest in its services. 16 Summary of performance COVID-19 bed occupancy UHS has experienced two distinct peaks in inpatient care for patients with COVID-19 infection, with smaller numbers of patients continuing to receive care outside these peak times. Bed occupancy reached a maximum of 173 in the first peak in April 2020, and 322 in the second peak in January 2021. All bed types Intensive care/higher care beds 17 Emergency access through our emergency and eye casualty departments Public concerns about safety, government restrictions on the activities people were able to do, and the efforts of community services contributed to significant reductions in the total number of patients who presented to our departments. All patients presenting to the emergency department Many changes were introduced within our departments in the course of the year to ensure that emergency assessment and treatment could be provided safely, including wearing of protective equipment by staff and patients, providing care in separate areas for patients suspected or known to have COVID-19, and using rapid laboratory tests to identify infection and confirm/exclude COVID-19 as a cause. Emergency access performance (measured as the percentage of patients discharged from emergency department care or admitted to a hospital bed within four hours of arrival to the department) improved significantly in 2020/21 compared to previous years. The national target of 95% was not achieved, however, the performance of our departments compared favourably with the average for acute trusts in England. 18 Emergency access four hour performance 19 Elective Waiting times Demand We saw a significant reduction in the number of elective referrals to hospital in the early part 2020/21, though they had returned close to pre-pandemic levels by the end of the year. It is likely that this pattern relates to a range of factors including reluctance from members of the public to attend healthcare facilities at that time, changes to the ways in which primary care was accessed, and efforts made within primary and community to avoid hospital referrals needing to be made. Accepted referrals The number of patients referred to hospital with suspected cancer also reduced during 2020/21; 7% fewer patients were seen across the year as a whole, though referrals returned to pre-pandemic levels or higher from July 2020 onwards. Patients seen following ‘Two week wait’ urgent referral for suspected cancer 20 Activity UHS hospital appointments, diagnostic tests and elective admissions were all significantly reduced during 2020/21 due to the impact of COVID-19. • During periods of higher bed occupancy with COVID-19 it was necessary to significantly reduce the number of elective admissions undertaken in order that additional staff could work in intensive care. Less clinically urgent and therefore longer waiting patients were primarily those affected. • Throughout the year, additional infection prevention measures have reduced the number of patients that can be seen in each session, particularly when higher risk ‘aerosol generating’ procedures are planned, but also as a result of additional PPE being worn or to enable greater distancing of patients attending outpatient departments. UHS was offered additional capacity at local independent sector hospitals and used this effectively to minimise these adverse impacts. Approximately 30% of outpatient appointments are now undertaken by telephone or video, helping to maintain the capacity for patient care whilst reducing the infection risk for those patients and helping to maintain distancing measures for those patients still attending our outpatient departments. The graphs below show 2020/21 activity levels as a percentage of those achieved in the previous year. Elective admissions (including daycase) 21 Outpatient attendances Performance The average waiting time for first outpatient appointments has remained close to nine weeks for the majority of the year. UHS has however experienced very significant deteriorations in the waiting times our patients experience for diagnostic tests to be undertaken and elective treatment to be provided. The reduced number of new patients referred to hospital early in 2020/21 has moderated the extent of the growth in the total numbers of patients waiting, and the greatest rate of growth has unfortunately been amongst those groups of patients already waiting longest. 22 Diagnostics Our performance measures for diagnostics report on a total of 15 different frequently used tests. The waiting list is approximately 50% bigger than it was before the pandemic and stable through the second half of the year. At the end of the year 28% of patients were waiting more than six weeks to receive their investigation compared to the national target of 1%. The tests with the largest numbers of longer waiting patients include non-obstetric ultrasound, MRI and endoscopies, and further recovery will be driven through a combination of recruitment, independent sector capacity and an additional endoscopy room which opened at the start of April 2021. Patients waiting for a diagnostic test to be performed (sum of 15 different frequently used tests) Percentage of patients waiting over 6 weeks for a diagnostic test to be performed 23 Referral to Treatment Our waiting list from referral to treatment increased in size by 6% (2,220 patients) during 2020/21, rising when the recovery in referral numbers exceeded the recovery in clinical activity, the total increase in waiting list size would have been significantly higher had it not been for the significant reduction in the referrals received by the hospital especially during the early months of the pandemic. Looking forward, we anticipate referrals numbers returning to pre-pandemic