All doctors who wish to retain their GMC licence to practise need to participate in revalidation.

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1 Appraisal and Revalidation Annual Update Introduction Revalidation Revalidation of doctors is a key component of a range of measures designed to improve the quality of care for patients; it is the process by which the General Medical Council (GMC) confirms the continuation of a doctor s licence to practise in the UK. The purpose of revalidation is to assure patients and the public, employers and other healthcare professionals that licensed doctors are up to date and fit to practise. Through a formal link with their organisation, determined usually by employment or contracting arrangements, doctors relate to a senior doctor in the organisation, the responsible officer. The responsible officer makes a recommendation about the doctor s fitness to practise to the GMC. The recommendation will be based on the outcome of the doctor s annual appraisals over the course of five years, combined with information drawn from the organisational clinical governance systems. Following the responsible officer s recommendation, the GMC decides whether to renew the doctor s licence. The responsible officer is accountable for the quality assurance of the appraisal and clinical governance systems in their organisation. Improvement to these systems will support doctors in developing their practice more effectively, adding to the safety and quality of health care. This also enables early identification of doctors, whose practice needs attention, allowing for more effective intervention. All doctors who wish to retain their GMC licence to practise need to participate in revalidation. Appraisal Medical appraisal is a process of facilitated self-review supported by information gathered from the full scope of a doctor s work. Medical appraisal can be used for four purposes: 1. To enable doctors to discuss their practice and performance with their appraiser in order to demonstrate that they continue to meet the principles and values set out in Good Medical Practice and thus to inform the responsible officer s revalidation recommendation to the GMC. 2. To enable doctors to enhance the quality of their professional work by planning their professional development. 3. To enable doctors to consider their own needs in planning their professional development. and may also be used

2 4. To enable doctors to ensure that they are working productively and in line with the priorities and requirements of the organisation they practise in.. Job planning, rather than appraisal, will normally be the primary means by which doctors ensure that they work productively and in line with the priorities and requirements of the Trust. However the outputs from each process may be used to inform the other e.g. if a doctor was unable to meet Trust objectives through a lack of training or skills then it would be appropriate for these matters to be considered as part of the appraisal process Purpose of this report Medical revalidation bears on all organisations in which doctors work, on clinical leaders and on doctors themselves. Its introduction from 3 December 2012 reinforces the interdependent responsibilities of healthcare organisations and individual professionals. Medical revalidation places new statutory duties on all of these organisations and individuals, and will over time provide additional assurance that doctors in the UK are fit to practise. This additional assurance for patients and the public derives from doctors practising in well structured, managed and governed systems. Medical revalidation also provides a powerful lever on organisations to drive improvements in the quality of patient care and treatment, and further underscores the paramount importance of robust systems for clinical governance, including appraisal and local quality assurance. Within this system: Organisations appoint a senior doctor (a responsible officer RO) to oversee systems for governance and appraisal for doctors, for dealing with practice concerns about doctors and for advising the GMC about doctors fitness to practise; Organisations are also responsible for providing resources to support ROs in their role as stipulated by the Medical Profession (Responsible Officers) Regulations 2010 and its 2013 amendment. Their local governance arrangements should incorporate constructive challenge around the way services are delivered and monitored; ROs must assure themselves that the quality of their systems supports the evaluation of doctors fitness to practise in a fair and consistent way; Individual doctors must demonstrate they continue to meet the values and principles expected of the profession set out in the GMC s core guidance Good Medical Practice. This is achieved by doctors reflecting on a portfolio of information and evidence at annual appraisal of the doctor s whole practice.

