Medical Revalidation Annual Report. Public Board Meeting

Transcription

1 Title: Report to: Medical Revalidation Annual Report Trust Board Date: 28 July 2014 Security Classification: Public Board Meeting Purpose of Report: This report informs the Board of the processes for ensuring appraisal and revalidation of doctors, and the associated processes for managing concerns in relation to medical practice. This report provides the Board with assurance in relation to its role as a designated body for the purpose of medical revalidation. Recommendations: The Trust Board is asked to: 1. Consider the annual report and discuss any further actions or assurance they require in respect of the revalidation of doctors and the maintaining of high professional standards. 2. Note that the report will be shared with the higher level Responsible Officer for the London Region, Dr. Oyebode. 3. Agree that resources are made available for appraisal and medical revalidation, including additional PAs for the appraisal lead and administrative support for the Head of Medical HR. 4. Agree that resources are made available within HR to support the maintenance of a database of MHPS investigations, to improve chasing of appraisal completion, to complete annual audits, and to regularly reconcile Trust data with GMC Connect. 5. Agree that resources are made available to increase the level of investigative resource within the Trust by agreeing training for additional medical investigators. 6. Note the statement of compliance (appended) confirming that the organisation, as a designated body, is in compliance with the regulations. Report Sponsor: Comments / views of the Report Sponsor: Jonathan Bindman, Medical Director/Responsible Officer A system is in place for ensuring appraisal and revalidation of doctors. Good quality appraisals are being conducted and doctors are being revalidated by the GMC at above the expected rate. However, 32% of annual appraisals are delayed, and 19% of doctors have not engaged with the process; there is limited audit

2 information about the reasons for this. The expectations of NHS England in respect of audit, information, and the quality assurance of medical appraisal require further development of the system. Recommendations are made concerning this. Where concerns are raised about doctors practice, there are processes within the Trust for investigating these. However, the approach has been on a case by case basis, processes have been prolonged, there has been a lack of investigation and administration resource, and limited systematic information has been collected. Recommendations are made to address these deficits. Report Author: Name: Jonathan Bindman Title: Medical Director Tel Number: jonathan.bindman@beh-mht.nhs.uk Name: Richard Parkin Title: Appraisal Lead Tel Number: richard.parkin@beh-mht.nhs.uk Report History: Budgetary, Financial / Resource Implications: Equality and Diversity Implications: Links to the Trust s Objectives, Board Assurance Framework and / or Corporate Risk Register First annual report Increased resources for medical appraisal will be needed including 2 APAs for appraisal lead and additional administration and audit time from Medical HR (band 5). More MHPS investigators should be trained. MHPS training for managers is being arranged with Bevan Britten. The establishment of a tracking system for concerns will make it possible to carry out ethnic monitoring in future. Action taken will assist in delivering our core strategic aims of: 1. Excellent Services and Staff List of Appendices: Medical Revalidation Annual Report

3 Medical Revalidation Annual Report 2013/2014 1

4 Contents 1. Executive summary Purpose of the Paper Background Governance Arrangements... 7 a. Policy and Guidance Medical Appraisal a. Appraisal Performance Data b. Appraisers c. Quality Assurance d. Access, security and confidentiality e. Clinical Governance Revalidation Recommendations Recruitment and engagement background checks Monitoring Performance Responding to Concerns and Remediation Risk and Issues Board Reflections Corrective Actions, Improvement Plan and Next Steps Appendix A: Appraisal completion, June Appendix B: Quality assurance audit of appraisal inputs and outputs Appendix C: Audit of revalidation recommendations Appendix D: Audit of concerns about a doctor s practice Appendix E: Audit of recruitment and engagement background checks Appendix F: Statement of Compliance

5 1. Executive summary The Trust is a Designated Body for the revalidation of doctors. It has a prescribed connection with 147 doctors at present, which includes all medical staff within the Trust apart from trainees on rotational training schemes. It therefore has regulated responsibilities in the areas summarised below. The Responsible Officer (RO) for the Trust, currently the Medical Director, is responsible for reporting to NHS England, via the NHS England Revalidation Support Team (RST) and the Higher Level RO, on fulfilment of the regulated responsibilities. NHS England has produced, in April 2014, a Framework of Quality Assurance for revalidation, involving quarterly returns (which have been submitted regularly by the Trust in the form shown in appendix A of this report, an Annual Organisational Audit (submitted by the Trust in May 2014), an annual Board Report according to standard template (which is followed by this report), and a Statement of Compliance to be signed by the Chair. The regulated responsibilities, discussed in this report, are: monitoring the frequency and quality of medical appraisals The frequency of medical appraisals is monitored monthly. A total of 100 doctors (68%) have been appraised in the year to 30 th June A further 20 (14%) have identified appraisal dates in the previous two years, leaving a total of 29 doctors (18%) for whom we have no evidence of their engagement with the appraisal process. A process for tracking and chasing incomplete appraisals is in place, but needs improvement. An audit of incomplete appraisals is recommended by NHS England using a template, and this is in progress in respect of those doctors with no appraisal in the previous year. Quality assurance of appraisals has been carried out, with an audit by the Responsible Officer (RO) of a random sample of appraisals stored in the equiniti system (appended). This showed appraisals are of a good standard judged on the information supplied by appraisees and rated by appraisers. However, the expectations of NHS England concerning quality assurance of the appraisal process are rising, and further development of our systems is needed if we are to quality assure appraisals and appraisers other than on self-rated measures. There is no dedicated resource for the medical appraisal system and it is likely that it will be necessary to identify this if BEH is to meet the expectations of NHS England. checking there are effective systems in place for monitoring the conduct and performance of their doctors; There is a system in place to investigate conduct and performance when concerns are raised. However, further training and policy implementation is required to ensure that concerns are raised appropriately and at the right level. There is a limited 3

