Medical revalidation in Scotland:

Transcription

1 Medical revalidation in Scotland: Local reports November 216 1

2 Healthcare Improvement Scotland is committed to equality. We have assessed the performance assessment function for likely impact on equality protected characteristics as defined by age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex, and sexual orientation (Equality Act 21). Our work on medical revalidation has been assessed as having a neutral impact. You can request a copy of the equality impact assessment report from the Healthcare Improvement Scotland Equality and Diversity Advisor on or contactpublicinvolvement.his@nhs.net. Healthcare Improvement Scotland 216 Published November 216 This document is licensed under the Creative Commons Attribution-Noncommercial-NoDerivatives 4. International Licence. This allows for the copy and redistribution of this document as long as Healthcare Improvement Scotland is fully acknowledged and given credit. The material must not be remixed, transformed or built upon in any way. To view a copy of this licence, visit 2

3 Medical revalidation in Scotland: local reports Contents 1 Introduction Findings NHS boards... 7 NHS Ayrshire & Arran... 7 NHS Borders NHS Dumfries & Galloway NHS Fife NHS Forth Valley NHS Grampian NHS Greater Glasgow and Clyde NHS Highland NHS Lanarkshire NHS Lothian NHS Orkney NHS Shetland NHS Tayside... 6 NHS Western Isles Healthcare Improvement Scotland NHS NHS Education for Scotland NHS Health Scotland NHS National Services Scotland NHS National Waiting Times Centre Board Scottish Ambulance Service The State Hospitals Board for Scotland Hospices Accord Hospice

4 Medical revalidation in Scotland: local reports Ardgowan Hospice Ayrshire Hospice Bethesda Hospice Children s Hospice Association Scotland Highland Hospice Marie Curie Hospice, Edinburgh Marie Curie Hospice, Glasgow St Columba s Hospice St Margaret of Scotland Hospice St Vincent s Hospice Strathcarron Hospice The Prince and Princess of Wales Hospice Regulated independent healthcare services Castle Craig Hospital Surehaven Glasgow Hospital Non-regulated healthcare services AbleMed Health Ltd Glasgow Centre for Reproductive Medicine Glasgow Memory Clinic MP Locums RS Occupational Health Mental Welfare Commission for Scotland Scottish Government Appendix 1 Glossary

5 Medical revalidation in Scotland: local reports 1 Introduction In Scotland, providing safe and effective person-centred care is central to the Scottish Government s Quality Strategy 1. Medical revalidation supports these aims and complements the work of the Scottish Patient Safety Programme. The aim of revalidation is to give the public confidence that medical doctors are performing well and are aware of the latest developments in their specialty. It also assists doctors to reflect on how they can improve their practice and how they interact with patients and colleagues. On behalf of the Scottish Government, Healthcare Improvement Scotland is responsible for the annual review of medical revalidation and annual appraisal arrangements in Scotland. We have developed and supported a national approach to providing assurance about the progress that organisations have made in preparing for and implementing medical revalidation in Scotland. Each year, we check and update the list of organisations to include in the review. Our list of designated and non-designated bodies is checked against those held by the General Medical Council (GMC), Scottish Government and a list of registered independent healthcare providers. Our list includes NHS boards, independent hospitals and hospices, and regulated and non-regulated private organisations which are registered in Scotland. This compendium of reports covers the period and should be read in conjunction with the national report Medical Revalidation in Scotland: available at: 1 Scottish Government. The healthcare quality strategy for NHSScotland. 21 [cited 216 Nov 28]; Available from: 5

6 Medical revalidation in Scotland: local reports 2 Findings The aim of our review is to find out how well organisations are progressing with medical revalidation. In particular, we report on: the number of doctors with a prescribed connection to the organisation and the percentage who have completed an annual appraisal the number of NHS Education for Scotland (NES) trained appraisers, and governance arrangements for reporting and providing an assurance on fitness to practise.. In March 216, evaluation panel members and representatives from the GMC and Scottish Government updated the self-assessment documentation used in last year s review and we sent these to the 45 participating organisations to complete and return to us by the end of May 216. We also requested four items of core evidence and asked organisations to provide an update on progress against any actions that were agreed by the panel last year. The evaluation panels met in July 216 to review the self-assessments and core evidence returned to us. The panels considered each of the completed self-assessments, reviewed the evidence presented, self-reported progress levels and also checked progress against actions identified by the panels from the previous year s review. As well as being able to see progress at an organisational level, the information allowed us to compare organisations between and within healthcare sectors, and on a national basis. This section presents the findings of the evaluation panels against the self-assessment and includes action points for NHS boards, independent hospitals and hospices, and regulated and non-regulated private organisations to consider during

7 Medical revalidation in Scotland: local reports 2.1 NHS boards NHS Ayrshire & Arran Data tables Number of doctors with a prescribed connection Number of doctors with a prescribed connection on 31 March Number of doctors eligible for appraisal in Number of completed appraisals Appraisal results (62%) Appraisal results (58%) Appraisal results (81%) Appraisal results (92%) Appraisal results (96%) Appraisal results (99%) Revalidation results Number of doctors eligible for revalidation in Number of positive recommendations 254 (97%) Number of deferral requests 7 (3%) Revalidation Number of doctors identified for revalidation in Number of doctors identified for revalidation in who had an appraisal between 1 April 212 and 31 March 213 between 1 April 212 and 31 March 213 Number of doctors identified for revalidation in who had an appraisal between 1 April 213 and 31 March 214 between 1 April 213 and 31 March 214 Number of doctors identified for revalidation in who had an appraisal between 1 April 214 and 31 March 215 between 1 April 214 and 31 March 215 Number of doctors identified for revalidation in who had an appraisal between 1 April 215 and 31 March 216 between 1 April 215 and 31 March (7%) 15 (94%) 18 (78%) 17 (94%) 2 (87%) 19 (95%) 18 (78%) 18 (1%) Number of NES-trained appraisers Number of NES-trained appraisers in organisation 6 7

8 Percentage Medical revalidation in Scotland: local reports Findings of the evaluation panel NHS Ayrshire & Arran is a designated body which has a Responsible Officer (RO) supported by a deputy RO, a primary care local appraisal advisor and a secondary care appraisal lead. The NHS board has a formal agreement in place for the provision of appraisal and RO services to Ayrshire Hospice. Governance relevant to revalidation NHS Ayrshire & Arran confirmed that it has arrangements in place to continually track the appraisal record of each doctor. This includes all missed or incomplete appraisals and deferrals. These are followed up to make sure any issues are addressed either with the appraisal system or the individual doctor. The appraisers are also encouraged to contact the appraisal lead if they anticipate problems with the completion of an appraisal. The panel noted that the audit of missed or incomplete appraisals is managed by the appraisal administrator. A copy of the annual report to the Board was provided to the panel. This report sets out the revalidation process in place, progress made and key actions to take forward. The panel noted that the annual report has been updated to include information about RO support and appraisal services provided to Ayrshire Hospice. NHS Ayrshire & Arran indicated that it does not have arrangements in place to check Form 4s (or relevant documentation) for new appointments. The NHS board explained that the appraisal administrator would request a copy of the most recent Form 4 if it was not recorded on SOAR. This would normally be requested within 1 month of notification. Where NHS board doctors are employed by more than one organisation, it is expected that they take responsibility for transfer of information between organisations. The panel regarded this situation as a system gap and would recommend that the NHS board reviews human resource practices to address this. Appraisal rates The graph below demonstrates the appraisal rates for NHS Ayrshire & Arran for to Figure 1: NHS Ayrshire & Arran percentage of completed appraisals compared with the Scottish mean appraisal rate NHS Ayrshire & Arran Scotland Appraisal year 8

9 Medical revalidation in Scotland: local reports Information for appraisal Supporting information: NHS Ayrshire & Arran indicated that it has arrangements in place to make sure that doctors are aware of their responsibility to include supporting information in their appraisal that reflects the whole of their practice. The NHS board also encourages doctors to review information on appraisal requirements on the GMC website. NHS Ayrshire & Arran reported that up-to-date relevant clinical activity information is available to doctors in most areas and that work is ongoing to improve the quality of this information. Complaints, compliments and concerns: NHS Ayrshire & Arran advised that information on complaints, compliments or concerns is sent directly to doctors on both an annual basis and also six weeks before revalidation. Doctors are expected to retain all information provided, which is relevant to appraisal in their appraisal portfolio. Multi-source feedback: The NHS board advised that colleague feedback is collected using the feedback tool available on SOAR. Multi-source feedback is discussed at the appraisal interview. Patient satisfaction: All doctors with patient contact must try and gather completed patient questionnaires. Any exemptions need to be recorded on the Form 4 at least once every 5 years and the reason for those exemptions documented. NHS Ayrshire & Arran reported that the CARE questionnaire is most frequently used to gather patients feedback. The NHS board highlighted that it would also accept other questionnaires, including the GMC patient survey and patient surveys approved by the relevant Royal College. A summary patient feedback report is produced for each doctor for discussion at their appraisal interview. The NHS board reported that some versions of the CARE questionnaire do not have space for comments. As this limits opportunities for learning, the NHS board introduced a local version that allows comments to be recorded. The panel considered this process as an area of good practice. Remediation, rehabilitation and targeted support The NHS board reported that support is arranged locally on an ad-hoc basis, following relevant policies. If there is a requirement, training or retraining is arranged on an individual basis. The rehabilitation services offered to doctors are supported by occupational health and are tailored to individual needs. NHS Ayrshire & Arran confirmed that any necessary further monitoring of the doctor s conduct or performance of fitness to practise is carried out in line with the organisation s capability policy. A copy of the NHS board s capability policy was provided to the panel as part of its medical revalidation submission. Self-reported assessment on progress to meet medical revalidation requirements During the self-assessment process, we asked organisations to reflect on their progress to meet medical revalidation requirements. NHS Ayrshire & Arran reported that it has welldeveloped systems and processes and can demonstrate sustainable improvement throughout the organisation. The panel agreed with this assessment. Good practice, improvements and challenges We asked for feedback on examples of good practice in relation to implementing medical revalidation. NHS Ayrshire & Arran reported that the appraisal lead for secondary care organises bi-annual half-day training sessions for appraisers to improve the quality of appraisals. The sessions are attended by the RO and provide appraisers the opportunity to discuss requirements and expectations. The NHS board also reported that the appraisal lead chairs business meetings which take place twice a year. It added that there are similar arrangements for primary care. 9

10 Medical revalidation in Scotland: local reports The RO and appraisal leads for primary and secondary care also meet twice a year to discuss the revalidation and appraisal system and agree on any improvements required. Examples of improvements agreed at the meetings include: moving the date of checking Form 4s from 1 to 3 months in advance of the revalidation date, to allow more time for any outstanding issues to be addressed and to reduce the number of deferments developing letters to be sent to all doctors in advance of their revalidation date the appraisal leads checking all Form 4s in advance of revalidation to ensure core evidence has been covered offering all appraisers an annual one-to-one meeting with the appraisal lead which includes review of a recent Form 4 and feedback on the adequacy of documentation of the core evidence required by the GMC for revalidation supporting collation of patient surveys with a view to providing comparative data for different specialities in the future reflecting on adverse events and quality improvement by all doctors, and being able to demonstrate that doctors are taking part in CPD. We also asked about challenges and NHS Ayrshire & Arran identified two areas. Firstly, the NHS board has ongoing issues with retaining and recruiting appraisers due to a 1% turnover of appraisers each year. Additional problems are caused by unplanned absences of appraisers during the appraisal year. Secondly, difficulty with securing NES-training places for new appraisers at short notice can lead up to a year-long gap between identification of new appraisers and the appraisers starting to appraise. The panel noted the challenges ahead with the number of appraisers available to undertake all the appraisals. Action point from 215 review Include a note in the annual report about the arrangements for RO and appraisal support that the NHS board provides to Ayrshire Hospice. Fully actioned Ongoing Action point for consideration during Review human resource practices to address a system gap where doctors are expected to take responsibility for transfer of information between organisations. 1

11 Medical revalidation in Scotland: local reports NHS Borders Data tables Number of doctors with a prescribed connection Number of doctors with a prescribed connection on 31 March Number of doctors eligible for appraisal in Number of completed appraisals Appraisal results (41%) Appraisal results (41%) Appraisal results (94%) Appraisal results (9%) Appraisal results (87%) Appraisal results (89%) Revalidation results Number of doctors eligible for revalidation in Number of positive recommendations 13 (95%) Number of deferral requests 5 (5%) Revalidation Number of doctors identified for revalidation in Number of doctors identified for revalidation in who had an appraisal between 1 April 212 and 31 March 213 between 1 April 212 and 31 March 213 Number of doctors identified for revalidation in who had an appraisal between 1 April 213 and 31 March 214 between 1 April 213 and 31 March 214 Number of doctors identified for revalidation in who had an appraisal between 1 April 214 and 31 March 215 between 1 April 214 and 31 March 215 Number of doctors identified for revalidation in who had an appraisal between 1 April 215 and 31 March 216 between 1 April 215 and 31 March (23%) 3 (1%) 8 (62%) 8 (1%) 8 (62%) 8 (1%) 9 (69%) 9 (1%) Number of NES-trained appraisers Number of NES-trained appraisers in organisation 56 11

12 Medical revalidation in Scotland: local reports Findings of the evaluation panel NHS Borders is a designated body and provides annual appraisal services to Castle Craig Hospital, Peebleshire. NHS Borders has a clear, formal arrangement in place, in the form of a service level agreement for the provision of appraisal services to Castle Craig Hospital. Governance relevant to revalidation NHS Borders confirmed that it has a process to continually monitor and track information about missed or incomplete appraisals. The NHS board explained that automatic notifications are sent from SOAR, to the local appraisal advisor and the relevant appraiser, to indicate that an appraisal is incomplete at 4 weeks, after the interview date. Each appraiser is responsible for monitoring the timing of appraisals for the appraisees that appear on their list. The NHS board confirmed that it is the appraisee s responsibility to discuss any problems with the local appraisal advisor or appraisal lead and also to report if their appraisal has been significantly delayed. The panel commended the RO s annual report to the clinical governance committee and noted the quality of this report, along with the three other items of supporting evidence provided by NHS Borders. The panel identified from the annual report that appraisal had been well established within primary care for many years and is provided to NHS Borders by NHS Lothian. The panel noted that NHS Borders had not consistently referred to this arrangement with NHS Lothian throughout its self-assessment submission. The annual report highlighted that multi-source feedback for primary care and the patient survey process are also managed through the arrangement that NHS Borders has with NHS Lothian. The NHS board reported on the arrangements it has in place to check Form 4s (or relevant documentation) for new appointments. NHS Borders highlighted that checking Form 4s is part of the process for applying to be included on the Performers List and completing an annual appraisal is a condition of remaining on the list. However, the NHS board confirmed that its RO does not have responsibility for any new appointments within independent doctors practices. The NHS board indicated that any concerns about a doctor s performance would be shared immediately between ROs, medical directors and local appraisal advisors and that a probity obligation is in place to share information if any doctor is aware of a colleague s poor performance. NHS Borders reported that it has a number of secondary care doctors who are employed between organisations and these doctors are usually appraised by the NHS board in which they spend most of their working time. However, the NHS board s appraisal lead has access to their Form 4 documentation on SOAR and is able to check that appraisals are taking place at an appropriate level and with due diligence. NHS Borders added that it has good personal communications with NHS Lothian and both NHS boards have agreed who takes primary responsibility for an individual doctor s appraisal and that relevant information and feedback are captured from the appraisal. 12

13 Percentage Medical revalidation in Scotland: local reports Appraisal rates The graph below demonstrates the appraisal rates for NHS Borders for to Figure 1: NHS Borders percentage of completed appraisals compared with the Scottish mean appraisal rate NHS Borders Scotland Information for appraisal Appraisal year Supporting information: NHS Borders reported that there is very clear information and guidance available on SOAR to make doctors aware of their responsibility to include items of supporting information that reflects the whole of their practice. Appraisees also receive regular updates from the local appraisal advisor and appraisal lead on exactly what documentation is required to be completed for their appraisal interview. NHS Borders highlighted that appraisees are aware that failure to bring information on significant events and or critical incidents to their appraisal constitutes a major probity issue and will be fully investigated by the NHS board. Within primary care, doctors based in one practice can have access to whole practice data, for example prescribing data and details of their Quality and Outcomes Framework achievements. NHS Borders described how doctors can also undertake self-directed quality improvement activities such as audit, trigger tools and clinical case audits. Any significant event analysis reports that doctors generate following group discussion should also be discussed at appraisal interview. NHS Borders reported that clinical data from secondary care is continuously recorded by the NHS board s planning and performance department, which provides a monthly set of extensive key performance indicators for the Board and for each major clinical department. A report is distributed to all senior medical staff to inform their activities and provide supporting evidence for appraisal. Complaints, compliments and concerns: The NHS board reported that complaints are recorded by feedback and complaints staff members who are responsible for co-ordinating the appropriate circulation of complaints. The feedback and complaints team also collates responses which are passed to the NHS board s chief executive. NHS Borders explained that doctors working in primary care have access to complaints and significant event analysis information within their individual practices. The panel agreed that the process that NHS Borders had described appeared to be very dependent on the appraiser and appraisee 13