levels, and being able to maintain the total size of our waiting list by delivering an equivalent number of treatments each month. Number of patients waiting between referral and commencement of a treatment for their condition The national target is that at least 92% of patients should be waiting for treatment no more than 18 weeks from their referral to hospital. Our performance against this measure is now 12% worse than one year ago, at 66%. Our performance continues to be typical of the major teaching hospital trusts that we benchmark with and the trend has been similar to that experienced across trusts in England. Percentage of patients waiting up to 18 weeks between referral and treatment 24 Unfortunately, the number of patients waiting significantly longer than the 18 week target has increased at a faster rate than the size of the waiting list as a whole. The graph below shows how the percentage of patients who have waited more 52 weeks increased. The number of patients who have waited more 52 weeks increased from 40 in March 2020 to 3,419 by March 2021 (of these 445 patients had waited more than 78 weeks). Such patients often require surgical treatment, particularly in the orthopaedic, ear nose and throat and oral surgery specialities. The impact on surgical care has been greater than that in outpatients during the pandemic, and it is also more challenging to increase capacity due to the need for additional operating theatres and a combination of different healthcare professionals to work within them. UHS opened an additional operating theatre in 2020/21, and has a further four theatres scheduled to open during 2021/22, which will make a significant contribution to our capacity to treat more patients. Unfortunately, the number of patients waiting significantly longer than the 18 week target is likely to continue to grow further in the short term, due to diagnostic investigations having been progressed less quickly than usual during the pandemic, the need to prioritise our increased treatment capacity according to the clinical urgency of conditions and because our scheduled capacity increases will not be completed before the autumn of 2021. Percentage of patients waiting more than 52 weeks, between referral and commencement of a treatment for their condition 25 Cancer Waiting Times UHS has been mostly successful in maintaining the timeliness of urgent services for patients with suspected cancer through the pandemic, and our performance has been amongst the best in both the south-east and nationally. UHS prioritised the theatre and intensive care capacity we were able to provide during the pandemic in order to meet the needs of those patients with the greatest clinical urgency, used capacity offered by independent sector hospitals to supplement that available within NHS, and operated a hub through which hospitals in Wessex were able to collaborate to continue critical cancer surgery during periods of peak COVID-19 demand. The national target is to provide the first definitive treatment to at least 85% of patients with cancer with 62 days of referral to hospital. Whilst UHS performance remained below this level in the majority of months, our performance has been significantly better than the national average, and has improved relative to other trusts. Treatment for Cancer within 62 days of an urgent GP referral to hospital 26 The national target is to provide the first definitive treatment to at least 96% of patients within 31 days of a decision to treat being made and agreed with the patients; both for the first and any subsequent treatments for cancer. UHS achieved this level on average across the year, and in the majority of months. The treatments provided are typically by means of surgery, chemotherapy/immunotherapy or radiotherapy. The most significant performance challenge this year has been in radiotherapy, where more sophisticated treatment plans improve patient outcomes but take longer to prepare, and there was also reduced treatment capacity whilst we replaced one of our ‘Linear Accelerator’ treatment machines with a new model. First definitive treatment for cancer within 31 days of a decision to treat Equality in service delivery Identifying and addressing health inequalities have been the central part of the Trust’s approach to improving the experience of care for our patients, families and carers. Over the past year, new initiatives have augmented progress on existing work to ensure there is appropriate support, due regard and recognition of those patients and their families and carers who are most at risk of poor experiences, outcomes and access to services. In 2020 we added two questions to our patient surveys, asking first if patients felt themselves to have a disability or require a reasonable adjustment, and, if yes, whether the Trust met this need. In 2020/21, the results were: TOTAL Had a disability / required a reasonable adjustment 27% Had this need met by the Trust (positive response) 95% This question was added to our major Friends and Family Test surveys as well as our local service-specific patient surveys. In June 2020 the Trust launched the sunflower lanyard scheme for hidden disabilities, participating in the national initiative to ensure that people whose disabilities are not visible are able to access further support and reasonable adjustments by means of a nationally recognised indicator (the sunflower). In 2020/21, 618 lanyards were issued with those needs recorded to ensure future reasonable adjustments are made for those individuals. 