University Hospitals Birmingham NHS Foundation Trust

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation
• Environmental sustainability – sustainable development

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The trust had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, and diversity and inclusion. It came from engagement with staff, patients and key stakeholders, and understanding the challenges and needs of people and their communities.

Our findings:

The trust had a comprehensive strategy co-produced by staff and partners for the 5 years from 2024 to 2029, although, we were told, with limited involvement from the public. The strategy was entitled Building Healthier Lives and based around 5 key priorities of (slightly paraphrased):

• Our patients – improving health and wellbeing and providing high quality and equitable care
• Our people – creating a culture where everyone feels like they belong, thrives and feels valued
• Our potential – being a centre for pioneering research, innovation, education and training
• Our place – working with partners to reduce health inequalities and being cornerstones for the community
• Our performance – making good use of resources to efficiently deliver plans

The trust’s narrative in the strategy report recognised the challenges of the population it served. This focused on the recognition of deprivation and inherent inequalities and how this negatively impacted on the health of that population. The strategy had been devised to deal with these challenges and others facing the trust to transform the organisation into a place where people were proud to work. The commitment was for every patient to know they would receive the highest quality and most equitable care possible.

There were measures of success built into the strategy. These included localised measures such as what patients and staff were saying in national surveys and wider-ranging measures in being able to demonstrate the trust was contributing to an increase in healthier life expectancy. Healthier life expectancy included being committed to environmental sustainability (see our section below); increasing local employment at the trust (employment being known to improve health); being a recognised asset for the local community; and tackling health inequalities.

Each theme of the strategy was led by members of the executive team which fitted with their substantive role. For example, the chief medical officer and the chief nurse were the leaders for the ‘our patient’ theme around high quality care and the ‘our potential’ theme around staff education and training. There were local strategies linked to the overarching plan, such as, the inclusion strategy, and research, development and innovation (RDI) strategy. The RDI strategy, for example, referenced the values and the themes and how its objectives linked to each of them. See further our section below on Learning, improvement and innovation. Each strategy was produced in a similar template to ensure they linked to the overarching trust strategy. For example, the inclusion strategy used the same language and format around objectives and milestones for consistency and to demonstrate it was joined up. We were told there needed to be further work around the digital and estates strategy to produce something measurable and achievable and in line with the key drivers.

The strategy was discussed at board committee meetings. For example, in the people and culture committee in May 2025, the members discussed the risks to delivery for each of the 5 themes in the strategy. Each of these was aligned to board committees to oversee. For example, the performance priority risks were owned by the infrastructure committee and the finance and performance committee, depending on the nature of the risk. The strategy was due to have a mid-point review in the autumn of 2025 to ensure it remained in line with global and national changes and was still in focus. There was a strategy for the medicines team covering the 5 years from 2022 to 2027. However, our conversations with the pharmacy team suggested not all staff were entirely sure what the shared vision and strategy were.

The trust’s values were co-produced with partners. They were developed in 2021 with input from around 1,400 staff and stakeholders. The values were ‘kind, connected and bold.’ They ran through many of the trust policies, frameworks, strategies, and plans. This included, for example, the behavioural framework, the trust’s 5-year strategy, and in the work of the Wise Council (see more below). The trust awarded staff who went “over and above in delivering for patients and colleagues alike” with a ‘Kind, Connected and Bold’ award to celebrate excellence. The trust website and newsletter published an extensive list of staff from all across the organisation being given these awards. In April 2025, there were 28 individuals or groups of staff given awards for often showing exceptional kindness to patients or recognised by their colleagues for their support.

There had been extensive work at the trust around culture and staff wellbeing. Our previous report published in March 2024 rated the trust as inadequate for well-led and we served a Warning Notice around failings in culture. We said how “the trust must resolve the longstanding issues with culture, staff wellbeing and staff safety and any form of unacceptable behaviour in all the forms described in this [the previous] report. The trust must find a mechanism to bring staff who have experienced the poor culture to be the driving force for change and find a way to make that safe and secure for staff. This includes the post-graduate doctors in training. It must make the environment for staff in which this takes place free of judgement and blame. In doing this, the trust will ultimately allow staff to be their best and bring safe and quality care for the patients and public it serves.”

The trust had met the breach of regulation laid out in our Warning Notice. It had responded with a comprehensive plan to address these criticisms and necessary actions. In terms of culture, a number of substantial initiatives were started alongside the culture review and trust improvement plan. This included in terms of bigger workstreams, the creation of the Wise Council; the engagement around development of the trust strategy (particularly where it related to culture as described above); an anti-bullying pledge; and the development of a ‘behavioural framework’ designed by colleagues and approved by the Wise Council.

The culture review was linked closely to the ‘our people’ priority and underpinned by a series of objectives and secondary measures. Each objective then had an extensive list of 28 milestones to be reached. In the trust board meeting of January 2025, it was agreed to formally conclude the work of the trust improvement plan and any actions yet to be completed would be part of business-as-usual through the relevant trust board committees.

There was a change in emphasis for some staff groups who said they had felt forgotten about. Two worthy of mention were firstly the allied health professionals. We heard from focus groups and a meeting with 2 of the senior staff in this specialty how they were getting a voice and more respect and inclusion. There was now a professional lead for allied health professionals. Secondly were the staff who worked in the community, specifically from Solihull Hospital. They were also represented by a community lead nurse on their hospital board. Those staff we met at the well-attended focus group at Solihull Hospital, which led on community work for the trust, spoke of feeling valued and appreciated at the trust for the work they were doing. Their allied health professional colleagues who were also present in high numbers at all focus groups at the hospitals were also spoken about for their value and commitment to patient care and safety.

Work had been carried out to bring staff much closer to the transformation of culture. One of the successes of the work undertaken was the creation of the ‘Wise Council.’ This group had the working title of ‘Wise Council’ which ended up being the actual name chosen by staff. The group was arguably a far more successful and growing group than was envisaged by anyone at the outset. It was launched in November 2023 and had grown to over 900 members by April 2025. It started from a conversation with key staff with roles in development, leadership and engagement sitting down with the Chief Executive Officer (CEO) and talking about what they were going to do about the serious culture issues. It was agreed to get external support from the local university which had expertise in this area and create a social movement to meaningfully engage with staff.

The group was diverse and challenging. Anyone was able to bring ideas for discussion around making things better. It was interesting to note topics ranged from smaller things like email traffic and parking, to some big topics, such as sexual safety and civility. The first awayday was held in 2025 which was well attended and more were planned to be held twice yearly. The Council had been instrumental in a number of key pieces of work including the behavioural framework, the change-maker training, and the new sexual misconduct policy. Furthermore it supported the new flexible working process and policy, and improved access to occupational health and wellbeing support. Future work mapped out as part of the trust improvement plan included increasing membership to a minimum of 1,500; making sure representation was within 10% of the make-up of the characteristics of University Hospitals Birmingham NHS Foundation Trust staff; and ensuring new starters were invited to join the Council. The Wise Council members were also invited to become Pillar Leads alongside the senior responsible officers for the trust’s ‘6 pillar programmes’ linked to the culture improvement plan.

There was commitment from the staff-side representatives to play a useful and meaningful role in the organisation. They had excellent insight into a wealth of issues in the organisation and were aware of the drivers for change and success which had been achieved. They had worked hard to ensure the staff they represented had as much access to knowledge and information as was available. To that end they had been actively involved in many aspects of the transformation including the behavioural framework, prevention of bullying charter and the flexible working strategy.

The trust had a group of experienced and dedicated governors. We met a group of the trust’s elected governors who included a public governor, a stakeholder governor (for the staff of the affiliated Royal Centre for Defence Medicine) and a staff governor who was a leader in the allied health professional field. Staff and public governors were elected, as required, to represent staff and patients/communities at an NHS trust with foundation status. Their role was to hold the non-executive directors to account; attend certain committees to support governance; and to update the trust board through their regular meetings with executives on experience and views from local communities. Their role was part of the trust’s constitution and staff governors were expected to represented different groups within the organisation. They met 4 times a year and held seminars on key subjects such as finance, values and strategy. Those governors we met spoke of how they felt included, heard, and valued. They had an improved and open relationships with the non-executive directors who were described as open, respectful and approachable. The governors were now receiving board and committee papers earlier than before which gave them chance to read and absorb the information.

There was a range of communication opportunities for staff across the organisation. This included a weekly briefing with the CEO, regular site briefings by the hospital executive directors, regular newsletters, emails and social media. The weekly briefing with the CEO, ‘CEO Connected’ was a weekly live briefing (with another executive if he was not available). Around 350 to 400 staff attended each time and the CEO took live questions. Staff and executives told us how the tone of questions asked by staff had changed from sometimes accusatory and even threatening, to collaborative and in line with the trust’s values. British Sign Language interpreters joined the CEO Connected calls. There were also relatively new calls being held by the CEO with anyone who was a leader of staff. There had been 2 calls so far by the start of May 2025, and over 1,000 staff attended the second of these once word had reached them.

There was a positive sense of change and enthusiasm from the majority of staff we met. During this assessment work, we visited each of the 4 hospitals and held open invitation focus groups with staff and met with each of the senior leadership teams. Almost all of the 510 staff we met at these open invitation focus groups felt the culture in the organisation had improved in the last 18 months since our previous inspection. Many staff put this down to the devolved structure which had been implemented over those 18 months.

Staff at Solihull Hospital spoke of their commitment to one another and their patients, and how their work in the community was both rewarding and of vital importance for the best patient experience. Staff at Birmingham Heartlands Hospital spoke of their loyalty to their hospital and their patients and the way they felt like a family. Staff at Good Hope Hospital said they recognised the shift in the atmosphere to something far more positive. They spoke about the good visibility of the leadership team and feeling they could approach them for support at any time. Staff at the Queen Elizabeth Hospital Birmingham spoke of how proud they were of what they had achieved since the pandemic and how proud they were of their colleagues.

There were some dissenting voices and staff who contacted us directly with different and negative experiences around culture and behaviours. Staff also spoke about how the devolved model to hospital-site management did not work as well for those staff who still had multi-site roles or were in teams that spread across services. There was some criticism as well for some of the complexities of patient pathways which some staff felt had become less clear or safe. Senior nurses were concerned about a lack of clarity at times about the ‘ownership’ of surgical patients and a lack of decision making when patients were on cross-site pathways. Some staff working across sites still felt there were times when they were lost as to who to contact for support. These were concerns we understood had been largely reported back to the organisation’s leaders who recognised there was more to do in some aspects of service delivery to make this equitable for all staff and patients.

In terms of motivation, the 2024 NHS Staff Survey reported 66% of staff saying they were enthusiastic about their job. This was up 5% since 2021 and 2022 and just below the peer group average for 2024 of 68%.

There were areas of culture and wellbeing of staff in the organisation which were improving well according to the NHS Staff Survey for 2024, but some other areas remained a cause for concern. The 2024 survey was completed by 9,375 trust staff, 38% of the staff number (although this was 11% below the peer group average of 49% completion within 122 equivalent NHS trusts). However, this response rate was an improvement since our previous report in 2023 (for which the survey covered the year 2022) when just 26% of staff (5,653) responded, the lowest among the peer group in that year. In 2023, the rate had improved to 29%.

The trust had received recognition from NHS England for the work carried out to improve the experience and engagement of colleagues in the organisation. In the 9 primary indicators in the survey, the trust scored worse than average for all measures in 2024, but the survey reported all 9 of these indicators were ‘significantly higher’ over the results from 2023 and each had improved over the 2022 results.

