agenda - trust board - uhs

Group Name: Trust Board – Open Session Date of Meeting: 1 February 2018 Venue: Conference Room, Heartbeat Education Centre, F Level,

North Wing, SGH Time: 9.00am Apologies to: Sue Diduch, Corporate Affairs Administrator 9.00 1. Chair’s Welcome, Apologies and Declarations of Interest 2. Minutes of Previous Meeting held on 30 November 2017 Enclosure 1 3. Matters Arising/Summary of Agreed Actions

9.10

4. Integrated Performance Report for Month 9 including: · Quarterly Patient Experience Report (QIF) · Quarterly Patient Safety Report (QIF)

(Jane Hayward, Director of Transformation & Improvement)

Enclosure 2

5. Quality & Safety Discussion Items 9.45

5.1 Guardian of Safe Working Hours Quarter Report (Derek Sandeman, Medical Director/Kathryn Nash, Consultant Hepatologist and Interim Guardian of Safe Working Hours)

Enclosure 3

9.55

5.2

Equality, Diversity and Inclusivity (EDI)/Workforce Race Equality Standard (WRES) Action Plan Quarter Report (Gail Byrne, Director of Nursing & Organisational Development/Gemma Genco, Head of Equality, Diversity & Inclusivity)

Enclosure 4

10.05

5.3 Learning from Deaths Quarter Report (Gail Byrne, Director of Nursing & Organisational Development/ Neil Pearce, Associate Medical Director for Patient Safety)

Enclosure 5

6. Finance Discussion Items 10.15 6.1 Finance Report for Month 9

(David French, Chief Financial Officer) Enclosure 6

7. Governance Decision Items 10.25 7.1 Chief Executive’s Report including items for ratification

(Fiona Dalton, Chief Executive) Enclosure 7

Discussion Items 10.30

7.2 Feedback from Council of Governors’ Meeting 16 January 2018 (Peter Hollins, Trust Chair)

Oral

10.35

7.3 Briefing from Chair of Audit & Risk Committee (Simon Porter, Chair A&RC)

Oral

10.40

7.4 Briefing from Chair of Quality Committee (Mike Sadler, Chair QC)

Oral

Agenda

10.45

7.5 Briefing from Chair of Strategy & Finance Committee (Simon Porter, Chair S&FC)

Oral

Information Items **

7.6 Annual Report 2017/18 including Quality Account Process (Fiona Dalton, Chief Executive/Amanda Lowe, Associate Director: Corporate Affairs)

Enclosure 8

10.50 8. Any other business 9. To note the date of the next meeting: Thursday

1 March 2018 in the Parent Education Seminar Room, F Level, Princess Anne Hospital

In attendance: Kathryn Nash, Consultant Hepatologist/Interim Guardian of Safe Working Hours Gemma Genco, Head of Equality, Diversity & Inclusivity Neil Pearce, Associate Medical Director for Patient Safety Rachel Davies, DHN/P, Division A (shadowing Gail Byrne)

Lucinda King, Cost Improvement & Transformation Lead Programme Manager (shadowing Jane Hayward)

Items Circulated: The following items have been circulated to the Board since the last meeting. Executive directors are happy to take questions from individual members, before the meeting, by e-mail or telephone, or to meet separately to discuss in more detail. 18 December 2017 Press Release: Surgeon calls for all patients to be offered music therapy during procedures Press Release: Highclere Castle to host Christmas reception for Southampton Children's Hospital

19 December 2017 Finance Report 2017-18 Month 8

5 January 2018 Press Release: Surgeons use new blood injection to help treat knee arthritis

9 January 2018 Integrated Performance Report 2017-18 Month 8

11 January 2018 Press Release: Southampton researchers show location impacts children's diets

15 January 2018 Press Release: Health minister marks fundraising milestone at hospital visit

19 January 2018 Press Release: Hospital trust shares digital innovations with Finnish business and government reps

25 January 2018 Press Release: Southampton's 'soft' laser therapy for cancer patients to be trialled nationwide

EXCLUSION OF PRESS, PUBLIC AND OTHERS The public and representatives of the press may attend all meetings of the Trust, but shall be required to withdraw upon the Board of Directors resolving as follows “that representatives of the press, and other members of the public, be excluded from the remainder of this meeting as publicity would be prejudicial to the public interest by reason of the confidential nature of the business to be transacted”

11.00-11.15 Follow-up discussion with governors

11.30-12.45 Clinical Visit – Mixed-Sex Accommodation/Breaches

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UHSFT – Directors’ Actions Summary for 1 February 2018 Trust Board – Open Session ___________________________________________________________________________________________________________________________________________

Action & Minute Reference By whom Target Date Current Status Trust Board 26 October 2017

Cancer Annual Report (Minute Ref 139/17) The Cancer Annual Report to be tabled at a future Trust Board Study Session.

AL

13/3/18

Item included on draft agenda for TBSS 13/3/18.

Trust Board 30 November 2017

Minutes of Previous Meeting (Minute Ref 147/17) 26 October 2017 Board minute 134/17 EDI/WRES Report to be amended to accurately reflect the degree of challenge provided in respect of progress against the action plan.

AL/GB

Matters Arising/Summary of Agreed Actions (Minute Ref 148/17 g) Ref 137/17 Ward Staffing Establishment Review Post-implementation evaluation of the safety and effectiveness of the Band 4 ward staffing model currently underway. Outcomes from the evaluation will be reported to the Board in January 2018.

GB/RC

29/3/18

Evaluations undertaken each time the model of staffing is changed in an area. It was subsequently agreed with the Director of Nursing that the full evaluation report for all areas would come to Board in March 2018.

Information Governance Annual Report 2016/17 (Minute Ref 156/17) Confirmation of the total number of serious IG incidents reported to the Information Commissioner to be provided.

JH

2 serious incidents have been reported.

as at 24/1/18

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Trust Board Minutes – Open Session Minutes of the Open Trust Board meeting held on Thursday, 30 November 2017, in the Conference Room, Heartbeat Education Centre, North Wing, University Hospital Southampton, commencing at 0900 and concluding at 1040. Present: Mr P Hollins, Trust Chair

Ms F Dalton, Chief Executive Mr D French, Chief Financial Officer Ms J Hayward, Director of Transformation & Improvement Mrs G Byrne, Director of Nursing & Organisational Development Dr D Sandeman, Medical Director Mr A Asquith, Deputy Chief Operating Officer (for Dr C Marshall) Ms L Lockyer, Non-Executive Director Dr D Price, Non-Executive Director Dr M Sadler, Non-Executive Director Ms J Douglas-Todd, Non-Executive Director

PH FD DAF JH GB DS AA LL DP MS JD-T

In Attendance: Ms A Lowe, Associate Director: Corporate Affairs Mr A Byrne, Director of Informatics Mr B Bird, Lead Governor Dr M Jonas, Staff Governor 1 Member of staff 2 Members of public

AL AB

145/17 Apologies Apologies were received from Prof I Cameron, Non-Executive Director, Mr S Porter, Senior Independent Director/Deputy Chair and Dr C Marshall, Chief Operating Officer.

Action By 146/17 Chair’s Welcome, Opening Comments and Declarations of Interest

The Chair welcomed everyone to the meeting. There were no declarations of a conflict of interest with any items on the agenda.

147/17 Minutes of Previous Meeting (Agenda item 3. Enclosure 1) MS requested the amendment of minute 134/17 (EDI/WRES Report) to accurately reflect the degree of challenge provided in respect of progress against the action plan. Action: Revise Board minute 134/17(EDI/WRES Report). The minutes of the meeting held on 26 October 2017 were AGREED as an accurate record, subject to the revision of minute 134/17.

AL/GB

148/17 148/17 a)

Matters Arising/Summary of Agreed Actions (Agenda item 3) Minute Ref 118/17: Action Complete

148/17 b) Minute Ref 131/17: All actions complete.

Enclosure 1

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148/17 c) 148/17 d)

148/17 e)

148/17 f)

148/17 g)

148/17 h)

Minute Ref 132/17: Action complete. Minute Ref 133/17: Action complete. Future reports will be updated to include this information. Minute Ref 134/17: Action complete. The composition of interview panels in now subject to monitoring. Minute Ref 135/17: Action complete. Minute Ref 137/17: Post-implementation evaluation currently underway. This will be reported to the Board in January 2018. Minute Ref 139/17: Action complete. This is scheduled to come to a future TBSS.

148/17 i) The Board NOTE the progress updates provided.

149/17 a)

Integrated Performance Report for Month 7 (Agenda item 4. Enclosure 2) MS summarised the items considered by the Quality Committee at its meeting on the 27 November 2017, noting that the review of the Integrated Performance Report had been limited due to delays in the report being issued. Other items considered by the Committee included Medication Errors, Emergency Department performance, Referral to Treatment (RTT) performance including demand management and the action plans developed to address areas of underperformance, Infection Prevention (C-Difficile) and Sepsis. JH introduced the report, noting that the report now included data for both Lymington and Royal South Hants (RSH) hospitals. Patient Safety GB said that during the month, one Never Event had been reported. This related to an ophthalmic patient who received a wrong site injection. There was no harm to the patient. Root cause analysis identified issues in respect of the correct patient consent procedure not being followed. Learning from this event has been shared across all theatres. There has been a decrease in the total backlog of Serious Incidents Requiring Investigation (SIRI), a plan is in place to reduce this to zero by the end of December 2017. Action continues to be taken to improve Thromboprophylaxis performance, with changes being made to local prescribing processes to ensure completion of the assessment. The Trust continues to perform well on all aspects of infection prevention and control. Patient Experience GB confirmed that the number of patients completing a Friends and Family Test (FFT) within the Emergency Department had declined during October. The team have been tasked with reviewing the processes used to collate this data as they are resource intensive and require manual data entry. PH sought confirmation of the timescales for improvement. GB was confident that a sustained improvement would be achieved by February 2018. GB summarised the positive outcome of the recent nutrition MUST assessment pilot, noting that Trust-wide rollout of this tool was imminent. FD highlighted an increase in the number of Same-Sex Accommodation breaches, noting that this shift in performance was as a result of a recent change to reporting definitions and not as a result of any change in practice.

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149/17 b)

Responsive The Deputy Chief Operating Officer summarised the Trust’s performance noting:

• The sustained increase in the number of referrals received remains challenging with the Trust continuing to treat more patients than ever before.

• Emergency Access Performance: Trust performance was 91.9% with the local health system achieving 94.1%. This is against a target of 90.3% for the quarter. This target is subject to confirmation from NHS Improvement.

• Cancer: The Trust failed the cancer breast symptom standard in September (reported a month in arrears). All other cancer standards were achieved.

• Referral to Treatment (RTT): The Trust did not meet the national target of referral to treatment within 18 weeks. Recovery plans have been formalised across specialties, with teams continuing to work hard to create the additional capacity required.

PH queried whether the issues with RTT performance relate solely to the sustained increase in the number of referrals received. AA advised that it was a combination of both the increasing number of referrals and the ability to recruit to vacancies, noting that for some specialties, there is a national shortage of suitably qualified staff. DS re-iterated the Trust’s commitment to reduce follow up activity over the next five years, recognising that many of the planned initiatives were not yet at the scale necessary to deliver a significant reduction in follow up appointments. MS highlighted the need to align ‘policy’ with ‘reality’, ensuring that all unnecessary follow up activity was promptly identified and stopped. LL sought assurance that the Trust continued to maximise capacity through outsourcing opportunities and seven day working. AA confirmed that all opportunities for additional capacity had been utilised despite the private sector becoming increasingly reluctant to take outsourcing as the NHS tariff is not financially attractive. FD highlighted the reliance being placed on Waiting List Initiative (WLI) payments and the subsequent impact on the Trust’s financial position. JH summarised Delayed Transfers of Care (DToC) performance, noting that the system wide trajectory was not achieved in October 2017. The Trust has met partner organisations and has a collective agreement to a commitment to achieve a target of 50 DTOCs by Christmas 2017. AA added that the achievement of the target of 50 would bring significant benefits to the Trust in terms of supporting patient flow and managing winter demand. JD-T highlighted performance with regards to the number of last minute cancelled operations, noting the significant year on year reduction. AA added that during October, there had been an increase in the number the number of patients not readmitted within 28 days. This reflects the level of pressure within theatres and anaesthetics.

149/17 c) RESOLVED That the Board NOTE the Integrated Performance Report

Finance 150/17

a) Finance Report for Month 7 (Agenda item 5.1. Enclosure 3) The Chief Financial Officer presented the report, noting for October:

• The surplus was £3.3m, £1.3m lower than plan. After 7 months, the Trust has delivered a control total surplus of £9.2m. The Trust needs to deliver a further £17.9m surplus in the remainder of the year to achieve the year-end target control total surplus of £27.1m.

• CIP delivery in the month was £3.4m against a target of £3.5m. To month 7 the Trust is £0.5m short of the planned CIP delivery of £14.3m.

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150/17 a) Cont’d

• Operating costs were £1.6m adverse in the month (compared to £2.1m in September). YTD operating costs are £15.2m adverse to plan due to non-achievement of QIPP (£13.2m) and the associated cost of pay and clinical supplies.

• Under the single oversight framework, the score for Finance and Use of Resources has worsened to a ‘2’, below plan for the first time this year

MS queried the reason for a decrease in critical care income. FD summarised the seasonal impact on both Paediatric and Adult Intensive Care Units, noting the challenges this presents when forecasting activity. In addition, other quality improvement initiatives such as the changes to the vascular pathway, the work undertaken within perioperative medicine for the early identification of complex patients requiring critical care and the ‘deteriorating patient’ initiative have impacted critical care activity.

150/17 b) RESOLVED That the Board NOTE the report and update provided.

Operational Performance 151/17

a) Informatics 6-month Report AB presented the report, summarising key developments including:

- The appointment of the GDE Programme Manager; - In addition to the GDE programme, the Trust will be working closely with

Hampshire Hospitals Foundation Trust as a ‘fast follower’; - The Trusts contract with imaging consortium SWASH expires in June 2020.

The formal contract exit process is underway; however, it is assumed that the Trust will continue to work with Portsmouth Hospital Trust, Salisbury Hospital, Isle of Wight and Southern Health.

- The Hyland Onbase document management system is now live within the Princess Anne Hospital.

- The critical care system is now live in neonatal intensive care. - The roll-out of the digital whiteboard has continued within medicine and h

been well received. The system has been modified to manage the red and green day’s improvement project.

- The ‘My Medical Record’ programme now has in excess of 6,000 users and a growing level of local and national interest.

151/17 b) RESOLVED That the Board NOTE the report and update provided.

Governance 152/17

a) Chief Executive’s Report (Agenda item 7.1. Enclosure 5) DAF highlighted the Sealing of Deeds in relation to the design and construction of the multi-storey car park, noting that the 778 spaced facility was now fully operational. Board members were provided with an oral update in relation to a recent public event, hosted with the Local Authority. The event was attended by 300+ residents, who were updated on future transport and parking plans. A number of concerns were raised by residents, predominantly these related to congestion on local roads and complaints about staff parking within residential areas.

152/17 b) RESOLVED That the Board NOTE the updates provided.

152/17 c) Items for Ratification Actions taken by the Chair as set out in paragraphs 5.1 – 5.2 were ratified.

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153/17

a)

Feedback from Council of Governors’ Meetings 10 October, 1 November and 14 November 2017 (Agenda item 7.2) PH summarised the activities undertaken by the Council of Governors, including:

- A question and answer session held with the Non-Executive Directors; - Review of Chief Executive’s Performance Report; - The approval of the appointment of two Non-Executive Directors,

Cyrus Cooper and Jane Bailey. - The re-appointment of KPMG as the Trust’s External Auditors. - The review and approval of changes to NED remuneration.

153/17 b) RESOLVED That the Board NOTE the update provided.

154/17 a)

Briefing from Chair of Quality Committee (Agenda item 7.3) MS advised that in addition to the briefing already provided to the Board, the Quality Committee also considered a paper on complaints and the actions being taken to improve the quality of complaint responses and review of the Clinical Effectiveness Outcomes for Cardiovascular & Thoracic (CV&T) and Radiology Care Groups, noting the outstanding outcomes achieved within the cardiac specialty.


155/17 a)

Briefing from Chair of Strategy & Finance Committee (Agenda item 7.4) DP provided an overview of the items discussed at the November meeting, including:

• Steam Replacement Programme Business Case • Adult Emergency Department Business Case • Lung Cancer Business Case • My Medical Record Update • Complete Fertility Update • Transition Care Unit Update • 2018/19 Budget Setting • Review of the Month 7 Financial Position


156/17 a)

Information Governance Annual Report 2016/17 (Agenda item 7.5) This report was provided for information only. MS highlighted inconsistency in the data reported, noting that the cover sheet identified one serious IG incident, however, page three of the report indicates there have been two serious IG incidents reported to the Information Commissioner. JH undertook to obtain clarification on the number of IG incidents and would circulate a revised report to Board members. Action: Provide confirmation of the total number of serious IG incidents reported to the Information Commissioner.

JH

156/17 b) RESOLVED That the Board NOTE the report.

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157/17 157/17 a)

Any Other Business (Agenda item 8) LL highlighted a recent news article in relation to the calculation of holiday pay for staff on a zero-hours contract and sought confirmation of any implications for ‘bank’ staff. DAF confirmed that a high-level review had not identified any potential liability. The staff bank is operated by NHS Professionals. PH advised that this was the last Board meeting in public for Non-Executive Directors Iain Cameron and David Price and thanked them for their valued contributions.

158/17 Date and Time of Next Meeting Thursday, 1 February 2018, commencing at 0900 in the Conference Room, Heartbeat Education Centre, F Level, North Wing, SGH.

Integrated KPI Board Report January 2018

Page 1

Integrated KPI Board Report for

December 2017 (unless otherwise stated)

Executive Sponsors

Jane Hayward Director of Transformation

[email protected]

Date of Board Meeting 01 February 2018

Enclosure 2

diducs

Typewritten Text

UHS Integrated KPI Trust Board

Report – Executive Digest January 18

Page 2

Are we safe? (Page 5) Overall performance on the safety KPIs remains very good. After last month’s surge in severe/moderate errors, this month there was only one unavoidable severe/moderate error which is currently undergoing full scoping and investigation. The number of overdue Serious Incident Reviews dropped to five in November and the plan to have zero remaining at the end of December; this will be reported next month. One SIRI was reported in November outside of the agreed timeframe. VTE assessments fell again this month, IT solution to support is with external provider – timescales are still being agreed with the company. Grade 2 pressure ulcers were low this month compared to last year and year on year comparison for the metric is good (66 v 192 YTD). Are we effective? (Page 10) In the rolling 12 months to June the Hospital Standardised Mortality Ratio is 95.57. This is now the 7th month that the Trust has been below 100. This change is linked to an improvement in the medical coding used to calculate this ratio. Whilst this remains a good performance the Trust is creeping up slightly and must continue to monitor this very carefully. In December four national audit reports were reviewed, none have been identified raising areas of concern. Are we caring? () The number of patients completing a Friends and Family Test return in the emergency department has dropped again in December and an alternative approach to obtaining patient feedback is being considered. Inpatient response rate dropped to 14.08% in December. While F&F test results remain good the negative scores have increased notably for ED, however with such a low response rate this should be discounted. The complaints per 1000 bed days target of 1.2 was met for November and there were 46 complaints which is a slight improvement. In December there were 33 Same Sex Accommodation breaches. NHSE has formally agreed to suspend fines for these breaches until the end of January. The Trust is still negotiating with the CCGs for fines to be ring-fenced and reinvested to prevent the breaches. Are we responsive? (Pages 19 - 23) Please note some elements of data from October now include patients being treated at Lymington Hospital, this impacts on activity and some performance targets. In December the emergency access 4 hour performance was 83.2% for UHS ED’s (Types 1, 2 & 3). This performance reflects an extremely challenging month for the hospital in terms of emergency pressures, with Type 1 ED attendances 4.8% higher than December 2016. We also took several ambulance diverts from Portsmouth Hospital, in the interests of patient safety. Our quarterly target was 90.3% (target is subject to confirmation by NHSI). It has been confirmed this target was achieved. Demand for the main ED (excluding other units) is up 2.6% year on year and 4.0% year to date. A full formal recovery action plan is in place to achieve 95% in March 2018.

UHS Integrated KPI Trust Board

Report – Executive Digest January 18

Page 3

The Trust did not meet the 92% target for Referral-to-Treatment in December and performance reduced to 87.86%. The backlog also rose 161 in the month. It is planned that the Trust will achieve 92% by August 2018. A formal recovery action plan has been requested by the CCGs, however this request has been delayed given the national instruction to stop non-urgent elective work in January. Not all Cancer standards were met in November (this is reported a month in arrears). Five standards reported below target – GP 2 Week Wait, Breast Symptoms, 62 Day Consultant Upgrade, 31 Day Standard and 31 Day subsequent treatment. However the 62 day target, which is nationally seen as the most important, was achieved. The Trust did not meet the diagnostics target again in December for the 3rd month. There are a very small number of breaches and the plan is to recover this as quickly as possible. The system has set a new trajectory to achieve 50 delayed transfers of care by Christmas. This was not achieved, but we did collectively manage to reduce the delays to 67 delays at the lowest point. This has supported the Trust through a difficult Winter period. The system plans to reduce this to 38 delays by Easter 2018. Project work is underway to focus on the number of patients discharged earlier in the day to help flow. The target is for 25% of patients discharged on the day to be discharged on the 12 noon or home before lunch. Performance in December was 20.57% down 2%. Within this some wards are showing exemplary performance and Gail Byrne, Director of Nursing, has been celebrating their success and sharing the learning. The Hospital remains incredibly busy, new referrals are up 6.1% year to date and new Cancer referrals have risen by 9.3%. The rolling 12 month LOS for emergency patients is down 0.35 days at an average of 5.79 days with a slight increase in the elective length of stay of 0.16 to 4.51 days (balanced by a move from inpatient to day cases). This continued reduction in emergency LOS is a testament to the work being completed by the clinical teams on access at the front door, SAFER board and ward rounds and reduced delayed transfers of care. Are we well-led? (Pages 24 - 31) Turnover over a rolling 12 month period has risen slightly to 13.33%. The registered nursing posts that are vacant continue to rise from 17.5% two months ago to 18.1% in December. There continues to be overseas recruitment to boost the numbers. Appraisals are very low again and the Trust must refocus its efforts to ensure all appraisals are completed in a timely way. Are we productive? (Page 32) Estates have had a dip in performance in December on percentage of maintenance completed within planned time, which is associated with a small rise in logged jobs. Other Estate indicators reported sustained achievement or slight improvement. Full details of financial performance are shown in the Finance Report.