27 Carers have always been essential partners in the care that we provide, and having introduced a new post at the end of 2019 to focus solely on carer experience, this work has culminated in a Trust strategy for improving the involvement, support and experience carers have of our services. We have, over the past year, introduced carers cards, virtual peer support and carer-specific information about services while actively participating in local and regional work on carers. In January 2021 we realised our ambition of becoming an accredited ‘Veterans Aware’ hospital, with our submission of evidence being recognised as ‘strong’ and indicative of an organisation that has made great progress in helping to provide enhanced support for the armed forces community. Towards the end of 2019 we worked with the disability organisation AccessAble to produce accessibility guides for all of our services and estate. These online guides allow patients and visitors with disabilities to plan their journey and identify potential challenges to the environment. In 2020/21 our guides had 5,000 unique visits per month. One of our COVID-19 initiatives, a patient support hub, was set up in May 2020 to provide a single point of support for our patients who had been advised to shield. The service has grown and now offers support to patients and carers who are vulnerable, disabled or with additional needs. This includes coordinating community transport, arranging companions to assist with attending appointments, hosting a technology library to support those who are digitally excluded in accessing virtual appointments and information, and most recently receiving funding to pilot volunteer-led support for diabetes patients. Across the Trust, we continue to actively promote the importance of asking patients and carers about disabilities and reasonable adjustments, flagging needs on our patient administrative system to prompt our services to take proactive steps to ensure that any needs or adjustments are met on each and every visit. This has been of vital importance for meeting accessible information and communication needs. We are currently one of first trusts to pilot a new translation app that provides immediate interpretation into different languages, and we have worked closely with our communication support partners to ensure that where virtual appointments are needed, people with communication needs (BSL, foreign language) are supported to access care virtually. Our specialist nursing liaison teams continued to support access to services throughout the pandemic, ensuring that patients with dementia, with learning disabilities and autism, were supported to attend hospital where necessary. Further information about the Trust’s work in relation to equality, diversity and inclusion can be found on page 69 and pages 106 and 160 in the quality report. Going concern After making enquiries, the directors have a reasonable expectation that the services provided by the Trust will continue to be provided by the public sector for the foreseeable future. For this reason, the directors have adopted the going concern basis in preparing the accounts, following the definition of going concern in the public sector adopted by HM Treasury’s Financial Reporting Manual. David French Chief Executive Officer 28 June 2021 28 Accountability report Directors’ report Board of directors The board of directors is usually made up of six executive directors and seven non-executive directors, including the chair. Since 1 January 2021 the number of non-executive directors has been reduced by one as Jane Bailey’s reappointment as a non-executive director was deferred to allow her to lead the Hampshire and Isle of Wight saliva mass testing programme. Jane is expected to return to the board of directors in her non-executive director role by 1 July 2021. Paragraph B.1.2 of the NHS foundation trust code of governance provides that at least half the board of directors, excluding the chair, should comprise non-executive directors determined by the board to be independent. Pending the reappointment of Jane Bailey as a non-executive director, the Trust has been operating with one fewer non-executive directors than is required by the Trust’s constitution and the Trust has been non-compliant with this paragraph of the code. During this period the provisions of the Trust’s constitution that a quorum for meetings of the board of directors requires at least one non-executive director and one executive director to be present and for the chair to have a second and casting vote in the case of an equal vote continued to apply. The board of directors has given careful consideration to the range of skills and experience it requires to run the Trust. Together the members of the board of directors bring a wide range of skills and experience to the Trust, such that the Board achieves balance and completeness at the highest level. The chair was determined to be independent on his appointment and the other non-executive directors have been determined to be independent in both character and judgement. This included specific consideration of Jane Bailey’s continued independence following her role leading the Hampshire and Isle of Wight saliva mass testing programme. The chair, executive directors and non-executive directors have declared any business interests that they have. Each director has declared their interests at public meetings of the board of directors. The register of interests is available on the Trust’s website. 