There had been an improvement in a number of important and key questions around culture within the staff survey over several years. However, some remain below the peer group average. These included:

• Q25a: The care of patients is my organisation’s top priority – At 68% this was at the highest level in the 4 years from 2021. The peer group average in 2024 was 74%.
• Q25b: My organisation acts on concerns raised by patients – At 63% this was at the highest level in the 4 years from 2021. The peer group average in 2024 was 71%.
• Q25c: I would recommend my organisation as a place to work – At 53% this was the highest level in the 4 years from 2021. The peer group average in 2024 was 61%.
• Q25d: If a friend or relative needed treatment I would be happy with the standard of care provided by this organisation – At 57% this was the highest level in the 3 years since 2022. The peer group average in 2024 was 62%.
• Q6a: I feel that my role makes a difference to patients – At 88% this was the highest level in the 4 years since 2021 and was the same as the peer group average in 2024 of 88%.

In the measure of a group of questions around culture, the trust scored 6.76/10 for having a compassionate culture. This had improved each year since the measure began in 2021, although below the peer group average of 7.05/10. In areas around culture needing improvement, 2 indicators were negative outliers in the improving trend. These were:

• Q8b: 64.5% of staff said the people they worked with were understanding and kind to one another. This was slightly down from 2023 (64.7%) and 2022 (66.1%). It was just over 4% worse than the peer group average for 2024.
• Q8c: 66% of staff said the people they worked with were polite and treated each other with respect. This was also slightly down from 2023 (66.4%) and 2022 (68.1%). It was also 4% worse than the peer group average for 2024.

The following 2 indicators of staff morale had improved but remained worse than the national average:

• Q26a: 33% of staff said they often thought about leaving the organisation. This had dropped from the peak in 2021 of 38% but was worse than the average of the peer group for 2024 of 28%.
• Q26b: 24% said they would look for another job in the next 12 months. This had dropped from the peak in 2021 of 27% but was worse than the average of the peer group for 2024 of 21%.

In responses around health and wellbeing, staff who responded to the NHS Staff Survey from 2024 said:

• Q11c: 45% had felt unwell in the last year due to stress. Nevertheless, this was the lowest result (best) for the last 5 years since 2020. The peer group average for 2024 was 41%.
• Q11d: 61% said they had come to work in the last 3 months despite not feeling well enough to perform their duties. This was the highest result (worst) in the last 5 years since 2020. The peer group average for 2024 was 56%.
• Q12e: 45% of staff felt worn out at the end of their shift. This was the lowest result (best) in the last 4 years since 2021. The peer group average for 2024 was 42.5%.

With the exception of the question around not feeling well enough to work, most of the other questions around health and wellbeing had seen improved scores, although remaining below the peer group average. The most improved score was in relation to Q11a: my organisation takes positive action on health and wellbeing. This had jumped 6% in the year 2024 to 51% and demonstrated the work the trust had been undertaking to improve this aspect of work-life for staff.

There was one area of specific discordance among a staff group where we met a number of individuals and people who spoke for groups of staff. This was among some of the consultant workforce, where we were contacted for individual conversations and we held several focus groups with groups of consultants. The predominant concerns were around failures in communication and engagement, and anxiety around speaking up and this being detrimental on their career. There was a reported lack of trust in the leadership. We were told by some of those we spoke with of how some key decisions affecting consultants directly had been taken at senior level without then giving consultants an explanation of why the decision was made and how it was reached.

There were said to still be pockets of bullying and harassment behaviours continuing unchecked and apathy when it came to reporting this. We were also told some consultants felt their decision-making powers had been taken away and the organisation was no longer clinically led but driven by financial priorities. Some told us some changes had been handled well but others were described by one senior consultant as “appalling.” The latest NHS Staff Survey backed this up to an extent.

The trust provided a view of the 2024 NHS Staff Survey split into certain staff groups. In the ‘medical and dental’ group (which included resident doctors), 782 staff responded. This was 8% of the overall response rate. Of the 108 questions in the staff survey, 93 or 86% were worse than or much worse than the trust average scores for this group. In some key measures around culture, the response from the medical and dental group was as follows:

• 18.4% reported they had experienced harassment, bullying and abuse from managers. This was against a trust average of 11.1%. National average of all NHS staff in the trust’s peer group, 10%
• 25.1% said they had experienced harassment, bullying and abuse from other colleagues. Trust average 21.2%. National average 18.5%
• 28% said the last time they experienced abuse, they or a colleague reported it. Trust average 50.3%. National average 51.9%
• 59.7% said they would feel safe raising concerns about unsafe clinical practice. Trust average 66. National average 70.4%
• 35.6% said they were confident the organisation would address their concern. Trust average 49.7%. National average 55.9%
• 45.6% said they would feel safe speaking up about anything that concerned them. Trust average 54.1%. National average 60.3%
• 28.4% said they were confident the organisation would address their concern. Trust average 42%. National average 48.2%

However, in some of the 2024 NHS Staff Survey questions, the medical and dental group answered more positively than the trust average results:

• 52.6% said they looked forward to going to work. Trust average 49.7%. National average 54.2%
• 91.5% said their role made a difference to patients. Trust average 87.2%. National average 88%
• 70.4% said they received the respect they deserved from colleagues. Trust average 67.3%. National average 70.4%

The trust had taken the decision to exceed the legal requirement for staff to make just one request a year around flexible working to enable more flexibility for staff recognising how life can change more often. This was to enable staff to have a better work-life balance and retain a more diverse workforce. The 2024 NHS Staff Survey supported this and showed:

• Q6b: My organisation is committed to helping me balance by work and home life – 46% of staff agreed, which was up from 36% in 2021 and up each year to 2024.
• Q6c: I achieve a good balance between my work life and home life – 52% of staff agreed, which was up from 46% in 2021.
• Q6d: I can approach my immediate manager to talk openly about flexible working – 67% of staff agreed, which was up from 62% in 2021.

The trust had also introduced flexible public holiday working so staff could elect to take a public holiday when it was more appropriate for them or for their cultural preference.

There was an effective process to protect doctors in training, resident, and locally employed doctors. The trust had appointed a consultant as the guardian of safe working hours (GSWH) with the current appointee to the role having just taken up the post at the time of our assessment. The Guardian was supported by a deputy who had been in a role a number of years and colleagues who supported the work. The previous post holder had been in the role for almost 10 years. This role was introduced by NHS England alongside the new ‘junior doctor’s contract’ in 2016/17. The GSWH must be (and was) independent of trust management and a champion for safe working hours for doctors in training and oversee safety-related exception reporting. Exception reporting included doctors working longer hours than scheduled, not able to take rest breaks, limited educational opportunities (due to workload) and absence of senior support when needed.

The GSWH reported to the trust board quarterly at least and produced a consolidated annual report. A statement about the findings of the annual report was included in the trust’s quality account and included information, as required, on rota gaps and plans for improvement.

Positive action had been taken to respond to exception reports. In the reports presented to the board, exception reports made by doctors in training were listed alongside an analysis of trends or comparators with previous periods. This enabled to board to see if these reports were rising or falling. In the 2023/24 academic year report to the board submitted in November 2024, the trend for exception reports showed they were mostly reducing over high levels in 2021/22 but had jumped up in the latter part of 2023/24. The overall downward trend was reported as a possible consequence of improved staffing and lower rota gaps. The report described how the previous exception reports had been acted upon and led to changes to work schedules and improved staffing, which was positive action around exception reports. It was also reported how the annual resident doctors survey had led to action around promoting exception reporting which might be the cause of the jump in the 3 months of May to July 2024 (the final quarter of the academic year).

The GSWH reported how from August 2024, the new doctor academic year, all locally employed doctors had access to the system to produce exception reports. This had been a long-held ambition for the GSWH which had been realised.

Alongside reports to the board, the GSWH produced regular interim reports for the resident doctors. This included information in the ‘you said, we did’ format. Doctors were reminded of the importance of taking rests and the need to submit exception reports if breaks were missed.

The previous and the new GSWH were committed to the role. They were focused on ensuring all exception reports were made in accordance with expectations, and they were addressed by the specialities or leaders as required. All new inductees were introduced to the Guardian and the role and expectations explained. In our interview with the Guardian, we heard about the growing health and wellbeing service for doctors in training and resident doctors and the “brilliant” work of the health and wellbeing officers.

The health and wellbeing officers were part of an advanced and valued service under the occupational health and wellbeing umbrella with a dedicated service for resident and trainee doctors. This was to prevent feelings of isolation, which can be prevalent with new or resident doctors. It also helped to support international graduates and doctors who might otherwise face being ‘lost’ in a new place and new country. This was in a wider service for all staff which the trust had appointed 2 consultants to lead in occupational health and wellbeing.

The team had recognised how the overall occupational health service as it had been set up was fragmented and wanted to make the service was more holistic and multidisciplinary. With commitment from the senior leadership team, 4 permanent wellbeing officers had been appointed. The waiting list for an occupational assessment had come down from around 15 weeks to 4/5 weeks and the team were on track to get this to 1/2 weeks. The team was also focused on bringing preventative services to staff. For example, a blood pressure campaign had been run focusing on porters and found some undiagnosed cases where intervention was arranged. This was planned for a larger programme in Summer 2025 alongside ambitions to make the service more personalised for staff, and to look towards continuing annual engagement events.

Wellbeing was a holistic multidisciplinary service. The team were being trained in areas such as safeguarding, mental health, homelessness, as well as a layer around counselling and psychiatry. They spoke with doctors across the trust about civility and how it saved lives. The trust occupational health team were now the leading organisation for health and wellbeing in the region and supported other NHS trusts and services. The team worked closely with the human resources (HR) team and the Freedom to Speak Up Guardian team. Feedback made to the team had been exceptionally positive and the service was clearly appreciated. As we have reported above, there was a rise in the number of staff who said the organisation took positive action on health and wellbeing in the 2024 NHS Staff Survey. This went from 45% in 2023, to 51% in 2024, one of the biggest increases in the staff survey questions.

During a visit to Birmingham Heartlands Hospital we visited the staff wellbeing hub and met the enthusiastic and committed manager who was overseeing a thriving and valued service. There was an array of well-considered information for staff, and services such as a school uniform exchange system. There was a confidential counselling service for staff with a team of experienced counsellors.

The trust had leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Our findings:

There were inclusive leaders at all levels who understood the context in which care, treatment and support were delivered. Our interviews with them and ongoing regular meetings and engagement since the previous inspection showed they embodied the culture and values of their workforce and organisation.

We met with senior leaders across the organisation and not just the trust board. We sat down in conversation with the senior leadership teams at all 4 hospital sites. We found a committed and dedicated group of people who were tuned in to their community, their patients, and their staff. Each hospital was different, and yet in all 4 of these meetings we met staff who spoke about choosing and wanting to work at the hospital where they were based and how it was a special place for them. They spoke about being given autonomy to make their hospital or service fit with the needs of their patients and community, but also being supported to deliver safe and effective care. They also spoke about the need to work collaboratively and how they were co-dependent on each other, with regular touch points with the trust executive leadership team. They recognised the value of mutual aid and learning from each other’s experiences and challenges. We also sat down with the nursing leaders and the medical directors based at the sites. There was clearly excellent mutual respect and support. Each recognised how their services were different but were committed to working together, being consistent and taking decisions to support better patient care.