Page Ref. KPI Target Dec 16 Jan 17 Feb 17 Mar 17 Apr 17 May 17 Jun 17 Jul 17 Aug 17 Sep 17 Oct 17 Nov 17 Dec 17

5 1.1.4 Clostridium Difficile Reduction (confirmed lapse in care) <=4 3 6 3 5 2 3 5 8 2 3 1 1 2

5 1.1.2 MRSA Bacteraemia Infection 0 0 0 0 0 1 0 0 0 0 0 0 0 0

5 1.1.1 Never Events 0 2 1 0 1 0 0 0 0 0 0 1 0 0

5 1.1.7 SIRIs (month in arrears) N/A 7 6 6 5 4 3 7 1 3 0 2 1 N/A

5 1.1.13 Safety Express Thermometer =>95.0% 97% 98% 95% 98% 96% 98% 98% 97% 98% 97% 97% 98% 98%

6-9 Focus: September to November 2017 Quarterly Patient Safety Report Notes:

10 2.5.1 Rolling 12-Month HSMR - UHS (reported 3 months in arrears) <100 104.43 104.53 103.75 94.00 93.46 92.44 93.16 94.16 95.07 95.57 N/A N/A N/A

10 2.5.2 Rolling 12-Month HSMR - SGH (reported 3 months in arrears) <100 96.69 97.40 97.09 87.00 86.97 86.18 87.00 87.93 88.91 89.91 N/A N/A N/A

N/A 2.1.4 Readmissions (month in arrears) =<10% 11.5% 9.6% 10.7% 11.0% 11.1% 11.2% 11.8% 10.5% 10.8% 10.6% 10.2% 10.5% N/A

N/A Focus: None this month Notes:

11 3.1.2 FFT Negative Score - Inpatients <=5% 0.78% 0.73% 0.84% 1.16% 1.34% 0.32% 0.54% 0.66% 1.04% 0.59% 1.39% 0.72% 1.33%

11 3.1.4 FFT Negative Score - ED <=5% 3.18% 0.56% 3.00% 1.79% 1.83% 1.53% 2.17% 1.35% 1.06% 1.76% 0.98% 2.12% 5.00%

11 3.1.6 FFT Negative Score - Maternity <=5% 0.00% 1.20% 1.48% 0.60% 1.26% 1.33% 0.65% 1.37% 0.83% 1.15% 0.66% 1.37% 1.43%

11 3.1.10 Complaints Received (month in arrears); current month is provisional N/A 45 29 35 23 30 54 41 42 49 32 53 46 41

11 3.1.9 Nutrition >=95% 82.95% 73.95% 76.98% 79.94% 78.80% 85.58% 86.73% 78.57% 84.68% 85.11% 78.66% 79.52% 83.47%

12-18 Focus: July to September 2017 Patient Experience Report Notes:

19 N/A Rolling 12-Month Total Inpatients (Elective, Non-Elective & Day Case combined) N/A 151,402 152,928 153,820 155,737 156,009 157,327 157,794 158,076 158,720 158,780 158,892 158,357 157,588

19 N/A Rolling 12-Month Total Outpatients (New & Follow-up combined) N/A 584,569 587,197 587,153 595,272 592,451 599,897 602,534 607,465 608,661 611,200 616,548 619,676 621,063

19 N/A Rolling 12-Month Total ED Attendances (All types combined) N/A 118,302 118,563 117,810 117,869 118,117 118,486 118,659 118,752 121,039 123,040 125,074 127,186 129,236

20 4.1.3 A&E: % patients spending less than 4 hours in ED (Type 1) =>95.0% 84.9% 82.1% 79.2% 88.3% 87.9% 85.5% 84.7% 90.1% 85.8% 91.5% 89.2% 87.1% 77.6%

20 4.1.8 A&E: % patients spending less than 4 hours in ED (Types 1, 2 & 3) =>95.0% 86.9% 84.4% 82.1% 89.7% 89.5% 87.4% 86.7% 91.4% 89.5% 93.3% 91.9% 90.5% 83.2%

21 4.2.1 RTT: % Incomplete Pathways Within 18 Weeks in Month =>92.00% 90.65% 91.37% 92.00% 92.39% 92.06% 92.10% 92.01% 91.00% 90.39% 89.23% 88.11% 88.34% 87.86%

21 4.2.5 RTT: Total Patients in Backlog <1200 2,501 2,326 2,171 2,050 2,163 2,199 2,240 2,496 2,933 3,371 3,739 3610 3771

22 4.3.1 Cancer: Urgent GP referrals seen in 2 weeks (month in arrears) =>93.0% 89.4% 94.1% 94.0% 95.5% 92.2% 96.3% 95.5% 95.0% 90.4% 94.0% 95.5% 91.7% N/A

22 4.3.3 Cancer: Treatment started within 62 days of urgent GP referral (month in arrears) =>85.0% 83.0% 76.1% 78.4% 82.1% 86.7% 88.9% 88.0% 85.6% 81.5% 86.4% 85.8% 85.4% N/A

23 4.5.2 Complex Discharge Census (monthly average) <=38 140 123.9 116.5 115.8 119.8 114.97 96.73 91.3 97.7 103.7 115.3 100.93 88.87

23 4.5.6 Red Alerts (monthly total) N/A 28 54 56 24 13 26 21 1 30 14 27 26 44

23 4.5.7 Black Alerts (monthly total) N/A 0 3 0 0 0 2 0 0 0 0 4 0 2

23 4.5.9 % Elective Operations Cancelled at the Last Minute <=1.0% 1.35% 1.61% 1.56% 1.14% 0.80% 1.01% 1.29% 1.23% 1.05% 1.01% 1.03% 1.97% 1.09%

N/A Focus: None this month Notes:

24 5.1.6 Staff FFT - % of Staff Likely or Extremely Likely to Recommend UHS as a Place to Work =>76% N/A

24 5.1.1 Turnover - Rolling 12-months <=12.00% 12.92% 12.78% 12.65% 12.87% 13.16% 13.00% 13.00% 13.04% 13.00% 12.92% 12.88% 12.83% 13.33%

24 5.1.2 Sickness Absence - Rolling 12-months <=3.00% 3.51% 3.55% 3.54% 3.52% 3.53% 3.53% 3.52% 3.58% 3.60% 3.56% 3.57% 3.55% 3.54%

24 5.1.4 Nursing Vacancies <=8.00% 13.2% 13.0% 12.9% 12.8% 13.7% 13.6% 14.4% 14.6% 15.5% 13.4% 13.0% 12.5% 12.8%

25-30 Focus: Ward Staffing Report - December 2017 Notes:

N/A Focus: Notes:

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Lymington Hospital Minor Injuries Unit included in total ED attendance figures and line 4.1.8 from August 2017.

5.1.1 Target changed from April 2017; previously <=10.00%.

The Finance data sheet and indicators were withdrawn from the Integrated KPI Board Report in October 2017.

Full details of financial performance can be found in the separate Finance Report.

77% 77% 76% N/A - Trust completes

Theme Ref. Target Source Oct Nov Dec QTD YTD Month YTD Detail

1.1.1 0 National 1 0 0 1 1 2 2

1.1.2 National 0 0 0 0 1 0 0

1.1.3 0 National 0 0 0 0 0 0 0

1.1.4 National 1 1 2 4 27 3 24

1.1.5 16/17+10%

Internal 276 257 210 743 2259 206 2239

1.1.6 3 Internal 5 8 2 15 25 1 20

1.1.13 =>95.0% Internal 97.09% 97.71% 98.00% 97.61% 97.39% 96.69% 97.51%

Sep Oct Nov QTD YTD Month YTD

1.1.7 N/A Internal 1 3 1 4 25 3 36

1.1.14 100% Internal 100.00% 100.00% 77.78% 94.00% 93.55% 66.67% 83.67%

1.1.15 0 Internal 15 6 5 N/A N/A 6 N/A

1.1.8 <=10 Internal 7 (3) 19 (12) 5 (1) 24 66 22 192

1.1.9 <=2 Internal 0 5 2 7 12 0 16

1.1.10 <=1 Internal 0 2 0 2 5 0 4

1.1.11 >=95 National 93.50% 93.33% 92.45% 92.89% 93.77% 95.30% 95.04%

Q1 Q2 Q3 Q4 N/A Q1 Q2

1.1.12 <8 a year 0 - - -

Patient Safety1. SafeJanuary 18

Page 5

This Year Last YearIndicator

1.1 Patient Safety

Never Events

MRSA bacteraemia infection

MRSA bacteraemia contaminant

Clostridium difficile reduction (Confirmed lapse in care)

Medication Errors

Safety Express Thermometer

% Thromboprophylaxis Patients Assessed

Medication Errors (Severe/Moderate)

1.1.6 Medication Errors. Two incidents in December. One is unavoidable and relates to an extravasation injury following an infusion of sodium bicarbonate. The other related to delayed IV antibiotics and is the subject of full scoping and investigation. All of the incidents are being followed up by the medication safety team to ensure learning. 1.1.14 - One SIRI reported in November was outside of the agreed timeframe. 1.1.15 - There were 5 overdue SIRIs as of the end of November, all of which had plans for closure in December. The divisional teams are working on prioritising overdue SIRIs for submission and closure and there is a monthly task and finish group chaired by the DDON to achieve the agreed target of 0 overdue SIRIs by end of December 2017 which is on track. 1.1.11 IT solutions to prevent prescribing of medication before a VTE risk assessment has been completed and have been put on the EMIS development list. Timescales to be confirmed, Feb 2018 at the earliest but May/June more likely.

2017/18 2016/17

Diabetes: Insulin-related medication errors (high harm)

This Year Last Year

Serious Incidents Requiring Investigation (SIRI)

Grade 2 Pressure Ulcers (of which avoidable). Reported a month in arrears.

Avoidable Hospital Acquired Grade 3 and 4 Pressure Ulcers

Avoidable High Harm Falls

SIRIs reported within 48 hours to CCG

Number of overdue SIRIs

1. Safe Quarterly Patient Safety Report January 18

Page 6

6

Period September – November 2017 Report From Tamsyn Langton, Interim Patient Safety Manager Executive Sponsor Gail Byrne, Director of Nursing and Organisational Development Purpose of the report • To provide members of Trust Board with an update on patient safety work streams. • To highlight areas of good progress and any areas that require further focused improvement

with proposed actions to be taken to address any areas of non-compliance. Members of Trust Board should note • Achievement of our trajectory targets on all grades of pressure ulcer reducing them all by more

than 20% on the previous year’s outturn • Q2 Sepsis CQUIN targets for 2017/18 partially achieved. Risk of not achieving full payments for

2017/18 CQUIN. • Improvement noted in quality contract KPIs on compliance with 60 day timescale to complete

SIRI investigations and 48 hours to log a new SIRI with commissioners • Concerns that the level of harm on incident forms is being over graded by reporters and

validators and the reported harm: no harm ratio within UHS is significantly higher than our peers.

• 95% target for completion of VTE risk assessments was not achieved in September, October or November however >95% of patients received the appropriate prophylactic treatment in October and November.

Executive Summary This the quarterly patient safety report for September to November 2017.

1. During September, October and November the trust continued to fail to achieve the 95% target for completion of VTE risk assessments. In September the percentage of patients also receiving appropriate prophylactic treatment fell to below the 95% target. The 95% target was achieved in October and November. An IT solution has been identified and will be completed as part of the EMIS development. Timescales to be confirmed, Feb 2018 at the earliest but May/June more likely.

2. In October 2017 the trust reported a Never event, related to an intravitreal injection being completed in the incorrect eye. The patient did not come to harm as a result of the injection (full details can be found in appendix A). There are ongoing discussions between the executive teams and the commissioners about two spinal cases which may be upgraded from SIRI to NE following completion of the investigations.

3. In September and October 2017, the central team achieved the KPI for timeliness of reporting SIRIs to the commissioners. In November 2017 we achieved 88%, with one SIRI not being reported within the agreed 48 hours timescale.

4. We have a continued focus on achieving the KPIs closure of SIRIs outside of the 60 day timescale and have reduced the number of overdue SIRI investigations from 15 to 5 with an identified date for closure to achieve the target of 0 overdue SIRIs by the end of December 2017.

5. Incident reporting rates remain consistent and the number of outstanding incidents requiring manager’s validation continues to decrease, although timeliness of this requires improvement. There are concerns that the level of harm on incident forms is being over graded by reporters and validators and the reported harm: no harm ratio within UHS is significantly higher than our peers.


Page 7

7

6. The trust achieved the 90% target for screening of patients to admission areas in Q1 and Q2 however has not achieved 90% in other areas of the CQUIN (full details can be found on page 15). There may be a risk that the full CQUIN may not be achieved by Q4.

7. One patient with a positive diagnosis of sepsis received antibiotics after the required time however had received antibiotics in ED therefore the delayed antibiotic was a missed dose as opposed to failure to start treatment.

8. There is an opportunity to receive a percentage rebate on our clinical negligence scheme for trusts payment to NHS resolution if we, as a trust, are able to demonstrate progress against 10 key actions agreed by the national maternity safety champions. These actions reflect best practice in maternity safety improvement. A full report on the trust progress against these key actions will be presented to QGSG by the interim director of midwifery.


Page 8

8

Patient safety dashboard Work Stream Indicator Annual Target

Sep-17 Oct-17 Nov-17

QTD (this year)

YTD (this year)

High Harm Falls

High Harm Avoidable Falls 3

0 0 0

0 3

Total High Harm Falls 55

5 10 2

12 47

Pressure Ulcers Avoidable grade 3 & 4 pressure ulcers 30

0 4 1

5 10

Grade 2 pressure ulcers 156

7 19 5

24 66

VTE

% of patients that have a VTE risk assessment upon admission >=95% 93.50% 93.33% 92.44%

92.89% 93.77%

% of patients that receive appropriate thromboprophylaxis (taken from Safety Thermometer)

>=95%

91.34% 95.12% 95.25%

95.19% 93.77%

Safety Thermometer Harm Free Care >=95%

96.91% 97.09% 97.74%

97.42% 97.31%

Medication Errors

A reduction in the number of medication related incidents that occur as a result of a failing in the discharge process

Reduction

17 13 6

80% of medicine reconciliations within 48 hours of admission 80%

88% 92% 80% 86% 83%

Decrease of inappropriately omitted doses to less than 3% <=3%

1.88% 2.08%

Infection Prevention & Control

MRSA post 48 hour cases 0

0 0 0

0 1

C difficile cases 43

3 1 1

2 25

SIRIs

Never Events 0

0 1 0

1 1

95% SIRIs Reported within 2 working days >=95%

100.00% 100.00% 88%

94% 93.55%

SIRIs overdue by 60 days 0

15 6 5

11 96

Incident Reporting Incidents per 1000 bed days >35

43.9

% of incidents identified as moderate and over <=4%

3.84% 6.10% 6.38%

6.24% 3.45%


Page 9

9

Q1 Q2 Q3 Q4

Sepsis

90% of patients appropriately screened on admission in ED, AMU, ASU and PAU

90%

91% 93%

90% of patients with red flag sepsis in ED, AMU, ASU and PAU receive IVAB within 60 minutes of admission and have an empiric review within 72 hours of prescribing antibiotics

90%

78% 85%

90% of patients who meet criteria for sepsis screening were screened for sepsis for all acute inpatient wards

90%

61% 58%

90% of patients with red flag sepsis receive timely antibiotics (60 minutes for new admissions or 90 minutes for existing inpatients) and have an empiric review within 72 hours of prescribing antibiotics

90%

79% 76%

Theme Ref. Target Source Q1 Q2 Q3 Q4 YTD Target Total Detail

2.1 National Audit

Participation2.1.1 53 National 46 0 0 N/A 46 60 59

2.2 NCEPOD 2.2.1 3 National 3 0 0 N/A 3 6 6

Aug Sep Oct Nov Dec YTD N/A

2.3.1 N/A National 5 4 4 10 4 N/A N/A

2.3.2 N/A National 0 0 1 2 0 N/A N/A

Q1 Q2 Q3 Q4 YTD Target Total

2.4 Outcomes Workstream

2.4.1 97 Internal 36 3 1 N/A 40 97 36

to May 17 to Jun 17 to Jul 17 to Aug 17 to Sep 17 YTD N/A

2.5.1 <=100 Internal 92.44 93.16 94.16 95.07 95.57 N/A N/A

2.5.2 <=100 Internal 86.18 87.00 87.93 88.91 89.91 N/A N/A

2.5.3 HSMR - Crude Mortality <=100 Internal 3.91% 3.90% 3.95% 3.97% 3.97% N/A N/A

2.1 UHS have participated in 46/47 National Audits to date. Did not participate in UK Parkinson's Audit data entry due to case ascertainment. Data entry may be done at a later date but will not form part of the National Report. There are still 6 audits TBC. 2.2 *National Confidential Enquiry into Patient Outcome and Death, currently participating in Cancer in Children, Teens and Young Adults Study, Heart Failure Study and Perioperative Diabetes. 2.3.1 4 National audit reports were reviewed in December 17. MBRRACE-UK perinatal confidential enquiry - term singleton, intrapartum stillbirth and intrapartum-related neonatal death November 2017, Rising to the Challenge - the fourth SSNAP Annual Report stroke care received between April 2016 and March 2017, MBRRACE - UK Saving lives, Improving Mothers' care 2013-2015 Report Dec 20017 and National Bowel Cancer Annual Report 20172.3.2 No audit reports have been identified as raising areas of concern.

2017/18 2016/17

Development of Outcomes by Specialty

Rolling 12-Months Last Year

2.5 HSMR

HSMR - UHS

HSMR - SGH

January 18

Page 10

2017/18 2016/17

2.3 National Audit Reports

Number of recently published National Audit reports

National Audit reports with areas of concern

Clinical Effectiveness2. Effective

Indicator

Participation in eligible National Audits (Quality Accounts)

Participation in eligible NCEPOD* studies

2017/18 2016/17

Theme Ref. Target Source Oct Nov Dec QTD YTD Month YTD Detail

3.1.1 >=20% National 17.47% 16.96% 14.08% 16.23% 18.36% 19.48% 19.92%

3.1.2 National 1.39% 0.72% 1.33% 1.14% 0.86% 0.78% 1.02%

3.1.3 >=10% National 5.01% 2.88% 1.24% 3.43% 6.67% 4.54% 6.96%

3.1.4 National 0.98% 2.12% 5.00% 1.65% 1.42% 3.18% 2.34%

3.1.5 >=20% National 30.96% 35.78% 31.25% 32.52% 32.01% 34.53% 27.57%

3.1.6 <=5% National 0.66% 1.37% 1.43% 1.14% 1.12% 0.00% 0.75%

3.1.8 20 National 17 49 33 99 99 0 0

3.1.9 >=95% National 78.66% 79.52% 83.47% 80.47% 82.30% 82.95% 82.92%

Sep Oct Nov QTD YTD Month YTD

3.1.10 N/A Internal 32 53 46 99 347 48 307

3.1.11 <1.2 Internal 0.86 1.36 1.14 1.25 1.12 1.16811 0.97441

This Year Last Year

Total Complaints Received (month in arrears)

3.1.1: Response rates in ED and inpatients continue to perform below trust target and national averages. Patient Insight Manager now in post and work with children's hospital commencing to improve historical low response rates there. Improvements in child health feedback will significantly improve overall inpatient response rate. ED continues to struggle, made worse by winter pressures. Review of how we collect ED service user feedback scheduled. Recommend rates continue to be high, with low negative scores across the areas. 3.1.8 We have seen as predicted a higher number of breaches over the difficult winter period. NHSE have formally agreed to suspend fines for MSA breaches until the end of January. We need to continue to negotiate with CCGs to identify how we can ring fence and reinvest fines into reducing the number of MSA breaches. These 33 patients relate to 9 breaches in both HASU and AMU in December.3.1.9: Final changes have been made to the new care plans and MUST tool documentation and this is now with COMMs, with a planned trust roll out as soon as care plans are available.

3.1 Patient Experience

Complaints per 1000 bed days(month in arrears)

Patient Experience3. CaringJanuary 18

Page 11


Nutrition: % Patients with a care plan in place

Same Sex Accommodation (Non Clinically Justified Breaches)

Maternity FFT Negative Score

Maternity FFT response rate

FFT Negative Score - ED

FFT response rate - ED

FFT Negative Score - Inpatients

FFT response rate - Inpatients

3. Caring Quarterly Patient Experience

Report January 18

Page 12

Period Quarter 2 July to September 2017 Report From Ellis Banfield, Head of Patient Experience Executive Sponsor Gail Byrne, Director of Nursing and Organisational Development. Purpose of the report To provide the Board with the quarterly report on patient experience. Executive Summary • Thematic triangulation of concerns made via available channels reveals recurrent issues with

communication. • Total complaints and concerns increased overall in Q2, with an increase complex concerns and a slight

decrease in complaints. • Clinical treatment and communication continue to account for nearly 50% of complaints raised. • There has been an increase in complaints raised by care / nursing homes about the quality of discharge of

their residents. Note action by Head of Patient Experience and Head of Compliance to engage with homes to better analyse the problems and establish better working relationships.