14 Medical revalidation in Scotland: local reports and that the NHS board did not appear to make the information regularly available to doctors, for the purposes of medical appraisal and revalidation, as it should be. Multi-source feedback: Each doctor undertakes multi-source feedback within the 5-year timeframe, before their revalidation date. The NHS board highlighted that it offers a range of options to doctors. For example, mental health staff undertake ACP 36, a 36-degree feedback system designed specifically for psychiatrists and administered by the Royal College of Psychiatrists. The NHS board added that other doctors working within secondary care use the multi-source feedback tool that is available on SOAR. Patient satisfaction: NHS Borders reported that doctors working in primary care arrange for the administration of patient questionnaires through their individual places of work. It highlighted that the CARE questionnaire is the most frequently used for gathering patient feedback. The NHS board explained that the distribution and collation of questionnaires for doctors working in a fixed practice is undertaken by individuals other than the doctor, for example practice clerical or administrative staff. The NHS board highlighted that this process is more challenging for peripatetic locums and local solutions are put in place to address this. For doctors working in secondary care, the patient questionnaire process is managed entirely by the NHS board s clinical governance department, independent of the doctor concerned. The GMC patient survey is used by doctors who see outpatients, with the exception of mental health, where an alternative system is used. Some specialties, such as anaesthetics, paediatrics and radiology, use forms designed by the individual professional bodies that have been approved by the NHS board s RO. NHS Borders explained that the analysis of patient questionnaire results is carried out by its clinical governance staff and a summary report is presented to the respective appraiser and appraisee. The panel noted that patient questionnaires are only distributed to outpatients and discussed how the NHS board would be unable to identify any improvement for patient output as a result of this action. The NHS board stated that it has extensive experience in the use of patient questionnaires which has been gained over a number of years. Remediation, rehabilitation and targeted support NHS Borders confirmed that its occupational health service is fully involved with any doctor requiring additional support, to make sure that they are appropriately rehabilitated, from a health perspective, before returning to work on a phased basis. The NHS board explained that performance remediation is assessed internally, or using an external advisor through the Royal College or the National Clinical Assessment Service and a remediation programme is developed with the individual doctor concerned. NHS Borders reported that individualised remedial actions are taken, based on the tailored feedback provided by internal or external assessment and an evaluation of the doctor s skills and performance. Self-reported assessment on progress to meet medical revalidation requirements During the self-assessment process, we asked organisations to reflect on their progress to meet medical revalidation requirements. NHS Borders reported that it has well-developed systems and processes and can demonstrate sustainable improvement throughout the organisation. The panel agreed with this statement. Good practice, improvements and challenges We asked for feedback on examples of good practice in relation to implementing medical revalidation within NHS Borders. The NHS board referred to the approach it takes to job planning within secondary care where appraisal is considered as part of the departmental use of Supporting Professional Activity, time spent undertaking activities that are essential to the long-term maintenance of the quality of the health service but do not represent direct patient care. NHS Borders explained that each of its departments is required to fund Supporting Professional Activity within their team and make sure that it covers the number of doctors requiring appraisal. NHS Borders reported that revalidation had contributed towards 14

15 Medical revalidation in Scotland: local reports embedding reflective practice into everyday clinical experience and the expectations of its doctors. We also asked about challenges and NHS Borders raised the issue that not all appraisers have time allocated in their job plans to accommodate their appraisal activity which means that many appraisers do not carry out the recommended 1 appraisals each year. The NHS board added that trying to sustain the numbers of appraisers is presenting the NHS board with a challenge as experienced appraisers are retiring and it is difficult to secure training places for potential new appraisers. The NHS board is actively encouraging retired appraisers to continue with their appraisal activity in an attempt to make sure that there is sufficient cover to meet the requirements of appraisal activity within secondary care. The panel commended the NHS board for submitting all of the required items of evidence to support its self-assessment submission and noted the thorough and detailed content of these documents. The panel discussed its concerns that the medical director s personal assistant appears to be responsible for managing the entire appraisal process and that this person is responsible for making sure that all doctors are appropriately appraised and that the appropriate documentation is available to the RO before revalidation. The panel agreed that arrangement presents a continued risk as the process is entirely person dependent. However, the panel acknowledged that NHS Borders had already identified the current management of the appraisal process as a risk and it had been included in the RO s annual report to the Board. The panel would expect to see evidence of some succession planning for administrative support to the appraisal process in next year s review. Action points from 215 review No action points were identified from the 215 review. Action point for consideration during Implement a succession planning exercise for administrative support for the appraisal process. 15

16 Medical revalidation in Scotland: local reports NHS Dumfries & Galloway Data tables Number of doctors with a prescribed connection Number of doctors with a prescribed connection on 31 March Number of doctors eligible for appraisal in Number of completed appraisals Appraisal results (97%) Appraisal results (73%) Appraisal results (99%) Appraisal results (96%) Appraisal results (92%) Appraisal results (8%) Revalidation results Number of doctors eligible for revalidation in Number of positive recommendations 56 (97%) Number of deferral requests 2 (3%) Revalidation Number of doctors identified for revalidation in Number of doctors identified for revalidation in who had an appraisal between 1 April 212 and 31 March 213 between 1 April 212 and 31 March 213 Number of doctors identified for revalidation in who had an appraisal between 1 April 213 and 31 March 214 between 1 April 213 and 31 March 214 Number of doctors identified for revalidation in who had an appraisal between 1 April 214 and 31 March 215 between 1 April 214 and 31 March 215 Number of doctors identified for revalidation in who had an appraisal between 1 April 215 and 31 March 216 between 1 April 215 and 31 March (6%) (%) 7 (39%) 7 (1%) 6 (33%) 6 (1%) 8 (44%) 8 (1%) Number of NES-trained appraisers Number of NES-trained appraisers in organisation 27 16

17 Medical revalidation in Scotland: local reports Self-assessment and follow-up NHS Dumfries & Galloway was late in submitting its self-assessment and evidence for consideration by the panel and due to this it had to be tabled on the day of the panel meeting. The panel highlighted concerns about the high number of missed appraisals and the perceived lack of governance arrangements or formal processes in place to support annual appraisal and medical revalidation. The panel chair and Healthcare Improvement Scotland contacted the NHS board s RO to seek confirmation that the data submitted was correct and to gather more information about the appraisal and revalidation processes in place. The RO provided slightly updated data for the number of completed appraisals, however there were still a high number of missed appraisals. Due to the number of concerns identified, one of the panel chairs and a member of Healthcare Improvement staff visited the NHS Dumfries & Galloway RO to discuss the panel s concerns and to seek assurance that the NHS board has the necessary governance arrangements and processes in place. This report is a summary of our findings. Findings of the evaluation panel NHS Dumfries & Galloway is a designated body and has an RO. Governance relevant to revalidation NHS Dumfries & Galloway confirmed there is an appraisal lead for secondary care who is an experienced NES-trained appraiser and has time within their job plan to provide an expert resource to the appraisers, review any arrangements and chair regular appraiser meetings. The appraisal lead within primary care has recently retired, so the RO is currently undertaking this role. The deputy medical director will eventually become the primary care appraisal lead, once they have completed the necessary training for the role. The NHS board reported that it does not have a process in place to monitor or track information about missed or incomplete appraisals on a continuous basis. The panel was concerned about the high number of missed appraisals, specifically within secondary care, and would strongly recommend that a process is put in place as soon as possible to continuously monitor and track missed appraisals. NHS Dumfries & Galloway confirmed that a formal audit of missed or incomplete appraisals for had initially not been undertaken. However, when the panel highlighted that the number of completed appraisals within secondary care had dropped considerably from previous years, the RO conducted an audit to establish the reasons why this had happened. The RO confirmed that the main reason that contributed to the drop was due to appraisals being postponed and the rescheduled dates were for after the 31 March 216 cut-off date. The RO confirmed that the majority of the missed appraisals in have now been completed. The RO also confirmed that a new process for supporting appraisal and an escalation process for appraisal have now been introduced and was working well and the NHS board anticipated that there would not be the same issues with missed appraisals during The panel was concerned that the RO was not initially aware of the considerable drop in the number of completed appraisals within secondary care and that an audit had not been undertaken routinely. The panel would recommend that an audit of missed or incomplete appraisals is undertaken every year to ensure that the reasons for the missed appraisals are known and to identify if there are any issues with the appraisal system or with an individual doctor that needs to be addressed. NHS Dumfries & Galloway confirmed that the medical revalidation update annual report was in the process of being drafted and will be presented to the healthcare governance committee in September 216. The NHS board acknowledged that it hasn t 17

18 Percentage Medical revalidation in Scotland: local reports completed an audit of the deferrals as the numbers are small and the reasons are already known by the RO. NHS Dumfries & Galloway reported that the RO does not check Form 4 documents for all new appointments for whom it has responsibility. However, the human resources department checks when the doctor s last appraisal was and sets the date for their next appraisal. The RO would only review the Form 4 documents for doctors who wish to join the NHS Dumfries & Galloway Performers List and potential issues have been highlighted. Appraisal rates The graph below demonstrates the appraisal rates for NHS Dumfries & Galloway for to Figure 1: NHS Dumfries & Galloway percentage of completed appraisals compared with the Scottish mean appraisal rate NHS Dumfries & Galloway Scotland Appraisal year Information for appraisal Supporting information: The NHS board confirmed that a formal process is not in place to ensure that doctors include items of supporting information within their appraisal documentation that reflects the whole of their practice. However, doctors are aware of their responsibility to ensure that their information covers the whole of their practice and appraisers check this during the appraisal. The NHS board confirmed that doctors can request clinical activity information from the NHS board s data analysts, who will run reports from the NHS National Services Scotland Discovery system, so this can be included within their appraisal documentation. Complaints, compliments and concerns: NHS Dumfries & Galloway reported that a process is not in place to feed information on complaints, compliments, concerns or critical incidents into the appraisal system. However, in the event of a serious event, the RO writes to the appraiser requesting that it is discussed during the appraisal. The appraisee is also copied into the communication. Information relating to incidents can be downloaded from the DATIX system and the complaints team can provide information to doctors on request, but there is no system to automatically feed all this information into the appraisal system. The panel was concerned that this is not a reliable process and is person dependent. Multi-source feedback: The NHS board confirmed that arrangements are in place to provide multi-source feedback. The appraisal administration team arranges the completion 18

19 Medical revalidation in Scotland: local reports of multi-source feedback and a report is produced. The report is sent to the appraisee for it to be discussed at their appraisal. Patient satisfaction: The NHS board reported that the process for administering patient feedback questionnaires is mainly done by nurses within the outpatient department so that there is less risk of influence by the doctors. The feedback questionnaires are collected and sent off for analysis and a feedback report produced. Remediation, rehabilitation and targeted support NHS Dumfries & Galloway confirmed that it does not have a formal process in place for doctors to undergo retraining or receive targeted support. However, if there was a need for this, an educational needs assessment would be commissioned from an appropriate Royal College. The process of remediation would then be discussed with the doctor and individual arrangements would be made, usually for a limited time, with further assessment at the end of the agreed time. The NHS board acknowledged that it does not offer its doctors rehabilitation services due to the small size of the organisation. However, it would arrange this service from a neighbouring NHS board, as required. Self-reported assessment on progress to meet medical revalidation requirements During the self-assessment process, we asked organisations to reflect on their progress to meet medical revalidation requirements. NHS Dumfries & Galloway reported that it has welldeveloped systems and processes and can demonstrate sustainable improvement throughout the organisation. The panel considered that the NHS board is developing plans and processes and can demonstrate sustainable improvement throughout the organisation. Good practice, improvements and challenges We asked for feedback on examples of good practice in relation to implementing medical revalidation. NHS Dumfries & Galloway confirmed that it was encouraging the use of video conference equipment to undertake appraisals, where appropriate, to reduce the amount of travel time and costs of travelling between sites. The NHS board reported that it does not believe that the introduction of medical revalidation has contributed to any local improvement within the organisation. We also asked about challenges and the NHS board reported that there are several doctors who have indicated that they are due to retire soon and they do not see the relevance of going through appraisal and revalidation. The RO stated that they feel that sometimes too great an emphasis has been placed on evidence gathering for appraisal and some doctors find this stressful. Overall, the panel was disappointed with the NHS Dumfries & Galloway submission and the high number of missed appraisals. The panel was concerned about the lack of formal processes in place and that the arrangements described were perceived to be very person dependent. The panel was also concerned about the lack of urgency shown by the NHS board and how serious it was about ensuring that the necessary governance arrangements and processes are put in place. The panel did receive some assurance that action had been taken by the NHS board with the introduction of the new process for supporting appraisal and an escalation process for appraisal. However, all the action points from the 215 review are still to be fully actioned and a number of new actions points for have been identified. Following the visit by one of the panel chairs, the concerns outlined by the panel remained. The panel was not assured that robust processes were now in place and will seek an update from NHS Dumfries & Galloway on progress with their action points in January

20 Medical revalidation in Scotland: local reports Action points from 215 review Continue to monitor the number of annual appraisals. Make sure that all appraisals are undertaken by appraisers who have completed NES national (enhanced) medical appraiser training. Ensure that the RO checks Form 4s (or relevant documentation) for all new appointments. Continue to maintain the appraisal system. Develop and implement a trained appraiser s action plan. Implement a clinical governance structure to support medical appraisal and revalidation. Fully actioned Ongoing Action points for consideration during Continue to monitor the number of annual appraisals and increase the number of completed appraisals to a minimum of 9%. Make sure that all appraisals are undertaken by appraisers who have completed NES national (enhanced) medical appraiser training. Ensure that the RO checks Form 4s (or relevant documentation) for all new appointments. Continue to maintain the appraisal system. Develop and implement a trained appraiser s action plan. Implement a clinical governance structure to support medical appraisal and revalidation. Implement a process to continuously monitor and track missed appraisals. Conduct an annual audit of missed or incomplete appraisals to ensure that the reasons for the missed appraisals are known and to identify if there are any issues with the appraisal system or with an individual doctor that needs to be addressed. Implement a formal process to feed information on complaints, compliments, concerns or critical incidents into the appraisal system. 2

21 Medical revalidation in Scotland: local reports NHS Fife Data tables Number of doctors with a prescribed connection Number of doctors with a prescribed connection on 31 March Number of doctors eligible for appraisal in Number of completed appraisals Appraisal results (89%) Appraisal results (83%) Appraisal results (94%) Appraisal results (92%) Appraisal results (92%) Appraisal results (84%) Revalidation results Number of doctors eligible for revalidation in Number of positive recommendations 25 (97%) Number of deferral requests 11 (4%) Revalidation Number of doctors identified for revalidation in Number of doctors identified for revalidation in who had an appraisal between 1 April 212 and 31 March 213 between 1 April 212 and 31 March 213 Number of doctors identified for revalidation in who had an appraisal between 1 April 213 and 31 March 214 between 1 April 213 and 31 March 214 Number of doctors identified for revalidation in who had an appraisal between 1 April 214 and 31 March 215 between 1 April 214 and 31 March 215 Number of doctors identified for revalidation in who had an appraisal between 1 April 215 and 31 March 216 between 1 April 215 and 31 March (29%) 5 (83%) 9 (43%) 9 (1%) 5 (24%) 5 (1%) 1 (48%) 1 (1%) Number of NES-trained appraisers Number of NES-trained appraisers in organisation 5 21

22 Percentage Medical revalidation in Scotland: local reports Findings of the evaluation panel NHS Fife is a designated body with an RO. The NHS board does not outsource annual appraisal services or external RO support. Governance relevant to revalidation The NHS board reported that its doctors have access to leadership and advice on all aspects of the appraisal system and explained that the RO and appraisal leads, from primary and secondary care, are available to advise doctors on any issues that arise. NHS Fife indicated that it had not carried out a formal audit of missed or incomplete appraisals. However, the NHS board explained that it uses SOAR to track appraisals and that this system also flags up any missed or incomplete appraisals. The panel recommended that a formal audit is carried out in future. The medical appraisal and revalidation co-ordinator collates information on the reasons for all deferrals every three months and provides a verbal report to the medical appraisal and revalidation group at each meeting. NHS Fife confirmed that it provides an annual report to its Board, with an update of the NHS board s progress with medical appraisal and revalidation. The panel described the annual report as outstanding and agreed that it was very thorough and detailed. The NHS board indicated that it has arrangements in place for the RO to check Form 4s (or relevant documentation) for new appointments. NHS Fife provided us with examples of how it shares information with other organisations: agreement between ROs. via SOAR. joint discussion about academic and or clinical posts with relevant bodies, and requests information from the Deanery on doctors who have completed their Certificate of Completion of Training, the certificate that doctors in the UK receive indicating that they have completed training in their chosen specialty and are eligible for entry onto the specialist or GP register. Appraisal rates The graph below demonstrates the appraisal rates for NHS Fife for to Figure 1: NHS Fife percentage of completed appraisals compared with the Scottish mean appraisal rate NHS Fife Scotland Appraisal year 22