Leaders had the skills, knowledge, experience, and credibility to lead effectively. They were visible and led by example, modelling inclusive behaviours. Most of the staff we met through our on-site assessment work at service level in the 4 hospitals and the dialysis units spoke highly of their leaders, at both a service level and senior level. They said they were visible and approachable. Staff at all sites talked about the devolved model of leadership which had been rolled out for around 18 months since autumn 2023. We were told of how this felt far more like a ‘family’ working together. They said this had manifested in leaders being more visible and the senior team had a focus on their own hospital and community directly. Some staff told us they were not part of an individual hospital or site, but part of a service which was still trust-wide. A few said they felt the devolved model had ended up with them being disadvantaged by not feeling as much part of the hospital where they were based much of the time. We fed these comments back to senior leadership to consider how best to make everyone’s working life more inclusive and how all staff could benefit from this ‘family’ sense of workplace.

Leaders were knowledgeable about issues and priorities for the safety, effectiveness, responsiveness and quality of services. The devolved model of leadership to hospital sites had secured a more granular view of issues faced and priorities for services, based around differing needs of the patient population. Those leaders we met were aware of the services or staffing groups where there was excellent work, and these were recognised and rewarded. They and their senior teams were also, mostly, aware of where there were areas of risk or concern and had oversight of action plans and improvement strategies.

In the pharmacy team, staff told us they had noticed a positive change in leadership in the last 2 years and felt that senior staff were more visible, open and approachable. Wellbeing of staff was a priority for the management team who approved flexible working in the majority of cases. Staff spoke of team bonding which was supported and encouraged with outside work activities.

Most staff thought their leaders were compassionate about patient care and staff wellbeing. In the 2024 NHS Staff Survey 6.82/10 staff who responded said they felt there was compassionate leadership. This was up from 6.69 in the previous year and up each year since the measure was started in 2021 but was below the NHS peer group average for 2024 of 6.98.

In more direct management questions in the 2024 NHS Staff Survey, staff reported on their managers’ support in these responses (all of which had improved over 2023):

• Q9g: 69% said their immediate manager was interested in listening to them when they described the challenges they faced. This was a 2% improvement over the previous year and just slightly below the peer group average for 2024 of 71%.

• Q9h: 67% said their immediate manager cared about their concerns. This was a 1% improvement over the previous year but below the peer group average for 2024 of 70%.

• Q9i: 64% said their immediate manager took effective action to help them with any problems they faced. This was a 2% improvement over the previous year but below the peer group average for 2024 of 67%.

Some staff did not always feel they could speak up and their voice would be heard, although this was improving. There was evidence of a continued anxiety among some staff of being fearful about speaking up. However, the Freedom to Speak Up Guardian service was widely respected and run by committed and caring individuals. The issues with trust and feeling safe to speak for the vast majority did not originate from concerns about the Guardian service.

Our findings:

The trust had established a Freedom to Speak Up Guardian service as required around 10 years ago following Sir Robert Francis’s report into failings at the Mid-Staffordshire NHS trust. The team provided confidential advice and support to staff where they were concerned about direct or indirect risks to patient safety or the ability to deliver quality care.

The service was reconfigured in 2024 and more than 50 Champions, who were trained staff volunteers, supported the service. The Guardians were a diverse team who included doctors, nurses and a pharmacist. One of the Guardians was appointed to work with the staff who were on site from the armed forces.

In our previous report published in March 2024, we said how “the trust must review, support and strengthen the role of the Freedom to Speak Up Guardian, including implementing the proposed or preferred local model at sites, and looking towards a more grassroots and simplified structure. It must ensure all staff are protected by the process when concerns are shared confidentially beyond the office of the Guardians and entrusted to managerial staff. Concerns must be addressed in a timely and respectful way. It must consider the reflection and planning tool and self-reflect on the service as indicated by NHS England and the National Guardian’s Office. This includes reviewing all requirements as laid out for executive and non-executive directors, the chief executive officer, and the Freedom to Speak up Guardian. This guidance was relaunched in 2022 and the trust board are required to approve the self-reflection by January 2024 at the latest.”

The Freedom to Speak Up Guardian service had recently been strengthened to include 0.5 whole-time-equivalent Guardians based on the 4 hospital sites to support a full-time lead Guardian post. This in effect provided staff with a 7-day service. The current Guardian was due to retire in summer 2025 after 8 years in the role, and a new Guardian would be appointed with a handover period organised.

In November 2024, the trust held its inaugural Freedom to Speak Up conference to celebrate the work of the team. Around 140 colleagues attended the event which was supported by external speakers and staff sharing their experiences.

The NHS 2024 Staff Survey results showed improving results for the annual staff survey around freedom to speak up but still more to do in this area for staff to feel safe and their issues would be addressed:

• Q25e: Only 54% of staff said they felt safe to speak up about anything that concerned them, although this was improved over 2023 by 4%. The peer group average for 2024 was 60%.

• Q25f: Only 42% of staff said they felt confident the organisation would address these concerns. However, this had improved from 2023 also by 4%. The peer group average for 2024 was 48%.

• Q20a: Only 66% of staff (peer average 70%) felt secure in raising concerns about unsafe clinical practice. However, this was up 3% over the previous year.

• Q20b: Only 50% of staff felt confident the organisation would address these concerns (peer average 56%). However, this was a 5% improvement over the previous year.

Although there was good evidence to show the contacts with the Guardians had been rising (282 in 2023/24 from 162 in 2022/23), due to hard work in promoting the service and increasing the number of people to talk to (and widening their availability), the concerns raised were fewer than typical in terms of patient safety and more focused on behaviours. In the annual report to the board for the 2023/24 year (presented in July 2024), the types of concerns being heard were:

• Allegations of incivility, microaggressions, harassment or bullying (33%)

• Workplace issues which were diverse but included excessive workload, inadequate staffing, access to leave, and HR disputes, among others (30.2%)

• Discrimination relating to protected characteristics (10.3%)

• Patient safety concerns (7.2%)

However, a notable change in behaviour was from a sizeable reduction in the number of staff raising concerns anonymously. Between October 2023 and September 2024, just 2% of cases were raised anonymously which was lower than the 10% at comparative NHS trusts in the region. In data published by the National Guardian’s Office, the trust was in the middle of similarly sized trusts in the Midlands in terms of the number of cases brought in the year October 2023 to September 2024. This number was expected to increase in the current year from the Guardians’ raised profile.

In the Guardian’s 2023/24 annual report was a compelling point about successful working practices. It was recognised that some teams, departments or services never contacted the Guardian. The Guardian recognised this might be a negative indicator, arising from a fear of speaking up or complacency, but could also be a positive learning opportunity. The Guardian had found some of these groups to be well led, provide opportunities for training and development, work related or personal, had shared goals, and were constructively self-critical. Furthermore there was a collaborative, supportive and systematic approach to learning from error, the use of respectful language, and being active in research and development.

The role of the Guardians was to give staff a voice, help them raise their concerns, ensure those concerns were heard and acted on, and to promote a healthy constructive learning culture. It was not established to adjudicate or arbitrate, or to control the management of concerns. It was recognised how the nuances of the role were sometimes not fully understood by staff contacting the service and this might have been a contributing factor in staff disengagement or disappointment.

The trust had work to do to enable staff to feel they could speak up without fear of retribution or detriment. The 2024 NHS Staff Survey had improved in this respect (questions improved by between 3% and 5% from 2023 to 2024) but was still some way away from the trust’s peer group averages. Several staff we met, particularly from the medical workforce, spoke of themselves or colleagues still being fearful about speaking up. They spoke about concerns, perceived or otherwise, from not being able to have their confidentiality maintained; fear of being disliked by colleagues or seen as a troublemaker; being disadvantaged in their career; or losing their job.

However, a high proportion of staff contacting the Freedom to Speak Up Guardian were from the medical staff (around 30% since 2018) with 20% consultants and 10% resident doctors. This was in marked contrast to national data when 6.5% of contacts were from doctors.

Pharmacy staff spoke of a positive open-door culture where they felt confident to raise concerns and speak up to anyone within the senior leadership team. They could also use an anonymous ‘suggestion box’ in each site to give feedback. However, some staff said they did not always feel listened to, and there was not always good communication around learning and feedback from incidents.

The trust’s engagement exercise to evaluate the arrangements for speaking up was undertaken in 2024. The report from the Chief People Officer tackled some of the gaps or weaknesses in the current system and made a series of wise recommendations. This included formalising the process around staff concerned of the risk of detriment and a framework for consistent resolution practices.

The trust had completed its self-reflection and planning tool as required by the National Guardian’s Office on how it assessed its Freedom to Speak up service. The trust had been open and honest in terms of some ways in which it no longer met the requirements for the service, some of which had been organised before these requirements came into force. There were well-thought-out actions recorded in the tool to address areas of improvement needed. However, these had not found their way into board papers within, say, the annual report of the Freedom to Speak Up service, and there was no obvious route to demonstrating where actions had been taken effectively. This was important as some of the actions were graded as 1 on a 1 to 5 scale, when 1 was seen as a point of significant failure (there were also a number of 5s at the other end of the scale and everything in between).

Diversity and inclusion were valued in in the workforce. The trust was building a reputation as a leader in this field with exceptional leadership for equality and diversity demonstrating dedication and commitment. Leaders supported work towards an inclusive and fair culture. Leaders acted to continually review and improve the culture of the organisation in the context of equality, diversity, and inclusion. Leaders took action to improve disparities in the experience of staff with protected equality characteristics, or those from excluded and marginalised groups. Any interventions were monitored to evaluate their impact. Leaders took steps to remove bias from practices to ensure equality of opportunity and experience for the workforce within their place of work, and throughout their employment.

Our findings:

Increasing the value of equality, diversity and inclusion was a key priority in the trust’s strategy. In the trust’s 5-year strategy (2024-2029) the second priority was “we have an inclusive culture where everyone at University Hospitals Birmingham NHS Foundation Trust feels like they belong, can thrive, knows they add value and feels valued.” The objectives included “creating a welcoming and inclusive workforce that thrives on the diversity of its people, celebrating unity in difference.” This would be measured by the trust being in the top 25% of those recommended by staff as a place to work in the NHS Staff Survey. The highly enthusiastic staff representing equality and diversity, as well as those we met in the trust’s staff networks, showed exceptional commitment and enthusiasm. Without being asked, they produced a whole folder of evidence for us of their work and actions to be a force for change in the valued area of equity and rights.

The trust had developed ‘inclusion objectives’ around the second priority. These were:

1. To increase representation in the workforce to reflect the diversity of the communities the trust served. This included a focus on hiring, development, and retention of staff from underrepresented groups. Milestone 1 was to increase the percentage of ethnic minority staff holding senior roles.

2. To build capability of leaders so they understand diversity and equality and nurture inclusive environments. This included a focus on training and encouraging inclusive practices.

3. To improve access by removing barriers and following accessibility standards. This included a focus on reasonable adjustments, monitoring and improving disability declaration rates, and increase the profile of the multifaith services.

4. To assess the impact of policies, practices and initiatives on people. This included a focus on equality impact assessments, and an intersectional plan to address pay gaps.

The trust had clear action plans to deliver this objective for a fairer and more inclusive workplace. Work carried out in terms of equality, diversity and inclusion by the trust’s inclusion team had included training around 650 managers to be disability champions. This was designed to support managers to understand the importance of staff sharing a disability and to better support disabled staff in reaching their full potential. The team were also involved in the progression of the violence and aggression prevention and reduction standard and associated actions. Support had been provided to launch the sexual misconduct policy, the workplace adjustment guidance, the flexible workforce policy, and good practice guidance around cultural and religious care for patients.

