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

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

Nursing and midwifery staffing report February 2026

Description: Report notes - Nursing and midwifery staffing hours - February 2026 Our staffing levels are continuously monitored through our staffing hub and we will risk assess and manage our available staff to ensure that safe staffing levels are always maintained The total hours planned is our planned staffing levels to deliver care across all of our areas but does not represent a baseline safe staffing level. We plan for an average of one registered nurse to every five or seven patients in most of our areas but this can change as we regularly review the care requirements of our patients and adjust our staffing accordingly. Staffing on intensive care and high dependency units is always adjusted depending on the number of patients being cared for and the level of support they require. Therefore the numbers will fluctuate considerably across the month when compared against our planned numbers. Enhanced Care (also known as Specialling) Occurs when patients in an area require more focused care than we would normally expect. In these cases extra, unplanned staff are assigned to support a ward. If enhanced care is required the ward may show as being over filled. If a ward has an unplanned increase or decrease in bed availability the ward may show as being under or over filled, even though it remains safely and appropriately staffed. CHPPD (Care Hours Per Patient Day) This is a measure which shows on average how many hours of care time each patient receives on a ward /department during a 24 hour period from registered nurses and support staff - this will vary across wards and departments based on the specialty, interventions, acuity and dependency levels of the patients being cared for. In acute assessment units, where patients are admitted, assessed and moved to wards or theatre very swiftly, the CHPPD figures are not appropriate to compare. The maternity workforce consists of teams of midwives who work both within the hospital and in the community offering an integrated service and are able to respond to women wherever they choose to give birth. This means that our ward staffing and hospital birth environments have a core group of staff but the numbers of actual midwives caring for women increases responsively during a 24 hour period depending on the number of women requiring care. For the first time we have included both mothers and babies in our occupancy levels which will have impacted the care hours per patient day for comparison in previous months. The staffing for Critical care areas which includes intensive care and high care beds, is flexed to meet the variable patient capacity, infection and acuity needs of the patients. Critical units staffing numbers include ensuring capacity to admit patients across ICU's at any time. Capacity challenges arising from increased patient admisssions, infection issues or increased acuity and complexity of patients can sometimes mean that wards need to be changed or re-configured at short notice to adapt to the changing situation. These decisions are sometimes swift in nature and the data in some cases therefore may not be fully reflective of all of these changes. At the beginning of February 2026 the trust had a fire that caused significant damage to the hospital. As a result many of the wards and areas of intensive care were affected, meaning patients were cared for in different specialties and in areas not normally used for inpatient care throughout Februray as part of the recovery operation. Wards have been adaptable and changing constantly to ensure we reduced the number of lost beds and were able to continue caring for our patients. We have continued to adapt our staffing model accordingly, however all of the data for February should be reviewed with caution as it will not accurately reflect all of these arrangements as rosters and specialty codes have not always been changed in line with the ward moves. Ward CC Neuro Intensive Care Unit CC Neuro Intensive Care Unit CC - Surgical HDU CC - Surgical HDU CC General Intensive Care CC General Intensive Care Day Night Day Night Day Night Registered nurses Total hours planned Registered nurses Total hours worked Unregistered staff Total hours planned Unregistered staff Total hours worked Registered nurses % Filled 4858 4329 650 586 89.1% 4508 4336 638 651 96.2% Unregistered staff % Filled 90.2% 102.0% CHPPD Registered midwives/ nurses 30.7 1802 1731 10415 9664 1378 1282 8906 8449 285 491 1252 1117 160 339 1349 1444 76.5% 74.1% 85.5% 87.4% 56.2% 69.0% 107.8% 129.3% 443.4 27.1 CHPPD Care Staff CHPPD Overall Comments Safe staffing levels maintained by sharing staff resource, Beds flexed to match staffing. 4.4 35.1 Safe staffing levels maintained by sharing staff resource, Additional staff used for enhanced care - support workers, Beds flexed to match staffing, RN's required for safety due to use of side rooms for Level 2 patients unobserved. Safe staffing levels maintained by sharing staff resource, Beds flexed to match staffing. Relocated due to the fire 83.2 526.6 Safe staffing levels maintained by sharing staff resource, Beds flexed to match staffing. Relocated due to the fire Safe staffing levels maintained by sharing staff resource, Additional staff used for enhanced care - support workers, Beds flexed to match staffing. 4.4 31.4 Safe staffing levels maintained by sharing staff resource, Additional staff used for enhanced care - support workers, Beds flexed to match staffing. CC Cardiac Intensive Care Day CC Cardiac Intensive Care SUR E5 Lower GI SUR E5 Lower GI SUR E5 Upper GI SUR E5 Upper GI SUR E8 Ward SUR E8 Ward SUR F11 IF SUR F11 IF SUR Acute Surgical Unit Night Day Night Day Night Day Night Day Night Day SUR Acute Surgical Unit Night SUR Acute Surgical Admissions Day SUR Acute Surgical Admissions Night SUR F5 Ward Day SUR F5 Ward Night THR F10 Surgical Day Unit Day THR F10 Surgical Day Unit Night CAN Acute Onc Services Day CAN Acute Onc Services Night CAN C4 Solent Ward Clinical Oncology Day CAN C4 Solent Ward Clinical Oncology Night CAN C6 Leukaemia/BMT Unit Day CAN C6 Leukaemia/BMT Unit Night CAN C6 TYA Unit Day 6155 5493 1368 690 1315 679 1957 1612 1470 919 938 643 1601 966 1941 1012 1587 649 975 644 1571 966 2668 3871 3932 1164 667 1065 658 1872 1398 1291 886 777 840 1594 1083 1483 1001 2003 112 940 622 1508 864 2303 1932 975 1806 793 642 635 865 633 944 632 1085 953 695 630 711 634 689 951 888 628 2975 653 913 506 938 643 621 322 415 675 814 710 576 711 621 1043 1013 545 633 722 495 861 967 1040 668 1512 198 1034 495 1087 943 562 62.9% 105.1% 71.6% 85.1% 96.7% 81.0% 96.9% 95.6% 86.7% 87.9% 96.4% 82.8% 130.6% 99.5% 112.1% 76.4% 98.9% 126.3% 17.2% 96.4% 96.6% 96.0% 89.5% 86.3% 128.1% 82.1% 91.1% 75.3% 98.3% 96.1% 106.3% 78.5% 100.4% 101.5% 78.0% 124.9% 101.7% 117.1% 106.3% 50.8% 30.3% 113.3% 97.7% 116.0% 146.7% 90.6% 383 93.5% 119.0% 0 81.4% 0.0% 23.2 130.8 101.3 19.3 4.7 323.2 78.7 4.7 4.1 11.9 4.3 8.2 10.6 4.4 91.9 78.3 12.2 2.5 243.2 53.8 3.3 3.4 11.7 3.7 1.9 0.0 27.7 222.7 179.7 31.5 7.2 566.4 132.5 8.0 7.5 23.6 8.1 10.1 10.6 Safe staffing levels maintained by sharing staff resource, Additional staff used for enhanced care - support workers, Due to fire 10 beds lost and SHDU located in CICU footprint. Additional RN's required for safety due to use of side rooms for Level 2 patients unobserved. Safe staffing levels maintained by sharing staff resource, Additional staff used for enhanced care - support workers. Safe staffing levels maintained by sharing staff resource, Skill mix swaps undertaken to support safe staffing across the Unit. Ward affected by fire Safe staffing levels maintained. Ward affected by fire Safe staffing levels maintained by sharing staff resource . Ward affected by fire Safe staffing levels maintained. Ward affected by fire Safe staffing levels maintained. Ward affected by fire Safe staffing levels maintained by sharing staff resource, Safe staffing levels maintained. Ward affected by fire Safe staffing levels maintained by sharing staff resource. Safe staffing levels maintained. Safe staffing levels maintained by sharing staff resource. Ward affected by fire Increase in acuity/dependency of patients in the month, Safe staffing levels maintained by sharing staff resource. Ward affected by fire Safe staffing levels maintained, Staff moved to support other wards. Staff moved to support other wards. Safe staffing levels maintained by sharing staff resource, Staffing appropriate for number of patients. Safe staffing levels maintained . Skill mix swaps undertaken to support safe staffing across the Unit. Day unit only. Safe staffing levels maintained, Additional beds open in the month, Safe staffing levels maintained by sharing staff resource. Safe staffing levels maintained, Additional beds open in the month, Safe staffing levels maintained by sharing staff resource. Safe staffing levels maintained, Additional staff used for enhanced care Support workers, Safe staffing levels maintained by sharing staff resource. Safe staffing levels maintained, Additional staff used for enhanced care Support workers, Safe staffing levels maintained by sharing staff resource. Safe staffing levels maintained, Skill mix swaps undertaken to support safe staffing across the Unit, Safe staffing levels maintained by sharing staff resource, Due to Fire ward having closed beds for 8 days in the month (12 beds). Safe staffing levels maintained, This ward has a high number of siderooms and if acuity/dependency of patients is raised Registered nurse or support workers are required to special on night duty, Safe staffing levels maintained by sharing staff resource, Due to Fire ward having closed beds for 8 days in the month (12 beds). Safe staffing levels maintained, Staff moved to support other wards, Safe staffing levels maintained by sharing staff resource. CAN C6 TYA Unit CAN C2 Haematology CAN C2 Haematology CAN D12 CAN D12 ECM Acute Medical Unit ECM Acute Medical Unit MED D5 Ward MED D5 Ward MED D6 Ward MED D6 Ward MED D7 Ward MED D7 Ward MED D8 Ward MED D8 Ward MED D9 Ward MED D9 Ward MED Respiratory HDU MED Respiratory HDU MED C5 Isolation Ward MED C5 Isolation Ward MED D10 Isolation Unit MED D10 Isolation Unit MED G5 Ward MED G5 Ward MED G6 Ward MED G6 Ward MED G7 Ward MED G7 Ward 618 596 0 Night 10.6 0 96.4% Shift N/A 1905 2132 354 466 111.9% 131.7% Day 5.9 1932 1880 962 Night 1116 97.3% 116.0% 681 688 287 597 101.0% 208.1% Day 3.2 1288 1284 638 Night 1018 99.7% 159.5% 2137 2492 1187 2218 116.6% 186.8% Day 6.3 Night 4164 4705 1902 3414 113.0% 179.6% 1342 1764 1545 1312 131.4% 84.9% Day 3.9 1012 1035 624 Night 1047 102.3% 167.8% Day 1018 1090 1754 1268 107.2% 72.3% 5.4 977 852 612 Night 783 87.2% 128.0% 657 776 951 993 118.0% 104.4% Day 0.0 Night 650 572 622 851 87.9% 136.8% 876 1710 1526 1323 195.1% 86.7% Day 4.4 Night 967 1048 610 1102 108.3% 180.8% Day 1300 1901 1534 1191 146.2% 77.7% 4.6 Night 966 1278 620 845 132.4% 136.3% Day 2144 1638 378 213 76.4% 56.4% 27.6 Night 1932 1569 295 219 81.2% 74.1% 727 875 1352 1402 120.3% 103.7% Day 4.9 667 678 605 1093 101.7% 180.7% Night Day 1015 1094 1308 1226 107.7% 93.7% 3.7 667 703 615 Night 772 105.3% 125.5% Day 1087 1253 1615 1439 115.3% 89.1% 2.9 Night 966 920 614 835 95.2% 136.0% Day 938 1197 1689 1450 127.6% 85.9% 3.3 Night 966 931 613 770 96.4% 125.6% Day 613 1051 687 1049 171.5% 152.7% 5.1 Night 644 795 623 931 123.4% 149.4% 0.0 10.6 Safe staffing levels maintained, This ward has a high number of siderooms and if acuity/dependency of patients is raised Registered nurse or support workers are required to provide enhanced care on night duty, Safe staffing levels maintained by sharing staff resource. Additional staff used for enhanced care - Support workers, Safe staffing levels maintained by sharing staff resource. 2.3 8.2 Additional staff used for enhanced care - Support workers, Safe staffing levels maintained by sharing staff resource. Additional staff used for enhanced care - Support workers, Safe staffing levels maintained by sharing staff resource. 2.6 5.8 Additional staff used for enhanced care - Support workers, Safe staffing levels maintained by sharing staff resource. Additional staff used for enhanced care - RNs, Additional staff used for enhanced care - Support workers, Safe staffing levels maintained by sharing 4.9 11.2 staff resource. Additional staff used for enhanced care - Support workers, Additional staff used for enhanced care - RNs, Safe staffing levels maintained. Additional staff used for enhanced care - RNs, Safe staffing levels maintained. 3.2 7.1 Additional staff used for enhanced care - RNs, Additional staff used for enhanced care - Support workers. Additional staff used for enhanced care - RNs, Safe staffing levels maintained, , . 5.7 11.0 Safe staffing levels maintained, Additional staff used for enhanced care - Support workers. Additional beds open in the month, Additional staff used for enhanced care - 0.0 0.0 Support workers. Safe staffing levels maintained, Additional staff used for enhanced care - Support workers. Increase in acuity/dependency of patients in the month, Safe staffing levels 3.9 8.3 maintained. Increase in acuity/dependency of patients in the month, Additional staff used for enhanced care - Support workers. Additional staff used for enhanced care - RNs, Safe staffing levels maintained. 3.0 7.6 Additional staff used for enhanced care - RNs, Additional staff used for enhanced care - Support workers. Safe staffing levels maintained. Temporarily moved due to fire. 3.7 31.4 Safe staffing levels maintained. Temporarily moved due to fire. Additional staff used for enhanced care - RNs, Additional staff used for enhanced care - Support workers. 7.9 12.8 Safe staffing levels maintained, Additional staff used for enhanced care - Support workers. Increase in acuity/dependency of patients in the month. 4.2 7.9 Increase in acuity/dependency of patients in the month, Additional staff used for enhanced care - Support workers. 3.0 5.9 Additional staff used for enhanced care - RNs, Safe staffing levels maintained. Safe staffing levels maintained, Safe staffing levels maintained. Additional staff used for enhanced care - RNs, Safe staffing levels maintained. 3.5 6.8 Safe staffing levels maintained, Additional staff used for enhanced care - Support workers. Additional staff used for enhanced care - Support workers, closed beds re IPC. 5.5 10.6 Additional staff used for enhanced care - Support workers, IPC closed beds. MED G8 Ward MED G8 Ward MED G9 Ward MED G9 Ward MED Bassett Ward MED Bassett Ward MED E12 MED E12 960 1240 1710 1699 129.1% 99.3% Day 3.6 Night 955 1146 611 1062 120.1% 173.8% Day 951 1150 1689 1364 120.9% 80.8% 3.0 Night 966 966 610 633 100.1% 103.8% Day 1189 1010 2229 1810 84.9% 81.2% 2.6 Night 966 886 930 1104 91.7% 118.7% Day 619 1101 1693 1627 178.0% 96.1% 3.6 Night 989 1035 573 1172 104.7% 204.5% CHI High Dependency Unit CHI High Dependency Unit CHI Paed Medical Unit CHI Paed Medical Unit CHI Paediatric Intensive Care CHI Paediatric Intensive Care CHI Piam Brown Unit CHI Piam Brown Unit CHI Ward E1 Paed Cardiac CHI Ward E1 Paed Cardiac CHI Bursledon House CHI Bursledon House CHI Ward G2 Neuro CHI Ward G2 Neuro CHI Ward G3 CHI Ward G3 1464 1105 417 8 75.5% 1.8% 15.9 Day Night 966 1028 322 12 106.5% 3.6% 2129 1704 724 667 80.0% 92.3% Day 8.0 Night 1849 1612 579 662 87.2% 114.3% Day 6554 5614 472 268 85.7% 56.9% 34.4 Night 5806 5245 330 380 90.3% 115.0% 3651 2695 973 445 73.8% 45.7% Day 12.6 Night 1288 1014 605 311 78.7% 51.3% Day 2296 1518 658 638 66.1% 97.0% 8.8 Night 1611 1332 271 393 82.7% 145.3% Day 771 475 558 406 61.6% 72.7% 4.3 Night 176 176 135 178 100.0% 131.9% Day 690 660 816 96 95.6% 11.8% 8.1 Night 672 660 630 24 98.3% 3.8% Day 2173 1586 1512 732 73.0% 48.4% 9.4 Night 1541 1268 881 385 82.3% 43.7% CHI Ward G4 SUN 2087 2159 1137 519 103.4% 45.6% 9.8 Day CHI Ward G4 SUN Night 1506 1493 572 385 99.1% 67.3% W&N Bramshaw Womens Unit Day 989 954 624 544 96.5% 87.1% 4.9 W&N Bramshaw Womens Unit Night 771 736 553 621 95.5% 112.2% W&N Neonatal Unit W&N Neonatal Unit Day 7827 5860 3116 1483 74.9% 47.6% 19.9 Night 6468 4873 2110 1060 75.3% 50.2% W&N PAH Maternity Service combined Day 10194 8551 3087 2375 83.9% 76.9% 11.0 W&N PAH Maternity Service combined Night 6730 6336 1138 1130 94.2% 99.4% CAR CHDU CAR CHDU 5142 4543 1440 1263 88.4% 87.7% Day 17.8 Night 4048 3842 872 902 94.9% 103.4% Safe staffing levels maintained, Additional staff used for enhanced care - Support workers, Discharge lounge staff covered from here. 4.2 7.8 Safe staffing levels maintained, Additional staff used for enhanced care - RNs. Additional staff used for enhanced care - RNs, Safe staffing levels maintained. 2.9 5.9 Safe staffing levels maintained. Safe staffing levels maintained. 4.0 6.7 Safe staffing levels maintained, Additional staff used for enhanced care - Support workers. Additional beds open in the month, Safe staffing levels maintained. 4.7 8.3 Additional beds open in the month, Additional staff used for enhanced care - Support workers. Additional beds open in the month, Increase in acuity/dependency of patients in the month, Safe staffing levels maintained by sharing staff resource, Beds flexed up to 7 to support PICU and ED flow. Staff moved to support other 0.1 16.1 wards. Ward Manger, Matron and Education team used to support increased acuity and capacity throughout the month. Skill mix swaps undertaken to support safe staffing for level 2 and 3 critical care. No requirement for Support workers. Additional staff used for enhanced care - Support workers, Patient requiring 24 hour 1:1 nursing in the month, Additional support staff due to 1:1 enhanced care 3.2 11.2 for a number of patients. Additional staff used for enhanced care - Support workers, Patient requiring 24 hour 1:1 nursing in the month. Increase in acuity/dependency of patients in the month, Safe staffing levels 2.0 36.4 maintained, Lots of ECMO patients requiring inreased staffing. Increase in acuity/dependency of patients in the month, Safe staffing levels maintained. Beds flexed to match staffing, Safe staffing levels maintained by sharing staff resource, Being supported by other wards across child health due to LTS and 2.6 15.2 hight maternity leave. Beds flexed to match staffing, Safe staffing levels maintained by sharing staff resource. Safe staffing levels maintained, Beds flexed to match staffing, Ability to flex 3.2 12.0 beds due to less PICU returning patients, this matched staffing. Safe staffing levels maintained, Beds flexed to match staffing. Safe staffing levels maintained by sharing staff resource, Band 7 working down 3.9 8.2 into staffing numbers to increase ratio to maintain bed occupancy. Support workers used to maintain staffing numbers, Safe staffing levels maintained. Safe staffing levels maintained. 0.7 8.9 Safe staffing levels maintained. Beds flexed to match staffing, Safe staffing levels maintained, When able, beds 3.7 13.1 flexed to maintain safe staffing and decrease NHSP spend. Beds flexed to match staffing, Safe staffing levels maintained. Increase in acuity/dependency of patients in the month, Safe staffing levels maintained by sharing staff resource, High unaccompained babies within unit 2.4 12.3 and high acuity has required extra RN resource as HCA uptake of NHSP not available. Safe staffing levels maintained. 3.4 8.2 Staffing appropriate for number of cots 4.7 24.6 Staffing appropriate for number of cots 2.6 13.6 Staffing appropriate for number of births Staffing appropriate for number of births Safe staffing levels maintained, Band 4 staff working to support registered 4.6 22.4 nurse numbers, Band 4 staff working to support registered nurse numbers. Safe staffing levels maintained. CAR Coronary Care Unit CAR Coronary Care Unit CAR Ward D3 Cardiac CAR Ward D3 Cardiac CAR Ward D4 Vascular CAR Ward D4 Vascular CAR Ward E2 YACU CAR Ward E2 YACU CAR Ward E3 Green CAR Ward E3 Green CAR Ward E3 Blue CAR Ward E3 Blue CAR Ward E4 Thoracics CAR Ward E4 Thoracics CAR Ward D2 Cardiology CAR Ward D2 Cardiology NEU Acute Stroke Unit NEU Acute Stroke Unit NEU Regional Transfer Unit NEU Regional Transfer Unit NEU ward E Neuro NEU ward E Neuro NEU HASU NEU HASU NEU Ward D Neuro NEU Ward D Neuro Day 2532 3018 1073 978 119.2% 91.2% 10.9 Night 2190 2229 816 770 101.8% 94.4% Day 2195 2021 747 854 92.1% 114.4% 5.9 1243 1111 616 594 89.4% 96.4% Night Day 1843 1667 1007 1323 90.4% 131.3% 4.7 948 894 869 1090 94.4% 125.5% Night Day 1521 1402 684 796 92.2% 116.3% 5.0 Night 638 627 560 661 98.3% 118.0% Day 1767 1463 910 898 82.8% 98.7% 5.9 946 829 559 738 87.6% 132.0% Night 1751 560 798 197 32.0% 24.6% Day 1.3 638 166 558 Night 187 26.1% 33.5% 2205 1848 904 1383 83.8% 153.0% Day 5.8 1177 961 557 1001 81.6% 179.7% Night 1244 1121 671 807 90.1% 120.3% 4.7 Day 638 652 562 Night 675 102.2% 120.1% 1476 559 2386 468 37.9% 19.6% Day 1.4 Night 924 384 1172 341 41.6% 29.1% 1050 954 361 453 90.9% 125.5% Day 10.4 605 652 467 Night 607 107.7% 130.0% Day 1654 1729 1092 1704 104.5% 156.0% 4.0 Night 1232 1178 994 1543 95.6% 155.2% 1631 1585 351 578 97.2% 164.9% Day 8.9 1232 1177 245 Night 341 95.5% 139.2% 1789 1831 1554 2267 102.3% 145.9% Day 4.6 Night 1243 1457 1355 1744 117.2% 128.7% Safe staffing levels maintained, Additional staff used for enhanced care - RNs. 3.6 14.5 Safe staffing levels maintained. Safe staffing levels maintained. 2.7 8.6 Safe staffing levels maintained, Skill mix swaps undertaken to support safe staffing across the Unit. Safe staffing levels maintained, Additional staff used for enhanced care - Support workers. 4.4 9.1 Safe staffing levels maintained, Additional staff used for enhanced care - Support workers. Safe staffing levels maintained. 3.6 8.7 Safe staffing levels maintained. Safe staffing levels maintained, Staffing appropriate for number of patients. 4.2 10.1 Safe staffing levels maintained, Staffing appropriate for number of patients, Additional staff used for enhanced care - Support workers, ward reduced to 18 beds post major incident. Ward closed to CVT pts post major incident and reutilised for another specialty. Activity captured on another roster 0.7 2.0 Ward closed to CVT pts post major incident and reutilised for another specialty. Activity captured on another roster Safe staffing levels maintained, Band 4 staff working to support registered nurse numbers, Additional staff used for enhanced care - Support workers. 4.9 10.7 Safe staffing levels maintained, Band 4 staff working to support registered nurse numbers, Additional staff used for enhanced care - Support workers. Safe staffing levels maintained, Additional staff used for enhanced care Support workers. 4.0 8.7 Safe staffing levels maintained, Additional staff used for enhanced care - Support workers. Safe staffing levels maintained, Additional staff used for enhanced care Support workers. Staffing appropriate for number of patients, Safe staffing levels maintained, , Ward split between stroke and surgery due to major incident. Only stroke staff 1.2 2.7 appearing on F8 roster. F5 staff caring for surgical patients however not appearing on roster. Staffing appropriate for number of patients, Safe staffing levels maintained. Support workers used to maintain staffing numbers, Safe staffing levels maintained. 6.8 17.2 Additional staff used for enhanced care - Support workers, Safe staffing levels maintained, Enhanced care used to monitor seizures in video telemetry patients. Additional beds open in the month, Safe staffing levels maintained. 4.5 8.5 Additional beds open in the month, Safe staffing levels maintained. Additional staff used for enhanced care - Support workers, Safe staffing levels maintained. 3.0 11.8 Additional staff used for enhanced care - Support workers, Safe staffing levels maintained. Additional staff used for enhanced care - Support workers, Safe staffing levels maintained, Enhanced care used in month. Ask of CSW03, often sent RMN due 5.6 10.1 to poor CSW03 fill. Additional staff used for enhanced care - Support workers, Additional staff used for enhanced care - RNs. SPI Ward F4 Spinal SPI Ward F4 Spinal T&O Ward Brooke T&O Ward Brooke T&O Trauma Admissions Unit T&O Trauma Admissions Unit 1376 1319 989 1395 95.9% 141.1% Day 4.1 924 957 859 1143 103.6% 133.0% Night 1010 970 977 870 96.0% 89.0% Day 3.3 644 644 900 Night 690 100.0% 76.7% 842 670 692 553 79.5% 79.9% Day 11.4 620 648 549 Night 594 104.5% 108.2% T&O Ward F1 Major Trauma Unit 2094 2051 1719 2106 98.0% 122.5% Day 4.6 T&O Ward F1 Major Trauma Unit Night 1611 1648 1541 1885 102.3% 122.3% T&O Ward F2 Trauma T&O Ward F2 Trauma 1477 1309 1708 2090 88.6% 122.4% Day 3.2 Night 925 773 1164 1757 83.5% 150.9% T&O Ward F3 Trauma T&O Ward F3 Trauma T&O Ward F4 Elective T&O Ward F4 Elective 1448 1490 1907 1619 102.9% 84.9% Day 3.8 Night 924 936 1468 1462 101.2% 99.6% 1191 1188 911 877 99.8% 96.3% Day 4.0 616 605 854 Night 924 98.2% 108.2% Additional staff used for enhanced care - Support workers, Safe staffing levels maintained, Additional staff required to support acuity and dependency. 4.6 8.7 Additional staff used for enhanced care - Support workers, Safe staffing levels maintained. Safe staffing levels maintained, Staff moved to support other wards, Skill mix swaps undertaken to support safe staffing across the Unit. 3.2 6.5 Additional staff used for enhanced care - Support workers. Staff moved to support other wards, Skill mix swaps undertaken to support safe staffing across the Unit. 9.9 21.2 Staff moved to support other wards, Skill mix swaps undertaken to support safe staffing across the Unit. Additional staff used for enhanced care - Support workers, Skill mix swaps undertaken to support safe staffing across the Unit, Increase in acuity/dependency of patients in the month. 5.0 9.6 Additional staff used for enhanced care - Support workers, Skill mix swaps undertaken to support safe staffing across the Unit, Increase in acuity/dependency of patients in the month. Additional staff used for enhanced care - Support workers, Skill mix swaps undertaken to support safe staffing across the Unit, Staff moved to support other wards, Increase in acuity/dependency of patients in the month. 5.9 9.1 Additional staff used for enhanced care - Support workers, Skill mix swaps undertaken to support safe staffing across the Unit, Staff moved to support other wards, Increase in acuity/dependency of patients in the month. Additional staff used for enhanced care - Support workers, Skill mix swaps undertaken to support safe staffing across the Unit, Staff moved to support other wards, Increase in acuity/dependency of patients in the month. 4.9 8.7 Additional staff used for enhanced care - Support workers, Skill mix swaps undertaken to support safe staffing across the Unit, Staff moved to support other wards, Increase in acuity/dependency of patients in the month. Additional staff used for enhanced care - Support workers, Skill mix swaps undertaken to support safe staffing across the Unit, Staff moved to support 4.0 8.1 other wards. Additional staff used for enhanced care - Support workers, Staff moved to support other wards.