23 Medical revalidation in Scotland: local reports Information for appraisal Supporting information: The NHS board reported that within primary care the appraiser makes sure that appraisees include items of supporting information that reflects the whole of their practice at their annual appraisal. In secondary care, the medical director writes every year to doctors to remind them of their responsibilities for annual appraisal. NHS Fife highlighted that the need for doctors to provide supporting information, is also discussed at appraiser and appraisee training sessions and appears in the NHS board s local policy as well as NHS Scotland s guidance on medical appraisal and revalidation. NHS Fife reported that its primary care doctors continue to review their referral activity as part of the Quality and Outcomes Framework, the annual reward and incentive programme detailing GP practice achievement results. The NHS board added that clinical activity data is provided to doctors by the NHS board s ehealth department and is taken from secondary care systems. However, NHS Fife explained that a new contract for doctors is currently being developed which might affect this process being carried out in the future. Doctors working in secondary care are able to request clinical activity information and the NHS board confirmed that it is currently providing a number of activity reports, on a regular basis, for consultant appraisal purposes. The NHS board added that clinical activity information was also available in Discovery, a browser-based system hosted by NHS National Services Scotland, which is currently creating consultant profile dashboards. NHS Fife highlighted that it is in the process of specifying a set of bespoke, activity-based reports that will be generated by a new system that is expected to be implemented in March 217. Complaints, compliments and concerns: NHS Fife reported that doctors working in primary care are asked to discuss any complaints that are submitted against them at their annual appraisal. The NHS board explained that, each year the medical director s office gathers information on complaints, incidents and medical legal issues relating to all doctors working in secondary care. The information gathered by the medical director s office is distributed to the individual doctors so that they can check the information provided and take it to their next appraisal interview for discussion. A letter is sent to doctors who have not been part of any complaints, incidents or medical legal issues to confirm this position and can be taken to the doctor s appraisal interview. Multi-source feedback: The NHS board confirmed that it uses SOAR to collect multi-source feedback and its doctors are provided with guidance on how to gather the information that they need. The NHS board added that multi-source feedback is included in, and reflected on, during appraisal interviews, at least once, in the 5-year revalidation cycle. However, if an appraisee does not wish to use SOAR to obtain colleague feedback, the individual can discuss this with their appraiser and consider using the paper version of the GMC colleague questionnaire, one of the questionnaires from the Royal Colleges or a questionnaire from an approved commercial provider. The NHS board added that if an appraisee requests to use an alternative approved questionnaire, such as one of the Royal College s questionnaires, then it is the individual s responsibility to make arrangements for the issue and collection of questionnaires, analysis of the feedback by an independent third party and payment of any costs involved. Patient satisfaction: NHS Fife reported that it issues 5 patient questionnaires to its doctor and it is the doctor s responsibility to pass the questionnaires on to a member of staff for distribution and collection. The NHS board confirmed that doctors are required to return 25 completed questionnaires for analysis, unless a separate agreement has been made with the appraiser. The questionnaires are returned to the medical appraisal and revalidation coordinator for analysis and a report is provided to the appraisee for discussion at their annual appraisal interview. NHS Fife confirmed that it has adopted the GMC patient questionnaire which it accesses on Formic, software which provides solutions for collecting and analysing clinical audit data. The NHS board explained that is has agreed that two specialties can use their own questionnaire and the questionnaire has been adapted so that it can be used on 23

24 Medical revalidation in Scotland: local reports Formic. If an appraisee asks to use an alternative approved questionnaire, such as one of the Royal College s questionnaires, it is their responsibility to manage the process and pay for any costs involved. Remediation, rehabilitation and targeted support The NHS board has a remediation policy which includes the opportunity for doctor s to undertake training or re-training, with appropriate support, where necessary. NHS Fife stated that its doctors are expected to engage with the NHS board and discuss any concerns that are raised. The NHS board said that it was keen to work collaboratively with its doctors and assist them to identify and accept support. Self-reported assessment on progress to meet medical revalidation requirements During the self-assessment process, we asked organisations to reflect on their progress to meet medical revalidation requirements. NHS Fife reported that it can demonstrate sustained good practice and innovation that is shared throughout the organisation and which others can learn from. The panel agreed with this assessment. Good practice, improvements and challenges We asked for feedback on examples of good practice in relation to implementing medical revalidation and NHS Fife referred to the local training sessions that it provides for its appraisers. The NHS board also reported that it carries out an annual quality audit of secondary care Form 4 documentation. An anonymised report of the findings is provided to all appraisers and to the medical appraisal and revalidation group; individual reports are also provided to the appraisers. NHS Fife confirmed that this particular audit aims to maintain and improve the quality of Form 4 documentation within the NHS board. NHS Fife reported that revalidation has contributed to local improvement, by encouraging it to have a more rigorous approach to appraisal. NHS Fife is now making sure that its doctors provide the NHS board with data on audit, managing complaints and reflective practice and it believes that this will improve patient care. The NHS board reported that one of the challenges it faces, in relation to the implementation of medical revalidation, is securing adequate numbers of secondary care appraisers. The panel commended the quality of feedback that the NHS board provides to its appraisers, as well as the NHS board s minimum standard data set which outlines what is expected of doctors in order to fulfil a recommendation to revalidate. The panel reiterated its thoughts on the NHS board s annual report to its Board which the panel said was outstanding. Action points from 215 review Fully actioned Ongoing Develop a system which provides all doctors within secondary care up-to-date and relevant clinical activity information. Ensure that there are enough NES-trained appraisers to undertake the appraisal of all doctors. Finalise and implement the current draft policy for remediation, rehabilitation and targeted support. Action points for consideration during Undertake a formal audit of missed and incomplete appraisals. Continue to monitor number of NES-trained appraisers to ensure there is a sufficient number to undertake appraisals for all doctors. 24

25 Medical revalidation in Scotland: local reports NHS Forth Valley Data tables Number of doctors with a prescribed connection Number of doctors with a prescribed connection on 31 March Number of doctors eligible for appraisal in Number of completed appraisals Appraisal results (82%) Appraisal results (86%) Appraisal results (96%) Appraisal results (98%) Appraisal results (95%) Appraisal results (92%) Revalidation results Number of doctors eligible for revalidation in Number of positive recommendations 21 (94%) Number of deferral requests 12 (6%) Revalidation Number of doctors identified for revalidation in Number of doctors identified for revalidation in who had an appraisal between 1 April 212 and 31 March 213 between 1 April 212 and 31 March 213 Number of doctors identified for revalidation in who had an appraisal between 1 April 213 and 31 March 214 between 1 April 213 and 31 March 214 Number of doctors identified for revalidation in who had an appraisal between 1 April 214 and 31 March 215 between 1 April 214 and 31 March 215 Number of doctors identified for revalidation in who had an appraisal between 1 April 215 and 31 March 216 between 1 April 215 and 31 March (26%) 6 (1%) 1 (43%) 1 (1%) 11 (48%) 11 (1%) 19 (83%) 19 (1%) Number of NES-trained appraisers Number of NES-trained appraisers in organisation 36 25

26 Percentage Medical revalidation in Scotland: local reports Findings of the evaluation panel NHS Forth Valley is a designated body and has an RO who is supported by the associate medical director and the primary and secondary care appraisal leads. The NHS board provides RO support and appraisal services to Strathcarron Hospice and reported that it has a formal agreement in place detailing these services with the hospice. However, the NHS board did not submit a copy of the agreement with its self-assessment. NHS Forth Valley reported that it will be providing appraisal support to NHS 24 in the next reporting year ( ) and a formal memorandum outlining the arrangements will be put in place for this. Governance relevant to revalidation NHS Forth Valley reported that it receives leadership and advice on all aspects of the appraisal process from the appraisal leads in primary and secondary care. The NHS board reported that missed or incomplete appraisals are monitored throughout the year and performance is reported to the revalidation steering group which meets at least three times a year. The audit of missed or incomplete appraisals was included in the annual report to the NHS board s clinical governance committee. NHS Forth Valley reported it has arrangements in place for the RO to check Form 4s (or relevant documentation) for new appointments that they have responsibility for. An agreement is in place with a local private hospital to share any relevant information that may affect the fitness to practise of any doctor who works for both organisations. The RO has also shared information with other ROs when a doctor has left the organisation. Appraisal rates The graph below demonstrates the appraisal rates for NHS Forth Valley for to Figure 1: NHS Forth Valley percentage of completed appraisals compared with the Scottish mean appraisal rate NHS Forth Valley Scotland Appraisal year Information for appraisal Supporting information: NHS Forth Valley confirmed that all doctors are aware of their responsibility to include items of supporting information that reflect the whole of their practice. Doctors in secondary care are advised to use the Academy of Medical Royal Colleges specialty guidance to inform their appraisal submission. Both primary and 26

27 Medical revalidation in Scotland: local reports secondary care doctors use SOAR which highlights the need for supporting information to cover the whole of their practice. NHS Forth Valley confirmed that it will continue to review and, where necessary, further develop and improve the support processes for appraisees. NHS Forth Valley described the systems in place for providing doctors with sufficient up-todate and relevant clinical activity information. The NHS board reported that within secondary care, there is still some scope for development in this area, although some progress has been made. A number of statistical reports have been developed and are available to doctors through NHS Forth Valley s clinical portal. The NHS board confirmed these reports are currently being tested by a group of doctors. Within primary care, practice prescribing reports are produced every 3 months. Doctors are able to access specific prescribing reports through PRISMS (a prescribing information system for Scotland). This is a web-based application, giving access to prescribing information for all prescriptions dispensed in the community for the past 5 years. The NHS board also gave examples of other data streams that doctors use. The NHS board reported that doctors on the Performers List, who are not working in a salaried practice setting, collect their own data for quality improvement activity every year, as part of their appraisal. Complaints, compliments and concerns: The panel noted that the NHS board had no formal processes for reporting concerns and critical incidents into the appraisal process. NHS Forth Valley reported that it is the appraisee s responsibility to make any information about concerns or fitness to practise available to the appraiser for discussion at the appraisal and the organisation s responsibility to make sure that this information is readily available. A report on the individual doctor is generated from Safeguard (the NHS board s incident reporting system) which identifies complaints and involvement in any incident reported in the system. NHS Forth Valley confirmed that, in practice, this is managed in primary care by NHS Forth Valley s general medical practitioner support system policy. Within secondary care, associate medical directors read the Form 4s relating to their unit and this is a way to make sure these issues are discussed. Appraisers raise any concerns about appraisees with the associate medical director or appraisal lead and this is discussed as part of the local appraiser development. Multi-source feedback: NHS Forth Valley reported that it has a process in place to incorporate multi-source feedback into professional development plans. Patient satisfaction: NHS Forth Valley reported it has a process in place within the appraisal system to gather patient feedback. Doctors in secondary care use the CARE questionnaire or the GMC questionnaire. The questionnaires have been adapted to suit particular specialties and situations based on specialist society and college guidance. The process is administered centrally and each report is produced and issued independently of the doctor. The NHS board reported it is arranging more support to make sure the questionnaires are distributed independently. Primary care doctors are expected to follow guidance from the GMC or on SOAR about the most appropriate patient satisfaction questionnaire to use, which may be the CARE questionnaire, the enablement questionnaire, the Edgecombe patient satisfaction questionnaire or the CARE general practice assessment questionnaire. Practice managers administer the process for doctors in the practice. However, NHS Forth Valley noted that the distribution of patient questionnaires for locums or sessional doctors may not be independent of the doctor. The NHS board confirmed the process is discussed at appraisal, including its practicalities and barriers. Remediation, rehabilitation and targeted support The NHS board reported that it has processes and policies in place for providing doctors with remediation, rehabilitation and targeted support. 27

28 Medical revalidation in Scotland: local reports Self-reported assessment on progress to meet medical revalidation requirements During the self-assessment process, we asked organisations to reflect on their progress to meet medical revalidation requirements. NHS Forth Valley reported that it is developing plans and processes and can demonstrate sustainable improvement throughout the organisation. The panel considered that the NHS board has well-developed systems and processes and can demonstrate sustainable improvement throughout the organisation. Good practice, improvements and challenges We asked for feedback on examples of good practice in relation to implementing medical revalidation and NHS Forth Valley gave us a number of examples of work they had taken forward. In particular, they highlighted doctors appraising outwith their own specialty and a clear agreement that appraisers have dedicated time in their job plans to carry out 1 appraisals each year. The NHS board also noted that it had a managed process of appraisals spread over the year. NHS Forth Valley confirmed that revalidation has contributed towards local improvement in the organisation by encouraging senior doctors to undertake and support improvement work and personal and leadership development. However, NHS Forth Valley reported that it is hard to be certain that the improvement would not have happened without the appraisal process. We also asked about challenges. NHS Forth Valley reported that steady progress has been achieved in addressing the key challenges identified in the previous submission for However, it confirmed that further development is required to be made in the following areas: developing a process for the regular review of appraisers, aimed at ensuring a high quality of appraisals is maintained, and ensuring continuing professional development for appraisers, including regular refresher training. Action point from 215 review Increase the number of NES-trained appraisers. Fully actioned Ongoing Action points for consideration during No action points were identified by the panel for

29 Medical revalidation in Scotland: local reports NHS Grampian Data tables Number of doctors with a prescribed connection Number of doctors with a prescribed connection on 31 March 216 1,285 Number of doctors eligible for appraisal in ,2 Number of completed appraisals Appraisal results ,16 (96%) Appraisal results ,21 (9%) Appraisal results ,142 (98%) Appraisal results ,67 (95%) Appraisal results ,114 (98%) Appraisal results ,175 (98%) Revalidation results Number of doctors eligible for revalidation in Number of positive recommendations 42 (93%) Number of deferral requests 32 (7%) Revalidation Number of doctors identified for revalidation in Number of doctors identified for revalidation in who had an appraisal between 1 April 212 and 31 March 213 between 1 April 212 and 31 March 213 Number of doctors identified for revalidation in who had an appraisal between 1 April 213 and 31 March 214 between 1 April 213 and 31 March 214 Number of doctors identified for revalidation in who had an appraisal between 1 April 214 and 31 March 215 between 1 April 214 and 31 March 215 Number of doctors identified for revalidation in who had an appraisal between 1 April 215 and 31 March 216 between 1 April 215 and 31 March (26%) 17 (1%) 28 (43%) 28 (1%) 37 (57%) 37 (1%) 6 (92%) 6 (1%) Number of NES-trained appraisers Number of NES-trained appraisers in organisation

30 Medical revalidation in Scotland: local reports Findings of the evaluation panel NHS Grampian is a designated body and provides appraisal and RO support to the University of Aberdeen and appraisal support only to NHS Orkney and NHS Shetland. A local agreement between NHS Grampian and the two NHS boards is in place detailing these arrangements. Governance relevant to revalidation NHS Grampian reported that it has structures in place to support all aspects of the appraisal process. The RO is supported by the deputy RO, primary care appraisal lead and secondary care appraisal leads. The NHS board confirmed it has a system in place for monitoring and tracking information on missed or incomplete appraisals. The NHS board sends appraisees reminder letters to complete their appraisal at key points throughout the year and sends a different letter to individual doctors who have not booked their appraisal towards the end of the year. The NHS board reported it had carried out an audit on doctors who had not undertaken an appraisal interview and a report detailing the findings and recommendations was produced. A SWOT (Strengths, Weaknesses, Opportunities and Threats) analysis in medical appraisal was presented to NHS Grampian s Board. The NHS board described how deferrals are managed in the appraisal system. The NHS board contacts the doctors who have deferred and a clear plan is put in place detailing the necessary steps to ensure a positive recommendation for revalidation is made at the next revalidation date. Doctors who are deferred for a second time must attend a face-to-face meeting with the RO or deputy RO and appraisal lead to make sure a clear plan is put in place to address any difficulties. The NHS board reported that its revalidation policy is being updated to reflect this. NHS Grampian reported that the RO (or their delegated representative) checks Form 4s (or relevant documentation) for new appointments. The NHS board confirmed that a transfer of information form is completed to share information between the ROs for doctors who are employed by more than one organisation. NHS Grampian promotes medical revalidation on its new medical directorate intranet pages. Copies of these pages were provided to the panel and included sections on: the background to medical revalidation and appraisal the revalidation process leaving or retiring, and training. 3

31 Percentage Medical revalidation in Scotland: local reports Appraisal rates The graph below demonstrates the appraisal rates for NHS Grampian for to Figure 1: NHS Grampian percentage of completed appraisals compared with the Scottish mean appraisal rate NHS Grampian Scotland Appraisal year Information for appraisal Supporting information: NHS Grampian confirmed that doctors are advised to include relevant supporting information that supports the whole of their practice. Guidance for this is on SOAR, which is used by all doctors. The supporting information is also included in NHS Grampian s draft appraisal policy, which is currently being updated. NHS Grampian described a number of ways on how it provides doctors in secondary care with sufficient up-to-date clinical activity information. Reports are produced from the NHS National Services Scotland (NSS) Discovery system for doctors in secondary care. NSS Discovery is an information system that provides approved users with access to a range of comparative information to support performance and quality improvement. This allows authorised users to look at data for an individual doctor or patient. NHS Grampian has also established a small group to encourage the use of this data set and to influence its content with the developers. The panel recommended this as good practice. The NHS board reported it is also developing reports using other software which will show activity against every consultant s job plan. NHS Grampian also confirmed that it has a number of ways in which doctors in primary care receive up-to-date clinical activity information so that they can reflect on, and improve, the delivery of clinical care. This includes feedback from PRISMS (a prescribing information system for Scotland), various health intelligence data and feedback from DATIX reports. Complaints, compliments and concerns: NHS Grampian reported that the system to enter information on complaints, compliments and concerns in to the appraisal system varies between its services. Doctors can record this information on a spreadsheet throughout the year and upload it on to SOAR. When preparing for their appraisal, doctors can contact the management team to ask the feedback service for this information. 31