Cultural and religious insight and education was a key factor in the inclusion agenda. The trust had a chaplaincy and multifaith team who were concerned with areas of cultural and religious equity (among other things like pastoral support). Their work included consultant induction to support an understanding of race and religious equity; being part of or arranging celebrations for different faiths and important religious festivals (such as Diwali, Christmas, and Ramadan); and organising the interfaith week in November 2024. In March 2025, a new prayer room for those of the Dharmic faith was opened at the Queen Elizabeth Hospital Birmingham.

Progress had been made around the equality standards, including in the quality of the reporting, although there was more to do to improve the results. In our report from 2023 we were concerned that 2 key national reports to the board about equality and diversity, the Workforce Race Equality Standard (WRES) and Workforce Disability Equality Standard (WDES) reports, failed to deliver the important messages to the trust board. Since that time, the reports had been redrafted and improved to a high standard. WRES data helps organisations to understand the experience of people from ethnic minority backgrounds and act to ensure they have equal access to career opportunities and received fair treatment in the workplace. WDES data is a set of measures which enables NHS organisations to compare the workplace and career experiences of disabled and non-disabled staff and ensure disabled staff receive fair treatment in the workplace. The trust was planning to disaggregate its data at site-level to enable the senior leadership teams to understand and improve their own WRES and WDES data.

The 2024 WRES data at trust-wide level presented a picture of both progress and challenges. The representation of ethnic minority staff had increased at the trust to 40.4% in 2024, an increase of 2.5%. However, there remained a gap in representation in higher pay bands showing ethnic minority staff still faced barriers in progressing to more senior roles. However, the indicator for access to training to support ethnic minority staff had shown an improvement and was now more equitable.

Areas the trust had seen some improvement but with more work to be done. This included reducing the incidence of:

• relatively low numbers of ethnic minority staff being shortlisted for roles

• ethnic minority staff being involved in disciplinary processes

• lower equal opportunities for career progression

• ethnic minority staff being subject to harassment from the public

However, a growing number of ethnic minority staff had reported harassment from other staff, and facing discrimination. The trust reported these last 2 concerns in the annual WRES report as being “deep rooted” and “longstanding.”

Actions to deal with these issues included the launch of the trust’s behavioural framework in June 2024 which was co-designed with around 1,600 staff. It described what behaviours were acceptable and those which were not. Examples of positive behaviour included “we build connections with people who are different from us and celebrate each other’s differences,” and “we understand what matters to people and respect their culture, values and beliefs.” Unacceptable behaviours, for example, included “we judge and discriminate against others,” “we make assumptions about a person's beliefs or needs without asking them.”

There was commitment to reducing actual and perceived bullying, and for staff to have better recognition of what was considered as bullying. In March 2024, the trust’s executive team signed an anti-bullying pledge. This was followed up with resources for staff on the trust intranet to describe what was meant or understood by bullying and harassment and tips for managers to prevent their staff experiencing it. The trust and key staff representing equality and inclusion recognised the intersectionality of different forms of inequality and discrimination, in that a person with a number of different protected characteristics might suffer more than one form of discrimination.

The trust had developed an action plan and key objectives to improve WRES data and inclusion in all protected characteristics. It addressed those areas needing improvement. For example, it included using fair recruitment experts to promote equitable recruitment practices; launching a talent management and succession planning initiative focusing on ethnic minority women; improving the process for staff when they complain; launching a reciprocal mentoring programme; and working closely with staff networks and the trust’s established Wise Council.

There was a report on current data in the papers for the people committee May 2025 and on milestones for each of the objectives. However, this did not specifically cover the action plan from the 2024 WRES report for which almost all were due to be completed by May 2025 at the latest.

The trust’s performance in the WDES showed notable improvements made although with some continuing disparities. The number of staff reporting as disabled increased in 2024 to 5.3% from 3.8% in 2023. This was for both clinical and non-clinical staff and across all job bands. In 2023, the WDES reported 5 times more staff were in the capability process but this had reduced in 2024 to zero, with no staff being in the process. The number of trust board members declaring a disability had increased from 4.3% to 8.7%, higher than the trust average. There was a 1% increase in the number of disabled staff feeling valued, and a 3% increase in the number of staff reporting adjustments had been made to support them. In areas where work was required, the WDES data reported fewer disabled staff feeling they had access to career progression; more staff with a disability coming to work when they were feeling unwell; and fewer staff feeling engaged (this measure came from an amalgamation of a number of key cultural indicators in the 2024 NHS Staff Survey).

Actions to deal with these issues included those described for WRES (behavioural framework and anti-bullying pledge). There had also been a continuous communications campaign encouraging staff to share their disability in the trust's electronic staff records. Since June 2024, the appraisal process asked staff about disability. The trust had worked with external providers to better understand the workplace adjustments needed to provide disabled staff with effective support. A dedicated ‘workforce adjustments officer’ had been recruited and in post since May 2024 to fast-track these adjustments. The trust had produced its first ‘workplace adjustment guidance’ to ensure staff were aware of the expert recommendations from sources such as occupational health and the ergonomics team. This had sped up the process for staff receiving adjustments as quickly as possible.

Disability work was recognised. Towards the end of May 2025, the trust was recognised as a ‘Disability Confident Leader’. Disability Confident encouraged employers to think differently about disability and take action to improve how they recruited, retained and developed disabled people. The trust reported how the programme was developed by employers and disabled people’s representatives to make it rigorous but easily accessible. This accreditation, awarded following assessment by the Business Disability Forum, was the result of collaborative efforts by staff teams and networks. It recognised among other things:

• A proactive and inclusive approach to discussing disability and offering reasonable adjustments during recruitment and onboarding (the process of getting new staff into their new role)

• A clear and practical workplace adjustment guidance document

• Strong staff networks, with clearly defined roles for network chairs

• Regular reviews of internal recruitment data to ensure transparency and fairness

• A comprehensive Workforce Disability Equality Standard (WDES) action plan

• A centralised pathway for implementing workplace adjustments

The trust had produced an action plan as part of the 2024 annual WDES report which followed the areas where improvements were needed. However, as with the WRES report, the specific actions were not reported to the people committee although most were due to be completed by May 2025.

There was a commitment to supporting equality, diversity and inclusion through peer-to-peer networks. The trust had a number of staff network groups to support equality, diversity and inclusion. We met with leaders representing all the current staff networks which were: the ‘disability and long-term health conditions staff network’ and the ‘neurodiversity staff network.’ We also met leaders from the REACH (Race Equality and Cultural Heritage) staff network and UHBe PROUD network representing LGBGTQ+ staff. This was a group of enthusiastic, committed and positive people who had not just lived experiences in the subject but also wanted to be a key part of the work towards an equitable workplace and tackling of discrimination. All these leaders had been involved with their networks in shaping trust processes and policies. They spoke highly of the support they had received from the Chief People Officer who was described as a true ally for equality, diversity and inclusion.

Multiple events had been held to promote recognition of the need for equality and inclusion. These included a week-long event helping to raise awareness for dyspraxia; events to mark the International Day of Persons with a Disabilities event; the neurodiversity celebration week which culminated in the University Hospitals Birmingham NHS Foundation Trust neurodiversity conference in March 2025 with over 180 colleagues attending.

As an organisation with around half of the staff identifying as being from an ethnic minority, there were multiple events around race equality. This included Black History Month with a conference at the trust’s Birmingham Heartlands Hospital; and the screening of a play based on the lived experiences of Black British women and their journey through breast cancer treatment and the inequalities they faced. The REACH network was closely linked to work on the RACE Equality Code (alongside other NHS trusts in the local area); a talent management programme called Working Up Hill to support ethnic minority women and their progression into senior positions; and the reciprocal mentoring programme, colleagues from an ethnic minority background being paired with a senior colleague to share lived experiences.

There was a commitment to the experiences of women, who made up 75% of the organisation. We met the chair of the ‘Women’s Inclusive’ staff network. Her colleagues talked about her hugely valued and pioneering work in many different aspects of women’s health. The work of the network had, for example, been fundamental in developing a masterclass to help managers support women experiencing symptoms of the menopause and developing women’s health clinics. The chair had recently been awarded the Excellence in Female Health Advocacy at the Great British Workplace Wellbeing Awards.

There was a recognition at the trust of the cost to the staff and the organisation from health inequalities. This was part of the NHS England improvement plan for equality, diversity and inclusion (high impact action 4). The actions by the inclusion team were to focus on reducing bullying and increasing civility. It was recognised and understood this could be a common cause of absenteeism and staff leaving, but also mental health problems and long-term sickness. Workforce data showed there was a disproportionate number of staff with protected characteristics who suffered from the possible effects of health inequalities or from bullying- and harassment-linked impacts.

Other more direct workstreams included prevention of uncontrolled diabetes in Black and Asian staff; breast cancer in Black staff; and hypertension, obesity, diabetes in ethnic minority staff who work permanent nights (high compared to those working permanent days). Groups and projects were established or being set up to work on these areas with an objective to reduce sickness, turnover and health inequalities. It was recognised how work was also needed alongside this to engage with the community as a preferred employer of local people.

There remained a gender pay gap at the trust although the gap was narrowing. As required by Equality Act 2010 Regulations 2017, the trust published its retrospective gender pay gap report for 2023/24 (in March 2025) as it had done each year since 2017. The gender pay gap related to reporting the difference between average rates of pay for men and women in an organisation.

The trust reported its data being for all directly employed staff including bank staff. In the most recent report to the board (March 2025 for the financial year 2023/24) the trust data showed there were 75% of staff who were female and 25% male. This ratio had changed only very marginally over the last few years. The smallest percentage of female staff were employed in the highest quartile (highest paid) group with the largest percentage of male staff in the same quartile (highest paid) group. This ratio had remained largely unchanged over the reporting period since 2017. It was attributed to by the trust due to the skew towards males in the consultant workforce (32% female, 68% male).

In 2023/24, the trust had a 11.3% gap between the median hourly pay for men and women. In a basic comparison with UK data, this was better than the national figure for 2023 for all staff (part-time and full-time) of 14.3%. At this trust, women earned on average around 89p for each £1 earned by male colleagues. The median gender pay gap figure is the difference between the hourly pay of the median man and the hourly pay of the median woman. The median for each is the man or woman who is in the middle of a list of hourly pay ordered from highest to lowest paid. In 2022/23 the median gap was 12% and in 2021/22 it was 13.5%, although the trust had not been reporting on this downward trend in its board reports.

When comparing mean average hourly pay, women’s pay was 24.4% lower than male colleagues. The mean gender pay gap figure uses hourly pay of all employees to calculate the difference between the mean hourly pay of men, and the mean hourly pay of women. The average rates of pay were affected by the disproportionate number of staff by gender working in the lower or higher paid bands.

In terms of bonus pay, there was a significant difference in the payment rate between men and women and in the number of people receiving bonuses. For 2023/24, the median bonus pay gap was 47% with 5.8% of men receiving a bonus compared with 1% of women. It was noted by the trust in its board report that this number had moved in the right direction and was down by 20% from 2022/23.