• Note continued high recommend rates across all FFT surveys, with ED maintaining a performance significantly above national average (97% recommend compared to 87% nationally).

• FFT response rates continue to be variable. Detailed breakdown of problem areas has resulted in some local focus on driving improvements, including child health whose response rate impacts overall inpatient rate.

• Trust performed ‘about the same’ as other trusts in the official published results of the CQC ED Survey 2016.

Action Required • The board is asked to note the summary report. (The full report is available on request)


Report January 18

Page 13

Key Issues / Executive Summary This report covers Q2: July, August, and September. It is a summary from a new and longer integrated patient experience report.

1 For noting

1.1 Triangulation of themes

The table above triangulates patterns in themes raised and the channel of escalation.

Cells highlighted red are the most frequent theme raised via that particular feedback channel.

There are some apparent patterns in how patients and families decide to raise issues about their experience. While clinical treatment was the top theme for formal complaints, it was raised less frequently across other channels. Similarly, values and behaviours of staff ranked highly for formal complaints, suggestive of complaints resulting in a breakdown in relationship between patient and staff.

Informal and complex concerns had appointments, admissions, and access to treatment as the highest ranked themes, suggesting that this channel is useful for patients trying to navigate difficulties with hospital administrative and operational processes.

Surveys and website feedback share common themes. Issues around patient care were raised very frequently, and these include responsiveness of staff to patient needs. Both the friends and family test and local inpatient surveys had relatively high levels of concerns reported about the ward environment, and this includes issues on noise at night, ward cleanliness, and provision of entertainment. Given the lesser frequency of these issues being raised formally, patients clearly feel more compelled to raise these issues at the time of being on the ward, when the impact on their experience is current.

Finally, communication was the theme ranked most highly across all feedback channels. This includes provision of information, general communication and engagement by staff with patients, and perceived language barriers.


Report January 18

Page 14

1.2 Complaints activity

Issues for noting:

• Increase in total complaints and concerns for Q1 (208) to Q2 (219).

• Increased profile for ophthalmology in terms of complaints and complex concerns raised in regard to waiting times for surgery and capacity.

• Plans in place for improving accessibility of the complaints and concerns service for patients and families less likely to raise issues about their care and services. These include a review of current patient information and literature, increase ward profile, and engagement locally with community organisations, care and nursing homes.

• Note spike in complaints received via CCGs about discharges to care / nursing homes. Head of Patient Experience and Head of Compliance currently engaging with care homes to identify problems and build better organisational relationships.

Care home concerns These are concerns raised externally by commissioners, GPs, and other outside agencies about the care and experience of UHS patients. Because they are made by agencies and not the patients or relatives, they are managed outside of the formal complaints process by the Quality Team. This report only covers concerns about discharges to care homes.


Report January 18

Page 15

1.3 Friends & Family Test activity

• Note targets met for recommend rates across all FFT surveys, indicating high levels of patient satisfaction across services. UHS outperforms national averages in all but two FFT categories (antenatal and postnatal).

• Response rates for FFT are variable. Note strong performance for ED and Maternity in Q2, but Inpatient response rate has fallen. Paediatric FFT responses for inpatients are affecting overall rates due to requirement to report adult and paediatrics together for NHS England.

• Note strong performance by division D for response rates across the division (40%). Poorer performing areas are often the result of regular and repeat patients not wishing to complete the survey at every visit (e.g. cancer care).

• Top three issues raised via patient surveys are: Ward environment Waiting times Patient care

Some key suggestions raised by patients include better provision of disabled facilities and better entertainment options on the wards.

Inpatient narrative Inpatient response rate has seen a decline over the last quarter, a trend that has so far continued into Q3. It is currently within a 2% threshold under trust target. Recommend scores continue to achieve target.

Target Q1 Q2 Q3 forecast

Children & young people (inpatient)

Recommend > 95% 98.6% 100% Not recommend < 5% 0% 0% Response rate > 20% 1.5% 2.5%

CYP narrative Paediatric wards are included in general inpatient reporting, internally and to NHSE. However, response rates for these wards have historically remained low. They currently sit at just over 2%.


Maternity (overall) Recommend > 95% 97.1% 96.6% Not recommend < 5% 1% 1.1% Response rate > 20% 30.1% 26%


Inpatients (inc. cyp) Recommend > 95% 96.8% 96.5% Not recommend < 5% 0.7% 1.4% Response rate > 20% 20.4% 18.2%


Report January 18

Page 16

Maternity narrative The Trust continues to achieve all targets set for maternity FFT, with high scores and strong response rates.


Emergency Department

Recommend > 95% 96.6% 97.1% Not recommend < 5% 1.8% 1.3% Response rate > 10% 1.9% 13.6%

Emergency Department narrative The response rate for ED hit a historic high of nearly 14% for Q2, having been at under 2% previously. Q3 is on target to fall to 5-7%.


Outpatients Recommend > 95% 96.3% 96.5% Not recommend < 5% 1.8% 1.9%

Outpatients narrative UHS continues to perform well in Outpatients, although overall number of responses is relatively low.

1.4 National Patient Surveys – Emergency Department 2016

Results published: October 2017 The Emergency Department national survey is part of the CQC’s programme of national patient surveys. A random sample of 1250 patients who used UHS ED department in September 2016 were sent the survey. Eligibility criteria stipulated that patients were over 16, had used ED in September 2016, and were not current inpatients at the time of sampling. Overall scores Black diamond indicates UHS in relation to best performing trusts (green), worst performing trusts (red), and most other trusts (amber). The two lowest scores were in ‘waiting times’ and ‘leaving the emergency department’, although it should be noted that the trust placed towards the higher end of the waiting times category.


Report January 18

Page 17

1.5 Bereavement Care update

Analysis Activity for the quarter has stayed much the same as the previous reporting period. The team expects more activity over the winter period. The Head of Bereavement Care is working with Picker to develop an online survey platform for an ongoing bereavement survey. The current contract held with Picker has a provision for a target survey and the aim is to provide bereaved families with a link to complete an online questionnaire when they are ready to let us know how they felt we supported them and their loved one through death and bereavement. Families will also be offered a paper survey to complete and return.


Report January 18

Page 18

1.6 Volunteer Services Update

Overall numbers of active volunteers at the Trust have decreased due to an audit of all volunteer records and a cleansing of database records for volunteers who were no longer active.

HelpForce Pilot HelpForce, an organisation created to drive the volunteer agenda in the NHS, awarded UHS £50,000 as part of a scheme to develop innovative volunteering projects across 5 pilot sites.

The UHS project seeks to roll out a blended volunteer role that incorporates the three most needed volunteer roles into one ‘Patient Support Volunteer’. These roles are:

• Time for You (befriending role, including social visits and emotional support) • Mealtime assistants (support patient nutrition) • Exercise volunteers (to prevent deconditioning)

Patient support volunteers will be adaptable and support the ‘Eat, Drink, Move’ programme which aims to aid patient recovery by ensuring they eat well, drink enough fluids, and stay mobile and active. The Trust is currently working with HelpForce’s ‘Insight and Impact’ team to identify metrics for monitoring the impact of the pilot. When these have been finalised, they will be reported here. Added focus will be on the number of volunteers recruited and trained. 48 applications have so far been received for the role.

Ref. To Target Month QTD YTD R-12 Month QTD YTD R-12We received…

4.6.1 New referrals** Nov N/A 16,992 34,980 140,534 208,543 -4.4% 1.6% 5.0% 6.1%

4.6.2 Urgent cancer referrals Nov N/A 1,526 3,091 11,821 17,365 6.8% 11.1% 8.5% 9.3%

We treated….

4.6.3 Main ED attendances Dec N/A 8,836 26,253 78,277 102,478 4.8% 2.7% 4.0% 2.6%

4.6.4 Other ED attendances incl Eye Unit & MIU* Dec N/A 3,119 6,428 22,468 26,758 N/A N/A N/A N/A

4.6.5 Non-elective Spells Dec N/A 6,085 18,031 54,699 73,071 -2.7% -1.9% 3.3% 4.0%

4.6.6. Elective Inpatient Spells** Dec N/A 1,518 4,765 14,716 19,701 -4.2% -5.0% -1.9% -2.5%

4.6.7 Elective Day Case Spells** Dec N/A 4,468 15,372 47,668 64,816 -11.0% -4.0% 0.8% 5.8%

4.6.8 Combined Elective Spells** Dec N/A 5,986 20,137 62,384 84,517 -9.3% -4.2% 0.1% 3.8%

4.6.9 New outpatient appointments** Dec N/A 15,531 54,865 163,723 218,875 1.5% 7.3% 6.0% 6.6%

4.6.10 Follow-up outpatient appointments** Dec N/A 27,732 100,103 299,147 402,188 -1.3% 5.4% 5.1% 6.0%

Our efficiency… Month QTD YTD R-12

4.6.11 Elective Length of Stay Dec N/A 4.51 0.16

4.6.12 Non-Elective Length of Stay Dec N/A 5.79 -0.35

4.6.13 Adult Medical Length of Stay Dec N/A 5.53 -0.23

4.6.14 Outpatient DNAs** Dec N/A 3,868 13,247 41,549 55,438 -123 -48 2,133 3,817

4.6.15 Outpatient DNA Rate** Dec N/A 8.20% 7.90% 8.20% 8.20% -0.20% -0.40% 0.00% 0.10%

4.6.16 Adult Midday Bed Occupancy Nov 90-95% 95.30% 95.15% N/A N/A -2.60% -2.75% N/A N/A

4.6.17 Paediatric Midday Bed Occupancy Nov 80-85% 96.30% 93.40% N/A N/A -3.30% -3.70% N/A N/A

* Includes Lymington Minor Injuries Unit (MIU) following service transfer August 2017

** From August 2017 will include activity transferred from Southern Health to UHS as part of the Lymington service move.

4. Responsive Activity January 18

Page 19

Compared to last year

Theme Ref. Target Source Oct Nov Dec YTD R-12 Month YTD Detail

4.1.1 N/A N/A 8,834 8,583 8,836 78,277 102,478 8,467 75,260

4.1.2 N/A 957 1,107 1,979 10,500 14,512 1,280 8,102

4.1.3 >95% National 89.2% 87.1% 77.6% 86.6% 85.8% 84.9% 89.4%

4.1.4 N/A N/A N/A N/A N/A N/A N/A 27.2% 26.3%

4.1.5 <5% National 6.9% 6.6% 7.1% 7.1% 6.9% 6.9% 6.3%

4.1.9 00:15 National 01:08 01:04 01:24 01:04 01:03 00:54 00:51

4.1.10 01:00 National 01:29 01:26 01:35 01:24 01:23 01:18 01:15

4.1.11 04:00 National 05:33 05:45 07:21 05:58 06:12 06:20 05:44

4.1.12 <5% National 6.1% 4.90% 6.30% 4.5% 4.2% 3.5% 3.1%

Oct Nov Dec YTD R-12 Month YTD

4.1.13 N/A N/A 400£ 600£ 200£ 4,400£ 5,200£ 800£ 4,600£

Oct Nov Dec YTD R-12 Month YTD

4.1.8 >95% National 91.9% 90.5% 83.2% 89.3% 88.5% 86.9% 90.8%

4.1.14 ≥ 90% Local 90.7% 89.1% 81.0% N/A N/A N/A N/A

4.1.15 ≥ 95% N/A 99.8% 99.9% 99.7% N/A N/A N/A N/A

4.1.16 ≥ 95% N/A 100.0% 100.0% 99.8% N/A N/A N/A N/A

4.1.17 ≥ 90.30%Delivery

Board94.1% 93.0% 87.7% N/A N/A N/A N/A

This Year

4 Hour Performance4. ResponsiveJanuary 18

Page 20


Main ED (type 1) attendances

Main ED (type 1) breaches

% Patients spending less than 4 hours in Main ED (type 1)

ED Conversion (Type 1)

% patients spending less than 4 hours in ED - Combined system total

4.1.8 - Lymington Hospital Minor Injuries Unit (MIU) included in attendance, breach and 4 hr performance measures from August 2017. 4.1.9 - 4.1.12 - Lymington Hospital MIU data not currently reported in these indicators from August 2017.4.1.4 Reporting not currently available due to changes associated with new Emergency Care Dataset implementation. Reporting will be revised and backdated.

Ambulance handover delays fines

This Year Last Year

% patients spending less than 4 hours in ED - UHS Main ED, Eye Casualty & Urgent Care Hub

% patients spending less than 4 hours in ED - Lymington Minor Injuries Unit% patients spending less than 4 hours in ED - RSH Minor Injuries Unit

4.1 ED Performance

% patients spending less than 4 hours in UHS ED's (Types 1, 2 & 3)

Time to initial assessment (Types 1, 2 & 3)

Time to treatment - Median (Types 1, 2 & 3)

Total time spent in ED - 95th Centile (Types 1, 2 & 3)

% patients who left the department before being seen (Types 1, 2 & 3)

Last Year

Emergency reattendance within 7 days (Type 1)

Theme Ref. Target Source Oct Nov Dec YTD R-12 Month R-12 Detail

4.2.1 =>92% National 88.11% 88.34% 87.86% N/A N/A 90.65% N/A

4.2.2 N/A N/A 80.86% 81.39% 80.84% N/A N/A 83.62% N/A

4.2.3 N/A N/A 88.38% 84.88% 86.81% N/A N/A 90.20% N/A

4.2.4 N/A N/A 31,446 30,972 31070 N/A N/A 26,758 N/A Below

4.2.5 N/A N/A 3,739 3,610 3,771 N/A N/A 2,501 N/A Below

4.2.6 N/A N/A 7.66 8.04 7.89 N/A N/A 6.99 7.40

4.2.7 <=1% National 1.18% 1.83% 2.18% N/A N/A 0.98% 0.97%

Sep Oct Nov YTD R-12 Month YTD

4.2.8 N/A N/A 17,589 17,988 16,992 140,534 208,543 17,777 133,844 Below

From August 2017 figures will include 18 week pathway patients transferred to UHS from Southern Health under the Lymington service move.

This Year Last Year

New referrals received(month in arrears)

Indicator

4.2 RTT Performance

% incomplete pathways within 18 weeks in month

% admitted patients within 18 weeks in month (adjusted for patient choice)

% non-admitted patients within 18 weeks in month

Total number of patients on an incomplete pathway

Total patients in backlog

Weeks waited for first outpatient appointment

% of Patients waiting over 6 weeks for diagnostics

RTT Performance4. ResponsiveJanuary 18

Page 21

This Year Last Year

15000

20000

25000

30000

35000

Apr

-12

Oct

-12

Apr

-13

Oct

-13

Apr

-14

Oct

-14

Apr

-15

Oct

-15

Apr

-16

Oct

-16

Apr

-17

Oct

-17

Total Incompletes

0

1000

2000

3000

4000

Apr

-12

Oct

-12

Apr

-13

Oct

-13

Apr

-14

Oct

-14

Apr

-15

Oct

-15

Apr

-16

Oct

-16

Apr

-17

Oct

-17

Total Backlog

0

50000

100000

150000

200000

250000

Apr

-13

Oct

-13

Apr

-14

Oct

-14

Apr

-15

Oct

-15

Apr

-16

Oct

-16

Apr

-17

Oct

-17

Rolling 12-Month Referrals

Theme Ref. Target Source Sep Oct Nov QTD YTD Month QTD Detail

4.3.1 =>93% National 94.0% 95.5% 91.7% 93.6% 93.8% 95.5% 96.2%

4.3.2 =>93% National 89.1% 94.5% 61.2% 76.6% 81.7% 93.0% 93.7%

4.3.3 =>85% National 86.4% 85.8% 85.40% 85.6% 86.9% 73.5% 78.7%

4.3.4 =>90% National 90.5% 95.0% 98.0% 96.7% 94.4% 94.4% 92.2%

4.3.5 =>86% National 92.3% 100.0% 60.0% 72.2% 89.6% 94.1% 92.1%

4.3.6 N/A N/A 100.0% None 66.7% 66.7% 73.3% 0.0% 33.3%

4.3.7 =>96% National 97.2% 96.3% 94.6% 95.4% 97.2% 94.0% 94.4%

4.3.8 =>94% National 94.8% 93.9% 81.8% 87.9% 93.7% 81.6% 86.9%

4.3.9 National 100.0% 100.0% 100.0% 100.0% 99.9% 100.0% 100.0%

4.3.10 =>94% National 99.4% 100.0% 98.3% 96.4% 99.6% 100.0% 100.0%

This Year Last Year

Cancer Performance - Whole Trust

4.3.3. 62 Day Standard using Interim IPT / breach allocation rules.

4. Responsive

4.3 Cancer Performance

- Whole Trust

Second or subsequent treatment (radiotherapy) 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 (surgery) started within 31 days of decision to treat

Breast symptoms referral seen in 2 weeks

Urgent GP referrals seen in 2 weeks

Indicator

Treatment started within 31 days of decision to treat

Rare Cancers - 31 Day

62 Day - Consultant Upgrades

Treatment started within 62 days of referral (Breast, Cervical & Bowel)

Treatment started within 62 days of urgent GP referral

January 18

Page 22


4.5.1 <=3.50% National 9.76% 8.15% 6.96% 8,75% 9.06% 12.01% 11.19%

4.5.2 <=38 Local 113.5 100.93 88.87 103.1 107.0 140.0 134.6

4.5.3 =>26 Local 20.6 19.4 24.26 21.3 21.1 21.6 21.0

4.5.4 =>25% Internal 20.13% 22.84% 20.57% 20.62% 20.77% 20.18% 21.15%

4.5.5 =>80% Internal 56.49% 64.19% 68.01% 61.91% 61.56% 65.82% 62.30%

4.5.6 N/A N/A 27 26 44 202 336 28 237

4.5.7 N/A N/A 4 0 2 8 11 0 8

4.5.8 N/A N/A 64 121 99 662 925 64 648

4.5.9 <=1% National 1.03% 1.97% 1.89% 1.25% 1.29% 1.18% 1.25%

4.5.10 N/A N/A 12 10 9 56 87 7 40

4.5.11 <=5% National 18.75% 8.26% 9.09% 8.46% 9.41% 10.94% 6.17%

January 18

Page 23

This Year Last Year

Average Number of Complex Discharges per Working Day

Complex Discharge Census (average)

Delayed transfers of care (CQC Calculation)

Indicator

Flow4. Responsive

4.5.4 Target reduced from =>30% to =>25% during October, November, December 2017. Will return to =>30% from January 2018.

4.5 Flow

% elective operations cancelled and not readmitted within 28 days

Number of patients who are not readmitted within 28 days

% elective operations cancelled at the last minute

Last minute cancelled operations

Black Alerts

Red Alerts

Weekend Discharge (EL & NEL Combined)

Early discharge on day (pre-midday)


5.1.1 <=12% ESR 12.88% 12.83% 13.33% N/A N/A 12.92% N/A

5.1.2 <=3.4% ESR 3.57% 3.55% 3.54% N/A N/A 3.51% N/A

5.1.3 =>92% ESR 83.19% 83.79% 83.09%We N/A N/A 86.41% N/A

5.1.4 <=8.00% Internal 13.00% 12.52% 12.84% N/A N/A 13.20% N/A

5.1.5 <=8.00% Internal 17.5% 17.6% 18.10% N/A N/A 17.30% N/A

Q1 Q2 Q4 Q1 Q2 Q2 Q4

5.1.5 25% Picker 22% 20% 19% 25% 24% 27% 24%

5.1.6 76% Picker 76% 76% 77% 77% 76% 73% 76%

We have done an analysis based on 8 Model Hospital Peers Hospitals' 12 month rolling turnover rate covering November 2016 to October 2017. The results are stated as below:- Turnover rate for All Staff (excluding Junior Doctors): The lowest is 7.93% and the highest is 17.5%, UHS had the 4th lowest turnover rate of 11.3%- Turnover rate for Nursing and Midwifery Registered: The lowest is 7.75% and the highest is 15.95%, UHS had the 5th lowest turnover rate of 11.58%

Sickness Absence- There continues to be a focus on sickness absence from the Employee relations service in partnership with Divisional HRPB oversight. Sickness absence remains at just over 3.5%.- The Live Well and Inspire Healthy workplace campaign continues with a focus on generating awareness for the range of activities and support available to staff. There has been a specific awareness campaign during September including staff briefings and an event on 27th of September in the front of the hospital to promote healthy living. Health checks for all staff have been launched in November. This includes the opportunity to undertake a quick assessment using an automated machine in the front entrance, or book a more detailed face to face appointment with Occupational Health.- Vaccination is now well underway for the 2017 Flu campaign. 66.8% of staff have received vaccination against a target of 70%.

Appraisals- The behaviours framework which underpin our values has been launched. This is now being tested as a new and integral part of the revised appraisal process and is being

Indicator

5.1 Human resources

HR - Turnover - Rolling 12-months

HR - Sickness absence - Rolling 12-months

HR - Appraisals completed (non-medical) - Rolling 12-months

Nursing Vacancies (Total Clinical Wards)

Staff FFT response rate

Staff FFT - % of staff likely or extremely likely to recommend UHS as a place to work.