32 Medical revalidation in Scotland: local reports Departments collate this information for improvement activity as well as for doctors to take to their appraisal. For locum doctors who have left the organisation, complaints are sent to their RO so these can be included in their appraisal. NHS Grampian reported that it is planning to implement a new system that produces reports linking complaints, compliments and concerns to the individual doctor using the DATIX system. The NHS board is currently in the process of developing guides for staff using the new system. Once established, this system should assist doctors to access reliable data on complaints and compliments for their annual appraisal, as well as assist the RO. The plan is to launch the new system at the end of August 216. Multi-source feedback: NHS Grampian confirmed that it promotes the use of WASP on SOAR to collect multi-source feedback and all doctors are encouraged to use this system. The NHS board reported that this is not mandatory as some doctors may have already undertaken multi-source feedback from other sources before their revalidation date. The appraisee and appraiser discuss the multi-source feedback at the appraisal and any concerns highlighted may be addressed through the doctor s personal development plan. Patient satisfaction: NHS Grampian reported it does not specify which questionnaire doctors use to gather patient feedback. It confirmed that the most frequently used questionnaires are GMC, CARE and Royal College patient surveys. The questionnaire is formatted so that doctors are unaware of who has completed it. NHS Grampian s intranet page has a letter from the RO which can be used to distribute the questionnaires to the patients. This letter explains to the patient why the feedback is being gathered. The NHS board reported that a number of appraisees have requested help to gather patient feedback as there is no supported system for this. It was noted that the RO has recommended in the medical appraisal report that was presented to the NHS Grampian Board that the NHS board should consider developing a system to collect patient feedback which doctors could access to obtain individual results. Remediation, rehabilitation and targeted support NHS Grampian has a process in place for doctors requiring remediation, rehabilitation and targeted support. It confirmed NHS Grampian s Framework for Support has a suite of policies and procedures for its medical and dental employees. The NHS board has taken initial steps to develop a remediation policy based on the national model, which is due to be completed within the next year. The NHS board reported that it works closely with its occupational health service for doctors requiring rehabilitation services. Self-reported assessment on progress to meet medical revalidation requirements During the self-assessment process, we asked organisations to reflect on their progress to meet medical revalidation requirements. NHS Grampian reported that it is developing plans and processes and can demonstrate sustainable improvement throughout the organisation. The panel considered that the NHS Grampian has well-developed systems and processes and can demonstrate sustainable improvement throughout the organisation. Good practice, improvements and challenges We asked for feedback on examples of good practice in relation to implementing medical revalidation and NHS Grampian gave us a number of examples of work it has taken forward. This includes a CPD programme, induction seminars, development sessions and development pathways for senior medical staff. NHS Grampian reported that it is looking to improve the system to help substantive or locum doctors who may be unfamiliar with appraisal and revalidation requirements. 32

33 Medical revalidation in Scotland: local reports We also asked about challenges and the following challenges were identified by NHS Grampian. The NHS board had discovered a significant number of doctors who had not disconnected themselves from NES when their training had finished. The NHS board has taken steps to discuss this with its human resources department and NES. There were particular issues with the recognition of trainer section on SOAR. This had delayed a number of Form 4s being signed off. An update to SOAR should solve this problem. Action points from 215 review Ensure an RO report or briefing paper is provided through formal governance procedures at least annually. Develop and implement a CPD policy and programme. Finalise suite of Framework for Support policies. Continue to monitor number of annual appraisals. Ensure that all appraisers have completed the NES national (enhanced) medical appraiser training. Ensure a system is in place to provide doctors with up-to-date clinical activity within primary care. Fully actioned Ongoing Action points for consideration during No action points were identified by the panel for

34 Medical revalidation in Scotland: local reports NHS Greater Glasgow and Clyde Data tables Number of doctors with a prescribed connection Number of doctors with a prescribed connection on 31 March 216 3,17 Number of doctors eligible for appraisal in ,968 Number of completed appraisals Appraisal results ,256 (8%) Appraisal results ,255 (83%) Appraisal results ,233 (75%) Appraisal results ,726 (88%) Appraisal results ,735 (92%) Appraisal results ,778 (94%) Revalidation results Number of doctors eligible for revalidation in Number of positive recommendations 941(94%) Number of deferral requests 55 (6%) Revalidation Number of doctors identified for revalidation in Number of doctors identified for revalidation in who had an appraisal between 1 April 212 and 31 March 213 between 1 April 212 and 31 March 213 Number of doctors identified for revalidation in who had an appraisal between 1 April 213 and 31 March 214 between 1 April 213 and 31 March 214 Number of doctors identified for revalidation in who had an appraisal between 1 April 214 and 31 March 215 between 1 April 214 and 31 March 215 Number of doctors identified for revalidation in who had an appraisal between 1 April 215 and 31 March 216 between 1 April 215 and 31 March (38%) 47 (85%) 8 (55%) 79 (99%) 95 (66%) 95 (1%) 17 (74%) 17 (1%) Number of NES-trained appraisers Number of NES-trained appraisers in organisation 33 34

35 Medical revalidation in Scotland: local reports Findings of the evaluation panel NHS Greater Glasgow and Clyde is a designated body and has an RO supported by two deputy ROs (one from primary care and one from secondary care) who provide leadership and advice on all aspects of the appraisal and revalidation process. In addition, secondary care has appointed appraisal leads who support the directorate and sector chiefs of medicine in the appraisal and revalidation requirements for their area. Primary care also has a local appraisal lead. The NHS board also provides RO support and appraisal services to six hospices and has a formal written agreement in place covering the services provided. The NHS board also provides appraisal support to Healthcare Improvement Scotland (clinical director), Glasgow Memory Clinic, police surgeons and The National Sports Injury Clinic, Hampden. Governance relevant to revalidation The NHS board continues to improve its infrastructure and systems to support appraisal and revalidation requirements. Appraisal leads within secondary care have been appointed during to support the directorate and sector chiefs of medicine in the appraisal and revalidation requirements for their area. Within primary care there is an established appraisal lead in place. There is a system in place locally for those not engaging in the process. This is managed through the NHS board s non-engagement policy, where required. Deferrals and non-engagement rates are discussed regularly at the NHS board-wide revalidation group meeting, which is chaired by the RO. From , a report on medical revalidation will be forwarded to the staff governance committee. A report setting out the revalidation process, progress made and sustained good practice is submitted to the staff governance group every September. The NHS board maintains a log of all deferrals, including the timescales and reasons for deferral. Reports can be produced using different variables to provide information on different patterns and trends in rates. The NHS board gave an example where it had identified that the grade of non-training clinical fellow has the highest deferral rate within the NHS board. The panel commended this audit of deferrals as good practice. The NHS board also has arrangements in place to check Form 4s (or relevant documentation) for new appointments. The NHS board has developed and implemented a template for transferring information between ROs where doctors are employed by more than one organisation. 35

36 Percentage Medical revalidation in Scotland: local reports Appraisal rates The graph below demonstrates the appraisal rates for NHS Greater Glasgow & Clyde for to Figure 1: NHS Greater Glasgow and Clyde percentage of completed appraisals compared with the Scottish mean appraisal rate NHS Greater Glasgow and Clyde Scotland Information for appraisal Appraisal year Supporting information: The NHS board uses a variety of methods to prompt doctors to include relevant supporting information that supports the whole of their practice such as letters to new starts advising of responsibilities, a dedicated revalidation page on the medical staffing intranet and appraiser and appraisee update sessions. Complaints, compliments and concerns: The NHS board reported that it has a system in place whereby a certificate is issued to appraisees and appraisers confirming whether or not any complaints or concerns were received in the previous year. This information is gathered from the DATIX system and forms part of the discussion at the appraisal meeting. The NHS board has recently implemented a new system within secondary care to support information sharing about significant clinical incidents during the previous year. Appraisees will be able to contact the medical staffing team to confirm whether they have been linked to any significant clinical incidents in the preceding year. Multi-source feedback: All doctors are signposted to the multi-source feedback resource on SOAR to complete their multi-source feedback and are advised to discuss the summary report at their appraisal. Discussion on multi-source feedback is documented on the Form 4. The Form 4s are quality checked by the deputy RO to make sure this has been recorded, and where necessary, it is incorporated into personal development plans. Patient satisfaction: All doctors with patient contact must attempt to gather patient feedback. Any exemptions to this are discussed at the NHS board-wide revalidation group. The CARE patient feedback questionnaire is the recommended form used to gather patient feedback. Other questionnaires can be used as long as they have been approved by the NHS board. The NHS board considered that the use of the patient questionnaires to date has been successful and it has established systems in place to manage these. Guidance is available for doctors on using the patient feedback processes and the NHS board reported that this system is operating well. 36

37 Medical revalidation in Scotland: local reports Remediation, rehabilitation and targeted support The NHS board has a remediation policy which offers a range of support options to doctors. Various support mechanisms are in place such as clinical support groups and occupational health and employee counselling services. The NHS board also provides appropriate educational opportunities to doctors to refine or improve their skills. Self-reported assessment on progress to meet medical revalidation requirements During the self-assessment process, we asked organisations to reflect on their progress to meet medical revalidation requirements. NHS Greater Glasgow and Clyde reported that it can demonstrate sustained good practice and innovation that is shared throughout the organisation and which others can learn from. The panel agreed with this assessment. Good practice, improvements and challenges We asked for feedback on examples of good practice relating to implementing medical revalidation. NHS Greater Glasgow and Clyde provided a number of examples of work, including: standardising processes to ensure consistency across the NHS board such as the nonengagement protocol, complaints certificate process and patient questionnaire process developing a template for sharing information between ROs for doctors employed by more than one organisation which has been shared with other NHS boards, and implementing a phased appraisal process; this structured approach has helped to increase the number of completed appraisals each year. The NHS board reported that the introduction of medical revalidation has supported and contributed to local improvements within the NHS board, including increasing appraisal completion rates each year. This increased engagement in the appraisal process has informed the NHS board about the areas or groups of staff or individuals who may require additional support. We also asked about challenges and the NHS board identified three areas: to increase the appraisal rate, the NHS board will focus on doctors who are near retirement and are not keen to engage in the process, and GPs with portfolio careers in the private or independent sector a new process structure relating to monitoring the appraisal and revalidation of doctors who work solely on the NHS board s medical bank requires to be implemented, and the NHS board requires keeping appraiser cohort numbers at sufficient levels for each sector and directorate and reported this as challenging due to the appraisers busy schedules, lack of appraisal training dates and limited places available for NES appraiser training. The panel commended NHS Greater Glasgow and Clyde on the good infrastructure in place, and the robust systems and quality assurance processes implemented to support and sustain appraisal and medical revalidation as described in the self-assessment. Action point from 215 review Continue to monitor and increase annual appraisal rates and aim for at least 95% of completed appraisals. Fully actioned Ongoing Action points for consideration during No action points were identified by the panel for

38 Medical revalidation in Scotland: local reports NHS Highland Data tables Number of doctors with a prescribed connection Number of doctors with a prescribed connection on 31 March Number of doctors eligible for appraisal in Number of completed appraisals Appraisal results (89%) Appraisal results (98%) Appraisal results (92%) Appraisal results (92%) Appraisal results (91%) Appraisal results (9%) Revalidation results Number of doctors eligible for revalidation in Number of positive recommendations 236 (89%) Number of deferral requests 3 (11%) Revalidation Number of doctors identified for revalidation in Number of doctors identified for revalidation in who had an appraisal between 1 April 212 and 31 March 213 between 1 April 212 and 31 March 213 Number of doctors identified for revalidation in who had an appraisal between 1 April 213 and 31 March 214 between 1 April 213 and 31 March 214 Number of doctors identified for revalidation in who had an appraisal between 1 April 214 and 31 March 215 between 1 April 214 and 31 March 215 Number of doctors identified for revalidation in who had an appraisal between 1 April 215 and 31 March 216 between 1 April 215 and 31 March (28%) 8 (1%) 18 (62%) 18 (1%) 18 (62%) 18 (1%) 17 (59%) 17 (1%) Number of NES-trained appraisers Number of NES-trained appraisers in organisation 14 38

39 Medical revalidation in Scotland: local reports Findings of the evaluation panel Governance relevant to revalidation NHS Highland is a designated body and provides annual appraisal services and RO support to Highland Hospice. There is no formal agreement in place for the provision of external RO support to Highland Hospice. However, as all of the doctors working at Highland Hospice have their prescribed connection with NHS Highland, there is no requirement for the hospice to formally outsource medical appraisal. NHS Highland is responsible for the annual appraisal of all doctors with a prescribed connection to it and this includes the doctors who work at Highland Hospice. The NHS board reported that it has two part-time secondary care appraisal leads and two primary care local appraisal advisors who are responsible for providing leadership and advice to doctors and assist the NHS board s RO with revalidation recommendations. NHS Highland indicated that it had not undertaken a formal audit of missed or incomplete appraisals. However, the NHS board explained that it has a monitoring and tracking system in place for secondary care, which is administered and managed by two senior medical staffing officers. NHS Highland reported that its system is continuing to work well and is supported by the NHS board s appraisal lead and RO. Within primary care, an ongoing, monthly audit of appraisals is carried out by the appraisal administrator, and first and second reminder letters are sent to appraisers and appraisees to request appraisal sign-off. The NHS board confirmed that the reasons for missed appraisals are discussed at meetings between the local appraisal advisor and the clinical director which take place every three weeks. Within secondary care, an appraisal tracking system is in place and managed by senior medical staffing officers. In addition to this, the NHS board has implemented an automatic appraisal reminder system where three levels of reminder letters are generated and sent to appraisers and appraisees. NHS Highland reported that the new system is working well and the panel commended the system and noted the additional electronic feedback systems that the NHS board has in place. The RO for NHS Highland presents an annual report to the NHS board s staff governance committee which directly reports to the Board. However, the panel noted that the copy of the annual report that NHS Highland had submitted was a prospective report which had been post dated and had not yet been presented to the Board. The panel discussed its concerns at the significantly high deferral rate that NHS Highland had reported and requested an explanation from the NHS board. NHS Highland reported that it had not undertaken an audit of deferrals and explained that deferrals are formally reported to the appraisal and revalidation steering group for discussion. The NHS board added that it continues to monitor deferrals and that letters are sent from the senior medical staffing officer, on behalf of the RO, for every deferral. The NHS board indicated that its RO (or delegated representative) checks Form 4 documents for all new appointments. It explained that it would request a copy of the previous year s Form 4 prior to appointment for any of its doctors who are employed by another organisation, where that organisation has the responsibility of undertaking their annual appraisal and, every year thereafter. The panel commended this approach and noted this as an area of good practice. 39

40 Percentage Medical revalidation in Scotland: local reports Appraisal rates The graph below demonstrates the appraisal rates for NHS Highland for to Figure 1: NHS Highland percentage of completed appraisals compared with the Scottish mean appraisal rate NHS Highland Scotland Appraisal year Information for appraisal Supporting information: NHS Highland reported that in-house learning sessions are available for all doctors to raise their awareness of responsibility to include items of supporting information that reflects the whole of their practice. The NHS board added that the RO had written to all doctors in the NHS board area to remind them of their responsibility to provide supporting information for appraisal and, of the need for the Form 4 to include sufficient information, to allow an informed recommendation on revalidation to be made. NHS Highland explained that most doctors collate their own clinical activity data and can request reports from the NHS board if necessary. The NHS board further explained that individual clinical activity reports, from the patient administration system, have historically been made available on request. However, over the past year, the reports have been more difficult to provide due to the ongoing implementation of a new system. NHS Highland confirmed that clinical activity data from other systems such as Theatreman and Digital Dictation are available to individual doctors on request. The NHS board added that activity for primary care is provided by the practice manager of the doctor s place of work. Complaints, compliments and concerns: NHS Highland reported that it is in the process of implementing a new system to monitor complaints for all doctors, as opposed to just doctors under notice for revalidation. The NHS board explained that its new complaint tracking system will highlight doctors who have three or more complaints made against them within a 12-month rolling year, or more than 1 complaints in a 5-year cycle. The NHS board anticipates that all of the complaints correspondence will eventually be sent to the clinical director, from the area in which the respective doctor works, for their consideration. For doctors working within secondary care, information relating to complaints, concerns and critical incidents is obtained from Datix, the patient safety and risk management software for healthcare incident reporting and adverse events. A report is generated from Datix and sent to an appraisee 4-weeks in advance of their appraisal date and should be included as evidence for their appraisal. 4