The trust board report of March 2025 on the gender pay gap stated the metrics had all marginally improved, but there had been no significant closing of the gap. The board were informed there would be a benchmarking exercise reported to the next people and culture committee, to enable to trust to see where it compared to other trusts. This was to include learning from other providers on actions where they had made progress in closing the gap. However, although there was a discussion at the May 2025 session of the people and culture committee on the gender pay gap, the benchmarking or learning from others had yet to be reported or considered. There was an action plan included with the board paper, but as with the comments in our previous report, there remained no measures of success described and no strategy to work towards making a material difference to this inequality. However, the issues from the gender pay gap were part of the inclusion strategy for the trust where this might be followed in more detail to make progress.

Although in an improving trajectory in some key areas, there were clinical performance standards not being met and some much below (worse than) local and national averages. There were concerns around financial resilience and finalisation of accounts. There were breaches of regulation in several service groups, including all 3 AE departments due to waiting times, handover delays and departmental crowding. This was due to pressures across the health and social care system but had a detrimental effect on safe patient care. There were delays in diagnostic tests and referral to treatment times, although the latter had consistently improved but with further progress needed. Opening of a new surgical hub and diagnostic facilities were beginning to help reduce waiting times. There was more to do in some cancer waiting times, but each of these had reduced.

We were concerned about the safety of medicines, premises, and some equipment in several services, including maternity, services for children and young people, and surgery.

However, the trust had clear responsibilities, roles, systems of accountability and good governance. These were used to manage and deliver good quality, sustainable care, treatment and support within a difficult climate for health and social care services. Leaders acted on the best information about risk, performance and outcomes.

Our findings:

Headline and key performance data was mixed with some, such as urgent and emergency care data, being worse than the England averages. At the time of our assessment, the most recent published performance data for AE was for March 2025. Ambulance handover delays over 60 minutes were 30.9%, significantly higher and worse therefore than the England average of 9.1%. The number of patients waiting in AE for more than 12 hours for a bed in the hospital was 16.2%. This was higher and significantly worse than the national average of 11.4%. Where it was not significantly worse than others was the percentage of type 1 patients (most serious) waiting 4 hours or less in AE which was 60.3% against the England average of 60.9% and the interim national standard of 73%. These statistics were part of the concern at the highest risk rating on the trust’s corporate risk register indicating an intense focus should be maintained in these areas. We served the trust with breaches of regulation around waiting times, handover delays, and departmental crowding in all 3 AE departments following our 2025 assessments.

From a low baseline after the pandemic, the trust had shown a consistently improved performance against the NHS constitutional standard to see 92% of patients referred to treatment within 18 weeks, although remained behind national and local averages. For February 2025, the trust had seen 51.4% of patients within 18 weeks, against a national average of 59.2% and regional Midlands average of 56.8%. In February, there were 112,137 patients on the trust’s waiting list, which had dropped from over 160,000 at its peak in July 2022. The trust had a target of 60% to achieve by March 2026 and senior leaders believed this to be achievable. In terms of long waits, there were no patients waiting over 78 weeks; 40 patients waiting over 65 weeks in January, which was close to the national average number; and 4,708 patients waiting more than 52 weeks. These long waits for patients represented 4.2% of the waiting list against a national average of 2.6% and the Midlands region of 2.4%. However, this had reduced from around 6% over the previous February 2024. Performance was expected to improve with the opening in early 2025 of the Solihull Hospital elective surgical hub. The new operating theatre unit had 6 new theatres which had a planned procedure rate of 15,000 each year.

There had been an increase in longer waiting times for diagnostic tests. The NHS constitutional interim standard for NHS trusts was for no more than 5% of patients to wait over 6 weeks of a referral for their test (the pre-Covid standard was 2%). In March 2025, 35.7% of patients at the trust had waited more than 6 weeks. This was around twice the national average of 18.4% waiting over 6 weeks. A significant number of patients (14.1%) had been waiting more than 13 weeks. This was also more than twice the national average of 6.1%. Performance was expected to improve with the opening in mid-May 2025 of the new Community Diagnostic Centre located in Chelmsley Wood Shopping Centre. The centre was established to provide X-rays, Computed Tomography (CT) scans, MRI scans, ultrasound and endoscopy services. The service was delivered in collaboration with the local Integrated Care Board (ICB) and a private provider and planned to deliver 65,000 tests each year. It was open from 8am to 8pm, 7 days a week with free parking and easy access. This was the second community facility following the first at Washwood Heath in July 2023 (offering up to 45,000 tests each year).

In outpatients, the trust had seen a significant increase in the numbers of patients referred from around 167,000 in the year 2021/22 to just under 200,000 for the year 2024/25. However, with a focus on reducing the numbers of patients not attending, validating patients, and reducing duplication on bookings, the trust had seen a drop of 10.4% to 9.3% in the ‘did not attend’ data for outpatients since 2022/23 to 2024/25.

There was more to do in some cancer waiting times, but each of these had reduced. In cancer performance, the trust saw and reported results back to 81% of its patients with their diagnosis within 28 days (the faster diagnosis standard) against a national average of 78.9%. This was the highest level for the trust since this data was commenced in April 2021 (when the trust reported 50.1%). The trust treated 89.4% of patients within the 31-day standard (national average 91.4%), which for the trust had stayed relatively constant; and 60.8% within the 62-day standard. This was against a national average of 71.4% but improved from 40.5% in April 2022 and was above the trajectory agreed with the integrated care board.

There were variable results for hospital-onset healthcare associated infections The trust was within statistical expectations for cases of MSSA, MRSA and Pseudomonas aeruginosa. However, for the 3 months to February 2025, it was in the bottom 25% of acute trusts for E. coli bacteraemia, Klebsiella and C. difficile when measured against 100,000 bed days. Where there had been increased incidents of hospital-onset infections, the board had been made aware though the integrated performance reports and advised of actions being taken to address these concerning rises.

There was a recognised risk and concern due to a rise in serious pressure ulcers and tissue damage. This was on the worry list for most of the hospital executives where it affected their patients, and the senior nursing leadership. There had been a rise in pressure ulcers above expectations in September 2024 to January 2025. There had been an issue reported with data since the move in mid-2024 to a new reporting system, but this had been resolved, but not all data was yet fully validated. However, the upward trend had been recognised and a programme of education and training being rolled out. The month of February 2025 already saw a large reduction in incidences although still above expectations.

The electronic systems and processes did not always help staff understand and manage risks. The ability to record suitable indicators for Paediatric Early Warning Scores and sepsis indicators for children and young people on the electronic patient records was still in the development phase. As a result, this area had yet to be audited using electronic data (some was reported manually) to provide assurance in the management of sepsis and deteriorating patient records. We sent the trust a formal letter in 2024 around concerns over management of sepsis following several serious incidents. The trust responded and has established working groups, set up mandatory training for sepsis, and we will continue to monitor progress alongside the trust board and committees.

The latest mortality data was positive. The Standardised Hospital Mortality Indicator (SHMI), last published for the period October 2023 to September 2024, was below the risk-alert level of 100 at 94.07 indicating fewer deaths than would be expected. However, there were 2 mortality triggers in September 2024 where more deaths were observed than expected. This was for fractured neck of femur and Non-Hodgkin’s Lymphoma. A review was underway for the first indicator and a learning review would be undertaken for the second.

There had been an improvement in the quality of governance papers and what they were now reporting to the board and the public for assurance. In our previous report published in March 2024 we said how “the trust must have qualitative assurance of learning and measurable improvement when things go wrong. This includes learning from serious incidents, complaints and avoidable deaths. It is insufficient to present numbers of instances but no themes or learning and evidence of subsequent change. The board must take assurance from improvements and actions which have measures, objectives and aims to demonstrate learning and change is valued, demonstrable and constant.” We served the trust with a Warning Notice around this breach of a regulation.

The trust had met the breach as laid out in the Warning Notice around governance processes. Board papers and those of trust committees now went into detail not just on details of incidents and events, but covered learning and actions needed when themes around patient safety emerged.

The trust board was fully established and settled after a redesign which had begun to take shape at the time of our previous inspection in 2023. Prior to that time, the board had run without the sub-committees operated now, and although as a unitary board, without executive management at the hospital sites. Today the board, under the clear direction and leadership of the Chair who came into post shortly before our previous inspection, had a revised and much improved governance structure with a comprehensive group of sub-committees chaired by non-executive directors.

There was learning from avoidable death and where poor practice had been identified. The topic of ‘learning from death’ was criticised in our previous report for making no reference to any learning and not following the requirements of the 2017 NHS National Quality Board guidance following the events in Mid Staffordshire. However, there had been a thorough review and overhaul of trust procedures for learning from death. Knowing to address the National Quality Board requirements was in the opening sentence in the trust’s clinical quality and patient safety integrated quality report learning from death review for October to December 2024. With the introduction of the role of medical examiner, the trust was now involving and supporting patients’ families following death of a loved one. This also enabled the trust to build a better understanding of how to support patient families or those integrally involved. The trust would always ask the family to be involved in any investigation into the death from the patient safety investigation process.

Deaths were recognised if evidence showed they were potentially avoidable. The report went into detail about specific cases which had been subsequently investigated and what learning had been taken. This was communicated to all those who needed to be made aware through the trust’s new ‘Listen – Learn – Share’ programme, which aimed to make investigations of serious incidents or events more consistent, more transparent and shared safely, without blame attached, and to embed learning.

The learning from death process also now included the establishment of a mortality review committee with a standing agenda to included Coroner’s notices (Regulation 28 Prevention of Future Death reports); review of key statistics; review of deaths of people with a learning disability or a child; deep dives; and monitoring speciality mortality and morbidity reviews. The reports to the board contained sufficient detail to give assurance of learning and improvement where identified.

The trust had audit programmes to examine patient safety and celebrate success. The trust’s new ‘ward accreditation programme’ was a tool designed for wards and departments to work towards quality standards using consistent measures of success, highlighting gaps, and defining goals for next steps. It was being rolled out in 2025. The tool used had been linked to the trust’s strategic goals. Levels of achievement depended on the results of the audits but escalated from fundamental, to enhancing, thriving and finally excellent. Each of these achievements was clearly described in how they were reached. Alongside this was the observations of care project which had been running since 2015. This was to specifically assess standards of communication between staff and patients, celebrate success and make improvements. In January to March 2025, trained staff visited 24 clinical areas. Most observations (51%) were judged as ‘enriching’ which was the second highest category. Just 2% were seen as negatively restrictive or negatively controlling (the 2 lowest categories). In the detailed report of findings was some narrative about observations including some describing genuine warmth often by healthcare assistants towards patients. Negative experiences tended to be around a lack of warmth or empathy towards the patient.

The trust was learning from other key important information including complaints, incidents, adverse events and episodes of avoidable harm (such as falls, hospital-acquired pressure ulcers, incidences of the need to use duty of candour, never events, and hospital-acquired infections). The reports to the trust board and its committees had improved to move away from being driven by quantitative data (in other words, for example, how many complaints they had or how many pressure ulcers they had reported). Reports now recognised where there was learning or themes and trends emerging from this valuable evidence. The trust still reported on the numbers, but added value to the importance of this information by showing it was learning and improving care.

There had been improvement on the time to respond to complaints. This was partially as the result of slightly fewer complaints, as the number was somewhat reduced on average each month in 2024, but moreover a concerted effort to meet expectations around responding to people who had complained. This was the case across all trust sites and divisions in July to September 2024, where the range was 80% to 100% responded to within 65 working days. However, this slipped in October to November 2024 (the latest available data for the June 2025 board papers) from 67% to 100%. The trust received around 250 compliments on average each month (measured over the 14 months of January 2024 to February 2025). We were told all complaint responses were quality assured at various levels before being signed by a hospital director or the CEO.

