REVALIDATION. Trust Board Briefing Paper November 2011

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1 REVALIDATION Trust Board Briefing Paper November 2011 What is revalidation? Revalidation is the process by which all doctors in future will have to demonstrate to the General Medical Council (GMC) that they are fit to practise. This will normally occur every five years. The purpose of revalidation is to assure patients, employers and other healthcare professionals that licensed doctors are up-to-date and are practising to the appropriate professional standards. Revalidation is based on local evaluation of doctors' performance against national standards set by the GMC and criteria recommended for specialists by the respective Royal Colleges. The GMC has agreed, following discussion and agreement with the UK Health Departments and the profession s representative organisations, to allow the appraisal process to be the principal vehicle by means of which the evidence required for revalidation will be collated and presented. Although this process is based on the medical appraisal system which has been in existence since 2003 that system has been considerably strengthened to meet with the demands of the GMC. Appraisal is based on a doctor s whole practice which means that the appraisal must take into account information regarding a doctor s performance within any organisation in which he or she works. This will include the primary employer, other NHS and private health facilities but also any other organisation with which the Doctor has an association which requires a Medical Qualification. This would include voluntary work. Recommendation of a doctor s fitness for revalidation will be based on five years of high quality appraisals and will be made to the GMC by the doctor s Responsible Officer. In the build up to implementation of Revalidation, the GMC has introduced the new role of GMC Employer Liaison Adviser (ELA). ELAs are senior experienced GMC advisers who are working with Trusts to advise on implementation of Revalidation but whose role is also to enable sensitive real time communications between Trusts and the GMC on performance issues with Doctors. Legislation including the statutory requirement for Responsible Officers has now been passed but implementation remains a work in progress. The GMC envisage a go live date in late Page 1

2 What is the role of the Responsible Officer (RO)? The role of Responsible officer (RO) has been created under the provisions of the Health and Social Care Act 2008 and has statutory responsibilities under the Medical Profession (Responsible Officer) Regulations The RO is a senior, licensed doctor in the organisation where she or he works. In the majority of Trusts the role has been incorporated into the post of Medical Director. The RO is directly answerable to the Department of Health rather than to the Trust. The RO will be responsible for ensuring that all medical staff are appraised, that any follow up action is taken, and that comprehensive records are kept of all appraisals. He or she will make a recommendation to the GMC about a doctor's fitness for revalidation, normally every five years. This will be based on the doctor's appraisals over this period, together with information derived from local clinical governance processes. The GMC will require assurance that each doctor is meeting the required standards and that there are no known concerns about the doctor's practice. Any concerns arising at any point in the 5 year cycle must be fully explored and dealt with locally with the assistance of the National Clinical Assessment Service (NCAS) where appropriate. The revalidation process will not alter the duty of any Trust to report serious concerns regarding a doctor to the GMC at any time. It should be noted that the Responsible Officer makes the recommendation for revalidation, however it will be for the GMC to decide whether the doctor concerned should be revalidated. The Trust RO is responsible for all non-training grade Medical Staff (GPs, Consultants, SAS grades and any other non-training grade posts). The Deanery is responsible for the revalidation of doctors in training. In practical terms the Responsible Officer has overall accountability for ensuring that : The Trust provides the resources requires for a doctor to fulfill their duties and comply with the requirements of revalidation All doctors are provided with governance and performance information held by the Trust on an annual basis and in a timely manner. Procedures are in place to investigate concerns about a medical practitioner s fitness to practice Doctors are referred to the GMC where appropriate Doctors comply with any undertakings laid down by the GMC High quality appraisal takes place for all doctors for whom they are responsible Page 2