41 Medical revalidation in Scotland: local reports For doctors working within primary care, the NHS board stated that it is the responsibility of the appraisee to identify complaints and incidents related to their personal practice and introduce these for discussion during the appraisal process. Multi-source feedback: NHS Highland advised that it continues to use a range of software systems including SOAR which provides NHS organisations with a range of online revalidation services such as patient and colleague feedback, for the documentation and management of appraisals. Patient satisfaction: NHS Highland reported that its doctors working within secondary care continue to use the CARE questionnaire to gather patient feedback. The NHS board s anaesthetists have used the Royal College of Anaesthetists patient questionnaire during NHS Highland explained that a staff guidance sheet and patient instruction letter are provided with the packs of questionnaires that are sent to clinical staff. The questionnaires are distributed at outpatient clinics by the clinic receptionists or nurses to make sure that information is reported independently from the doctors. The panel noted that the NHS board had reported that patient questionnaires were only distributed at outpatient clinics. The panel discussed the importance of organisations gathering real-time data and patient feedback that is reflective of the whole of the doctor s practice. NHS Highland confirmed that the majority of doctors working in primary care also use the CARE questionnaire which provides a report with benchmarking against national results for all doctors. The NHS board added that a template is available on SOAR which its doctors often use to record their reflections on the results of their patient questionnaires. Remediation, rehabilitation and targeted support NHS Highland reported that it has a remediation, rehabilitation and support policy and submitted a copy of this document for panel review, together with two documents also used by the NHS board to support its doctors with additional training needs. NHS Highland highlighted that any further monitoring of a doctor s conduct, performance or fitness to practise is picked up and reviewed by the NHS board s performance, appraisal and revalidation group. Self-reported assessment on progress to meet medical revalidation requirements During the self-assessment process, we asked organisations to reflect on their progress to meet medical revalidation requirements. NHS Highland reported that it has well-developed systems and processes and can demonstrate sustainable improvement throughout the organisation. The panel agreed with this assessment. Good practice, improvements and challenges We asked for feedback on examples of good practice in relation to implementing medical revalidation and NHS Highland gave us a number of examples. The NHS board highlighted that it continues to operate a robust appraisal and revalidation system and an effective system for appraiser allocation. The NHS board added that the appointment of secondary care appraiser leads has enhanced the NHS board s existing system for engagement and support. It also referred to the appraisal reminder system and reported that this was proving to add value to the NHS board s engagement rates for medical appraisal. NHS Highland confirmed that it is now actively reviewing Form 4 information at the point of completion to make sure that there is sufficient evidence to support revalidation. When asked about how revalidation has supported and or contributed to local improvement in the organisation, NHS Highland reported that it has greater confidence in the quality of its doctors and its ability to identify doctors who may be under-performing, which allows mediation to be undertaken at an earlier stage. We also asked about any challenges that organisations might face in relation to the implementation of medical revalidation. NHS Highland reported that it is continuing to look at 41

42 Medical revalidation in Scotland: local reports ways to improve its patient feedback return rates and is currently trialling a system where a link to an online survey is included in clinic letters that are issued to patients. The panel agreed that NHS Highland had demonstrated that it has good governance systems in place and commended the NHS board s complaints tracking system which it had recently implemented. Action points from 215 review Fully actioned Ongoing Provide an RO report, at least annually, through formal governance arrangements. Continue to monitor appraisal rate. Continue to develop processes for the management of patient feedback. Action points for consideration during Continue to monitor the appraisal rate. Consider looking at distributing patient questionnaires to inpatients in order to gather patient feedback that is reflective of the whole of practice. Evidence developments in the management of patient feedback and details of the outcome of the system that the NHS board is currently trialling. 42

43 Medical revalidation in Scotland: local reports NHS Lanarkshire Data tables Number of doctors with a prescribed connection Number of doctors with a prescribed connection on 31 March 216 1,116 Number of doctors eligible for appraisal in ,1 Number of completed appraisals Appraisal results (77%) Appraisal results (8%) Appraisal results (93%) Appraisal results (82%) Appraisal results (89%) Appraisal results (93%) Revalidation results Number of doctors eligible for revalidation in Number of positive recommendations 34 (95%) Number of deferral requests 16 (4%) Revalidation Number of doctors identified for revalidation in Number of doctors identified for revalidation in who had an appraisal between 1 April 212 and 31 March 213 between 1 April 212 and 31 March 213 Number of doctors identified for revalidation in who had an appraisal between 1 April 213 and 31 March 214 between 1 April 213 and 31 March 214 Number of doctors identified for revalidation in who had an appraisal between 1 April 214 and 31 March 215 between 1 April 214 and 31 March 215 Number of doctors identified for revalidation in who had an appraisal between 1 April 215 and 31 March 216 between 1 April 215 and 31 March (36%) 13 (1%) 18 (5%) 18 (1%) 21 (58%) 21 (1%) 29 (81%) 29 (1%) Number of NES-trained appraisers Number of NES-trained appraisers in organisation 76 43

44 Percentage Medical revalidation in Scotland: local reports Findings of the evaluation panel Governance relevant to revalidation NHS Lanarkshire is a designated body. The NHS board provides RO support and appraisal services to St. Andrew s Hospice. A formal agreement is in place between NHS Lanarkshire and St Andrew s Hospice which is based on the national agreement template. NHS Lanarkshire has processes in place to track any missed or incomplete appraisals. A database has been developed which is managed by human resources, medical education and revalidation teams. Details of new starts, leavers, job planning and appraisal information is regularly captured by the SOAR administrator and revalidation team which, in turn, issues automatic reminders in advance of appraisal due dates. The NHS board provided an anonymised report from the database as part of its self-assessment documentation. This provided a full update to the panel on any missed or incomplete appraisals for primary and secondary care doctors and included up-to-date status commentary. The panel commended the NHS board on this additional information supplied within its data submission. NHS Lanarkshire provides an annual report on appraisal progress to its governing body. A copy of this report was provided as part of the NHS board s self-assessment. This included an addendum stating that the progress of appraisals at St. Andrew s Hospice was provided verbally. The panel encourage NHS Lanarkshire to include a written statement on the status of appraisals at St. Andrew s Hospice in its annual report. An audit for all deferrals during the period 1 April 215 to 31 March 216 was carried out by the NHS board and was provided as part of the self-assessment submission. This report outlined a small number of deferrals and that a process is in place to ensure follow-up and engagement with individual doctors. The NHS board confirmed that it has a process in place to check Form 4s (or relevant documentation) for all new appointments as part of the medical staffing database. Doctors who are employed by more than one organisation are managed on a case by case basis by the NHS Board due to the very small numbers involved. Appraisal rates The graph below demonstrates the appraisal rates for NHS Lanarkshire for to Figure 1: NHS Lanarkshire percentage of completed appraisals compared with the Scottish mean appraisal rate NHS Lanarkshire Scotland Appraisal year 44

45 Medical revalidation in Scotland: local reports Information for appraisal Supporting information: NHS Lanarkshire has a process in place to make sure that doctors are aware of their responsibility to include items of supporting information that reflects the whole of their practice. The NHS board does this by ensuring that all its appraisers are reminded regularly about the need to cover all areas of practice in the appraisal. In addition, all new appointments take part in an appraisal session as part of the induction programme. The panel highlighted this as an area of good practice. Doctors collect clinical activity information for their appraisals by submitting a request to the NHS board s information services department. NHS Lanarkshire reported that it is working with the Discovery team to develop consultant scorecards. These are expected to be available in the near future. Complaints, compliments and concerns: NHS Lanarkshire reported it has a process in place to inform the appraisal system of complaints. If concerns relating to an appraisee s practice or involvement of an appraisee in a critical incident are felt to require discussion at appraisal, the appraisee will be requested to do this. In serious adverse event reports this will be highlighted as a recommendation. The NHS board s patient affairs department receives information from the revalidation team on a monthly basis for all doctors in secondary care due for revalidation. For primary care, the NHS board reported that the responsibility for collecting this information is the responsibility of the doctor. The NHS board also sends a list of logged complaints to the appraiser as a reminder for appraisal discussion. Multi-source feedback: It was reported in NHS Lanarkshire s self-assessment that the majority of its doctors use the WASP system to collect multi-source feedback. All new doctors appointed to the NHS board receive an appraisal induction session which covers the use of the NES multi-source feedback tool. The NHS board noted in its self-assessment that its appraisers are fully trained to provide feedback. Patient satisfaction: NHS Lanarkshire reported that most of its doctors in secondary care use the CARE questionnaire to gather patient feedback. The NHS board reported that as well as the CARE questionnaire, it also uses the Royal College of Physician s tool and a locally developed tool specific to learning and development services. Doctors are supported by the revalidation team by providing blank questionnaires on request. Reception and nursing staff then assist doctors to distribute and collect the questionnaires and then return completed questionnaires to the revalidation team for analysis. Reports are then made available to doctors for inclusion in their appraisal portfolios. The NHS board reported that, overall, responses are positive from patients. Remediation, rehabilitation and targeted support The NHS board has a process in place to provide support and remediation services to doctors. These processes are supported by various human resources policies. A copy of the NHS board s effective management of employee conduct policy and procedures was provided. The panel encouraged the NHS board to add more guidance on remediation as this policy mainly supports disciplinary procedures. Rehabilitation services are available to doctors in NHS Lanarkshire through its occupational health service. Self-reported assessment on progress to meet medical revalidation requirements During the self-assessment process, we asked organisations to reflect on their progress to meet medical revalidation requirements. NHS Lanarkshire reported that it has welldeveloped systems and processes and can demonstrate sustainable improvement throughout the organisation. The panel agreed with this assessment. Good practice, improvements and challenges We asked for feedback on examples of good practice in relation to implementing medical revalidation and NHS Lanarkshire reported that its in-house developed database has been a 45

46 Medical revalidation in Scotland: local reports key example of good practice. NHS Lanarkshire reported that medical revalidation has contributed to local improvements for the NHS board. It noted in particular, that it has seen an increased focus on CPD as well as an increase in quality improvement activity. NHS Lanarkshire reported that the continuous need to find additional appraisers for secondary and primary care as a challenge to the NHS board. The panel commended NHS Lanarkshire on its increase on appraisal rates from 89% during , to 93% in Action point from 215 review Include a paragraph on St. Andrew s Hospice in the RO report to the Board. Fully actioned Ongoing Action point for consideration during Include a written statement on appraisal status at St Andrew s Hospice in its annual report. St. Andrew s Hospice St. Andrew s Hospice, provides specialist palliative care services to those who require complex symptom management or end of life care. It is a specialist hospice which provides multidisciplinary support for patients, their families and carers. NHS Lanarkshire provides the hospice with appraisal services and RO support. A formal agreement is in place for the outsourcing of these services as outlined in the introduction to this report. However, as the doctors working in the hospice have a prescribed connection to NHS Lanarkshire, the review panel saw no added value of the hospice being a designated body. All non-training grade doctors, for example consultants, associate specialists and specialty doctors have an appraiser appointed to them by NHS Lanarkshire and receive an annual appraisal in line with the revalidation process. Updates on senior medical staffing issues, including updates on appraisal and revalidation, are discussed at weekly meetings and also form part of the chief executive s report to the Board of Trustees which meets every 3 months. The hospice outlined its governance structure which links its subcommittees into its integrated governance committee. The lead clinician provides doctors with clinical activity information every month. The hospice is also introducing an electronic patient records system to enable doctors to access reports on clinical activity. The hospice has a process in place to gather feedback from patients and their families. The hospice reported that its satisfaction surveys indicate that the dignity of its patients and the quality of service provided is highly rated. In addition to this, there is an engagement and feedback policy for the management of complaints, comments or suggestions. Information relating to medical staff is fed back to the lead clinician. The panel was satisfied with the governance arrangements that the hospice has in place for the management of medical appraisal and revalidation. 46

47 Medical revalidation in Scotland: local reports NHS Lothian Data tables Number of doctors with a prescribed connection Number of doctors with a prescribed connection on 31 March 216 2,27 Number of doctors eligible for appraisal in ,195 Number of completed appraisals Appraisal results ,951 (92%) Appraisal results ,946 (92%) Appraisal results ,949 (91%) Appraisal results ,955 (95%) Appraisal results ,992 (92%) Appraisal results ,21 (92%) Revalidation results Number of doctors eligible for revalidation in Number of positive recommendations 778 (97%) Number of deferral requests 23 (3%) Revalidation Number of doctors identified for revalidation in Number of doctors identified for revalidation in who had an appraisal between 1 April 212 and 31 March 213 between 1 April 212 and 31 March 213 Number of doctors identified for revalidation in who had an appraisal between 1 April 213 and 31 March 214 between 1 April 213 and 31 March 214 Number of doctors identified for revalidation in who had an appraisal between 1 April 214 and 31 March 215 between 1 April 214 and 31 March 215 Number of doctors identified for revalidation in who had an appraisal between 1 April 215 and 31 March 216 between 1 April 215 and 31 March (24%) 16 (64%) 5 (49%) 36 (72%) 65 (63%) 57 (88%) 73 (71%) 73 (1%) Number of NES-trained appraisers Number of NES-trained appraisers in organisation

48 Medical revalidation in Scotland: local reports Findings of the evaluation panel NHS Lothian is a designated body and provides RO services to Marie Curie, Edinburgh and St. Columba s Hospice, Edinburgh. A formal agreement, using the national agreement template, is in place for the provision of external RO services from NHS Lothian to both hospices. A service level agreement is in place with NHS Borders for the provision of appraisal support to primary care doctors. Governance relevant to revalidation The NHS board has arrangements in place to monitor and track information regarding missed or incomplete appraisals and had carried out an audit of primary and secondary care appraisals for The NHS board reported that its local appraisal advisor receives notifications from SOAR if an appraisal is incomplete at 4-weeks after the appraisal interview date and works with the appraisal administrator to review outstanding appraisals. The appraiser is responsible for monitoring the timing of appraisals for the appraisees who appear on their list and is encouraged to contact the local appraisal advisor, at an early stage, if an appraisal is significantly delayed or if they anticipate problems with the completion of an appraisal. NHS Lothian indicated that the RO does not check Form 4s (or relevant documentation) for new appointments. Instead, systems are in place to delegate and manage this process. The NHS board explained that in primary care, completing an annual appraisal is part of the process of applying for inclusion in the Performers List and a condition of remaining on this list, therefore, the RO does not have responsibility for new appointments within independent doctor s practices. For secondary care, the NHS board has developed and tested a process which involves the appraisal administrator being notified of all new starts from medical recruitment. The appraisal administrator contacts the doctor with a request for the individual s Form 4, or evidence of a previous appraisal and this information is added to SOAR. A similar process is in place for doctors joining the staff bank, where it has been established that their employment with NHS Lothian is their only employment and, they are not being appraised elsewhere. NHS Lothian indicated that where doctors are employed by more than one organisation, it has a process in place to share information between the organisations. The NHS board confirmed that concerns over performance would be shared immediately between ROs, medical directors and local appraisal advisors and that a probity obligation is in place for all doctors to share information if they are aware of a colleague s poor performance. The panel suggested that the NHS board s process for sharing information with organisations should be formalised. NHS Lothian has an arrangement for its RO to meet regularly with the manager of Spire Edinburgh Hospitals to share information and concerns. The panel commended this arrangement and highlighted it as an area of good practice. It also noted that a similar process was now in place with The Edinburgh Clinic. 48

49 Percentage Medical revalidation in Scotland: local reports Appraisal rates The graph below demonstrates the appraisal rates for NHS Lothian for to Figure 1: NHS Lothian percentage of completed appraisals compared with the Scottish mean appraisal rate NHS Lothian Scotland Appraisal year Information for appraisal Supporting information: The NHS board indicated that it has a process in place to make sure that doctors are aware of their responsibility to include items of supporting information that reflects the whole of their practice. However, the NHS board did not provide any details of the process that is in place or how it works in practice. NHS Lothian reported that all of its appraisers have access to SOAR appraisal Form 2 and they are trained to explore all aspects of a doctor s medical practice during the appraisal interview. The NHS board continues to experience challenges in secondary care with private practice and doctors with commitments to other NHS boards and external duties. It also reported that out of specialty appraisals can cause additional complexities. The NHS board confirmed that it has a system for providing doctors with sufficient up-to-date and relevant clinical activity information. Within primary care, doctors based in one practice can have access to whole practice data, for example, prescribing and quality and outcomes framework achievements. A variety of sources of clinical activity information are available for those working within secondary care. Complaints, compliments and concerns: NHS Lothian confirmed that it has a process in place to feed information on complaints, compliments, concerns and significant adverse events into the appraisal system. The NHS board uses Datix, an integrated risk management information system for healthcare, to generate monthly reports for complaints and adverse events that occur in secondary care. These reports are sent to the respective doctors for use in the appraisal process. The data recorded in Datix is also stored on a spreadsheet which can only be accessed by the RO, secondary care appraisal lead and appraisal administrator. In primary care, complaints and significant event analysis reports are available to doctors through their practice. The NHS board stated that doctors are required to discuss all complaints at their appraisal interview as a matter of probity. Multi-source feedback: The NHS board indicated that it has arrangements in place to provide multi-source feedback to doctors and to incorporate the information into personal 49

50 Medical revalidation in Scotland: local reports and professional development plans. However, the NHS board provided no explanation of the arrangements that it has in place or how they work in practice. Patient satisfaction: NHS Lothian reported that the most frequently used questionnaire in primary care is the CARE questionnaire. It explained that doctors arrange for the administration of patient questionnaires through their place of work. For doctors working in a GP practice, the distribution and collation of questionnaires can be readily carried out by persons other than the doctor, for example, practice clerical or administrative staff. The NHS board highlighted that this particular method is more challenging for some locums and, in some cases, local solutions are implemented and discussed at the appraisal interview. In secondary care, questionnaires are distributed by a member of staff, other than the doctor, and collected and returned to the relevant department before being passed to the appraiser. The NHS board stated that the majority of questionnaires are distributed to its outpatient clinics. Some specialties use alternative processes to distribute and collect forms and the collation and feedback are carried out by the appraiser. NHS Lothian has agreed to the use of these questionnaires on the basis that they are subject to annual review and approved by the RO and appraisal lead. The NHS board stated that a tablet-based questionnaire was being trialled. However, the panel noted the NHS board also reported this trial in last year s submission and had not reported or updated on its findings. Remediation, rehabilitation and targeted support The NHS board has a framework in place for the management of primary care performance concerns and doctors in difficulty which has been agreed by the NHS board and the local medical committee. The framework covers processes for arranging remediation, rehabilitation and targeted support for independent contractors and is part of the remit of the doctors support scheme. For secondary care, there is a framework in place which is specific to the individual doctor concerned and is managed by the associate medical director and human resource staff within the scope of the framework for tackling concerns locally. The panel was content with the systems that the NHS board has in place for primary and secondary care. Self-reported assessment on progress to meet medical revalidation requirements During the self-assessment process, we asked organisations to reflect on their progress to meet medical revalidation requirements. NHS Lothian reported that it has well-developed systems and processes and can demonstrate sustainable improvement throughout the organisation. The panel agreed with this assessment. Good practice, improvements and challenges We asked for feedback on examples of good practice in relation to implementing medical revalidation. NHS Lothian explained that cross-specialty appraisal has been implemented within secondary care. The NHS board also reported that its medical director chairs a local advisory group which takes place twice every year and provides good links with NHS Borders, Edinburgh University, the dean of the medical school and local medical committees. We also asked about challenges and the NHS board reported that it experiences difficulties dealing with instances where there are multiple deferrals, in some cases where it could be deemed as non-engagement. The panel noted that the NHS board had submitted all of the required core evidence and has maintained its appraisal rate from the previous year. The panel commended the quality of the NHS board s annual report to its staff governance committee and identified the NHS board s improvement plan, an appendix to the annual report, as an area of good practice. 5

