Public Board Meeting. Medical Revalidation Annual Report

Transcription

1 Agenda Item 14.1 Public Board Meeting 29th September 2016 Medical Revalidation Annual Report Presented for: Presented by: Author: Corporate objective: Position statement Dr Phil Ayres, Associate Medical Director Kirsty Blakemore, Medical Revalidation Manager To be the hospital of choice for patients and staff. To achieve the best possible clinical outcomes for every patient every time. Key points 1. To note the progress, compliance with national policy and legal requirements and our improvement plan For decision and information Information 2. Confirm commitment to supporting the progress of this work Decision 3. Confirm that the annual assurance statement should be signed Decision

2 1. Summary This is the Trust Responsible Officer s end of year report. It covers the progress we have made in implementing medical revalidation and the improvements planned for this year. This report is, of itself, a required item of assurance, and we are also required to submit an assurance statement, signed off by or on behalf of the Board. 2. Background The GMC s aims for medical revalidation are that it: is the process by which licensed doctors are required to demonstrate on a regular basis that they are up to date and fit to practise. supports doctors in their professional development, contributes to improving patient safety and quality of care and sustains and improves public confidence in the medical profession. facilitates the identification of the small proportion of doctors who are unable to remedy significant shortfalls in their standards of practice and remove them from the register of doctors. To achieve these aims, the GMC requires that all doctors identify the Designated Body (usually their employer) that monitors and assures their practice. LTHT is a Designated Body for over 1000 doctors and this report is about them. Revalidation is overseen in England by NHS England and the Trust s revalidation outcomes have been reviewed by a visiting senior team from NHS England as recently as May Part of the assurance required by NHS England is the sign-off of the assurance statements. This year, we are unable to respond positively to assurance statement 6 (the presence of effective systems to monitor clinical performance) as we are partly dependent on the implementation of the Trust s data warehouse solution to achieve this. All our other systems to monitor clinical performance (serious incident review, quality review, clinical governance systems, mortality review, peer review, etc.) function well. This gap in our revalidation system is also reflected in responses 2.5 and 3.1 in the Annual Organisation Audit (Appendix 2). These responses were subject to review by the NHS England team, above, and were not considered to be critical. 3. Equality Impact Assessment An Equality Impact Assessment is due by the end of September. 4. Publication Under Freedom of Information Act This paper has been made available under the Freedom of Information Act 5. Supporting Information The following papers make up this report:

3 Medical Revalidation Responsible Officers Report - Appendix 1. AOA NHS England benchmarked organisational audit - Appendix /2016 Appraisal figures - Appendix Recommendation The Board is asked to: Note the excellent progress being made in this area. Confirm commitment to supporting the progress of this work. Confirm that the annual assurance statement should be signed, noting the progress required in our data systems to enable effective monitoring of clinical performance. Dr Phil Ayres Responsible Officer Associate Medical Director August 2016

4 Medical Revalidation Responsible Officer Report¹ Appendix 1 1. EXECUTIVE SUMMARY LTHT is a designated body with 1084 doctors assigned to it for the appraisal year, of which 92% of doctors completed their yearly appraisal on time. The Trust is maintaining its high appraisal completion rates. Doctors with incomplete appraisals are actively managed by the Chief Medical Officer and Responsible Officer. 2. PURPOSE OF THE PAPER To update on progress and improvement for medical revalidation in 2015/ BACKGROUND Medical Revalidation was launched in 2012 to strengthen the way that doctors are regulated, with the aim of improving the quality of care provided to patients, improving patient safety and increasing public trust and confidence in the medical profession. Designated Bodies have a statutory duty to support their Responsible Officers in discharging their duties under the Responsible Officer Regulations² and it is expected that their boards will oversee compliance by: monitoring the frequency and quality of medical appraisals in their organisations; checking there are effective systems in place for monitoring the conduct and performance of their doctors; confirming that feedback from patients is sought periodically so that their views can inform the appraisal and revalidation process for their doctors; and ensuring that appropriate pre-employment background checks (including pre-engagement for locums) are carried out to the required standards. 3. GOVERNANCE ARRANGEMENTS Progress in implementing a high-quality system for revalidation is overseen by the Revalidation and Appraisal Steering Group. A working group and a number of other groups contribute to this oversight. The Steering Group is chaired by the Responsible Officer (RO) and its membership includes the Chief Medical Officer (CMO), medical leads for operations, professional development and medical workforce, as well as front-line clinicians who have volunteered to help the Group with its work. The Group reports to the board through this annual report.

