Board Meeting 15 July Medical Revalidation

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1 Agenda Item 5 Paper E Board Meeting 15 July 2015 Medical Revalidation Director: Kathy McLean, Medical Director Purpose 1. This paper provides a summary of the requirements of Medical Revalidation and the implications for the NHS Trust Development Authority (NHS TDA). It is a requirement of Medical Revalidation that the Responsible Officer of the NHS TDA provides a report to the Board annually, setting out the position of the NHS TDA regarding its responsibilities. The NHS TDA Board is recommended to receive this report, and to agree that the Chair will complete a Statement of Compliance (Annex A) by 30 th September Background 2. 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. Revalidation is governed by the Responsible Officer Regulations The Medical Profession (Responsible Officers) Regulations, 2010 as amended in 2013 and The General Medical Council (Licence to Practise and Revalidation) (Amendment) Regulations 2015 which come into force on 1 st August Designated bodies have a statutory duty to support Responsible Officers in discharging their duties and it is expected that the board will oversee compliance. 3. In November 2012 the NHS TDA Board confirmed the appointment of Dr Kathy McLean as the NHS Trust Development Authority s Responsible Officer for Medical Revalidation. The Responsible Officer must ensure there are appropriate local clinical governance processes and systems. 4. Doctors must undertake annual medical appraisals by a trained appraiser, informed by supporting information defined by the General Medical Council (GMC). On the basis of annual appraisals and other information, the Responsible Officer will make a revalidation recommendation to the GMC, normally every five years. The GMC will consider the Responsible Officer s recommendation and decide whether to renew the doctor s licence to practise. 1

2 5. In October 2013, the NHS TDA Executive group approved the NHS TDA Medical Appraisal Policy, and use of the National Clinical Assessment Service (NCAS) model for doctors in difficulty (remediation). The NCAS is an operating division of the NHS Litigation Authority. 6. At present the NHS TDA is responsible for medical appraisals and revalidation for two doctors. This number may increase if further recruitment activity takes place, but a number of vacancies have been filled through secondment arrangements. Revalidation responsibilities for doctors on secondment remain with their employer rather than the NHS TDA. The number of doctors with a prescribed connection to the NHS TDA is relatively small, and implementation of the requirements of Medical Revalidation at the NHS TDA has been proportionate. Governance Arrangements 7. The Framework of Quality Assurance for Responsible Officers and Revalidation was first published by NHS England on 4 April Designated bodies are required to report to NHS England quarterly the number of medical appraisals which have been completed, and complete an annual audit. Responsible Officers are also asked to present an annual report to their Board or equivalent management team, and the Chairman or Chief Executive Officer should sign off a Statement of Compliance by 30 th September Medical Appraisal 8. A senior external appraiser was engaged to fulfil medical appraisal requirements in Both doctors with a prescribed connection to the NHS TDA completed their annual appraisal during (100%). No doctors are in remediation or disciplinary processes. Revalidation Recommendations 9. No revalidation recommendations were due during , though one was due and was successfully completed in April Recruitment and engagement background checks 10. All necessary checks, such as previous employment references and GMC registration confirmations, have been and will continue to be made as part of recruitment processes. 2

3 Risk and Issues 11. The number of doctors employed by the NHS TDA may increase if there is further recruitment activity. While the number will remain small, the Responsible Officer will review processes during to ensure they continue to fulfil requirements of Medical Revalidation. Recommendations 12. The NHS TDA Board is recommended to receive this report, and to agree that the Chair will complete a Statement of Compliance (Annex A) by 30 th September

4 Annex A Statement of Compliance Designated Body Statement of Compliance The board of the NHS Trust Development Authority (TDA) has carried out and submitted an annual organisational audit (AOA) of its compliance with The Medical Profession (Responsible Officers) Regulations 2010 (as amended in 2013) and can confirm that: 1. A licensed medical practitioner with appropriate training and suitable capacity has been nominated or appointed as a responsible officer; Comments: In November 2012 the NHS TDA Board confirmed the appointment of Dr Kathy McLean as the NHS Trust Development Authority s Responsible Officer for Medical Revalidation 2. An accurate record of all licensed medical practitioners with a prescribed connection to the designated body is maintained; 3. There are sufficient numbers of trained appraisers to carry out annual medical appraisals for all licensed medical practitioners; Comments: See next section 4. Medical appraisers participate in ongoing performance review and training / development activities, to include peer review and calibration of professional judgements (Quality Assurance of Medical Appraisers or equivalent); Comments on sections 3 and 4: A senior external appraiser was engaged to fulfil medical appraisal requirements in All licensed medical practitioners 1 either have an annual appraisal in keeping with GMC requirements (MAG or equivalent) or, where this does not occur, there is full understanding of the reasons why and suitable action taken; Comments: Both doctors with a prescribed connection to the NHS TDA completed their annual appraisal during (100%) 6. There are effective systems in place for monitoring the conduct and performance of all licensed medical practitioners 1, which includes [but is not limited to] monitoring: in-house training, clinical outcomes data, significant events, complaints, and feedback from patients and colleagues, ensuring that information about these is provided for doctors to include at their appraisal; 7. There is a process established for responding to concerns about any licensed medical practitioners 1 fitness to practise; 1 Doctors with a prescribed connection to the designated body on the date of reporting. 4

5 8. There is a process for obtaining and sharing information of note about any licensed medical practitioners fitness to practise between this organisation s responsible officer and other responsible officers (or persons with appropriate governance responsibility) in other places where licensed medical practitioners work; 9. The appropriate pre-employment background checks (including preengagement for Locums) are carried out to ensure that all licenced medical practitioners 2 have qualifications and experience appropriate to the work performed; and 10. A development plan is in place that addresses any identified weaknesses or gaps in compliance to the regulations. Comments: The number of doctors employed by the NHS TDA may increase through the TDA expansion. While the number will remain small, the Responsible Officer will review processes during to ensure they continue to fulfil requirements of Medical Revalidation. Signed on behalf of the designated body Name: Sir Peter Carr, NHS TDA Chair Signed: Date: 15 th July Doctors with a prescribed connection to the designated body on the date of reporting. 5

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