The pharmacy team felt there were effective governance, management and accountability structures with regular governance meetings. Staff knew what their roles and responsibilities were, and the senior leadership team had oversight. There was an effective governance structure for the safe use of medicines with medicine safety risks reported to the board. However, across some of the services we assessed, medicines were not always stored and managed safely and audits were not picking up some of the issues we found at on a number of sites. This included AE, maternity, services for children and young people, and surgery. Medicine optimisation and pharmacy related risks were included in a risk register. The main identified risk for the safe medicine optimisation service was linked to workforce and the ability to maintain the effective delivery of clinical pharmacy and aseptic services. However, these risks did not seem to be shared with the wider team.

There was some excellent feedback from patient groups, but more to be done in one specific area around privacy, dignity and wellbeing at all hospital sites. In evidence from the most recent Patient-led Assessment of the Care Environment (known as PLACE audits), the trust came out better for 2024 than the national average for NHS trusts in all categories with the exception of privacy, dignity and wellbeing. The trust and each of the 4 hospital sites were above the national average for cleanliness, food, condition, appearance and maintenance, dementia, and disability standards. The exception was a poor response to the standard around privacy, dignity and wellbeing. The national average was 88.2% but the trust scored 83.1% with individual sites in the range of 81.1% to 85%.

Some other survey data from patients also needed further action. In CQC’s patient experience surveys, the trust had many results in the category ‘about the same’ as other trusts. However, the CQC maternity survey published in 2025 had 19 of the 57 questions reported by women as ‘worse than expected’ and 1 as ‘much worse than expected’. In 4 of the questions there was a statistically significant decrease in positive responses over the report from the previous year. In CQC’s urgent and emergency care survey for 2024, published in 2025, the trust was ‘about the same’ for 9 of the 11 questions, but 2 were ‘somewhat worse’. These were patients with negative experiences of waiting times and experience of leaving A&E.

However, the trust told us how improving both maternity and A&E patient experience remained a priority for the organisation. This had also been a theme in CQC’s regular engagement with the trust. The maternity and neonatal improvement programme board, and women's and children's hospital patient experience group, were both active in improving maternity experiences. The NHS friends and family test data provided insight on maternity experiences. Maternity scores from July to December 2024 had steadily increased and since January 2025, they had not dipped below 80% of positive responses. Overall scores in 2025 so far were an improved position in comparison to 2024’s reported experience through the friends and family test.

There was improvement in the board assurance framework (BAF). In our previous report published in March 2024 we said it was difficult to get strategic assurance from the BAF which acted more as a corporate risk register. A revised BAF was now following a clear process with each of the 8 risk entries linked to trust strategy and with a relevant member of the trust board and trust committee being responsible for the entry. The BAF, as required, described the strategic themes the risks were likely to affect. It gave the initial, current and target risk score and how each risk was being mitigated. The type of assurance being used for each control was described against its value to the mitigation. Actions were listed to address perceived or known weaknesses in mitigation. The board received a detailed report from the trust board executive in relation to the risk, which made the BAF leader page less cluttered with detail and easy to follow. It had been reviewed in some depth by the board at the March 2025 meeting and had a more prominent place where it’s value and need for focus was now recognised.

The trust board were given clear performance metrics for staffing and their workforce which had seen some improvements. In our previous report published in March 2024 we said how “the trust must ensure the board are assured about the competence, experience and skills of the workforce to deliver the regulated activities. This includes assurance around mandatory training, competency training, and appraisals of all staff.”

There was a comprehensive report covering workforce data which enabled the board to gain assurance (or otherwise if that was the case) that many of the leading indicators around vacancies, turnover, appraisals, sickness and training were either meeting or close to objectives. There was sufficient detail to see possible emerging or new risks and areas for closer attention. The trust used statistical process control indicators to evaluate data, so there was sufficient clarity in the data to check for unanticipated variances or emerging concerns. The headline data was:

• In March 2025, the vacancy rate for all staff was 6.7%. This was on a falling (improving) trajectory.
• There had been a significant decrease in the number of vacancies for nurses at the trust. In September 2022, the peak was over a 1,000 vacancies for nurses. By January 2025, the trust had a positive variance of 68 posts (whole-time-equivalent), so more than the planned establishment. Turnover for nursing staff was below trust level by at least one percentage point over the year to March 2025. The tide turned in late 2022 when prior to that time, turnover of nursing staff was continually higher than trust turnover.
• Due in large part to the success of the nursing recruitment, agency costs were below the trust target. For March 2025, agency costs were 0.9% of the payroll bill, against a target of 3.7%.
• Time taken to recruit staff was also better than the trust target. In March 2025, recruitment time to hire was 12 days against a target of 21 days.
• In our previous report published in March 2024, we said how “the trust must ensure the people (HR) department has resources and resilience…for supporting fast and effective recruitment.” There was a clear improvement in the metric around recruitment.
• In March 2025, the sickness absence rate was 5.5% (5.9% for the year to date). This was above the planned sickness absence rate of 4%. The predominant reason for sickness was in the category for anxiety, stress, depression or other psychiatric illnesses. This level of sickness had been much the same over the past few years.
• In March 2025, the 12-month rolling turnover for all staff was 8.8%. This was better than the target of 9%. This was on a falling (improving) trajectory.

In our previous report published in March 2024 we said how “the trust must ensure the people (HR) department has the resources and resilience to deal with the issues of culture…The effective function of the people department must concern the board to provide assurance of a protected and resilient workforce.” This remained not entirely resolved according to trust board papers. The trust improvement plan rated this as amber indicating the actions remained open. However, there had been additional recruitment to the HR function albeit within financial constraints. The HR team was focusing on areas considered the most critical for the trust in order to have the most impact.

There was an innovative and committed team looking after digital and informatics services. New appointments had been made to the team to strengthen its work in clinical and nursing information and other new staff coming into post. The trust-designed patient record system had been regularly audited with staff groups and data integrity and was both constantly improving and staff had few complaints, and most said it had made working safer and more efficient. As it was locally designed, it was able to be updated and amended far easily than many ‘off-the-shelf’ patient record systems.

There were processes to manage trust systems in the event of a security incident or system failure. These included ongoing live back-ups, and tools to monitor threats. Wards were being supported with an offline computer made available in case of system failure with the previous 24 hours of patient information available for continuity of care. Wards had sets of instructions about what to do in a computer failure situation and had practice runs for staff.

The trust had external oversight of digital security. In 2022, the trust commissioned an external audit of its cyber security and this was updated in 2024. The report noted the significant progress made in certain areas, but with still some things to tackle. For reasons of security we will not report on these here, but the trust was aware of the areas still to improve and had mitigations around any that were a risk to patient safety.

The trust met it’s requirements to undertake Fit and Proper Person Tests for those in executive or other roles that met the inclusion criteria. The trust chair had approved the submission to NHS England that all legal requirements had been met in the most recent version which was for the year 2024/25. We undertook a review of a sample of the records held by the trust as evidence of its board members and others in the criteria were fit and proper and found these to be all in order and as required.

There were some areas of concern within financial governance relating to delays in finalising accounts and the team’s resilience. In 2024/25, the trust received an income of around £2.6bn and (subject to audit) expected to report a deficit of £31.4m, £14.9m more than its plan. The senior leadership told us the Integrated Care System (ICS) had been able to achieve its financial plan overall, although within that total, the trust itself had the benefit of applying both £43.6m from a prior period adjustment to its own accounts; and support of around £38m from the ICB. Achievement of its cost improvement plan had relied on one-off savings to a greater extent than planned. Management told us the underlying deficit of the trust had been assessed as in the region of £165m at that point.

In the 2024/25 financial year (April 2024 to March 2025), the trust had invested around £68m in infrastructure, including digital, equipment and buildings. It had some Private Finance Initiative (PFI) buildings, mainly at the Queen Elizabeth Hospital Birmingham. Leaders told us they had good working relationships with the buildings’ owner and maintenance provider. The trust had assessed it had a backlog of maintenance on its buildings of around £400m, of which it assessed that around £200m related to the Heritage Building on the Queen Elizabeth Hospital Birmingham site. For the 2025/26 financial year, the trust had been granted supplementary capital of £6m for each site to address backlogs in the maintenance of critical infrastructure.

For 2025/26, the trust had agreed a plan to deliver a financial deficit of £4.2m. To deliver this plan it would need to deliver cost-efficiencies of £129m. The trust leadership team told us at the time of the inspection around £80m of this target had been identified.

There were experienced staff in the finance team. The Chief Financial Officer had been with the trust and its predecessors for more than 25 years and was well-versed in the NHS and trust matters. In addition to the finance portfolio, they were also responsible for the trust infrastructure including digital, informatics, estates and sustainability. The chairs of both the finance and performance and the audit and risk committee were both accountants with senior financial leadership experience in the NHS and public service. They evidenced effective challenge and leadership contribution within the unitary board.

The trust’s external auditor had given an unmodified opinion on the 2023/24 accounts, although stating, “Our financial statement audit opinion will refer to the significant weaknesses in arrangements including noting the continued weakness in respect of the governance and economy, efficiency and effectiveness arrangements which we qualified our opinion in 2022/23 under the Value for Money reporting arrangements and additional weaknesses identified in the current year.”  

The 2023/24 audit of the trust’s accounts had led not only to a 4-month delay in accounts finalisation; but had also drawn attention to weaknesses in the trust’s systems of internal control. Action plans to rectify these weaknesses were being implemented; but in consequence vacancies in a couple of key roles had exposed a lack of resilience in the finance teams responsible for accounts closure. We noted at the time of the assessment that the submission of draft accounts to NHSE had been delayed.

The ICB had agreed the trust’s ambitious financial plans for 2024/25 that relied on achieving significant savings in its workforce costs. It had not managed to achieve the levels of change planned; and had had to take emergency measures to reduce costs.

The trust had implemented a devolved site-based management model in October 2023. It had requested its internal auditor to undertake a review of the operation of governance and accountability arrangements at site level, and senior staff told us the trust had agreed management actions to strengthen assurance and reduce variability in the implementation of governance arrangements.

Looking forward, the trust was aware it faced another challenging year financially, with significant cost improvement required. The CEO had briefed staff and told us that they had confidence that the trust would deliver its agreed plans for 2025/26.

The trust understood its duty to collaborate and work in partnership, so services worked seamlessly for people. Staff shared information and learning with partners and collaborated for improvement.

Our findings:

The trust understood its duty to collaborate with stakeholders and work in partnership and strategically with key organisations. This included both providers and commissioners of health and social care and the local authority, but also the organisation behind the PFI contract for the Queen Elizabeth Hospital Birmingham and its services. There was also partnership working with key stakeholders around the environment, net-zero carbon emissions and sustainability.

