REPORT TO THE TRUST BOARD 20 DECEMBER Update Report on Consultant Appraisal and Revalidation

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1 REPORT TO THE TRUST BOARD 20 DECEMBER 2012 J Title Update Report on Consultant Appraisal and Revalidation Executive summary This paper is an update report, following the annual report to the Trust Board in August 2012, regarding the Trust s progress towards achieving implementation of Revalidation. Revalidation legislation has now been approved and commenced on 3 December This report highlights both the areas of progress and those requiring further attention. Due Regard to the positive general duties of the Equality Act 2010 has been taken in the development of this paper. The Medical Appraisal and Revalidation Policy and Procedure has been consulted upon through the Local Negotiating Committee and through our consultation we are able to evidence Due Regard across the 9 protected characteristics. Recommendation The Trust Board is asked to; Confirm that the Trust is ready to implement revalidation Support the purchase of a fit for purpose medical revalidation e-system Accept indemnity for the actions of the Responsible Officer and Appraisers. Related Trust objectives Risk and assurance Legal implications/ regulatory requirements Presenting Director We will attract, retain and develop a diverse, capable and flexible workforce The importance of having fit to practice medical staff. The risk is that if doctors are not successful revalidated there will be manpower and reputational implications. There is an element of financial risk involved in the purchase of an e-system and any remediation procedures. The report confirms that a lot of preparatory work has been done at LPT to ensure readiness for the implementation of revalidation. Plans are in place to address the remaining actions. UK Statutory Instrument - The Medical Profession (Responsible Officer) Regulations 2010 Professor Sab Bhaumik, Medical Director

2 Author(s) Angela Salmen, Senior Medical Staffing Manager

3 TRUST BOARD 20 DECEMBER 2012 UPDATE REPORT ON CONSULTANT APPRAISAL AND REVALIDATION Introduction/Background 1. This update report should be taken in conjunction with previous annual reports, the most recent being 30 August Since the last report, The Secretary of State for Health (Mr Jeremy Hunt) has announced that from 3 December 2012, revalidation of doctors in the UK will commence. 3. Through revalidation, doctors are required to demonstrate, via their annual appraisal, that they are working in a way that meets the values and principles set out by the General Medical Council (GMC) in Good Medical Practice. 4. Responsible Officers will revalidate first, by March About a fifth of licenced doctors will revalidate between April 2013 and March The majority of licenced doctors will revalidate by the end of March Aim 5. This report summarises the progress made to ensure readiness for revalidation and the implementation programme at LPT. Recommendations 6. The Trust Board is asked to 6.1 Confirm that the Trust is ready to implement revalidation. 6.2 Support the purchase of a fit for purpose medical revalidation e- system. 6.3 Accept indemnity for the actions of the Responsible Officer and Appraisers. Responsible Officer (RO) 7. Each doctor will relate to a Responsible Officer (RO) who will make recommendations to the GMC on Revalidation. Professor Sab Bhaumik is the RO for 128 doctors contracted to the Leicestershire Partnership NHS Trust. Dr Stephen Frost, Associate Medical Director for Appraisal and Revalidation is the Deputy RO.