5 Through this structure, revalidation has been designed, developed and implemented by numerous clinicians and lead appraisers, supported by HR but in a way that conforms to national requirements and standards. 4. MEDICAL APPRAISAL 4.1 Appraisal Figures 2015/2016 A detailed breakdown at Appendix 3; key point s are³: Total Completed 1005 (92%) 904 (89%) 836 (90%) 730 (88%) Special Circumstances 37 (3%) 27 (3%) 15 (2%) 23 (3%) No Appraisal 49 (5%) 80 (8%) 80 (8%) 76 (9%) New Starters An audit has been completed and all doctors that failed to complete an appraisal in have been identified and written to. Those doctors that have since completed their appraisal or disclosed mitigating circumstances have been advised that they have a gap in their appraisal history but no further action is needed. Those doctors that have not completed an appraisal have been set an appraisal deadline of the 30th September A further audit will be run in October to ensure that all the outstanding appraisals have been completed; further action will be undertaken if necessary, such as notifying the GMC of failure to engage in the process. 4.2 Appraisal Re-Alignment Appraisal re-alignment began in the appraisal year where we aimed to simplify the Trust-wide task of ensuring appraisal completion, and enable a more reflective process. The Trust has moved away from the rush of medical appraisals that take place every year between January and March in order to relieve the pressure on many staff at year-end, and mirrors similar action taken by NHS England. All doctors were provided with a new appraisal month which enabled us to identify doctors who were likely to miss an appraisal, and offer extra support to those doctors to ensure an appraisal was completed in the appraisal year. This has increased our overall appraisal compliance rates and it is anticipated that moving doctors further from the end of the appraisal year will further increase compliance in 2016/ Appraisers There are currently 224 active appraisers within the Trust. CPD workshops are now being run on a bi-monthly basis. All active appraisers are required to attend two workshops in 3 years to maintain their competence.

6 Following feedback from NHS England we will also introduce appraiser networking conferences and forums to allow for further peer support and sharing of best practice, in addition to assigning appraisers to doctors for a 3 year period. 4.3 Appraisal toolkit The web-based appraisal toolkit (PReP) has been in use across the Trust for four years and all medical appraisals are now completed on this system. The contract expires on the 31st March Quality Assurance The Appraisal Summary and PDP Audit Tool (ASPAT) has been implemented by LTHT. The audit tool enables LTHT to score the appraisal outputs to ensure that the appraisal process is meeting the required standards. The ASPAT forms part of a new feedback structure to our appraisers in order to increase quality in the appraisal system. A Wayfinder campaign was also run, asking medical staff What can we stop, start, do differently to improve medical appraisal? and How would you say appraisal has benefited your patients? Initial findings have been very positive and suggestions for improvements have been added to the existing improvement plan. Quick wins such as creating a central repository for supporting appraisal documentation will be implemented quickly; the full results will be published in October. Our whole appraisal and revalidation system has been externally reviewed by the NHS England leadership team for the North. The review endorsed out existing improvement plan and made 2 additions. There were no major criticisms. 4.5 Clinical Governance Assurance and performance in this area are reported elsewhere, overseen by the Chief Medical Officer (CMO) and Chief Nurse. Key aspects of clinical governance for the RO at LTHT are the collection and use of clinical information and systems to assist clinicians in their annual appraisal and more rarely to trigger the raising of concerns about a doctor s practice from our clinical risk management systems. Both are the subject of new approaches being taken in the current year and there are high levels of collaboration between the relevant departments and the RO s team. However, until significant progress is made in the availability of clinical outcomes via the Trust s data warehouse programme, there will be a gap in the levels of assurance we have in relation to clinical performance. 5. MEDICAL REVALIDATION 5.1 Revalidation Recommendations The revalidation recommendation panel (RO, CMO, Senior Medical Managers, Trust Medical Appraisal Lead and HR) has reviewed portfolios resulting in 952 recommendations to the GMC since revalidation started in