Url: /Media/UHS-website-2019/Docs/About-the-Trust/performance/Nursing-and-midwifery-staffing-report.pdf

Finance and Performance Reports 2021-22 month 4 July 2021

Description: Report to the Trust Board of Directors Title: Agenda item: Sponsor: Author: Date: Purpose Issue to be addressed: Finance Report 2021
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Trust-governance-and-corporate-docs/2021-Trust-document/Finance-and-performance-reports/Finance-and-Performance-Reports-2021-22-Month-4-July-2021.pdf

Finance and Performance Reports 2022-23 Month 2 May 2022

Description: Report to the Trust Board of Directors Title: Agenda item: Sponsor: Author: Date: Purpose Issue to be addressed: Finance Report 2022-23 Month 2 9.3 Ian Howard – Chief Financial Officer Philip Bunting – Interim Deputy Director of Finance 30 June 2022 Assurance Approval or reassurance Ratification Information X The finance report provides a monthly summary of the key financial information for the Trust. Response to the issue: Financial Planning / National Context In June 2022, Trust Board approved a revised planning submission for UHS of: • A break-even financial position, noting a phasing of deficit in M16 improving to surplus in M7-M12. • Achievement of 106% elective recovery activity, above the 104% target • Receipt of an additional £7m national funding • A revised CIP target of £45.4m (4%) • A revised phasing of the financial plan This was part of a Hampshire and Isle of Wight submission that achieved break-even overall. UHS submitted the plan on the basis that the financial risks within the plan were noted and that should the Trust exceed Elective Recovery Programme targets, additional funding would flow to cover the additional costs of delivery, as outlined in the planning guidance. Within the M2 finance report the plan has been adjusted to reflect the improvement to breakeven and change in phasing. The revised planning submission highlighted significant financial risks within the plan and indicated a range of financial projections between break-even and £57m deficit, should risks around CIP delivery, activity risks, Covid-19 risks and further inflationary pressures all materialise. The report aims to track performance against plan and risk-based scenarios. M2 Financial Position UHS reported a deficit of £1.3m in May 2022, which when added to a £3.7m in April 2022 means a reported deficit of £5m YTD. This compares to a revised plan deficit of £2.8m, therefore is £2.2m adverse to plan. Page 1 of 16 However, it should be noted that a number of items relate to M1: • 2 months of £7.1m additional national funding have been included in May, £0.6m of which relates to M1 • Clinical supplies costs of £0.9m were underreported in M1 and have been reported in M2, partially off-set by £0.2m of other adjustments. The true reported position is therefore a £3.8m deficit in M1 and a £1.1m deficit in M2. Underlying Position The month 2 position has been supported by additional non recurrent measures of £2.7m meaning that the restated month 2 deficit is £3.8m, aligned to that of month 1. The overall underlying financial position is therefore a deficit of £7.6m YTD. This is £4.8m adverse to the plan for month 1 and 2 (£2.8m planned deficit). Key drivers The key drivers for the underlying deficit to plan are as follows: • Cost Improvement Plans – due to the considerable operational pressures the development of plans from Q4 21/22 have been delayed. Only £1m has been recognised in month 1 and 2 against a plan of £4.3m generating a £3.3m shortfall. • Further analysis on CIP has been provided to F&IC as part of the finance spotlight. • Covid costs continuing in excess of plan by £1.5m YTD – this mainly relates to staff sickness absence backfill costs which have improved in May following a spike in April. • Operational Pressures / Emergency Demand – ED continues to experience volumes in excess of planned levels driving up expenditure especially on premium rate staffing. Elective Recovery Framework UHS achieved 109% in May. This included: • 107% in elective • 118% in outpatients (including procedures but excluding followups) • Capped 85% in follow-ups, with actual activity at 130% April activity has also now been coded in more depth and illustrates achievement of 103%. This activity level is extremely positive for achievement of the 106% target for the year and is despite continuing operational pressures and ED demand. It should be noted that Covid pressures eased during May, although staff absence rates remained above 19/20 levels. A further £1.1m of income has been included in the financial position. Page 2 of 16 However, this has off-set an increase in clinical supplies costs associated with the additional activity. It should be noted that some uncertainty remains over national calculations of performance, with data for April expected in July. Financial Trajectory A run rate continuing at this level of deficit would generate a £46m underlying deficit across 2022/23, which is towards the worst-case scenario outlined in the revised planning submission of £57m. We would however expect CIP delivery and financial recovery plan projects to improve this position throughout the year to mitigate this risk. This would lead to a reduced cash balance, a reduced ability to invest in capital and revenue improvements, and increased local, regional and national scrutiny. It is therefore not sustainable to continue at this rate of underlying deficit. Response to the financial challenge Due to the scale of financial risk, a recovery plan is being developed to drive an improvement trajectory. Progress has been made in the last month, with TEC approving the creation of a Recovery Board, with the first meeting set up in July, and a programme manager recruitment process initiated. The purpose of the Financial Recovery Programme Board will be to: • Improve financial performance • Improve control of income and expenditure • Oversee the achievement of the financial aspects of the 2022/23 annual plan • Deliver an improvement to underlying financial performance which provides a foundation for financial sustainability in 23/24 and beyond • Prepare the organisation for a transition from financial recovery to business as usual whilst continuing to deliver on the trust’s financial and non-financial objectives An update will be incorporated into the finance report for F&IC in July. Capital • Within the revised planning submission, we took the opportunity to revise the profile of the capital plan to align with expenditure plans. Internal capital expenditure totalled £1.5m in May which was on-plan. • The trust has an internal capital plan of £49m for 2022/23. Many of the major projects have yet to commence and are in the planning phases hence an acceleration in spend is expected in future months. Spend, and any emerging risks and opportunities, will be monitored closely in year via Trust Investment Group. • Significant progress has been made with External CDEL opportunities: o A business case for wards (£10m) has been submitted to NHSE Regional Officer for review as part of Elective Page 3 of 16 Targeted Investment Fund plans. o A meeting has been held with Specialised Commissioning regarding confirmed CDEL of £5.1m for Neonates, noting that this does not include cash funding. A business case is expected to be submitted in July. There is added complexity within the case due to the potential loss of bed capacity, with mitigation options currently being explored. o Bids for additional CT scanners for ED and for the Targeted Lung Programme are in the process of being submitted. o Southampton and Southwest Hampshire have submitted a draft bid to NHSE Region for Community Diagnostic Centre expansion at RSH. Review of Finance Report The finance team have reviewed and refreshed the finance report. Due to competing priorities, the outcomes of this refresh are partially complete, with further changes to the reporting format anticipated in July. Other It should be noted that an announcement on Agenda for Change pay awards is anticipated imminently. Trusts have planned for a 2% increase as per national planning guidance, with a further contingency held nationally. The Trust are actively exploring additional capacity in the Independent Sector and through Insourcing companies, subject to IR35 compliance checks. These cases are being considered on a case-by-case basis linked to growth in waiting lists, capacity constraints, length of time on waiting list (104/78/52 week waits), patient safety risk and financial implications. The additional activity is only available at tariff or in some cases above tariff, meaning it is not covered by a 75% marginal rate. This may cause additional in-year cost pressures. Implications: Risks: (Top 3) of carrying out the change / or not: • Financial implications of availability of funding to cover growth, cost pressures and new activity. • Organisational implications of remaining within statutory duties. • Financial risk relating to the month 2 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) Summary: Conclusion Trust Board is asked to note this report. and/or recommendation Page 4 of 16 2022/23 Finance Report - Month 2 Report to: Board of Directors and Finance & Investment Committee May 2022 Title: Finance Report for Period ending 31/05/2022 Author: Philip Bunting, Interim Deputy Director of Finance Sponsoring Director: Ian Howard, Chief Financial Officer Purpose: Standing Item The Board is asked to note the report Executive Summary: In Month and Year to date Highlights: 1. Trust Board approved a revised plan in June, which is reflected within this report: • A revised break-even position, phased with deficit in M1-6 improving to surplus in M7-12. • Achievement of 106% Elective Recovery performance • Delivery of 4% (£45m) of CIP 2. In month 2, UHS reported a deficit position of £1.3m with a £5m deficit YTD. This is £2.2m behind plan. CIP delivery remains lowin month at £0.5m, off-plan by £1.7m. 3. However, there were a number of transactions in month which were non-recurrent, including additional national funding for inflation relating to month 1. The underlying in month deficit was £3.8m which was similar to April. A run rate continuing at this level would generate a £46m deficit across 2022/23, although that is expected to improve as CIP and Recovery Plan actions are implemented. 4. The main income and activity themes seen in M2were: – Despite operational pressures and ED demand, UHS has delivered 109% of Elective Recovery activity in month 2, above target and plan levels. – Additional income of £1.1m has been included within the position, at 75% marginal rate, off-setting the variable costs of the additional activity. National calculations on performance are anticipated to be three months in arrears. 1 Page 5 of 16 2022/23 Finance Report - Month 2 Finance: I&E Summary A deficit of £1.3m position was reported in May 2022 as planned. There are three main drivers for this position: Covid-related absences have continued to reduce during May but we are still seeing c.100 daily absences. The excess cost related to backfill is estimated at c.£1m per month. ED continues to experience volumes in excess of planned levels driving up expenditure especially on premium rate s ta ffi ng. CIP delivery in M2 was £0.5m, compared to our pl an of £2.1m. CIP identification for 2022/23 is now £9.5m, 48% of the £20m di vi sional target. CIP i denti fi ed for 2022/23 increased by 4.4m over the most recent month. Of the identified £9.5m total, £6.2m is planned as recurrent. Existing cost pressures from 2021/22 also continue to drive the underlying deficit related to energy costs and drugs. NHS Income: Other income Total income Costs Total expenditure EBITDA EBITDA % Clinical Pass-through Drugs & Devices Other Income excl. PSF Top Up Income Pay-Substantive Pay-Bank Pay-Agency Drugs Pass-through Drugs & Devices Clinical supplies Other non pay Current Month Cumulative Plan Actua Actua Plan l Variance Plan l Variance Plan Forecast Variance £m £m £m £m £m £m £m £m £m 69.8 70.0 (0.2) 139.5 139.0 0.5 837.0 837.0 0.0 11.2 11.4 (0.2) 22.4 21.9 0.6 134.6 134.6 0.0 10.6 13.7 (3.2) 21.1 28.0 (6.9) 126.6 126.6 0.0 0.9 0.8 0.1 1.7 1.4 0.3 8.3 8.3 0.0 92.4 95.8 (3.5) 184.8 190.3 (5.5) 1,106.6 1,106.6 0.0 48.7 49.0 0.3 97.2 98.2 1.0 591.6 591.6 0.0 3.3 3.9 0.6 6.8 8.0 1.3 33.2 33.2 0.0 1.2 1.5 0.3 2.5 3.0 0.6 12.0 12.0 0.0 5.2 3.8 (1.4) 10.4 8.7 (1.7) 59.7 59.7 0.0 11.2 11.4 0.2 22.4 21.9 (0.6) 134.6 134.6 0.0 7.3 8.7 1.5 14.6 15.2 0.7 74.6 74.6 0.0 15.8 17.8 2.0 31.8 38.6 6.8 189.6 189.6 0.0 92.7 96.2 3.4 185.7 193.7 8.0 1,095.3 1,095.3 0.0 -0.4 -0.3 (0.0) -0.9 -3.4 2.5 11.2 11.2 0.0 Non operating expenditure/income -0.4%-0.3% (0.1%) -0.5%-1.8% 1.3% -0.9 -1.0 (0.1) -1.9 -1.8 0.1 1.0% -11.1 1.0% -11.1 0.0% 0.0 Surplus / (Deficit) Less Donated income Profit on disposals Add Back Donated depreciation Net Surplus / (Deficit) 2 Page 6 of 16 (1.3) (1.3) 0.0 (2.8) (5.2) 2.4 0.1 0.1 0.0 -0.1 -0.1 (0.0) -0.2 -0.1 (0.1) -1.4 -1.4 0.0 - - 0.0 - - 0.0 - - 0.0 0.1 0.2 0.1 0.2 0.4 0.1 1.3 1.3 0.0 (1.3) (1.3) (0.0) (2.8) (5.0) 2.2 0.0 0.0 0.0 2022/23 Finance Report - Month 2 Monthly Underlying Position The graph shows the underlying position for the Trust from April 2021 to present. 3.0 This differs from the reported financial position as it has been 2.0 adjusted for non recurrent items (one offs) and also had any 1.0 necessary costs or income rephased by month to get a true 0.0 picture of the run rate. (1.0) A decline in the underlying position can be observed from the first half of 2021/22 moving (2.0) i nto the l ater hal f of that year. At this point a change in the (3.0) financial regime and increased efficiency targets, together with (4.0) increased energy costs, led to a £2m per month deficit (5.0) preva i l i ng. A further step change has then (6.0) occurred from April 2022 with reductions in covid funding together with efficiency targets resulting in underlying performance reducing to £3.8m per month in April and May. This is £1m per month favourable to the worse case scenario modelled within the planning projections for the year but significantly worse than the plan posi ti on of c£1.4m per month. Apr-21 May-21 Jun-21 Jul-21 Aug-21 Sep-21 Oct-21 Nov-21 Dec-21 Jan-22 Feb-22 Mar-22 Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 Mar-23 Underlying Financial Position (£'m) Plan Underlying Actuals / Forecast Worst Case Modelling 3 Page 7 of 16 Activity Income 2022/23 Finance Report - Month 2 Clinical Income Elective spells £20 10 £15 8 6 £10 4 £5 2 £0 0 1 2 3 4 5 6 7 8 9 101112 1 2 3 4 5 6 7 8 9 101112 2021/22 2022/23 Plan - Activity Actual - Activity Plan - Income Actual - Income Outpatients Total £12 80 £10 60 £8 £6 40 £4 20 £2 £0 0 1 2 3 4 5 6 7 8 9 101112 1 2 3 4 5 6 7 8 9 101112 2021/22 2022/23 Plan - Activity Plan - Income Actual - Activity Actual - Income Activity Income Activity Income Non elective spells £21 7 £20 6 5 £19 4 £18 3 2 £17 1 £16 0 1 2 3 4 5 6 7 8 9 101112 1 2 3 4 5 6 7 8 9 101112 2021/22 2022/23 Plan - Activity Actual - Activity Plan - Income Actual - Income A&E - Emergency Medicine £3 14 £2 12 10 £2 8 £1 6 4 £1 2 £0 0 1 2 3 4 5 6 7 8 9 101112 1 2 3 4 5 6 7 8 9 101112 2021/22 2022/23 Plan - Activity Plan - Income Actual - Activity Actual - Income Activity Income 5 Page 8 of 16 Activity Income 2022/23 Finance Report - Month 2 Clinical Income Adult critical care £5 3 £4 3 3 £3 3 £2 3 3 £1 3 £0 2 1 2 3 4 5 6 7 8 9 101112 1 2 3 4 5 6 7 8 9 101112 2021/22 2022/23 Plan - Activity Actual - Activity Plan - Income Actual - Income Tariff excluded drugs 14 12 10 8 6 4 2 0 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 2021/22 2022/23 Plan - Activity Plan - Income Actual - Activity Actual - Income Activity Income Income Neonatal & paediatric critical care £3 3 £3 2 £2 2 £2 £1 1 £1 1 £0 0 1 2 3 4 5 6 7 8 9 101112 1 2 3 4 5 6 7 8 9 101112 2021/22 2022/23 Plan - Activity Actual - Activity Plan - Income Actual - Income Tariff excluded devices 4 3 2 1 0 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 2021/22 2022/23 Plan - Activity Plan - Income Actual - Activity Actual - Income Income 6 Page 9 of 16 2022/23 Finance Report - Month 2 Elective Recovery Fund 22/23 The graph shows the ERF performance for 22/23 as well as a trend against plan for 21/22. In 22/23 the Trust has a plan to achieve 106% of 19/20 activity for elective inpatients, outpatient first attendances and outpatient procedures, above the 104% national target. The table highlights overall performance against the 19/20 pre-Covid baseline, highlighting M2 performance of 109%. An ERF payment of £1.1m has been provisionally included within Trust income, off-setting additional variable costs of delivery. However, there remains some uncertainty over the national calculation, with figures expected to be released three months in arrears. Income £m £16.0 £14.0 £12.0 £10.0 £8.0 £6.0 £4.0 £2.0 £0.0 ERF 104% performance 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 2021/22 Actual - Chemotherapy Actual - Follow Up Attendances Plan - Chemotherapy Plan - Follow Up Attendances Actual - Elective Spells Actual - Outpatient Procedures Plan - Elective Spells Plan - Outpatient Procedures 5 6 7 8 9 10 11 12 2022/23 Actual - First Attendances Actual - Radiotherapy Fractions Plan - First Attendances Plan - Radiotherapy Fractions Elective Recovery Framework Performance Elective performance Outpatient first and procedures performance Chemotherapy performance Radiotherapy performance Overall ERF performance Outpatient follow up performance M1 M2 97% 107% 110% 118% 147% 108% 119% 104% 103% 109% 127% 130% 9 Page 10 of 16 2022/23 Finance Report - Month 2 Substantive Pay Costs Total pay expenditure in April was £55.5m, up slightly on April by £1.9m. Most of the 65.0 increase relates to substantive staffwith the payment of the two April 60.0 Bank Holiday enhancements in May payroll. Covid staff costs are estimated at £2.6m 55.0 in month, remaining flat from M1. 50.0 Increases in pay costs over the last 24 months are under 45.0 review as part of challenging where costs can be targeted for reduction in a post 40.0 pandemic environment. 35.0 Total Pay Covid Agency Bank Substantive Plan Total 10 Page 11 of 16 2022/23 Finance Report - Month 2 Temporary Staff Costs Expenditure on bank staff has decreased slightly month on month by £0.2m. The decreases were evenly spread across all staff groups although currently still significantly above plan. The primary driver for this is Covid sickness backfill. Agency spend decreased slightly from April to May by £0.1m. However, within this there were larger movements in staff groups as illustrated in the graph. Medic agency spend increased by £0.3m in May but both nursing (£0.1m) and Admin and Estates (£0.2m) spend fell. Although volatile month to month spend remains at c£1.4m per month and has done since July 2021. Spend £ Spend £ 6,000,000 5,000,000 4,000,000 3,000,000 2,000,000 1,000,000 0 1,800,000 1,600,000 1,400,000 1,200,000 1,000,000 800,000 600,000 400,000 200,000 - Bank Total Spend Agency Total Spend Page1112 of 16 Pl a n Nurs i ng Me di cs Sci e nt & Te ch Admi n & Es ta te s Tota l Ba nk Nursing Medics Scient & Tech Admin & Estates Total Agency 2022/23 Finance Report - Month 2 Cash The cash balance decreased in May to £140.9m and is analysed in the movements on the Statement of Financial Position. A gradual reduction in cash is expected over the next two years as capital expenditure plans exceed depreciation. The deficit position is also reducing the cash balance. 180.0 160.0 140.0 120.0 100.0 80.0 60.0 40.0 20.0 - The latest position on our Better Payment Practice Code road map to compliance project is also outlined. The percentage for May is a slight decrease against April 2022. This is due to staff sickness and leave. However, the total count percentage is greater than the target of 95%. As the new financial year progresses it is expected that the 95% will remain stable and improve further. Sep-20 Oct-20 Nov-20 De c- 20 Jan-21 Feb-21 Ma r- 21 Apr-21 May-21 Jun-21 Jul-21 Aug-21 Sep-21 Oct-21 Nov-21 De c- 21 Jan-22 Feb-22 Ma r- 22 Apr-22 May-22 Cash Position Actual Minimum Cash Holding 12 Page 13 of 16 2022/23 Finance Report - Month 2 Capital Expenditure (Fav Variance) / Adv Variance Expenditure on capital schemes was £1.5m in month 2 and £2.9m year to date. The main areas of expenditure were design fees and initial costs on the wards and theatres schemes, IT and equipment leases. It should be noted that we took the opportunity to rephase the plan as part of our revised submission, including a more realistic phasing of expenditure. This including matching the revised plan to actual expenditure to date. The level of monthly spend is expected to rise significantly from the current low levels as major schemes begin, so the Trust are forecasting to spend our full £49.0m capital allocation. Additional funding awards for wards and the expansion of neonates are anticipated, but not finalised, and shown in the forecast. Month Year to Date Full Year Forecast Scheme Org Internally Funded Schemes Strategic Maintenance UHS Refurbish of neuro theatres 2 & 3 UEL General Refurbishment Fund UHS Refurbishment of Theatres/F level Fit Out UEL Oncology Centre Ward Expansion Levels D&E UEL Fit out of C Level VE (MRI) Capacity UEL Donated Estates Schemes UHS Other Estates Schemes UHS Information Technology (incl Pathology Digitiation) UHS IMRI UHS Medical Equipment panel (MEP) UHS Other Equipment UHS Other UHS Slippage UHS Donated Income UHS Total Trust Funded Capital excl Finance Leases Leases Medical Equipment Panel (MEP) - Leases UHS Equipment leases UHS IISS UHS Fit out of C Level VE (MRI) Capacity UHS Adanac Park Car Park UHS Total Trust Funded Capital Expenditure Disposals UHS Total Including Technical Adjustments Externally Funded Schemes Maternity Care System (Wave 3 STP) UHS Digital Outpatients (Wave 3 STP) UHS Oncology Centre Ward Expansion Levels D&E UEL Neonatal Expansion UHS Total CDEL Expenditure Page 14 of1136 Plan Actual Var Plan Actual Var Plan Actual Var £000's £000's £000's £000's £000's £000's £000's £000's £000's 397 173 224 794 794 0 0 0 0 0 0 0 0 0 0 109 130 (21) 218 218 137 216 (79) 274 274 0 0 0 0 0 67 113 (46) 134 134 5 6 (1) 10 10 286 387 (101) 571 539 52 37 15 104 104 2 2 0 4 4 85 7 78 169 169 266 321 (55) 538 538 0 0 0 0 0 (83) (113) 30 (166) (134) 1,323 1,279 44 2,650 2,650 0 0 0 0 0 0 85 170 (85) 170 170 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1,408 1,449 (41) 2,820 2,820 0 0 0 0 0 1,408 1,449 (41) 2,820 2,820 0 0 0 0 0 0 18 18 0 37 37 0 0 0 0 0 0 0 0 0 0 1,426 1,467 (41) 2,857 2,857 0 8,255 8,255 0 0 730 730 0 0 1,097 1,097 0 0 5,000 5,000 0 0 8,000 8,000 0 0 6,592 6,592 0 0 5,362 5,362 0 0 2,681 2,681 0 32 5,448 5,448 0 0 1,300 1,300 0 0 2,500 2,500 0 0 1,550 1,550 0 0 691 691 0 0 (6,380) (6,380) 0 (32) (6,760) (6,760) 0 0 36,066 36,066 0 0 700 700 0 0 500 500 0 0 3,115 3,115 0 0 5,619 5,619 0 0 3,000 3,000 0 0 49,000 49,000 0 0 0 0 0 0 49,000 49,000 0 0 0 89 89 0 0 592 592 0 0 0 10,000 (10,000) 0 0 5,130 (5,130) 0 49,681 64,811 (15,130) 2022/23 Finance Report - Month 2 Statement of Fi nanci al Positi on The May statement of financial position illustrates net assets of £467.2m, with the main movements in the position explained below. Receivables and payables both moved by significant amounts as a result of an offsetting technical adjustment involving the coding of NHS England receipts. Cash reduced by £12.1m from M1 to M2 partially reflecting the pressure on the I&E position and some catch up on payment of payables. Statement of Fi nanci al Positi on Fixed Assets I nventori es Recei va bl es Cash Pa ya bl es Current Loan Current PFI and Leases Net Assets Non Current Liabilities Non Current Loan Non Current PFI and Leases Total Assets Employed Public Dividend Capital Retained Earnings Revaluation Reserve Other Reserves Total Taxpayers' Equity 14 Page 15 of 16 2021/22 YE Actuals £m 471.9 17.0 53.1 148.1 (204.2) (1.7) (9.1) 475.0 (23.0) (6.8) (33.6) 411.6 261.9 115.6 34.1 411.6 (Fav Variance) / Adv Variance M1 Act £m 464.7 17.4 100.8 153.0 (255.4) (2.5) (9.1) 468.8 (21.3) (6.8) (33.0) 407.7 261.9 105.3 40.5 2022/23 M2 Act £m 470.6 17.4 46.8 140.9 (197.4) (2.5) (8.5) 467.2 (21.2) (6.8) (32.8) 406.4 261.9 104.0 40.5 MoM Movement £m 6.0 0.1 (54.1) (12.1) 58.0 0.0 0.6 (1.6) 0.1 0.0 0.2 (1.3) 0.0 (1.3) 0.0 407.7 406.4 (1.3) 2022/23 Finance Report - Month 2 Efficiency and Cost Improvement Programme 22/23 – M2 Cost Improvement Programme (CIP) Delivery in Month 2 • This month, the Trust increased the efficiency improvement required in 2022/23 from £33.0m to £45.4m, reflecting a national request for NHS systems to re-submit their annual operating plans, and to take further actions to balance their income and expenditure within the year. • The plan is to be delivered by: • £20m CIP through Divisional and Directorate budgets • £25.4m efficiency from central schemes / budgets • CIP delivery YTD at M2 was £992k, compared to our plan of £4.3m. • CIP identification for 2022/23 is now £9.5m, 48% of the £20m di vi sional target. CIP i denti fi ed for 2022/23 i ncreased by 4.4m over the most recent month. Of the identified £9.5m total, £6.2m is planned as recurrent. • Targets for identification have been set - 75% (£15m) by the end of Q1 and 100% identification by the end of Q2. • Central schemes are not anticipated to deliver value within Q1, and much of the (increased) savings target of £25.4m is not yet supported by robust schemes. There are a number of areas of potential opportunity which are being investigated further to support delivery however: • Theatre supply chain management • Additional income by exceeding 104% of the 19/20 activity l evel • Reductions in agency spend, costs related to Covid-19, and additional business cases £k £k In-month CIP delivery 22/23 M1-2 2500 2000 1500 1000 500 0 19/20 CIP Delivery 22/23 CIP Delivery 22/23 CIP Plan 1 2 690 1900 458 534 2134 2134 Month Cumulative delivery 22/23 M1-2 5000 4000 3000 2000 1000 0 19/20 CIP Delivery 22/23 CIP Delivery 22/23 CIP Plan 1 2 690 2587 458 992 2134 4268 Month 19/20 CIP Delivery 22/23 CIP Delivery 22/23 CIP Plan 15 Page 16 of 16 Report to the Trust Board of Directors Title: Agenda item: Sponsor: Author Date: Purpose Integrated Performance Report 2022/23 Month 2 9.2 David French, Chief Executive Jason Teoh, Director of Data and Analytics 30 June 2022 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 Integrated Performance Report reflects the current operating environment and is aligned with our strategy. Implications: This report covers a broad range of trust services and activities. 