FOUNDATION TRUST BOARD OF DIRECTORS – 30 SEPTEMBER 2015 ANNUAL REPORT ON MEDICAL APPRAISAL

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Situation: The Board of Directors appointed the Medical Director as the Responsible Officer for revalidation in 2009 and receives an Annual Report on Medical Appraisal. The FT Chairman received a letter dated 5 June 2014 signed jointly by the Chief Executives of the GMC, the CQC, Monitor and the NHS Trust Development Authority on effective governance to support medical revalidation. This letter draws the attention of the Board of Directors to its statutory responsibilities to ensure all doctors keep up to date and remain fit to practice and links closely with the Annual Report on Medical Appraisal. Background: • • • • •

All doctors have had an appraisal completed for the 14/15 appraisal year. All doctors with a revalidation date in the appraisal year have been revalidated by the GMC. The Trust continues to work closely with the GMC in relation to concerns about doctors. Appraiser training, refresher training and appointment of Trust approved appraisers is ongoing. The Trust continues to fund the e-appraisal system from Allocate.

Assessment: This report forms part of the evidence required by NHS England as part of the Annual Organisation Audit (AOA) presented to the Quality and governance committee August 2015. This report is for the appraisal period 1st April 2014 to 31st March 2015. The Annual Report on Medical Appraisal is produced as a stand-alone document and is structured in the format identified in the Framework of Quality Assurance (FQA) published by NHS England. Recommendations: The Board of Directors is asked to consider and endorse NHFT’s Annual Report on Medical Appraisal. Also receive the joint correspondence from the Chief Executives of the GMC, CQC, Monitor and the NHS Trust Development Authority on effective governance to support medical revalidation, noting the statutory responsibilities for the Board. Governance table: Paper sponsored by Dr Alex O’Neill-Kerr, Medical Director Paper authored by Dr Alex O’Neill-Kerr, Medical Director Date submitted 24th September 2015 ORR considerations and/or FOMI implications Equality considerations

A Framework of Quality Assurance for Responsible Officers and Revalidation 8th Annual Report on Medical Appraisal Dr Alex O’Neill-Kerr, Medical Director August 2015

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1.

Executive summary • • • • •

2.

All doctors have had an appraisal completed for the 14/15 appraisal year. All doctors with a revalidation date in the appraisal year have been revalidated by the GMC. The Trust continues to work closely with the GMC in relation to concerns about doctors. Appraiser training, refresher training and appointment of Trust approved appraisers is ongoing. The Trust continues to fund the e-appraisal system from Allocate.

Purpose of the Paper

This report forms part of the evidence required by NHS England as part of the Annual Organisation Audit (AOA) presented to the Quality and governance committee August 2015. This report is for the appraisal period 1st April 2014 to 31st March 2015. The Annual Report on Medical Appraisal is produced as a stand-alone document and is structured in the format identified in the Framework of Quality Assurance (FQA) published by NHS England.

3.

Background

The Trust Board received the first Annual Report on appraisal and revalidation in July 2009. The report detailed the progress towards revalidation, using the Assuring the Quality of Medical Appraisal for Revalidation tool (AQMAR); which was replaced by the Organisational Readiness Self Assessment tool (ORSA). From April 2014 the Revalidation Support Team handed over the control of revalidation to NHS England and the Annual Organisation Audit (AOA) has replaced the ORSA. Medical Staffing keeps a database of all Trust doctors and ensures that they all have a Licence to Practice. The database is checked weekly to identify any doctors who require renewal within six weeks and are monitored to ensure the Licence to Practice is valid. The list of doctors with a prescribed connection to the Trust is maintained on a database (GMC Connect) set up by the GMC. The database identifies the revalidation dates of all doctors, and if doctors move to another organisation the revalidation date migrates with them. At the time of this report (August 2015) there 2

are 71 doctors with a prescribed connection to the Trust on GMC Connect (83 in 2014). Revalidation and recertification applies to medical staff and dentists are not included in this report as they are not required to revalidate.

4.

Governance Arrangements

The Medical Director was appointed the Responsible Officer (RO) by the Board in 2009 and has overall responsibility for medical appraisal in the Trust. The Deputy Medical Director for Children’s Services has been appointed as the deputy to the Responsible Officer.

a.