7 2012. The frequency of each recommendation and comparison to England as a whole is shown below. LTHT England. Figures taken from: Recommendations made to the GMC Positive Recommendations 847 (88.9%) (80.2%) Deferrals 103 (10.8%) (19.5%) Failure to Engage 2 (0.2%) 425 (0.2%) LTHT has a much lower deferral rate than the rest of England and we are committed to reducing the deferral rate further, in particular for those doctors where the reason for deferral was due to incomplete 360 feedback, either from patients or colleagues. To date LTHT has made three late recommendations to the GMC, but these were completed within 24 hours of the deadline. Overall Leeds Teaching Hospitals has a lower rate of making late revalidation recommendations at 0.4% compared to England which has an rate of 1.2%. An analysis of the causes of our late returns revealed non-systematic human error. 5.2 Policy and guidance The medical revalidation policy was updated in 2015; was reviewed by the NHS England team this year, and will be reviewed again by us in September RECRUITMENT AND ENGAGEMENT BACKGROUND CHECKS All doctors employed by LTHT are subject to the NHS mandatory preemployment recruitment checks prior to appointment, including locum doctors. In April 2014, a new category of fitness to practise impairment 'not having the necessary knowledge of English' was introduced by the GMC, requiring Trusts to ensure that doctors have sufficient knowledge of the English language necessary for the work to be performed in a safe and competent manner. The pre-employment checks carried out on all doctors provide this assurance at LTHT.

8 7. MONITORING PERFORMANCE The approach taken in LTHT is to use existing routine systems to monitor the fitness to practise of all doctors. This includes Mortality and morbidity reviews Clinical governance forums and meetings in specialties Participation in national and local audits Whistleblowing systems Clinical directors hold responsibility for identifying and managing concerns about performance, or escalating them where it is felt that they may be serious. Progress towards near real-time monitoring of clinical outcomes is dependent on the Trust implementing its data warehousing project. 8. RESPONDING TO CONCERNS AND REMEDIATION The Trust s approach to identifying and responding to concerns is covered by our Principles for Responding to Concerns and the Guidance and Principles for Remediation, all of which are published on our intranet. 8.1 Doctors at Risk The table below contains data regarding the numbers of doctors at risk during that required formal action by the Trust internally, or by the GMC where there was an outcome other than case closed with no further action. Low Level Concern* Medium Level Concern High Level Concern Conduct Capability Health *Low Level Concern: Concern resolved informally without formal sanction; Medium Level Concern: Concern which has or may result in a formal outcome from the Trust or GMC; High Level Concern: Serious concern which has or may have implications for the doctor s employment or professional status 8.2 Doctors in training Doctors in training have their RO at the Health Education Yorkshire and Humber Deanery (HEYH). The process for providing HEYH with reports has been agreed with them and implemented. 9. RISKS AND ISSUES There are no risks or issues that need to be escalated for the Board s attention.

9 10. IMPROVEMENT PLAN We have a structured improvement plan available on request from Kirsty Blakemore. 11. RECOMMENDATIONS Board Members are asked to: Note the excellent progress being made in this area. Confirm commitment to supporting the progress of this work. Confirm that the annual assurance statement should be signed, noting the progress required in our data systems to enable effective monitoring of clinical performance. Dr Phil Ayres Responsible Officer Associate Medical Director August 2016