4 8. Professor Bhaumik will be revalidated by 31 March LPT is now routinely maintaining and updating the list of doctors connected to this organisation on its GMC Connect account. Organisation Readiness Self Assessment Tool (ORSA) 10. ORSA is a self-assessment tool, developed by the NHS Revalidation Support Team (RST), which captures data to help designated bodies determine their readiness for revalidation. It also informs the England Revalidation Delivery Board and the GMC regarding progress towards implementation in England. The full ORSA exercise is an annual process, supplemented by interim progress reporting. 11. LPT has submitted all ORSA reports as required. In the September 2012 ORSA report, we indicated that LPT was the designated body for 128 doctors and that 107 had a complete appraisal. 6 doctors were unavailable for appraisal due to them being on maternity leave or long term sickness absence. There were 15 doctors that were out of date with appraisal although 10 had dates scheduled and action has been taken to address the remaining appraisals 12. Completed appraisal rates for December 2012 are contained within Appendix It is expected that regular reporting and monitoring of medical revalidation will continue, to provide assurance to the Midlands and East Cluster Responsible Officer, regulators, patients, the public, the profession and other interested bodies, that designated bodies are fulfilling their statutory obligations and their systems are sufficiently effective to support the responsible officer s recommendations. Outstanding actions from ORSA 14. Designated bodies are required to have in place a policy for Remediation, Reskilling and Rehabilitating identified doctors. ORSA reported that in March 2012, 35.9% of Mental Health Trusts had a policy in place for re-skilling, rehabilitation and remediation 1. The Trust has written a draft policy which is currently being consulted upon. It is anticipated that an approved policy will be in place by the end of the financial year. 15. Another issue for a satisfactory and meaningful appraisal is the timely availability of relevant accurate and ideally comparative data. This is a particularly difficult area for our areas of clinical practice because meaningful quality indicators are difficult to achieve. 1 ORSA Report August A report on implementation indicators for revalidation in England as at 31 March Benchmarking data from the 30 September 2012 Interim ORSA report is not yet available.

5 16. There is a challenge for LPT to measure, collect and produce appropriate data and to deliver this reliably into the appraisal process. Steps have been taken to improve and facilitate this data collection process and we anticipate systems will be much improved once an electronic appraisal/revalidation system has been purchased. Appraisal 17. LPT has in place an agreed Medical Appraisal and Revalidation Policy and Procedure. 34 Appraisers have been appointed and trained to provide revalidation ready appraisals. Currently, LPT has in place a system of paper forms and reports to satisfy the requirements of the GMC as outlined in Good Medical Practice : Framework for Appraisal and Revalidation, March A number of electronic systems have been reviewed by the Associate Medical Director and Senior Medical Staffing Manager and two organisations have subsequently been invited to present their systems to a wider group at LPT in December. The procurement of an electronic appraisal/ revalidation system is expected to be complete by March Revalidation scheduling 18. LPT submitted its scheduling information to the GMC as required. The GMC have since accepted the information and confirmed that 25% of doctors are to be revalidated in Year 1, April 2013 March 2014, 36% of doctors in Year 2, April 2014 March 2015 and 39% of doctors in Year 3, April 2015 March LPT has put forward all doctors holding medical management posts (Deputy Medical Director, Associate Medical Director and Clinical Director) and all Appraisers for revalidation in the first year. All have been sent guidance about what they should be doing to prepare for the first cycle. 20. On 3 December 2012 the GMC wrote to every licensed doctor who has a revalidation submission date between December 2012 and August In January 2013 they will write to all licensed doctors with a revalidation submission date from the start of September 2013 onwards, telling them when their date will be in the first cycle. Conclusion 21. Much preparatory work has been done at LPT to ensure readiness for the implementation of revalidation. Plans are in place to address the remaining actions from ORSA and ensure processes are formalised for any remediation matters that may arise in the future.

6 Appendix 1 Completed Medical Appraisals as at 04/12/2012 In December 2012 our completed appraisals, for Consultants, Associate Specialists and Specialty Doctors are recorded as: Division Staff in Post No. not eligible for appraisal* No. eligible for appraisal No. up to date with appraisal % of completed appraisals (from those eligible) Adult Mental Health % Adult Learning Disabilities % Community Services % FYPC % Total % * Those not eligible for appraisal include individuals on maternity leave, long term sickness absence or a new starter into post. There are 4 doctors out of date with an annual appraisal, 2 of those are by one month or less: Division Total no. out of date have dates arranged are 1 month Adult Mental Health 1 1 Adult Learning Disabilities 0 Community Services 1 1 are 2-3 months are 4-6 months are more than 6 months FYPC 2 2 Total There is a system within Medical Staffing to remind doctors when they are approaching their appraisal renewal date and a process for following up those that do not arrange dates. Doctors that are for more than one month will be met with by their Divisional Clinical Director to ensure that a clear date is arranged. Reports escalate to the Associate Medical Director and Medical Director on those that do not maintain an annual appraisal. Individuals are informed that the Responsible Officer cannot make a recommendation for revalidation for those doctors that have not engaged in the process.