6 resource for investigation of concerns and there have been delays result in initiating and completing investigations. There are systems for ensuring that concerns which have been raised with the GMC or NCAS are investigated, and those bodies track the concerns they are aware of and communicate regularly with the Responsible Officer (RO). However up to now there has been no system within the Trust for tracking the process of investigation and therefore no way of auditing and reporting data. Local data is now being collected by the RO, though there is incomplete data concerning the time at which concerns were first raised. Considering the period from to , a total of four doctors have been the subject of concerns requiring investigation (three in relation to capability, one in relation to conduct); one investigation has been completed, two are in progress and one not yet initiated. NCAS advice was sought in one case. A further doctor has been referred to NCAS for advice in relation to the effect of sickness on fitness to practice. No doctors are currently under investigation by the GMC, though one doctor under investigation by the GMC who was dismissed from the Trust in July 2103 was shown on the GMC Connect database as having a prescribed connection with the Trust until removed in July confirming that feedback from patients is sought periodically so that their views can inform the appraisal and revalidation process for their doctors Doctors are expected to obtain and report patient feedback on their practice as individuals as part of their appraisal, and systematic feedback is a minimum requirement of appraisal for revalidation. The audit of appraisals shows that patient feedback is routinely obtained, though systematic multi-source feedback from service users and colleagues may only be carried out only in the year before revalidation. Doctors can also access other patient feedback held by the Trust on their teams and services, and incorporate it into their appraisals where it is relevant to their own practice. The audit of appraisals provided an opportunity to check whether this takes place and confirms that individual doctors do obtain and use data in this way to some extent. However, NHSE envisages that there should be systems within the Trust for providing comprehensive routine data within medical appraisals and the Trust does not have such systems. Ensuring that appropriate pre-employment background checks (including pre-engagement for Locums) are carried out to ensure that medical practitioners have qualifications and experience appropriate to the work performed. The Trust carries out pre-employment background checks on all medical staff. An audit, appended, shows that this is taking place and describes the content of background checks. The staff currently carrying out these checks do not routinely establish whether the doctor being employed is known to NCAS or the GMC, nor are references sought from a previous RO. While this information is likely to be communicated to the Trust through regular contacts with NCAS and the GMC, routine checking of the GMC connect database should be instituted. 4

7 2. Purpose of the Paper The purpose of revalidation and appraisal is to ensure that doctors are practising safely and effectively and that the Trust and the wider NHS, via the NHSE Revalidation Support Team and the Higher Level RO, can be assured of this. Appraisal also provides an opportunity for the Trust to develop the medical workforce and ensure that the Trust s objectives and those of individual doctors are broadly aligned. Revalidation is a new process (launched in 2012 and fully in operation from April 2013) and this paper is intended to inform the Trust Board about the development of the process of revalidation in the Trust since its inception. Doctors are revalidated by the GMC, after following a process developed and monitored by the Revalidation team within NHS England. Revalidation is intended to take place on a five year cycle, but is based on the preexisting system of annual appraisal within the Trust. While this is an internal process, the NHS England Revalidation Team seeks external assurance via the RO about the appraisal process. This report, together with appraisal of the RO (and the possibility of external validation checks of our processes) is intended to provide that assurance. NHS England has produced, in April 2014, a Framework of Quality Assurance for revalidation, involving quarterly returns (which have been submitted regularly by the Trust in the form shown in appendix A of this report, an Annual Organisational Audit (submitted by the Trust in May 2014), an annual Board Report according to standard template (which is followed by this report), and a Statement of Compliance to be signed by the Chair. The Framework was discussed at a conference for ROs in May 2014 attended by the RO. It was made clear in presentations from NHS England that it will require higher levels of assurance than have been sought previously, and will require not only that processes are in place for revalidation appraisals, but that all aspects of the process are quality assured. In addition to appraisal, assurance that doctors are practising safely is dependent on an effective system by which concerns about doctors practice can be raised and investigated, and prompt and appropriate actions taken where concerns are valid. This report describes the current processes for investigating concerns, and provides data on current concerns within the Trust. 3. 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 system. 5