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 26 Report to Trust Board in June 2022 Integrated KPI Board Report Covering up to May 2022 Sponsor – David French, Chief Executive Officer Reviewed – Jason Teoh, Director of Data and Analytics Page 2 of 26 Report to Trust Board in June 2022 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 26 Report to Trust Board in June 2022 Introduction The Integrated Performance 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. Our indicators and this report structure will continue to be regularly reviewed, and feedback would be welcome. This month there have been no material changes in the format of the report. Some minor changes have been made to the report this month: • Workforce Numbers (WR3-L) graph has been split out the 2021/22 and 2022/23 workforce plans for clarity. • Year to Date (YTD) figures, where available, have been added to the report. • Targets have been agreed for a number of the metrics. Where available these have now been added to the report. Page 4 of 26 Report to Trust Board in June 2022 Summary This month the ‘Spotlight’ section features a Patient Experience section reviewing our patients’ feedback on involvement in decisions, and the experience of patients with disability. • The Trust conducts a number of Friends and Family Test (FFT) surveys each year to provide an insight to patient experience at UHS. • Although there is some variation between divisions, and between months, the results indicate that patients feel involved in their care, with 87% of adults and 92% of paediatric patients reporting this. • On average, 90% of patients who identify as having a disability reported back that they feel their needs were met. • Overall, we are pleased with the results of the survey as it demonstrates strongly that we continue to ensure that we meet the specific needs of patients in our care. Areas of note in the appendix include: 1. May 2022 saw a reduction in the number of healthcare acquired (23) and probable hospital associated (12) COVID-19infections as the rates of COVID-19infection in the community reduced. 2. There has been an increase in pressure ulcers this month, with category 2 ulcers increasing to 0.46 per 1,000 bed days, and category 3 ulcers increasing to 0.67 per 1,000 bed days (compared to target of 0.3 per 1000 bed days). The primary reasons for category 2 ulcers have been around the lack of correct preventative methods (such as correct mattresses or pillows). In category 3, the primary reasons were staffing pressures meaning that two hourly turning targets were not consistently achieved, alongside a lack of knowledge amongst workforce due to reduced training and overall staff pressures. The patient safety teams are working with the divisions to address these. 3. Ongoing high volumes of attendances to Emergency Department (ED) continue to apply downward pressure to the ED four-hour standard, which was reported at 64.7%. However, UHS remains in the upper quartile of teaching hospitals for Emergency Department performance, demonstrating that this remains a wider national problem, rather than being localised to UHS. 4. Higher GP referrals means the number of patients on the waiting list continues to grow to just over 49,000 patients reported at the end of May 2022. 5. High demand for diagnostic procedures, combined with the impact of Easter, bank holidays, and school holiday periods through April and May 2022, have caused the diagnostic waiting list to increase to around 11,100 patients. However, the proportion of breaches have remained steady as UHS has increased diagnostic activity. 6. Our cancer standards remain under pressure due to high referral volumes, with pressures seen within the skin, head & neck, and urology tumour sites. On 62D we continue our upper quartile performance when compared against teaching hospitals. However, we are mid-range for 31 day Page 5 of 26 Report to Trust Board in June 2022 performance, and in May 2022 have also seen a drop to third quartile in 31 day subsequent treatment linked to the urology and skin modalities. We are working with the Wessex Cancer Alliance to review potential improvements to the urology pathway, and in skin are looking to ensure that we have the right clinic capacity in line with the recent referral volumes. Ambulance response time performance The following is the latest Category 1 to 4 information published by South Coast Ambulance Service (SCAS) published within its May 2022 board papers, relating to the Southampton, Hampshire, Isle of Wight, and Portsmouth area. The SCAS Integrated Performance Reviewto their Board states that “increased task time, both on scene and at hospital alongside high levels of sickness impacted on performance”. Southampton, Hampshire, Isle of Wight, and Portsmouth SCAS response time by category Performance measure April 22 Actual April 22 Plan Category 1 Mean 00:09:21 00:07:00 Category 1 90th percentile 00:17:04 00:15:00 Category 2 Mean 00:38:25 00:18:00 Category 2 90th percentile 01:23:53 00:40:00 Category 3 90th percentile 04:37:16 02:00:00 Category 4 90th percentile 05:29:57 03:00:00 UHS continues to ensure that it does not significantly contribute to ambulance handover delays. In the week commencing 13 June 2022, our average handover time was 16 minutes across 657 emergency handovers, and 16 minutes across 32 urgent handovers, just missing the 15-minute hand over target. Page 6 of 26 Report to Trust Board in June 2022 Spotlight Spotlight: Patient experience This month the ‘Spotlight’ section reviews patients’ feedback on involvement in decisions, and the experience of patients with disability. Data is sourced through our Friends and Family Test (FFT) surveys from the following questions: A. Were you involved in decisions about your care and treatment? B. Do you regard yourself as having a disability, impairment, or other condition that requires extra support or reasonable adjustments? o If yes, did the hospital staff do everything they could to provide this support or adjustments? Question A is included on both adults, and children and young people, surveys, while Question B is included on adult surveys only due to many parents, guardians, and carers providing this support for their child. In preparation for the implementation of the updated FFT guidance and launch of new Trust survey system early 2020, the Patient Experience team conducted engagement sessions with clinical teams and patients to undertake a review of the FFT survey forms. Following these sessions several questions from the National CQC surveys were added to collect continuous data on specific areas including the two questions above. Survey forms were launched in February 2020 and following a pause of FFT surveys due to COVID-19, the surveys were relaunched early 2021. This report reviews the data from April 2021 until March 2022. Were you involved in decisions about your care and treatment? • For the year (Apr 21 – March 22), the average number of patients reporting they felt involved is 87%, with children and young people at 92%. • The Trust average response rate for FFT surveys is 8%, with over 12,000 patients responding to this question in 2021-2022. • Quarter one saw the highest response rate, while December 2021 received the highest scores at 89%. • Over 3,000 children and young people responded to this question, and December and February saw our highest engagement with 96% involvement. Page 7 of 26 Report to Trust Board in June 2022 Spotlight Breakdown by division The Patient Experience team produce an experience of care report which is shared with divisions, and the team also attend divisional governance meetings to provide and discuss results. In additiona, all relevant divisional staff have access to the survey system so that they can monitor and review their own results, and some produce their own governance FFT reports where required. The Patient Experience team also receives notifications of all negative comments, so these can be followed up with senior leads where required, or where wider trends can be identified. The number of patients reporting they felt involved has fluctuated throughout the year but has generally remained above 80%. In October 2021 and January 2022, Division A saw their scores drop to 78% and 79% respectively. Division C is the only area that received scores above 90% consistently. Divisions C and D have seen the highest number of responses of Friends and Family Test surveys. Division B has the lowest response rate, but with a significant increase in responses at the end of quarter four. Metric Apr 21 May 21 Jun 21 Jul 21 Aug 21 Sep 21 Oct 21 Nov 21 Dec 21 Jan 22 Feb 22 Mar 22 Felt involved (Patient Experience) Div A - Score 83 82 85 86 83 80 78 86 80 79 82 90 Response rate 7.3 7.9 11 22.8 7.2 4.7 5.6 6.3 4.7 3 3.2 10.6 Felt involved (Patient Experience) Div B - Score 86 87 92 89 86 91 86 88 87 87 86 89 Response rate 1.3 3.5 2.7 2.6 1.9 1.3 1.6 2.1 1.7 1.6 1.4 5.1 Felt involved (Patient Experience) Div C - Score 92 92 91 93 93 93 92 93 95 93 95 91 Response rate 27.1 45.2 44.4 121.9 40.6 26.7 23.4 23.2 20.8 26.5 15.6 42 Felt involved (Patient Experience) Div D - Score 83 86 83 81 84 82 85 81 85 85 84 83 Response rate 43.2 33.5 35 66.9 27.7 24.7 28.3 19.9 17.1 13 14.9 36.2 Page 8 of 26 Report to Trust Board in June 2022 Spotlight Experience of patients with a disability There are two questions included on the surveys around disability: 1. Do you regard yourself as having a disability, impairment, or other condition that requires extra support or reasonable adjustments? 2. If yes, did the hospital staff do everything they could to provide this support or adjustment? This report will focus on the supplementary question, question 2. These were introduced to review the support patients with disabilities receive whilst in our care. UHS launched the sunflower scheme trust wide in June 2020, which provide lanyards to identify staff, patients and carers who need additional support and prompt staff and colleagues to ask: “how can I help you today?”. % patients responding 100 90 80 70 60 50 40 30 20 10 0 Apr 21 Experience of patients with a disability % patients reporting needs met or that they had a disability or support need May 21 Jun 21 Jul 21 Aug 21 Do you regard yourself as having a disability? Sep 21 Oct 21 Nov 21 Dec 21 Jan 22 Adjustments made for patient with disability (Patient Experience) - Score Feb 22 Mar 22 Page 9 of 26 Report to Trust Board in June 2022 Spotlight Divisional graphs The purple line is the percentage of patients reporting they had their support needs met and the blue line shows the percentage of patients who reported they had a disability or support need. Division A 100 Division B 100 80 80 60 60 40 20 0 Apr 21 May 21 Jun 21 Jul 21 Aug 21 Sep 21 Oct 21 Nov 21 Dec 21 Jan 22 Feb 22 Mar 22 40 20 0 Apr 21 May 21 Jun 21 Jul 21 Aug 21 Sep 21 Oct 21 Nov 21 Dec 21 Jan 22 Feb 22 Mar 22 Division C 100 Division D 100 80 80 60 60 40 40 20 20 0 Apr 21 May 21 Jun 21 Jul 21 Aug 21 Sep 21 Oct 21 Nov 21 Dec 21 Jan 22 Feb 22 Mar 22 0 Apr 21 May 21 Jun 21 Jul 21 Aug 21 Sep 21 Oct 21 Nov 21 Dec 21 Jan 22 Feb 22 Mar 22 A total of 18,557 FFT survey responses were received to this question in 2021 – 2022, with just under a quarter of patients who completed the survey reported as having a disability (hidden or physical) or additional need. The first quarter saw the highest number of responses. The number of patients who identified as having a disability and reporting their needs were met was an average of 90% for the year. Quarter three saw this figure reduce to 82% and 87% in November and December. Page 10 of 26 Report to Trust Board in June 2022 NHS Constitution 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 monitored 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 26 Report to Trust Board in May 2022 NHS Constitution Monthly Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May target % Patients on an open 18 week pathway 75% (within 18 weeks ) UT28-N UHSFT 8 69.5% 9 8 7 9 9 10 10 10 9 8 6 5 68.1% 5 ≥92% Teaching hospital average (& rank of 20) South East average (& rank of 17) 8 7 8 8 8 7 9 9 8 8 8 8 7 7 55% % Patients following a GP referral for 100% suspected cancer seen by a specialist within 2 weeks (Most recently externally reported 12 13 16 90.1% 15 16 16 17 17 14 16 12 13 13 13 CN1-N data, unless stated otherwise below) 9 UHSFT Teaching hospital average (& rank of 20) South East average (& rank of 17) 65% 5 13 11 13 14 14 14 9 10 7 5 86.9% 4 4 ≥93% Cancer waiting times 62 day standard - 100% 89.9% Urgent referral to first definitive treatment (Most recently externally reported data, 5 3 11 13 15 16 13 12 15 13 13 11 12 7 UT34-N unless stated otherwise below) 74.4% UHSFT 1 Teaching hospital average (& rank of 19) South East average (& rank of 17) 40% 1 4 6 7 7 2 4 5 3 4 4 2 3 Patients spending less than 4hrs in ED - 95% (Type 1) 8 UT25-N UHSFT Teaching hospital average (& rank of 16) 4 South East average (& rank of 16) 45% 84.0% 6 8 4 4 4 4 5 4 4 4 4 2 6 4 4 3 5 3 8 10 6 4 4 4 64.7% 4 8 4 4 ≥85% ≥95% 50% % of Patients waiting over 6 weeks for diagnostics UT33-N UHSFT 12 9 10 10 10 9 7 6 7 7 7 7 6 7 23.3% ≤1% Teaching Hospital average (& rank of 20) 21.5% South East Average (& rank of 18) 17 0% 16 16 17 16 15 14 12 13 14 14 13 12 13 YTD 67.3% 86.9% 74.4% 66.0% 23.7% 1 Page 12 of 26 Report to Trust Board in May 2022 Outstanding Patient Outcomes,Safety and Experience Appendix Outcomes UT1-N HSMR - UHS HSMR - SGH UT2 HSMR - Crude Mortality Rate Monthly Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May target YTD 83 82.8 78.3 81.7 ≤100 77.9 73 3.1% 2.9% 2.7% 14days 42 36 - after admission (validated) 05 0 0 0 3 0 7 6 11 22 20 14 23 Probable hospital-associated COVID 80 UT8 infection: COVID-positive sample taken > 7 days and = 92.0% 529 325 70.3% - Q1 22-23 Quarterly target - - Apr May 10.5% Monthly target 19% by 2026 WR10 14% % of Band 7+ Staff who have declared a disability or long term health condition 13.4% 13.5% - WR11 WR12 12% 8.0 Staff recommending UHS as a place to work: White British staff compared with all other ethnic groups combined -White British -All other ethnic groups combined 6.0 Staff recommending UHS as a place to 8.0 work: Non disabled /prefer not to answer compared with Disabled -Non disabled /prefer not to answer -Disabled Q4 1921 Q1 21-22 7.36 7.18 7.25 7.03 Q2 21-22 7.36 7.14 7.30 6.90 Q3 21-22 7.44 7.12 7.02 7.18 Q4 21-22 7.30 7.02 Q1 22-23 Quarterly target - 7.09 6.90 - 6.0 Staff recommending UHS as a place to 8.0 work: Sexuality = Heterosexual WR13 compared with all other groups combined 7.25 6.90 7.00 7.20 7.19 6.87 7.08 6.81 - -Sexuality = Heterosexual -All other groups combined 6.0 WR11, WR12,WR13: Average recommendation score of 10 = Highly recommend to 0 = Strongly not recommended, results from National Quarterly Pulse Survey Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Monthly target 54.0% FN6 Percentage of staff living locally (inside the Southampton City boundaries) 52.5% 53.9% - 51.0% Percentage of staff residing in deprived50.0% FN7 areas (lowest 30% - national Index of Multiple Deprivation) 0.0% 23.2% 24.3% - YTD YTD target YTD YTD target YTD YTD target Page 18 of 26 Appendix 7 Report to Trust Board in May 2022 Integrated Networks and Collaboration Appendix Local Integration Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Monthly target Number of inpatients that were 200 NT1 medically optimised for discharge (monthly average) 0 Emergency Department NT2 activity - type 1 This year vs. last year Percentage of virtual appointments as a NT3 proportion of all outpatient consultations This year vs. last year 114 12,500 11,435 7,548 2,500 70% 56.1% 34.5% 0% 195 ≤80 11,981 10,985 - 35.2% 23.3% ≥25% YTD 22,745 25.3% YTD target - - ≥25% 8 Page 19 of 26 Report to Trust Board in May 2022 Foundations for the Future Appendix Digital Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May My Medical Record - UHS patient 110,000 FN1 accounts (cumulative number of accounts in place at the end of each month) 0 71,921 117,686 Monthly target - My Medical Record - UHS patient 25,000 FN2 logins (number of logins made within each month) 15,000 Patients choosing digital correspondence 15% - Total choosing paperless in the month FN3 - Total offered but not yet choosing paperless in the month - % of total My Medical Record service users who have chosen paperless 0% (cumulative) 19,927 1886 1941 2.0% 24,286 - 10,000 958 7.4% 5,000 - 4,309 0 Reduction in transcription through FN4 implementation of voice recognition In development - software YTD 47,301 YTD target 9 Page 20 of 26 Report notes - Nursing and midwifery staffing hours - May 2022 Our staffing levels are continuously monitored through our staffing hub and we will risk assess and manage our available staff to ensure that safe staffing levels are always maintained The total hours planned is our planned staffing levels to deliver care across all of our areas but does not represent a baseline safe staffing level. We plan for an average of one registered nurse to every five or seven patients in most of our areas but this can change as we regularly review the care requirements of our patients and adjust our staffing accordingly. Staffing on intensive care and high dependency units is always adjusted depending on the number of patients being cared for and the level of support they require. Therefore the numbers will fluctuate considerably across the month when compared against our planned numbers. Enhanced Care (also known as Specialling) Occurs when patients in an area require more focused care than we would normally expect. In these cases extra, unplanned staff are assigned to support a ward. If enhanced care is required the ward may show as being over filled. If a ward has an unplanned increase or decrease in bed availability the ward may show as being under or over filled, even though it remains safely and appropriately staffed. CHPPD (Care Hours Per Patient Day) This is a measure which shows on average how many hours of care time each patient receives on a ward /department during a 24 hour period from registered nurses and support staff - this will vary across wards and departments based on the specialty, interventions, acuity and dependency levels of the patients being cared for. In acute assessment units, where patients are admitted , assessed and moved to wards or theatre very swiftly, the CHPPD figures are not appropriate to compare. The maternity workforce consists of teams of midwives who work both within the hospital and in the community offering an integrated service and are able to respond to women wherever they choose to give birth. This means that our ward staffing and hospital birth environments have a core group of staff but the numbers of actual midwives caring for women increases responsively during a 24 hour period depending on the number of women requiring care. For the first time we have i
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Finance and Performance Reports 2020-21 Month 4 July 2020

Description: 2020/21 Finance Report - Month 4 Report to: Board of Directors and Finance & Investment Committee August 2020 Title: Finance Report for Period ending 31/07/2020 Author: Philip Bunting, Acting Assistant Director of Finance Sponsoring David French, Chief Director: Financial Officer Purpose: Standing Item The Board is asked to note the report Executive Summary: In Month and Year to date Highlights: 1. In July 2020, the Trust reported a breakeven position. A ‘top-up’ payment of £7.3m (up £2.2m from June) was however required to supplement the block contract in order to fully offset trust expenditure. The financial regime in place for April 2020 – September 2020, following extension for 2 months, provides trusts with a minimum breakeven guarantee. 2. In month £3.6m (£1.8m pay and £1.8m non pay) was incurred on additional expenditure related to Covid19. This was up £0.3m from June, however included backdated IT costs of £0.5m, hence was £0.2m down after adjusting for this. Covid costs are expected to reduce further in August as shielding staff return. 3. The main themes seen in M4 were : – Clinical income was funded via block payment rather than activity based. If payment had continued on a payment by results basis the trust would have received £3.5m less income. This gap has improved by £8.5m compared to June. – Elective income was indicatively 73% of planned levels (56% in June) and Non Elective income was 93% of planned levels (84% in June) . The Trust is not financially exposed to the risk of underperformance due to the current block contract. – Activity within independent sector hospitals increased 16% from June (700 patients up from 600 in June). Currently the cost of independent sector hospital provision is met centrally. – Pay remained broadly static, reducing by £0.1m from June. The YTD overspend correlates with the additional level of expenditure being incurred due to Covid. – Pass through drugs and devices expenditure increased by £2.6m from June with noticeable increases in Neurology homecare drugs. CF drugs continue to be a pressure above the block. 1 Page 1 of 15 2020/21 Finance Report - Month 4 Finance: I&E Summary A breakeven financial position prevailed for month 4 following ‘top-up’ income of £7.3m in addition to the safety net provided by block contract payment. The topup value increased by £2.2m from June driven by increased drugs spend. Both Other Income and Other non pay were distorted in month by £4m matched income and expenditure relating to a Covid research grant. Adjusting for this Other Income continues to fall behind planned levels by c£2.5m per month. This is due to private patient income, education and training income and other SLA income all reporting adverse variances due to Covid-19. Pay costs were marginally down from June (£0.1m). They remain adverse to plan due to £8.1m of Covid expenditure YTD. Pass through drugs and devices costs increased significantly (up £2.6m) as Neurology prescribing spiked in addition to continued numbers of patients shifting to homecare. Clinical supplies costs , drugs and other non pay costs were flat collectively after adjusting for the £4m grant expenditure. They were all adverse to plan in month however due to continued Covid related costs such as PPE. Also £0.5m of Covid related backdated IT costs were incurred. Current Month Year to Date M1 - 4 Plan £m NHS Income: Clinical 54.1 Pass-through Drugs & Devices (Blocked) 9.9 Other income Other Income excl. PSF 10.2 Top Up Income - Total income 74.2 Costs Pay-Substantive 41.0 Pay-Bank 1.9 Pay-Agency 1.1 Drugs 1.5 Pass-through Drugs & Devices 9.9 Clinical supplies 4.0 Other non pay 11.6 Total expenditure 71.0 EBITDA 3.2 EBITDA % 4.3% Depreciation 2.2 Non Operating Income/Expenditure 0.9 Surplus / (Deficit) 0.1 Actual Variance Plan £m £m £m 53.8 0.4 216.6 9.9 0.0 39.7 11.5 (1.4) 40.7 7.3 (7.3) - 82.5 (8.3) 297.0 42.2 1.2 164.1 2.6 0.7 7.8 0.9 (0.2) 4.6 1.8 0.3 5.7 12.1 2.2 39.7 6.5 2.6 16.2 13.5 1.9 46.1 79.7 8.7 284.1 2.8 0.4 12.9 3.4% 0.9% 4.3% 1.5 (0.6) 8.7 1.3 0.3 3.8 0.0 0.1 0.4 Emergency Actual Variance Budget £m £m £m 214.2 2.4 216.6 39.7 0.0 39.7 35.7 5.0 40.7 16.2 (16.2) 0.0 305.8 (8.9) 297.0 169.0 4.9 164.1 10.4 2.7 7.8 3.1 (1.5) 4.6 6.2 0.5 5.7 41.4 1.8 39.7 19.9 3.7 16.2 44.1 (2.0) 46.1 294.1 10.0 284.1 11.7 1.1 12.9 3.8% 0.5% 4.3% 8.3 (0.4) 8.7 3.4 (0.3) 3.8 0.0 0.4 0.4 2 Page 2 of 15 2020/21 Finance Report - Month 4 Underlying Run Rate Position These graphs show the actual 5.00 underlying position for the trust throughout 2019/20 and for April to July 2020/21. - The following have been -5.00 removed from 2020/21 position: • The block contract uplift of £3.5m in month (£60.5m YTD) which represents the value of income over and above that which would have prevailed under PbR. • Covid-19 related expenditure of £3.6m in month (£13.8m YTD). • ‘Top-up’ funding of £7.3m in month (£16.3m YTD) which bridges financial performance to breakeven. -10.00 -15.00 -20.00 -25.00 10.00 This illustrates that without the funding safety net of the current financial regime a deficit in month of £7.2m (£63m YTD) would have prevailed. -10.00 -20.00 Looking at expenditure, the Trust required £7.3m top-up, however this covered £3.7m Covid expenditure, £2.6m passthrough drugs overperformance and circa £2.5m non-NHS income losses. -30.00 -40.00 -50.00 -60.00 -70.00 Monthly Underlying Position Start Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20 Oct-20 Nov-20 Dec-20 Jan-21 Feb-21 Mar-21 2020/21 Emergency Budget 2019/20 Underlying Actuals 2020/21 Underlying Actuals Cumulative Underlying Position Start Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20 Oct-20 Nov-20 Dec-20 Jan-21 Feb-21 Mar-21 Page 33 of 15 2020/21 Emergency Budget 2019/20 Underlying Actuals 2020/21 Underlying Actuals 2020/21 Finance Report - Month 4 Clinical Income (Fav Variance) / Adv Variance Clinical income for the month of July was £0.4m adverse to plan and including Non NHS income was £0.6m adverse to plan. Much of this income is now fixed with confirmed block contract funding in place for April to September. The adverse variance is driven by channel islands activity as the trust is still on a PbR contract which is underperforming due to activity limitations. July has seen improvements from June with PbR equivalent income 94% of block contracted values (albeit this includes high cost drugs). Adjusting for this 87% of plan was achieved. POD GROUP NHS Clinical Income Elective Inpatients Non-Elective Inpatients Outpatients Other Activity CQUIN Blocks & Financial Adjustments Other Exclusions Pass-through Exclusions Subtotal NHS Clinical Income Covid block adjustments Total NHS Clinical Income Non NHS Clinical Income Private Patients CRU Overseas Chargeable Patients Total Non NHS Clinical Income In Month In Month In Month Plan £000s Estimate Variance £000s £000s £12,393 £18,725 £7,129 £11,306 £669 (£137) £4,066 £9,913 £64,063 £0 £64,063 £9,035 £17,424 £6,327 £9,383 £535 £1,073 £6,497 £9,913 £60,187 £3,518 £63,705 £3,358 £1,301 £802 £1,922 £134 (£1,210) (£2,431) £0 £3,876 (£3,518) £358 £545 £363 £182 £208 £81 £127 £127 £210 (£83) £881 £655 £226 2020/21 YTD Plan £000s YTD Estimate £000s YTD Variance £000s Emergency budget M1-M4 £000s 2019/20 YTD Actuals £000s £49,573 £74,899 £28,514 £45,223 £2,674 (£547) £16,263 £39,652 £256,251 £0 £256,251 £24,214 £60,252 £21,385 £33,174 £1,827 (£401) £14,922 £39,652 £195,026 £58,830 £253,856 £25,359 £14,646 £7,129 £12,049 £847 (£146) £1,341 £0 £61,225 (£58,830) £2,395 £49,573 £74,899 £28,514 £45,223 £2,674 (£547) £16,263 £39,652 £256,251 £0 £256,251 £47,966 £71,796 £28,339 £42,701 £2,851 (£1,376) £1,260 £38,725 £232,262 £0 £232,262 £2,181 £833 £508 £3,522 £1,014 £572 £424 £2,009 £1,167 £262 £84 £1,513 £2,179 £833 £508 £3,521 Elective activity increased, representing 73% of planned levels (up from 56% in June) and non elective values increased to 93% of planned levels (up from 84% in June). Independent sector hospitals continue to be utilised and activity within these increased 16% from June to July to over 700 patients. An additional 180 theatre sessions also took place on the SGH site in July when comparing to June (up 11%). Grand Total £64,943 £64,359 £584 £259,773 £255,865 £3,908 £259,771 £232,262 Income (£m) Activity ('000) NHS Clinical Income & Activity £70 600 £60 500 £50 400 £40 £30 300 £20 200 £10 100 £0 0 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 2019/20 2020/21 Plan - Activity Actual - Activity Plan - Income Actual - Income 5 Page 4 of 15 2020/21 Finance Report - Month 4 Clinical Income Activity ('000) Income (£m) Elective spells In month -1,866 activity, -£3,358,069 YTD -14,250 activity, -£25,359,356 £16.0 10.0 £14.0 £12.0 8.0 £10.0 £8.0 30% 6.0 £6.0 4.0 £4.0 2.0 £2.0 £0.0 0.0 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 2019/20 2020/21 Plan - Activity Actual - Activity Plan - Income Actual - Income Activity ('000) Income (£m) Non elective spells In month -541 activity, -£1,300,921 YTD -5,184 activity, -£14,646,092 £20.0 7.0 9% 6.0 £15.0 5.0 4.0 £10.0 3.0 £5.0 2.0 1.0 £0.0 0.0 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 2019/20 2020/21 Plan - Activity Actual - Activity Plan - Income Actual - Income Outpatients In month -5,604 activity, -£801,790 YTD -49,291 activity, -£7,128,607 £10.0 70.0 £8.0 60.0 50.0 £6.0 7% 40.0 £4.0 30.0 20.0 £2.0 10.0 £0.0 0.0 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 Activity ('000) Income (£m) A&E InInmmoonnthth-5-2,6,80040aactcitvivitiyty, ,-£-£84013,7,39409 YYTTDD-4-197,2,49218aactcitvivitiyty, ,-£-£72,1,62484,6,10170 £2.5 14.0 £2.0 12.0 10.0 £1.5 10% 8.0 £1.0 6.0 4.0 £0.5 2.0 £0.0 0.0 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 2019/20 2020/21 2019/20 2020/21 Plan - Activity Actual - Activity Plan - Income Actual - Income Plan - Activity Actual - Activity Plan - Income Actual - Income 6 Page 5 of 15 Activity ('000) Income (£m) 2020/21 Finance Report - Month 4 Clinical Income Activity ('000) Income (£m) Adult critical care In month -798 activity, -£521,639 YTD -4,183 activity, -£3,244,251 £5.0 3.5 £4.0 3.0 2.5 £3.0 19% 2.0 £2.0 1.5 1.0 £1.0 0.5 £0.0 0.0 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 2019/20 2020/21 Plan - Activity Actual - Activity Plan - Income Actual - Income Activity ('000) Income (£m) Neonatal & paediatric critical care In month-386activity,£275,615 £2.5 YTD -1,929 activity, -2.5 £2.0 11% £1,794,808 2.0 £1.5 1.5 £1.0 1.0 £0.5 0.5 £0.0 0.0 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 2019/20 2020/21 Plan - Activity Actual - Activity Plan - Income Actual - Income Income (£m) Tariff excluded drugs In month +£2,921,219 YTD +£3,575,217 £12.0 24% £10.0 £8.0 £6.0 £4.0 £2.0 £0.0 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 2019/20 2020/21 Plan - Activity Actual - Activity Plan - Income Actual - Income Income (£m) Tariff excluded devices In month -£111,454 YTD -£2,089,843 £2.5 £2.0 18% £1.5 £1.0 £0.5 £0.0 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 2019/20 2020/21 Plan - Activity Actual - Activity Plan - Income Actual - Income Note: Drugs impacted by CF drugs approved by NICE from April – circa £19m FYE 7 Page 6 of 15 2020/21 Finance Report - Month 4 Income and Activity The tables shown illustrate by division and care group the % of the activity and income plan being achieved across months 14 for elective and outpatient activity. Elective activity has improved in July to 73% of pre-Covid levels. There is however variation at care group level although all care groups are now over 55%. Key to note, for the future financial regime, is that when restated for the removal of independent sector activity this would be 57% of the price plan for July. If pre-Covid independent sector activity is removed from the target this % improves slightly to 61%. Outpatient activity has improved in July to 89% of preCovid levels. Within this non face to face attendances have been priced in an equivalent manner to face to face attendances to avoid a distortion as many more attendances are now taking place virtually. Page 87 of 15 2020/21 Finance Report - Month 4 Income and Activity Non elective activity has increased to over 90% of preCovid levels in month with some specialties reporting growth in year so showing over 100%. It is expected activity levels for non elective will return to preCovid levels going forward as lockdown measures are eased. Page 88 of 15 2020/21 Finance Report - Month 4 Productivity & Benchmarking The current financial reporting framework of being brought back to break-even whilst achieving lower levels of activity makes it difficult to assess the performance of the Trust. Monitoring the ratio between proxy income and pay shows July returned to pre-Covid levels of productivity. This is slightly distorted due to pass thru drugs (within income) that will be removed from the analysis going forward. The bar graph shows the comparator performance of neighbouring hospital trusts when assessing their level of PbR equivalent revenue as a % of their block contract. Distortions could exist (e.g. high cost drugs, specialised high-cost activity) however, and this isn't necessarily in correlation with productivity. The level of private sector provision available locally in addition to the specific geography for each trust all has a bearing. Some specific work has started with Oxford reviewing any successes or learning that may be transferable to UHS. Income £ to Pay £ Ratio 1.40 1.20 1.00 0.80 0.60 0.40 0.20 0.00 Q1 2019/20 Q2 2019/20 Q3 2019/20 Q4 2019/20 Q1 2020/21 Jul-20 100% 90% 80% 70% 60% 93% 90% 82% 71% 76% 72% 59% 50% PbR % equivalent of Block Contract (£) 76% 70% 66% 72% 64% 57% 77% 68% 61% 63% 60% 55% 51% 82%84%82% 77% 64% 59% 40% 30% 20% 10% 0% University Oxford Portsmouth Salisbury NHSFT Royal Berkshire Frimley Health Bournemouth & Poole Hospital Hampshire Hospital University Hospitals Trust NHSFT NHSFT Christchurch NHSFT Hospitals NHSFT Southampton Hospitals NHSFT NHSFT Apr-20 May-20 Jun-20 Jul-20 Page190of 15 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20 Oct-20 Nov-20 Dec-20 Jan-21 Feb-21 Mar-21 2020/21 Finance Report - Month 4 Substantive Pay Costs Total pay expenditure in July was £45.7m (down £0.1m from June). There were no bank holiday enhancements in month (£0.35m in June) although included £0.2m of pay arrears relating to overseas recruits. Covid related staffing expenditure totalled £1.8m. This has funded sickness / self isolation backfill in addition to increased medical and nursing staffing costs, and other elements of workforce expansion. These additional elements are forecast to reduce from August as a large number of shielding staff return and student nurses and doctors start to take up substantive posts. Some Covid related pay costs will remain however as the trust continues to run segregated pathways in ED and requires increased staff to support testing as well as exit and entrance teams. Attempts are being made to rationalise these costs were possible. £m £m 48.0 Total Pay 46.0 44.0 42.0 40.0 38.0 36.0 34.0 32.0 30.0 43.0 42.0 Substantive Pay 41.0 40.0 39.0 38.0 37.0 36.0 35.0 Start Apr May Ju n Ju l Aug Sep Oct Nov Dec Jan Feb Mar 18.0 17.0 Substantive Pay 16.0 15.0 14.0 13.0 12.0 11.0 10.0 9.0 8.0 7.0 Covid Agency Bank Substantive Plan Total Substantive Plan Substantive Actual 20/21 Substantive Actual 19/20 Medical N ursi ng Other £m Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20 Oct-20 Nov-20 Dec-20 Jan-21 Feb-21 Mar-21 11 Page 10 of 15 2020/21 Finance Report - Month 4 Temporary Staff Costs Agency spend has increased by £0.3m from June to July. This is partly due to staff returning to host areas to support elective recovery meaning several areas, such as critical care, are now requiring greater agency usage. Previously staffing requirements have been flexed down in many elective focused service areas in order to support Covid-19 patients. Expenditure on bank staff was up £0.2m from June and remains consistent with usage since January 2020. This does however continue to be above average levels of spend in 19/20 by c£0.4m per month. This is driven mainly by admin bank usage which has been deployed to staff the entrances and exits to the trust 24/7 costing £150k per month. This area of spend is under review as it has led to admin and estates bank spend doubling when compared to pre-Covid levels. 1,300, 000 1,200, 000 1,100, 000 1,000, 000 900, 000 800, 000 700, 000 £ 600,000 500, 000 400, 000 300, 000 200, 000 100, 000 0 -100, 000 3 ,2 0 0, 00 0 3 ,0 0 0, 00 0 2 ,8 0 0, 00 0 2 ,6 0 0, 00 0 2 ,4 0 0, 00 0 2 ,2 0 0, 00 0 2 ,0 0 0, 00 0 1 ,8 0 0, 00 0 £ 1,600,000 1 ,4 0 0, 00 0 1 ,2 0 0, 00 0 1 ,0 0 0, 00 0 8 0 0, 00 0 6 0 0, 00 0 4 0 0, 00 0 2 0 0, 00 0 0 2020/21 Agency NHSI Ceiling and Spend 2020/21 Bank Total Spend Page1112of 15 2020/21 NH SI Ce iling Nursi ng Me dic s Scient & Tech Admin & Estates Total Agency NHSI Plan Nursi ng Medics Scient & Tech Admin & Estates Total B ank 2020/21 Finance Report - Month 4 Cash The cash balance reduced slightly from June to July (down £1.9m) although remains significantly up from 2019/20. The significant step change seen from April follows a change in the cash regime of the NHS as monthly block contract payments are now paid in advance of the month required. This is an interim measure due to Covid and is likely to be reversed in year. Adjusting for that, cash still continues to remain significantly higher than the minimum holding. 180 160 Cash Position 140 120 100 80 60 40 20 0 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 Plan 19/20 (for reference) Actual Minimum Cash Holding 13 Page 12 of 15 2020/21 Finance Report - Month 4 Capital Expenditure The capital expenditure position for the year to July shows expenditure of £18.4m against a plan of £19.3m, £0.9m below that budgeted. Excluding externally funded schemes and Covid 19 related expenditure, which should be reclaimed, the expenditure is £14.6m against a plan of £18.2m, £3.7m below budget. The most significant areas of underspend YTD are leases (£1.3m underspent) and IT where much of the infrastructure spend has been recorded in the Covid 19 budget line (£1.3m underspent). We are currently forecasting to underspend on internally funded schemes by £2.6m. This is mainly due the fact that approximately £3.1m of expenditure on the Vertical Extension E Level Fit Out scheme will be delayed until 2021-22 as the existing GICU will now not be refurbished this financial year. The overall forecast position is £10.2m above the original plan, but this is due to new externally funded schemes, notably the expansion and refurbishment of the ED for which the trust will receive £9m. Scheme Childrens Hospital/ED Adult Resus IT Schemes Strategic Maintenance Medical Equipment Panel GICU Expansion Fit out of E Level, Vertical Extension Refurbish Eye Theatre Theatre K Plant Room Spend to Save Radiotherapy Equipment Decorative Improvements / Staff Fund ED offices and minors space Fit out of E &F level North Wing Courtyard East Wing Annex Shell Oncology Ward Build Side Rooms Other Projects Assumed Slippage Total Trust Funded Capital excl Finance Leases Finance Leases - Medical Equipment Panel Finance Leases - Divisional Equipment Finance Leases - IISS Finance Leases - Other Donated Asset Additions Total Trust Funded Capital Expenditure (CDEL Allocation) Energy Efficiency Fit out of E Level, Vertical Extension ED Expansion and Refurbishment Backlog Maintenance Digital Maternity (STP Wave 3) Digital Outpatients (STP Wave 3) HSLI Enterprise Wide Scheduling Pathology Digitisation Coronavirus Equipment and Works Total CDEL Expenditure Page 13 of1145 Month Plan Actual Var £000's £000's £000's 0 144 (144) 680 (4) 684 250 346 (96) 50 2 48 1,494 1,276 218 121 99 22 0 182 (182) 10 210 (200) 149 149 0 137 1 136 50 0 50 239 1 238 22 60 (38) 0 21 (21) 600 334 266 0 00 455 232 222 1,717 0 1,717 5,974 3,053 2,921 150 0 150 42 0 42 880 889 (9) 100 0 100 (231) (450) 219 6,915 3,492 3,422 194 62 132 0 00 0 00 0 00 0 0 0 0 0 0 37 4 33 0 0 0 0 552 (552) 7,146 4,110 3,036 (Fav Variance) / Adv Variance Year to Date Full Year Forecast Plan Actual Var Plan Actual Var £000's £000's £000's £000's £000's £000's 890 705 185 1,141 1,502 (361) 2,262 1,010 1,252 7,564 6,564 1,000 954 1,028 (74) 3,750 3,750 0 263 342 (79) 1,000 1,000 0 6,181 6,282 (101) 12,128 12,128 0 255 205 50 5,013 1,913 3,100 8 314 (306) 1,849 1,849 0 160 398 (238) 334 334 0 511 414 97 810 1,460 (650) 603 156 447 700 700 0 200 0 200 600 600 0 258 16 242 586 586 0 1,207 534 673 1,207 636 571 0 33 (33) 1,490 1,490 0 1,174 820 354 5,782 5,930 (148) 0 0 0 932 932 0 1,306 856 450 3,576 4,077 (501) 132 0 132 (1,423) (1,000) (423) 16,364 13,114 3,250 47,039 44,451 2,588 350 0 350 2,200 2,200 0 168 0 168 500 467 33 2,325 1,887 438 5,535 5,535 0 319 0 319 2,265 2,265 0 (1,282) (450) (832) (3,482) (3,482) 0 18,244 14,550 3,694 54,057 51,436 2,621 884 1,008 (124) 1,667 1,667 0 0 0 0 5,000 5,000 0 0 0 0 0 9,000 (9,000) 0 0 0 1,730 1,730 0 0 0 0 1,350 675 675 0 0 0 589 295 294 148 17 131 444 444 0 0 0 0 1,080 0 1,080 0 2,841 (2,841) 0 5,890 (5,890) 19,276 18,417 859 65,917 76,137 (10,220) 2020/21 Finance Report - Month 4 Statement of Financial Position The June statement of financial position illustrates net assets of £437.2m which is broadly similar to May. Working capital movements have created contra variances between payables and receivables in month. The payables balance is distorted when compared to 2019/20 as it includes £63m of deferred income as block contract payments are currently paid in advance. Normalising for this payables are flat compared to the closing position for 2019/20. This continues to be an area of focus for the finance department. Statement of Financial Position Fixed Assets Inventories Receivables Cash Payables Current Loan Current PFI and Leases Net Assets Non Current Liabilities Non Current Loan Non Current PFI and Leases Total Assets Employed Public Dividend Capital Retained Earnings Revaluation Reserve Other Reserves Total Taxpayers' Equity 2019/20 Actuals £m 379.0 15.2 73.0 97.3 (115.6) (3.3) (7.4) 438.2 (20.4) (11.5) (33.4) 372.9 220.7 132.0 20.2 0.0 372.9 (Fav Variance) / Adv Variance M3 Act £m 386.1 14.2 56.3 158.9 (167.9) (3.5) (7.8) 436.3 (20.6) (10.5) (32.6) 372.6 220.7 131.6 20.2 0.0 372.6 2020/21 M4 Act £m 389.0 14.5 67.2 157.0 (179.1) (3.5) (7.9) 437.2 (20.8) (10.2) (32.7) 373.5 221.3 132.0 20.2 0.0 373.5 MoM Movement £m 2.8 0.3 10.9 (1.9) (11.2) (0.0) (0.1) 0.9 (0.2) 0.3 (0.1) 0.9 0.5 0.4 0.0 0.0 0.9 15 Page 14 of 15 2020/21 Finance Report - Month 4 Financial Regime Changes Emergency Budget – Phase 3 (M7 to M12) Block Contract (19/20 base) Non-NHS income (at 100%) Non-Rec Covid Funding High-cost drugs & devices Private Sector Capacity Retrospective top-up to break-even Adjusted version of M1-6 Nationally calculated Loss of NonNHS income not funded Non Recurrent nationally calculated allowance Moved back to Pass-through or top up Locally agreed via national framework Additional central funding Removed UHS Phase 3 Emergency Budget To deliver: Elective Day Case OP Procedures 90% by October 20 First Outpatients Follow-up Outpatients Inclusive of virtual appts 100% from September 20 MRI CT Endoscopy Procedures 100% by October 20 Over-performance HIOW System Level? Marginal Rate payment @ X% PbR Details TBC (75%?) Under-performance HIOW System Level? Marginal Rate reduction @ Y% PbR Page 145 of 1D5 etails TBC (25%?) Report to the Trust Board of Directors dated Thursday, 27 August 2020 Title: Agenda item: Sponsor: Date: Purpose Issue to be addressed: Integrated Performance Report 2020/21 Month 4 4.4 Chief Executive 24 August 2020 Assurance Approval or reassurance Y Ratification Information This report is intended to support the Trust Board in assuring that: • the care we provide is safe, caring, effective, responsive and well led in the context of the Covid 19 pandemic • at the same time we continue our journey toward our vision of World Class Care for Everyone. Response to the issue: For the year 2020/21 the Integrated Performance Report has adapted to reflect the current operating environment. In particular we have aligned it with the Care Quality Commission Key Lines of Enquiry and then cut it again to reflect delivery of our Strategic Goals and annual corporate objectives. Implications: This report covers a broad range of trust services and activities. It is (Clinical, Organisational, intended to assist the Board in assuring that the Trust meets regulatory Governance, Legal?) requirements and corporate objectives. Risks: (Top 3) of carrying This report is provided for the purpose of assurance. out the change / or not: Summary: Conclusion This report is provided for the purpose of assurance. and/or recommendation Page 1 of 23 Integrated KPI Board Report covering up to Jul 2020 Sponsor - Andrew Asquith, Director of Financial and Productivity Improvement, andrew.asquith@uhs.nhs.uk Page 2 of 23 Chart Type Cumulative Column Example Cumulative Column Year on Year Line Benchmarked Line Percentiles Control Chart Variance from Target Report Guide 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). A line percentiles chart is used to represent the distribution of a variable. The 50th percentile shows the median value, we also show the 5th, 25th (lower quartile), 75th (upper quartile) and 95th centiles. A control chart shows movement of a variable in relation to it's 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 it's 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 it's target. 2 Page 3 of 23 Report to Trust Board in August 2020 Introduction The Trust Integrated Performance Report is presented to the Trust Board each month. For the year 2020/21 the Integrated Performance Report has adapted to reflect the current operating environment. In particular we have aligned it with the Care Quality Commission Key Lines of Enquiry and then cut it again to reflect delivery of our Strategic Goals and annual corporate objectives in order to: • Demonstrate that we can assure ourselves that the care we provide is safe, caring, effective, responsive and well led in the context of the Covid 19 pandemic • Ensure that at the same time we continue our journey toward our vision of World Class Care for Everyone. We might adjust/ or add to these indicators – informing the Board and keeping a comparative narrative – if the situation changes as we work through these unusual circumstances. An example of this might be measuring vulnerable groups as the evidence around COVID emerges. The monthly Trust Integrated Performance Report is currently complemented by a ‘Covid-19 Balanced Scorecard’ which is considered by the UHS Integrated Assurance Group, and also available to Board Members, on alternate weeks. July 2020 Summary During July the direct impact of Covid 19 infections upon the Trust continued to reduce. The number of beds occupied by patients with Covid 19 reduced from a total of 15 to 5 during the month, and a total 14 patients were discharged during the month having had a positive diagnosis during their inpatient stay. Non-elective admission volumes in total remained at approximately 90% of their normal levels. Elective referrals increased to approximately 66% of their normal levels. Elective care activity as a whole continued to be significantly adversely impacted; primarily by the need to adhere to a range of additional infection control measures, and by restrictions to the types of care some of our staff could safely provide due to their own health risk factors. The trust has sought to prioritise the reduced elective capacity available towards those patients requiring assessment or treatment more urgently, and to provide assessments by telephone or video whenever appropriate. The trust is developing a range of activity recovery and service change plans in order to further respond to the challenge of meeting patient’s needs in the current environment where patients and staff require additional protection from the threat of Covid 19 transmission. 3 Page 4 of 23 Report to Trust Board in August 2020 RESPONSIVE • Emergency Department timeliness continued to improve in July, reaching 94.5% across the month (RE 10). Other Trusts have also achieved similar improvement, though UHS had the third best performance out of 8 ‘peer’ Major Trauma Centres (RE9). Attendance numbers increased to approximately 80% of the normal level (RE 8), whilst enhanced infection control precautions remained in place. • Reductions in the amount of elective care that we are able to provide are resulting in significant increases in the length of time that patients are waiting for appointments, investigations and treatments. We are focussed on responding to this challenge as quickly as possible but need to exercise appropriate caution to ensure service activity is increased in a way that is safe for patients and staff. The data demonstrates steady increases in elective admissions in July to approximately 71% of normal (RE 13), and in outpatients a) a substantial increase in the contribution of non-face to face appointments b) modest increases in total activity in June and July to approximately 71% of normal (RE 16 / 17). • The percentage of patients waiting up to 18 weeks from referral to treatment deteriorated further to 49% (RE 14). The total number of patients waiting has returned to pre-Covid levels (RE 15), and is expected to increase further, due to the recovery in the number of referrals being made to hospital (RE 12). The percentage of patients waiting more than 6 weeks for a diagnostic test (RE 20) also reduced from 42% to 35%, though the total number of patients waiting continued to increase and is now at pre-Covid levels (RE 19). The average waiting time for new outpatient appointments reduced significantly in July (RE 18). • Cancer performance measures for June indicate that UHS 62 day performance (RE 21) improved and was the second best amongst our 10 ‘peer’ teaching hospitals, and that 31 day performance (RE 22) improved to 96.5% and achieved the national standard. Performance levels are likely to improve further during July (based upon provisional data). The number of patients still waiting with pathways greater than 104 days (RE 23) has increased, but remains within our normal variation currently, we are working to address Covid 19 related impacts upon investigation for Colorectal and Head and Neck Cancer. The overall percentage of patients being ‘diagnosed’ within 28 days of referral (RE 24) has recovered to 80%, 5% above our target. 4 Page 5 of 23 Report to Trust Board in August 2020 RESPONSIVE May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Monthly Target 6,800 6,692 5,989 RE1 Non-elective Spells (including CDU) - 4,000 7.5 RE2-L Non Elective LOS Rolling 12 months 6.44 6.0 250 RE3 Number of patients medically optimised for discharge Longer LOS Census average RE4-N (Patients with LOS > =21days) 0 209 227.03 183.21 139.39 - 6.19 99 - 105 - RE5-l Adult midday bed occupancy 94.3% 68.0% 90-95% RE6 Last minute cancelled operations not readmitted within 28 days 15000.0% RE7 Hospital initiated cancelled ops 71% 776654536532533 Patients spending less than 4hrs in ED RE10-N UHS Total (includes SGH all types and lymington until Jul 19) 90.66% 83.2% 75.80% 81.7% 94.5% 94.50% Q Target - 95% 95% RE11-N Total time spent in ED Total Percentiles UHS Mean, 3:21 50th, 3:09 90th, 3:58 Mean, 2:41 - - 50th, 2:43 RE12 Accepted Referrals RE13 Elective spells 25000 0 2,000 0 20016 1,718 13169 - - 1,216 - - 6 Page 7 of 23 Report to Trust Board in August 2020 RESPONSIVE RE14-N % Patients on an open 18 week pathway (within 18 weeks ) May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul 778494%%% 86.0% 48.97% 35000 Total number of patients on a waiting RE15-N list (18 week referral to treatment pathway) 28000 54,679 RE16 Face to face outpatient attendances 50,000 33517 33401 24,237 Target > =92% - 0 50,000 RE17 Non-face to face outpatient attendances 8,666 0 RE17 - Latest month is awaiting approx ~3k outpatient attendances to be reported 17,996 - RE18 Average weeks waited for first outpatient appointment RE19 Patients waiting for diagnostics 9.84 8.67 7.50 8,200 4,000 RE20-N % of Patients waiting over 6 weeks for diagnostics 17% 19% 7.6 7623 2.1% 9.4 - 7875 - 35.33% RE22-N 31 day cancer wait performance (latest data held by UHS) no.patients Target to recover QTD May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun /July target 0.9 76.8% 75.4% 81.7% N=> 90% N = 14 L=> L= 19 of 94 75% 71.4% 95% 83657864565512 0.5 96.0% 96.54% 92.3% 88.6% N=> 96% N=9 of 714 0.9467787 RE23 Snapshot of waits > 104 days (from referral on a 62 day pathway) 26 33 38 41 55 52 41 29 35 27 29 25 36 - - 11 100% RE24-N 28 Day Faster Diagnosis 70% 10,000 RE25 My Medical Record - UHS patient logins 5,000 0 2500 76% 4,177 1904 RE26 Number of Estates Help desk requests 900 and percentage completed on time 100% 85% 50% 76.6% => 75 80% % - 6,675 - 1557 - 89.1% > 85% 73.27% 88.3% 8 Page 9 of 23 Report to Trust Board in August 2020 SAFE • The majority of measures indicate that safety has been maintained during July. • The level of red flag staffing incidents (SA 14) demonstrate the positive impact of redeployment of our staff between departments, employment of 3rd year students, and arrangements to enable staff with health risk factors to return safely to clinical roles, together with reductions in the number of patients being seen by the hospital. • New Covid-19 diagnoses amongst hospital inpatients (SA 5, SA6) have reduced significantly, and there were no cases of ‘probable’ transmission or ‘healthcare-acquired’ Covid-19 in UHS inpatient services in July. In July the Trust launched the ‘Covid Zero’ campaign which aims to enable the Trust to return services as quickly as possible, whilst keeping staff and patients safe from the threat of COVID-19 by ensuring there is no transmission of the disease. The campaign encourages all people to follow government guidance when walking apart, wear a mask where you can’t, and continue to wash your hands as often as possible. • A reduction in the percentage of statutory and mandatory maintenance completed on time seen in June has been rapidly addressed since, and returned to target in July. Monthly May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Target YTD YTD Target SA1-N Cumulative Clostridium difficile 2 SA2 MRSA bacterium 0 100 SA3 Clinical cleaning scores for very high risk areas 99 95 SA4 Serco cleaning scores for very high risk areas 100 99 95 5 18 24 18 0 0 99 98 - 14days after admission 00 0 0 0 0 0 0 0 0 0 20 30 14 1 0 Probable hospital-associated 50 SA6 COVID infection: COVID-positive sample taken > 7 days and 95% - YTD Target - - > 95% 11 Page 12 of 23 Report to Trust Board in August 2020 CARING • The majority of measures indicate that UHS has continued to provide caring services during June. • Nursing Care hours per patient per day reduced, but remained significantly above our normal levels (CA 7), patients recorded as moved overnight for non-clinical reasons remained below the average (CA 6), and no same sex accommodation breaches were recorded (CA 8). • The number of complaints closed on time (CA 5) is