30 The current members of the board of directors are: Non-executive directors Peter Hollins Chair Peter graduated in chemistry from Hertford College, Oxford. Joining Imperial Chemical Industries in 1973, he undertook a series of increasingly senior roles in marketing and then general management. Following three years in the Netherlands as general manager of ICI Resins BV, in 1992 he was appointed as chief operating officer of EVC in Brussels – a joint venture between ICI and Enichem of Italy. He played a key role in the flotation of the company in 1994, before returning in 1998 to the UK as chief executive officer of British Energy where he remained until 2001. From 2001, he held various chairmanships and non-executive directorships. In 2003, he decided to return to an executive role as chief executive of the British Heart Foundation in which post he remained until retirement in March 2013. He joined Southampton University Hospital Trust as a non-executive director in 2010, became senior independent director and deputy chairman of UHS in 2014 and was appointed chair in April 2016. Trust roles: • Chair of remuneration and appointment committee • Chair of governors’ nomination committee Jane Bailey Non-executive director In 1985, Jane joined the pharmaceutical company Glaxo as a management trainee, having graduated from London University with a degree in environmental science and pharmacology. Here she rose to senior commercial vice-president, gaining experience of a broad range of disease areas across different regions of the world. She specialised in leading global research and development teams in the formation of strategies to bring new medicines to patients. She also worked to ensure that the medicines developed were supported by robust evidence demonstrating their clinical and cost-effectiveness. In delivering this she gained extensive experience of leading large diverse teams across a complex global organisation. For five years, Jane ran her own strategy development consultancy, working across a breadth of healthcare organisations. In 2017 Jane gained an MSc in public health, with distinction, at King’s College, London University. Her studies focused on how to ensure the public are engaged in development of healthcare services and how social theories can help inform effective disease prevention and management. Jane is a director of Wessex NHS Procurement Limited, a joint venture between the Trust and Hampshire Hospitals NHS Foundation Trust and a director of Healthwatch Portsmouth. Trust roles: • Deputy chair and senior independent director • Chair of finance and investment committee • Audit and risk committee member • Charitable funds committee member • People and organisational development committee member • Remuneration and appointment committee member • Wellbeing Guardian 31 Non-executive directors Dave Bennett Non-executive director Dave graduated in chemistry from the University of Southampton before entering management consulting, becoming a partner in Accenture’s strategy practice. In 2003 he joined Exel Logistics (later acquired by DHL), managing the company’s healthcare business across Europe and the Middle East. During this time, he established NHS Supply Chain, a UK organisation responsible for procuring and delivering medical consumables for the NHS in England, as well as sourcing capital equipment. Dave joined the board of Cable & Wireless as sales director in 2008. He later set up his own strategy consulting practice serving the healthcare sector, completing numerous projects in the UK and the US. Dave has also served as a non-executive director at The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust between 2009 and 2016, where he chaired the Trust’s quality committee. Dave is a non-executive director at the Faculty of Leadership and Medical Management and a director of Royal College of General Practitioners (RCGP) Enterprises Ltd and RCGP Conferences Ltd. Trust roles: • Chair of charitable funds committee • Chair of finance and investment committee (from 1 January 2021) • Audit and risk committee member (from 9 February 2021) • Quality committee member • Remuneration and appointment committee member • Chair of Trust’s organ donation committee 32 Non-executive directors Cyrus Cooper Non-executive director Cyrus Cooper is professor of rheumatology and director of the MRC Lifecourse Epidemiology Unit. He is also vice-dean of the faculty of medicine at the University of Southampton and professor of epidemiology at the Nuffield Department of Orthopaedics (rheumatology and musculoskeletal sciences, University of Oxford). He leads an internationally competitive programme of research into the epidemiology of musculoskeletal disorders, most notably osteoporosis. His key research contributions have been: • discovery of the developmental influences which contribute to the risk of osteoporosis and hip fracture in late adulthood • demonstration that maternal vitamin D insufficiency is associated with sub-optimal bone mineral accrual in childhood • characterisation of the definition and incidence rates of vertebral fractures • leadership of large pragmatic randomised controlled trials of calcium and vitamin D supplementation in the elderly as immediate preventative strategies against hip fracture. He is president of the International Osteoporosis Foundation, chair of the BHF Project Grants Committee, an emeritus NIHR senior investigator, a director of The Rank Prize Funds and associate editor of Osteoporosis International. He has previously served as chairman of the Scientific Advisors Committee (International Osteoporosis Foundation), the MRC Population Health Sciences Research Network and the National Osteoporosis Society of Great Britain. He has also been president of the Bone Research Society of Great Britain and has worked on numerous Department of Health, European Community and World Health Organisation committees and working groups. Cyrus has published extensively on osteoporosis and rheumatic disorders and pioneered clinical studies on the developmental origins of peak bone mass. In 2015, he was awarded an OBE for services to medical research. Trust roles: • Quality committee member • Remunerati
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