8 Provider organisations have a statutory duty to support their Responsible Officers in discharging their duties under the Responsible Officer Regulations 1 and it is stated in the Board Report template (on which this report is based) that it is expected that provider 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 ensure that medical practitioners have qualifications and experience appropriate to the work performed. Barnet Enfield and Haringey Mental Health Trust (BEH) has responded to the Regulations to date by establishing a Revalidation Lead role, held by Richard Parkin, who has worked with the previously established appraisal structures to monitor the completion of appraisal and ensure that doctors are recommended to the GMC for revalidation. This system has now been in place since the formal beginning of revalidation in April 2013 and a total of 37 doctors (25%) were formally recommended by the Trust for revalidation and revalidated by the GMC in the first year. In respect of managing conduct and performance of doctors, there are relevant polices which are described below. However, the processes by which concerns are appropriately raised and investigated are insufficiently developed. There is limited assurance that all concerns are appropriately raised with the RO and clear decisions made about investigations. Where concerns have been raised with the RO, there is a system in place by which investigations have been commissioned, but these have not been tracked or monitored and delays have resulted. Where concerns have been raised with NCAS or the GMC there are systems in place to ensure that these are monitored and discussed with these bodies until closed. All revalidation appraisals must include formal feedback from patients, and the Revalidation Lead checks that this is in place. The Trust also has systems in place for making pre-employment background checks when medical practitioners are appointed. However, there are some gaps in assurance. Recommendations are made to address these. 1 The Medical Profession (Responsible Officers) Regulations, 2010 as amended in 2013 and The General Medical Council (Licence to Practise and Revalidation) Regulations Order of Council

9 4. Governance Arrangements Outline of organisational structures and responsibilities, including how progress is monitored monthly/quarterly Structures The Trust has until now had limited formal structures for managing medical appraisal and revalidation. The appraisal lead meets regularly with medical leads who are the principal appraisers in the Trust, and reports to the Medical Director, who has also met with the medical leads. The Medical Director meets regularly with the Head of Medical HR and frequently but irregularly with the appraisal lead. There are no Trust committee structures at which revalidation and appraisal is discussed, and this appears to be largely because there are so few people involved that these have not been felt to be necessary. Responsibilities Doctors have a responsibility for seeking annual appraisal and ensuring they collect the necessary information electronically. The Trust purchases equiniti software and each doctor is provided with a log in which enables them to upload data securely to the equiniti Revalidation Management System (RMS) system and make it available to their appraiser, the revalidation lead and the RO. Each doctor accumulates a portfolio on line which includes evidence of Continuing Professional Development (CPD) and a Personal Development Plan (PDP), feedback from colleagues and patients, information on complaints and compliments, and information from Serious Incidents (SIs). Doctors use the Royal College of Psychiatrists system of monitoring CPD by attendance at a peer group and reporting attendance to the college (a system with clear standards and some internal validation checks) and obtain a CPD certificate from the College which is included in appraisal portfolios. Medical leads in each service line are responsible for accessing appraiser training and conducting appraisals, and also identify other senior doctors within their service line as appraisers. They provide information to the revalidation lead and the Head of Medical HR on completed appraisals. Appraisers use the equiniti system prior to appraisal to review the appraisal portfolio and rate it, then to record their meeting with the appraisee and summarise their findings and recommendations. The appraisal and revalidation lead, Richard Parkin, is responsible for advising appraisers of available training, ensuring that there are sufficient appraisers to carry out appraisals of all doctors, and allocating appraisers where appraisal is not carried out by the medical leads. He reviews completed appraisals, enters information into the equiniti software to ensure tracking of completed appraisals, and has also had delegated authority to 7