making a slow recovery following disruption to complaint investigations during the peak of Covid 19 admissions, achieving only 43% compared to our target of > =70%. The number of complaints still being investigated remained stable in July, the number of complaints being resolved was matched by the number of new complaints received. Monthly May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Target 1.0% CA1-N FFT Negative Score - Inpatients 5% =35% 1.30 CA4-L Complaints per 1000 units 0.00 CA5-L % Complaints closed within 35 days 80% 0% 0.34 87% =70% 12 Page 13 of 23 Report to Trust Board in August 2020 0% CARING Monthly Target May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul 100% % Patients reporting being CA6 involved in decisions about care and treatment 50% 86% > =90% 100% % Patients reporting finding CA7 somebody to talk to about worries and fears 50% 100% % Patients with a CA8 disability/additional needs reporting those needs/adjustments were met 50% 89% > =90% 99% > =90% Monthly May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Target CA9 Overnight ward moves with a reason marked as non-clinical 141.58 75.92 10.26 68 50 - 18.0 Total nursing staff all inpatient CA10 areas - Care hours per patient day13.0 (CHPPD) 8.6 12.4 - 8.0 40.0 Same Sex Accommodation 32 CA11 (Non Clinically Justified 20.0 11 12 Breaches) 5 2 4 4 1 1 0 0.0 15 - 0 0 0 0 13 Page 14 of 23 Report to Trust Board in August 2020 EFFECTIVE • The number of clinical outcome measures developed and recognised by the trust continued to increase in quarter 1, the percentage of outcome measures RAG rated green also increased by 1% (EF 1, EF 2). • The Hospital Standardised Mortality Ratios of Southampton General Hospital and UHS as a whole (EF 3), remain well within the benchmark, and are reported quarterly on a national basis – we await national information relating to quarter 1. • 98% of eligible patients were screened for alcohol and smoking (EF 5) in July which continues to meet the target. Improvements were demonstrated in both the Advice or medication offered in relation to smoking (EF 7) and Advice or referral in relation to moderate/high alcohol dependence (EF 6) (although the latter remains significantly below target). EF1-L Cumulative Specialities with Outcome Measures Developed May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul 47 52 52 53 54 223 234 250 255 260 Monthly Target +1 100% EF2 Developed Outcomes RAG ratings 75% 78% 77% 79% 80% 81% - 50% 100 EF3-N HSMR - UHS HSMR - SGH 75 4.5% 80% 14 Page 15 of 23 Report to Trust Board in August 2020 EFFECTIVE 80% May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul % patients screened & found to EF6-N have either moderate or high alcohol dependence given advice 90% 89% 79% or referral 70% % patients screened & found to 100% 85% 89% EF7-N smoke given brief advice or a medication offer 60% Monthly Target > 90% > 90% 15 Page 16 of 23 Report to Trust Board in August 2020 WELL LED • Staff sickness absence rates (WL 5) continued to improve to 2.9%, and remain within the target of =92% appears unlikely this year, and work is taking place to propose a realistic target and associated recovery plan, which will retain focus on the quality of appraisals (as reflected in our staff survey). This will be discussed at the Trust’s People and Organisational Development Committee on 16 September. • Medical appraisals (WL 3) were suspended during the peak of Covid 19 and performance has been adversely affected by this. In July there was an improvement of 4% in the number of appraisals completed within the previous 12 months but significant further improvement is required. • Our research measures are reported quarterly. WL1-L Substantive Staff - Turnover Monthly May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Target 13.86% 13.18% 12.50% 12.7% 12.6% 92% 77.22% 16 Page 17 of 23 Report to Trust Board in August 2020 WELL LED Monthly May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Target WL3-L 100.00% Staff - Medical appraisals completed - Rolling 12-months 50.00% 0.00% 69.00% WL4-L Staff vacancies 10.00% 5.00% 0.00% 5.60% WL5-L Staff - Sickness absence 4.39% 3.7% 3.04% 3.46% 2.94% =76% 30% 20% WL9-L Black & Minority Ethnic Band 7+ Percentage 9% 8.6% 7% 9.2% 15% by 2023 WL10 Cumulative Number of staff trained in QI 1001 1064 1171 WL10 - QI training programme, and reporting, is currently temporarily suspended as team members support urgent change programmes as part of our Covid 19 response and recovery WL11 Statutory & Mandatory Training Achieving Target 8 8 8 8 8 7 7 7 7 7 7 7 6 6 6 4 4 4 4 4 5 5 5 5 5 5 5 6 6 6 - 100 WL12 Number of Apprenticeship Starts 53 - 50 29 28 23 0 18 Page 19 of 23 Report to Trust Board in August 2020 WELL LED 0 Monthly May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Target WL13-L Comparative CRN Recruitment Performance by clinical specialty 44% 44% 52% 56% 52% > =50% WL14-L Comparative CRN Recruitment Performance - weighted 2 4 5 5 6 Top 5 WL15-L Comparative CRN Recruitment - contract commercial 15 15 13 13 13 Top 10 Proportion of studies closing in FY on 88% WL16-L time and to recruitment target - 59% 65% 65% non-commercial 50% > =80% 452 WL17 NIHR CRF & BRC publications Year on year growth 329 246 137 19 Page 20 of 23 Report to Trust Board in August 2020 Changes and Corrections Section Safe KPI SA10 KPI Name Serious incidents requiring investigation Type Detail Change/Correction Definition changed to incidents based on week reported. Error was linking report to outdated source, figures corrected retrospectively from this report. 20 Page 21 of 23 Nursing and midwifery staffing hours - July 2020 Report notes Our staffing levels are monitored daily and we will risk assess and fill any gaps to ensure that safe staffing levels are always maintained The total hours planned is our planned staffing levels to deliver care across all of our areas but does not represent a baseline safe staffing level. We plan for an average of one registered nurse to every five or seven patients in most of our areas but this can change as we regularly review the care requirements of our patients and adjust our staffing accordingly. Staffing on intensive care and high dependency units is always adjusted depending on the number of patients being cared for and the level of support they require. Therefore the numbers will fluctuate considerably across the month when compared against our planned numbers. Enhanced Care (also known as Specialling) Occurs when patients in an area require more focused care than we would normally expect. In these cases extra, unplanned staff are assigned to support a ward. If enhanced care is required the ward may show as being over filled. If a ward has an unplanned increase or decrease in bed availability the ward may show as being under or over filled, even though it remains safely and appropriately staffed. CHPPD (Care Hours Per Patient Day) This is a measure which shows on average how many hours of care time each patient receives on a ward /department during a 24 hour period from registered nurses and support staff - this will vary across wards and departments based on the specialty, interventions, acuity and dependency levels of the patients being cared for. The maternity workforce consists of teams of midwives who work both within the hospital and in the community offering an integrated service and are able to respond to women wherever they choose to give birth. This means that our ward staffing and hospital birth environments have a core group of staff but the numbers of actual midwives caring for women increases responsively during a 24 hour period depending on the number of women requiring care. During the last 2 weeks in March and beyond a number of our clinical areas started to change specialty and size to respond to the COVID-19 situation (e.g G5-G9, Critical Care and RHDU). Repurposing of wards to respond to the COVID-19 social distancing recommendations and to enable the separation and restart of services continues with changes sometimes being swift in nature. The data may in some cases not be fully reflective of these changes. WARD C4 (Solent ward) C4 (Solent ward) C6 C6 C6 (Teenage Cancer Trust unit) C6 (Teenage Cancer Trust unit) D2 D2 D3 D3 Critical Care Critical Care E5A E5A E5B E5B F10 E F10 E F11 F11 ASU ASU F6 F6 F5 F5 Acute medical unit Acute medical unit D5 D5 D6 D6 D8 D8 D9 D9 E7 E7 Respiratory high dependency unit Respiratory high dependency unit C5 C5 D10 D10 F7 F7 G5 G5 G6 G6 G7 G7 G8 G8 G9 G9 Registered nurses Total hours planned Registered nurses Total hours worked Unregistered Unregistered Registered staff staff nurses Total hours Total hours % planned worked Filled Day 1332.9 1416.5 1059.8 1110.9 106.3% Night Day Night Day Night Day Night Day Night Day Night 1070.5 2903.2 2047.5 718.0 682.5 1270.9 1058.0 1723.0 1047.3 21552.0 19882.8 956.3 2644.8 1939.0 706.5 605.5 1657.0 1196.8 1635.2 1037.0 20859.6 20121.1 712.8 160.8 0.0 316.5 0.0 1077.8 713.1 743.5 698.8 3225.7 2572.7 1030.5 423.3 251.0 341.5 66.3 1073.5 863.3 999.2 834.8 3146.3 2757.2 89.3% 91.1% 94.7% 98.4% 88.7% 130.4% 113.1% 94.9% 99.0% 96.8% 101.2% Day Night 1367.5 707.5 1018.3 707.5 667.5 356.5 1316.5 586.5 74.5% 100.0% Day Night 1416.0 713.0 1181.1 727.0 777.0 356.5 1320.3 638.5 83.4% 102.0% Day Night 2333.5 1069.5 1568.1 1058.0 537.5 713.0 1507.0 782.0 67.2% 98.9% Unregistered staff % Filled CHPPD Registered midwives/ nurses CHPPD Care Staff 104.8% 5.0 4.5 144.6% 263.3% 8.4 1.2 Shift N/A 107.9% 9.7 3.0 Shift N/A 99.6% 7.2 4.9 121.1% 134.4% 5.6 3.8 119.5% 97.5% 27.7 4.0 107.2% 197.2% 3.8 4.2 164.5% 169.9% 4.1 4.2 179.1% 280.4% 5.0 4.3 109.7% 75.2% 130.8% Day 1938.8 1458.9 798.9 1045.3 4.5 4.0 Night 708.0 713.0 713.0 904.0 100.7% 126.8% 69.2% 136.3% Day 1477.4 1022.0 389.0 530.0 9.5 4.8 Night 715.0 720.0 356.5 346.0 100.7% 97.1% 65.2% 244.4% Day 2323.7 1515.1 583.7 1426.4 4.1 4.1 Night 1069.5 923.7 713.0 1021.5 86.4% 143.3% 76.2% 112.6% Day 1983.0 1511.7 1295.5 1458.5 4.5 4.2 Night 1069.5 1035.0 713.0 908.5 96.8% 127.4% 121.0% 102.9% Day 3561.5 4307.7 3404.4 3503.0 10.0 8.9 Night 3565.0 3958.0 2461.0 111.0% 3898.8 158.4% Day 1362.5 1033.3 1667.0 1394.5 75.8% 83.7% 3.7 4.1 Night 1000.0 748.0 865.0 566.5 74.8% 65.5% Day 1186.5 874.5 1498.5 1590.8 73.7% 106.2% 3.8 6.2 Night 701.5 586.3 934.5 794.5 83.6% 85.0% Day 1155.7 744.2 1568.0 1146.4 64.4% 73.1% 2.2 3.2 Night 701.5 437.5 945.5 608.5 62.4% 64.4% Day 1326.5 1205.0 1686.5 1778.0 90.8% 105.4% 3.0 4.0 Night 1069.5 897.0 952.8 1041.5 83.9% 109.3% Day 1116.0 1094.5 1324.0 1408.5 98.1% 106.4% 3.4 3.9 Night 713.0 724.5 713.0 724.5 101.6% 101.6% Day 926.5 820.0 255.5 315.3 88.5% 123.4% 14.0 4.5 Night 828.5 759.0 103.5 196.0 91.6% 189.4% Day 1363.0 1113.8 1123.0 891.3 81.7% 79.4% 10.6 7.0 Night 1035.0 862.5 540.5 414.0 83.3% 76.6% Day 1128.5 896.0 1320.0 1457.0 79.4% 110.4% 3.3 4.3 Night 713.0 667.5 713.0 598.0 93.6% 83.9% 89.9% 86.6% Day 1091.9 981.4 1768.0 1530.8 4.1 5.3 Night 759.0 759.5 713.0 736.0 100.1% 103.2% Day 1027.5 1269.5 1866.5 1653.0 123.6% 88.6% 3.7 4.2 Night 1034.5 873.5 724.5 770.5 84.4% 106.3% Day 1053.0 1031.5 1809.5 1708.0 98.0% 94.4% 3.6 4.7 Night 1046.5 851.0 851.0 736.0 81.3% 86.5% Day 738.4 744.5 1451.3 1609.0 100.8% 110.9% 3.6 6.7 Night 678.0 712.5 1069.5 1123.0 105.1% 105.0% Day 1073.9 1031.4 1795.5 1770.0 96.0% 98.6% 3.0 4.0 Night 1023.5 851.0 713.0 747.8 83.1% 104.9% Day 1063.0 1016.5 1714.0 1816.3 95.6% 106.0% 3.3 4.6 Night 1000.5 862.5 736.0 759.0 86.2% 103.1% CHPPD Overall 9.4 9.6 12.7 12.1 9.4 31.7 7.9 8.2 9.3 8.5 14.3 8.2 8.7 18.9 7.8 10.1 5.4 7.0 7.3 18.5 17.6 7.6 9.4 8.0 8.3 10.3 7.0 7.9 Comments Safe staffing levels maintained. Safe staffing levels maintained; Band 4 staff working to support registered nurse numbers; Support workers used to maintain staffing numbers. Safe staffing levels maintained; Support workers used to maintain staffing numbers. Safe staffing levels maintained. Safe staffing levels maintained. Safe staffing levels maintained; Staffing appropriate for number of patients. Safe staffing levels maintained. Safe staffing levels maintained. Safe staffing levels maintained. Safe staffing levels maintained. Safe staffing levels maintained; Staffing appropriate for number of patients. Safe staffing levels maintained; Staffing appropriate for number of patients. Safe staffing levels maintained; Band 4 staff working to support registered nurse numbers; Support workers used to maintain staffing numbers. Safe staffing levels maintained. Safe staffing levels maintained; Band 4 staff working to support registered nurse numbers; Support workers used to maintain staffing numbers. Safe staffing levels maintained. Safe staffing levels maintained; Band 4 staff working to support registered nurse numbers; Support workers used to maintain staffing numbers. Safe staffing levels maintained. Safe staffing levels maintained; Band 4 staff working to support registered nurse numbers; Support workers used to maintain staffing numbers. Safe staffing levels maintained. Safe staffing levels maintained; Band 4 staff working to support registered nurse numbers; Support workers used to maintain staffing numbers. Safe staffing levels maintained. Safe staffing levels maintained; Band 4 staff working to support registered nurse numbers; Support workers used to m
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Trust-governance-and-corporate-docs/2020/finance-and-performance-reports-2020-21-month-4-july-2020-1.pdf

BEACON protocol v8.0 07Mar2023 signed

Description: A randomised phase IIb trial of BE AC v izumab added to Temozolomide O ± Irin tecan for children with N refractory
Url: /Media/UHS-website-2019/Docs/PaediatricOncology/beacon-protocol-v8.0-07mar2023-signed.pdf

Papers Trust Board - 10 March 2026

Description: Date Time Location Chair Apologies Agenda Trust Board – Open Session 10/03/2026 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-10-March-2026.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 Centre 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 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 11 November 2025 9:15 Approve the minutes of the previous meeting held on 11 November 2025 4 Matters Arising and Summary of Agreed Actions To discuss any matters arising from the minutes, and to agree on the status of any actions assigned at the previous meeting. 5 QUALITY, PERFORMANCE and FINANCE Quality includes: clinical effectiveness, patient safety, and patient experience 5.1 Briefing from the Chair of the Finance, Investment & Cash Committee 9:20 David Liverseidge, Chair 5.2 Briefing from the Chair of the People and Organisational Development 9:30 Committee Jane Harwood, Chair 5.3 Briefing from the Chair of the Quality Committee 9:40 including Maternity and Neonatal Safety 2025-26 Quarter 2 Report Tim Peachey, Chair 5.4 Chief Executive Officer's Report 9:50 Receive and note the report Sponsor: David French, Chief Executive Officer 5.5 Performance KPI Report for Month 8 10:20 Review and discuss the report Sponsor: Andy Hyett, Chief Operating Officer 5.6 11:00 5.7 11:15 5.8 11:25 5.9 11:30 5.10 11:45 5.11 11:55 5.12 12:05 5.13 12:15 6 6.1 12:25 7 12:35 8 Break Finance Report for Month 8 Review and discuss the report Sponsor: Ian Howard, Chief Financial Officer ICB System Report for Month 8 Receive and discuss the report Sponsor: Ian Howard, Chief Financial Officer People Report for Month 8 Review and discuss the report Sponsor: Steve Harris, Chief People Officer Learning from Deaths 2025-26 Quarter 2 Report Review and discuss the report Sponsor: Paul Grundy, Chief Medical Officer Attendee: Jenny Milner, Associate Director of Patient Experience Infection Prevention and Control 2025-26 Quarter 2 Report Review and discuss the report Sponsor: Natasha Watts, Acting Chief Nursing Officer Attendees: Julian Sutton, Clinical Lead, Department of Infection/Julie Brooks, Deputy Director of Infection Prevention and Control Medicines Management Annual Report 2024-25 Receive and discuss the report Sponsor: Paul Grundy, Chief Medical Officer Attendee: James Allen, Chief Pharmacist Annual Ward Staffing Nursing Establishment Review 2025 Discuss and approve the review Sponsor: Natasha Watts, Acting Chief Nursing Officer CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL Annual Assurance for the NHS England Core Standards for Emergency Preparedness, Resilience and Response (EPRR) Review and discuss the report Sponsor: Andy Hyett, Chief Operating Officer Attendee: John Mcgonigle, Emergency Planning & Resilience Manager Any other business Raise any relevant or urgent matters that are not on the agenda Note the date of the next meeting: 10 March 2026 Page 2 9 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. 10 Follow-up discussion with governors 12:45 Page 3 Agenda links to the Board Assurance Framework (BAF) 13 January 2026 – Open Session Overview of the BAF Risk 1a: Lack of capacity to appropriately respond to emergency demand, manage the increasing waiting lists for elective demand, and provide timely diagnostics, that results in avoidable harm to patients. 1b: Due to the current challenges, we fail to provide patients and their families / carers with a high-quality experience of care and positive patient outcomes. 1c: We do not effectively plan for and implement infection prevention and control measures that reduce the number of hospital-acquired infections and limit the number of nosocomial outbreaks of infection. 2a: We do not take full advantage of our position as a leading University teaching hospital with a growing, reputable, and innovative research and development portfolio, attracting the best staff and efficiently delivering the best possible treatments and care for our patients. 3a: We are unable to meet current and planned service requirements due to the unavailability of staff to fulfil key roles. 3b: We fail to develop a diverse, compassionate, and inclusive workforce, providing a more positive staff experience for all staff. 3c: We fail to create a sustainable and innovative education and development response to meet the current and future workforce needs identified in the Trust’s longer-term workforce plan. 4a: We do not implement effective models to deliver integrated and networked care, resulting in sub-optimal patient experience and outcomes, increased numbers of admissions and increases in patients’ length of stay. 5a: We are unable to deliver a financial breakeven position, resulting in: inability to move out of the NHS England Recovery Support Programme, NHS England imposing additional controls/undertakings, and a reducing cash balance impacting the Trust’s ability to invest in line with its capital plan, estates/digital strategies, and in transformation initiatives. 5b: We do not adequately maintain, improve and develop our estate to deliver our clinical services and increase capacity. 5c: Our digital technology or infrastructure fails to the extent that it impacts our ability to deliver care effectively and safely within the organisation, 5d: We fail to prioritise green initiatives to deliver a trajectory that will reduce our direct and indirect carbon footprint by 80% by 2028-2032 (compared with a 1990 baseline) and reach net zero direct carbon emissions by 2040 and net zero indirect carbon emissions by 2045. Agenda links to the BAF No Item Linked BAF risk(s) 5.5 Performance KPI Report for Month 8 5.7 Finance Report for Month 8 5.8 ICB System Report for Month 8 5.9 People Report for Month 8 5.10 Learning from Deaths 2025-26 Quarter 2 Report 5.11 Infection Prevention and Control 2025-26 Quarter 2 Report 5.12 Medicines Management Annual Report 2024-25 5.13 Annual Ward Staffing Nursing Establishment Review 2025 6.1 Annual Assurance for the NHS England Core Standards for Emergency Preparedness, Resilience and Response (EPRR) 1a, 1b, 1c 5a 5a 3a, 3b, 3c 1b 1c 1b 1b, 3a 1b Appetite (Category) Minimal (Safety) Current risk rating 4x5 20 Cautious (Experience) Minimal (Safety) 4x4 16 4x4 16 Open (Technology & Innovation) 3x4 12 Open (workforce) Open (workforce) Open (workforce) 4x5 20 4x3 12 4x4 16 Cautious (Effectiveness) 3x3 9 Cautious (Finance) 5x5 25 Target risk rating 4 x 2 Apr 6 27 3 x 2 Apr 6 27 2 x 3 Apr 6 27 3 x 2 Mar 6 27 4 x 3 Mar 12 30 4 x 2 Mar 8 30 3 x 2 Mar 6 29 3 x 2 Dec 6 25 3 x 3 Apr 9 30 Cautious (Effectiveness) Open (Technology & Innovation) Open (Technology & Innovation) 4x5 20 3x4 12 2x4 8 4 x 2 Apr 8 30 3 x 2 Apr 6 27 2 x 2 Dec 4 27 Does this item facilitate movement towards or away from the intended target risk score and appetite? Towards Away Neither x x x x x x x x x Minutes Trust Board – Open Session Date 11/11/2025 Time 9:00 – 13:00 Location Conference Room, Heartbeat Education Centre Chair Jenni Douglas-Todd (JD-T) Present Diana Eccles, NED (DE) Keith Evans, Deputy Chair and NED (KE) David French, Chief Executive Officer (DAF) Paul Grundy, Chief Medical Officer (PG) Steve Harris, Chief People Officer (SH) Jane Harwood, NED/Senior Independent Director (JH) Ian Howard, Chief Financial Officer (IH) Andy Hyett, Chief Operating Officer (AH) David Liverseidge, NED (DL) Tim Peachey, NED (TP) Alison Tattersall, NED (AT) Natasha Watts, Acting Chief Nursing Officer (NW) In attendance Craig Machell, Associate Director of Corporate Affairs and Company Secretary (CM) Lauren Anderson, Corporate Governance and Risk Manager (LA) (item 6.2) Martin de Sousa, Director of Strategy and Partnerships (MdS) (item 6.1) Lucinda Hood, Head of Medical Directorate (LH) (item 5.13) Diana Hulbert, Guardian of Safe Working Hours and Emergency Department Consultant (DH) (item 5.12) Vickie Purdie, Head of Patient Safety (VP) (item 7.3) Kate Pryde, Clinical Director for Improvement and Clinical Effectiveness (KP) (item 5.13) Scott Spencer, Health and Safety Advisor (SS) (item 7.3) 4 governors (observing) 2 members of staff (observing) 1. Chair’s Welcome, Apologies and Declarations of Interest The Chair welcomed attendees to the meeting. There were no interests to declare in the business to be transacted at the meeting. It was noted that no apologies had been received. The Chair provided an overview of meetings she had held and events that she had attended since the previous Board meeting. 2. Patient Story Item deferred to the next meeting. 3. Minutes of the Previous Meeting held on 9 September 2025 The draft minutes tabled to the meeting were agreed to be an accurate record of the meeting held on 9 September 2025, subject to a minor correction at 5.10. Page 1 4. Matters Arising and Summary of Agreed Actions The matters arising and actions were noted. • Actions 1281, 1283 and 1284 were closed. • Action 1282 was to be addressed through item 5.6 below. • In respect of action 1285, the Quality Committee would monitor progress on complaints response times. 5. QUALITY, PERFORMANCE and FINANCE 5.1 Briefing from the Chair of the Audit and Risk Committee Keith Evans was invited to present the Committee Chair’s Report in respect of the meeting held on 13 October 2025, the content of which was noted. It was further noted that: • In terms of the internal audit reports, which had been received by the committee, whilst there were a number of points for the Trust to address, no areas of significant concern had been identified. • There was a focus on ‘imposter fraud’ whereby individuals who had turned up to carry out a shift were not who they claimed to be. Whilst there had been no reported incidents at the Trust, the Trust had implemented controls at the ward level, which would be subject to testing during 2025/26. 5.2 Briefing from the Chair of the Finance, Investment & Cash Committee David Liverseidge was invited to present the Committee Chair’s Reports in respect of the meetings held on 22 September and 3 November 2025, the contents of which were noted. It was further noted that: • In September 2025, the Trust had reported that it was in line with its Financial Recovery Plan. Of the £110m Cost Improvement Programme (CIP) target, 76% had been fully developed. • The committee had reviewed the Finance Report for Month 6 (item 5.8), noting that the Trust had reported an in-month deficit of £5.4m, which was in line with the Financial Recovery Plan. • The committee had expressed concern that 17% of the CIP target was not fully developed and that the Trust was £2.5m off-track in terms of delivery of the target at Month 6. • Whilst progress had been made in terms of addressing patients with no criteria to reside and mental health patients, this remained an area of concern. • The committee considered the NHS England Medium Term Planning Framework, noting that the first submission by the Trust was due prior to Christmas 2025. 5.3 Briefing from the Chair of the People and Organisational Development Committee Jane Harwood was invited to present the Committee Chair’s Reports in respect of the meetings held on 22 September and 3 November 2025, the contents of which were noted. It was further noted that: • There continued to be little improvement in terms of the number of patients with no criteria to reside or mental health patients, which impacted staffing numbers. • The Trust was adopting a harder line in respect of its approach to violence and aggression, which included a greater willingness to exclude individuals. • The current participation rate in the Staff Survey was lower than the national average, which was likely indicative of staff morale and engagement. Page 2 • The Trust’s workforce numbers remained above plan, with limited options available to address this issue, especially in the absence of funding for restructuring costs. 5.4 Briefing from the Chair of the Quality Committee Tim Peachey was invited to present the Committee Chair’s Report in respect of the meeting held on 13 October 2025, the content of which was noted. It was further noted that: • The committee received an update in respect of mental health patients, noting that although there were significant issues in the Emergency Department, the whole pathway for these patients remained a problem. • The committee carried out a six-monthly review of the Trust’s progress against its Quality Priorities, noting that good progress had been made on four of the six priorities and two were slightly behind. 