Nursing Vacancies (Registered Nurse only in clinical wards)

2016/17 2017/18 2015/16

Human Resources5. Well LedJanuary 18

Page 24

This Year Last Year

5. Well Led Ward Staffing Report

December 2017

January 2018

Page 25

The following highlight report (in fulfilment of the National Quality Board (NQB) expectations on trust board awareness of safe staffing) focuses on any ‘hotspot’ areas in December 2017 which the board needs to be aware of in each Division after review of the overall staffing figures, daily staffing reports and staffing incident reports. The table below represents the high level summary of the planned and actual ward staffing levels reported for December 2017. This is the information which has been uploaded and will be for public display via NHS choices from early February 2017. Detailed ward by ward information is also included as part of this KPI report. From May 2016 Care Hours Per Patient Day (CHPPD) showing average care hours per patient for SGH, PAH and CMH has been included as part of the Model Hospital dashboard and is included in this report. Costs per ward have also been included in the model hospital dashboard since December 2016. Staffing position for December 2017

December 2017 Day

Night

Care Hours Per Patient Day

(CHPPD)1

Site Name

Average fill rate - registered

nurses/ Midwives (%)

Average fill rate - care staff

(%)

Average fill rate -

registered nurses/

Midwives (%)

Average fill rate -

care staff (%)

Reg. midwives/

nurses Care Staff

Total care

hours per

patient SOUTHAMPTON GENERAL HOSPITAL

79.8%↓

115.4%↓

89.3%↓

128.6%↓

5.1↔

3.3↔

8.3↓

COUNTESS MOUNTBATTEN HOUSE

91.8%↑

118.4%↓

95.5%↑

114.1%↓

3.6↔

3.9↑

7.5↑

PRINCESS ANNE HOSPITAL

81.5%↓

64.5%↑

97.9%↓

73.9%↑

6.3↓

2.0↓

8.3↓

NB: Arrows indicate changes against the previous month and do not represent either a positive or negative performance position. Whilst it can be seen that we were not able to staff many clinical areas with our planned level of registered nurses due to current vacancy levels, we maintained our staffing levels at or above minimum safety levels. This was achieved by using our nursing bank and agency, through reviewing nurse staffing on a daily basis across the Trust and deploying non-ward based staff to support. ‘Hotspot’ areas for nursing/midwifery staffing in December 2017 Key metrics show that staffing and capacity challenges were extreme during periods in December despite the reduced levels of annual leave for staff across the holiday period. Acuity and dependency remained high across the trust and staff sickness impacted a number of areas.

1 CHPPD, split into registered nurses/midwives and health care support workers is calculated using this formula:-

Actual hours worked_ Patient count at midnight


December 2017

January 2018

Page 26

Exceptions by Division are detailed below: Division A Surgery – The surgical ward vacancies are improving slowly but the wards continue to be challenged with staffing. Band 2-4 staff have been over-recruited to support the ward areas and the band 6 supervisory roles have been boosted to improve supervision for junior staff. Cancer Care –Registered nursing vacancies at CMH continue to be a challenge and this is being supported by movements within the care group, recruitment of additional support staff and the support of bank/agency. D2, D3 and AOS experienced high levels of activity with additional capacity required during the month. Critical Care – All critical care areas are working together to safely staff shifts despite fluctuating levels of acuity and occupancy. RN vacancy rate is stable at 11% across the 4 units. With lower patient occupancy during the initial part of December staff were moved across the division to support other care groups. The latter part of the month saw a pressure on capacity and led to necessary use of high cost agency for break-glass safety reasons after a period of 7 weeks without usage. Division B The Divisional registered nurse vacancy position remains significant at 21.2% (104 FTE) up on the previous month and inclusive of the recruitment of the newly qualified staff. The division’s daily staffing challenges have remained consistent in December with some shifts remaining at ‘critical’ levels. Key mitigating actions and daily senior nurse focus have supported the ward teams to keep patients safe; golden key release is monitored carefully in order to ensure that high cost agency is only used for true ‘break glass’ eventualities however the latter part of December saw a rise in the number of requests to maintain safety. Following consultation, all the divisions’ matrons are now providing a core hours, evening and weekend on site service and one element of their role is to lead safe staffing planning and decision making. ED and AMU - The vacancy position within the Emergency Care group rose slightly to 12.6% (24 FTE) for RN’s. The activity challenges experienced at the end of December were particularly focussed on ED and AMU and this was reflected in the requests for high cost agency for break glass safety reasons. Emergency medicine wards & Medicine for Older People – Registered nurse vacancies rose to 29.9% (78 FTE) and this was reflected in the need to use high cost agency for break-glass safety reasons and an increase in staff moving from across the hospital to support. Medicine continues to over-recruit unregistered staff which really supports the risk associated with the RN vacancy rate. Division C Child Health - RN vacancies across child health rose slightly to 14.5% (47 FTE) despite the appointment of the new qualified children’s nurses. This has impacted on the ability to open the beds closed over the summer however there is an improved pipeline of starters expected from January Maternity & Neonates– Vacancies for midwives have further reduced this month. A further intake of external NQM’s appointed in October are now fully orientated and working within the clinical areas. They have been brought constructive practice suggestions from their home NHS Trusts that the service is learning from. Whilst vacancies remain low, December saw high levels of short term sickness within the midwifery workforce due to seasonal illness. Both the Obstetric led and Midwifery led pathways have worked together to cross cover in order to continue to provide safe care and minimise use of agency staff.


December 2017

January 2018

Page 27

Division D The overall Divisional registered nurse vacancy position remained stable at 20% (92 FTE) with a pipeline of 11 registered nurses to start in the next 2 months. Staffing of uncommissioned capacity to support the capacity challenges has resulted in an increased usage of high cost agency. T&O and Neurosciences remain areas of focus with trained nurse vacancies of 33.9% (43 FTE) and 23.6% (33 FTE) respectively. High vacancies are being managed with staff doing bank shifts, over recruitment of band 3 and 4’s and deploying staff across wards.

------------------------ Staff continue to reference the ‘red flags’ identified in the NICE guidance on safe staffing when completing adverse event reports (AER) linked to staffing. These red flags highlight when patient care has potentially been impacted due to staffing shortfalls. These AERS are reviewed, actioned and mitigated in real-time to reduce the risks. They are also themed monthly and identified actions taken forward linked to the reporting on safe staffing and the trust risk register. Care group and divisional reports are also available to enable focus on trends in incidents being reported from each clinical area. In December there were 110 staffing incident reports in total covering 7 different staff groups. This is a significant increase on the 81 reported in November and brings the level back to the high seen in August and September before vacancy improvements. These incidents have been rated from near miss to moderate (18) impact. This also shows a rise in the number of incidents rated at moderate (11 in November). We will be monitoring the rise both in the number of incidents and severity closely. Of these incidents, 88 61 were related to nurse staffing, a rise on the 61 reported in November. There was 1 Midwifery incident reported for the month. Hotspot areas identified through the reporting are being closely reviewed by the divisions. In addition to the existing system, in August we introduced the capability to report red flag incidents in real-time on the safecare acuity/dependency system in healthroster. These red flags will then be reviewed at the daily staffing meetings.

------------------------ The overall vacancy level for ward staffing (registered, unregistered and other support roles) worsened slightly in December reflecting a normal pattern for this time of the year. The overall vacancy level now stands at 407 FTE (12.8%). This is made up of 378 FTE (18%) registered vacancies and -1 FTE (- 0.1%) unregistered vacancies as a result of conscious over-recruitment. It should also be noted that, with the arrival of the most recent cohort of nurses from overseas, an increased number of 57 registered overseas nurses are currently working as unregistered nurses as they await the results of their English language testing (IELTS) requirements and competency requirements stipulated for NMC (Nursing and Midwifery Council) registration. Graph 1 below details the breakdown of temporary staffing cover across the last year. Overall use rose slightly in the month despite the reduced levels of annual leave for staff across the holiday period. High cost agency usage rose with 6 FTE (99 shifts) in December 2017 for break glass safety reasons. This equates to 1.6% of the total temporary nursing staff usage. The extreme capacity pressures at the end of the month led to the higher level of requests. Shifts escalated to high cost agency remained unfilled in a


December 2017

January 2018

Page 28

number of cases and all measures were taken to manage staffing across the trust to ensure safety was maintained. Daily escalation processes continue to support the most effective deployment of staff in real-time with the use of ‘safecare’ acuity/dependency data embedded as part of the daily staffing reviews. Graph 1


December 2017

January 2018

Page 29

Graph 2 – Ward Staffing - Predicted vacancies


5.2.1 85% Internal 83% 83% 82% N/A N/A 78% N/A

5.2.2 Internal 80% 77% 71% N/A N/A 67% N/A

5.2.3 85% Internal 87% 86% 88% N/A N/A 80% N/A

5.2.4 Internal 85% 85% 85% N/A N/A 83% N/A

5.2.5 85% Internal 75% 75% 75% N/A N/A N/A N/A

5.2.6 85% Internal 84% 84% 82% N/A N/A 78% N/A



5.2.9 Internal 88% 88% 88% N/A N/A 84% N/A

5.2.10 90% Internal 85% 84% 83% N/A N/A 76% N/A

5.2.11 85% Internal 87% 88% 88% N/A N/A 78% N/A

5.2.12 85% Internal 87% 87% 87% N/A N/A 70% N/A

Q1 Q2 Q3 Q4 Q2 Q3

5.2.13 No risk InternalMinor Risk

Minor Risk

Minor Risk N/AMinor Risk

Minor Risk

5.2.14 No Risk InternalMinor Risk

Minor Risk

Minor Risk N/AMinor Risk

N/A

5.2.17 250 Internal n/a18

starters -7.2%

12% N/A N/A N/A

5.2.18 85% Internal N/A 27% N/A N/A N/A N/A

% Uptake of Apprenticeship in 2017/18

5.2 Education &

Training

Percentage of new starters who have completed their care certificate within the allocated timeframe for the quarter

Safeguarding Adults

National Learning and Development Agreement Compliance (Q2 & Q4 only)

Quality of practice experience for doctors in training (annual report with quarterly qualitative updates)

Infection Prevention - Non Clinical

Equality & Diversity

Prevent Training

Basic Life support Non Clinical

Child Protection (L3 only)

2017/18

5.2.17 New indicator introduced from 2017/18 quarter 2. Replaces 5.2.15 previously reported. 5.2.18 New indicator introduced from 2017/18 quarter 2. Replaces 5.2.16 previously reported.

Education & Training5. Well LedJanuary 18

Page 30


Information Governance

Local Induction

Basic Life support and AED Clinical

Fire Safety

Moving and Handling - Practical Only

2016/17

Infection Prevention - Clinical

Theme Ref.Annual Target Source Oct Nov Dec QTD YTD Month YTD Detail

5.3.8 1.2 (£m) Internal £0.00 £0.00 £0.00 £0.00 £1.24 N/A N/A

5.3.9 2.3 (£m) Internal £1.22 £0.01 £0.00 £1.23 £4.95 N/A N/A

Oct Nov Dec QTD YTD Month YTD

5.3.10 Top 5 Internal 3rd 3rd 4th N/A N/A N/A N/A

5.3.11 Top 5 Internal 14th 13th 15th N/A N/A N/A N/A

5.3.12 Internal 19th 18th 18th N/A N/A N/A N/A

5.3.13 ≥ 80% Internal 57% 57% 57% N/A N/A N/A N/A


5.3.15 20950 Internal 1,058 943 808 2,809 11,688 N/A N/A

Q1 Q2 Q3 Q4 Month YTD

5.3.16 ≥95% Internal 100% 93% N/A N/A N/A N/A

5.3.17 ≥65% Internal 50% 46% N/A N/A N/A N/A

Oct Nov Dec QTD YTD Month YTD5.3.18 16.2 (£m) Internal £1.71 £1.51 £1.61 £4.83 £14.55 N/A N/A

The Research & Development KPI page was revised in October 2017 and new KPI indicators were introduced. Consequently comparative data for 2016/17 is not available.5.3.10 - 4th of 500 organisations; this is expected to go down as we focus on more complex studies which have lower absolute recruitment5.3.13 - Focus is currently on maximising weighted recruitment to non-commercial studies5.3.14 - Initiatives on improving weighted recruitment are having a positive impact. Work is ongoing.5.3.15 - Recruitment from October will be -500 less per month due to the premature closure of the OAE maturation study. Action is being taken to improve patient recruitment across studies and data input. November and December data is still being uploaded. Q3 & Q4 recruitment is historically higher due to winter season studies (e.g. Flu and Respiratory).

Value of awarded grant applications led by UHS - NIHR funders

Value of awarded grant applications led by UHS - all funders (incl. NIHR)

National ranking for recruitment to CRN portfolio - all CRN portfolio studies (of 500 NHS orgs)

National ranking for recruitment to CRN portfolio - interventional studies (of 500 NHS orgs)

National ranking for recruitment to CRN portfolio - commercial studies (of 144 English Trusts)

Percentage of commercial CRN portfolio studies closing on target (NIHR CRN metric)

Last Year

This Year Last Year

5.3 Research &

Development

‘70 day target' - 1st patient recruited within 70 days for UHS R&D confirmation of capability and capacity

Percentage of all commercial studies closing on time (NIHR CCF metric)

Percentage share within Wessex of weighted recruitment to CRN portfolio studies (of 14 trusts)

Number of participants recruited to CRN portfolio studies

Indicator

Total R&D Income - invoiced

This Year Last Year

Research & Development5. Well LedJanuary 18

Page 31

This Year Last Year

CRN Portfolio Recruitment

NIHR Central Commissioning Fund Metrics - Quarterly in arrears

Grant Applications

Finances

2017/18

Theme Ref. Target Source Oct Nov Dec QTD YTD Month YTD* Detail

6.3.1 N/A N/A 2,178 2,259 2,315 6,752 19,133 1,709 11,386

6.3.2 85% Internal 86.7% 83.7% 78.70% 83.0% 84.3% 91.9% 75.4%

6.3.3 N/A N/A 153 110 131 394 978 183 1,191

6.3.4 95% Internal 98.7% 100.0% 100% 99.5% 98.8% 95.6% 91.3%

6.3.5 N/A N/A 278 347 371 996 2,698 313 2,467

6.3.6 95% Internal 100.0% 98.8% 99.70% 99.5% 98.9% 95.8% 89.0%

6.3.7 N/A N/A 85 99 100 284 798 105 998

6.3.8 85% Internal 97.6% 100.0% 100% 99.3% 96.5% 98.1% 94.7%

Estates6. ProductiveJanuary 18

Page 32

This Year Last Year

* Data reported from Dec-15 onward are automatically generated from the Estates department maintenance database.

Indicator

6.3 Estates

Estates - % Planned Maintenance Completed - Good Practice

Estates - Mandatory Logged Maintenance Jobs

Estates - Statutory Logged Maintenance Jobs

Estates - Total Logged Maintenance Jobs

Estates - Good Practice Logged Maintenance Jobs

Estates - % Planned Maintenance Completed - Mandatory

Estates - % Planned Maintenance Completed - Statutory

Estates - % Maintenance completed within planned time

of 5

Trust Board meeting 1 February 2018

Title

Guardian of Safe Working Hours Quarter Report

Sponsoring Executive

Dr Derek Sandeman, Medical Director

Authors’ names & Job titles

Dr Kathryn Nash: Consultant Hepatologist and Interim Guardian of Safe Working Hours

Purpose of the paper

For information ☑

To note o Formal approval o

For decision o

History

The Guardian role is integral to the 2016 Junior Doctors Contract with the fundamental remit to provide assurance to the Trust Board that doctors’ working hours are safe.

Main issues / Executive Summary

Employment and expenditure

527 Junior Doctors in Training are currently employed by the Trust. 95% are now working on the new contract.

238 non-training Fellows are employed, 66% on 2016 UHS local terms and conditions.

Vacancy rate remains ~6.5%. 95% of all vacant hours were filled by the internal locum bank. Locum spend via the internal bank remains high £250,000 per month (Appendix 1). 70% of the expenditure relates to covering vacancies

Exception reporting

474 exception reports have been submitted since the contract began (Appendix 2.1)

• Only ~17% doctors have completed an exception report • Number of exception reports submitted when the hospital

has been under pressure has been low, likely under reporting • Cost to the organisation of exception reporting is currently

low, but likely to increase if reporting can be embedded fully • 3 exception reports this quarter have been logged as

“immediate safety concern”. One was an error in reporting. The other two related to sickness of 2 medical SpRs overnight between Xmas and New Year.

• There have been no financial penalties given out as a result of contract breaches with exception reporting system

Work schedule review undertaken in urology/vascular FY1 rota has seen positive changes in working pattern with reduction in exception reports. Further feedback from current trainees is planned.

Enclosure 3

of 5

Junior doctor executive forum meet quarterly led by the Chief Registrars. There is increasing engagement from junior doctors Consultant Rota Leads meet quarterly to share good practice. Workload remains intense in many areas and there is ongoing need for wider overview of the workforce, use of junior doctors, advanced nurse practitioner roles etc across the organisation to help with planning for future staffing.

Implications

More work is needed to promote exception reporting at junior doctor and at consultant level There needs to be ongoing monitoring of exception reporting and support given to the Consultant Rota Leads who are managing these. The overall impact of the new contract financially and on service provision is unclear and is difficult to quantify currently:

• Many factors which impact on rota gaps • Under usage of exception reporting system

Action Required

The Board is invited to note the report and ongoing concerns regarding work intensity, exception reporting and rota gaps.

Next Steps

Next quarterly report due April 2018

of 5

Appendix 1: Summary of junior doctor vacancies across work and total internal locum usage.

Area Total Vacancies

Total hours booked via the bank (Sept-Nov)

Total bank spend (Sept-Nov)

Anaesthetics 3 625 £46,178 Intensive Care (All) 2 317 £15,396 Cancer Care 1 1117 £53,365 Surgery (inc ENT) 6 1180 £53,056 Emergency Care (inc AMU)

10 3808 £198,377

Medicine for Older People

2 126 £5,040

Pathology 3 25 £1,023 Specialist Medicine 6 896 £49,870 Ophthalmology 1 893 £61,398 Child Health 6 678 £39,206 O&G / Neonates 1 508 £27,071 T&O 1 1967 £82,024 Neurosciences 2 82 £3,550 CV&T 6 1245 £72,305 Total 49 13,467 £707,859

Note: There is a discrepancy between vacancy numbers and total hours booked. Further information required to understand the reasons for this e.g. covering sickness, WLI payments etc

of 5

Appendix 2.1: Number of exception reports since implementation of contract (as at 18/01/18)

Oct-16

Nov-16

Dec-16

Jan-17

Feb-17

Mar-17

Apr-17

May-17

Jun-17

Jul-17

Aug-17

Sep-17

Oct-17

Nov-17

Dec-17

Jan-18

No of episodes 10 2 9 1 16 16 19 38 5 16 106 73 108 61 79 45 No of exceptions 10 2 9 1 15 13 15 24 5 9 81 58 87 51 63 31

Appendix 2.2: Reason for exception

Oct-16

Nov-16

Dec-16

Jan-17

Feb-17

Mar-17

Apr-17

May-17

Jun-17

Jul-17

Aug-17

Sep-17

Oct-17

Nov-17

Dec-17

Jan-18

Hours 6 2 7 0 12 13 11 24 4 17 96 66 100 53 69 44 Education 1 0 0 1 2 3 2 3 1 0 9 5 7 6 6 0 Pattern 3 0 2 0 1 0 5 11 0 0 1 0 0 2 3 1 Support 0 0 0 0 0 0 1 0 0 0 0 2 1 0 1 0

of 5

Appendix 2.3: Exception report outcome:

Outcome of exception report

Compensation: Time off in lieu

107

Compensation: Overtime Payment

326

No further action 33 Request more information 19 Pending 33

Appendix 2.4: Exception report summary and future work

• Only a minority of doctors appear to have engaged with the exception reporting system • Reasons for lack of engagement are multiple and solutions will require ongoing education

and support across the hospital • Without this information it is difficult to have confidence in the safety of current junior doctor

working and to plan future staffing • Where exception reporting has been used (vascular/urology) work schedule review has

been undertaken and changes appear to have had a positive impact • Assuming that information is incomplete it is difficult to predict the future financial risk to the

hospital Proposals:

• Work with consultants and junior doctors to promote exception reporting and the benefits of this

• Explore reasons for under reporting - work with Chief Registrars to undertake a brief survey

Trust Board meeting 1 February 2018 Title

Equality, Diversity & Inclusivity Quarterly Report


Gail Byrne – Director of Nursing and Organisational Development


Gemma Genco – Head of Equality, Diversity and Inclusivity


For information ☑

To note o Formal approval o

For decision o

History

Trust Executive Steering Group and members of Trust Board approved the WRES Action Plan in November 2017. Work towards achieving its objective are all in progress. The EDI Strategy is currently being developed with a number of engagement and consultation events being held throughout February to ensure a wide range of perspectives are considered. The Strategy and accompanying action plan will be presented to Board for approval in April.


This paper aims to provide an update on progress of the wider EDI agenda and to provide a progress update against the WRES Action Plan for final approval.

Implications

It is essential that we maintain the momentum now gained on this agenda to ensure legal compliance and improved working and visiting experiences.

Action Required

• To receive the update on progress and be assured that progress against the EDI action plan is being achieved

• Note that the EDI strategy is currently under review; and the equality objectives and resulting action plans will be presented for approval at the next meeting.

• Trust Board Mmmbers are also asked to attend one of the EDI Strategy Engagement Events in February (dates and venues included in 3.1).

Next Steps

The Equality, Diversity and Inclusivity Steering Group will oversee and monitor progress on the delivery of the WRES Action Plan along with other activity to progress the EDI agenda. Members of the Trust Board are asked to continue to support this agenda.

Enclosure 4

Page 1 of 23

1 Purpose

1.1 The purpose of this paper is to provide TEC members with an update on progress towards the EDI agenda.

2 Key Issues

1. Current priorities are the development of the 3 year EDI Strategy and action plan, publishing our annual workforce data and completion of our EDS2 contractual obligations. Work on all these streams is in hand and final publications will be provided at the April TEC and Trust Board.

2. Consideration is being given to how best to expand and improve staff representatives from the different characteristics to further progress the EDI agenda, as traditionally this has been limited to staff networks.

3. There is a need to map and review the groups associated with the EDI agenda as it appears there is some duplication of efforts and work.