3 Copies of all documentation are held securely. A quality assurance system is in place The GMC receives recommendations for revalidation in a timely fashion in the agreed format (yet to be determined) What is the Role of the Trust Board? The Trust Board must ensure that the RO has adequate resource to carry out his or her duty. This will include allowing sufficient time, and providing managerial support, training and funding for the appraisal process. It will also include provision for Remediation of any doctor who requires training or other support in achieving revalidation. Although the RO is primarily accountable to the DoH for revalidation, any deficiency in the Trust revalidation process is likely to be highlighted in the event of an appeal re failure to revalidate an individual. It is also likely that the CQC will include Revalidation in their quality monitoring. The Revalidation process: Annual appraisal for consultants and Associate Specialist and Specialty doctor is already a contractual requirement (and has been carried out in this Trust since 2003). Medical appraisal differs fundamentally from appraisal in other settings due to its elemental link with external professional regulation and revalidation. Medical appraisals are based on a doctor s performance as described in the GMC s Good Medical Practice: Areas covered by the appraisal: 1. Quality of clinical care feedback including audits 2. Continuing Professional Development 3. Feedback from patients 4. Feedback from colleagues 5. Complaints, clinical incidents and significant events 6. Probity 7. Health Multi Source Feedback (MSF) The GMC recommends that feedback from both colleagues and patients is obtained at least once in each five year appraisal cycle. Page 3

4 The process in Southport & Ormskirk Trust: The post of RO is held by Dr Geraldine R Boocock, Medical Director. She is supported by Dr Paul Mansour who includes responsibility for Revalidation in his Associate Medical Director portfolio. Dr Martin Shaw has taken on the role of revalidation doctor (one PA). In addition to this a 0.6 WTE Band 5 Revalidation Manager has been appointed. In 2010/11 the Trust took part in the Mersey revalidation pilot which provided non-recurring funding for one WTE revalidation manager and 0.6 WTE secretarial support. It also provided the Trust with an electronic appraisal tool. The pilot was extremely successful from the Trust s viewpoint with virtually 100% uptake by Consultants and Staff & Associate Specialist (SAS) Doctors far higher than other participant Trusts. Unfortunately with the completion of the pilot this resource has now been withdrawn and, in the absence of external funding support, the team has been downsized to the structure outlined above. Currently this resource appears to be adequate but as the demands of revalidation are fully elucidated over the next year it is possible that the team will need to expand in which case a business case will be brought to SEMT. With the loss of the pilot electronic tool and the pressing need for Trusts to have robust systems in place, many private companies are in the process of developing commercial systems. We feel that to take this route is unnecessary and would be unwise at this stage and therefore in conjunction with our own IT department we are developing short and medium term solutions. The short term solution is in the form of a Word based electronic document stored centrally on Sharepoint with suitably tailored permissions to allow on-line completion by appraiser & appraisee. This system is now functional & will be used for the next round of appraisals, currently about to commence. Alongside this we are also developing a fully electronic web-based tool which is now in the final stages of construction. We plan to pilot the tool this year with a view to rolling it out to all senior doctors in 2012/13. The Trust received a visit from our GMC ELA on 1 November. He was pleased with progress made and particularly commented upon the electronic documentation referred to above. Training: The RO & Deputy have completed 2 of the recommended 3 mandatory training modules arranged by the GMC Revalidation Support Team and are enrolled on the third module. In addition to this they attend the Mersey & Cheshire Action Learning sets, which are networks for supporting and developing staff who are taking on this new and evolving role. Page 4

5 All appraisers have received update training and sessions for appraisees are underway. Inevitably new appraisers will need to be trained in the future. This together with other as yet unidentified funding demands will be brought to the SEMT for discussion. Governance: The Revalidation Steering Group comprises the Revalidation Team and also representatives of the Consultant and Staff & Associate Specialist body, HR, IT and Risk department, Clinical Education Centre (CEC) and Renacres Hall Hospital Medical Advisory Committee. The group reports to the Trust HR Sub Committee. The Trust Appraisal & Revalidation Policy is at present in advanced draft form completion is dependent on publication of the final GMC Medical Appraisal Guide (MAG) document which will not be available until next year. The GMC has produced a self assessment tool for all Trusts to assist in setting up the appropriate systems and processes in readiness for Revalidation implementation in late 2012: Organisational Self Assessment Tool for Revalidation (ORSATR) This covers setting up of governance, management and HR and HR processes. The Trust has just made its latest submission showing satisfactory progress. Conclusion: It is the intention of the GMC that Medical revalidation will be fully implemented in late Processes for implementation in this Trust are in an advanced stage of development. Current resources appear to be adequate. This briefing document is presented to the Trust Board for information. In the event of any significant change which could strategically impact on the Trust a further paper will be presented. Dr Geraldine Boocock Responsible Officer/Medical Director November 2011 Page 5