The trust’s strategy was mirrored with that of key stakeholders. One of the significant relationships for the trust was with the ICB for the Birmingham and Solihull Integrated Care System (ICS). The ICB’s key strategy around population health and wellbeing (Integrated Care Strategy) was published in 2023. The most recent iteration of the joint forward plan for the region contained the 4 key strategies for the NHS, namely:

• Improving outcomes in population health and healthcare

• Tackling inequalities in outcomes, experience and access

• Enhancing productivity and value for money

• Helping the NHS support broader social and economic development

Part of the focus from the ICB in collaboration with the trust was around integration. The local teams in the trust’s 4 acute hospitals were working closely with the ICB’s ‘place committees’, and ‘community integrators’ – building local teams to work together to improve patient experience, use of resources, and NHS performance. The senior teams in the hospitals were also building relationships with GPs and others in the health and social care system, as they recognised the importance of this for joined-up care for their patients. There was also the opportunity for sharing learning from one another and understanding each other’s challenges.

The trust’s CEO was a partner member of the ICB representing acute hospital trusts and the Chair was a member of the ICS Partnership. Trust staff attended the weekly system oversight group to monitor progress against the above national priorities. There was important cooperation with the ICS’s people committee to understand and align workforce and people objectives and strategies. The trust also worked with the public health team at the ICS. This was leading to a co-production of a health inequalities strategy which would be population-based and focus on diversity and equity. However, the trust recognised there was more to do around health inequalities and the strategic objective needed to have more focus and measures to see progress clearly.

There was some inter-organisational working, but more to be done to look at joined up working and patient pathways. Some of this was carried out at service level (such as the emergency department leadership meeting with the mental health trust and the ambulance service) but there was scope for trust board committees to meet for improved shared learning and opportunities. This was an area that would need time and commitment from already exceptionally busy staff but was recognised as a potential investment for the future.

The trust performance was scrutinised by both the Solihull and Birmingham Health and Social Care ‘overview and scrutiny committees.’ Both the committees reported on their joint working with the trust through the annual quality account. Both recognised the content of the previous CQC report into the trust and recognised the need for scrutiny in the past 18 months as the trust strived to improve.

The trust worked with multiple partners across health and social care and also education and training, research and clinical trials. It also worked with private companies in projects and education. The trust worked closely with its local specialist and acute services to support improved waiting times for patients.

In pharmacy services, there was good collaboration and partnership working to ensure information was shared externally with partners. The pharmacy team worked closely with, for example, the Birmingham and Solihull community services, being part of the pharmacy operational regional meetings, and the regional integrated medicines optimisation committee to share ideas and learn from one another.

The trust worked with patient groups and representatives to ensure they had feedback and were able to address areas of concern or recognise achievement highlighted by patients and partners. Groups included the Patient and Public Involvement Forums with 55 members and the Youth Voice Council who represented young people from 16 to 24 years of age who were both patients and transitioning to adult services. The youth council had 15 members. There was a Carers Support Service – who participated in multiple working groups representing those who were active carers for family and friends. The trust also had a group of dedicated volunteers at each hospital site, many of whom we met and spoke with. They were clearly valued and a great support for staff and patients.

The trust had encouraged staff to establish support groups for one another. One such group was the Parents and Carers of Neurodiverse Children and Young Adults supported by the research, development and inclusion team. Led by 2 senior research nurses with their own lived experience, the group offered support to families and carers around diagnosis pathways, the education system, managing stress, and building resilience. It acted as a safe space for listening and sharing. One of the members said: “The group is invaluable to staff caring for neurodivergent children, and it really helps supporting each other. All the members are amazing, understanding and inspirational in their own ways and it’s nice to know we are not alone.”

In terms of medical education, the trust was the principal teaching hospital for University of Birmingham where partnership working was developing innovative medical education programmes and clinical research.

University Hospitals Birmingham NHS Foundation Trust was the primary receiving hospital for military personnel or entitled personnel working for defence who were injured or taken ill overseas. The Royal Centre for Defence Medicine (RCDM), whose HQ was located at Queen Elizabeth Hospital Birmingham, worked in partnership the trust to support the patient pathway. The trust supported around 70% of the RCDM personnel with around approximately 300 fulfilling a clinical role at the trust.

The trust had an informative website with access to a library of resources and live information. The website could be translated into any language.

The trust focused on continuous learning, innovation and improvement across the organisation. Staff and leaders had a good understanding of how to make improvements happen. People using the service were involved in the development and evaluation of improvement and innovation initiatives. There were processes to ensure learning happened when things went wrong. Staff were supported to develop their skills and were constantly encouraged to contribute to innovation. Staff and leaders were engaged with research, development and innovation.

Our findings:

Leaders demonstrated a good understanding of how to make improvements happen. There had been improvement at all services we assessed during this process in 2025 and some rated outstanding on their first assessment. With two exceptions, all services we assessed had either improved (with none now rated as inadequate). Good Hope Hospital’s medical care had improved from inadequate for well-led to good, as had the same hospital’s urgent and emergency care service (AE). The Queen Elizabeth Hospital Birmingham’s urgent and emergency care service remained requires improvement, but safe had improved from inadequate to requires improvement. Surgery services, which had not been assessed since 2019 dropped from good to requires improvement with safe and responsive needing concerns addressing. Solihull Hospital’s outpatients department was rated as outstanding overall. Runcorn Road Dialysis Unit was rated outstanding overall in its first assessment. Castle Vale Renal Unit was rated good overall and outstanding for the caring key question. Services for children and young people at Good Hope and Birmingham Heartlands Hospitals were both rated for the first time as good overall. However, Birmingham Heartlands Hospital’s maternity services’ safe rating remained inadequate, but the service overall had improved to requires improvement from inadequate. Many executives highlighted maternity as a quality area needing improvement.

Staff we met at these services said the culture of improvement was well embedded and they felt no barriers to making improvements and this was fully encouraged, although well-managed to ensure trust objectives were still achieved.

There was an active research, development and innovation (RDI) team involved in and having completed many projects over the years. The RDI department had a 5-year strategy covering 2025 to 2030. This was linked to the trust’s strategy around ‘Building Healthier Lives’ with 5 key objectives linked to the trust’s 5 themes described in our Shared direction and culture section above. The department wanted to ensure:

• Every patient could participate in RDI
• The team had a culture of continuous learning and development
• The trust was a centre for pioneering research and innovation
• Research reflected the demographics of the population
• All RDI programmes were financially and environmentally sustainable

University Hospitals Birmingham NHS Foundation Trust supported a wide-ranging research and development infrastructure with a large level of income from its commercial work. It hosted several bodies within the National Institute for Health and Care Research (NIHR). The team provided support to other local research alliances including for genomic medicine and cancer.

The trust board received the annual review of research and development for 2023/24 at its June 2024 meeting. The report described how the Department of Health and Social Care and NIHR recognised the challenges faced in supporting RDI after the COVID-19 pandemic although recognising it remained valued and supported. The report to the board highlighted the achievements at the trust in the year and these included:

• Vaccine studies following the success of the COVID-19 trials expanded, including the well reported and unique colorectal cancer vaccine trial. The first patient had been recruited into the trial who featured in a documentary and in national news media.
• Cell, gene and immunotherapy studies with 30 studies being undertaken of the 192 nationally registered.
• Working within NHS England priorities which involved cancer research studies, some in exceedingly rare and highly aggressive cancers, and work in radiotherapy around rare brain tumours.

The RDI team were working on over 1,000 active studies, had over 400 consultants and allied health professionals as principal investigators, and recruited between April 2024 and January 2025, over 6,000 patients. Each hospital site was connected to the work. The work of the group was presented in a special session by the CEO at one of the ‘CEO connected’ events.

Patient experience was sought and 99% of those who responded to a survey said they were always treated with courtesy and respect by research staff; 96% of patients felt research staff valued them for taking part; and 90% would agree to taking part again. There was also a focus on equity, equality, diversity and inclusion and the trust, along with partners, piloted a Race Equality Framework toolkit co-designed with patients. This was to help organisations assess themselves in terms of health equity in RDI. It had specific reference to certain heritage groups from Black African, Asian or Caribbean backgrounds where there were known inequalities in healthcare. The report described in a good level of detail what work had been undertaken, what was planned and what was ongoing. However, what it lacked was more about the impact and positive outcomes for patients that had been seen or were anticipated.

As our section on Governance, management and sustainability above reports, the trust was demonstrating learning from adverse events or avoidable harm. This included an improved process around learning from avoidable death, learning from complaints or serious incidents, and learning from avoidable harm. Our previous report criticised the governance papers for focusing on quantitative data such as how many of each event had occurred rather than what was going to happen to resolve these failings. This had improved in the latest papers, although there remained a gap in assuring the board that actions taken, and changes and improvements had led to embedded and change and made a meaningful contribution to better patient care.

There were projects for improvements which would positively impact patient care. These included a patient engagement project to understand why patients had missed appointments with a view to reducing these incidences. There was also patient engagement around patient-initiated follow-up; follow-up reduction; remote consultation; and digital exclusion. Some of this work was already showing the improvements expected. For example, outpatient lists had fewer patients with the rollout of the NHS DrDoctor App. Over 100,000 patients were using the App and better communication with patients had led to around 14,000 appointments being cancelled as no longer needed and therefore offered to other patients.

The trust hosted a research showcase in May 2025 at the Queen Elizabeth Hospital Birmingham. This was in celebration of International Clinical Trails Day 2025. There were events at the other hospital sites with staff on hand to talk about their work, and interactive displays and presentations. At the Queen Elizabeth Hospital Birmingham, we visited the vaccine trials stand, met the liver research team, and the research in emergency and acute care team (or REACT) and found dedicated, enthusiastic and committed staff.

There was a common theme from our many focus groups with staff speaking about the excellent and valued opportunities to learn, improve and develop in the organisation. Staff in the pharmacy team said the senior leadership team encouraged innovation and progression with staff being given study leave for learning and development. The 2024 NHS Staff Survey supported this with the following indicators all of which were improved over the past 4 years since these questions started. However, some remained below the peer group:

• Q24b: 54% of staff said there were opportunities for them to develop their career. This was just slightly above the peer group average for 2024 and the best result in the 4 years since the indicator had been added to the survey in 2021 (up 5% in 4 years).
• Q24c: 68% of staff said they had opportunities to improve their knowledge and skills. This was slightly below the peer group average for 2024 at 69% but the best result in the in the 4 years since the indicator had been added to the survey in 2021 (up 6% in 4 years).
• Q24d: 53% of staff said they felt supported to develop their potential. This was below the peer group average for 2024 at 56% but the best result in the in the 4 years since the indicator had been added to the survey in 2021 (up 7% in 4 years).
• Q24e: 58% of staff said they were able to access the right learning and development opportunities when they needed to. This was slightly below the peer group average for 2024 at 59% but the best result in the in the 4 years since the indicator had been added to the survey in 2021 (up 6% in 4 years).

Pharmacy staff said there was a positive culture around continued improvements within the department with leadership being open to ideas. Clinical staff were given the opportunity to undertake the clinical diploma and the independent prescribing course. Staff in the aseptic team were encouraged to take the science manufacturing technicians course.

The trust board were updated on training opportunities offered to staff. These included one of the largest apprenticeship programmes supporting the long-term nursing workforce strategy. It had 650 trainee nursing associates in partnership with local universities; 81 registered nurse degree apprenticeships on a top-up programme; and 22 operating department practitioner degree apprenticeships. A new registered midwifery degree apprenticeship, developed with the University of Birmingham, was launched in September 2024. The trust was also collaborating with local universities to accredit some in-house training up to master’s degree level. This included hepatology, plastics and reconstructive surgery, critical care, minor injury, trauma, and neurology and critical care outreach.

