Present
- Pauline Vickers, Non Executive Director (Chair).
- Rachael Blake, Non Executive Director.
- Richard Chillery, Chief Operating Officer.
- Maria Clark, Non Executive Director.
- Dr Richard Falk, Non Executive Director.
- Steve Forsyth, Chief Nurse.
- Kathryn Gillatt, Non Executive.
- Director Carlene, Holden Director of People and Organisational Development.
- Toby Lewis, Chief Executive.
- Jill Savoury, Interim Director of Finance.
- Dr Diarmid Sinclair, Chief Medical Officer.
- Dave Vallance, Non Executive Director.
In attendance
- Richard Banks, Director of Health Informatics.
- Philip Gowland, Director of Corporate Assurance and Board Secretary.
- Dr Jude Graham, Director for Psychological Professions and Therapies.
- Jo McDonough, Director of Strategic Development.
- Shabir Pandor, NExT Director.
- Sarah Dean, Corporate Assurance Officer (minutes).
- James Hatfield, Freedom To Speak Up Guardian.
- 2 members of staff, 1 member of public and 3 governors were in attendance.
Welcome and apologies
Reference
Board public: 25/11/01.
Mrs Vickers welcomed all attendees to the meeting. Apologies for absence were noted from Mrs Kathryn Lavery, Chair, and Sarah Fulton Tindall, Non Executive Director. Mr Pandor was welcomed to his first meeting, and he would commence the role of NExT director from 1 December.
Quoracy
Reference
Board public: 25/11/02.
Mrs Vickers declared the meeting was quorate.
Declarations of interest
Reference
Board public: 25/11/03.
Mrs Vickers presented the declarations of interest report and confirmed there had been amendments to Mrs Vickers and to Ms Clark’s declarations of interest to the register since the last meeting. Changes to Ms Blake’s declarations were noted and would be included in the paper at future meetings.
The board received and noted the changes to the declarations of interest report.
Staff story
Reference
Board public: 25/11/04.
Ms Holden and Mr Forsyth introduced a video that celebrated the achievement of recruiting 350 volunteers (promise 3) and included personal stories of volunteers and their contributions to the organisation. It and emphasised the importance of recognising their impact on services and community connection.
The video and subsequent discussion illustrated how volunteering had provided structure, confidence, and career pathways for individuals, including those in recovery or seeking new skills, and highlighted the reciprocal benefits for both volunteers and people who were known to services.
Mr Forsyth outlined the range of backgrounds that volunteers represented, including age, sexual orientation, and race, and noted that while not all diversity was visible in the video, the organisation was working in this area and was meeting the success measure that has been set. He explained the ongoing efforts to streamline the volunteer recruitment process, aiming for a steady state of 400 volunteers, and acknowledged the need for continual efforts to maintain and grow the programme efficiently.
Mrs Vickers noted the intended reflection time later on the agenda.
Standing items
Minutes of the previous board of directors meeting held on the 25 September 2025
Reference
Board public: 25/11/05.
The board approved the minutes of the meeting held on the 25 September 2025 as an accurate record subject to minor amendment (minute item board public 25/09/18 reference to dementia and good quality care).
Matters arising and follow up action log
Reference
Board public: 25/11/06.
The board received the action log and noted the progress updates. All actions noted as “propose to close” were agreed.
Board Assurance Committee reports to the board of directors
Report from the Quality Committee (QC)
Reference
Board public: 25/11/07.
Dr Falk presented the paper and gave the key highlights correcting the final sentence as it actually related to always measures which were discussed and would be presented later on the agenda.
The midyear review of the Patient Safety Incident Response Framework (PSIRF) approach highlighted the processes in place to ensure oversight of patient safety events and learning. A recent 360 Assurance audit of PSIRF had been undertaken and being finalised to be presented to the Audit committee.
An update report was presented on mortality with no concerns for escalation.
The effectiveness report was recognised as technically limited and required work to demonstrate quality effectiveness, which would return in January.
Mr Lewis raised a point related to PSIRF, and that only around 50% of incident investigations had been fully completed. Mr Forsyth responded that interventions were in place to improve compliance, with Radar expected to help achieve 100%. The learning element, often overlooked, would become embedded in the Radar closure processes.
Mr Forsyth confirmed the biannual staffing review assured that current establishments were appropriate using the mental health optimisation tool. The board received and noted the report from the Quality Committee.
Report from the Audit Committee (AC)
Reference
Board public: 25/11/08.
Ms Gillatt presented the paper and provided key highlights.
The Deloitte auditors’ annual report provided assurance that the trust’s financial statements and value for money arrangements fully comply with national guidelines. The auditors issued an unmodified audit opinion, confirming that the financial reporting and governance processes meet required standards. In addition, Deloitte offered strong commendations to the finance team for their significant progress and improvement.