3 Summary of Progress

3.1 EDI Strategy Engagement Events The EDI Strategy is due for renewal and as part of developing the new 3 year EDI strategy and action plan, 3 Engagement Events are planned for February. The purpose of these events will be to elicit the views of our staff, patients, visitors, contractors and local community on the following proposed objectives. The proposed Strategic Objectives for 2018 – 2021 are:

1. Better Health Outcomes 2. Improved Patient Access and Experience 3. A Representative and Supported Workforce 4. Inclusive Leadership 5. Places and Spaces – Our Environment 6. Local Community and Procurement

Please note that the first 4 objectives are in line with the EDS2 objectives. Event dates are as follows: Date Time Venue Friday 2nd February 9:30am – 12:30pm Lecture Rm A, Education Centre, South

Academic Block Thursday 8th February 5pm – 8pm Conference Room, Heartbeat Education

Centre, F Level, North Wing – subject to change to a community venue

Wednesday 14th February

2:30pm – 5:30pm Lecture Rm A, Education Centre, C Level, South Academic Block

The basis of these consultations, along with various qualitative and quantative data already available to the Trust will be developed into the final strategy and accompanying action plan which will be presented at the next TEC and Board meetings for final approval. All members of the committee are requested to attend one of these events and to encourage staff and patient involvement.

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3.2 Workforce Race Equality Standards (WRES) Activity/Progress against action plan The WRES Action Plan was approved at Board in November 2017 and work towards achieving its aims has been progressing well. Plans are being developed to seek greater engagement with the WRES agenda from all staff, but in particular BME staff. Of particular focus this year is: • Improving the quality of feedback provided to individuals after shortlisting and interview • Understanding and addressing the barriers to promotion for BME staff • Reviewing recruitment training provided to reduce unconscious bias in shortlisting and

selection Actions to address these focuses are already in progress in collaborative pieces of work between the EDI and HR teams. The action plan found in appendix 1 is a live document recording the Trust’s progress towards meeting these objectives. The Committee should be assured that actions are progressing according to timescales. 3.3 WRES Frontline Staff Forum The WRES programme has now been in place for the past two years. The National WRES Team recently approached a number of Trusts to participate in a new BME Frontline Staff Forum that was being developed as part of Phase 2 of the WRES strategy (appendix 2). The purpose of this forum is to hear first-hand from frontline staff across the service whether the WRES programme is impacting positively on their working lives and to hear what they believe needs to be done to improve race equality in their own organisations. The group consists of 25 frontline staff from across the countries, who over a period of six months meet to discuss the WRES and how they view its impact. This group aim to produce a report at the end of the 6 month facilitated period and present their findings to the National WRES strategic Advisory Group. UHS agreed to participate in this forum and identified, as requested a BME staff member to represent the Trust. The staff member is working closely with the Trust’s EDI team, sharing learnt good practice and developments of the WRES programme that are influencing and assessing our own progress towards our WRES objectives. 3.4 Staff Profile The Trust is legally obliged to annually publish information about its workforce. Initial analysis indicates that the Trust’s workforce profile mirrors that of the national NHS workforce. Once the workforce profile is complete we will be able to determine how reflective we are of our local community. The final workforce profile will be used to inform actions identified within the WRES action plan with regards to where BME staff appear in the workforce and where targeted efforts should be made to support staff with development and promotion opportunities. A full workforce profile will be available on the website by the end of January 2018 and provided in the next report.

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3.5 Patient Health Inequalities

It is important that the Trust provide the same focus towards health inequalities and experiences of patients and visitors that it affords its staff. The EDI Strategy Engagement event will provide patients, visitors and the local community the opportunity to have their say on shaping and accessing our services in ways that best meets their needs. In addition to this the Head of Patient Experience and Involvement is working across a number of groups to better coordinate our efforts on this front.

3.6 Disability Access Group A new Disability Access Group has been established to;

• have strategic oversight of accessibility issues across UHS site(s), to ensure compliance with the requirements of the Equality Act (2010) in relation to all aspects of building and service accessibility.

• ensure that the lived experience of staff and service users with disabilities is no less favourable than other service users.

• ensure UHS carries out its employment duty to provide reasonable workplace adjustments for staff with disabilities.

The first meeting of this group is scheduled for mid January. 3.7 Gender Pay Gap Since the introduction of the Equality Act 2010 (Specific Duties) Regulations 2011 (SDR), there has been a duty for public bodies to publish information on the diversity of their workforce. Further to this there has been an amendment to the SDR that made Gender Pay Gap reporting mandatory for all public sector employers with more than 250 employees to have to measure and publish their gender pay gaps.

As an employer of over 250 employees, UHS is required to publish information annually for all employees who are employed under a contract of employment, a contract of apprenticeship or a contract personally to do work. This will include those under Agenda for Change terms and conditions, medical staff and very senior managers. All calculations should be made relating to the pay period in which the snapshot day falls. For the first year, this will be the pay period including 31 March 2017. Work is being undertaken by the HR team to provide all the required information within the mandatory year period of the snapshot date. This will be presented to TEC and Board once finalised and ready for publication.

3.8 Community Links Project

The Trust is working with Southampton Council of Faiths (SCoF) on diversity related initiatives. Feedback we received from the Faith community is that they want to gain a better understanding of UHS as an employer, i.e. the types of jobs and careers available (other than medical) within the NHS (UHS) and how you can get into them. In response to this a careers/jobs event has been organised for 12th February 2018 where up to 20 people from the Faith community (Muslim on this occasion) will be invited to come into the Trust and receive:

• A tour of the hospital showing people doing roles that are not medical for e.g. receptionists, painters, health scientists etc.

• A talk on what sort of qualifications you need to get into the field and how to get them • A practical session helping them to create a CV

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It is hoped that this will form a blue print for similar future events that can be offered to wider community groups from protected characteristics, i.e. hard to engage with communities.

3.9 National Inclusion week – National Inclusion Week is the UK’s high profile annual week of activities and events that highlight the importance of inclusion across UK workplaces. It is a unique opportunity to get connected to and engage with people who are passionate about inclusion in the workplace and beyond. This week usually occurs at the start of October and it has been decided to replace the Trust’s annual Diversity Conference with participation in National Inclusion Week instead. A working party is being created to plan this event. The group will be seeking volunteers from across the Trust from all protected characteristics to run workshops and activities. External speakers/leaders in the EDI field are also being researched to provide the event with the gravitas it warrants. All events will be open to all staff and volunteers; and some sessions available to patients and visitors. 3.10 CQC Meeting

On the 27th November the CQC held a forum for BAME staff to share their experience of working life at UHS. It was a well attended event with approximately 25 staff from a range of bands and professions across the Trust. In addition to this opportunity to share their experiences staff were given a link to the CQC website to use if they had any further comments or to share with colleagues who were unable to attend the forum but wished to comment. There were no concerns escalated by the CQC to the Trust following the forum. A follow up event by UHS is currently being planned to capitalise on the voice that was evident at this event. This will afford an opportunity to share the WRES data and action plan whilst seeking engagement and involvement from a range of BAME staff in task and finish groups to help achieve the WRES objectives.

3.11 Hearing Loops

We have recently had an audit (including testing) of our hearing loop facilities undertaken by Deaf Awareness Technology at the main hospital site. The company have submitted a report outlining the status of the installed hearing loops and identified areas where a hearing loop system (permanent or portable) would be beneficial/compliant. These findings and recommendations will be presented to the newly formed Disability Access Group and the EDI Steering Group later this month to determine how we move forward with addressing the recommendations. Additionally, the recent PLACE report identified that our other Trust sites also do not provide adequate support for hearing impaired/Deaf staff and patients so an audit of these sites has also been requested.

3.12 Accessible Information Standard The implementation of the Accessible Information Standard is a statutory requirement for all NHS trusts. It aims to ensure that patients and carers with information and communication support needs have those needs met in an appropriate and timely way. The alert / flag functionality is now in EMIS test environment with a launch likely to be in March 2018. This will allow for the basic recording of information and communication support needs in PAS. IT are working to ensure this flag will be available in systems EMIS feeds- eDocs, CHARTS.

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The AIS delivery group is currently working on defining categories need and detail. Provision will be extended to mental health and dementia communication and information support needs to maximise the new functionality. Working group includes representatives from the vulnerable adult teams to ensure expertise. The challenge will be to ensure that UHS is equipped to meet patient needs once recorded. This includes supplying information in alternative formats as standard, as well as ensuring staff have the ability to communicate in appropriate ways with all patients with needs. A fuller update will be available in the Q3 Patient Experience Report.

3.13 National Workforce Disability Equality Standard (WDES) NHS England recently provided a document entitled: National Variation Agreement for existing 2015/16, 2016/17 and 2017-19 (November 2016 edition) form contracts. Within this document the following statement was published in relation to the forthcoming National Workforce Disability Equality Standard (WDES) With effect from 1 February 2018, Service Condition 13.7 is deleted and replaced by the following:

13.7 In accordance with the timescale and guidance to be published by NHS England, the Provider must: 13.7.1 implement the National Workforce Disability

Equality Standard; and 13.7.2 report to the Co-ordinating Commissioner on its

progress.

NHS Trust/FT

UHS have been acting as a pilot organisation with the National WDES Team so as soon as the timescale and guidance is published by NHS England, the Trust will be well placed to move forward with working towards these standards. 3.14 Changing Places Facility In the last report it was reported that the Trust had introduced an Adult Assisted Changing Facility, essentially a toilet designed for people (service users and visitors) with multiple and complex disabilities who may have one or more assistants with them or are unable to use standard accessible toilets. Whilst this is an excellent facility feedback received has highlighted that there are number of enhancements that can be made to make the facility accessible to a wider number of users who would benefit from it, i.e. staff with multiple disabilities and those with motorised wheelchairs where standard accessibility toilets are not suitable. The following recommendations were approved at the December EDI Steering Group and work has started on achieving them.

1. That this facility be renamed to Changing Places Toilet and appropriate signage

displayed

2. That this facility be changed to an Uncontrolled Access by Key (RADAR) facility

3. Staff who would benefit from utilising this facility should be permitted to do so

4. Promotion of this facility, including details of its purpose, location and how to access it be widely available both to the public and staff. The facility should also be registered with the Changing Places Consortium to promote good practice - http://www.changing-places.org

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http://www.changing-places.org/�

5. Customer service staff should be aware of the equipment provided within the facility to help field enquiries

6. This facility must remain a protected space and must not be used for storage or any other purpose

7. Some items of equipment within the facility need changing/adaptation, i.e. bins with sensors as opposed to foot pedal, to better meet users needs

4. Next Steps / Way Forward

• Deliver a revised EDI Strategy, accompanied with reviewed equality objectives and action plan.

• Submit the EDS2 report and finalise the accompanying action plan.

• Establish UHS as a Third Party Reporting Centre and developing a true culture of

Zero Tolerance

• Complete the work required to provide a best practice Changing Places Toilet

• Develop engagement and involvement activities for staff and patients to become actively engaged in the EDI agenda.

• Continue to deliver on the WRES action plan and begin planning for the introduction of WDES

• Create a Task and Finish Group to start work towards achieving the Disability Confident Leader Award.

5. Recommendation

5.1 Members of the Trust Executive Committee are asked to continue to support this agenda. Members are also asked to attend one of the EDI Strategy Engagement Events in February (dates and venues included in 3.1).

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Workforce Race Equality Standards (WRES) Annual Action Plan 2017/18

Objective/Key Deliverable

Action(s) Impact / Measure Lead Deadline Progress RAG

1 Percentage of staff in each AfC Bands 1-9 and VSM compared to overall workforce Key Issue(s) - Decrease of BME

staff in non-clinical Bands 6 & 7

- Decrease of BME staff in clinical Bands 5 & 8+

• Identify (through data analysis) where over/under representation of BME staff occurs within all Bands and develop proactive initiatives, i.e. signposting to Nursing Apprenticeship

• Review where job adverts are placed and identify opportunities to target specific communities (linked to above action)

• Develop a 3 year plan to increase opportunities for BME staff to progress to higher Bands

Increase in BAME staff in Non-Clinical bands 6 & 7 and Band 5 and Band 8+ in Clinical areas

Director of HR (supported by EDI HR Advisor)

Jan 2018 Jan 2018 Jan 2018

Analysis currently being completed and will be published by 31.01.18. Discussions taking place between EDI lead and HR Discussions taking place between EDI lead and HR. Meeting with E.Charles being scheduled on next steps after Inclusive Leadership training ends

2 Relative likelihood of staff being appointed from shortlisting Key Issue(s) - White staff are

1.77 times more likely to be successful

• Map appointments against the diversity of interview panels (i.e. BME Staff on panel) to ensure a fair process

• Interviewers to provide honest and quality verbal or written feedback to all internal candidates (develop a standard proforma)

• Proforma to be provided to unsuccessful all applicants’ line managers (with permission) to be developed with their support into a meaningful Personal

Increase in BME staff being appointed from shortlisting

Head of EDI (supported by EDI HR Advisor) Director of HR (supported by EDI HR Advisor)

Mar 2018 (6mths to be meaningful) Dec 2017 Dec 2017

Currently under review by HR Team Currently under review by HR Team Currently under review by HR Team

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Development Plan, monitored through 1:1s and appraisals.

• Review (and compare) feedback from all applicants on the recruitment process to implement appropriate improvement actions

• Introduce a BME Talent Pool providing secondments, shadowing, hands-on work experience and fast track opportunities for BME staff

Director of HR (supported by EDI HR Advisor)

Mar 2018 March 2018

Currently under review by HR Team Analysis of current Inclusion Leadership Programme due end of Feb will inform this piece of work.

3 Relative likelihood of staff entering the formal disciplinary process, as measured by entry into a formal disciplinary investigation Key Issue(s) - To continue to

reduce the number of formal disciplinary procedures entered into for all staff and maintain an equal likelihood of BME and White staff entering into such a process

• Review recorded disciplinaries for trends, i.e. ethnic groups disproportionately appearing, reasons for disciplinaries etc and agree appropriate action to address identified trend

• Review Disciplinary Policy and Code of Conduct to ensure clarity and ease of use for all

• Deliver training to managers Unconscious Bias and having Meaningful Conversations Regarding Working Practices of Staff

• Promote the Staff Support Advisor’s Role to support staff with employment issues

Maintain equilibrium that BME and White staff are equally as likely to enter formal proceedings

Head of EDI (supported by EDI HR Advisor) Director of HR Head of Leadership Development EDI HR Advisor

Apr 2018 Apr 2017 Mar 2018 Feb 2018

Data requested. Deadline moved back in line with completion of above action Meeting scheduled (Feb) on how this can best be delivered Being undertaken as part of FTSU launch

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4 Relative likelihood of staff accessing non-mandatory training and CPD Key Issue(s) - To maintain an

equilibrium between staff groups accessing training and CPD

• Map and review offer of all training and CPD

• Develop proactive initiatives from results of above action

Maintain BME and White staff as being equally as likely to access non-mandatory training and CPD

Head of Leadership Development & Head of EDI

Dec 2017 Dec 2017

Meeting scheduled (Feb). Deadline to be amended after meeting

5 Percentage of staff experiencing harassment, bullying or abuse from patients, relatives or the public Key Issue(s) - Percentage of BME

staff experiencing this has increased by 4% and is also 4% higher than it is for White staff

• Establish UHS as a Third Party Reporting Centre

• Embed Root Cause Analysis system and learning for every reported hate incident and share learning as appropriate

• Fully utilise campaigns, i.e. Zero Tolerance to champion this agenda

Reduce harassment, bullying or abuse by at least 3%

Head of EDI Feb 2018 From immediately Ongoing

UHS has been involved in a City campaign and will formally launch in Feb Ongoing Initial discussions around implementing / developing a Zero Tolerance culture are taking place

6 Percentage of staff believing that the Trust provides equal opportunities for career progression or promotion. Key Issue(s) - There remains 11%

difference (lower) in BME views on

• Consult with BME Staff to identify potential barriers to career progression or promotion

• Introduce/design a BME staff mentoring and Coaching Programme

• Fully promote and utilise campaigns, i.e. NHS Personal, Fair and Diverse to champion this agenda

• Share WRES data widely across the Trust

Increase BME staff reporting equal opportunities for promotion and development from 78% to 84%

Head of EDI Head of Leadership Development Head of EDI

Dec 2017 Feb 2018

Consultation events planned for Feb 2018 Meeting scheduled (Feb 2018) To be uploaded on EDI web & staff net pages

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equal opportunities

to highlight the increase in this perception over the past 12 months

• Widely share the actions that we are taking to address the issues raised by WRES

in Feb/Mar 2018 Feedback forum scheduled for Feb

7 Percentage of staff personally experiencing discrimination at work from Manager/Team Leader or other Colleagues Key Issue(s) - There remains a

10% difference in BME staff personally experiencing discrimination

• Promote Zero Tolerance Policy (Review policy)

• Publish WRES data and action plan alongside a contextual briefing for all staff

• Utilise BME staff experiences to update the mandatory and specialist EDI training, i.e. collect personal stories

Decrease in personal experience of discrimination for all staff narrow the gap between perceptions between BME and White staff by 3%

Head of EDI Head if EDI Head of Leadership Development

Nov 2017 Feb 2018 Mar 2018

Discussions in progress In progress Consultation events planned

8 Percentage of staff experiencing harassment, bullying or abuse from staff Key Issue(s) - Staff experiencing

harassment, bullying or abuse from staff has increased for both BME and White

• Re-run the Ethnicity & Inclusivity Workshop to raise awareness of WRES and highlight Trust Values and Zero Tolerance Policy

• Increase engagement initiatives with BAME staff to gain an understanding of their experiences and how to overcome them

• Develop active EDI leaders/champions

Decrease in percentage of all staff experiencing of harassment, bullying or abuse Gap between BME and White staff perceptions is narrowed by 5% A minimum of 3 task and finish groups are established

Head of Leadership Development

Planned by Dec 2017 Sept 2018 Sept 2018

Inclusivity Week 2018 plans in progress Focus group events currently being planned Planning/discussions taking place

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staff, but remains 3% higher amongst BME staff

9 Percentage difference between organisations’ Board voting membership and its overall workforce. Key Issue(s) - BME staff are

disproportionately under-represented at Board level

• The Board will actively support talent management of BME staff, i.e. acting as sponsors as part of BME staff development

• The Trust to engage with appropriate activities to further the WRES action plan

• Pursue target recruitment practices to increase BAME Board representatives

Head of Leadership Development/ Trust Board

Planned by Dec 2017 Planned by Dec 2017

Meeting scheduled Feb 2018

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NHS Workforce Race Equality Standard: Phase two strategy (2017/18 – 2018/19)

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OFFICIAL

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Contents 1 Purpose ............................................................................................................... 3

2 Background ......................................................................................................... 3

3 WRES phase one: progress and achievements to date ...................................... 4

4 WRES phase two: the three strategic components ............................................. 5

4.1 Enabling people ............................................................................................. 5

4.2 Embedding accountability .............................................................................. 6 4.3 Evidencing outcomes .................................................................................... 7

5 WRES phase two: the operational expression .................................................... 8

5.1 Workstreams ................................................................................................. 8 5.2 Proposed deliverables ................................................................................... 9

6 Resource and support ....................................................................................... 11

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1 Purpose This paper outlines the current position of the NHS Workforce Race Equality Standard (WRES) programme, and presents the proposed strategic approach and its operational expression for the next phase: 2017/18 to 2018/19. 2 Background The WRES was introduced in April 2015 – to help support NHS organisations make the necessary operational and cultural changes needed to advance workforce race equality. It enables them to then make fundamental improvements in their organisations that will ultimately improve the quality of care for all patients. To date, good progress has been made on helping NHS trusts to establish the reporting architecture and baseline data against the nine WRES indicators that focus upon workforce representation and staff experience. Organisations are now developing annual WRES action plans that are reflective of their WRES data, and in doing so, are working towards operational changes on this agenda. In this regard, the role of regulation through introducing the WRES within the key policy levers for providers of NHS services and commissioning organisations has been a defining enabler. We know that workforce race equality, and equality in general, is a challenge that requires organisations to go beyond operational change as a result of data evidence, compliance and regulation. The parallel challenge to conquer here, and possibly the most difficult one, is that of behavioural, cultural and transformational change on the workforce race equality agenda. In order to realise the system-wide change we want to see on this agenda, it is proposed that the next phase of the WRES programme needs to focus upon three key areas:

(i) Enabling people: meaningful engagement, focused improvement, sustainability.

(ii) Embedding accountability: system alignment, regulation, new healthcare architecture.

(iii) Evidencing outcomes: data and intelligence, replicable good practice, evaluation.

This strategic approach is underpinned by international evidence from major change programmes on workforce equality, and in particular, on what works: accountability, leadership, metrics and transparency – underpinned by a convincing narrative. This was also outlined in the 2015 BMJ paper by Priest et al1, to which members of the WRES team contributed. The proposed strategic approach outlined in this paper has been engaged upon – including with the WRES Strategic Advisory Group.

1 2015 BMJ paper by Priest et al

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http://www.bmj.com/content/351/bmj.h3297

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3 WRES phase one: progress and achievements to date

Objective Deliverable Outcome Progress Identify the problem to acknowledge and understand the scale of the issues at organisational, sector and regional levels

Research highlighting the scale and nature of inequality gaps between black and minority ethnic (BME) and white staff across the NHS. WRES indicators enabling organisations to identify, understand and address the gaps.

Acceptance across NHS that there exist serious issues that need to be tackled. Enable all NHS providers, clinical commissioning groups (CCGs) and Arm’s Length Bodies (ALBs) to acknowledge their own challenges.

Achieved. Substantial progress - still work to be done with CCGs and ALBs.

Create narrative making the WRES a necessity for staff satisfaction, patient care and effectiveness

Create and disseminate a range of evidence-based communication – media, conferences, workshops, board meetings, collaboration.

Consensus that improving workforce race equality was a necessity for organisations and for patient care and safety.

Substantial progress made.

Effective system alignment embedding workforce race equality into core business

Mandated requirement to collect, analyse, publish data and action plans using the Unify2 IT system. Include progress on WRES within NHS standard contract, CQC inspections, CCG Improvement and Assessment Framework, and within the NHS Five Year Forward View.

A credible, simple, light-burden framework that made leadership and organisations accountable.