3 Appraisal and Revalidation Annual Update Background This is the first annual report to the Trust Board. It aims at briefing the board on the appraisal and revalidation systems in the Trust, providing reassurance, providing relevant data, and highlighting any challenges. Management of Appraisal and Revalidation The Trust had appointed Prof T Kendall as the Responsible Officer. Dr S Girgis was then appointed as the Associate Medical Director for Revalidation (and also Lead Appraiser). Both received the Responsible Officer Training. Daniel Last has become a project officer. IT developed an electronic appraisal and revalidation system and many of our doctors have completed their appraisal using this system, however there have been a number of technical difficulties and a second version is now being developed. All current appraisers have received top up training (6) and further 4 new appraisers received appropriate training. This ensured that we have sufficient numbers of trained appraisers within the Trust and also within each directorate. 2 of these appraisers also received Case Investigators Training. A system of Quality Assurance of both appraisers and appraisals has been developed. A special body (Revalidation Steering Group-RSG) has been developed to oversee the appraisal and revalidation system. Membership includes the RO, AMD for Revalidation, all appraisers, Daniel Last and Nigel Donaldson. They meet quarterly. There is an extended annual meeting to review the system, assure quality, update training and make decisions on improvement required. 57 doctors, (44 consultants, 12 SAS grade and 1 other ) have a prescribed connection to Sheffield Health and Social Care NHS FT 1 doctor is exempt from annual appraisal as they are on sabbatical. 1 doctor is a new starter and we are awaiting details of their appraisal history 45 of the doctors (82%) have had an appraisal within the previous 13 months. (13 months has been chosen to allow for the 28days post-appraisal grace period to complete and submit documentation) This compares favourably with other Trusts nationally. The most recent data available (2012/13) shows that nationally the average appraisal rate was 73%, amongst mental health trusts the average was 83% Of the 55 appraisals due in the previous 13 months: 15 (27%) are or were late (appraisal discussion not signed off within 13 months of the previous appraisal) 10 (18%) are currently recorded as outstanding 9 (16%) were not signed off within 28days of the appraisal discussion

4 An exception audit to determine the reasons for all late appraisals and for those with a delay in being signed off is an on-going process. To date: 78% of delayed sign offs were due to problems with the original IT e-system. The other two are due to lack of time on the part of the appraise to complete the documentation 80% of late appraisals were due to annual leave or other availability issues. Of these, 7 (58%) were due to the unavailability of the appraise due to annual leave, sickness or other commitments 5 (42%) were due to the annual leave or other time commitments of the appraisers. To date, 10 doctors have been due for revalidation. All have received positive recommendations from the RO and have been revalidated by the GMC. There have been no deferrals and no non-engagement recommendations. Nationally, the deferral rate for mental health bodies is 5.5% There are 4 doctors remaining to be revalidated by the end of the financial year. There are no concerns regarding the remaining revalidations There is 1 doctor with GMC undertakings relating to health reasons Quality Assurance Each appraisal which is completed is reviewed by the Directorate Analyst and scored against the Appraisal Quality Assurance Criteria, adapted from nationally agreed criteria. Low scoring appraisals are escalated for review by the AMD for Revalidation. Each year the AMD for Revalidation meets with the appraiser to review their appraisal QA reviews, the output of this review feeds into the appraiser s appraisal as a piece of supporting evidence. Each year, a selection of QA Reviews are distributed amongst the appraisers for peer review, the findings of this peer review are reviewed in the extended annual RSG meeting. Each appraisee is asked to complete a feedback sheet for the appraiser which feeds into the annual Appraiser QA review. In line with national guidance, version 2 of the e-system will include electronic feedback forms, allowing the returns to be monitored, counted and collated into a single feedback report. Quality assurance of the system of a whole has been undertaken throughout the implementation period through mandatory Organisational Readiness Self Assessments (ORSA) submitted to the revalidation support team. The last ORSA return was in May 2013 (appendix I), where we were able to respond positively to all but one questions (3.3 Auditing of incomplete appraisals) though this is now in place. By way of comparison, 23% of mental health designated bodies had not completed an audit of incomplete appraisals according to the most recent ORSA submission Further to this, an assurance was provided to the North of England Revalidation Team summarising our revalidation action plan in October (appendix II)