5.5 Chief Executive Officer’s Report David French was invited to present the Chief Executive Officer’s Report, the content of which was noted. It was further noted that: • NHS England had published the Medium Term Planning Framework, which was intended to encourage organisations to think beyond a 12-month time horizon and to progress the NHS 10-Year Plan. The Trust was expected to provide its first submission prior to Christmas 2025, but the detailed planning assumptions had yet to be received from NHS England. It was noted that a more detailed report on the Medium Term Planning Framework was to be received as part of the closed session of the meeting. • The Strategic Commissioning Framework had been published by NHS England, which provided welcome clarifications about the future role of integrated care boards. • The Trust had been placed into Tier 1 for both Urgent and Emergency Care and for Elective performance. There was a national expectation that trusts would have no patients waiting over 65 weeks for elective care by 21 December 2025. Where organisations had more than 100 such patients at the end of October 2025, they had been placed into Tier 1. The Trust was taking steps, including mutual aid, to attempt to address the number of long waiters, but there was insufficient capacity in the system. • Resident doctors were due to strike for a further five-day period commencing on 14 November 2025, having rejected the Government’s latest offer to resolve the ongoing dispute with the British Medical Association. • The Hampshire and Isle of Wight Integrated Care Board and NHS England South East Region had carried out a visit to the Trust’s paediatric hearing services in May 2025. The report, received in October 2025, had been positive about the service. • The Trust and the University of Southampton had been awarded £16.3m by the National Institute for Health and Care Research. The Trust was one of only four organisations out of 15 applications to receive an award. • The NHS Business Services Authority had announced the award of a £1.2bn contract to Infosys to deliver a new and enhanced workforce management system for the NHS to replace the existing Electronic Staff Record system. The 2030 target date for implementation was considered ambitious. Further details would be considered by the People and Organisational Development Committee when available. Page 3 5.6 Performance KPI Report for Month 6 Andy Hyett was invited to present the ‘spotlight’ report in respect of Diagnostics, the content of which was noted. It was further noted that: • Diagnostics performance was a key element of the pathway, as delays in diagnosis had a consequential impact on the overall length of pathways such as those for cancer and patients on a Referral To Treatment pathway. • Although there were some concerns with Diagnostics in the Trust, the Trust, generally, performed better than other organisations. The Board discussed the matters raised in the Diagnostics ‘spotlight’. This discussion is summarised below: • There had been a long-standing issue with waiting times for cystoscopy due to insufficient capacity. However, a plan was being developed to improve the situation, although it was considered appropriate that the plan should also address broader issues with urology as a whole. • There was concern regarding the availability of magnetic resonance imaging (MRI) scanners, particularly as two scanners were out-of-action. It was noted that the current set-up in terms of MRI scanners was not fit for the longer term and a strategy for the future needed to be developed. • There was a disparity between capacity and demand in respect of the neurophysiology service, as this service had previously relied on outsourcing. • Generally, activity was increasing, but overall performance appeared to be declining. There was also the additional financial challenge that Diagnostics was funded under a ‘block’ contract arrangement which did not fully take into account the demand for these services. • There were concerns about the electrical supply capacity at the Southampton General Hospital site and the ability of the Trust to expand its Diagnostic capacity with this limitation. It was considered that a better longer-term model would be for scanners at local community diagnostics centres. Actions Andy Hyett agreed to work on and present at either a future Board meeting or Trust Board Study Session the Trust’s longer-term strategy with respect to MRI scanners and imaging. Andy Hyett agreed to develop a longer-term plan for cystoscopy/urology and to report back to the Board during Quarter 4. Andy Hyett agreed to develop a long-term solution to the neurophysiology service. Andy Hyett was invited to present the Performance KPI Report for Month 6, the content of which was noted. It was further noted that: • The Trust’s Emergency Department had recorded performance of 67.6% against the four-hour standard during September 2025. The department remained busy with c.450 patients and 120 ambulance attendances per day. • There had been some initial performance impacts with the roll out of the MIYA system in the Emergency Department, but this appeared to have now been addressed with performance up to previous levels. • A number of initiatives were being introduced into the Emergency Department in order to improve performance. These included the layout of the service, pathway re-designs, having General Practitioners in the department, and arranging with non-urgent patients to attend at a scheduled time rather than waiting in the department. Page 4 • In October 2025, the Trust had recorded 363 patients waiting over 65 weeks on a Referral To Treatment pathway against a national target of no such patients by the end of December 2025. • The Trust was making use of the independent sector, weekend working, and was requesting capacity from other providers to address the number of patients waiting over 65 weeks. • The planned industrial action by resident doctors posed a challenge, noting that the national expectation was that trusts maintain 95% of their capacity during this period. It was noted that, in contrast to previous instances of industrial action, resident doctors were apparently less forthcoming in terms of whether they intended to participate in the industrial action. • The Trust continued to report one of the lowest Hospital Standardised Mortality Rates in England. • The Trust’s cancer performance, based on a BBC article, was 21 out of 121 trusts. It was noted that whilst the number of patients being referred on a cancer pathway had increased significantly, the number of patients diagnosed with cancer had not materially changed. • There appeared to have been an increase in the number of pressure ulcers and ‘red flag’ incidents. Work was ongoing to address the findings of the pressure ulcer audit which had been presented to the Quality Committee on 2 June 2025. • The number of patients having no criteria to reside and mental health patients remained high. Actions Andy Hyett agreed to clarify the basis of the calculation of the ‘Watch & Reserve antibiotics usage per 1,000 adms’ metric. 5.7 Break 5.8 Finance Report for Month 6 Ian Howard was invited to present the Finance Report for Month 6, the content of which was noted. It was further noted that: • The Trust had submitted its Financial Recovery Plan to NHS England in August 2025, which committed to an additional £23m improvement in the Trust’s financial position to deliver a full-year position of a £54.9m deficit. In the absence of these additional improvements, the Trust had been forecasting a year-end position of a £78m deficit. The revised target was subject to a number of assumptions, including the need for demand management and improvements in non-criteria to reside and mental health patient numbers. • There were a number of risks to the achievement of the Financial Recovery Plan, including whether there would be improvements in mental health and non-criteria to reside and/or steps taken to manage demand, high levels of activity, and whether it would be possible to reduce the workforce and close theatres. The need for the Trust to focus on achieving the 65-week wait target in particular could impact the Trust’s ability to close capacity. • The Trust had reported an in-month deficit of £5.4m (£30.8m year-to-date), which was in line with the trajectory set out in the Financial Recovery Plan. The Trust’s underlying deficit had seen some marginal improvement during the period. • The Trust’s cash position remains an area of significant concern. Cash requests had been made to NHS England, but the latest request for November 2025 had been rejected. It was therefore likely that the Trust would need to manage its supplier payments in accordance with its available cash. Page 5 5.9 ICS System Report for Month 6 Ian Howard was invited to present the ICS System Report for Month 6, the content of which was noted. It was further noted that: • The Hampshire and Isle of Wight Integrated Care System had reported a year- to-date deficit of £48m. • A significant improvement in the run-rate would be required for the system to be able to deliver its 2025/26 plan. • The system was one of the worst in England in terms of the number of beds occupied by patients having no criteria to reside with approximately 23% of beds being occupied by such patients compared with a national average of 12%. • The system was also below plan in terms of its targets for access to General Practitioners and targets relating to mental health patients. It was noted that the performance in these areas had a consequential impact on the Trust’s performance in areas such as urgent and emergency care performance. 5.10 People Report for Month 6 Steve Harris was invited to present the People Report for Month 6, the content of which was noted. It was further noted that: • The overall workforce fell by 73 whole-time-equivalents (WTE) during September 2025 and was reported as being 54 WTE above the Trust’s 2025/26 plan. The reduction in workforce had been driven through a combination of the impact of the recruitment controls, mutually agreed resignation scheme (MARS) leavers, and a significant drop in use of temporary staff during the month. • On 15 October 2025, the Trust had heard the collective grievance brought by the Royal College of Nursing in respect of the removal of enhanced NHS Professionals rates. It was decided not to reverse the decision in order to maintain equity with the rest of the workforce and consistency across other local providers. A number of actions had been agreed following the hearing. • Sickness rates had increased to 3.8%, although the Trust still benchmarked well against peers. • There were concerns about the potential impact of influenza during the winter period and therefore the Trust was taking a number of actions to promote vaccination of staff. The Trust was currently third in terms of uptake in the Region. • The level of participation in the national Staff Survey remained a challenge with only 32% of staff having completed the survey compared with a national average of 38%. It was considered likely that the recent difficult decisions taken and the impact on staff was impacting staff experience and engagement. • The People and Organisational Development Committee would be examining statutory and mandatory training levels together with the latest proposed national changes. Page 6 5.11 NHSE Audit and review of 'Developing Workforce Safeguards' including UHS Self-Assessment Return Natasha Watts was invited to present the NHS England audit and review of ‘Developing Workforce Safeguards’ (2018), including the Trust’s Self-Assessment Return, the content of which was noted. It was further noted that: • ‘Developing Workforce Safeguards’ was published in October 2018 and included a range of standards to assure safe staffing across the workforce. NHS England had initiated an audit, review and improvement plan amidst concern about a national reduction in compliance. • The Trust had submitted a self-assessment as part of this NHS England review. This assessment showed that the Trust continued to comply with the majority of the standards. • The audit exercise has been used as an opportunity to identify opportunities for improvement. Twelve recommendations have been developed, of which nine were assessed as ‘green’ and three as ‘amber’. 5.12 Guardian of Safe Working Hours Quarterly Report and Update on 10-Point Plan Diana Hulbert was invited to present the Guardian of Safe Working Hours Quarterly Report and Update on the 10-Point Plan, the content of which was noted. It was further noted that: • Resident doctors were due to strike for five days from 14 November 2025. This would be the thirteenth strike in recent years. It was noted that, in addition to pay, the dispute also concerned working conditions and the shortage of posts and consequent risk to resident doctors of unemployment. • The Trust had performed a self-assessment against the 10-Point Plan and it was noted that the majority of the plan’s contents had been considered by the Trust for some time. There were also a number of dependencies on the part of NHS England in areas such as lead employer models. • A national review of statutory and mandatory training was expected to enable portability of training records to facilitate staff moving between NHS organisations. • There had been significant improvements in respect of gaps in rotas. 5.13 Annual Clinical Outcomes Summary Luci Hood and Kate Pryde were invited to present the Annual Clinical Outcomes Summary Report, the content of which was noted. It was further noted that: • The paper provided an overview of the clinical outcomes reviewed by the Clinical Assurance Meeting for Effectiveness and Outcomes (CAMEO) over the 12-month period to September 2025. • The majority of specialities provide reports to CAMEO, although outcome data can be more difficult in some areas to capture than in others. • The outcomes reviewed by the CAMEO and outputs from this body were also influencing the development of the Trust’s clinical strategy. • The strains on the capacity of services posed a risk to clinical outcomes. Page 7 • There was potential that a ‘quality’ override could form part of the NHS Oversight Framework in the future, operating in a similar manner to the ‘financial’ override by limiting the segmentations available to an organisation. 6. STRATEGY and BUSINESS PLANNING 6.1 Corporate Objectives 2025-26 Quarter 2 Review Martin De Sousa was invited to present the review of Corporate Objectives 2025/26 for the second quarter, the content of which was noted. It was further noted that: • Of the 12 objectives agreed for 2025/26, six were rated ‘green’, four were ‘amber’ and two were ‘red’. • The ‘red’ rated risks were that relating to the Trust’s financial performance and that relating to the Trust’s achievement of its workforce plan for 2025/26. 6.2 Board Assurance Framework (BAF) Update Lauren Anderson was invited to present the Board Assurance Framework update, the content of which was noted. It was further noted that: • BDO had completed its audit of the Trust’s risk maturity and had presented its report to the Audit and Risk Committee on 13 October 2025. The audit had highlighted a number of strengths including the Board Assurance Framework, risk definition, and use of risk in decision-making. In terms of opportunities for improvement, the audit report suggested some improvements in articulation of operational risks and use of ‘SMART’ methodology for actions. • The Board Assurance Framework had been reviewed by relevant executive directors and committees since it was last presented to the Board. There had been no changes to the ratings or target dates. 7. CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Feedback from the Council of Governors’ (COG) Meeting 28 October 2025 The Chair presented a summary of the Council of Governors’ meeting held on 28 October 2025. It was noted that the meeting had considered the following matters: • Chief Executive Officer’s Performance Report • Governor attendance at Council of Governors’ meetings • Review of the Council of Governors’ Expenses Reimbursement Protocol • Appointment of Jane Harwood as Deputy Chair with effect from 1 October 2025 • Membership engagement • Feedback from the Governors’ Nomination Committee It was noted that the Trust’s work on violence and aggression received particular attention from the Governors. 7.2 Register of Seals and Chair’s Action Report The paper ‘Register of Seals and Chair’s Actions Report’ was presented to the meeting, the content of which was noted. Page 8 It was further noted that one further item had been sealed on 7 November: Deed of Guarantee between University Hospital Southampton NHS Foundation Trust (Guarantor) and CHG-Meridian UK Limited (Beneficiary) regarding the payment and due performance obligations of UHS Estates Limited (UEL) under the Guaranteed Contract and specifically the Stryker Power Tools delivered to UEL under the pre-contract open build period with CHG. Seal number 307 on 7 November 2025. Decision: The Board agreed to ratify the application of the Trust Seal to the documents listed in the ‘Register of Seals and Chair’s Actions Report’ and to the additional document referred to above. 7.3 Health and Safety Services Annual Report 2024-25 Spencer Scott was invited to present the Health and Safety Services Annual Report 2024/25, the content of which was noted. It was further noted that: • The number of incidents reportable pursuant to the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) had increased substantially to 68 such incidents compared to 39 in 2023/24. The majority of these incidents related to moving and handling or exposure to infectious diseases. • There was a concern that there had been a reduction in the number of health and safety related reports and escalations whilst at the same time the number of RIDDORs had increased. • Four areas of concern were highlighted: Entonox surveillance of maternity staff, display screen equipment compliance, the Southampton General Hospital loading bay, and workplace temperatures during the summer. 8. Any other business There was no other business. 9. Note the date of the next meeting: 13 January 2026 10. Items circulated to the Board for reading The item circulated to the Board for reading was noted. There being no further business, the meeting concluded. 11. Resolution regarding the Press, Public and Others Decision: The Board resolved that, as permitted by the National Health Service Act 2006 (as amended), the Trust’s Constitution and the Standing Orders of the board of directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. The meeting was adjourned. Page 9 List of action items Agenda item Assigned to Deadline Status Trust Board – Open Session 15/07/2025 - 5.11 Freedom to Speak Up Report 1267. Data Mbabazi, Christine 10/03/2026 Pending Explanation action item Christine Mbabazi to include data from other mechanisms for reporting concerns in future Freedom to Speak Up reports. Trust Board – Open Session 09/09/2025 - 8 Any other business 1286. Organ donation Machell, Craig 03/02/2026 Pending Explanation action item Craig Machell agreed to add organ donation to the agenda of a future Trust Board Study Session. Update: Scheduled for TBSS on 03/02/26. Trust Board – Open Session 11/11/2025 - 5.6 Performance KPI Report for Month 6 1293. MRI scanners and imaging Hyett, Andy 13/01/2026 Pending Explanation action item Andy Hyett agreed to work on and present at either a future Board meeting or Trust Board Study Session the Trust’s longer-term strategy with respect to MRI scanners and imaging. 1294. Cystopscopy/urology Hyett, Andy 13/01/2026 Pending Explanation action item Andy Hyett agreed to develop a longer-term plan for cystoscopy/urology and to report back to the Board during Quarter 4. Page 1 of 2 Agenda item Assigned to Deadline Status Trust Board – Open Session 11/11/2025 - 5.6 Performance KPI Report for Month 6 1295. Neurophysiology Hyett, Andy 13/01/2026 Pending Explanation action item Andy Hyett agreed to develop a long-term solution to the neurophysiology service. 1296. Watch & Reserve antibiotics usage Hyett, Andy 13/01/2026 Pending Explanation action item Andy Hyett agreed to clarify the basis of the calculation of the ‘Watch & Reserve antibiotics usage per 1,000 adms’ metric. Page 2 of 2 Agenda Item 5.1 i) Committee Chair’s Report to the Trust Board of Directors 13 January 2026 Committee: Finance, Investment and Cash Committee Meeting Date: 24 November 2025 Key Messages: Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) Any Other Matters: • The committee received an update in respect of the Trust’s commercial activities, noting that the Trust had robust systems in place to maximise cost recovery for private patient and overseas visitor income. The Trust’s private patient unit project continued to progress. The Trust was also seeking a partner to manage its parking provision. • The committee received the Finance Report for Month 7. The Trust had reported a £5.1m in-month deficit (£35.9m year-to-date), which was in line with the trajectory contained in the Financial Recovery Plan. The underlying deficit remained flat at £6.4m. Whilst there had been a slight reduction in the number of mental health patients, there were c.240 patients having no criteria to reside at any point during the period. There was an increased level of scrutiny in respect of non-pay expenditure. • The committee reviewed an update on the Trust’s measures for financial improvement, noting that the Trust was forecasting achievement of £85-95m against its target of £110m Cost Improvement Programme delivery for 2025/26. • The committee noted the Trust’s approach and the timelines associated with the Medium Term Planning submission. It was noted that the framework set ambitious financial and performance targets. • The committee received an update in respect of the Trust’s Theatre Experience Programme, noting that there had been a 3% increase in utilisation and a 3% reduction in cancellations. • The committee reviewed the Trust’s productivity, noting that the Trust’s productivity had fallen by 3.3% compared to the prior year due to high-cost growth. • The committee received an update in respect of the Trust’s cash position and forecast and supported a proposal to request further cash support for January 2026. • The committee received an update on Capital Planning for 2026/272029/30. It was noted that it was expected that the Trust would be allocated c.£40m per annum, although there were concerns about the impact of the Trust’s cash position and the ability of the Trust to meet this level of expenditure. N/A N/A Page 1 of 2 Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Limited Assurance Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. No Assurance There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Not Applicable Where assurance is not required and/or relevant. Risk Rating: Low Medium High Not Applicable Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda Item 5.1 ii) Committee Chair’s Report to the Trust Board of Directors 13 January 2026 Committee: Finance, Investment and Cash Committee Meeting Date: 15 December 2025 Key Messages: • • • • • • The committee received the Finance Report for Month 8 (see below). The committee discussed the Trust’s future transformation programmes, noting that the areas of focus would be: urgent and emergency care, elective care, and automation of administrative processes. The committee was assured that the programmes were felt to be suitably ‘bold and ambitious’ and were grounded in realistic opportunities, rather than ‘blue sky’ ideas. The committee reviewed the draft capital plan for 2026/27 – 2029/30, noting that the Trust had been allocated c.£40m of capital departmental expenditure limit (CDEL) per year. It was noted that the Trust’s cash position could place constraints on the Trust’s capital programme. The opportunity to secure funding from national programmes outside of CDEL should be pursued vigorously. The plan was to be discussed in a Trust Board Study Session prior to submission in February 2026. The committee reviewed, challenged and discussed the Trust’s medium-term plan ahead of the first submission to NHS England on 17 December 2025. The committee provided feedback in respect of the proposed submission noting that some of the assumptions within the 2025/26 plan had not materialised with regard to matters such as reductions in non-criteria to reside numbers and the committee sought assurance that learnings had been applied to the development of the medium-term plan submission. The committee was assured that such assumed reductions within the 2026/27 plan were based purely on actions which were deemed to be within the Trust’s control. The committee suggested some changes with regard to the plan, particularly around growth assumptions in the cost base, and agreed to recommend the revised plan to the Board for approval. It was noted that more detail and reviews would be required prior to the final submission date in February 2026. The committee received an update in respect of the Trust’s cash position and supported a proposal to make a further request for cash support from NHS England for January 2026. The Trust reviewed and supported a proposal for transforming the Southern Counties Pathology network. Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) 5.7 Finance Report for Month 8 Assurance Rating: Risk Rating: Substantial High • The Trust had reported an in-month deficit of £4.9m (£40m year-todate), which was consistent with the Trust’s Financial Recovery Plan. • November 2025 had been a challenging month due to costs associated with industrial action, patients with no criteria to reside and mental health patients. • The Trust had received c.£3m of income out of £6.1m for elective over-performance. • There had been a slight improvement in the Trust’s underlying deficit. Page 1 of 2 Any Other N/A Matters: Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Limited Assurance Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. No Assurance There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Not Applicable Where assurance is not required and/or relevant. Risk Rating: Low Medium High Not Applicable Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda Item 5.2 i) Committee Chair’s Report to the Trust Board of Directors 13 January 2026 Committee: People & Organisational Development Committee Meeting Date: 21 November 2025 Key Messages: • • • • The committee reviewed the People Report for Month 7 including progress against the workforce plan. During October 2025, the overall workforce grew by 14 whole-time-equivalents (WTE). Although the substantive workforce had reduced by 15 WTE, there had been lowerthan-expected turnover and increased temporary staffing usage due in part to high sickness levels. The Trust remained on track, however, with respect to its Financial Recovery Plan trajectory. There were concerns about the response rate to the Staff Survey, which was below the national average. The Trust’s vaccination campaign for staff had started well with the uptake rate for the flu vaccine amongst staff at 43%. The committee considered the outputs of the review by NHS England of statutory and mandatory training and the implications for UHS. It was noted that a revised framework would facilitate passporting of training between NHS organisations. The Trust was aligned to the Core Skills Training Framework across six out of eleven areas and ten out of eleven areas for the Utilising E-Learning for Health material. The committee received an update in respect of the Trust’s Inclusion and Belonging strategy. It was noted that resource constraints and the impact of the current financial and operational environment on staff morale had impacted progress towards achievement of the objectives set out in the strategy. The committee reviewed the People risks contained within the Trust’s Board Assurance Framework. Assurance: N/A (Reports/Papers reviewed by the Committee also appearing on the Board agenda) Any Other N/A Matters: Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Limited Assurance Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. Page 1 of 2 No Assurance Not Applicable Risk Rating: Low Medium High Not Applicable There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Where assurance is not required and/or relevant. Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda Item 5.2 ii) Committee Chair’s Report to the Trust Board of Directors 13 January 2026 Committee: People & Organisational Development Committee Meeting Date: 15 December 2025 Key Messages: Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) • The committee reviewed the People Report for Month 8 (see below) including progress against the workforce plan and Financial Recovery Plan. • The committee considered the workforce implications of the Trust’s medium term plan submission, noting that there were a number of national expectations and targets, such as those relating to sickness rates and elimination of agency spend. In addition, the committee noted the risks associated with the plan, including those where the Trust was reliant on progress with respect to non-criteria to reside and mental health numbers. • The committee received an update regarding the Trust’s Violence and Aggression workstream, noting that the Trust had adopted a revised approach to violence, aggression and abuse directed at staff with a greater willingness to take action against violent/abusive patients and members of the public. A violence and aggression board had been established to provide executive oversight and leadership, and the Trust’s policy was being revised. This work would be accompanied by a comprehensive communication plan for both staff and members of the public. • The committee reviewed the Trust’s progress against its objectives for Year 4 of its People Strategy. 5.9 People Report for Month 8 Assurance Rating: Risk Rating: Substantial High • The overall workforce fell during November 2025, with substantive numbers falling by 52 whole-time-equivalents (WTE). However, temporary staffing use had increased during the month due to increased sickness and operational pressures, which offset much of the reduction in substantive numbers. • The Trust was over its original plan by 214 WTE despite a decrease of nearly 400 WTE since 31 March 2025. In order to hit the Trust’s Financial Recovery Plan target, the overall workforce would need to fall by a further 137 WTE (including a 72 WTE reduction in temporary staffing) by the end of March 2026. • A forecast based on the previous year’s temporary staffing usage for the remaining months of the year indicated that the Trust would end the year approximately 500 WTE above the Trust’s 2025/26 plan. • The Trust had submitted a baseline assessment against the 10 Point Plan to improve Resident Doctors’ working lives in August 2025, which indicated that the Trust compared favourably against other organisations in the South East. The main issues concerned space available for doctors to work in and timeliness of reimbursement of course-related expenses. • The Trust was expected to meet a target of 95% of job plans having been signed off prior to 31 March 2026. At the start of December 2025, 55% of job plans had been signed off. Page 1 of 2 Any Other Matters: • Sickness absence had increased in November 2025 to 4.2% in month due to seasonal illnesses. • The staff survey closed on 28 November 2025. The completion rate for the staff survey had been lower t