Successfully delivered.

Share initial replicable good practice and processes across the wider system

Provide organisations and boards with sufficient examples of evidenced good practice underpinned by research evidence.

Share evidence from the system of validated replicable good practice.

Work is developing; more to do.

Collaboration and engagement with key stakeholders at every level building organisational and system capacity

Build alliances and meet all possible relevant networks and stakeholders. Develop specific initiatives co-produced where possible.

Established the WRES Strategic Advisory Group. Established collaborative relationships with all healthcare ALBs and professional bodies.

Successful. Further work is ongoing.

Monitor and evaluate the effectiveness of the WRES

Evaluate the WRES team’s work and progress internally. Undertake independent evaluation of the WRES programme.

Ongoing monitoring and internal review by the WRES Team. Commission WRES independent evaluation.

Ongoing. Work is now commencing on the independent evaluation.

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Objective Deliverable Outcome Progress Sustainability of the agenda going forward

Establish capability and capacity within the system – at all levels – for the workforce race equality agenda to be sustained beyond the lifespan of the WRES programme.

Establish satellites of WRES experts across the country to support organisations on the agenda. Critical mass of employers undertaking replicable good practice.

More work to be done. We are at early stages.

4 WRES phase two: the three strategic components The strategic approach outlined below aims to close the gaps between BME and white staff workplace experiences and opportunities, including those cited within the next steps of the Five Year Forward View2. 4.1 Enabling people

2 Next steps of the Five Year Forward View

Objectives: I. Develop timely and effective communications and engagement on

the need to shift the deep-rooted cultures of workforce race inequality across healthcare organisations.

II. Supporting NHS organisations to understand and continuously improve upon their WRES data, including concerted attention upon regions, sectors, and disciplines that need focused support.

III. Assuring capability and capacity for the WRES to make continuous and sustainable improvements in workforce race equality across the NHS.

Strategic outcomes:

I. Organisations and staff at all levels are fully informed and updated on the WRES programme of work and the compelling narrative that underpins it.

II. Universal action in closing the gaps in workforce race equality within organisations, but at a scale and intensity that is proportionate to the levels of inequality that exist.

III. WRES knowledge and expertise is spread across the country with increased availability of sustained WRES implementation support at local level.

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https://www.england.nhs.uk/wp-content/uploads/2017/03/NEXT-STEPS-ON-THE-NHS-FIVE-YEAR-FORWARD-VIEW.pdf

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Evidence indicates that in order for deep-seated cultures in organisations to shift, focus needs to be paid simultaneously to a number of conditions including the consistent communication of the narrative, and robust understanding of performance (i.e. the WRES data) that informs action. Continued work on data, including that stemming from organisational responses to the WRES indicators, is essential. Organisations need to understand that the data is not the end point, but a means to an end; they should develop a spirit of enquiry and continuous improvement with regard to the data and action plans. Some organisations and parts of the system are embracing the challenge of this agenda well, whilst others have much more work to do. One of the primary goals of the WRES programme is to close the gaps in experiences and opportunities between BME and white staff across the NHS; to level the gradient of inequality between groups, whilst raising the bar for all staff. Providing additional, focussed support to sectors (ambulance trusts) and regions (London) with the steepest gradients will help to achieve this aspiration. Identifying, training and establishing subject matter experts on workforce race equality across the system will help to: (a) target resource to organisations and sectors that require focused support; (b) provide sustainability to the implementation of the WRES and to the agenda in general; (c) de-centralise reliance of knowledge and expertise from the national WRES office; and (c) establish the practice of organisations working collaboratively with peers in identifying solutions and good practice examples for common local challenges.

4.2 Embedding accountability

Objectives: I. Ensuring system alignment – key policy levers for NHS providers and

commissioners have workforce race equality embedded at their core

II. Supporting the effective regulation and assurance of organisations against the WRES

III. Supporting the hardwiring of workforce race equality into the new

healthcare architecture Strategic outcomes:

I. Effective incentives and sanctions relating to workforce race equality help to change behaviours within organisations

II. Inspection and assurance of organisations stimulate continuous improvements on workforce race equality over time

III. Workforce race equality is part of everyday business within new healthcare organisations and footprints

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It is essential that the WRES maintains strategic and operational alignment within key policy levers for providers and commissioners of NHS services. Ensuring workforce race equality is at the heart of current and future healthcare architecture is central to the mainstreaming and long-term sustainability of the agenda. Embedding this agenda into the minimum number of policy levers that have the maximum impact across NHS organisations will be a core objective. Levers within which the WRES is to be included and maintained include: the NHS standard contract; the CCG Improvement and Assessment Framework; CQC inspections of hospitals; the NHS Mandate. In addition, further work will be carried out with CCGs, both as employers and commissioning organisations. It is also essential to continue the work with the independent healthcare providers – to help support the independent sector in creating the foundations needed for effective WRES implementation – working closely with the Association of Independent Healthcare Organisations. The WRES features within the Next Steps on the NHS Five Year Forward View. Work to embed the WRES within Sustainability and Transformation Plans (STPs), and Accountable Care Systems (ACSs), will be further strengthened and accelerated.

4.3 Evidencing outcomes

Objectives: I. Supporting the provision of research, data and intelligence to help

facilitate meaningful insight into the workforce race equality agenda

II. Drawing local threads of replicable good practice into explicit national patterns – exploiting common opportunities for transformational change on the agenda

III. Evaluating the capability and proficiency of the WRES to help NHS

organisations in making continuous improvement in workforce race equality

Strategic outcomes:

I. High quality data and intelligence that strengthen the narrative and inform the development of robust action plans/targets at local and organisational level

II. Robust approaches and good practice initiatives for national

spread – facilitating system-wide progress on closing the gaps in workforce race equality

III. Sustainable and fit-for-purpose WRES that helps organisations to

improve on workforce race equality

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Continued work on data and evidence, including that stemming from organisational responses to the WRES indicators is essential. There is a clear need for the establishment of a sustainable system for the collection, analyses and benchmarking of WRES data. The annual collection of WRES data needs to be meaningful for each organisation; therefore it will be essential to establish both inter- and intra-organisational benchmarking and the setting of local-level targets that focus upon continuous improvement over time, as appropriate.

Continuous improvement from using the workforce race equality agenda will benefit greatly from the sharing of replicable good workplace practices and processes. As the implementation of the WRES develops further, it will be essential to draw together local good practice threads, exploiting opportunities for transformation in workplace race equality. Work with STPs will be critical here.

Work is underway to commence the independent evaluation of the WRES programme. Phase one of the evaluation will provide an independent assessment on the design of the WRES and its initial implementation by organisations. Phase two will examine emerging outcomes, and how improvements can be made, to ensure the WRES is able to affect change across the NHS and beyond.

5 WRES phase two: the operational expression

5.1 Workstreams

The ‘enabling people’ component of the work programme will focus upon a number of operational initiatives and deliverables that will provide effective support and sustainability to WRES implementation across the NHS. This will help to decentralise total reliance of knowledge and expertise from the national WRES Team, whilst establishing the practice of organisations working collaboratively with peers in identifying solutions and good practice examples for common local challenges. The workstreams will include:

Provide timely, effective and proactive WRES communications and support to the system, including regional and national WRES events and joined up communications on high profile platforms e.g. the CNO summit.

Mobilise senior leaders, boards, and BME workforce across the NHS. Workforce and leadership development across Sustainability and Transformation Plans (STPs), Accountable Care Systems (ACSs) and work with the NHS Leadership Academy will be critical.

Deliver focused support to areas that show the largest gaps in WRES indicators: e.g. the ambulance sector, and the London region.

Identify, train and establish satellites of ‘WRES experts’ across the NHS.

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Continue work with the Institute for Healthcare Improvement (IHI) to establish cultural change on this agenda using improvement methodology.

‘Embedding accountability’ on the workforce race equality agenda is an essential element of the work programme – focus is required upon a number of key operational initiatives that include:

Ensure the WRES continues to feature within the NHS standard contract for providers of NHS service and within the CCG Improvement and Assessment Framework.

Identify and share the worst performing NHS trusts on this agenda with CQC, to help inform inspection and facilitate concerted support.

Support assurance, inspection and public scrutiny of performance against the WRES indicators (CCGs, CQC, Healthwatch).

Support CCGs and independent healthcare organisations with WRES implementation – facilitating the sharing of replicable good practice.

Identify four STPs across the country to provide concerted support with WRES implementation and a programme of opportunities for BME workforce – to share good practice widely.

Drawing upon innovative research, sharing replicable good practice and ensuring the capability and proficiency of the WRES programme ate key components that will help support sustainability of the agenda. The operational expression of the ‘evidencing outcomes’ element of the WRES strategy will include:

Oversee innovative and topical research in the area workforce race equality, including on the relationship between WRES outcomes and: quality of BME staff networks; CQC ratings; agency staffing levels.

Produce the annual WRES data analyses report for NHS trusts, CCGs, and independent healthcare providers.

Identify, verify and disseminate examples and models of replicable good practice across the country.

Commission the independent evaluation of the WRES.

Revise and update the WRES and associated support to the system, as appropriate

5.2 Proposed deliverables

The strategic approach for the WRES programme and associated workstreams will help support NHS organisations (and those organisations providing NHS services) to show year-on-year improvements in closing the gap in BME and white staff experiences and opportunities within the workforce. In turn, this will support

Page 21 of 23

OFFICIAL

10

the aspiration of enabling the NHS to become a better and more inclusive employer by making full use of the talents of its diverse staff and the communities it serves, as outlined in the Next Steps on the Five Year Forward View. We know that sustained progress leading to transformational changes on this agenda will take time to establish; however work such as that underway on Quality Improvement methodology and the identification and sharing of replicable good practice will be helpful. The above points should be kept in mind when focussing upon the proposed deliverables for the next two and five year periods, as outlined below.

Deliverable March 2019 March 2022 Risk(s)

% Bands 8, 9 and VSM who are BME (deliverable and milestones to be replicated for senior medical managers)

All trusts and ALBs have BME % of Bands 8, 9 and VSM at 30% of overall BME staff in workforce

All trusts and ALBs have BME % of Bands 8, 9 and VSM at 50% of overall BME staff in workforce; 20% of trusts have same %

Strategic approach to workforce race equality not consistently implemented by organisations

Relative likelihood of staff white and BME staff being appointed from shortlisting*

All trusts and ALBs reduce relative likelihood to below 1.75; 20% reduce likelihood to below 1.50

All trusts and ALBs reduce relative likelihood to below 1.50 on average; 20% of trusts have same likelihood

Replicable good practice is not validated, accepted or implemented as a strategic priority

Relative likelihood of White and BME staff entering the disciplinary process (2-year average)

All trusts and ALBs reduce relative likelihood to below 1.75; 20% have same likelihood

All trusts and ALBs reduce relative likelihood to below 1.50 on average; 40% of trusts have same likelihood

Replicable good practice is not validated, accepted or implemented as a strategic priority

Relative likelihood of BME staff accessing non-mandatory training and development

All trusts and ALBs reduce relative likelihood to below 1.25

All trusts and ALBs have the same likelihood

Gaming of the indicator

Relative likelihood of BME staff being bullied by colleagues and managers*

All trusts and ALBs reduce relative likelihood to below 1.20

All trusts and ALBs have the same likelihood

Unclear how effective NHS-wide initiative on bullying in general will be

BME board representation

National average for trust boards will rise to 9%

National average for trust boards will rise to 11%; Exec members will rise to 20% of BME workforce

Progress too slow on WRES indicators relating to appointments; accessing non-mandatory training.

* Deliverable cited in the Next Steps on the Five Year Forward View

Page 22 of 23

OFFICIAL

11

6 Resource and support The national WRES Team will be an essential element in taking forward the WRES programme through the next phase during 2017/18 to 2018/19. Form follows function; we will therefore ensure that the central team has the appropriate skill-set, experience and the financial backing to effectively deliver on the next phase of the programme. The programme has been allocated £950k for 2017/18 and the like for 2018/19. This level of financial backing will be essential in ‘cranking-up’ and further developing the support on WRES implementation across the NHS. It is envisaged that the wider system, including the healthcare ALBs, will work more closely and collaboratively with the WRES Team during phase two – ensuring a greater system-wide sustainability approach to this agenda going forward.

Page 23 of 23

Trust Board meeting 1 February 2018 Title

Learning from Deaths Quarter 3 Report


Gail Byrne, Director of Nursing and Organisational Development


Mr Neil Pearce, Associate Medical Director Mark Green, Head of Bereavement Care


For information ü To note o

Formal approval o

For decision o

History

Since 2014 IMEG and TMRG have been undertaking reviews of adult inpatient deaths


In March 2017 the DH published National guidance on learning from deaths. From April 2017, Trusts have been required to collect information on deaths, reviews, investigations and resulting quality improvements; and from Q3 of this year, this information has to be reported via a quarterly paper presented to its public board meeting

Implications

None

Action Required

Trust Board to note ongoing reporting requirements.

Next Steps

1) Link thematic learning from M&M, TMRG & SISG processes and improve dissemination of learning 2) Improve the methods by which mortality review data is recorded to ensure that accurate reports for Trust Board are produced, with any concerns or learning clearly identified

1 Introduction In March 2017 the DH published National guidance on learning from deaths. From April 2017, Trusts have been required to collect information on deaths, reviews, investigations and resulting quality improvements; and from Q3 of this year, this information has to be reported via a quarterly paper presented to its public board meeting. This includes assigning an avoidability score to all those deaths reviewed. However, there is no requirement to review all deaths, rather only those where concerns are raised by relatives; unexpected deaths; deaths of patients with either a learning disability or a severe mental illness; or deaths in a speciality or treatment group where an alarm has been raised (for example, an elevated mortality rate). Trusts were also required to publish a policy setting out how they respond to and learn from the deaths of their patients. This paper sets out the progress made to-date and improvements needed to ensure we are able to fully meet these requirements. 2 Key Issues The Internal Medical Examiner Group (IMEG) has been carrying out “hot” review of adult inpatient deaths since September 2014, progressively expanding its scope to include all adult inpatient deaths since June 2015 and more recently to include deaths in the Emergency Department. The value of the IMEG reviews is that deaths with ‘potentially avoidable features’, which might not otherwise be reported under the criteria set out in the national guidance, are independently reviewed and escalated for further investigation. The outcomes from IMEG have been reported to Trust Board in the past and acknowledgement has been

Enclosure 5

Page 1 of 8

made of its usefulness in identifying avoidable features in the treatment and management of a minority of patients who die in the Trust.

Although not formally required to report outcomes to Trust Board, the data for Q1 and Q2 of this year were provided using the Learning from Deaths Dashboard (attached). It should be noted that the avoidability scores assigned to this group are rather crude and have been allocated retrospectively from April to August, based on the escalation of cases deemed to require further investigation. It is also acknowledged that in some cases, investigations take time to complete and may run over into the following reporting period. These will be identified in each quarterly update and reported on subsequently.

Page 2 of 8

IMEG and mortality review process (Q1 & Q2 - 2017)

IMEG Review

(n=1072)

No Care Concerns

No Further Action (n=941)

Care appears to be below expectations

Potential serious adverse event / avoidable death

TMRG (structured case note reviews

completed) (n=46)

Scoping Meeting (n=25)

Avoidability

Rating

Avoidability

Rating

Avoidability Rating 1, 2, or 3 (n=15) Action: Root Cause Analysis and

action plan

Avoidability Rating 4, 5, or 6 (n=1057) Action: Feedback to clinicians,

discussion at M&M

Avoidability Rating 1. Definitely avoidable = 0 2. Strong evidence of avoidability = 2 3. Probably avoidable (more than 50:50) = 12 4. Possibly avoidable, but not likely (< 50:50) = 12 5. Slight evidence of avoidability = 50 6. Definitely not avoidable = 983

No adverse event but potential learning

Speciality M&M

(with directed questions)

(n=75)

Deaths in Scope (n=1103)

Deaths in ED not reviewed in Q1

(n=31)

Outstanding case note reviews (n=0)

LeDeR deaths included in above

Total LeDeR deaths = 7 (all cases subject to scoping) Avoidability Rating – >3 (for all cases)

Page 3 of 8

IMEG and mortality review process (Q3 - 2017)

No adverse event but potential learning

Speciality M&M

(with directed questions)

(n=54)

IMEG Review

(n=677)

No Care Concerns

No Further Action (n=565)

Avoidability Rating 1. Definitely avoidable = 0 2. Strong evidence of avoidability = 1 3. Probably avoidable (more than 50:50) = 2 4. Possibly avoidable, but not likely (< 50:50) =10 5. Slight evidence of avoidability =27 6. Definitely not avoidable = 613

TMRG (structured case note reviews

completed) (n=30)

Avoidability

Rating

Avoidability

Rating

Care appears to be below expectations

Outstanding case note reviews (n=10)

Potential serious adverse event / avoidable death

Scoping Meeting (n=22)

Avoidability Rating 1, 2, or 3 (n=3) Action: Root Cause Analysis and

action plan

Avoidability Rating 4, 5, or 6 (n=650) Action: Feedback to clinicians,

discussion at M&M

Outstanding decisions

(n=8)

Outstanding answers (n=25)

LeDeR deaths included in above

Total LeDeR deaths = 7 Avoidability - >3 for all cases


Awaiting CPM Results (n=6)

Page 4 of 8

Paediatric mortality review process (CDAD) (Q3 - 2017)


CDAD Review (n=12)

Avoidability Rating 1, 2 or 3 (n=0)

Avoidability Rating 4, 5 or 6 (n=12)

Decisions Outstanding

(n=1)

Avoidability Rating 1. Definitely avoidable = 0 2. Strong evidence of avoidability = 0 3. Probably avoidable (more than 50:50) = 0 4. Possibly avoidable, but not likely (< 50:50) =1 5. Slight evidence of avoidability =6 6. Definitely not avoidable = 5

Page 5 of 8

3 Data Analysis Historically (2014-17), approximately 2.3% of adult inpatient deaths reviewed through the combination of IMEG, TMRG and SISG have been considered to have been probably avoidable. For Q1 & Q2 combined, 1.4% of deaths were deemed to have a greater than 50-50 probability of being avoidable (scoring 1 – 3 on the dashboard). Avoidability for Q3 appears to have dropped further to around 0.5%, although a number of the more complex cases (2.7%) have still to be reviewed in detail and scored, and it is likely that a number of these will be deemed to have been avoidable. There is also a difference in the way in which avoidability is scored now compared to how it has been assessed in the past, previously a numeric score (locally developed scoring system, range 1-5) was only applied to cases reviewed in TMRG whilst other cases which were likely to be avoidable were reviewed as serious adverse events, without a numeric score being applied although we have assumed that any case deemed to be an SIRI or SEC would have scored within the range 1-3 on the current Royal College of Physicians methodology. Now all deaths are graded numerically, through IMEG, TMRG and SISG processes. As already mentioned, whilst the escalation and investigation of deaths has remained at a similar level, the assignment of avoidability during the first five months of this year has been retrospective and may therefore not be as accurate as it will be for future reports. UHS has a relatively low hospital standardised mortality ratio, which gives the reassurance that although our mortality review processes are identifying cases with avoidable features and potentially avoidable deaths, overall the quality of care compared with other NHS trusts remains good. Rigorous “hot” review of all inpatient deaths through IMEG combined with a low threshold for triggering systematic case note review or serious adverse event investigation appears to be identifying a similar level of potentially avoidable mortality to that seen in internationally recognised studies such as PRISM. The pathway to effectively reducing avoidable mortality is to recognise firstly that it occurs. It seems likely that the processes for mortality review embedded in UHS will identify higher levels of avoidable mortality than those identified by the majority of other trusts. This should be viewed in a positive light as a reflection of the effectiveness of scrutiny of our combination of hot review (IMEG), standardised case notes review (TMRG) and serious adverse event investigations (SISG). 4 Next Steps We have been able to manipulate some elements of the Safeguard system to allow us to more closely identify which deaths have been escalated for further investigation and to monitor their progress. Further improvements by the Safeguard software developers with specific upgrades for the recording of serious events as well as elements of the learning from deaths agenda will be available for use in the near future. Using Safeguard will facilitate production of reports on thematic learning from avoidable mortality and allow us to monitor trends in different clinical areas across the trust. Work is being undertaken with some of our local CCGs to identify patients who die within 30 days of discharge. A handful of these deaths are currently included within the data, usually where a patient has been discharged for end of life care but has not been seen by their GP prior to death resulting in the need for the cause of death certificate to be issued by the discharging clinical team. Whilst there is no national requirement to report paediatric deaths at trust board level, it seems appropriate to demonstrate that we are providing a similar level of scrutiny for patients of all ages within the trust. We have therefore included details of the number of paediatric death reviews undertaken by the Child Death and Deterioration Group (CDAD).

Page 6 of 8

5 Recommendation It is recommended that Trust Board continue to support the evolution of mortality review within UHS.

Future mortality reports should contain both the nationally required mortality dashboard figures as well as other relevant and accessible breakdowns of mortality statistics.