Internal audit progress remained strong. The first half of the year (H1) audits were nearing completion, and action tracking continued to be robust. The half 2 (H2) audit scopes were being reviewed and finalised by executives, with action tracking remained at 100%.
The Audit Committee discussed clinical audit progress with particular attention to shared responsibilities and the need for timely reaudit cycles. Work was ongoing to strengthen these processes.
The Audit Committee approved action related to medical declarations of interest compliance, to coordinate with the appraisal team to ensure all medical consultants and prescribers completed their declarations of interest, aiming for 100% compliance before the next meeting. Mr Lewis suggested to deescalate the action. He acknowledged the importance of balancing assurance with practicality, particularly in light of job planning priorities. The emphasis would be on integrating declarations into job plans to avoid unnecessary duplication and reduce the sense of being “chased”, while maintaining transparency and compliance.
Ms Gillatt referred to the strong work on counter fraud and anti bribery measures, including a successful half day session that reinforced organisational awareness and controls.
The board received and noted the report from the Audit Committee.
Report from the Mental Health Act (MHA) Committee
Reference
Board public: 25/11/09.
Ms Clark, on behalf of Ms Fulton Tindall, presented the paper and highlighted key points.
Consent to treatment under sections 3 and 2 achieved a 100% compliance rate for which was an excellent outcome and reflected strong practice.
There remained concern with the continuing decline in compliance rates in Rotherham which remained an outlier in Consent to treatment on admission and Section 132 Rights being read within 24 hours. The Mental Health Act Committee understood that work was underway that seeks to show improvement by March 2026.
A key development is the ability to view compliance data at ward level, which would be invaluable for tracking and targeted action. The report provided detailed compliance figures, and while Rotherham showed particular concern, other areas also required attention.
Regarding training compliance, there had been a decline in Mental Health Act level 3 mandatory training and only slight improvement in reducing restrictive interventions training, which remain below expectations.
The board received and noted the report from the Mental Health Act Committee.
Report from the People and Organisational Development (POD) Committee
Reference
Board public: 25/11/10.
Ms Blake presented the paper and acknowledged that the difficult subjects and range of perspectives shared, provided a deeper understanding of the initiatives currently underway, with some items later on the agenda.
The People and Organisational Development included a discussion on the October open staff meetings on racism, reaffirming the commitment to being an anti racist organisation and the importance of coproducing solutions with staff.
The Freedom to Speak Up report included the growing number of champions and the success of Freedom to Speak Up Week. The people and organisational development emphasised the need for continued board support and reiterated that detriment for speaking up would not be tolerated.
Excellent progress on the apprenticeship levy had been made with near 100% utilisation including innovative courses that demonstrated a holistic approach to patient enrichment, particularly on inpatient wards.
In response to Mr Lewis, Ms Holden and Dr Sinclair explained there was no systemic issue with doctors’ rotas, supported by proactive monitoring and compliance with national frameworks.
The board received and noted the report from the People and Organisational Development Committee.
Report from the Public Health, Patient Involvement and Partnerships (PHPIP) Committee
Reference
Board public: 25/11/11.
Mr Vallance presented the paper and highlighted key points.
The Public Health, Patient Involvement and Partnerships (PHPIP) Committee celebrated reaching a major milestone in volunteer engagement, promise 3, with 351 active volunteers and more volunteers in the onboarding process. Appreciation was expressed to all teams and volunteers involved for their commitment, and improvements in volunteer recruitment processes were noted as making participation easier and more sustainable. Mr Lewis emphasised the importance of sustaining improvements beyond numerical targets, reducing operational strain, and embedding continuous learning.
The Public Health, Patient Involvement and Partnerships Committee committee welcomed progress on promise 2, highlighting emerging clarity and proposal for an awareness campaign targeting staff and line managers.
Positive developments were also reported for Flourish, particularly in respect of the favourable Care Quality Commission feedback for core services and Woodfield24, having been assessed as Good.
The board received and noted the report from the Public Health, Patient Involvement and Partnerships Committee.
Report from the Finance, Digital and Estates (FDE) Committee
Reference
Board public: 25/11/12.
Mrs Vickers presented the paper and highlighted key points.
The Finance, Digital and Estates (FDE) Committee discussed the savings plan, noting the £10,000,000 target and the need for sensitive, inclusive, and collaborative communication and engagement throughout implementation.
The estates enabling plan continued to progress with emphasis that the plan must focus on future readiness and quality, not just speed. Consideration was given to outsourcing elements of estates work while maintaining quality and safety standards. External advisors were being appointed to support specifications and commercial aspects. A detailed paper on the estate enabling plan would return to the Board in March 2026.
There were significant digital developments including the rollout of SystemConnect in several clinical areas, supporting promise 14 and reducing four week waits. The system would enable patient self referral and streamlines processes, improving patient experience. Rollout was planned between October and February, with plans for further rollout across all services by April with considerations for digital inclusion.