10 recommend doctors for revalidation to the NHS England Medical Revalidation team. The Medical Director, Jonathan Bindman, is responsible for oversight of the system. The Responsible Officer role in respect of appraisal was formerly delegated to the Revalidation Lead and Dr. Parkin was managing the system of recommendations for revalidation and all functions associated with overseeing the revalidation software (which includes a formal process of RO approval for appraisals to be put forward for revalidation), however following the Medical Director completing RO training, this role is now his responsibility. The Head of Medical HR, Umer Shaikh, is responsible for maintaining an accurate list of prescribed connections, which is in the form of an excel database containing the names of all doctors (apart from trainees on rotational training schemes) in the Trust, with the help of administrative staff, providing monthly reports on the progress of appraisal, and providing quarterly data to the RST. The Chief Executive has oversight of the management of doctors when a concern about performance is raised, and has the responsibility of appointing a case manager and reporting to the Board. The Board is responsible for overseeing compliance with the regulatory responsibilities. Monitoring Monitoring of progress of appraisal is carried out by the Head of Medical HR, who maintains a database of appraisals and communicates with the appraisal lead and medical leads as above; the database is provided regularly to the Medical Director. He receives and chases information from medical leads concerning appraisal and updates the spreadsheet which shows which appraisals have been completed and who has been revalidated. He has provided quarterly reports to NHS England showing the number of staff appraised, and has updated the appraisal lead on the progress of appraisal overall. The Head of Medical HR has worked together with the appraisal lead and the Medical Director to provide an annual quality assurance template to NHS England, last submitted in May The data collected is based on the NHS England reporting template. This has an inherent problem in that it seeks quarterly information about the number of appraisals carried out within the financial year. Appraisals in the previous year then drop out of the figures as each quarterly return is completed. The number of completed appraisals is therefore always below 100%, and it is not possible to identify from the figure whether doctors without a completed appraisal in the previous year have had one in the preceding quarter (or indeed been revalidated), and their appraisal is simply delayed, or are failing to engage with the appraisal process at all. 8

11 A separate audit is required to establish this and will be conducted. Process of internal assurance (what assurance can the board / executive have regarding compliance to regulations?) Gaps in assurance There have up to now been some significant gaps in assurance. On the appointment of the current MD in December 2013, the Head of Medical HR post was not permanently appointed to and the interim (Umer Shaikh), having started in August 2013, had identified a range of problems left by his predecessor, many of which (such as those relating to allocation of rotating junior doctors and staffing of rotas, and others relating to sickness and matters of concern described below) required urgent attention. It became apparent that the spreadsheet of doctors maintained by Medical HR had some inaccuracies in respect of consultants, consultant locums, and non-consultant grade doctors. The appraisal lead has been carrying out his role with no identified time or supporting resources. As a result he has been unable to correct the lists of employed doctors himself, and has had to rely on data supplied by medical HR to chase appraisals. He has largely relied upon the motivation of individual doctors, or supervisors of non-consultant grade doctors, to take responsibility for arranging appraisal and revalidation, and has not been able to audit missed appraisals and establish, of those who have not completed appraisals within the year, in how many cases this can be attributed to legitimate reasons such as maternity leave and long term sickness, and in how many cases there may be a problem of engagement. It is clear from data collected for this report that there are a number of doctors for whom there is no evidence of appraisal, particularly among SASG and locum doctors. The role of the Responsible Officer was not clearly established, with a lack of clarity about which parts of the role were delegated. The appraisal lead had the delegated responsibility for making revalidation recommendations to the GMC but oversight by the MD was limited, and there was a lack of clarity about responsibility for managing performance concerns, with responsibility shared in individual cases between the appraisal lead, Clinical Directors and the Medical Director. There has been up to now no single source of information concerning doctors under investigation for performance concerns, and no tracker identifying when concerns were raised, when and by whom decisions have been made about whether to investigate these, or what progress has been made by investigations. The numbers are small, none are currently at the serious level, and all cases are known to either the appraisal lead, the MD or CDs, but the lack of a clear tracking process, and central accountability, has resulted in policies not being followed. However, regular meetings have taken place between the GMC liaison officer and the Medical Director, with sharing of agreed minutes of the discussion, and there has therefore 9

12 always been assurance that the progress of any GMC investigations of doctors are known by the Trust, and also that consideration has always been given where concerns have been raised about whether a formal referral to the GMC is necessary (in most cases it is not, but the decision not to do so needs to be evidenced). The GMC maintains a record of all doctors with whom the Trust has a prescribed connection, and this database (GMC Connect) is also used to record all doctors recommended for revalidation by the Trust, and the outcome (revalidated or deferred). The appraisal lead has regularly accessed this database and submitted revalidation recommendations. However, there has been no cross checking of the database against the Head of Medical HR s records of doctors employed by the Trust. As a result, the GMC list of doctors with a prescribed connection included doctors who have left the Trust; in one case a doctor under investigation by the GMC was recorded as employed by the Trust until July 2014, having in fact been dismissed in July In addition, long term sickness of doctors has been managed within service lines with the involvement of business partners. It has been insufficiently recognised that long term sickness is likely to give rise to concerns about fitness to practice which should be formally considered according to MHPS, and NCAS advice sought. This has given rise to significant problems in two cases. Improvements in assurance In recent months the situation in respect of assurance has progressed in a number of respects. Umer Shaikh has been substantively appointed. The MD has sought information directly from CDs concerning the consultant database (initially for an audit presented to the Audit Committee in March) and assured himself it is accurate. He has also sought information directly from CDs concerning consultant locums, established a list and passed the information to the head of Medical HR to update the database. He is now assured he is aware of all locum consultants employed by the Trust, both agency and NHS. The MD has completed RO training and attended quarterly RO events organised by the RST, as well as the national annual conference of ROs. He has clarified the role and responsibilities of the RO within the Trust, in discussion with the appraisal lead and HR business partners, accessed and reviewed the relevant databases, and audited appraisals and concerns as described in this paper. The Head of Medical HR has, following discussions with the Head of HR, recently appointed two band 5 administrators who will start work in July/August. This is the beginning of a dedicated department of Medical HR which will be able to take on the work of centralised data collection. However, responsibilities for recruitment will remain elsewhere in HR, and HR business partners will also have responsibilities in 10