51 Medical revalidation in Scotland: local reports Action points from 215 review No action points were identified by the panel for Action point for consideration during Provide an update on the trial of the tablet-based patient questionnaire. 51

52 Medical revalidation in Scotland: local reports NHS Orkney Data tables Number of doctors with a prescribed connection Number of doctors with a prescribed connection on 31 March Number of doctors eligible for appraisal in Number of completed appraisals Appraisal results (3%) Appraisal results (59%) Appraisal results (96%) Appraisal results (9%) Appraisal results (98%) Appraisal results (94%) Revalidation results Number of doctors eligible for revalidation in Number of positive recommendations 2 (95%) *Number of deferral requests 3 (14%) *A doctor can have more than one deferral and a positive recommendation within one appraisal year Revalidation Number of doctors identified for revalidation in Number of doctors identified for revalidation in who had an appraisal between 1 April 212 and 31 March 213 between 1 April 212 and 31 March 213 Number of doctors identified for revalidation in who had an appraisal between 1 April 213 and 31 March 214 between 1 April 213 and 31 March 214 Number of doctors identified for revalidation in who had an appraisal between 1 April 214 and 31 March 215 between 1 April 214 and 31 March 215 Number of doctors identified for revalidation in who had an appraisal between 1 April 215 and 31 March 216 between 1 April 215 and 31 March 216 Number of NES-trained appraisers Number of NES-trained appraisers in organisation 6 52

53 Percentage Medical revalidation in Scotland: local reports Findings of the evaluation panel NHS Orkney is a designated body with an RO. NHS Orkney confirmed that NHS Grampian provides appraisal support and there is a formal agreement in place detailing the services NHS Grampian provides. The agreement also has a provision for the NHS Grampian RO and appraisal lead to provide support or advice, if required. Governance relevant to revalidation NHS Orkney reported that it has an appraisal working group that meets every month to monitor and track the appraisal information. Due to the small number of appraisals involved, the NHS board confirmed that the appraisal working group is able to keep track of the progress of the appraisal arrangements for all doctors. If there are any concerns relating to the appraisals, the NHS board reported that these would be addressed immediately by the group. Therefore, an audit for missed or incomplete appraisals was not required. It also reported that the appraisal working group is aware of the circumstances for any deferrals and because of the small numbers involved, an audit of deferrals was not required. NHS Orkney confirmed a report on medical revalidation was presented to NHS Orkney s staff governance committee every year. This was documented in the committee s minutes for submission to the Board. NHS Orkney reported that the RO checks the Form 4s (or relevant documentation) for new appointments. Due to the small number of doctors in question, the NHS board has no formal system in place for sharing information between organisations. This process would be managed locally when required. Appraisal rates The graph below demonstrates the appraisal rates for NHS Orkney for to Figure 1: NHS Orkney percentage of completed appraisals compared with the Scottish mean appraisal rate NHS Orkney Scotland Appraisal year 53

54 Medical revalidation in Scotland: local reports Information for appraisal Supporting information: The NHS board confirmed it has a process in place for doctors to include relevant supporting information that supports the whole of their practice. Every year, the RO s the doctors to remind them to include all relevant information. Complaints, compliments and concerns: NHS Orkney reported that it does not have a formal system in place to provide information on complaints, compliments, and concerns to its doctors. However, it reported that doctors receive feedback information from the incident management system on any incidents that involved them. Doctors are notified every year that this information is required for their appraisal. NHS Orkney confirmed that the appraisal working group also receives a feedback report every 3 months from the incident management system. Multi-source feedback: The NHS board reported that doctors use the multi-source feedback resource on SOAR for gathering feedback. The multi-source feedback is documented and checked before a doctor is revalidated. Patient satisfaction: NHS Orkney has a process in place for managing patient questionnaires. The NHS board reported it uses the GMC questionnaire to gather patient feedback. The NHS board confirmed that the RO s personal assistant sends the questionnaires to an appropriate secretary, outpatient clerk or practice manager for distribution and collection to and from patients without involving of the doctor in question. The feedback received is collated into a report and sent to the appraisee to include in their appraisal documentation. After the report has been sent to the appraisee, it is deleted so that NHS Orkney does not retain a copy. Remediation, rehabilitation and targeted support NHS Orkney reported it has access to NHS Grampian s problem assessment group to support and manage doctors who require training or re-training or rehabilitation services. The NHS board has no formal process for monitoring doctors conduct, performance or fitness to practise but confirmed it would follow NHS Grampian s policies for managing this, if required. NHS Orkney and NHS Grampian are in the process of developing a business case for sharing human resources services to formalise the existing working arrangements. Self-reported assessment on progress to meet medical revalidation requirements During the self-assessment process, we asked organisations to reflect on their progress to meet medical revalidation requirements. NHS Orkney reported that it can demonstrate sustained good practice and innovation that is shared throughout the organisation and which others can learn from. The panel considered that the NHS board has well-developed systems and processes and can demonstrate sustainable improvement throughout the organisation. Good practice, improvements and challenges We asked for feedback on examples of good practice in relation to implementing medical revalidation. NHS Orkney highlighted the flexible system it has in place for using appraisers and the monthly appraisal working group meetings, where doctors appraisal and revalidation status are reviewed and corrective action taken, if necessary. It also reported that locum recruitment processes have improved due to better pre-employment checking mechanisms. We also asked about any challenges and the NHS board reported that sustaining the number of required trained appraisers is challenging in a small NHS board. 54

55 Medical revalidation in Scotland: local reports Action points from 215 review No action points were identified from the 215 review. Action points for consideration during No action points were identified by the panel for

56 Medical revalidation in Scotland: local reports NHS Shetland Data tables Number of doctors with a prescribed connection Number of doctors with a prescribed connection on 31 March Number of doctors eligible for appraisal in Number of completed appraisals Appraisal results (93%) Appraisal results (1%) Appraisal results (98%) Appraisal results (7%) Appraisal results (84%) Appraisal results (95%) Revalidation results Number of doctors eligible for revalidation in Number of positive recommendations 17 (94%) Number of deferral requests 3 (17%) Revalidation Number of doctors identified for revalidation in Number of doctors identified for revalidation in who had an appraisal between 1 April 212 and 31 March 213 between 1 April 212 and 31 March 213 Number of doctors identified for revalidation in who had an appraisal between 1 April 213 and 31 March 214 between 1 April 213 and 31 March 214 Number of doctors identified for revalidation in who had an appraisal between 1 April 214 and 31 March 215 between 1 April 214 and 31 March 215 Number of doctors identified for revalidation in who had an appraisal between 1 April 215 and 31 March 216 between 1 April 215 and 31 March (5%) 1 (1%) 1 (5%) 1 (1%) Number of NES-trained appraisers Number of NES-trained appraisers in organisation 5 56

57 Percentage Medical revalidation in Scotland: local reports Findings of the evaluation panel NHS Shetland is a designated body with an RO. NHS Shetland has outsourced appraisal services to NHS Grampian and a formal agreement is in place detailing the services NHS Grampian provides. The agreement also has a section about NHS Grampian providing RO support. Governance relevant to revalidation NHS Shetland receives appraisal support and advice on all aspects of the appraisal process from the lead appraiser at NHS Grampian. There is an agreement with NHS Grampian that additional appraisers can be provided if required. The NHS board reported it has administrative processes in place to monitor and track appraisals and revalidation requirements. The corporate services team manages the appraisal process and revalidation requirements for acute medical staff, and primary care administration staff manage the GP appraisal process. NHS Shetland reported that an audit had been carried out to determine the reasons for any missed or incomplete appraisals and this information is documented on a spreadsheet. Every year, a medical revalidation report is submitted to NHS Shetland s clinical and governance committee but the NHS board advised a report was not submitted in 215. However, it did submit evidence to show that medical revalidation was discussed and documented in the clinical governance committee minutes for October 215. NHS Shetland reported that the RO checks Form 4s (or relevant documentation) for all new appointments they have responsibility for. The NHS board confirmed the process for sharing information between organisations, when doctors are employed by more than one organisation. Any relevant information will be shared between NHS Shetland s RO and the clinical director and/or the RO in the other health board and vice versa for any relevant incidents that may have occurred out with NHS Shetland. Appraisal rates The graph below demonstrates the appraisal rates for NHS Shetland for to Figure 1: NHS Shetland percentage of completed appraisals compared with the Scottish mean appraisal rate NHS Shetland Scotland Appraisal year 57

58 Medical revalidation in Scotland: local reports Information for appraisal Supporting information: The NHS board confirmed it has a system in place to ensure that doctors are aware of their requirements and responsibilities to include supporting documentation that reflects the whole of their practice. The RO informs all doctors of the requirements and also discusses this with newly appointed doctors following their appointment. Complaints, compliments and concerns: The corporate services team uses DATIX to manage the process for feeding information on complaints, compliments, concerns or critical incidents into the appraisal system. The appraisee receives a report of any complaints received before their appraisal meeting. Multi-source feedback: NHS Shetland reported that its doctors use the multi-source feedback resource on SOAR. Each doctor orders the feedback questionnaires from the primary care appraisal co-ordinator and administrative staff distribute and collect feedback forms. The forms are posted to the Client-Focused Evaluations Programme (CFEP UK Surveys), a survey company which specialises in colleague and patient for healthcare organisations. The survey company analyses the completed questionnaires and provides a report to the NHS board. Patient satisfaction: The NHS board reported that doctors use the CFEP UK Surveys questionnaire form to gather patient feedback. The questionnaires are sent to the doctor s departmental manager and are distributed by the relevant staff, but not the doctor. All inpatients are issued with a questionnaire when they are discharged. The departmental manager collates the forms. The forms are sent to the survey company for analysis and a feedback report is provided to the doctor. The NHS board confirmed that it finds the CFEP UK Surveys questionnaire form simple to use, and as all doctors use the same form, consistent information is received. The panel commended NHS Shetland for the systems it had in place to manage the information required for appraisal. Remediation, rehabilitation and targeted support NHS Shetland confirmed that it has a process in place for doctors to undergo training or retraining. Doctors note their training requirements in their personal development plans. If specific areas of learning are identified through the system for reporting complaints or significant events, then arrangements will be made with the individual to undergo the relevant training. Doctors who require rehabilitation can be referred to the NHS board s occupational health service, and support from NHS Grampian can be sought. The NHS board described the process it has in place to monitor doctors conduct and performance. An individual supervision plan is produced identifying the learning and supervision needs required. An approved supervisor will be identified to provide support and the RO audits the process and interviews both doctor and supervisor to ensure satisfactory compliance. Self-reported assessment on progress to meet medical revalidation requirements During the self-assessment process, we asked organisations to reflect on their progress to meet medical revalidation requirements. NHS Shetland reported that it has well-developed systems and processes and can demonstrate sustainable improvement throughout the organisation. The panel agreed with this assessment. 58

59 Medical revalidation in Scotland: local reports Good practice, improvements and challenges We asked for feedback on examples of good practice in relation to implementing medical revalidation. NHS Shetland highlighted its effective administration systems in place and the effective linkage of complaints and DATIX to appraisers. We also asked if revalidation had contributed to local improvement within the organisation and the NHS board said that it provided a structured opportunity to discuss any doctor s performance issues which have resulted in improved behaviour. The NHS board reported that ensuring there are a sufficient number of NES-trained appraisers to undertake appraisals is a challenge. Action points from 215 review No action points were identified in the 215 review. Action points for consideration during No action points were identified by the panel for

60 Medical revalidation in Scotland: local reports NHS Tayside Data tables Number of doctors with a prescribed connection Number of doctors with a prescribed connection on 31 March Number of doctors eligible for appraisal in Number of completed appraisals Appraisal results (66%) Appraisal results (43%) Appraisal results (77%) Appraisal results (82%) Appraisal results (94%) Appraisal results (89%) Revalidation results Number of doctors eligible for revalidation in Number of positive recommendations 381 (98%) Number of deferral requests 1 (3%) Revalidation Number of doctors identified for revalidation in Number of doctors identified for revalidation in who had an appraisal between 1 April 212 and 31 March 213 between 1 April 212 and 31 March 213 Number of doctors identified for revalidation in who had an appraisal between 1 April 213 and 31 March 214 between 1 April 213 and 31 March 214 Number of doctors identified for revalidation in who had an appraisal between 1 April 214 and 31 March 215 between 1 April 214 and 31 March 215 Number of doctors identified for revalidation in who had an appraisal between 1 April 215 and 31 March 216 between 1 April 215 and 31 March (28%) 7 (1%) 7 (28%) 7 (1%) 19 (76%) 19 (1%) 2 (8%) 2 (1%) Number of NES-trained appraisers Number of NES-trained appraisers in organisation 91 6

61 Medical revalidation in Scotland: local reports Findings of the evaluation panel NHS Tayside is a designated body and provides external RO support and annual appraisal services to Rachel House Children s Hospice and Robin House Children s Hospice which are operated by Children s Hospice Association Scotland (CHAS).There is a formal agreement, based on the national template, in place between NHS Tayside and CHAS for the provision of these services. Governance relevant to revalidation NHS Tayside reported that its appraisal lead manages appraisal and revalidation on a daily basis and refers any problems to the RO for discussion and resolution. The appraisal lead and the RO meet regularly to share relevant information. The NHS board had undertaken an audit of missed and incomplete appraisals for secondary care and submitted a copy of this for the panel to review. NHS Tayside reported that the completion of appraisals is monitored regularly by the appraisal lead s office and doctors are contacted to establish the reason for non-completion of their appraisal, where necessary. The appraiser may also be contacted if there appears to be a problem with setting up the appraisal interview. Doctors who do not engage with the process are issued a warning letter from the RO and the appraisal lead, to remind them of their contractual obligation to have an annual appraisal and that failure to engage may result in the doctor being referred to the GMC. The NHS board submitted a copy of its annual report to the staff governance committee which included an action plan and recommendation. However, the panel noted that the annual report was strongly focused on secondary care and the report had been signed off by the lead appraiser for secondary care and the RO. The NHS board reported that the appraisal lead checks Form 4s (or relevant documentation) for new appointments, on behalf of the RO. NHS Tayside described the process that it has in place to share information between organisations where doctors are employed by more than one organisation. The NHS board has a reciprocal arrangement in place with appraisal leads from other NHS boards to save copies of Form 4 documents for doctors who have moved to NHS Tayside from another NHS board. NHS Tayside is now requesting that doctors, who are employed by another NHS board but providing services to NHS Tayside, make their Form 4s available to their ROs. 61

62 Percentage Medical revalidation in Scotland: local reports Appraisal rates The graph below demonstrates the appraisal rates for NHS Tayside for to Figure 1: NHS Tayside percentage of completed appraisals compared with the Scottish mean appraisal rate NHS Tayside Scotland Appraisal year Information for appraisal Supporting information: The NHS board explained that SOAR requests doctors to include items of supporting information for appraisal that reflects the whole of their practice. The NHS board added that doctors can get supporting information from the organisations that support their specialties and that the majority of its doctors are now using SOAR for appraisal. NHS Tayside reported that its doctors can provide clinical activity information from their own logbooks and college log. The NHS board stated that the GMC requires doctors to audit their own work and provide information on the outcomes they have achieved. Complaints, compliments and concerns: NHS Tayside indicated that it has a process in place to feed information on complaints, compliments and critical incidents into the appraisal system. The NHS board explained that its complaints department is given a list of appraisers and appraisees and each person on the list is sent an with details of the number of complaints that concern them and whether or not the complaints have been resolved. The NHS board added that this information should be discussed at appraisal interview. Multi-source feedback: The NHS board reported that it manages multi-source feedback and incorporates it into personal and professional development plans through SOAR. Patient satisfaction: NHS Tayside reported that patient questionnaires are distributed at clinics and the completed forms are collected by a nurse or designated person, other than the doctor. The data from the forms are entered into a spreadsheet and a report is generated and ed to the appraisee and appraiser, 3 weeks before the date of appraisal. The NHS board stated that its doctors use the CARE, GMC and Royal College of Anaesthetists questionnaires to gather patient feedback. The NHS board confirmed that the system that it has in place is managed by the appraisal lead s office and works well. The panel noted that it appears that patient feedback is only gathered from clinics and does not provide the NHS board with any feedback from its inpatients. 62