The board received and noted the report from the Finance, Digital and Estates Committee.
Trust People Council (TPC)
Reference
Board public: 25/11/13.
Mr Vallance presented the paper and highlighted key points.
There was continued focus on organisational culture as a key enabler for delivering the strategy. Plans were in place to cocreate a dedicated session on culture for the January meeting, aimed at clarifying what culture means in practice and ensuring staff feedback was heard and acted upon. The discussion also covered the trust’s commitment to becoming positively anti racist, with progress to be reviewed through the upcoming stocktake in the upcoming agenda item.
Ms Clark addressed sickness absence trends and the need for deeper analysis, including links to caring responsibilities and flexible working arrangements. Ms Holden explained a sickness absence deep dive was scheduled with operational teams next week to explore those issues further. Mr Lewis acknowledged that flexible working was well established in some areas but remained challenging in shift based roles.
The board received and noted the report from the Trust People Council.
Chief executive’s report
Reference
Board public: 25/11/14.
Mr Lewis drew attention to the key items within his report.
It was noted that the medical education oversight by the Deanery, which had been in place since March, was successfully removed earlier this week. He noted the appointment of Dr Milmore as Director of Postgraduate Medical Education. In addition, the appointment of the Lead Resident role was nearing completion.
The NHS medium term financial framework 2026 to 2029 had been issued following the NHS 10 year plan with emphasis on digital innovation. The focus echoed the organisational plans, with work underway to review opportunities for technology to support treatment and reduce administrative burden, such as SystemConnect, and alignment with national policy.
Care group delivery reviews in the prior few days saw strong engagement around Care Opinion and evidence of meaningful change, particularly in children’s services. Good progress was observed and evidenced regarding Care Quality Commission readiness, and a substantive discussion on this topic was planned for the January board meeting.
In relation to neurodiversity waiting times, Children’s services remained strong and on track to deliver 18 week compliance by 2026 in North Lincolnshire and Doncaster, although prescribing issues in North Lincolnshire remain unresolved. Funding adjustments were planned for 2026, moving resources into Rotherham.
Adult neurodiversity pathways remained unresolved, with approx. 6,000 patients waiting, including 2,000 for autism assessments. In responding to Mr Vallance, Mr Lewis noted the actions on recurrent demand and supply agreed in September but confirmed there remained no coherent backlog plan to present to the board. A wider discussion might be required on whether the trust was best placed to provide this service was the present position persisted. Mr Lewis referred to discussions held at the private board in August regarding the dysfunctionality of the payment regime. Optimism was expressed that South Yorkshire Integrated Care Board (ICB) would progress tariff reform. Initial impact assessments suggest a neutral financial position but the changes would give us a basis for growth.
The trust awards recently held celebrated the success and recognised excellent practice and staff pride, while acknowledging the challenges ahead into 2026.
Mr Lewis asked the board to endorse the proposal in relation to specialty medical staff ambitions (the SAS-6, para 3.7). This would support the development of specialty doctors. For example, this moved specialty roles into leadership positions, taking a lead from Dr Mike Seneviratne who was now our associate medical director.
Mr Vallance referred to the importance of amplifying positive messages alongside difficult changes, particularly for recruitment and engagement. Mr Lewis acknowledged the need to maintain staff morale during a period of financial strain and organisational change.
Ms Clark stated her interest in relation to speciality medical staff and advised she sat on the board of a Specialty and Specialist (SAS) Committee for three years. She declared her support for the proposal, recognising the value this would bring.
Ms Blake acknowledged the large volume of national changes. She referred to the youth advisory council and development with place partners. Mr Lewis explained there had been multiple meetings with the youth advisory group and ongoing work with the children’s care group director to respond to four key points, including waits and employment. Plans include collaboration with the chief executive of City of Doncaster Council and an academy group to prototype a school experience model. Mr Lewis advised place based work was progressing, with strong engagement across three partnerships. The Integrated Care Board had indicated reduced involvement going forward, and discussions were underway to determine backfill arrangements by April. Funding responsibilities were noted as a potential challenge, requiring alignment with organisational values if costs were shifted.
Dr Graham referenced the continued balance of celebrating achievements with transparency about challenges, ensuring staff and stakeholders remained engaged and informed. Dr Graham requested a further update with regard to eating disorder services. Mr Lewis explained the process to qualify for certain contracts, and work continued with South Yorkshire Integrated Care Board colleagues, with investment from providers matched by the integrated care board. Clinical concerns remain that current plans may act as a temporary solution rather than a comprehensive approach. Mr Lewis would present a detailed proposal to the integrated care board in January. Credit was given to Sheffield Health Partnerships University Trust for work on opening up day services across South Yorkshire and progressing inpatient provision proposals.