13 respect of managing doctors about whom concerns have been raised. Regular communication will be needed to ensure that accurate data can be maintained. The MD has established a tracker of doctors about whom concerns have been raised, and brought together information from the CDs, HR, the GMC and NCAS. It has not proved possible to establish when some of the concerns were raised or the timescales of investigation, though it is apparent that these are prolonged and of the two investigations commissioned before December 2013, one has been completed only recently with the departure of the doctor, and another remains incomplete. There is one case in which a concern has been raised and a decision made not to investigate formally, though the process by which the decision has been made is unclear. The MD is now including long term sickness within the tracking database to ensure the necessary consideration to MHPS has been given, and has involved NCAS in one such case and been given detailed advice which is being taken forward with the service line. The MD has met regularly with the GMC local liaison officer (Tony Americano). In addition, NCAS have recently appointed Neil Margerison (a former Medical Director of this Trust) as an identified link and the MD and appraisal lead have met him, shared information and also had telephone discussions for advice. Further mitigations required 1. There is an urgent need for an audit of missed appraisals, identification of all doctors who are unable to complete an appraisal at present for legitimate reasons, and allocation of appraisers and appraisal dates to the remainder, with tracking of progress. The appraisal lead is conducting this audit. 2. Following the audit there will be a need for better maintenance of accurate data on employed doctors, closer tracking of appraisals and chasing of missed appraisals. This will require adequate resourcing of the appraisal lead role and the support of the new band 5 administrators in HR to clean up the database of employed doctors and to support the tracking of subsequent appraisals. 3. The Head of Medical HR needs to access GMC Connect and check the GMC data against our records of employed doctors. 4. The RO needs to establish a structure of regular quarterly meetings to monitor the progress of appraisals, involving the appraisal lead, the Head of Medical HR, and HR business partners involved in management of doctors sickness and performance. 11

14 5. Consideration needs to be given to identifying specific business partners within HR to develop additional expertise in the management of doctors according to MHPS. a. Policy and Guidance There are three Trust polices which set out the relevant governance arrangements. The Consultant Appraisal Policy was drafted in 2004, and reviewed in 2009 and 2013; it is due for review in It remains broadly relevant and accurate, having been updated to include references to revalidation and to the Trust s use of equiniti software. It is dated only in that it makes various references to signed paperwork being submitted to various members of the management, which has been superseded by the equinity Revalidation Management System (RMS). There are some respects in which the policy is not being followed: there is a reference to an annual board report confirming that all consultants are appraised, which does not appear to have been submitted regularly. It is suggested that there should be a maximum of six appraisees per appraiser, and in some cases here are more. It is also suggested that the MD should identify which aspects of routine service data should be considered for inclusion in appraisal files and this has not been done. The Revalidation and appraisal for Non Training Grade Medical Staff Policy and Procedure was issued in October 2012 and is due for review in October It overlaps with the Consultant Appraisal Policy to a large extent (and much of the latter policy is included as an appendix) but is more detailed on the development of revalidation and the role of the Responsible Officer; some of this material is now dated as the system has developed, but not to a material extent. This policy is applicable to Staff Grade and Associate Specialist (SASG) doctors as well as consultants but makes no mention of this fact, or of differences between them. At review, the two policies should be combined and a specific section on SASG doctors included. As with the consultant appraisal policy, the main respect in which it has not been followed is the lack of regular reporting to the Board of appraisal rates. There is also a detailed table concerning monitoring of the policy which includes monthly reporting of data on appraisal, which is being done, but also quarterly monitoring by a RO/Project Group Workforce Committee which does not appear to have been implemented, and some suggestions about evaluating appraisals which do not appear to have taken place until the present report, and a system of evaluation of appraisers and the appraisal system (through peer review) which has not been implemented. The Policy For Handling Concerns About Doctors Performance (including guidance on disciplinary procedures) is included in the Trust list of policies without the usual front sheet specifying review dates. However, it is stated that It implements the framework set out in Maintaining High Professional Standards (MHPS) in the Modern NHS, issued under the direction of the Secretary of State for Health on 11 February 2005, and was agreed by the Local Negotiating Committee (LNC), 12