Policy and Guidance

The Trust set up a process to train and appoint appraisers from the consultant and SAS doctors’ workforce in open competition. The FQA toolkit requires a formal structure for appraiser training and requires evidence that appraisers have undergone appropriate training and have demonstrated the skills and competencies required for enhanced appraisal. This is maintained through appraisal feedback forms. Trust guidance has been produced based on the MAG, this identifies a clear structure for appraisal. The Revalidation Support Team has produced a guidance document for appraisal The Medical Appraisal Guide (MAG) which is available on the NHS England website.

5. a.

Medical Appraisal Appraisal and Revalidation Performance Data

Detailed activity levels of appraisal outputs in individual departments:

b.

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Number of doctors and dentists 91

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Number of completed appraisals 67

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Number of doctors in remediation and disciplinary processes - Nil

Appraisers

Following training and successful demonstration of skills the Trust has appointed 30 Trust approved appraisers (3 of these are dentists, four are Specialty doctors). All consultants, SAS and Trust locum doctors were contacted by the e-appraisal system informing them of the date of their appraisal and the name of their Appraiser for 2014/15. 3

c.

Quality Assurance

Quality assurance of the appraisal process The Medical Appraisal Guide (MAG) explains the appraisal processes, including the inputs to appraisal, the appraisal discussion and the outputs from appraisal. The Responsible Officer has submitted the Audit Or Appraisal (2014/15) at the end of March 2014 using the NHS England portal. The output of the AOA was presented to Quality and Governance Committee in August 2015. The Responsible Officer and deputy have undergone training in revalidation as required by NHS England and have completed and passed Modules 4, 5 and 6 of the Responsible Officers Training in 2013. They have continued to attend top up training in 2014/15 Each consultant has a Personal Development Budget of £1000 per annum, which can be rolled over into the following financial year. All consultants are entitled to 10 days study leave per year. The study leave budget is used to support the training needs identified in the PDP. The Responsible Officer has completed an annual audit of the use of study leave which is included in this Report. A Personal Development Plan (PDP) is agreed annually as part of the appraisal process. The PDP is agreed at the appraisal between the appraiser and appraisee and signed off as one of the outputs of the appraisal process. The PDP is available to the RO on the Trust e-appraisal system. An anonymised sample audit of PDP’s has been completed and is included in this report. Audit The RO conducted the following audits for the 2014/15 appraisal year: • • •

annual anonymised sample audit of the appraisal documentation – completed annual audit of appraisee feedback forms – completed audit of appraiser training feedback - completed

Hospitality Register Review The RO has reviewed the Hospitality Register kept by the Trust Board Secretary. The review did not identify any inappropriate hospitality and the submissions were in keeping with the policy. Annual anonymised sample audit of the appraisal documentation A random sample of ten appraisal records were audited, these included consultants and SAS doctors from a range of specialities. All of the forms were typed, all of the forms covered the domains of Good Medical Practice and all of the appraisal summary forms had been signed by both the appraiser and appraisee and dated. 4

Annual audit of appraisee feedback forms The audit analysed 38 feedback forms were completed in 14/15. No appraiser was rated borderline or poor in any domain. 100% of appraisees would choose the same appraiser again. All appraisees felt they had sufficient time for the appraisal decisions. All appraisees agreed that the appraisal process was satisfactory or above. Appraisal training All successful candidates appointed as Trust approved appraisers are subject to a six month probation (based on appraisee feedback and audit of their appraisal paperwork) and are reviewed annually by the RO. All appraisees rated the appraisers as satisfactory, good or very good in all 11 domains. On average 79% of appraisers were rated very good in all domains. An audit of pre and post appraisal training scores was completed by Mark Carroll (FY2). The audit recommended: • • •

Equality and diversity training to be included in the training day. The GMC Good Medical Practice document should be given to all attendees as part of the appraisal training pack. Areas identified in the feedback to be included in the slide pack.