The board received and noted the chief Executive’s report and the forward actions it contained, the difficult decisions needed to secure large-scale delivery of our 2025 and 2026 plans.
Freedom to Speak Up (FTSU) guardian six month update
Reference
Board public: 25/11/15.
James Hatfield introduced the paper and gave key highlights on the Freedom to Speak Up (FTSU) position between April to September 2025.
Inappropriate attitudes and behaviours remained the most reported Freedom to Speak Up concern. James explained there was emphasis on improving how feedback was delivered, ensuring it was constructive and supportive. He noted examples recently led through the Chief Executive, which had been well received.
Ms Blake referred to the discussions at the recent People and Organisational Development (POD) Committee and asked whether James felt there was further action required to support staff wellbeing, learning, and resilience. James replied he would encourage all leaders to increase visibility in their areas and openly speak with staff, with focus on the wellbeing.
Mr Lewis noted current Freedom to Speak Up levels were proportionate to peer organisations and questioned when protected characteristic reporting would become available. James advised raising concerns would go live on Radar in December, and anonymised Freedom to Speak Up reporting would also be available. James highlighted other routes to raise concerns through Freedom to Speak Up champions.
Mr Lewis voiced a concern over the absence of protected characteristics data from the report. This was discussed and James committed to ensure all future reports did contain this information.
Action
Steve Forsyth.
Mr Chillery referred to the wider engagement underway through community services redesign and transparent communications. He explained this may evoke anxiety, fear or anger and may lead to an influx of FTSU concerns in quarter 4. Ms Holden referred to discussions at the People and Organisational Development (POD) Committee and noted only a small proportion of staff had raised concerns to date (24 cases from over 4000 staff), highlighting the need to promote Freedom to Speak Up champions and strengthen line manager visibility to resolve issues early.
In response to Mr Pandor, James advised year to date the number of concerns reported were similar to the previous year. Mr Lewis cautioned the trend may increase during the next quarter for the reasons already mentioned.
Mr Lewis highlighted the importance of building a culture where people were able to speak up and that there were other forms by which to do so, and not only through Freedom to Speak Up processes such as speaking to the spiritual leaders, line managers and trade unions. He agreed to consider with executive colleagues outside this meeting of a broader culture of speaking up beyond formal Freedom to Speak Up processes.
Action
Toby Lewis.
Promise 1 progress and actions
Reference
Board public: 25/11/16.
Mr Lewis presented the paper and highlighted the progress made in delivery of promise 1 but also the remaining ask, which was significant. Peer support was the largest single investment in the past two years and would remain a priority next year. Mr Lewis emphasised the need for board understanding of peer support, its purpose and benefits before committing further funds. Research showed role clarity and strong relationships delivered mutual benefits, but current coverage varied across services with gaps in role clarity and consistency. Next steps included completing a gap analysis, setting common standards, revising policies, and developing an outcome framework. The approach would shift from trial and error to a structured program over the next six months.
Dr Sinclair emphasised the need to measure outcomes for this major investment and leverage research opportunities. Dr Graham advised peer support brought value to care but also governance, procurement, and service design. Mr Chillery acknowledged some challenge and caution remained in embedding peer support within traditional medical models and addressing towards community power.
The next steps included developing an outcomes framework focusing on both qualitative and quantitative measures, which captured diverse benefits and clarifying employment models to avoid siloed approaches. Mr Forsyth explained the peer support journey would shortly be presented to Doncaster partners and local authority, emphasising sustainability through integration across organisations and embedding in policy and safety plans. Mr Lewis recognised the importance for clear language and transparency about workforce changes as peer support roles expand.
The board reaffirmed its commitment to concurrent peer support alongside care, recognising cultural and governance challenges and the importance of oversight and celebrating progress.
The board received and noted the progress made in delivery of promise 1 and the actions contained.
Promise 14 delivering a 4 week wait for all referrals
Reference
Board public: 25/11/17.
Mr Chillery presented the paper and highlighted the progress on services achieving the referral to assessment 4 week wait standard.
Significant progress had been made, with some services slightly ahead of timetable, but the real focus was on ensuring sustainability. Most services have identified that they have enough supply to meet demands, with the exception of podiatry services. All other services offered some assurance of meeting 4 weeks from March 2026. Mr Chillery confirmed that the mapping of secondary pathways would be finalised in December.
Mr Chillery explained the importance of maintaining weekly allocation oversight, and the risks posed by small service teams and potential pathway changes. Key risks in achieving 4 weeks in the next 4 months could include small service vulnerabilities, such as staff sickness and capacity fluctuations. It was acknowledged the community services redesign and demand capacity work would support long term improvements however, it will be a turbulent time of change for community services.