15 presumably at around that time. It is essentially a restatement of the nationally agreed approach, and much of it remains relevant in that the approach to MHPS agreed in 2005 is still current, though it has developed in some respects. The policy refers at various points to the necessity of seeking advice from the National Clinical Assessment Service (NCAS). Though NCAS has developed its policies and procedures to some extent since 2005, by involving them the local procedures will be kept up to date. At review, it could largely be substituted by a section in the appraisal policy advising that where concerns arise they will be handled in accordance with NCAS advice and nationally agreed procedures. The principal respect in which the policy does not appear to have been followed in the Trust is that it recommends a process for the investigation of concerns which involves informing the Chief Executive and Board and appointing a non-executive director to oversee all investigations of doctors performance; in the small number of current cases under investigation this does not appear to have taken place. Increasingly the RST is developing guidelines which can be incorporated straightforwardly into policy and in future it may be easier to develop local policies which simply reference the national guidance via web links, obviating the need for updating Trust policies. 5. Medical Appraisal a. Appraisal Performance Data A database of appraisal is maintained by the Head of Medical HR, who provides monthly reports to the appraisal lead and RO concerning progress. The data is reported on a rolling basis, consisting of the number of appraisals completed in the previous year, reported by grade of doctor (substantive consultant, locum consultant, and staff grade/associate specialist (SASG). Data on appraisal completion by service line has only been reported for substantive consultants to date, given concerns about the accuracy of the database for other grades referred to elsewhere. This report provides data as at the end of June 2014, the most recent data available, as this has been the subject of more detailed analysis than the data at the end of the financial year 2013/4. Appendix A reports the appraisal data in the format previously required by the NHSE Revalidation Team, showing 68% of all doctors had an appraisal in the year to the end of June Reporting the data by grade of doctor: Grade No. Valid appraisals Rate, % Consultant Locum Consultant SASG Total

16 Reporting the consultants included in this data by service line: Service Line No. Valid appraisals Rate, % Severe & Complex non-psychotic Psychosis Forensics Enfield Community Services Dementia & Cognitive Impairment Crisis & Emergency Corporate Total A full and formal audit of the missing appraisals data using the NHS England template is required and is being undertaken. However, the data available in the appraisal spreadsheet has allowed an initial analysis to be undertaken to address the key issue of how many missed appraisals are a result of delays in completion by doctors who are engaged in the process and have been appraised previously, and how many doctors are not engaging in the process. A review of the data by the MD and appraisal lead shows that of 23 consultants without a valid appraisal in the year to , 15 have evidence of a previous appraisal: 7 in the six months prior to the appraisal window ( ), a further 5 in the previous six months, and 3 in the year before that ( ). One of these doctors is on long term sick leave, and a further one is known to have had an appraisal awaiting sign off. Thus 77 consultants (92%) have evidence of engagement with the appraisal process. Of the remaining 7 consultants, one is on a long term secondment and one is on a career break, leaving 5 (6%) for whom we have no evidence of engagement in appraisal. Considering SASG doctors, of the 16 without a valid appraisal (41%), two had appraisals in the six months prior to the window, but 14 (36%), of whom one is on maternity leave, have no evidence of engagement with the appraisal process. Considering locum and fixed term doctors, of 8 without a valid appraisal (33%), one had evidence of appraisal in the preceding 6 months and 7 (29%) have no evidence of engagement with appraisal. In total, of 147 doctors with a prescribed connection in June 2014, 119 (81%) have engaged with the appraisal process but for 28 (19%) we have no evidence concerning appraisal and this requires urgent follow-up, which is being undertaken. b. Appraisers The Trust currently has 29 Consultants who have appraisal responsibility. Twenty of these do either one or two appraisals per year of their non-training grade medical staff. There are then 6 service line medical leads who, as part of their job description, have a responsibility for ensuring that all non-training grade medical staff are having an annual appraisal in line with GMC revalidation requirements. 14