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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-2018-19

Description: ANNUAL REPORT AND ACCOUNTS 2018/19 incorporating the quality account 2018/19 Presented to Parliament pursuant to Schedule 7, paragraph 25 (4) (a) of the National Health Service Act 2006 University Hospital Southampton NHS Foundation Trust Annual report and accounts 2018/19 incorporating the quality account 2018/19 Presented to Parliament pursuant to Schedule 7, paragraph 25 (4) (a) of the National Health Service Act 2006 3 ©2019 University Hospital Southampton NHS Foundation Trust 4 TABLE OF CONTENTS Overview and performance report Welcome from our Chair 7 A word from the chief executive 8 Overview of the Trust Statement of purpose and activities 9 History of UHS 9 Our executive team structure 10 Structure of our services 11 Our vision and values 12 Our priorities, key issues and risks 13 Performance report Going concern disclosure 16 Reporting structure 16 Key performance indicators 17 How we monitor performance 18 Detailed analysis and explanation of the development and performance of UHS 18 Regulatory body ratings 23 Environmental matters 24 Social, community, anti-bribery and human rights issues 25 Accountability report Members of the Trust Board 27 Trust Board purpose and structure 31 Board meeting attendance record 2018/19 32 Well-led framework 33 Strategy and finance committee 34 Quality committee 34 Audit and risk committee 35 External auditors 36 Governance code 36 Performance evaluation of Trust Board and its committees 36 Remuneration 36 Countering fraud and corruption 36 Independence of external auditor 37 Internal audit service 37 Better payment practice code 37 Statement as to the disclosures to auditors 37 Disclosures 37 Income disclosures 38 Governance disclosures 38 Approach to quality governance 38 Council of Governors 40 Annual remuneration statement 49 Remuneration and appointments committee 52 Governors’ nomination committee 54 Staffing report 58 Staff survey results 62 Trade union facility time 66 Statement of chief executive’s responsibilities as the accounting officer 69 Annual governance statement 70 Voluntary disclosures Equality, diversity and inclusion 78 Environmental sustainability and climate change 80 Southampton Hospital Charity 84 Developments in informatics 85 Leading research into better care 85 Investing for the future 86 Quality account and quality report 2018/19 Chief executive’s welcome 88 Our approach to quality assurance 90 Our commitment to safety 90 Duty of candour 91 Our commitment to staff 91 Freedom to speak up 94 Our commitment to education and training 95 Our commitment to staffing rota gaps 96 Our commitment to technology to support quality 97 Our commitment to the Care Quality Commission 98 Our commitment to improving the environment for our patients 100 Review of quality performance 101 Clinical research 101 Review of services 102 CQUIN payment framework 103 Data quality 103 Participation in national clinical audits and confidential enquiries 104 How we are implementing the priority clinical standards for seven day hospital services 105 Learning from deaths 106 Progress against 2018/19 priorities 109 Priorities for improvement 2019/20 128 Conclusion 132 Responses to our quality account 133 Statement of directors’ responsibilities 138 Independent auditor’s report 139 Quality account appendix Appendix 1: Our quality priorities 2019/20 143 Appendix 2: Quality performance data 144 Appendix 3: CQUIN data 151 Appendix 4: Clinical audit and confidential enquiries data 154 Appendix 5: British Society of Urogynaecology 156 Appendix 6: National clinical audit: actions to improve quality 157 Appendix 7: Local clinical audit: actions to improve quality 161 Appendix 8: Shared decision making 173 Appendix 9: Registration with the Care Quality Commission 174 Annual accounts Statement from the chief financial officer 177 Foreword to the accounts 178 Independent auditor’s report 179 Financial accounts and notes 186 5 OVERVIEW AND PERFORMANCE REPORT OVERVIEW AND PERFORMANCE REPORT Welcome from our chair 2018/19 was a year of change in the leadership of UHS. Following the departure of Fiona Dalton in March 2018 to run a hospital group in Canada, David French took on the role of interim chief executive officer. On behalf of the Trust Board I would like to thank David for agreeing to do so and also for doing such an outstanding job. During the year we welcomed three new non-executive directors to the Trust; Jane Bailey, Professor Cyrus Cooper and Catherine Mason. Catherine’s talents were also recognised by Solent NHS Trust and she has since left to help lead their organisation as chair. We were delighted to welcome Paula Head as chief executive in September after a rigorous and robust recruitment process. Paula’s experience as chief executive of Royal Surrey County Hospital NHS Trust and, prior to that of Sussex Community NHS Foundation Trust, shone through and we were confident that under her leadership UHS would continue to develop, grow and improve. Demand for our services continues to rise rapidly as the result of a changing demographic and other factors, and at a rate far greater than our income. Despite this our staff continue to deliver exceptional care. I was delighted that this was recognised by the Care Quality Commission in their recent inspection when they again rated us as Good. The revised NHS Long Term Plan will inevitably require us to adapt to the changing pattern of healthcare, but we do so with enthusiasm. This year has shown just how adept we are as an organisation at responding positively to change, not only rising to the challenges it presents, but thriving with it. This is evident in the significant investments we have made in the Trust’s estate this year. Phase one of our new children’s emergency department is complete thanks to the continued support of the Murray Parish Trust. We also approved one of the largest capital investments in our history with the updating and expansion of our general intensive care unit. We recognised that it was as crucial to invest, not just in the physical environment within which we provide healthcare, but within the digital environment too, acknowledging that UHS is an NHS digital exemplar. We have invested significantly in information technology to enhance accessibility and improve both patient and staff experience. We look forward with confidence to helping lead the NHS into a new phase of delivering health and care for the United Kingdom into 2019/20. Peter Hollins Chair 7 OVERVIEW AND PERFORMANCE REPORT A word from the chief executive Since arriving at UHS to take up my position as chief executive officer, I have heard and witnessed some incredible achievements by staff at the Trust. Dr Joanne Horne was named biomedical scientist of the year at the Advancing Healthcare Awards for her work in histopathology; Dr Beth McCausland, quality improvement fellow in dementia care, was named foundation doctor of the year by Royal College of Psychiatrists; Sarah Charters, consultant nurse and mental health lead for the emergency department was awarded an MBE for services to vulnerable adults and her vulnerable adult support team were also winners of a Nursing Times Award in the emergency and critical care category. The medicine for older people therapy team led by Hannah Wood was named most inspiring team at the national #EndPJParalysis awards while Marie Nelson, matron in research and development, and senior research sisters Jane Forbes and Kirsty Gladas won the silver award for clinical research site of the year at the PharmaTimes International Clinical Researcher of the Year Awards. Jean Piernicki, senior nurse manager in occupational health, was awarded the title of Queen’s Nurse in recognition of her high level of commitment to patient care and nursing practice. Fiona Chaâbane, a senior clinical nurse in neurosciences was named winner of the nursing and midwifery award at the BBC’s The One Show Patients Awards. The medicines advice service, led by Dr Simon Wills, picked up the HSJ Value Award for training and development for its medicines learning portal and Matthew Watts, head of news, was named operational services support worker of the year for the south of England at the Our Health Heroes Awards 2018. We were also delighted that the energy and sustainability team collected the clinical NHS Sustainability Award for its green wards project. These are just a few of the individual and team successes achieved this year. Our entire organisation can also be incredibly pleased and encouraged by the outcome of the recent Care Quality Commission (CQC) inspection, which rated UHS ‘good’ overall, with many individual areas being recognised as outstanding by the CQC. You can find full details of the inspection on page 98 of the quality account. Such positive inspection results link to equally positive staff survey results which saw UHS ranked as the second highest acute trust for staff satisfaction and fifth highest for staff recommending the Trust as a place to work and receive treatment. It’s made me incredibly proud to be able to say that I am part of such a driven team and it’s clear that the UHS team share my drive and determination to improve things for patients and staff every day. This is evident in both the successes I have already mentioned, but also in the pioneering work that is taking place across every department. Informatics has been pioneering new digital initiatives which they recently shared with Hadley Beeman, chief technology adviser to the secretary of state and social care. Surgeons Bhaskar Somani and Stephen Griffin have created a ‘twin surgeon’ model that has revolutionised the treatment of kidney stones in children. Dr John Paisey, consultant cardiologist, and his team were among the first in the world to implant and programme a pacemaker using Bluetooth technology. They performed four of the first five procedures in the world. While Professor Mike Grocott and his team created ‘surgery school’ which is transforming the fitness of patients prior to their operations and thereby reducing length of stay. These are by no means the entirety of our achievements this year and I would like to take the opportunity to thank every single member of staff at the Trust who continues to make UHS one of the leading trust’s in the UK. Paula Head Chief executive officer 8 OVERVIEW AND PERFORMANCE REPORT Overview of the Trust Statement of purpose and activities UHS is a large teaching hospital located on the south coast of England. We have a tripartite mission to provide clinical care, educate current and future healthcare professionals, and undertake research to improve healthcare for the future. Our clinical care encompasses local acute and elective care for 680,000 people who live in Southampton, the New Forest, Eastleigh and Test Valley. We also provide care for the residents of the Isle of Wight for many services. As the major university hospital on the south coast, UHS provides the full range of tertiary medical and surgical specialities (with the exception of transplantation, renal services and burns) to over 3.7 million people in central southern England and the Channel Islands. UHS is a centre of excellence for training the doctors, nurses and other healthcare professionals of the future. We work with the University of Southampton and Solent University to educate and develop staff at all levels, including a large apprenticeship programme, undergraduate and post-graduate education. Our role in research, developed in active partnership with the University of Southampton, is to contribute to the development of treatments for tomorrow’s patients. This work distinguishes us as a hospital that works at the leading edge of healthcare developments in the NHS and internationally. In particular we have nationally-leading research into cancer, respiratory disease, nutrition, cardiovascular disease, bone and joint conditions and complex immune system problems. We are one of the largest recruiters of patients into clinical trials in the country. Over 11,900 people work at the Trust, making it one of the area’s biggest employers. We also benefit from the contributions of over 1,000 volunteers. Our turnover in 2018/19 was more than £878m. History of UHS The Trust has its origins in the 1900s when the Shirley Warren Poor Law Infirmary was built on the site of what is now Southampton General Hospital. In the early half of the century, the site began to expand, including the opening of the school of nursing and the creation of the Wessex Neurological Unit. In 1971 a new medical school was opened in Southampton and the 1970s and 1980s saw a significant building programme encompassing the current footprint of Southampton General Hospital, Princess Anne Hospital and Countess Mountbatten House. During the 1990s, services were increasingly centralised at the general hospital, with the eye hospital and cancer services being relocated from elsewhere in the city. The Wellcome Trust funded a clinical research facility at the hospital in 2001 and this unit remains the foundation for much of the Trust’s groundbreaking medical research. In the last decade, development has continued with the opening of the North Wing Cardiac Centre in 2006, the creation of a major trauma centre with on-site helipad and the opening in 2014 of Ronald McDonald House for the relatives of sick children. Organisationally, Southampton University Hospitals Trust was formed in 1993, creating a single management board for acute services in Southampton. Eighteen years later, University Hospital Southampton NHS Foundation Trust (UHS) was formed (1 October 2011) when Southampton University Hospitals NHS Trust was licensed as a foundation trust by the then regulator, Monitor (now known as NHS Improvement (NHSI)). 9 OVERVIEW AND PERFORMANCE REPORT Our executive team structure Associate director of corporate affairs (interim) Charlie Helps Constitution; Council of governors; legal services; insurance; risk management; policy management; freedom of information (FOI) general data protection regulations (GDPR) Chief executive Paula Head Director of HR Steven Harris Employee relations; pay and reward; resourcing and temporary staffing; staff engagement; staff performance and appraisal; occupational health and wellbeing; childcare services; communications Medical director Dr Derek Sandeman MD for research & development; clinical effectiveness; clinical practices and outcomes; professional regulation & standards; GP relationships Director of nursing & organisational development Gail Byrne Chief financial officer & deputy chief executive David French Clinical governance & patient safety; education; patient experience; clinical practice & outcomes; professional regulation & standards; complaints/PALS; HR/workforce; voluntary services; fundraising Caldicott Guardian Financial management; financial strategy; investment & ROI; audit; procurement; capital programme management; estates; Commercial development Division A Surgery Cancer care Critical care & theatres Chief operating officer Caroline Marshall Major incident planning; security Division B Division C Emergency medicine Women & newborn Specialist medicine/ ophthalmology Pathology Child health Support services Director of transformation & improvement Jane Hayward Division D Cardiovascular & thoracic Neurosciences Trauma & orthopaedics Cost improvement & transformation; information technology; information governance; core platform systems; informatics development; strategy; commissioning; business & capacity planning Senior Information Risk Owner (SIRO) Radiology 10 OVERVIEW AND PERFORMANCE REPORT Structure of our services Our organisation is split into five areas, with our clinical services grouped into four divisions. Within each division there are care groups. Each division, with the exception of Trust headquarters, is led by a divisional management team consisting of: • divisional clinical director (DCD) • divisional director of operations (DDO) • divisional head of nursing/professions (DHN) • divisional research and development lead • divisional finance manager • divisional planning and business development (or strategy) manager • divisional education lead • division HR business partner • divisional governance manager (DGM) The diagram below outlines the five divisions and care groups/services within each. Each care group has a clinical lead, care group manager and matron/s for specific services as a minimum. Division A Surgery Cancer care Critical care Theatres Division B Emergency medicine Medicine for older people Pathology Specialist medicine and ophthalmology Genetics Division C Child health Women and newborn Support services Division D Cardiovascular and thoracic Neurosciences Trauma and orthopaedics Major trauma centre Radiology TRUST HQ Corporate affairs Communications Finance Human resources Informatics Patient support services Claims and litigation Cost improvement and transformation Estates and capital developments Research and development 11 OVERVIEW AND PERFORMANCE REPORT Our vision and values Our Forward vision outlines who we are and what we stand for, as well as describing the current challenges we face and our priorities for the future. It also provides an in-depth review of our three Trust values, which are summarised below: putting patien putting patien putting patien putting patien putting patien putting patien putting patien putting patien putting patien king together king together king together king together king together king together king together king together king together ts first ts firwsotr ts firwsotr wor ts first ts firwsotr ts firwsotr wor ts first ts firwsotr ts firwsotr wor always imparlwovaiynsg imparlwovaiynsg improving always imparlwovaiynsg imparlwovaiynsg improving always imparlwovaiynsg imparlwovaiynsg improving ts first ts first ts first wor wor wor putting patien putting patien putting patien king together king together king together always imparlwovaiynsg imparlwovaiynsg improving Patients and families will be at Our clinical teams will provide the heart of what we do and services to patients and are their experience within the crucial to our success. hospital, and their perception We have launched a leadership ofmtheeasTurruensgtop,aftwiesnuitlslcfbcnigreesptsaosti.euntrs fnigrsptatients first clsintrrikacintageltgomgyetahtnherkraianggtteoegmnetsehuernkrrintegstteoogaeumthresr are engaged in the day-to-day management and governance of the Trust. alw alw alw Our growing reputation in research and development and our approach to education and training will continue ays improtvoinagiyns icmoprropvionagrysaitmeprnoveinwg ideas, technologies and greater efficiencies in the services we provide tients first tients first tients first together together together mproving mproving mproving putti putting pa putti putting pa putti putting pa wo working wo working wo working always i always i always i 12 OVERVIEW AND PERFORMANCE REPORT Our priorities, key issues and risks Our top eight priorities 1 Promote and live our values. We will: • be clearer about the behaviours we expect from our staff • recruit, train and promote people who demonstrably share our values in everything they do 2 Improve safety, quality and productivity. We will: • Sign up to safety and deliver on our promises to patients as part of this campaign • Focus on improving outcomes by measuring and publishing clinical outcomes for all specialties • Focus on improving the whole patient experience, so that patients feel treated with compassion by all staff in every contact • Develop the concept of excellent administrative care, organising our services well so that the patient journey runs smoothly • Commit to productivity improvement across all areas • Develop innovative solutions that allow us to deliver services more efficiently while making better use of our capacity 3 Our staff and education mission. We will: • Attract the best staff by offering them a better deal and the best place to work • Continue to invest in education and training opportunities for our staff including leadership development • Ensure that our leaders and staff understand and deliver our equality and diversity agenda • Prioritise excellent communication that allows the voice of our staff to be heard and acted on • Focus on the staff of the future by developing our education and training capability for clinical and non-clinical staff • Work with our local education providers to offer excellent education opportunities and bring high calibre people into healthcare roles in our hospitals 4 Become a hospital without walls. We will: • Increase the number of patients we care for who are not inpatients within the hospital. Some of these will be cared for in another residential location or at home in partnership between ourselves and other organisations • Be clear about services where we wish to provide end-to-end integrated care, and those where we wish to work with partners to integrate care across organisations • Work with health and social care partners (public, private and third sector), where necessary using new organisational models, to ensure that patients are always cared for in the right setting • Work more closely with general practices and support innovation being led by primary care 13 OVERVIEW AND PERFORMANCE REPORT 5 Specialised services. We will: • Engage with commissioners to plan changes in service models according to national service specifications • Continue to plan and manage the ongoing drift of sub-specialist work particularly in paediatrics and complex surgical services • Maintain and develop the critical mass that is increasingly required to care for complex and specialist patients • Work with Salisbury NHS Foundation Trust, the University of Southampton and other partners to play our part in the genomic revolution, building on the Genomic Medicine Centre and seeking to become a Genomics Central Laboratory Hub for the region • Develop our clinical informatics ability to ensure that we can take advantage of new information available for the benefit of patients 6 Preventative care. We will: • Continue to expand our screening programmes as national policy and commissioning intentions develop • Take every opportunity to further support and improve the health of our staff • Ensure that our clinical translational research programme, much of which is directly relevant to health promotion, accelerates translation of research into benefit for the local population 7 Discovery. We will: • Develop a detailed plan to continue increasing the number of UHS patients who are offered access to clinical trials and maximise the impact of the research we undertake • Work with the University of Southampton to submit a strong bid for the next round of Biomedical Research Centre / Biomedical Research Unit funding opportunities • Support the University of Southampton to create an international centre for cancer immunology to accelerate the development of new immune therapies to treat cancer 8 All stages of life. We will: • Continue to expand our paediatric services in partnership with community and local acute paediatrics and develop the physical infrastructure of a modern children’s hospital as quickly as finances allow • Continue to improve transition and the care of teenagers and young adults • Develop elderly care services that are integrated across the acute and community sectors • Continue to develop our end of life care 14 OVERVIEW AND PERFORMANCE REPORT Key issues and risks 1 Failure to deliver national access targets, which impacts patient experience and patient safety. Whilst we are meeting some of the national constitutional standards in waiting times, we are not meeting them all. A number of actions have been taken in relation to improving responsiveness and working with local health and social care partners to reduce delayed transfers of care. The Trust will continue to work to reduce delayed transfers of care, as well as reviewing the efficiency of discharge processes during 2019/20. 