Page 7 of 8

Universtiy Hospital Southampton NHS Foundation Trust: Learning from Deaths Dashboard - December 2017-18

Time Series: Start date 2017-18 Q1 End date 2018-19 Q2

This Month This Month This Month262 262 0

This Quarter (QTD) This Quarter (QTD) This Quarter (QTD)670 670 3

This Year (YTD) This Year (YTD) This Year (YTD)1766 1735 16

Score 5Slight evidence of avoidability Definitely not avoidable

This Month 0 0.0% This Month 0 0.0% This Month 0 0.0% This Month 1 0.4% This Month 8 3.2% This Month 242 96.4%

This Quarter (QTD) 0 0.0% This Quarter (QTD) 1 0.2% This Quarter (QTD) 2 0.3% This Quarter (QTD) 10 1.5% This Quarter (QTD) 27 4.2% This Quarter (QTD) 606 93.8%

This Year (YTD) 0 0.0% This Year (YTD) 3 0.2% This Year (YTD) 14 0.8% This Year (YTD) 22 1.3% This Year (YTD) 77 4.5% This Year (YTD) 1589 93.2%

Time Series: Start date 2017-18 Q1 End date 2018-19 Q1

This Month This Month This Month

3 3 0

This Quarter (QTD) This Quarter (QTD) This Quarter (QTD)

7 7 0

This Year (YTD) This Year (YTD) This Year (YTD)

14 14 0

Total Number of Deaths, Deaths Reviewed and Deaths Deemed Avoidable (does not include patients with identified learning disabilities)

201 201 0

Last Quarter Last Quarter

Total Number of Deaths in Scope Total Number of deaths considered to have

been potentially avoidable (RCP<=3)

Last Month Last Month Last Month

Total Number of Deaths, Deaths Reviewed and Deaths Deemed Avoidable for patients with identified learning disabilities

Total Deaths Reviewed

Total Deaths Reviewed by RCP Methodology Score

Definitely avoidable Strong evidence of avoidability Probably avoidable (more than 50:50) Probably avoidable but not very likely

0 0 0

Score 1 Score 2 Score 3 Score 4 Score 6

Last Quarter540 540 1

Last Year Last Year Last Year

Last Quarter Last Quarter

Total Number of Deaths in scope Total Deaths Reviewed Through the LeDeR

Methodology (or equivalent)Total Number of deaths considered to have

been potentially avoidable

Last Month Last Month Last Month

Description:The suggested dashboard is a tool to aid the systematic recording of deaths and learning from care provided by NHS Trusts. Trusts are encouraged to use this to record relevant incidents of mortality, number of deaths reviewed and cases from which lessons can be learnt to improve care.

Summary of total number of deaths and total number of cases reviewed under the Structured Judgement Review Methodology

0 0 0

Summary of total number of learning disability deaths and total number reviewed under the LeDeR methodology

7 7 0

Last Year Last Year Last Year

2 2 0

Last Quarter

0 100 200 300 400 500 600 700 800

Q1 2017-18 Q2 Q3 Q4 Q1 2018-19 Q2

Mortality over time, total deaths reviewed and deaths considered to have been potentially avoidable (Note: Changes in recording or review practice may make comparison over time invalid) Total deaths

Deaths reviewed

Deaths considered likely to have been avoidable

0

1

2

3

4

5

6

7

8

Q1 2017-18 Q2 Q3 Q4 Q1 2018-19

Mortality over time, total deaths reviewed and deaths considered to have been potentially avoidable (Note: Changes in recording or review practice may make comparison over time invalid)

Total deaths

Deaths reviewed

Page 8 of 8

Executive Summary:

In Month and Year to date Highlights:

1. In December the Trust delivered a control total surplus of £3.4m, £1.5m better than Plan. After 9 months of the financial year the

Trust surplus is £16.3m, £0.5m above Plan (compared to £1.9m better than Plan at Q1 and £0.5m better at Q2). The Trust now needs to deliver a further £10.8m surplus in the remainder of the year to achieve the year-end target control total surplus of £27.1m. Additional winter pressure monies of £1.8m have been received for the period December through March and hence NHSI expectations are now a surplus of £28.9m.

2. Under the single oversight framework, the score for Finance and Use of Resources has remained at ‘1’.

3. CIP delivery in the month was £2.2m against a target of £3.5m. To month 9 the Trust is now £1.6m short of the planned CIP delivery of £21.4m. From October, the Trust CIP target increases to £3.5m per month and continues at this rate until March 2018.

4. Clinical income (excluding all STF income) in December was £56.8m, £3m less than November but £1.1m more than Plan. Net of the QIPP target agreed with Commissioners, income was £3m ahead of Plan in the month. After 9 months, the Trust is 3.8% (£18.6m) ahead of the clinical income Plan, of which £17m relates to QIPP which is assumed has not been achieved.

5. Operating costs were £1.8m adverse in the month (compared to £5.6m in November) due to non-achievement of QIPP related activity reduction (£1.9m). YTD operating costs are £22.6m higher than Plan due mostly to non-achievement of QIPP (£16.9m), pay CIP performance and clinical supplies.

6. The cash position is £9.5m below plan and represents a combination of higher working capital of £15.8m and lower operating cash flows of £1.2m offset by lower financing costs of £1.9m and lower investing activities of £5.6m. This adverse position to Plan is primarily driven by delays in receipt of 2017/18 over-performance payments from Commissioners.

1

Report to:

Strategy & Finance Committee January 2018

Title:

Finance Report for Period ending 31/12/2017

Author:

Paul Goddard

Sponsoring Director:

David French

Purpose:

Standing Item

The Committee is asked to note the report

2017/18 Finance Report - Month 9

Enclosure 6

Page 1 of 10

All Divisions saw a reduction in pay expenditure compared with November although the pay bill was still £1.1m greater than Plan. Executive Directors continue to monitor this performance with each Division; working on actions to reduce expenditure over the next 3 months with a heavy focus on the pay bill.

2

Finance: I&E Summary

Total income excl QIPP was £1.2m favourable against Plan. Inpatient activity was over Plan both in elective and non-elective offset by lower than planned levels of outpatient and critical care activity. High cost drugs and devices were also below Plan although this will be reflected in an underspend in OPEX. OPEX was £0.1m favourable to Plan excl QIPP. Overall expenditure was £3.7m lower than in November and £0.9m down on the average. Pay in December was £0.4m below forecast and non-pay including drugs was £1.5m lower, of this approx £1.1m relates to high cost drugs which has been offset by lower income.

Overall: Green

MetricYTD Actual YTD Metric YTD Plan

Capital service cover rating 2.45 2 1Liquidity rating 2.45 1 2I&E Margin Rating 2.76% 1 1I&E Margin Variance Rating -0.02% 2 1Agency Variance from ceiling 26.08% 1 1Use of Resources Average Metric 1.40 1.20Use of Resources Final Metric 1 1

2017/18


Full Yr

Plan Actual Plan Actual Plan Actual VarAve

DoneToDo

£m £m £m £m £m £m £m £m £mNHS Income: Clinical 55.8 56.8 1.1 506.2 507.8 1.6 G 677.5 468.9 8% 56.4 56.6

QIPP Reduction -1.9 - 1.9 -17.0 - 17.0 G -22.7 -Other income Other Income excl. STF 7.6 7.8 0.2 68.5 71.3 2.8 G 91.3 75.5 -6% 7.9 6.7

Core STF Income 1.8 1.8 - 11.6 11.6 - G 17.8 13.1 -11% 1.3 2.1Total income 63.3 66.4 3.1 569.3 590.6 21.4 G 764.0 557.5 6% 65.6 63.3Costs Pay 36.6 37.7 1.1 333.1 336.5 3.4 A 442.8 320.9 5% 37.4 35.4

Drugs 8.6 7.1 -1.5 76.0 71.4 -4.5 G 101.1 69.2 3% 7.9 9.9Clinical supplies 6.7 7.6 0.9 60.8 66.3 5.5 R 81.2 65.3 2% 7.4 5.0Other non pay 8.6 8.0 -0.6 75.9 77.3 1.4 A 101.5 69.4 11% 8.6 8.1QIPP Reduction -1.9 - 1.9 -16.9 - 16.9 R -22.5 -

Total expenditure 58.6 60.4 1.8 528.9 551.5 22.6 R 704.0 524.8 5% 61.3 58.4EBITDA 4.7 6.0 1.3 40.3 39.1 -1.2 A 59.9 32.6 20% 4.3 6.9

Depreciation 1.9 1.8 -0.1 17.0 15.8 -1.2 G 22.7 15.9 0% 1.8 2.3PDC and interest 0.8 0.8 -0.0 7.5 7.0 -0.4 G 10.1 7.0 0% 0.8 1.0

Control Total Surplus / (Deficit) 1.9 3.4 1.5 15.8 16.3 0.5 G 27.1 9.7 67% 1.8 3.6

2.77% 2.76% -0.02% A 3.55%

Year to Date Prior Year to DateCurrent Month

Variance£m

Variance£m

I&E Margin

Page 2 of 10

Overall the Trust’s Use of Resources score is ‘1’ with our forecast position to be a ‘1’ at the end of the financial year. Capital Service Cover ‘2’ EBITDA would need to be £0.6m higher to achieve a '1' and £18.8m lower to deteriorate to a '3'. Liquidity Rating ‘1’ Liquidity would need to reduce by £5.0m to reduce to a '2'.

3

Use of Resource Metric

0.0

0.5

1.0

1.5

2.0

2.5

3.0

Apr-

17

May

-17

Jun-

17

Jul-1

7

Aug-

17

Sep-

17

Oct

-17

Nov

-17

Dec-

17

Jan-

18

Feb-

18

Mar

-18

Cove

r (no

. of t

imes

)

Capital Service Cover

CSC Actual

CSC Plan

1 rating

2 rating

3 rating

-16

-14

-12

-10

-8

-6

-4

-2

0

2

4

Apr-

17

May

-17

Jun-

17

Jul-1

7

Aug-

17

Sep-

17

Oct

-17

Nov

-17

Dec-

17

Jan-

18

Feb-

18

Mar

-18

Liqu

id D

ays

Liquidity Rating

LR Actual

LR Plan

1 rating

2 rating

3 rating


0.0

1.0

2.0

3.0

4.0

Apr

-17

May

-17

Jun-

17

Jul-1

7

Aug

-17

Sep-

17

Oct

-17

Nov

-17

Dec

-17

Jan-

18

Feb-

18

Mar

-18

Risk

Rat

ing

Overall Risk-Rating

Plan

1 rating

2 rating

3 rating

Actual

Page 3 of 10

I&E Margin ‘1’ YTD surplus would need to reduce by £16.3m to reduce to a 2. I&E Margin Variance ‘2’ YTD surplus would need to fall by £5.7m before reducing to a '3' or increase by £0.1m to improve to a '1'. Agency Ceiling ‘1’ Agency spending could increase by £3.0m before falling to a '2'.

4

Use of Resource Metric

-3%

-2%

-1%

0%

1%

2%

3%

4%

Apr

-17

May

-17

Jun-

17

Jul-1

7

Aug

-17

Sep-

17

Oct

-17

Nov

-17

Dec

-17

Jan-

18

Feb-

18

Mar

-18

Mar

gin

I&E Margin

I&E Margin Actual

I&E Margin Plan

1 rating

2 rating

3 rating

-2.5%

-2.0%

-1.5%

-1.0%

-0.5%

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

Apr-

17

May

-17

Jun-

17

Jul-1

7

Aug-

17

Sep-

17

Oct

-17

Nov

-17

Dec-

17

Jan-

18

Feb-

18

Mar

-18

Mar

gin

Varia

nce

I&E Margin - Variance

I&E MarginVariance Actual

I&E Variance Plan

1 rating

2 rating

3 rating


-60.0%

-50.0%

-40.0%

-30.0%

-20.0%

-10.0%

0.0%

10.0%

20.0%

30.0%

40.0%

Apr

-17

May

-17

Jun-

17

Jul-1

7

Aug

-17

Sep-

17

Oct

-17

Nov

-17

Dec

-17

Jan-

18

Feb-

18

Mar

-18

Mar

gin

Var

ianc

e

Agency Variance from ceiling

1 rating

2 rating

3 rating

Agency Variancefrom ceiling

Page 4 of 10

G

G G

G

G

G

G

G

G

GG G

G

G

GG

G

G

G G

G G

G

G

G

GG G

G G G G G

AA

A

A

A

A

A

A

A

A

A

A

A

A

A

A

A

A

AA

A

A

A

A

A

A

AA

A A

A

A

A

RR

RR

R

R

RR

R RR

R

R

R

R

R

R

R

R

R

R

R

R

R

R

R

R R

R

R

R

R

R

BB

B B B B B B B B B BB

B B B B B B B BB B B B B B B

BB B B B

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

120.0%

A15 A16 A17 M15M16M17 J15 J16 J17 J15 J16 J17 A15 A16 A17 S15 S16 S17 O15O16O17 N15N16N17 D15 D16 D17 J16 J17 J18 F16 F17 F18 M16M17M18

Bedstate2015/16 - 2017/18

The bed state information shown highlights a 3 year comparison. The December 2017 bed state illustrates a challenging picture when compared with December 2016 and 2015 with both black and red alert status on the increase and amber and green decreasing. This will explain the inpatient performance versus Plan in the month based on the draft activity information received for December.

5

Bedstate


Page 5 of 10

In 2017/18 70% of the STF will be awarded based on achieving the control total surplus (excl STF income). The remaining 30% will be linked to ED performance to include implementing the GP streaming service from Q3 onwards. The full £2.7m of STF has been included in our results for Q1 and has now been received with a further £3.6m (full STF) included in the Q2 results. The Trust is still awaiting final outcome of an appeal lodged with NHSI regarding Q2 ED performance and related payment (£1.1m). The proportion of STF increased to 30% (from 20%) in Q3 (£1.8m per month) and will increase again to 35% in Q4 (£2.1m per month). The full STF for Q3 has been assumed in these results as, with partners, the Trust achieved ED performance of 91.6% in Q3. Delivery board target for Q3 was 90.3%.

6

Sustainability & Transformation Funding


£ £ ££ £ £

£ £ £ED

EDED

ED ED ED

ED ED ED

0.00

0.20

0.40

0.60

0.80

1.00

1.20

1.40

1.60

1.80

2.00

Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18

£m

Sustainability & Transformation Funding 2017/18

£ E D

Page 6 of 10

The chart shows clinical income in November, including an estimate for final cut. Inpatient performance was better than planned levels in November. Outpatient performance was also slightly better than planned in November. Critical care activity returned to planned levels in the month which means other activity was on Plan in November. The over performance in exclusions is driven by high cost drug activity being above planned levels. Commissioner QIPP activity reduction plans are not delivering and this is driving the over performance in financial adjustments. The Trust continues to provide for commissioner challenges and CQUIN failure which will be resolved as data and reports become available.

7

Clinical Income


2016/17

Inpatients £196,592 £320,245 £213,980 £217,263 £3,284 £26,867 £27,551 £683 £27,158 £25,745Outpatients £61,657 £91,788 £61,070 £63,551 £2,480 £8,045 £8,562 £517 £7,944 £7,059Other Activity £65,889 £105,502 £70,469 £66,180 (£4,289) £8,772 £8,751 (£21) £8,273 £9,830Exclusions £84,077 £135,064 £88,897 £88,439 (£458) £11,921 £12,196 £275 £11,055 £11,656Financial Adjustments £9,721 (£9,202) (£6,750) £9,215 £15,965 (£788) £1,036 £1,825 £1,152 (£4,604)S& T Funding £11,600 £17,806 £9,497 £9,497 £0 £1,781 £1,781 £0 £1,187 £2,077

Grand Total £429,536 £661,204 £437,163 £454,145 £16,982 £56,598 £59,877 £3,279 £56,768 £51,765

2017/18 Prod Plan 2017/18 Prod Plan Monthly Run RateYTD

Variance £000s

In Month Plan £000s

Annual Plan £000s

YTD Plan £000s

YTD Actuals £000s

In Month Actual £000s

In Month Variance

£000sDone To DoPOD GROUP

YTD Actuals £000s

Page 7 of 10

8

Overall WTEs and Staff Costs Substantive, Bank & Agency –

8400

8900

9400

9900

10400

10900

WTEOverall Headcount WTE

32,000

33,000

34,000

35,000

36,000

37,000

38,000

39,000

£000

Overall Pay Budget v Actual

1,100

1,200

1,300

1,400

1,500

1,600

WTEMedical Headcount WTE

3,2003,3003,4003,5003,6003,7003,8003,9004,000

WTENursing Headcount WTE

2,4002,5002,6002,7002,8002,9003,0003,1003,2003,300

WTEOther Clinical Headcount WTE

1,2001,3001,4001,5001,6001,7001,8001,9002,0002,100

WTEAdmin Headcount WTE

10,000

10,500

11,000

11,500

12,000

12,500

13,000

13,500

£000Medical Budget v Actual

11,000

11,500

12,000

12,500

13,000

13,500

£000Nursing Budget v Actual

6,000

6,500

7,000

7,500

8,000

8,500

£000Other Clinical Budget v Actual

4,000

4,500

5,000

5,500

£000Admin Budget v Actual

Overall worked headcount in the Trust decreased by 44wtes from November to 9,942wtes.

Agency usage reduced by £0.1m with £0.8m being spent, a reduction of £0.1m compared to the average for the first 8 months of the year. Agency WTE decreased by 17wtes. The usage remains well within the NHSI agency ceiling.

Bank usage decreased to £1.4m from £1.7m in November. This reduced due to the lack of available bank staff in December. Bank WTE reduced by 48wtes. Net of staff recharges, the monthly pay-bill was £37.7m, £1.1 higher than Plan as the plan assumed a ramp up in pay CIP delivery from October.

Service developments such as Lymington and the opening of Hybrid theatre were not including in our NHSI plan.

Delivery of cost efficiencies (CIP) is key to remaining within the pay targets for the remainder of the year and going into 18/19.

Budget

Actual


Page 8 of 10

9

Temporary Staff Costs

0

100,000

200,000

300,000

400,000

500,000

600,000

700,000

800,000

900,000

1,000,000

1,100,000

1,200,000

1,300,000

1,400,000

1,500,000

1,600,000

£

2017/18 Agency NHSI Ceiling and Spend

2017/18 NHSICeiling

Nursing qualified

Nursingunqualified

Medics

Scient & Tech

Admin & Estates

Total Agency

0

2,000,000

4,000,000

6,000,000

8,000,000

10,000,000

12,000,000

14,000,000

16,000,000

18,000,000

£

2017/18 Agency Year to Date Spend

AgencySpend

NHSICeiling

December’s agency spend across all staff groups was £0.8m in the month. This is a reduction of £0.1m compared to November and is lower than the 17/18 NHSI ceiling by £0.4m. There were reductions in agency spend in AHPs and non-medical staff with medical and nursing spending slightly more than November. Trust-wide bank expenditure was £0.3m lower than November and £0.2m lower than the average for 17/18. Bank expenditure paid at standard NHS rates, is expected to continue to grow in 17/18 offsetting more expensive agency. The reduction from November is linked to a mix of supply shortages due to sickness absence and annual leave and lower seasonal demand.


Page 9 of 10

NHSI are monitoring the Trust against a Capital Expenditure Limit (CDEL) of £43m – which is the capital expenditure plan excluding finance leases and donations. NHSI are therefore expecting The Trust to forecast over-performance against CDEL in the monthly monitoring. In addition to previously confirmed PDC funding of £1m for GP streaming capital , £5.0m under the Global Digital Exemplar (GDE) , and £0.7m for Cyber Security Resilience, the Trust will now receive £1.8m for an additional linear accelerator this year. This is expected to be in addition to any funding for a linac anticipated in 2018/19. Donated income is now forecast to be slightly under plan for the year.

10

Capital Expenditure


NHSIPlan Actual Var Plan Actual Var Plan

Scheme £000's £000's £000's £000's £000's £000's £000's

Childrens Hospital 20 0 (20) 180 79 (101) 2,800IT Schemes 550 1,094 544 4,958 3,718 (1,240) 6,600Linac Bunker 0 85 85 1,140 815 (325) 1,140Strategic Maintenance 200 228 28 1,903 2,029 126 2,400Medical Equipment Panel 231 388 157 1,396 737 (659) 2,169Radiotherapy Equipment Replacement 0 2 2 100 279 179 5,438SHDU Expansion 0 1 1 1,220 1,076 (144) 1,260GICU Expansion 20 0 (20) 180 91 (89) 2,412Theatre Modernisation 0 17 17 1,161 1,116 (45) 2,140Other Schemes 2,247 146 (2,101) 14,133 7,721 (6,412) 16,638Total Excluding Finance Leases 3,268 1,961 (1,307) 26,371 17,661 (8,710) 42,997

Leased additions- IISS 685 0 (685) 7,025 3,334 (3,691) 9,015Leased additions- Other 186 0 (186) 9,988 8,524 (1,464) 10,554

Total 4,139 1,961 (2,178) 43,384 29,519 (13,865) 62,566

Less:Losses on disposals - - - - 6 6 -Donated asset additions (130) - 130 (1,168) (1,038) 130 (1,556)

Performance against Capital Departmental Expenditure Limit (CDEL) 4,009 1,961 (2,048) 42,216 28,487 (13,729) 61,010

Month Year to Date

Page 10 of 10

Enclosure 7

Trust Board Meeting 1 February 2018

Title

Chief Executive’s Report on Current Issues


Fiona Dalton, Chief Executive


Amanda Lowe, Associate Director: Corporate Affairs


For information o

To note ☑ Formal approval ☑

For decision o

1. To alert Trust Board to current news items available on the website.

2. To update the Trust Board on items of interest in the past month, not covered elsewhere on the agenda.

3. To inform Trust Board of business undertaken by TEC.

4. To inform Trust Board of the signing and sealing undertaken in accordance with SFIs.

5. To seek ratification of the Chair’s actions undertaken with regard to contracts in accordance with SFIs.

History

Monthly report.

Action Required

1. Ratify the actions undertaken by the Chair (paragraphs 6.1- 6.2). 2. Note this report.

1. Current News

Current news is available on the Trust website at http://www.uhs.nhs.uk and CEO blog at Chief Executive's Blog 4 December 2017

2. Recent Press Stories 2.1 The Daily Telegraph (front page), The Sun, The Independent, the Daily Mail, the Daily Mirror,

The Scotsman, the Western Mail, the Daily Echo and more than 36 local and regional titles reported Dr Oliver Bevington’s call for parents to avoid using over-the-counter cough syrups and medicines to treat coughs and colds in children in favour of “old fashioned” honey and lemon.

2.2 The Portsmouth News featured the story of baby Max Olivares, who celebrated his first birthday in hospital having spent a year receiving treatment for a heart condition.

