CENTRAL MANCHESTER UNIVERSITY HOSPITALS NHS FOUNDATION TRUST Agenda Item 9.3.1 Report of: Paper prepared by: Date of paper: Subject: Professor R C Pearson, Medical Director Miss S Rowlands, Trust Assurance Manager (Operations) 06 th August 2015 Annual Report to the Board of Directors: Management of Medical Appraisal and Revalidation Indicate which by Information to note Purpose of Report: Support Resolution Approval Consideration of Risk against Key Priorities: (Impact of report on key priorities and risks to give assurance to the Board that its decisions are effectively delivering the Trust s strategy in a risk aware manner) The issues contained in this report have an impact on medical staff employment and organisational reputation. Recommendations: The Board is asked to receive this update as part of the annual Board report on the implementation of Medical Revalidation and submit an annual statement of compliance to the higher level Responsible Officer (NHS North of England). 1 P age
Executive Summary This report describes the Trust s progress towards the management of Medical Appraisal and Revalidation since Revalidation commenced in December 2012. Summary of key points: all doctors and dentists employed by the Trust are expected to undertake annual appraisal compliance with medical and dental appraisal in 2014/15 was 88% there are 216 trained appraisers within CMFT there are currently 959 doctors with a GMC-prescribed connection to CMFT between 03 December 2012 and 31 March 2015, 578 doctors with a prescribed connection to CMFT have received a recommendation to the GMC. Of these, 501 were positive recommendations, 76 were requests for deferral and there was one non-engagement notice Introduction Medical Revalidation has been introduced to help reassure patients, the public and the medical profession that doctors are up to date and fit to practice. It also functions to support doctors development. It is a legal requirement for all doctors, practicing in the U.K., to be registered with the General Medical Council (GMC) and to hold a licence to practice. Revalidation applies to all practising doctors in the U.K., including trainees and clinical academics, and in all sectors (NHS and private). The first revalidation cycle started in December 2012 (Year 0) with an expectation that the majority of licensed doctors will have been through first revalidation by March 2016. CMFT appointed the Medical Director to the statutory role of Responsible Officer (RO) with responsibility for implementing the revalidation process within the Trust. He is supported by an Associate Medical Director with oversight of revalidation and appraisal, the Director of Clinical Effectiveness, Head of Medical Staffing and Trust Assurance Manager (Operations). Appraisal Engagement with appraisal is a key element of revalidation, forming the basis for the recommendation made by the RO. The GMC requires all doctors to have an annual appraisal, based on the GMC s Good Medical Practice (GMP) framework, signed off by both Appraiser and Appraisee. Annual appraisal is also a contractual requirement. The Trust s Appraisal Policy has been reviewed to ensure that it complies with the requirements of the enhanced medical appraisal for revalidation. 2 P age
CMFT appraisal process All doctors and dentists must ensure that they undergo appraisal within each financial year and are responsible for the continuous collection of their portfolio of evidence covering their full scope of practice. For doctors (and dentists who are registered with the GMC as well as the General Dental Council), continued engagement with appraisal is necessary over the course of the 5-year revalidation cycle. From 1 April 2014 appraisals should occur in the doctor s birth month. This enables the Divisions and the Corporate Departments to monitor appraisal on a monthly basis, address non-compliance at an early stage, and seeks to avoid an end of year rush to complete appraisals. In order to maintain a reasonable gap between appraisals in gaining alignment with birth month, fulfilling this directive will take up to 24 months. NHS England Report NHS England undertakes an Annual Organisational Audit (AOA), designed to help designated bodies assure themselves and their boards or management bodies that the systems underpinning the recommendations they make to the General Medical Council (GMC) on doctors fitness to practise, and the arrangements for medical appraisal and responding to concerns, are in place and functioning effectively. The AOA also provides a mechanism for assuring NHS England, as the Senior Responsible Owner for implementation of the Responsible Officer Regulations in England, that systems are functioning, effective and consistent. Their report was published in July 2015, and details the systems that the organisation has in place for implementing the Responsible Officer Regulations, together with providing comparative results nationally. The results show that CMFT performs favourably in comparison to other DBs both regionally and nationally. In response to these results, the Medical Director s Office, in addition to the Medical Staffing Department, will produce an action plan to address any development needs that have been identified. Compliance with Appraisal Tables 1-4 show the number of doctors employed by CMFT who have a connection with CMFT in revalidation terms, and appraisal completion rates in the period 01 April 2014 31 March 2015. Numbers do not include numbered training grade doctors whose RO is Dean of Health Education England (NW). Appraisals are classified as 1 completed and signed off within (1b) or outwith (1b) 28 days of appraisal meeting; 2 approved late or missed (absence from work); 3 missed and unapproved. The lowest percentage of completed appraisals was for Trust Doctors. These doctors are appointed on fixed term contracts. Whilst it is the responsibility of the individual doctors to have an appraisal, it has been recognised that this group of doctors may need additional support. This has been discussed with Clinical Heads of Division and reinforced in appraisal training. There was also a mistaken believe that doctors who 3 P age