There were education teams focused on learning right across staff from induction through to ongoing development. The programmes were extensive and intended predominantly for staff in clinical practice and management roles. The School of Nursing, AHPs and Midwifery programme included a new starter day, study days for particular roles such as senior staff nurses and sisters/nurse in charge. There were also study days for senior leadership focusing on civility, managing staff and governance. Staff were offered training as part of the mental health awareness programme. There was a 2-day package for healthcare support workers; a harm prevention course; sessions for staff in outpatients; health and wellbeing; and health care of older people. Specialist courses included a wide range of subjects, such as acute medicine; vascular care; surgical assessment; post-operative care; burns and plastics; trauma and orthopaedic services, and many others. The trust had accredited courses in neuroscience care, plastics care, and trauma care. Others were under development.

There was a full education programme for nursing associates as we reported above. The trust had the highest number of staff in England on this course which was recognised as a good route to enter nursing training. The trust also had learner-led programmes particularly aimed at student nurses. This was set up to enable students to take the lead in certain parts of the role they were being trained for on certain wards to give them confidence and support mentoring and coaching. It also gave early indication of students who might be struggling and need more support. We met 2 students at a board meeting who presented their really positive experience of this to the trust board members with confidence. They talked about how they had seen real improvements in their skills through being given the chance to lead. There had been a notable and likely connected rise in students taking up their permanent posts with the trust.

The trust offered a wide range of training for foundation doctors following the completion of their medical degree. The Foundation Programme, run by the trust’s consultants, was a 2-year programme with training rotations offered at the Queen Elizabeth Hospital Birmingham, Good Hope Hospital, and Birmingham Heartlands Hospital. New doctors were offered rotations in a number of specialties including work in the community, acute medicine and surgery. Post-graduate medical education teams were on hand to provide support and guidance. Trainees were able to link with others who were further into their programme. Foundation Year (FY) 1 trainees were given a BUDI (Bridging Undergraduate to Doctor Initiative) who was an FY2 trainee, and there were BUDI families to have wider support and interaction. We have reported in our section on Shared direction and culture of the support available to resident doctors and this extended to all doctors in training. The trust followed national study leave policies and trainee doctors were able to have a 5-day ‘taster’ of a specialty to give them a rounded view of medical care.

There had been significant improvement in the morale, confidence and support to resident and trainee doctors. In our previous report we wrote about some serious concerns with bullying and intimidation. Those doctors we met during our assessments remarked on how most of them felt this had turned around to a positive and supportive environment. Most of them put this down to the new devolved model of working and having a medical leader on site. Some doctors were still not feeling entirely safe, but the senior medical leadership were open and visible, and appointed for their focus on culture and safety for staff. The changes had led to more applications for consultant posts and some high-calibre people joining the trust. There had been a rise in the number of foundation year 3 trainee doctors wanting to stay at the trust with significant improvements to training.

The education team spoke of the excellent support of senior executives for their programme, specifically the chief nurse, chief medical officer and chief of people.

In terms of staff being given the opportunity to discuss their role, their performance and future opportunities at an annual appraisal of their work, the 2024 NHS Staff Survey showed improvements in this area. In 2024, 82% of staff said they had an appraisal (peer group average 85%) which was up from 75% in 2021 (when the measure started). However, only 25% of staff said this helped them improve how they did their job. Although this was an area of concern across the NHS as this was almost the same as the peer group average of 26%. However, it was up from 2021 (when the measure started) by 7%. The question around the appraisal helping with clear objectives for staff was steadily improving as was the recognition of the work of staff being valued by the organisation.

In terms of delivering appraisal, the trust had marginally improved the number of doctors (from 2,637 employed) who had undergone the mandatory annual appraisal from 83% in April 2024 to 84% in April 2025 but had again missed the trust target of 90%. Achieving 90% was an action for 2024 which had not been met and was an action again for 2025. There were tasks to support those doctors who had not completed their appraisal and the trust reported it was on track to reach the 90% objective.

For staff overall, the appraisal rate for May 2025 was reported as 83%. This was below the trust target of 90% but had improved from 76% in October 2024. The target had been reached by staff at Solihull Hospital (91%) but all other sites or staff groups were behind the target. It was recognised by the board as a key performance indicator needing to be achieved and would be raised with staff to bring it up to an acceptable level.

For mandatory training, the trust had a set of mixed results when looked at by subject. Although some new ones had recently been added. However, it had achieved 89.9% in January 2025 (the latest available data from the May 2025 people report) and was therefore almost meeting the 90% target. Some subjects which were required by all staff, such as infection prevention and control level 1, were at 95% but dropped to just 70% for clinical staff requiring level 2. Inclusion and diversity level 1 had been undertaken by 99% of staff. In the year to January 2025, the trust was up at around 93% each month, but the drop in January had come as more mandatory subjects were added.

The trust understood any negative impact of its activities on the environment and strived to make a positive contribution in reducing it and support people to do the same.

Our findings:

Staff and leaders understood the threat from climate change and were taking action to reduce the impact on the environment of healthcare activity. The trust and its staff had a genuine commitment to reduce the significant threat to the health of people who used services, their colleagues, and the wider population.

In October 2020, the NHS became the world’s first health service to commit to reaching a carbon footprint of net zero by 2040 for the emissions it controlled directly. The ambition is to reach an 80% reduction by 2028 to 2032. For those things the NHS can influence rather than directly control, the target is net zero by 2045 (80% is the ambition by 2036 to 2039). This was embedded into legislation in July 2022. The NHS Long Term Plan included commitments related to health and the environment, including around climate change, reduction in use of plastics, particularly single use, improving air quality, and minimising waste and water use.

To deliver this ambition, NHS trusts were required to focus on 2 primary actions:

• Enable and produce direct interventions to reduce waste and carbon dioxide emissions within estates and facilities, travel and transport, supply chain and medicines.

• Take actions to improve levels of waste and emissions, accelerate sustainable models of care (such as care closer to or at home), workforce impacts, networks and leadership commitments, and funding and finance mechanisms.

As required by NHS England, the trust had developed its 2022-2025 Green Plan. The Green Plan was required to include aims, objectives and delivery plans for carbon reduction and sustainability. The plan was approved, as required, by the trust board and a non-executive director had been appointed to oversee environmental sustainability for the board. It was due to be refreshed in 2025 for a further 3 years and was expected to come back to the trust board in July. The trust board infrastructure committee was otherwise responsible for the detail and oversight of the Green Plan and environmental sustainability.

The trust had set 6 priority sustainability objectives set around 6 specific areas of focus. These were:

• Estates, assets and utilities

• Travel and transport

• Waste

• Goods and supplies

• Green spaces and biodiversity

• Sustainable clinical pathways

There was progress in a number of key areas. NHS England had provided the trust with measures of carbon emission figures covering the 5 years from 2019/20 to 2023/24. This excluded business travel and fleet data as this had not been gathered for the last 2 years. The trust was reported as having achieved reductions in 4 of the 5 categories from year 1 to year 5. Namely in inhalers (for asthma-associated treatment), water, anaesthetic gases, and building energy. There was a reduction in waste but just for the year 2023/24 when compared with 2022/23, but otherwise waste had risen since 2019/20 and had not yet returned to that low point having more than doubled in the year 2020/21 compared with the first year of the report.

Within the 6 areas of focus were 9 themes for the trust. The action plan associated with these themes showed some good progress for many, although others had more to achieve. The team we met to discuss the subject of environmental sustainability showed commitment and enthusiasm. The trust had a head of sustainability and had taken the lead in procurement for the integrated care system with a focus on efficiency and reduction of carbon emissions, recognising the wider impact and wanting to drive the agenda.

The trust had made inroads in securing funding from government grants for environmental schemes. This included the geothermal heat scheme which was a £15m capital scheme for which the trust would contribute 10%. The trust was allocated a share of around £11.4m of the NHS Public Sector Decarbonisation Scheme (PSDS) Phase 3C Update for a new energy centre at Solihull Hospital. The PSDS was a national programme to drive the reduction in admissions from public sector buildings by 75% by 2037. Previous awards had been made under Phase 1 and Phase 3a. Staff were already prepared to submit applications for the Phase 4 scheme. There had been a number of decarbonisation schemes at many sites, including introduction of solar panels, updating insulation materials, and moving to the use of air-source heat pumps. At Birmingham Heartlands Hospital the steam-fired heat system had been replaced with a new heat-pump based system. The second phase of loft-cavity wall insulation had been completed and the trust was working on the installation of more solar panels. New roof insulation had been installed at one of the older buildings at the Queen Elizabeth Hospital Birmingham along with LED lighting and new networks of pipes. These schemes, along with several others were expected to save around 3,000 tonnes of CO2e each year.

The trust had been awarded a grant with the University of Birmingham from the NIHR of £2.35m for research into ‘green’ operating theatres, with a focus on reusable drapes and gowns, anaesthetic gases, and recycling and reuse.

There were a number of actions already showing results. This included:

• Environmental sustainability champions among staff – the trust had around 80 volunteers already in the team who met each month with the head of sustainability.

• Triaging of thrombectomy in stroke patients using artificial intelligence. This eliminated unnecessary hospital transfers and patients being treated in the right place.

• Working closely with a bus company to promote increased use of regular bus transport. The target set in 2022 of 5% of staff using buses was achieved and a new target of 10% was set. Alongside this, all new staff were provided with a 4-week free bus pass and there were other offers available for staff and patients to have free or discounted bus fares.

• A digital food ordering trial to reduce waste was successful at one of the hospital sites and the trust was looking to pilot this at other sites.

• The trust had taken delivery of its first 18 tonne electric HGV truck for site deliveries. There was a focus on moving towards electric or hybrid power for all trust vehicles.

• The trust had a centralised distribution warehouse in Aston and this streamlined deliveries and reduced carbon emissions from multiple journeys from multiple sites.

Staff were involved with the Greener Nursing Challenge, encouraging nurses to promote sustainability in healthcare, and the emergency departments had started on the Royal College of Emergency Medicine’s Green ED initiative.

The trust had a target for the reduction of the prescribing of antimicrobials. Data showed the use had increased significantly during the period of the pandemic and taken a long time to reduce. However, the trust prescribing was now below the 2019 original baseline and was moving towards the new target for 2024-2029. January 2025’s data showed the trust above the target of just over 2,600 doses given every day to around 2,700 on average. There was a push towards the use of oral antibiotics rather than those given through intravenous doses. The pharmacy team had determined that 30% of patients they evaluated could have been on oral rather than IV antibiotics. There were a number of clear benefits from this change including a reduction in CO2. There were other initiatives within pharmacy including changing from the use of plastic to paper bags for discharge medicines and bins for bottles in all sites to support recycling.

In other areas of focus, the trust had achieved substantial savings in anaesthetic gas emissions. The use of desflurane (a very harmful greenhouse gas) had been reduced to its lowest levels. The utilisation of nitrous oxide (N2O) was consistently decreasing with plans to go further by replacing the manifold systems with cylinders.

There had been a focus and improvement in waste management. All sites had mixed recycling facilities. The trust was committed to the NHS Clinical Waste Strategy. This included a strategy for 2024/25 to have a 60:20:20 split in waste segregation. Offensive waste being 60%, 20% for both incineration and infection waste. However, none of the trust documents provided evidence of this being achieved, or progress towards this goal.

There was progress and a financial benefit from saving costs from computers being left on for extended periods when not in use. All non-essential computers were shut down at a certain time in the evening unless the user overrode the warning. This had saved substantial costs of electricity. Any computers found not being used for over 6 weeks were repurposed.