The recommendations will be incorporated into the training day in November 2015 and the feedback forms will be re-audited. The Trust has completed and submitted the AOA and has audited missed appraisals for 2014/15. The Trust uses the appraisal documentation provided in the ‘eappraisal’ platform which complies with the standards set out in AOA. An anonymised sample audit of the appraisal documentation has been completed to ensure the quality of appraisal. All the documentation required for the appraisal is uploaded to the Trust e-appraisal system; the appraisal paperwork is completed and stored electronically. The Trust has funded appraiser training as recommended in the last Annual Report. The Trust has funded an Administrator to manage Job Plans and support the RO in the revalidation process. The RO chairs a regular appraiser peer group meeting which supports Trust Appraisers and provides top-up training. The RO provided appraiser and top up training for appraisers in September 2015. 3 new and 9 approved appraisers completed the one day training programme. All attendees completed a pre and post assessment exercise as detailed in the Framework of Assuring Quality (FQA).

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d.

Clinical Governance

Mandatory Training Mandatory training is an aspect of doctor’s ongoing training needs that has now been included in the appraisal. If mandatory training has not been completed this is challenged at the appraisal and reflected on in the appraisal and an action plan linked to the personal development plan documented and reviewed at the following year’s appraisal. IT support for appraisal An electronic appraisal system was purchased from Allocate in 2010; this provides an electronic e-appraisal system and was available during the 2014/15 appraisal year. The electronic system allows the RO to have access to all the appraisal paperwork necessary for revalidation as well as the data needed to audit the appraisal process as recommended by NHS England (FQA). Monitoring The GMC has appointed an Employer Liaison Advisor (ELA) for the Trust; the RO meets with the ELA on a regular basis to discuss issues which may impact on a doctor’s revalidation. A new ELA is due to start in December 2015. Governance, SI’s and Complaints Appraisee’s request data on SI’s and complaints relating to them by e-mail. This forms part of the evidence uploaded to the appraisal folder and is included in the appraisal discussion and where appropriate, reflective practice.

6.

Revalidation Recommendations

Revalidation Recommendations The RO has recommended 31 doctors to the GMC for revalidation. All of the doctors recommended for revalidation were revalidated by the GMC. Non engagement The RO keeps a record of doctors who are not engaging in the appraisal process, the Trust has a local process to monitor non engagement and this is discussed with the GMC Relationship Manager. The GMC can intervene in situations of non engagement by bringing the revalidation date forward and in extreme cases by removing the doctor’s licence to practice.

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To date no doctors have been identified as not engaging. Deferral requests The revalidation date can be deferred by the GMC at the request of the RO in situations where the doctor is off due to long term sickness or exclusion and there is insufficient evidence to make a recommendation. The RO has made one deferral request for the appraisal year 2014/15, which was due to long term sickness. The GMC supported the deferral. Appraisal (Dentists and Doctors) Medical staffing undertook an exercise earlier this year to re-allocate all appraisees in order that there is a fair and equal distribution amongst appraisers due to staff (appraisers) leaving the Trust. The Trust has a total of 91 doctors and dentists, all of whom are eligible for appraisal and revalidation. Missed appraisals are those which were due within the appraisal year but not performed or which were performed outside the 9 to 15 month window for ‘annual appraisal.’ Incomplete appraisals are those where, for example the appraisal discussion was not completed or where the personal development plan or appraisal summary have not been signed off within 28 days of the appraisal meeting. Out of the 91 doctors and dentists, 67 had complete appraisals, 14 had missed appraisals and 10 are recorded as being incomplete due to the appraisal being signed off after the 28 day cut off period. Having said this, all appraisals have now been signed off.

7.

Responding to Concerns and Remediation

Referrals to the GMC 4 Consultants have been discussed with the GMC Employer Liaison Advisor; 2 Consultants were discussed generally and 2 Consultants discussed were regarding revalidation deferral.

8.

Risk

The Trust is required to provide evidence of independent external quality assurance of appraisals once in every five year revalidation cycle. The RO recommended in the last RO report that internal audit provide independent verification of the Trust’s revalidation process using the guidance issued by NHS England ‘A Framework of Quality Assurance for Responsible Officers and Revalidation’ this was included in the Internal Audit Plan 2014/15 and was completed in Q1 of 2015. The audit rated the systems and governance relating to the Trust revalidation process risk as low.

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All the recommendations of the Annual Report 2013/14 have been completed. Doctors are encouraged to use IWGC to provide annual feedback from patients and colleagues. This will not, however, replace the 360 which is required every 5 years.

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