Mr Vallance praised the progress in reducing waits, noting reputational benefits, digital support, and the need to evaluate patient experience and service flow. Mr Chillery highlighted Care Opinion and SystemConnect as tools to empower patient feedback, and self management of appointments by patients, confirming their positive impact on communities.
In response to Dr Falk, Mr Chillery confirmed the podiatry service had seen a sustained 100% growth in referrals following a successful campaign, which meant the service would not now deliver in timescale, and highlighted the need for two additional posts via investment bids. The recent pathway changes to the primary care network health and wellbeing pathway meant they may not achieve in timescale, although work was underway to try to address that. Although wheelchair services met the four-week assessment target, full delivery of some wheelchairs would take 18 weeks. Mr Chillery emphasised that ongoing monitoring and assurance were required to maintain progress and manage capacity.
Dr Sinclair questioned whether the shorter waits had started to attract patients from neighbouring trusts. Mr Chillery stated there was no evidence to suggest a shift of being a preferred provider but emphasised the importance of monitoring cross referrals and demand from neighbouring trusts. He stressed that progress must be measured methodically, ensuring secondary waits were also identified and addressed.
Mr Lewis felt that the key metric for sustainability would be having all services achieving allocation within one week, creating flexibility to manage spikes. Mr Chillery offered confidence that this would be in place through 2026.
The board received and noted the progress made in delivery of promise 14. A further update would be provided to the board in March 2026.
Always events planning
Reference
Board public: 25/11/18.
Mr Forsyth presented the paper and highlighted the introduction of five always measures (AMs) datasets. He reinforced the importance of the initiative as a major cultural and operational shift, designed to ensure real time accountability and improve patient experience.
The always measures dataset would drive a major cultural shift to 100% compliance in key areas and enable real time monitoring via dashboards with rapid escalation protocols (24 hours to directorate leaders or teams, up to five days for executive review). Mr Forsyth gave a recent example of measure 5 and the impact this had in addressing urgent communication needs for a patient with a hypoxic brain injury, demonstrating its practical value.
Dr Falk noted that this approach represented a fundamental change from current practices. Mr Lewis referenced previous learnings and reflected on the cultural shift required for successful implementation and sustainability. He emphasised the need for strong local accountability alongside a phased implementation approach in 2026 to test out the always measures. Mr Vallance acknowledged that this would challenge existing organisational norms and test line manager capability but that it was essential for enhancing care quality and improving responsiveness.
Ms Blake highlighted the importance of managing carer involvement sensitively and ensuring care assessments delivered meaningful outcomes.
Mr Lewis noted that it was clear that Always Events go live would need very careful planning and calibration, and further discussions were needed before those arrangements can be confirmed.
The board received and noted the Always Events report.
Anti racism stocktake at the trust
Reference
Board public: 25/11/19.
Ms Holden presented the paper and gave key highlights on the progress toward becoming an anti racist organisation. Drawing on staff open meetings and other material previously shared with the board she outlined a change of approach, focused on our 557 line managers and their cultural competency as anti racist leaders. She also highlighted work on antisemitism that had been planned since summer 2025.
Colleagues, including Dr Falk, voiced concerns about language, noting terms like “global majority” and “BME” as potential microaggressions. Ms Blake stressed the persistence of discrimination across protected characteristics and the importance of maintaining focus despite external pressures.
Mrs McDonough acknowledged social media challenges and the organisation’s limited ability to remove harmful posts, while confirming that staff posting or liking discriminatory content would continue to be addressed under policy. Mr Lewis stressed the need for behaviour change, focusing on the skills and accountability of 557 line managers to actively assess and demonstrate cultural competency.
Responding to Mr Forsyth, Ms Holden acknowledged the importance of inclusive language and careful framing to avoid offence. She highlighted social media policy challenges, referencing a fitness to practise case and difficulties managing discriminatory posts. She stressed the value of staff sharing experiences while recognising the risk of re-traumatisation, with consensus on balancing storytelling with action and ensuring staff feel supported. Ms Holden outlined the ongoing tender and evaluation process for Equality, Diversity and Inclusion training, which will include antisemitism, and invited board members to participate in that tender process should they wish to be involved.
Mrs Vickers agreed on the need for a clear plan to drive behavioural change, maintain momentum, improve staff understanding, and address behaviours through education, accountability, and robust frameworks.
The board received and noted the anti racism report, acknowledged the approach taken and feedback received, and supported the proposal to undertake targeted unannounced service visits focused on culture from April 2026.
Financial plan 2026 to 2027 and workflow workforce changes
Reference
Board public: 25/11/20.
Mrs Savoury presented the initial element of the paper, which reaffirmed that the Board approved medium term financial plan, having been reviewed against the published subsequent guidance remained extant. She drew attention to income uncertainties which persisted.