17 The service line medical leads therefore conduct the majority of appraisals, and almost all of the consultant appraisals in some service lines. There is some delegation of appraisal duties to other consultants in the service lines namely Dr Sherine Mikhail in the NLFS, Dr. Lorna Richards in SCNP who does a number of appraisals in the Eating Disorder Service, and Dr. Imelda Duignan, who has recently stepped down as service line medical lead for the Psychosis service line (and been replaced by Dr Latha Weston), but who will continue appraisals for a further period. The 9 consultants who are carrying out the bulk of the appraisals have all had appraiser training from the Royal College of Psychiatrists. Dr Richard Parkin is an approved Royal College appraisal trainer. He has delivered further training locally, available to all non-training grade doctors across the Trust. All the Consultants who have any appraisal responsibility with the exception of one have attended this training. Dr Parkin will shortly be arranging for further refresher training. Dr Parkin has recently joined the London Appraisal Lead Network and will be attending an event in September The service line medical leads meet monthly and part of the function of this meeting is to discuss any appraisal problems or concerns through peer support. Quality assurance is maintained through Dr Parkin s scrutiny of appraisal portfolios and outputs e.g. PDPs, appraiser sign-off statements and summaries of discussion prior to submitting a revalidation recommendation. Within the last 12 months the equiniti Revalidation Management System has added an appraisee feedback questionnaire on the performance of the appraiser and this adds another level to the quality assurance process, though insufficient data is as yet available for analysis. c. Quality Assurance For the appraisal portfolio: An audit of appraisals (appendix B), was conducted by the MD, based on reading through a random selection of 20 appraisals from the 97 entered onto the equiniti Revalidation Management System (RMS), which the Trust has selected as its IT provider. Appraisal portfolios were read in detail, including evidence of patient and colleague feedback, complaints and SIs. Results show that all appraisals on the system include the basic elements of a personal development plan (PDP), evidence of an appraiser review of the portfolio and an appraisal meeting, and doctor and appraiser sign off including the appraiser s assurance that the doctor is fit to practice. The audit provides assurance that the content of appraisals is good, with a College CPD certificate (evidence of CPD group meetings and a minimum number of hours of training, validated by peers) routinely included. The principal gaps in assurance identified by the audit are: Quality improvement work is routinely included and signed off by appraisers. However this varies widely in scope, from participation in team meetings at which quality issues are raised, to detailed cycles of audit in which specific service improvements attributable to the doctor are evidenced. 15

18 Many appraisals contain patient feedback only in the form of compliment letters or cards, and do not contain systematic patient feedback. This was rated negatively in the audit as it will not meet the necessary standard for revalidation. It is notable however that all completed revalidation appraisals do include patient feedback as part of a multi-source 360 degree feedback (MSF), as a minimum requirement, and it is to be expected therefore that all doctors will obtain this feedback during their 5 year revalidation cycle. Clear systems for obtaining it are established and used (the leading providers appear to be equiniti itself, and the Royal College of Psychiatrists, though other forms of MSF are occasionally used and are acceptable if systematic and using sufficient patients). The NHS England audit requires that patient feedback is included by year 3 of the cycle but it is not clear why this needs to be the case. This is the principal reason why many appraisals in this audit were rated as insufficiently complete for their point in the revalidation cycle, many appraisals one or two years from revalidation not including MSF (from either patients or colleagues), but provided they are completed before revalidation this is not a significant concern. Arguably all doctors should be in the habit of obtaining systematic patient and colleague feedback more often than every five years, and once all doctors have been through the revalidation process and understood the ease of obtaining this and the benefits for their practice, it should be possible to demand a higher frequency of systematic feedback at Trust level. The audit tool asks that information on all complaints and incidents involving the doctor are included. This is impossible to assure using current Trust information systems, and the question has been rated positive in this audit wherever there is a clear statement in the appraisal concerning SIs or complaints either giving details or stating that none occurred. It is an aspect of the appraisal software that where an SI or complaint is reported, a reflective note is included and this is therefore routinely present. Where the item is rated negatively in the audit it is not possible to distinguish between those cases where there were none to report or where the item was missed for some other reason. One appraisee obtained a letter from the service manager listing all complaints involving the team and a statement that no concerns about the doctor s practice were found on investigation. If done routinely by doctors this might provide a way forward to increase assurance that all complaints or incidents are included in the appraisal but this will place some additional burdens on managers. Complete assurance would require that the SI and complaints processes are able to supply reports by team and by doctor, which may be a way forward but again will involve some additional resource. We will recommend to appraisers to advise appraises that a specific statement should be included in appraisal about how information about SIs and complaints have been obtained, and that where there are none this should be explicitly stated (this is necessary for revalidation appraisals in any case). In this case it may be appropriate to reflect on lessons learned from SIs not directly involving the doctor, and the Trust s plans to expand the scope and frequency of learning events should assist in this. 16