are new to the organisation do not need to have an appraisal in their first year. This again has been clarified with the Divisions. Table 1 no. doctors with prescribed connection to CMFT Table 2 - no. doctors who have completed an appraisal Table 3 - no. doctors with approved late or missed appraisal 4 P age
Table 4 - no. doctors with missed appraisal 360 o feedback activity levels The GMC requires all doctors to undertake 360 o feedback at least once in their 5-year revalidation cycle. The Trust has invested in an electronic 360 o feedback system, provided by Equiniti 360 Clinical. As revalidation dates are staggered, the 360 o feedback reflects the dates when each clinician needs to have completed this process relative to their revalidation date. Table 5 demonstrates the number of doctors registered for 360 o feedback using Equiniti and their progress to date. This is based on a rolling number, which will increase as more and more doctors are registered as part of the requirements of their revalidation cycle. Table 5 no. doctors who have been registered for 360 o feedback and progress to date Total no. doctors registered for 360 o feedback using Equiniti 360 Clinical No. 360 o feedback completed No. 360 o feedback in progress No. 360 o feedback not started % 360 o feedback completed 845 638 54 74 75 Revalidation recommendations (table 6) There are three potential options available to the RO: positive recommendation for renewal of licence to practise deferral this is a neutral act and is usually related to a doctor who has engaged with the process of appraisal but needs to defer in order to provide further information. It may also be used when a doctor is on maternity leave, sabbatical or long term sick leave 5 P age
non-engagement this may be linked to a performance process through HR. The doctor will be contacted by the GMC. Continued non-engagement may result in the doctor losing their licence to practise. Table 6 recommendation made to the GMC by CMFT s RO to date since 03 December 2012 31 March 2015 Recommendation type No. recommendations made % of total recommendations (n=578) Positive 501 86.6% Deferral 76 13.2% Non-engagement 1 0.2% Quality assurance of appraisal and revalidation Process In order to ensure that CMFT meets the requirements set out by the GMC with regards to appraisal and revalidation, the Equiniti Revalidation Management System (RMS) was procured in November 2012. In summary, the RMS: allows doctors to collect and store their supporting information for appraisal and revalidation electronically and in one central place enables the appraiser to check the appraisee s supporting information prior to the appraisal interview. The appraiser only proceeds when they are happy that the information is sufficient and appropriate (i.e. meets the requirements of the GMC s GMP framework) allows the appraisal to be completed and signed off electronically. This ensures that the RO has remote access to all relevant information and assurances are given that the appraisal has been completed in full External The Regional Revalidation & Appraisal Clinical Lead for NHS North has undertaken a screening review of CMFT as a designated body. The conclusion was: We would like to congratulate you on your good appraisal rate. As we found everything to be satisfactory there is no action to be taken by us. Alternative RO On AOA 1.5 you answered n/a. Where a Conflict of Interest or Appearance of Bias has been identified and agreed with the higher level responsible officer; has an alternative responsible officer been appointed? However we recommend you have the arrangement of an alternative RO in place to facilitate action if ever required. 6 P age
Performance review, support and development of appraisers CMFT has trained 216 appraisers, including training on the enhanced appraisal system and top up training for revalidation. It is expected that each appraiser will: have undergone approved training and refresh this at 3-yearly intervals be assessed in the role once no less than every three years be supported by the Medical Director / AMD for Appraisal and Revalidation, meeting as a group once a year Feedback on every appraisal and appraiser is requested from all appraises annually via the Equiniti RMS, following their appraisal. This is discussed with appraisers individually and as a group. Challenges There are a number of challenges to be faced in the coming year with regards to appraisal and revalidation. These include: continued implementation of and engagement with Equiniti RMS collation and maintenance of robust and accurate data with which to report appraisal compliance on both Trust and Divisional levels Divisions are monitoring compliance with appraisal on a monthly basis to ensure improved performance. Recommendations The Board is asked to note the contents of this paper, progress made to date and the challenges to be faced in the coming year. The Board is asked to delegate authority to the Chair to approve the submission of the Annual Statement of Compliance regarding Quality Assurance on Revalidation (embedded). CMFT - FQA Statement of complian 7 P age