The first two years of the three year financial plan must be submitted to NHSE by 17 December, with revisions planned for February following updated national guidance and integrated care board allocations. To meet tight timelines, the board were asked to delegate authority for submissions to be jointly signed off by Mrs Vickers, Chair of Finance, Digital and Estates (FDE) Committee and Mr Lewis on behalf of the board.
Mr Lewis confirmed that cash and capital projections required further refinement due to changes in national capital policy, with the most significant differences expected between December and February submissions. The trust’s medium term financial plan assumes a flat cash position and a 1.5% net income uplift. A well developed plan would be submitted to NHSE on 17 December, with confidence in the organisation’s planning capability supported by robust financial and workforce triangulation processes: this was grounded in work over some months.
Mrs Vickers then asked Mr Lewis to introduce the workforce change element of the paper. He noted the balance between a 4% change, or £6,000,000 pay bill changes, as relatively modest, and the reality for affected and concerned teams. He reminded the board of the Trust People Council discussion previously cited which included exploration of support structures.
Mr Lewis drew attention to the section of the paper which confirmed the changes planned in backbone services. Recognising changes, where they involved transfer of undertakings (protection of employment) transfer (TUPE transfer) or role displacement would be subject to consultation, he noted that the scale of change was around 25 roles among just over 600. Overall reductions in corporate costs, including non-pay changes, met the £2,000,000 figure set out in the July 2025 plans for 2026 and 2027. He recognised that further changes within the nursing and facilities directorate would need to be managed carefully, and that changes in payroll and accounts payable had been subject to much discussion. He praised staff for their engagement in testing ideas and felt confident that the backbone changes were well balanced.
He noted the quality safety impact assessment (QSIA) and other processes needed to confirm the schemes, recognising that the executive group had reviewed the corporate schemes together in October. The review process for quality safety impact assessment would focus most time on the community clinical schemes which were returning to the Board in December: with this paper offering a precis of developing proposals. The adult mental health changes aim to improve productivity and consistency while preserving flexibility, with built in allowances for education, research, and well-being, plus a 5% activity growth buffer. Children’s services proposals continued to be refined, with a final version expected shortly following feedback. Adult physical health changes were the most extensive because they seek during 2026 to move the trust’s service model towards neighbourhood team working. This formed part of our Promises but was also national strategy. Mr Lewis recognised the need to future proof services and avoid repeated incremental changes.
Mr Lewis drew attention to the conclusion and recommendations emphasising the board’s leadership role over the coming four months. He highlighted a view that the risk lay in implementation from April, which was why work on that will start in January.
Dr Falk queried whether skill mix gaps had been factored into the cost base for clinical staffing. Mr Lewis confirmed no changes to inpatient ward staffing levels were included in the current plan, with any adjustments to be considered through the investment fund process only. He assured the board that safe staffing data did not indicate unsafe levels and stressed the importance of using robust comparisons and evidence-based decisions given variations in financial viability across organisations.
Dr Sinclair discussed future service models and noted a likely shift to less specialised teams in mental health and physical health. Dr Sinclair acknowledged potential challenges in managing perceptions of fairness and consistency, with teams such as assertive outreach facing increased scrutiny under national policy.
Dr Graham highlighted the need to manage organisational change carefully during a period that also included winter pressures, noting potential short term productivity impacts. The quality safety impact assessment on 8 December would review backbone and clinical schemes collectively, with attention to smaller professional groups where reductions could affect workforce sustainability. Mr Lewis confirmed that within the plans all clinical professions were impacted.
Mrs McDonough highlighted staff concerns about the scale of proposed changes and the need to maintain clear communication of the rationale. She noted productivity gains, including sustaining the four week wait target. The discussion stressed the importance of robust quality safety impact assessment processes, thoughtful measurement thresholds for 2026 and 2027 implementation, and acknowledged cultural challenges in achieving consistent productivity.
Mr Chillery noted that workforce change initiatives were underway across the integrated care board and praised the care group directors for their efforts in engaging staff throughout the organisation. He explained that the proposed productivity gains were in some ways modest, data driven, and include built in buffers to ensure feasibility.
Mr Forsyth highlighted several positive developments already achieved, including implementing the real living wage, maintaining investment in inpatient services, and introducing innovative care models that improve outcomes without additional staffing. He stressed that staff engagement would remain a priority and, while changes were challenging, the overarching aim was to deliver better services while keeping sight of the rationale for transformation.
The board received and noted the Financial Plan 2026 to 2027 and workflow workforce changes, and noted the work to engage staff and develop ideas for a safe but balanced 2026 to 2027 financial plan.
The board delegated submission of the 17 December plan documents to NHS England as outlined.
The board recognised the anxiety of colleagues about the scale and pace of change required, and supported the recommended corporate backbone change schemes.
The board agreed to review the final shape of patient-service changes at its next meeting on 16 December.