19 The full scope of doctors work is included routinely in appraisals and this included in several cases audited details of work outside the Trust for other NHS, private or voluntary providers. This work also featured in reflective notes in the portfolios, hence a number of positive ratings concerning information being provided from other places of work (but note that the question is badly designed as where no supporting information is rated as present this is usually because there is no relevant work to rate rather than failure to supply it). However, there was little evidence of systematic or objective feedback from this work. We will ask appraisers to seek this from appraisees. A range of information would be useful and increase the quality of the appraisal. It should depend on the amount of work done for other providers, but where this is substantial, written feedback from the clinical directors of other organisations, multi-source feedback, evidence concerning SIs and complaints, or copies of appraisals by other organisations should logically be included in the appraisal. For the individual appraiser There has to date been no formal quality assurance of individual appraisers within the Trust other than that they have been trained before becoming appraisers. NHS England suggests that quality assurance of appraisers could include: An annual record of the appraiser s reflection on appropriate continuing professional development An annual record of the appraiser s participation in appraisal calibration events such as reflection on appraisal network meetings 360 feedback from doctors for each individual appraiser how collected, reviewed, collated and fed back to the appraiser, how calibrated with the feedback for other appraisers? Other suggestions for quality assurance of appraisal were made at the RO conference attended by the Trust RO, which included peer visits between Trusts at which appraisers could meet and share experiences. While quite feasible for BEH, given the number of neighbouring Trusts within easy reach, and existing contacts, this has not been considered up to now. The appraisal lead is also considering peer review within the Trust by arranging for appraisers to attend and observe appraisals by other appraisers. As noted above, the equiniti system now includes data fields which allow appraisees to provide systematic feedback on their appraisers, and this will be analysed in due course. As above, the clinical leads have met regularly to discuss appraisals and issues arising, and this does in practice provide a degree of appraisal calibration, and this could be extended. 17

20 For the organisation There has been limited formal quality assurance of the process of appraisal. NHS England suggests the following should be considered Audit of timelines of process of appraisal by department System user feedback Review of lessons learned from any complaints Review of lessons learned from any significant events At present, this is not collected and the Board are invited to consider how medical appraisal could be audited further in a way which is of value to the organisation. However, psychiatry is largely team based, and it could be argued that processes of learning lessons from complaints and significant events take place at a Trust level already and do not need to be considered within the medical appraisal framework. d. Access, security and confidentiality The equiniti system provides a secure system for the management of appraisal data. In the audit carried out (appendix B), no patient identifiable information was noted to have been included within appraisal portfolios, and clear warnings are displayed within the system to reduce the likelihood of this happening. e. Clinical Governance NHS England suggests that corporate data should be supplied to individual doctors to support appraisal. This could take the form of complaint or incident data provided to individual doctors. No system has been developed currently to do this, but doctors will be informed of complaints about them either directly when informal resolution is sought, or by the investigator for the service when a complaint is investigated. Currently the responsibility rests with them to collect and summarise this data for appraisal. Similarly doctors will become aware of significant incidents when these are the subject of investigation, and will be invited to participate in debriefing meetings or feedback from investigations, at which point the responsibility lies with them to make reflective notes for their appraisal folders. It is clear many doctors do this but as discussed above, there is currently no assurance that doctors will be aware of all complaints or incidents which involve them, or that they include them all in their appraisal portfolios. 18

21 6. Revalidation Recommendations As described in appendix C, a total of 37 doctors were revalidated in the year April 2013-March This represents 25% of all doctors to be revalidated, slightly ahead of the target of 20% originally set by NHSE. A further 22 (15%) have been revalidated as at Progress is therefore significantly ahead of the 20% originally envisaged by the GMC as being revalidated in the first year of the 5 year revalidation cycle, and the 40% envisaged by the second year will clearly be achieved (note however that the 59 revalidated includes doctors who have retired or left the Trust since being revalidated, and percentages of the current eligible workforce are therefore not exact); this is a positive result from the work of the Revalidation Lead. 7. Recruitment and engagement background checks Pre-employment background checks are routinely carried out by the HR administrators, as reported in Appendix E. This data has not previously been collected in the format sought by the RST audit template, hence some gaps in the data provided, but it provides adequate assurance that background checks take place. The staff currently carrying out these checks do not routinely establish whether the doctor being employed is known to NCAS or the GMC, nor are references sought from a previous RO. While this information is likely to be communicated to the Trust through regular contacts with NCAS and the GMC, routine checking of the GMC connect database should be instituted. There has been some discussion at RO events about whether ROs should routinely supply references whenever a doctor with a prescribed connection moves between organisations, but this is likely to be an administrative burden and subject to error given the frequency of movement between organisations. In practice, provided concerns about doctors are discussed with the GMC and NCAS, who link their data by GMC number, and entered into GMC Connect if a formal investigation is under way, there will be adequate assurance that serious concerns are communicated. It remains the case however that if concerns are not managed according to adequate processes at local level it will be difficult to communicate appropriately with other organisations about them, a problem long recognised with current approaches to taking up references. 8. Monitoring Performance Process by which the performance of all doctors is monitored. This report is confined to the issue of investigation of concerns where these are raised. Concerns may arise from patient or colleague complaints, formal or informal, and are likely to come first to local managers and thence to CDs and to the RO. As considered above, these need to be managed more systematically. There is a wider issue about whether doctors performance should be routinely monitored in such a 19