2.3 The Guardian, The Independent and The Times ran items on UHS involvement with a project launched by national organisation HelpForce designed to improve and expand volunteering opportunities in the NHS.

2.4 Optometry Today reported consultant ophthalmologist Parwez Hossain’s warning some patients in the UK may be losing their sight unnecessarily due to a "poor understanding" of the effectiveness of emergency corneal transplantation.

2.5 The Daily Mail ran a patient story on a procedure being used to treat kidney stones at the Trust known as ultra-mini percutaneous nephrolithotomy.

Page 1 of 7

http://www.uhs.nhs.uk/Home.aspx�

http://www.uhs.nhs.uk/AboutTheTrust/Newsandpublications/Chief-executives-blog/Chief-executives-blog-4-December-2017.aspx�

2.6 The Daily Echo and the Jersey Evening Post reported the University of Southampton is now £1 million away from its £25 million campaign to fund a pioneering Centre for Cancer Immunology at Southampton General Hospital.

2.7 The Daily Echo ran an item on a Christmas carol event held in Romsey Market Place to raise funds for the children’s emergency and trauma department appeal along with a follow-up piece.

2.8 The Daily Telegraph, the Daily Mail, the Daily Express, the Daily Mirror, the i newspaper, The Herald, the Western Daily Press, the Daily Echo and more than 30 other local and regional titles reported urological surgeon Bhaskar Somani’s call for all patients to be offered the chance to listen to music during their procedures to reduce pain and anxiety.

2.9 The Daily Echo and Romsey Advertiser ran items on a project launched by LifeLab that will see youngsters from across the city help to develop ideas for a digital game to improve health and lifestyle.

2.10 The Health Service Journal reported the Trust’s chief executive Fiona Dalton will leave the Trust in March to become the chief executive officer of Providence Healthcare in Vancouver.

2.11 The Sunday Mirror spent a night in the emergency department for a feature on the work of staff in the NHS over the festive period and also referred to the visit in its comment column.

2.12 The Daily Echo and other local newspapers ran items on Christmas Day babies born at the Princess Anne Hospital.

2.13 The Daily Echo and the Portsmouth News reported a national Freedom of Information request on hospital car parking income and referred to the Trust as part of a regional round-up. The Trust was also referenced in articles published by the Daily Mirror and The Metro. Statement supplied.

2.14 BBC South and ITV Meridian ran an item on a special trip for young oncology patients from the Piam Brown unit at Southampton Children’s Hospital which saw Santa join them on a flight over the Solent.

2.15 BBC Radio Solent and ITV Meridian reported an innovative initiative – the 999 Club – which aims to reduce young people's fears of treatment and admission which involves inviting them into the emergency department.

2.16 BBC Radio Solent interviewed consultant urological surgeon Bhaskar Somani on his research into the use of music therapy for patients undergoing outpatient procedures.

2.17 Jack FM reported Lady Carnarvon’s Christmas event at Highclere Castle to raise funds for the Piam Brown unit.

2.18 BBC South Today visited Southampton Children’s Hospital to take in the Starlight children’s pantomime for young patients on the wards and also covered the story of one-year-old heart patient Max Olivares (mentioned above).

2.19 ITV Meridian, BBC Radio Solent, Wave 105 FM and Heart Hampshire ran items on the national FOI request into car parking income and referred to the Trust as part of a regional round-up.

3. NHS England Assurance of Emergency Preparedness Resilience and Response (EPRR)

2017/18 Following on from the EPPR assurance meeting held in October 2017 and a site visit to the Trust by the regional NHS England Head of EPRR, the Trust has received formal confirmation that it is ‘substantially compliant with the 2017 EPRR core standards’. This provides us with assurance that robust plans are in place to enable the Trust to respond in the event of an emergency, this is particularly important in light of the Trust’s role as a major trauma centre.

Page 2 of 7

4. Trust Executive Committee (TEC) The Trust Executive Committee (TEC) is a formal standing committee of the Trust, which

executes actions from the Board and supports the operational management of the Trust. The agendas for the December 2017 and January 2018 meetings are attached at Appendix 1 and reports are available to Board members on request.

5. Signing & Sealing The Seal of the Trust is required to be fixed to some documents. There were 5 seals fixed for

the period of this report:

5.1 Lease of Telecommunications Space at Princess Anne Hospital, Tremona Road, Southampton, Hampshire SO16 6YD, between University Hospital Southampton NHS Foundation Trust (Landlord) and Cornerstone Telecommunications Infrastructure Limited (Tenant). Seal number 140.

5.2 Deed of Variation relating to Lease of part of the roof space at Southampton General Hospital, Tremona Road, Southampton, Hampshire SO16 6YD, between University Hospital Southampton NHS Foundation Trust (Landlord) and Airwave Solutions Limited (Tenant). Seal number 141.

5.3 Deed of Rectification between Canada Life Limited (Landord) and University Hospital Southampton NHS Foundation Trust (Tenant) relating to Underlease for The Multi-Storey Car Park, Southampton General Hospital, Tremona Road, Southampton. Seal number 142.

5.4 Agreement executed as a Deed between University Hospital Southampton NHS Foundation Trust (the Employer) and ARB Mechanical Engineering Ltd (the Contractor) relating to the Replacement of Existing Chillers. Seal number 143.

5.5 Lease of Telecommunications Space at Princess Anne Hospital, Tremona Road, Southampton, Hampshire, SO16 6YD, between University Hospital Southampton NHS Foundation Trust (Landlord) and EE Limited and Hutchison 3G UK Limited (Tenant). Seal number 144.

6. Chair’s Actions

The Board has agreed that the Chair may undertake some actions on its behalf. The following actions have been undertaken by the Chair. All awards of contract are subject to a full tender process.

6.1 Award of Contract for External Defibrillators (Manual & AED) RRP replenishment programme over 5 years from Zoll Medical UK Ltd at a total cost of £896,728 excluding vat. Approved by the Chair on 2 January 2018.

6.2 Single Tender Action for Interim Procedure Pack Contract for Theatres for 12 months from Unisurge at a cost of £773,268 excluding vat. This 12-month contract is placed ahead of a formal tender process scheduled to commence in April 2018. Approved by the Chair on 22 January 2018.

7. Recommendation 7.1 To ratify the actions undertaken by the Chair (paragraphs 6.1 – 6.2).

7.2 To note this report.

Page 3 of 7

Trust Executive Committee

Agenda

Date of Meeting: 6 December 2017 Venue: Lecture Room A, Education Centre, C Level, South Academic Block, SGH Time: 8.00-10.30am Apologies to: Sue Diduch, Corporate Affairs Administrator Time Agenda Item Enc/Oral 8.00 1. Chair’s Welcome, Apologies and Declarations of Interest 2. Minutes of Previous Meeting held on 15 November 2017 Enclosure 1 3. Matters Arising/Summary of Agreed Actions Enclosure 2 4. Quality & Safety Discussion Items 8.10

4.1 Quality & Safety Update (Gail Byrne, Director of Nursing & Organisational Development/ Derek Sandeman, Medical Director)

Oral

8.20 4.2 Patient Experience 2017/18 Quarter 2 Report (Gail Byrne, Director of Nursing & Organisational Development/ Ellis Banfield, Head of Patient Experience)

Enclosure 3

5. Operational Performance Decision Items 8.30

5.1 Additional Capacity for CT Guided Ablation and Diagnostic CT Business Case (Caroline Marshall, Chief Operating Officer/Andrew Asquith, Deputy Chief Operating Officer/Jacqui McAfee, DDO, Division D/ Natasha Watts, Interim DHN/P, Division D/Anne Drummond, CGM, Radiology)

Enclosure 4

Discussion Items 8.40 5.2 Access Times and Operational Performance for November 2017

(Caroline Marshall, Chief Operating Officer/Andrew Asquith, Deputy Chief Operating Officer)

Oral

6. Finance Discussion Items 8.50

6.1 Advertising & Sponsorship Update (David French, Chief Financial Officer/Nael Clarke, Commercial Director)

Enclosure 5 Item withdrawn

9.00

6.2 Cost Improvement Plan 2017/18 Update (Jane Hayward, Director of Transformation & Improvement/ Tristan Chapman, Head of Cost Improvement & Transformation)

Enclosure 6

7. Strategy Decision Items 9.10

7.1 ENT/Audiology Business Case (Jane Hayward, Director of Organisational Development/ Sue Leamore, Deputy Director of Strategy/Andrew Webb, DCD, Division A/Greg Chapple, DDO, Division A)

Enclosure 7

9.20

7.2 Regional Spinal Services Transfer Business Case (Jane Hayward, Director of Organisational Development/ Sue Leamore, Deputy Director of Strategy/Paul Grundy, DCD, Division D/Jacqui McAfee, DDO, Division D)

Enclosure 8

Appendix 1

Page 4 of 7

9.30

7.3 Mechanical Thrombectomy Business Case (Jane Hayward, Director of Transformation & Improvement/ Sue Leamore, Deputy Director of Strategy/Paul Grundy, DCD, Division D/Jacqui McAfee, DDO, Division D)

Enclosure 9

Discussion Items 8. Governance Decision Items 9.40

8.1 Ratification of UHS Intellectual Property Policy (David French, Chief Financial Officer/Nael Clarke, Director of Commercial Development/Karen Underwood, R&D Senior Contracts Manager)

Enclosure 10


8.2 Violence and Aggression Issues and Plans Developed to Mitigate Risk (Caroline Marshall, Chief Operating Officer/Andrew Asquith, Deputy Chief Operating Officer)

Enclosure 11 Item deferred to February

9. Information Items NO DISCUSSION 9.1 Staffing Status Report

(Gail Byrne, Director of Nursing & Organisational Development) Enclosure 12

9.2 Postgraduate Medical Education Gradings and Hotspots Quarter

Report (Derek Sandeman, Medical Director) Enclosure 13

9.3 Patient Level Information & Costing System (PLICS) – Service

Line Reporting 2017/18 Quarter 2 (David French, Chief Financial Officer)

Enclosure 14

9.4 Income Risks & Opportunities 2017/18 Quarterly Report (Jane Hayward, Director of Transformation & Improvement)

Enclosure 15

10. Minutes from TEC Sub-Committees and Reporting Groups 10.1 Research & Development Steering Group 16 November 2017

(Christine McGrath) Enclosure 16

10.2 Quality Governance Steering Group 17 October 2017 (Gail Byrne) Enclosure 17 10.3 Division A Board (Greg Chapple) Not received 10.4 Division B Board (Duncan Linning-Karp) Not received 10.5 Division C Board (Martin DeSousa) Not received 10.6 Division D Board (Jacqui McAfee) Not received 10.00 11. Any Other Business 11.1 Agenda for the next meeting – TEC 17 January 2018 (papers to be

received by Corporate Affairs by noon 11 January 2018) Enclosure 18

Apologies: Caroline Marshall

In Attendance: Ellis Banfield, Head of Patient Experience Anne Drummond, CGM, Radiology Nael Clarke, Commercial Director Tristan Chapman, Head of Cost Improvement & Transformation Sue Leamore, Deputy Director of Strategy Karen Underwood, R&D Senior Contracts Manager

Page 5 of 7

Trust Executive Committee

Agenda

Date of Meeting: 17 January 2018 Venue: Conference Room, Heartbeat Education Centre, F Level, North Wing Time: 8.00-10.30am Apologies to: Sue Diduch, Corporate Affairs Administrator Time Agenda Item Enc/Oral 8.00 1. Chair’s Welcome, Apologies and Declarations of Interest 2. Minutes of Previous Meeting held on 6 December 2017 Enclosure 1 3. Matters Arising/Summary of Agreed Actions Enclosure 2 4. Quality & Safety Discussion Items 8.10

4.1 Quality & Safety Update (Gail Byrne, Director of Nursing & Organisational Development/ Derek Sandeman, Medical Director)

Oral

8.15 4.2 Draft Quality Improvement Framework (QIF) Priorities 2018/19 (Gail Byrne, Director of Nursing & Organisational Development/ Juliet Pearce, Interim Deputy Director of Nursing for Quality)

Enclosure 3

8.25

4.3 Equality, Diversity & Inclusivity (EDI)/WRES Action Plan Quarter Report (Gail Byrne, Director of Nursing & Organisational Development/ Gemma Genco, Head of Equality, Diversity & Inclusivity)

Enclosure 4

8.35 4.4 Patient Safety 2017/18 Quarter 3 Report (Gail Byrne, Director of Nursing & Organisational Development/ Juliet Pearce, Interim Deputy Director of Nursing for Quality/ Tamsyn Langton, Interim Patient Safety Manager)

Enclosure 5

8.45

4.5 PLACE Findings 2017 (Gail Byrne, Director of Nursing & Organisational Development/ Kate Pye, DHN/P, Division C)

Enclosure 6

5. Operational Performance Decision Items 8.55 5.1 New Consultant Business Case: Cellular Pathology

(Derek Sandeman, Medical Director/Paul Grundy, DCD, Division D) Enclosure 7

9.00 5.2 New Consultant Business Case: Urology (Derek Sandeman, Medical Director/Andrew Webb, DCD, Division A)

Enclosure 8

9.05 5.3 New Consultant Business Case: Upper GI (Oesophagastric) Surgery (Derek Sandeman, Medical Director/Andrew Webb, DCD, Division A)

Enclosure 9

9.10 5.4 New Consultant Business Case: Breast Radiology (Derek Sandeman, Medical Director/Paul Grundy, DCD, Division D)

Enclosure 10

Discussion Items 9.15 5.5 UHS Graduate Management Scheme

(Fiona Dalton, Chief Executive/Steve Harris, Human Resources Director/Martin DeSousa, DDO, Division C/Brenda Carter, Head of Resourcing/David Young, Head of Leadership Development)

Enclosure 11

9.25 5.6 Access Times and Operational Performance for December 2017 (Caroline Marshall, Chief Operating Officer/Andrew Asquith, Deputy Chief Operating Officer)

Oral

Page 6 of 7

6. Finance Discussion Items 9.35 6.1 Finance Report for Month 9


9.45 6.2 Use of Resources Assessment Framework (Gail Byrne, Director of Nursing & Organisational Development/ Juliet Pearce, Deputy Director of Nursing for Quality/ Serena Gaukroger-Woods, Head of Clinical Quality Assurance/ Fiona Boyle, Finance Manager, Data Quality for Transformation)

Enclosure 13

7. Strategy Decision Items 9.55 7.1 Expansion of Paediatric Oncology Services Business Case

(Jane Hayward, Director of Transformation & Improvement/ Martin De Sousa, DDO, Division C)

Enclosure 14


7.2 Draft Capital Plan 2018/19 (Jane Hayward, Director of Transformation & Improvement/ David French, Chief Financial Officer/Sue Leamore, Deputy Director of Strategy)

Enclosure 15

8. Information Items NO DISCUSSION 8.1 Staffing Status Report

(Gail Byrne, Director of Nursing & Organisational Development) Enclosure 16

8.2 Quarterly Market Update

(Jane Hayward, Director of Transformation & Improvement) Enclosure 17

8.3 Capital Programme 2017/18 Quarter 3 Report


8.4 Review of Payroll Approvals Group and Payroll Policy &

Procedure (David French, Chief Financial Officer/Steve Harris, Human Resources Director)

Enclosure 19

8.5 Board Assurance Framework including Operational Risk Register 2017/18 Quarter 3 Report (Amanda Lowe, Associate Director: Corporate Affairs)

Enclosure 20 A&RC report

8.6 Inspections, Accreditations and Peer Reviews/Visits 2017/18 Quarter 3 Report (Amanda Lowe, Associate Director: Corporate Affairs)

Enclosure 21 A&RC report

8.7 General Data Protection Regulation (GDPR) Briefing (Amanda Lowe, Associate Director: Corporate Affairs)

Enclosure 22

8.8 Replacement Consultant Business Case: Paediatric Haematology (Derek Sandeman, Medical Director)

Enclosure 23

8.9 Replacement Consultant Business Case: Paediatric Radiology (Derek Sandeman, Medical Director)

Enclosure 24

9. Notes from TEC Sub-Committees and Reporting Groups 9.1 Research & Development Steering Group 14 December 2017

(Christine McGrath) Enclosure 25

9.2 Trust Investment Group 9 November 2017 and 14 December 2017 (David French)

Enclosure 26

9.3 Division D Board 10 November 2017 (Jacqui McAfee) Enclosure 27 9.4 Division A Board (Greg Chapple) Not received 9.5 Division B Board (Duncan Linning-Karp) Not received 9.6 Division C Board (Martin DeSousa) Not received 10.15 10. Any Other Business 10.1 Agenda for the next meeting – TEC 14 February 2018 (papers to be

received by Corporate Affairs by noon 8 February 2018) Enclosure 28

Apologies: Suzanne Cunningham, Katie Prichard-Thomas (Gina Stanley to attend)

Page 7 of 7

of 4

Trust Board Meeting 1 February 2018

Title

2017/18 Annual Report Process


Fiona Dalton, Chief Executive


Amanda Lowe, Associate Director of Corporate Affairs


For information o

To note ☑ Formal approval o

For decision o

To appraise the Trust Board of the process to be adopted for preparing the 2017/18 annual report.

Executive Summary

Schedule 7, paragraph 26 of the NHS Act 2006 (the 2006 Act) requires NHS foundation trusts to prepare an annual report. The annual report and accounts of the Trust consist of:

• the performance report • the accountability report • the quality report • the auditor’s report including certificate • the foreword to the accounts • four primary financial statements and • the notes to the accounts.

The annual report and accounts must be formally approved by the Trust Board. The Trust is required to lay the annual report and accounts, with any report of the auditor before Parliament before the summer recess begins to enable parliamentary scrutiny.

Implications

An inefficient process will lead to unnecessary time and cost in revising versions of the annual report.

Action Required

• To note the proposed process for preparing and submitting the 2017/18 annual report

• To note the requirement for the Council of Governors and key stakeholders to be formally consulted on the content of the Quality Account.

Next Steps

To circulate this paper to each of the report leads and commence drafting the report content.

Enclosure 8

of 4

1 Purpose 1.1 This paper sets out the process to be adopted for the production of the 2017/18 annual

report.

2 Background 2.1 The annual report is a document which is required by statute. It includes the annual

accounts, quality report, annual governance statement, remuneration report and other narrative specified in the Annual Reporting Manual produced by NHS Improvement.

2.2 In 2017, the Trust produced a first draft of the report in March (using month 9 data), leaving gaps for known amendments that would be required to make the report reflect a full year.

3 2017/18 Annual Report Plan 3.1 NHS Improvement has recently published the Annual Reporting Manual. The timeframes

and requirements are comparable to those outlined in the 2016/17 publication.

3.2 A timetable similar to that developed for 2016/17 Annual Report, including the Quality Report and Accounts, has been developed. The draft timelines and responsible officers for the constituent parts of the annual report are outlined in Appendix A.

4 Conclusion 4.1 The process as set out above leads to a higher standard of publication and enables

improved governance arrangements.

5 Recommendation 5.1 Board members are asked to note the draft timeline at Appendix A.

of 4

APPENDIX A

Timelines and responsible officers

Action Lead Approximate date required by

Launch 2018/19 Quality Improvement Framework consultation

Director of Nursing January

Brief Council of Governors on the annual report timeline

Associate Director of Corporate Affairs

Tuesday, 13 March 2018

First draft narrative and data tables (using month 9 data):

• Introduction

• Chief Executive’s Statement

• Performance Report

• Corporate Governance Report

• Remuneration & Staff Report

• Accountability Report

• Sustainability Disclosure

• Equality & Diversity Disclosure

Comms Team

Fiona Dalton

Jane Hayward

Amanda Lowe

Steve Harris

Amanda Lowe

Mark Bagnall

Gail Byrne

Friday, 23 February 2018

• Quality Account (1st draft) Gail Byrne

• Finance Director’s Report David French

Compile annual report first draft for submission to TEC

Comms Team Wednesday, 8 March 2018

Draft Quality Account submission to Council of Governors (CoG)

DoN/HPE Tuesday, 7 March 2018

Discuss quality report draft at CoG CoG Tuesday, 13 March 2018

Discuss annual report draft at TEC TEC Wednesday, 14 March 2018

Governors to provide comments/ feedback on draft quality account

CoG Friday, 16 March 2018

TEC members to provide comments/ feedback on draft annual report

TEC Friday, 16 March 2018

Amend annual report (including quality account) for TEC/CoG comments

Comms Team Monday, 19 March 2018

Circulate the draft annual report (including quality account) to Board for comment

Amanda Lowe Wednesday, 21 March 2018

Discuss annual report content Trust Board Thursday, 29 March 2018

of 4

Action Lead Approximate date required by

Provide final data tables and any additional narrative required for events in final weeks of the year

All Directors Monday, 9 April 2018

Provide draft accounts and notes David French Date to be agreed with Auditors

Issue final draft Quality Account for one month consultation

Gail Byrne Wednesday, 11 April 2018

Provide comments received from Quality Account consultation to comms for final edits

Gail Byrne Wednesday, 9 May 2018

Circulate the final draft of the annual report to Audit and Risk Committee for review and agreement at meeting on 21 May 2018

Amanda Lowe Friday, 11 May 2018

Review and agree annual report and all constituent parts

Audit and Risk Committee

Monday, 21 May 2018

Obtain external audit signed opinions David French Tuesday, 22 May 2018

Circulate final annual report to Board* Comms Team / ADCA

Tuesday, 22 May 2018

Agree annual report Trust Board Thursday, 24 May 2018

Sign annual report Chairman / CEO Thursday, 24 May 2018

Submit approved annual report to NHS Improvement

Amanda Lowe Friday, 25 May 2018

Submit annual report to Parliament Amanda Lowe Monday, 25 June 2018

Submit report laid before Parliament to NHS Improvement

Amanda Lowe Monday, 25 June 2018

Present annual report to Council of Governors

Amanda Lowe Tuesday, 10 July 2018

* Additional Board scheduled

agenda - trust board - uhs

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