Care Quality Commission readiness: well led
Reference
Board public: 25/11/21.
Mrs Vickers invited colleagues to take the paper as read and opened up for discussion and questions for Mr Gowland. Mr Gowland explained the link and interdependent work related to the four key Care Quality Commission domains which the board would be sighted on in January. The board noted that the report reflected progress over the past six months and introduced how clinical directorates demonstrated compliance against a related maturity matrix.
Mr Gowland confirmed that feedback on the provider capability assessment was expected in early December. The external well led review tender closes on 15 December, with the successful bidder due to start before Christmas and provide a draft report by 31 March 2026.
The board discussed the need to ensure confidence in self assessments by reflecting multiple perspectives rather than relying on a single viewpoint. Strengthening triangulation through the directorate maturity matrix and evidence testing was highlighted as essential.
The board received and noted the update and status of the Care Quality Commission readiness well led report and the next steps and planned reporting schedule.
Integrated quality performance report (IQPR) incorporating older peoples quality indicators
Reference
Board public: 25/11/22a.
Mrs Vickers invited colleagues to take the paper as read and opened up for discussion and questions for Mr Chillery and Dr Sinclair.
In response to Mr Lewis, Dr Graham explained that using diagnosis specific length of stay data, overseen by the high quality therapeutic care taskforce (HQTC), would provide more precise and actionable insights by aligning stays with diagnostic categories and national benchmarks. This approach would set realistic patient expectations, identify non clinical delays, and improve collaboration with internal teams and partners to expedite discharge. Clinicians would receive data on their own practice to support accountability and service improvement. Work remained ongoing with regular executive oversight to address clinical challenges and ensure ownership as the process evolves.
The board acknowledged the integrated quality performance report had previously been received at board committee level for scrutiny and challenge. Regarding older people quality indicators, Dr Sinclair explained the further work required to develop the quality indicators including the separation of organic patients had not been negatively impacted by service changes.
The board received and noted the integrated quality performance report, incorporating the older people indicators.
Health inequalities: review of integrated performance and quality report (IPQR)
Reference
Board public: 25/11/22b.
Mrs Vickers invited colleagues to take the paper as read and opened up for discussion and questions for Mrs McDonough.
Dr Falk highlighted concerns about the large volume and complexity of data, questioning how it could be turned into meaningful action and delivery. Mr Lewis agreed and suggested reviewing the format and focus of future reports, with a new reporting format to be confirmed in April.
Mr Vallance noted discussions at the Public Health, Patient Involvement and Partnerships (PHPIP) Committee highlighted the need for shorter, more concise papers with clearer data synthesis. He acknowledged the current format was complex and required improvement to present actionable insights. Mrs McDonough stressed the importance of linking performance data to service improvement, confirming plans to refine reporting and ensure data informed decision making. Some metrics, such as splitting adult and older adult populations, remain in development.
The board received and noted the health inequalities review of the integrated quality performance report and noted the comparison of the integrated quality performance report data to our local population, against four of the protected characteristics.
Action
Jo McDonough.
Promises and priorities scorecard
Reference
Board public: 25/11/23.
Mrs Vickers invited colleagues to take the paper as read and opened up for discussion and questions for Mr Lewis.
Mrs McDonough highlighted the value of the rating league table in showing where objectives were on track, where progress had been made, and where further work was required. She noted the pressure this placed on approximately 557 line managers and raised concerns about how best to support them given competing priorities.
Dr Graham agreed the league table format was helpful and it was confirmed that future reports would include directional arrows to show progress. Dr Graham emphasised the interdependencies between some promises and the risks posed by limited investment or support from partners. Mr Forsyth questioned how success would be defined for those promises with vague measures.
Ms Holden welcomed the clarity provided by the league table and stressed the need to reinforce the rationale behind the promises, particularly for staff who had joined since the strategy was launched. Ms Blake suggested exploring opportunities for non executive involvement in championing key priorities. Mr Vallance raised challenges in embedding change and implementing real time data.
Mr Lewis explained that the league table reflected three implementation approaches: initiatives that required distributed ownership, those needing active driving before becoming business as usual, and centrally deliverable projects. He proposed a comprehensive review in the spring to assess barriers, success factors, and engagement ahead of the annual members’ meeting in July. He noted the difficulty of evaluating impact and the need for clarity on success measures and delivery chains. Mr Lewis also highlighted interdependencies across geographies and partnerships and confirmed there was engagement with the integrated care board to strengthen integrated care. He agreed to explore mapping non executive interests to align with strategic priorities.
Mr Lewis agreed to consider non executive directors in championing specific promises, where colleagues’ expertise and enthusiasm could add value rather than create formal roles.
The board received and noted the promises and priorities scorecard and the self assessment provided, augmented by the narrative within the paper. The board acknowledged the effort across 23 directorates to deliver 28 Promises by the end of 2028, and recognised continued focus on in year delivery of both parts of promise 14.