63 Medical revalidation in Scotland: local reports Remediation, rehabilitation and targeted support NHS Tayside reported that doctors who require training or re-training would be managed by the NHS board s remediation steering group and facilitated by the human resources directorate. The NHS board added that the RO would monitor the doctor s progress. Rehabilitation is undertaken in conjunction with advice provided by occupational health services, for example phased return to work, workplace assessments or redeployment, if necessary. The NHS board has a policy in place to manage any conduct or performance issues. NHS Tayside reported that the management of these issues would be undertaken in consultation with the NHS board s medical director. Self-reported assessment on progress to meet medical revalidation requirements During the self-assessment process, we asked organisations to reflect on their progress to meet medical revalidation requirements. NHS Tayside reported that it has well-developed systems and processes and can demonstrate sustainable improvement throughout the organisation. The panel considered the NHS board to be at the stage of developing plans and processes and able to demonstrate sustainable improvement throughout the organisation. Good practice, improvements and challenges We asked for feedback on examples of good practice in relation to implementing medical revalidation and NHS Tayside highlighted that the number of its doctors engaging with medical appraisal and revalidation has increased significantly. The NHS board also referred to the annual survey it carries out, at the end of the appraisal year, which looks at outcomes from appraisers and appraisees. NHS Tayside reported that the implementation of medical revalidation in Scotland has increased the compliance of its doctors to undertake annual appraisal. NHS Tayside reported a number of challenges that it faces in relation to the implementation of medical revalidation: general reluctance of doctors to engage in appraisal after revalidation and the lack of realisation that five appraisals will be required for the next cycle of revalidation the number of retiring appraisers, some of them unexpectedly, and the long waiting time for training new appraisers, and the publication of the outcome of the GMC survey has not helped to enhance confidence in the medical revalidation process and the benefits of appraisal for both the doctor and their patient. The panel noted that NHS Tayside submitted all of the required items of supporting evidence for review. However, the panel was concerned about the lack of any clear action plan to increase the number of appraisers and address the significant difference in primary and secondary care appraisal rates. The panel recommended that the NHS board looks at developing an action plan to manage the number of appraisers who are retiring. Action points from 215 review Ensure that the RO (or delegated representative) checks Form 4 (or relevant documentation) for all new appointments. Information on complaints to be made available to doctors as a matter of routine. Fully actioned Ongoing 63

64 Medical revalidation in Scotland: local reports Action points for consideration during Consider reporting equally on primary and secondary care progress with medical appraisal and revalidation in its annual report to the Board (or relevant sub-committee). Establish a plan to manage the situation of appraisers taking early retirement to ensure there is a sufficient number of secondary care appraisers. 64

65 Medical revalidation in Scotland: local reports NHS Western Isles Data tables Number of doctors with a prescribed connection Number of doctors with a prescribed connection on 31 March Number of doctors eligible for appraisal in Number of completed appraisals Appraisal results (79%) Appraisal results (89%) Appraisal results (9%) Appraisal results (74%) Appraisal results (95%) Appraisal results (82%) Revalidation results Number of doctors eligible for revalidation in Number of positive recommendations 22 (1%) Number of deferral requests 2 (9%) Revalidation Number of doctors identified for revalidation in Number of doctors identified for revalidation in who had an appraisal between 1 April 212 and 31 March 213 between 1 April 212 and 31 March 213 Number of doctors identified for revalidation in who had an appraisal between 1 April 213 and 31 March 214 between 1 April 213 and 31 March 214 Number of doctors identified for revalidation in who had an appraisal between 1 April 214 and 31 March 215 between 1 April 214 and 31 March 215 Number of doctors identified for revalidation in who had an appraisal between 1 April 215 and 31 March 216 between 1 April 215 and 31 March (1%) 2 (1%) 2 (1%) 2 (1%) 2 (1%) 2 (1%) 2 (1%) 2 (1%) Number of NES-trained appraisers Number of NES-trained appraisers in organisation 6 65

66 Percentage Medical revalidation in Scotland: local reports Findings of the evaluation panel NHS Western Isles is a designated body with an RO. It provides RO support and appraisal services to Bethesda Hospice. The provision of these services is formalised by a local enhanced service contract between NHS Western Isles and Bethesda Hospice. Governance relevant to revalidation NHS Western Isles reported that it had not completed an audit of missed or incomplete appraisals, as overdue appraisals are monitored by the NHS board s revalidation appraisal steering group which meets every 3 months. NHS Western Isles provides an annual report to its corporate management team to give an update on the NHS board s progress with medical appraisal and revalidation. However, the panel noted that the annual report did not include any details of progress with appraisal and revalidation in Bethesda Hospice. NHS Western Isles reported that it had no deferrals for the period 1 April March 216 and, due to the low number of doctors it has, the NHS board had not carried out an audit of deferrals. The NHS board explained that it manages any deferral cases on an individual basis. The panel noted that there is currently no local appraisal adviser in NHS Western Isles. The arrangement that the NHS board previously had with NHS Highland to provide local appraisal adviser support, ended in December 215. NHS Western Isles confirmed that it would soon have a local appraisal adviser in place. NHS Western Isles has a process in place for the RO to check all Form 4s (or relevant documentation) for all new appointments. Where doctors are employed by more than one organisation, the NHS board does not have a process to share information between organisations. The panel would encourage the NHS board to develop a process to support the sharing of information between NHS Western Isles and other organisations where its doctors are employed. Appraisal rates The graph below demonstrates the appraisal rates for NHS Western Isles for to Figure 1: NHS Western Isles percentage of completed appraisals compared with the Scottish mean appraisal rate NHS Western Isles Scotland Appraisal year 66

67 Medical revalidation in Scotland: local reports Information for appraisal Supporting information: Doctors with a prescribed connection to NHS Western Isles are responsible for gathering information on all aspects of their practice for appraisal. Although there is no formal process in place for the NHS board to make sure its doctors adhere to this obligation, the appraisers are aware of this and provide feedback to the doctors. The NHS board has developed a live interface dashboard reporting system which provides up-to-date clinical activity data and information. The panel complimented the NHS board on its use of the dashboard. Complaints, compliments and concerns: The NHS board reported that complaints are a standing item on the revalidation and appraisal steering group agenda. In addition to the review of complaints through this group, doctors and appraisers are provided with a summary of complaints ahead of appraisal interviews. The medical director is also provided with this information ahead of making any recommendations for revalidation. The panel commended NHS Western Isles on its process for managing complaints. Multi-source feedback: NHS Western Isles encourages all doctors to use the 36 degree feedback tool to gather multi-source feedback. Doctors are required to collect multi-source feedback at least once in every 5-year cycle. Patient satisfaction: The NHS board has a process in place to manage patient feedback. It reported that depending on the specialty, patients may be randomly selected to complete the CARE questionnaire to gather their feedback. The NHS board reported that its patients appear to be more than willing to share information on their experience with NHS Western Isles. The panel commended the NHS board on its use of a range of tools to gather patient feedback. Remediation, rehabilitation and targeted support NHS Western Isles provides training and re-training to doctors by working in collaboration with the NHS board s medical director, appraisal lead clinician and NES. The NHS board supports doctors requiring rehabilitation, on an individual basis and in liaison with occupational health, to make sure that the doctor has full access to the appropriate services required. Self-reported assessment on progress to meet medical revalidation requirements During the self-assessment process, we asked organisations to reflect on their progress to meet medical revalidation requirements. NHS Western Isles reported that it has welldeveloped systems and processes and can demonstrate sustainable improvement throughout the organisation. The panel considered that the NHS board is developing plans and processes and can demonstrate sustainable improvement throughout the organisation. The panel recognised that this has been a transitional time for the NHS board and also noted the relatively low appraisal rate. The panel would encourage NHS Western Isles to make progress with its arrangements to appoint a local appraisal advisor. Good practice, improvements and challenges We asked for feedback on examples of good practice in relation to implementing medical revalidation. NHS Western Isles reported that the implementation of the revalidation and appraisal steering group has resulted in an increased level of compliance with the appraisal process. The NHS board s group of appraisers is now entirely locally based and the NHS board s revalidation and appraisal policy has been reviewed. The NHS board reported that medical revalidation has contributed to local improvements within the organisation. An example provided by the NHS board is that personal development plans have now been implemented as part of the appraisal process. 67

68 Medical revalidation in Scotland: local reports We also asked about challenges and two areas were identified by the NHS board: cross-specialty appraising in secondary care within a small team, and unrealistic for secondary care appraisers to reach the target of 1 appraisals each. Action points from 215 review Fully actioned Ongoing Implement a process to check Form 4s (or relevant documentation) for all new appointees. Approve and implement the medical appraisal policy. Action points for consideration during Include details of progress with appraisal and revalidation at Bethesda Hospice in the RO s annual report. Explore options to increase and sustain appraisal rates. Approve and implement the medical appraisal policy. Establish a process to share information in cases where doctors work across organisations. 68

69 Medical revalidation in Scotland: local reports Healthcare Improvement Scotland Data tables Number of doctors with a prescribed connection Number of doctors with a prescribed connection on 31 March Number of doctors eligible for appraisal in Number of completed appraisals Appraisal results (1%) Appraisal results (1%) Appraisal results (1%) Appraisal results (1%) Appraisal results (1%) Appraisal results (1%) Revalidation results Number of doctors eligible for revalidation in Number of positive recommendations 1 (1%) Number of deferral requests Revalidation Number of doctors identified for revalidation in Number of doctors identified for revalidation in who had an appraisal between 1 April 212 and 31 March 213 between 1 April 212 and 31 March 213 Number of doctors identified for revalidation in who had an appraisal between 1 April 213 and 31 March 214 between 1 April 213 and 31 March 214 Number of doctors identified for revalidation in who had an appraisal between 1 April 214 and 31 March 215 between 1 April 214 and 31 March 215 Number of doctors identified for revalidation in who had an appraisal between 1 April 215 and 31 March 216 between 1 April 215 and 31 March 216 Number of NES-trained appraisers Number of NES-trained appraisers in organisation 2 69

70 Medical revalidation in Scotland: local reports Findings of the evaluation panel Healthcare Improvement Scotland is a designated body and has an RO. Support for managing medical revalidation is provided by the organisation development and learning team. During the reporting period , the organisation had eight doctors with a prescribed connection to it. The panel noted that the RO continued to have two appraisals, but that all aspects of the RO s work and practice are fed into the main substantive appraisal. Healthcare Improvement Scotland is a small organisation and the panel noted that it has outsourced appraisal services to NHS National Services Scotland. The panel has seen the final signed agreement covering these arrangements. Governance relevant to revalidation The organisation reported that the RO uses the SOAR system to track appraisal records. The RO reports annually to the staff governance committee and a copy of the latest report was provided. There were no incomplete appraisals during the reporting period and the panel also noted there were no deferrals in this period. Information for appraisal Supporting information: The RO prompts doctors to include relevant supporting information that supports the whole of their practice. Complaints, compliments and concerns: The organisation confirmed that it has a process to feed information on complaints, compliments and concerns into the appraisal system. It expects the appraisee to present this information for discussion at appraisal. Multi-source feedback: The organisation reported that multi-source feedback is managed as part of the NHSScotland 36 degree feedback process, or though SOAR. Following discussion at appraisal of the summary feedback, the appraisee is expected to include this information in their personal development plan. Patient satisfaction: Most doctors working for the organisation do not have patient contact. The doctor who does work directly with patients uses the CARE patient feedback form. The panel noted that some doctors working with other NHS boards, for example in their forensic work, were required to verbally ask questions and complete the questionnaire on behalf of detainees for reasons of health and safety. Remediation, rehabilitation and targeted support The panel noted that Healthcare Improvement Scotland s management and capability policy was submitted as evidence but noted it was out of date. However, the panel was assured it was the policy that was referred to by the organisation. Self-reported assessment on progress to meet medical revalidation requirements During the self-assessment process, we asked organisations to reflect on their progress to meet medical revalidation requirements. Healthcare Improvement Scotland reported that it is developing plans and processes, and can demonstrate sustainable improvement throughout the organisation. The panel agreed the organisation has made progress since last year, and has addressed the issue of outsourcing appraisal which is important for such a small team. Therefore, the panel agreed with this assessment. Good practice, improvements and challenges We asked for feedback on examples of good practice in relation to implementing medical revalidation and Healthcare Improvement Scotland referred to the in-house peer review and CPD for both the Death Certification Review and clinical directorate. Healthcare Improvement Scotland has also simplified and improved appraisal information and support for their national clinical leads. 7

71 Medical revalidation in Scotland: local reports The panel agreed this was good practice which could be considered by other organisations running national programmes with input from a range of practitioners from other organisations. We also asked about challenges and Healthcare Improvement Scotland identified that the majority of its doctors are no longer in clinical practice. In summary, the panel agreed Healthcare Improvement Scotland has made progress and in particular has addressed previous concerns about outsourcing appraisal. Action points from 215 review Outsource appraisal and put in place a formal agreement to cover this. Healthcare Improvement Scotland will be asked to confirm this. RO to consider a single, whole practice appraisal. Discussions and meetings concerning other areas of practice are important and should feed into the single appraisal. Revalidation recommendations for non-executive Board members should be assigned to another RO for transparency. Action points for consideration during Fully actioned Ongoing Update the Healthcare Improvement Scotland management and capability policy (211) as the one submitted as evidence was out of date. Describe the arrangements in place to provide multi-source feedback and to incorporate this into personal and professional development plans. The panel noted the arrangements in place for the RO s appraisal and requested confirmation that information from all aspects of the RO s work and practice are fed into the main appraisal. The panel also requested an explanation of the governance arrangements in place to facilitate this process. 71

72 Medical revalidation in Scotland: local reports NHS 24 Data tables Number of doctors with a prescribed connection Number of doctors with a prescribed connection on 31 March Number of doctors eligible for appraisal in Number of completed appraisals Appraisal results (1%) Appraisal results (1%) Appraisal results (1%) Appraisal results (1%) Appraisal results (1%) Appraisal results (1%) Revalidation results Number of doctors eligible for revalidation in Number of positive recommendations Number of deferral requests Revalidation Number of doctors identified for revalidation in Number of doctors identified for revalidation in who had an appraisal between 1 April 212 and 31 March 213 between 1 April 212 and 31 March 213 Number of doctors identified for revalidation in who had an appraisal between 1 April 213 and 31 March 214 between 1 April 213 and 31 March 214 Number of doctors identified for revalidation in who had an appraisal between 1 April 214 and 31 March 215 between 1 April 214 and 31 March 215 Number of doctors identified for revalidation in who had an appraisal between 1 April 215 and 31 March 216 between 1 April 215 and 31 March 216 Number of NES-trained appraisers Number of NES-trained appraisers in organisation 1 72

73 Medical revalidation in Scotland: local reports Findings of the evaluation panel NHS 24 is a designated body and has an RO. The RO s appraisal is managed through Scottish Government s RO appraisal arrangements. NHS 24 reported it has outsourced appraisal services to NHS Forth Valley for its other doctor following a recommendation made in last year s report. NHS 24 confirmed that a formal letter detailing the appraisal arrangements with NHS Forth Valley is still being developed. Governance relevant to revalidation NHS 24 reported that it receives advice on all aspects of appraisal through the RO network and other ROs who are actively involved in appraisal. NHS 24 reported that an audit of incomplete or missed appraisals was not necessary due to the small number of doctors with a prescribed connection to it. However, NHS 24 confirmed that appraisal due dates are formally recorded in the doctor s personal file and the dates are referenced at the doctor s 6- monthly performance update. NHS 24 confirmed that it provides an annual report on medical appraisal and revalidation progress to its Board. NHS 24 reported it has a process in place for the RO to check Form 4s (or relevant documentation) for any new appointments. Information for appraisal Supporting information: NHS 24 confirmed that doctors are reminded at regular one-toone conversations of their responsibility to include relevant supporting information that supports the whole of their practice within their appraisal documentation. NHS 24 described how it provides doctors with relevant clinical activity information. A live information service portal is used which provides rich live data that the medical directorate reviews every day. This is also used to inform decisions about preparedness and improvement plans. Complaints, compliments and concerns: NHS 24 reported that information on complaints, compliments and concerns are made available to the RO and actioned appropriately. Multi-source feedback: NHS 24 reported that one of its doctors is in a management role and uses the 36 degree feedback process as part of personal development planning. Patient satisfaction: NHS 24 confirmed how it regularly seeks patient feedback. Its patient affairs team randomly selects NHS 24 callers in line with good practice. Every week, it surveys 5 patients at random and 6-monthly reports of the results are produced. NHS 24 uses specifically designed in-house patient questionnaires to meet its service needs. NHS 24 has also used the patient opinion website, a nationally endorsed feedback mechanism, on their online feedback page to gather patient feedback. NHS 24 acknowledged that it exploring other ways to maximise patient feedback, such as using online surveys and standard letters. Remediation, rehabilitation and targeted support NHS 24 confirmed it has a process in place for doctors to undergo training or re-training. Where relevant learning needs are identified by the doctors, this would be discussed with the RO to consider the appropriateness of the training. It confirmed that the RO is agreeable to support specific training where there is a benefit to the organisation. NHS 24 reported that human resources would source rehabilitation services from a local NHS board, if required. NHS 24 confirmed it has a process in place for further monitoring of the doctor s conduct, performance or fitness to practise. This would be carried out by the RO on a one-to-one basis and through regular monthly medical directorate meetings. Self-reported assessment on progress to meet medical revalidation requirements During the self-assessment process, we asked organisations to reflect on their progress to meet medical revalidation requirements. NHS 24 reported that it has well-developed systems 73