2 Capacity and occupancy, which impacts on patient flow and the quality and timeliness of care. Operational risks have been identified across a number of services/specialties linking to issues around increasing referrals, system capacity and delayed transfers of care. We have mitigated this by implementing daily reviews to assess system capacity and escalation requirements aligning capacity plans with the wider system, developing plans to reduce length of stay with strong clinical leadership and oversight and working with local health and social care partners to reduce delayed transfers of care. 3 Staffing, both in terms of recruitment and retention. To mitigate this risk we will continue to focus on making UHS an attractive employer by: • developing band four posts and apprentices • leveraging the ‘Think UHS’ recruitment brand • continuing to recruit within Europe and further afield • working with universities to increase student nurses • enhancing medical overseas fellows posts • reviewing all junior doctor rotas in light of the new contract • using flexible and temporary staff when needed • creating different roles linked to our research agenda • reviewing training and education to enhance retention. 15 OVERVIEW AND PERFORMANCE REPORT Performance report Going concern disclosure After making enquiries, the directors have a reasonable expectation that the Trust has adequate resources to continue in operational existence for the foreseeable future. For this reason, they continue to adopt the going concern basis in preparing the accounts. Reporting structure As a large NHS university hospital foundation trust, UHS monitors performance within individual teams throughout the year with feedback processes in place to escalate issues to more senior management teams. At a corporate level we have an established executive reporting structure. Monthly Trust Board Public meeting where executive directors present high level summary to chairman and non-executive directors. For further information see page 31. Audit and risk committee Strategy and finance committee Quality committee Trust executive committee (TEC) Review performance/issues/risks in greater depth For further detail on role of these committees please refer to the annual governance statement section on page 70. Trust Board study sessions Trust Board members meet to focus on a specific issue. Performance meetings Operational management team (led by chief operating officer) and division and care group management teams focus on individual patient and service pathways to develop improvement plans. 16 OVERVIEW AND PERFORMANCE REPORT Key performance indicators (KPIs) The Trust publishes a monthly integrated KPI Board report on our website which provides both the Board and the public with an overview of our performance. This report is constantly evolving as new areas of monitoring are developed and new areas of national focus become apparent. For 2018/19 the format of the monthly report followed the five key Care Quality Commission (CQC) questions: • Are we safe? • Are we effective? • Are we caring? • Are we responsive? • Are we well-led? The monthly report features the following sections: • Overview – Aggregation of commentary supporting all sections of the report • Safe • Effective • Caring • Activity • Emergency access • Referral to treatment and diagnostics • Cancer waiting times • Flow • Staffing • Research and development • Estates • Digital This report also includes summary versions of quarterly reports submitted to the Trust executive committee, which go into greater detail about patient experience, patient safety, clinical effectiveness outcomes, and infection prevention. In addition, a separate finance Board report is submitted to Trust Board on a monthly basis. The Emergency Access, Activity and Flow section have several KPI’s that are relevant to the key risk of delivering the national access target. Some of the KPI’s are: • Number of attendances • Time to initial assessment • Hospital red/black alerts • Delayed transfers of care • Non-elective length of stay The Activity and Flow section have several KPI’s that are relevant to the key risk of capacity and occupancy. Some of the KPI’s are: • Length of stay • New referrals • Number of attendances • Bed occupancy • Hospital red/black alerts The Staffing (HR) section has several KPI’s that are relevant to the key risk of Staffing. Some of the KPI’s are: • Staff turnover • Nursing vacancies • Friends and Family Test – percentage of staff who recommend UHS as a place to work You can see full copies of the monthly report by visiting www.uhs.nhs.uk 17 OVERVIEW AND PERFORMANCE REPORT How we monitor performance In addition to reviewing the data submitted to the Trust Board in these papers, we have a suite of tools available to compare UHS performance to that of comparable trusts around the country. Depending on the measures being monitored, UHS has a number of peer groups to benchmark against including other local providers, major trauma centres and university hospital teaching trusts. Each NHS trust will service a different size and type of population and will offer a slightly different range of services so it is important to understand that this benchmarking provides an initial indication of performance rather than an absolute guide to our position nationally. In 2018/19 we continue to review the National Model Hospital data as it is published from NHS Improvement. The data and ability to compare our performance has helped to highlight areas of excellent practice and areas where there is potential to improve. The Trust is engaging with the model hospital team and has a member of staff on the ‘model hospital ambassador program’, as well as reviewing areas highlighted as having potential opportunities alongside finance and operational teams. Detailed analysis and explanation of the development and performance of UHS Activity, capacity and occupancy Over the past three years we have seen significant increases in all types of activity. This is linked to demographic growth, new specialist techniques and services transferring from other providers, including vascular services from Portsmouth. In addition, UHS now has responsibility for surgical services at Lymington. The graph and table below demonstrate this increase in activity. UHS growth in activity – 2016/17 to 2018/19 800,000 700,000 600,000 500,000 400,000 300,000 200,000 100,000 0 Inpatient spells (inc. day cases) 2013/14 2016/17 Outpatient appointments 2017/18 2018/19 ED attendances (type one) Referrals (excl March) Inpatient spells (inc. day cases Outpatient appointments ED attendances (type one) Referrals (excl March) 2016/17 160,000 630,045 99,273 189,194 2017/18 157,993 658,147 104,616 197,522 2018/19 168,791 695,343 110,771 207,209 Increase 2016/17 to 2018/19 5.5% 10.4% 11.6% 9.5% 18 OVERVIEW AND PERFORMANCE REPORT Hospital alert status The hospital alert status is decided by the operations centre after assessing the bed and staffing position, and is recorded twice daily at the Trust bed meetings (though the status may change at any time). Black alert is the highest level of alert and is issued when there are no empty beds available across the Trust with no expected discharges, the emergency department is full, and if actions are not taken several ambulances are likely to be delayed for long periods of time, stopping them from responding to 999 calls (this is based on a national definition of escalation). Red alert is when the majority of the hospital is under significant operational pressure and is likely to include a mismatch between supply and demand of beds and/or there are no beds available, with patients waiting more than three hours in the emergency department, and patients with a clinical decision for admission but no bed identified for them to move to. The Trust will undertake a wide range of actions in response to this, including the opening of additional overnight beds (usually within day wards), the redistribution of staff or bed capacity to support areas under most pressure, Trust-wide communication to request a focus on actions which will enable patients to be discharged or the admission avoided and the potential review of less urgent elective operations to maintain bed availability for patients with more urgent needs. In 2015/16 a black alert was recorded seven times at the twice daily bed meetings. In 2016/17 this was increased to eleven, in 2017/18 this increased to twenty, however in 2018/19 there were no black alerts. The chart below shows red alerts logged during 2018/19. Red alerts 2018/19 60 Number of AM and PM alerts 45 30 15 0 4/1/18 6/1/18 8/1/18 10/1/18 12/1/18 2/1/19 Contributing to this change has been an increase in day cases and an increase in length of stay (LoS) for elective patients linked to a more complex case mix. UHS delayed transfers of care 2018/19 The chart below shows the total bed days attributable to delayed transfers of care at UHS in 2018/19. 3,600 Percentage of bed days lost 3,200 2,800 2,400 2,000 April 2018 June 2018 August 2018 October 2018 December 2018 February 2019 19 OVERVIEW AND PERFORMANCE REPORT Referral to treatment (18 weeks) performance National target: 92% of all patients on 18 week pathway and not yet treated should have waited 18 weeks or less at the end of the month (incomplete pathways target). How did we do? UHS did not meet the target this year. Achievement of this target in 2018/19 should be set against a rise in patient referrals, which highlights the increased demands being placed on the Trust. The Trust has finished the financial year with no patients waiting greater than 52 weeks, and a total referral to treatment waiting list lower than in March 2018. Emergency department (ED) performance There are three types of emergency departments: Type Type Type ONE TWO THREE 3 24 hour with full resuscitation facilities 3 Consultant-led 3 Designated accommodation for patients admitted via ED 3 Single specialty emergencies (eye or dental) 3 Consultant-led 3 Designated accommodation 3 Minor injuries/walk-in centres 3 Doctor or nurse-led 3 Can be routinely accessed without appointment 3 May be co-located within an ED or sited in the community We run all three types of departments and all three types are subject to the national target and are therefore reflected in our figures. National target: The constitutional standard states that 95% of patients should be treated and either admitted or discharged within fours of arrival into ED. However, NHS Improvement set local targets for all NHS organisations with an ambition that the NHS would return to meet the 95% target by March 2019. The local targets set by quarter (to allow for seasonal variations) for UHS were: Quarter 1 - 90% Quarter 2 - 91.4% Quarter 3 - 90% Quarter 4 - 90-95% How did we do? 2018/19 was another challenging year for emergency patients for the whole Hampshire and Isle of Wight area. Whilst we had a positive start to the year achieving quarter 1 and 2 targets, we did not meet quarter 3 or 4 targets. We did, however, meet out local delivery system targets. 20 OVERVIEW AND PERFORMANCE REPORT The graph below shows our performance against the four hour target over the last year (including all UHS types and Lymington). National 4 hour access target – UHS performance 100% 95% 90% 87.1% 85% 80% 82.1% 82.3% 87.4% 87.4% 93.0% 90.5% 84.7% 82.9% 85.7% 90.7% 88.9% 84.8% 77.9% 81.1% 75% Jan 2018 Feb 2018 Mar 2018 Apr 2018 May 2018 June 2018 July 2018 Aug 2018 Sep 2018 Oct 2018 Nov 2018 Dec 2018 Jan 2019 Feb 2019 Mar 2019 The graph below shows our local delivery system performance against the four hour target over the last year (including all SGH types, Lymington and Southampton Treatment Centre). National 4 hour access target – Local delivery system 100% 95% 91.0% 90% 91.1% 95.1% 92.8% 88.7% 87.1% 89.2% 91.5% 85% 92.9% 88.4% 83.3% 85.9% 80% 75% Apr 2018 May 2018 June 2018 July 2018 Aug 2018 Sep 2018 Oct 2018 Nov 2018 Dec 2018 Jan 2019 Feb 2019 Mar 2019 21 OVERVIEW AND PERFORMANCE REPORT Cancer waiting times There are nine separate cancer waiting times standards (below), each of which can then be split into tumour site specific performance groups. Measures Urgent GP referrals seen in two weeks Breast symptoms referral seen in two weeks Treatment started within 62 days of urgent GP referral Treatment started within 62 days of referral (breast, cervical and bowel screening) 62 day consultant upgrades Treatment started within 31 days of decision to treat Second or subsequent treatment (surgery) started within 31 days of decision to treat Second or subsequent treatment (anti-cancer drugs) started within 31 days of decision to treat Second or subsequent treatment (radiotherapy) started within 31 days of decision to treat Target > 93% > 93% > 85% > 90% > 86% > 96% > 94% > 98% > 98% 18/19 YTD (up to and including Feb 19) 86% 50% 74% 80% Achieved 8 8 8 8 86% 3 93% 8 85% 8 100% 3 100% 3 The number of patients referred under the two week wait urgent suspected cancer protocol seen within two weeks of their referral, rose by 7.7% in 2018/19. The chart below shows the rise in demand for UHS cancer services over the past three years UHS growth in cancer actvity – 2016/17 to 2018/19 (up to and including month 11) 18,000 16,000 14,000 12,000 10,000 8,000 6,000 4,000 2,000 0 Two week waits 2016/17 up to and incl Feb 62 day target patients 31 day target patients 2017/18 up to and incl Feb 2018/19 up to and incl Feb For staffing performance, please refer to page 58. For financial performance please see page 177. Paula Head, chief executive officer 28 May 2019 22 OVERVIEW AND PERFORMANCE REPORT Regulatory body ratings Single Oversight Framework NHS Improvement’s Single Oversight Framework provides the framework for overseeing providers and identifying potential support needs. The framework looks at five themes: 1. Quality of care 2. Finance and use of resources 3. Operational performance 4. Strategic change 5. Leadership and improvement capability (well-led) Based on information from these themes, providers are segmented from one to four where ‘4’ reflects providers receiving the most support, and ‘1’ reflects providers with maximum autonomy. A foundation trust will only be in segments three or four where it has been found to be in breach or suspected breach of its licence. Segmentation During 2018/19 the Trust was confirmed as being placed within segment ‘2’. This segmentation information is the Trust’s position as at 31 March 2019. Current segmentation information for NHS trusts and foundation trusts is published on the NHS Improvement website. Finance and use of resources The finance and use of resources theme is based on the scoring of five measures from ‘1’ to ‘4’, where ‘1’ reflects the strongest performance. These scores are then weighted to give an overall score. Given that finance and use of resources is only one of the five themes feeding into the Single Oversight Framework, the segmentation of the Trust disclosed above might not be the same as the overall finance score here. Area Financial sustainability Financial sustainability Financial sustainability Overall scoring Care Quality Commission ratings: Metric Capital service cover Liquidity Income and expenditure margin Distance from financial plan Agency spend Q1 Q2 Q3 Q4 2 2 1 1 1 1 1 1 1 1 1 1 1 2 2 1 1 1 1 1 1 1 1 1 Overall rating for this trust Are services at this trust safe? Are services at this trust effective? Are services at this trust caring? Are services at this trust responsive? Are services at this trust well-led? Good Requires improvement Outstanding Good Requires improvement Good 23 OVERVIEW AND PERFORMANCE REPORT In December 2018, the CQC inspected four core services; urgent and emergency care, medicine, maternity and outpatients. It also looked at management and leadership, and effective and efficient use of resources. The CQC report (published on the 17 April 2019) rated the Trust as ‘good’ overall and ‘outstanding’ for providing effective services. “Our inspectors found a strong patient-centred culture with staff committed to keeping their people safe, and encouraging them to be independent. Patients’ needs came first and staff worked hard to deliver the best possible care with compassion and respect. Inspectors saw many areas of outstanding practice, with care delivered by compassionate and knowledgeable staff. Several teams led by example with a continuous focus on quality improvement. The Trust did face some challenges especially with the ageing estates. Some patient environments were showing significant signs of wear and tear – but again staff were doing their utmost to deliver compassionate care”. Dr Nigel Acheson Deputy chief inspector of hospitals (South) Environmental matters We recognise that the Trust’s business has an impact on the environment. As a large hospital we undertake a wide range of activities and use a large amount of resources, for example: • The Trust generates approximately 3,000 tonnes of waste yearly, half of which is clinical waste. If not properly treated this huge amount of waste can cause soil, water and air pollution depending on the disposal route. • Due to the large number of visitors and deliveries we attract every day, traffic congestion is regularly experienced on and around the site, which impacts the air quality around the hospital. We are committed to environmental sustainability and consider it as part of the business culture. We acknowledge that reducing waste and minimising the consumption of scarce resources is consistent with financial sustainability. Our sustainability disclosure section on page 80 provides greater detail on the steps we are taking to reduce our activities’ impact on the environment. 24 OVERVIEW AND PERFORMANCE REPORT Social, community, anti-bribery and human rights issues We recognise our responsibilities under the European Convention on Human Rights (included in the Human Rights Act 1998 in the UK), which are relevant to health and social care. These rights include the: • right to life • right not to be subjected to torture, inhuman or degrading treatment or punishment • right to liberty • right to respect for private and family life The Trust is committed to ensuring it fully takes into account all aspects of human rights in our work. At University Hospital Southampton we value our reputation for top quality care and financial probity and conduct our business in an ethical manner. The Bribery Act 2010 was introduced to make it easier to tackle the issue of bribery which is a damaging practice. Bribery can be defined as ‘giving someone a financial or other advantage to encourage them to perform their duties improperly or reward them for having done so’. To limit our exposure to bribery we have in place an Anti-Fraud, Bribery and Corruption Policy, a Standards of Business Conduct Policy and a Freedom to Speak Up (formerly Raising Concerns) Policy. These apply to all staff and to individuals and organisations who act on behalf of UHS. We also employ a local counter fraud specialist who will investigate, as appropriate, any allegations of fraud, bribery or corruption. The success of our anti-bribery approach depends on our staff playing their part in helping to detect and eradicate bribery. Therefore, we encourage staff, service users and others associated with UHS to report any suspicions of bribery and we will rigorously investigate any allegations. In addition, we hold a register of interest for directors, staff, and governors and ask staff not to accept gifts or hospitality that will compromise them or the Trust. The Board of Directors carries out its business in an open and transparent way. We are committed to the prevention of bribery as well as to combating fraud and expect the organisations we work with to do the same. Doing business in this way enables us to reassure our patients, members and stakeholders that public funds are properly safeguarded. There are no important events since the year end affecting the foundation trust. No political donations have been made. The Trust has no overseas branches. 25 FR STAND BODY ACCOUNTABILITY REPORT Members of the Trust Board Board member Name Title Paula Head Chief executive officer David French Deputy chief executive officer and chief financial officer Gail Byrne Director of nursing and organisational development Jane Hayward Director of transformation and improvement Biography Declarations Paula joined the Trust as chief executive in September 2018, having been chief executive at the Royal Surrey County NHS Foundation Trust in Guildford and before that at Sussex Community NHS Foundation Trust. She began her career as a pharmacist working in the community, hospitals and at health authorities before moving into general management and her first board position at Kingston Hospital. Since then she has spent time on the boards of commissioners and providers, including director of transformation at Frimley Park Hospital NHS FT. Paula lives in Hampshire and has a daughter studying medicine at the University of Southampton. Daughter is a medical student at University of Southampton; Member of Hampshire & Isle of Wight Sustainability and Transformation Partnership Executive Delivery Group David joined the Trust in February 2016 and led on finance, procurement, estates and commercial development until March 2018, when he became interim chief executive officer. He read Economics and Social Policy at the University of London before joining ICI plc, where he qualified as a chartered management accountant. David has extensive healthcare experience from the pharmaceutical industry, mostly Eli Lilly and Company where he held many commercial and financial roles in the UK and overseas. He joined the NHS in 2010 as chief financial officer of Hampshire Hospitals NHS Foundation Trust. He also serves as a non-executive director for Vivid Housing Limited, a social housing provider across Hampshire and the Solent. Non-executive director and chair of audit and risk committee, Vivid Housing Limited; Director, UHS Estates Limited, a wholly-owned subsidiary of UHSFT; Director, Southampton Commercial Estates Development Partnership (CEDP) Project Company Limited, a whollyowned subsidiary of UHSFT; Member of Solent Acute Alliance; Member of Hampshire & Isle of Wight Counter Fraud Board; Member of Hampshire & Isle of Wight Sustainability and Transformation Partnership Capital Planning Panel (from May 2018) Gail joined the Trust in 2010 as deputy director of nursing and head of patient safety. Prior to this, she has worked at the Strategic Health Authority as head of patient safety, and director of clinical services at Portsmouth Hospital. Gail has also worked in Brisbane, Australia as a hospital Macmillan nurse, and as general manager of a special purpose vehicle company for the private finance initiative at South Manchester Hospitals. Husband is a consultant surgeon in the Trust; Daughter is a midwife at UHS (from March 2019) Jane joined the Trust in 2000 as a clinical services manager for the cardiothoracic directorate after spending two years in Hertfordshire as director of performance and 11 years at Barts and the London Hospitals in various roles including planning, finance and commissioning. Jane has led on human resources, information management and technology, improvement and modernisation and has been chief operating officer. Jane joined the Trust Board in February 2008 and became director of transformation and improvement in January 2014. Director, UHS Estates Limited, a wholly-owned subsidiary of UHSFT; Father and mother are UHSFT simulated patients (voluntary position) Dr Derek Medical Sandeman director Dr Caroline Marshall Chief operating officer Derek was appointed to the Trust as a consultant physician in 1993 and went on to develop a regional endocrine service. Throughout his career he has had extensive clinical leadership experience, most recently serving eight years as clinical director. Derek’s leadership roles have also included programme director for postgraduate education and the Wessex Endocrine Royal College representative. He has a strong history of wider system engagement, working collaboratively with partners to improve systems resilience and pathways. Caroline joined the Trust in 1997 as a consultant hepatobiliary and neuroanaesthetist. She has held the posts of college tutor for the Royal College of Anaesthetists and UHS mentoring and coaching lead. In 2008, she became clinical service director for critical care, and then divisional clinical director for division A between 2010 and 2013. Caroline served as interim chief operating officer between January to December 2014, and was then appointed to the substantive post. Her portfolio includes the executive lead for cancer and the executive lead for major trauma. Director of UHS Pharmacy Limited, a wholly-owned subsidiary of UHSFT; Member of Hampshire & Isle of Wight Sustainability and Transformation Partnership Clinical Executive Group Daughter is employed within the emergency department at UHS (from 1 August 2018) 27 ACCOUNTABILITY REPORT Non-executive directors Name Title Peter Hollins Chair Simon Porter Senior independent director and deputy chair Dr Mike Non-executive Sadler director Biography Declarations Peter graduated in chemistry from Hertford College, Oxford. Joining Imperial Chemical Industries in 1973, he undertook a series of increasingly senior roles in marketing and then general management. Following three years in the Netherlands as general manager of ICI Resins BV, he was appointed in 1992 as chief operating officer of EVC in Brussels – a joint venture between ICI and Enichem of Italy. He played a key role in the flotation of the company in 1994, returning in 1998 to the UK as chief executive officer of
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