Action
Toby Lewis.
Strategic delivery risks (SDRs)
Reference
Board public: 25/11/24.
Mr Gowland presented the report and reaffirmed the importance of continuing to monitor and address strategic risks through the relevant committees and executive leadership. Progress had been made across several areas, including leadership development programmes, improved data availability, and partnership engagement, particularly with primary care. Those initiatives were designed to strengthen service delivery and support the organisation’s strategic objectives, although challenges remained, particularly in relation to workforce capacity and seven day service provision.
Mr Gowland highlighted the potential distraction posed by external publications and performance reporting, which could divert focus from the organisation’s agreed priorities. Following review of the NHS 10 year plan, the five strategic risks previously identified remain valid. Since the publication of the medium term planning framework, the Board were again asked to consider if there were any additions or changes to the current strategic delivery risks and create additional risks.
Mr Lewis noted emerging issues such as workforce retention and neighbourhood model implementation may require additional consideration in the coming months. Mrs Vickers referred to the financial medium term planning framework and suggested no further changes to the strategic delivery risks.
Mr Vallance reflected on discussions at the Public Health, Patient Involvement and Partnerships (PHPIP) Committee and its review of the strategic delivery risk 3. Mr Chillery referred to the challenges and opportunities associated with community service redesign, and whilst strategic delivery risk 3 and strategic delivery risk 5 had reference community aspects, they were currently weighted towards primary care and leadership development. Mr Chillery questioned whether they adequately reflected the scale and complexity of the work underway in community services, particularly given the potential disruption posed by forthcoming national GP neighbourhood contracts. Following discussion and whilst no immediate changes were made, there was consensus that by March, when greater clarity on national GP contracts was expected, a review of risk wording and intent may be necessary to ensure alignment with organisational priorities and systemwide developments.
The board received and noted the update position for each strategic delivery risk, and confirmed no immediate changes were required to the current five strategic delivery risks.
Operational risk report
Reference
Board public: 25/11/25.
Mr Gowland presented the report and highlighted the key developments made. Recent reviews had highlighted the need for stronger alignment of risk management processes across the organisation. Mr Gowland explained whilst some risks were added recently, further work was required to ensure they were correctly referenced and integrated into the risk framework. This would be a key focus in the coming weeks, with discussions scheduled at the Risk Management Group meeting in December. A more structured approach to operational risk assessment was being developed to provide greater clarity beyond tolerance thresholds and to identify opportunities for improvement.
Delivery reviews had revealed that some teams still had no recorded risks and several actions remained overdue. Mr Gowland advised that addressing those gaps would be prioritised to ensure consistency and accountability. Emerging risks, including those related to anti racism and equality, required close monitoring and accurate reflection.
In response to Ms Gillatt’s query regarding patient care risk (RSK-375), Mr Gowland explained that the identified backlog of Driver and Vehicle Licensing Agency (DVLA) medical review cases in Rotherham related to patients’ ability to drive. Eight cases remain outstanding however remedial action was underway and expected to be resolved by next week. Indemnity arrangements had been clarified with the organisation’s insurers and processes had been updated to allow suitably qualified staff, not only doctors, to complete Driver and Vehicle Licensing Agency reviews.
Mr Lewis noted the two key risks related to medication safety with shared care arrangements for lithium prescribing and medicines information systems (RSK-038 and RSK-083). Dr Sinclair advised progress had been made to enable clinician level prescribing visibility, and the functionality would expand to include team level reporting and cost analysis. This enhancement would support rapid responses to safety alerts and strengthen governance. Full functionality was expected by March. Mr Lewis recommended the Board be kept sighted on those core patient safety risks.
The board received and noted the operational risk report and noted the revised reporting thresholds based on risk appetite and the planned work to address the extended number of risks that were currently outside of appetite and tolerance.
Supporting papers (previously presented at committee)
Supporting papers
Reference
Board public: 25/11/26.
Mrs Vickers informed the board of the medical revalidation report for information which was presented as a supporting paper that had previously been presented at people and organisational development committee level for scrutiny and challenge.
The board received and noted the medical revalidation report for information
Any other urgent business
Reference
Board public: 25/11/27.
There was no further business raised.
Any risks that the board wishes the risk management group (RMG) to consider
Reference
Board public: 25/11/28.
There were no risks identified.
Public questions
Reference
Board public: 25/11/29.
There were no public questions.
Closing statement
Reference
Board public: 25/11/30.
The chair resolved:
“That because publicity would be prejudicial to the public interest by reason of the confidential nature of the business to be transacted, the public and press would be excluded from the remainder of the meeting, which would conclude in private.”
Page last reviewed: January 14, 2026
Next review due: January 14, 2027
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