5 Performance review, support and development of appraisers Each year the AMD for Revalidation meets with the appraiser to review their appraisal QA reviews, the output of this review feeds into the appraiser s appraisal as a piece of supporting evidence. Developmental needs of the appraiser are discussed and included in his/her PDP. The annual meeting of RSG includes peer review of appraisals and discussion of any challenges appraisers are facing and refresher training (recapping essential elements of appraisals and any new information). Clinical Governance To meet the GMC requirements, each year appraises must submit at least 2 pieces of Quality Improvement activity; typically these will be case-based discussions. To this end, peer appraisal groups have been restructured to facilitate their additional function of acting as a case-based discussion group. Other mandatory supporting information includes; evidence of Continuing Personal Development, this is most commonly evidenced by CPD certificate issued by RCPsych confirming that the doctor is in good standing with the College for CPD; Details of all complaints received, which is provided by the Complaints department; Details of all SUIs in which they have been named as provided by the Risk department. In addition to this, over the course of a five year revalidation cycle; each doctor is required to provide evidence of 2 clinical audits and 1 record keeping audit. The Information department will provide data to support this. They are also required to participate in a 360 feedback programme, the ACP360 provided by the Royal College of Psychiatrists. To support the performance management aspect of appraisal, the information department will provide activity and outcome data as requested. Risk department provides a summary of SUIs where the doctor is named. Complaints and litigation Department provides evidence on complaints and compliments. Daniel Last will issue a reminder to the doctor and the appraiser (and to complaints, risk and information department) 3 months in advance of appraisal date. Appraisals are expected to occur within a 2 months window (1 month on either side of the expected date). Access, security and confidentiality The e-system in place has access control in place. Access to appraisal forms is initially limited to the doctor, their clinical director, their appraiser (where this is not their clinical director) and the revalidation team (RO, AMD Revalidation and Directorate Analyst). Doctors have the option to allow access to their secretary/pa. In addition, access may be granted on a time limited basis to other appraisers as necessary to enable peer review of appraisals. The e-system is secured by the Trust s IT system, access is restricted by Trust log-on details.

6 Appraisal Policy An Appraisal Policy was developed and agreed to help underpin the requirements of revalidation.. This was agreed with the Revalidation Steering Group and the BMA at the Joint Local Negotiating Committee it was introduced in November An initial review period of a year was provided for in order to help identify any improvements. The Policy has been reviewed and amendments have been drafted in respect of - The arrangements for the Responsible Officer s appraisal (to reflect the reorganization of the Strategic Health Authorities.) - Setting out a process for escalating concerns where a doctor is not engaging in the process (links into GMC guidance) - Leaving the Trust to determine the scope for charging for any non employees (other than Honorary Consultants) for whom the Trust has to administer the appraisal arrangements or make recommendations regarding revalidation. These draft changes have been agreed by the RSG and are in the process of being agreed by the JLNC. Remediation The Trust developed an addendum to its local Maintaining High Professional Standards Policy, explicitly on remediation. No remediation programmes have had to be taken forward under the policy. The addendum has been reviewed and no amendments identified. An area which is under consideration, however, is the extent to which the policy should prescribe a financial contribution from the doctor concerned for the cost of any remediation. Nationally there is no agreement on this principle as yet and it has been agreed by the JLNC that should a situation arise it will be treated, in the interim pending national clarification, on a case by case basis. Conclusions and Next Steps The appraisal and revalidation infrastructure within the Trust has evolved and will continue to evolve alongside national and regional developments. There is an RO, AMD for revalidation and a project officer (analyst). The Trust has a sufficient number of trained appraisers. There is a system of quality assurance of appraisers and appraisals. Policies are in place. An electronic system has been developed, but it has caused some teething problems. It is currently being upgraded and will be subject to thorough testing. This report has been reviewed and approved by the Revalidation Steering Group in its meeting of the 25 th November 2013

7 Recommendations We recommend that the Board accept the report and to note its responsibilities in ensuring that the RO has sufficient resources to carry out his duties. We also recommend that the Board support funding for improving and maintaining the electronic system in line with the recommendation from the Revalidation Support Team of the Department of Health.