74 Medical revalidation in Scotland: local reports and processes and can demonstrate sustainable improvement throughout the organisation. The panel agreed with this assessment. Good practice, improvements and challenges We asked for feedback on examples of good practice in relation to implementing medical revalidation. NHS 24 reported it has developed a Memorandum of Understanding with NHS Borders to allow its associate medical director to do the required number of clinical sessions to maintain up-to-date skills for medical revalidation purposes. We also asked about challenges and NHS 24 reported that, as it is a small NHS board, it has had to outsource appraisals. Action points from 215 review Outsource annual appraisal services. NHS 24 will be asked to confirm it has done this. RO to attend RO network meetings and events. Fully actioned Ongoing Action point for consideration during Implement a formal agreement for the provision of external appraisal services from NHS Forth Valley. 74

75 Medical revalidation in Scotland: local reports NHS Education for Scotland Data tables Number of doctors with a prescribed connection Number of doctors with a prescribed connection on 31 March Number of doctors eligible for appraisal in Number of completed appraisals Appraisal results (1%) Appraisal results (1%) Appraisal results (1%) Appraisal results (1%) Appraisal results (7%) Appraisal results (1%) Revalidation results Number of doctors eligible for revalidation in Number of positive recommendations 2 (1%) Number of deferral requests Revalidation Number of doctors identified for revalidation in Number of doctors identified for revalidation in who had an appraisal between 1 April 212 and 31 March 213 between 1 April 212 and 31 March 213 Number of doctors identified for revalidation in who had an appraisal between 1 April 213 and 31 March 214 between 1 April 213 and 31 March 214 Number of doctors identified for revalidation in who had an appraisal between 1 April 214 and 31 March 215 between 1 April 214 and 31 March 215 Number of doctors identified for revalidation in who had an appraisal between 1 April 215 and 31 March 216 between 1 April 215 and 31 March 216 Number of NES-trained appraisers Number of NES-trained appraisers in organisation 4 (1%) 75

76 Medical revalidation in Scotland: local reports Doctors in training NHS Education for Scotland (NES) confirmed that as at 31 March 216, the total number of doctors in training was 5,673 and reported that, for the appraisal year 1 April 215 to 31 March 216, 643 trainees were revalidated. Findings of the evaluation panel NES is a designated body with an RO. It is responsible for supporting NHS services in Scotland by developing and delivering education and training programmes. NES is commissioned by the Scottish Government to provide appraisal training to all ROs and appraisers in Scotland. NES also administers the SOAR appraisal system as well as supporting the IT structures for the system. Governance relevant to revalidation NES reported that it did not undertake an audit of missed or incomplete appraisals for doctors in training for the period Doctors in training are managed differently from trained doctors in the system through a tightly managed process of Annual Review of Competence Progression. The results of this review are directly submitted to GMC. This process is accepted by the GMC as meeting the requirements for the revalidation of doctors in training. Any missed or incomplete appraisals for trained doctors are monitored through an annual review of SOAR. The NHS board stated that due to the small number of trained doctors that it employs, it does not provide an annual report to its Board as there is limited activity to report on. The panel noted this as an action point for the NHS board. NES reported that it had not undertaken an audit to determine the reasons for any deferrals. The NHS board explained that trainee deferrals are mostly a result of adjustments to the dates for certificate of completion of training, for example following time out of training. The NHS board confirmed that deferrals for trained doctors are managed through the annual audit of the SOAR system. The NHS board confirmed that its RO checks Form 4s for all new appointments. Where doctors are employed by more than one organisation, NES explained that the RO is responsible for the sharing and collection of information between organisations. It also noted that there is a process in place to share information on trainee doctors. Information for appraisal Supporting information: Doctors are reminded by appraisers of the requirement to provide information which reflects all aspects of their practise at appraisal. NES does not provide doctors with up-to-date clinical activity data. Doctors are responsible for gathering this data from the NHS board or other organisation where they provide direct clinical care to patients. Complaints, compliments and concerns: Information on complaints, compliments and concerns are provided to doctors through the NHS board s educational governance committee. The management of this for trainee doctors is provided though the NHS boards but also though the NES training programme. Multi-source feedback: NES reported that its doctors use SOAR to gather multi-source feedback. Additionally, doctors also use the executive cohort appraisal system to collect this feedback. Patient satisfaction: NES doctors do not provide direct patient care therefore, the NHS board reported that its does not have a process to gather patient feedback. Remediation, rehabilitation and targeted support NES reported that it manages all requirements for training, re-training and remediation through its established training programme for doctors in training. For the small number of trained doctors employed, NES would manage all issues relating to re-training or remediation on an individual basis. The medical director and RO would also have a personal 76

77 Medical revalidation in Scotland: local reports oversight throughout the process. All doctors employed by NES have access to occupational health services which is managed through its human resources department. Self-reported assessment on progress to meet medical revalidation requirements During the self-assessment process, we asked organisations to reflect on their progress to meet medical revalidation requirements. NES reported that it can demonstrate sustained good practice and innovation that is shared throughout the organisation and which others can learn from. The panel considered that the NHS board has well-developed systems and processes and can demonstrate sustainable improvement throughout the organisation. Good practice, improvements and challenges We asked for feedback on examples of good practice in relation to implementing medical revalidation. NES reported that it is continually developing SOAR and that further training is being rolled out throughout Scotland to bring appraisers to a uniform standard is ongoing. NES highlighted in its self assessment that the only challenge it faces with regards to the implementation of medical revalidation is the training of appraisers. It reported that it is in excess of the amount that NES was originally commissioned to carry out. The panel noted that appraiser training would continue on a regular basis to maintain the level of appraisers required. In particular, to cover organisations and NHS boards where there is a continued shortage of appraisers and also to support the ongoing rotation of doctors retiring from the appraiser role. Action points from 215 review Continue to monitor the number of annual appraisals. Continue to develop contingency planning for SOAR. Fully actioned Ongoing Action points for consideration during Continue to monitor the number of annual appraisals. Continue to develop contingency planning for SOAR. Provide an annual report to the NES board to assure that doctors with a prescribed connection to NES are up to date with appraisal and revalidation requirements. Continue to provide appraiser training to address current demand for the service. 77

78 Medical revalidation in Scotland: local reports NHS Health Scotland Data tables Number of doctors with a prescribed connection Number of doctors with a prescribed connection on 31 March Number of doctors eligible for appraisal in Number of completed appraisals Appraisal results Not available Appraisal results (5%) Appraisal results (1%) Appraisal results (1%) Appraisal results (1%) Appraisal results (1%) Revalidation results Number of doctors eligible for revalidation in Number of positive recommendations 1 (1%) Number of deferral requests Revalidation Number of doctors identified for revalidation in Number of doctors identified for revalidation in who had an appraisal between 1 April 212 and 31 March 213 between 1 April 212 and 31 March 213 Number of doctors identified for revalidation in who had an appraisal between 1 April 213 and 31 March 214 between 1 April 213 and 31 March 214 Number of doctors identified for revalidation in who had an appraisal between 1 April 214 and 31 March 215 between 1 April 214 and 31 March 215 Number of doctors identified for revalidation in who had an appraisal between 1 April 215 and 31 March 216 between 1 April 215 and 31 March 216 Number of NES-trained appraisers Number of NES-trained appraisers in organisation 78

79 Medical revalidation in Scotland: local reports Findings of the evaluation panel NHS Health Scotland is a designated body with an RO. The NHS board outsources appraisal support to NHS National Services Scotland and a copy of the agreement between the two organisations was provided as part of the self-assessment submission. This agreement states that the RO for NHS Health Scotland is appraised separately by the Scottish Government. Governance relevant to revalidation The NHS board reported that there were no missed or incomplete appraisals during the period 1 April March 216 and that an audit was not required. Due to the small number of doctors within the organisation, the RO personally monitors and tracks appraisal progress. The NHS board reported that it provides its governing body with an annual report on the progress with revalidation. There were no deferrals during the period 1 April March 216. The RO for NHS Health Scotland checks all Form 4s (or relevant documentation) for all new appointments for whom they have responsibility. The NHS board reported that, every year, it requests information on its doctors who are routinely employed by other organisations. All relevant information for these doctors is collected and fed into the appraisal process. Information for appraisal Supporting information: All NHS Health Scotland doctors are responsible for collecting the supporting information required to reflect the whole of their practice for appraisal. The NHS board reported that it has a system for providing doctors with sufficient up-to-date and relevant clinical activity data. However, due to the nature of the NHS board s work, this is limited. The organisation supports and assists doctors with collecting any relevant data through its standard governance routes. Complaints, compliments and concerns: The NHS board reported that doctors are responsible for including information on complaints, compliments and concerns within their appraisal documentation and this is discussed at their appraisal. Multi-source feedback: All doctors are encouraged to use the multi-source feedback resource on SOAR to gather feedback. The NHS board reported that it is willing to support alternative approaches, as appropriate, to gather feedback for personal development plans. Patient satisfaction: The use of patient feedback questionnaires does not apply to NHS Health Scotland doctors as they do not have direct patient contact. Remediation, rehabilitation and targeted support There is a management of employee capability policy in place to provide training or retraining to doctors within NHS Health Scotland. The NHS board reported that a bespoke process for training requirements would be put in place dependent on individual learning requirements. The NHS board confirmed that it offers its doctors rehabilitation services and this is also covered by the organisation s capability policy. Self-reported assessment on progress to meet medical revalidation requirements During the self-assessment process, we asked organisations to reflect on their progress to meet medical revalidation requirements. NHS Health Scotland reported that it has welldeveloped systems and processes and can demonstrate sustainable improvement throughout the organisation. The panel agreed with this assessment. Good practice, improvements and challenges We asked for feedback on examples of good practice in relation to implementing medical revalidation. NHS Health Scotland did not provide any examples in its self-assessment. 79

80 Medical revalidation in Scotland: local reports Action point from 215 review Replace the interim agreement for the provision of external appraisal services from NHS National Services Scotland with a more formal agreement. Fully actioned Ongoing Action points for consideration during No action points were identified by the panel for

81 Medical revalidation in Scotland: local reports NHS National Services Scotland Data tables Number of doctors with a prescribed connection Number of doctors with a prescribed connection on 31 March Number of doctors eligible for appraisal in Number of completed appraisals Appraisal results (1%) Appraisal results (98%) Appraisal results (1%) Appraisal results (1%) Appraisal results (1%) Appraisal results (1%) Revalidation results Number of doctors eligible for revalidation in Number of positive recommendations 14 (1%) Number of deferral requests Revalidation Number of doctors identified for revalidation in Number of doctors identified for revalidation in who had an appraisal between 1 April 212 and 31 March 213 between 1 April 212 and 31 March 213 Number of doctors identified for revalidation in who had an appraisal between 1 April 213 and 31 March 214 between 1 April 213 and 31 March 214 Number of doctors identified for revalidation in who had an appraisal between 1 April 214 and 31 March 215 between 1 April 214 and 31 March 215 Number of doctors identified for revalidation in who had an appraisal between 1 April 215 and 31 March 216 between 1 April 215 and 31 March 216 Number of NES-trained appraisers Number of NES-trained appraisers in organisation 7 81

82 Medical revalidation in Scotland: local reports Findings of the evaluation panel NHS National Services Scotland (NSS) is a designated body which has an RO, deputy RO and an appraisal lead. There are 39 doctors with a prescribed connection to the NHS board. NSS confirmed that it provides appraisal support to Healthcare Improvement Scotland, NHS Health Scotland and the Scottish Government. NSS provided a copy of the formal agreement with Healthcare Improvement Scotland and NHS Health Scotland, and reported that a formal agreement with the Scottish Government is still to be agreed. Governance relevant to revalidation NSS performed an audit for the year 1 April March 216 and reported that there were no missed or incomplete appraisals. NSS reported that its appraisal administrators regularly track individual doctors appraisal progress using the SOAR system. The organisation s clinical governance committee receives an annual report which provides assurance that NSS is meeting its obligations for medical revalidation. There were no deferrals reported by NSS during the period Any deferrals would be managed on an individual basis and tracked using an in-house spreadsheet. NSS reported that Form 4s (or relevant documentation) for all new appointments are checked as part of the recruitment process. NSS uses a form developed by NHS Greater Glasgow and Clyde and a copy was provided as part of its self-assessment submission. NSS reported it does not have a formal system to share information where NSS doctors are employed by more than one organisation. However, NSS confirmed that its communications are sufficiently robust to share key points, both positive ones and ones that could raise concerns. Information for appraisal Supporting information: NSS reported that every year, the appraisal lead provides the appraisers with a written brief outlining the expectations required of them for appraisal. Also, an is sent to all NSS doctors, and the other doctors who receive NSS appraisal support, highlighting what is expected and prompts them to include supporting information which reflects the whole of their practice within their appraisal. NSS also provides support and guidance to all doctors and appraisers on the medical revalidation process. NSS confirmed that there is no system that captures clinical activity information. However, the strategic business unit will support any doctor, who undertakes clinical activity, to collate clinical activity information for their appraisal. Complaints, compliments and concerns: NSS does not have an automatic process in place to add information on complaints, compliments, concerns or critical incidents into the appraisal system. This is partly because of the nature of work that doctors employed by NSS undertake. Doctors employed by NSS provide expert and specialist clinical advice to teams within NSS and across NHSScotland with limited direct contact with patients. NSS reported that appraisers ask for information about any significant issues the appraisee has been involved in and this is recorded on the Form 4. Multi-source feedback: All NSS doctors have access to the NHSScotland leadership 36 degree multi-source feedback tool. The organisational development team manages the multi-source feedback process and is qualified to deliver personal feedback to participants. The outputs from the multi-source feedback and any associated action plans are discussed at appraisal. Patient satisfaction: NSS confirmed that only a small group of doctors employed by NSS has direct patient contact, so the majority of NSS doctors are exempt from the patient feedback process. For those doctors who do have direct patient contact, blank anonymous GMC questionnaires and postage paid return envelopes are distributed by the medical director s personal assistant. Completed questionnaires are returned to the clinical 82

83 Medical revalidation in Scotland: local reports directorate and are collated and shared with the doctor and their current appraiser for discussion at appraisal. Remediation, rehabilitation and targeted support NSS confirmed that it offers support to any doctor requiring training or re-training. The NSS occupational health team would make arrangements for any member of staff who requires additional training to be offered a placement within a territorial NHS board. NSS also offers its doctors rehabilitation services and this is included within the organisation s human resources policies. The process is led by the organisation s health working lives team and can be accessed by the individual doctor making a self-referral or through their line manager. Any return to work will be managed on an individual basis and is led by the medical director of the strategic business unit and is supported by the healthy working lives team and human resources department, as required. Self-reported assessment on progress to meet medical revalidation requirements During the self-assessment process, we asked organisations to reflect on their progress to meet medical revalidation requirements. NSS reported that it has well-developed systems and processes and can demonstrate sustainable improvement throughout the organisation. The panel agreed with this assessment. Good practice, improvements and challenges We asked for feedback on examples of good practice in relation to implementing medical revalidation. NSS reported that it has a clear, documented process which has been run by the same administration team since medical revalidation started and this has encouraged doctors to be co-operative as they understand the process and the requirements. We also asked about challenges and NSS identified two areas. Due to the balance of workload and appraisal commitments, NSS reported that it is impractical to assign more than six or seven appraisees to each appraiser every year. NSS also reported that the training of additional appraisers has a long lead time. Action points from 215 review Fully actioned Ongoing Implement a formal agreement with Scottish Government for the provision of appraisal administration services to the Scottish Government group of ROs and other doctors. Implement a process for the RO (or their delegated representative) to check Form 4s (or relevant documentation) for all new appointments for whom they are responsible. Action point for consideration during Implement a formal agreement with Scottish Government for the provision of appraisal administration services to the Scottish Government group of ROs and other doctors. 83

84 Medical revalidation in Scotland: local reports NHS National Waiting Times Centre Board Data tables Number of doctors with a prescribed connection Number of doctors with a prescribed connection on 31 March Number of doctors eligible for appraisal in Number of completed appraisals Appraisal results (73%) Appraisal results (72%) Appraisal results (1%) Appraisal results (93%) Appraisal results (85%) Appraisal results (95%) Revalidation results Number of doctors eligible for revalidation in Number of positive recommendations 38 (97%) Number of deferral requests 3 (8%) Revalidation Number of doctors identified for revalidation in Number of doctors identified for revalidation in who had an appraisal between 1 April 212 and 31 March 213 between 1 April 212 and 31 March 213 Number of doctors identified for revalidation in who had an appraisal between 1 April 213 and 31 March 214 between 1 April 213 and 31 March 214 Number of doctors identified for revalidation in who had an appraisal between 1 April 214 and 31 March 215 between 1 April 214 and 31 March 215 Number of doctors identified for revalidation in who had an appraisal between 1 April 215 and 31 March 216 between 1 April 215 and 31 March (14%) 2 (29%) 1 (5%) Number of NES-trained appraisers Number of NES-trained appraisers in organisation 15 84

85 Percentage Medical revalidation in Scotland: local reports Findings of the evaluation panel NHS National Waiting Times Centre is a special health board. It is a designated body with an RO and a deputy RO. Governance relevant to revalidation The NHS board performs an annual audit to provide assurance to the organisation s governing body that it is adhering to the obligations required for medical revalidation. A copy of the audit report was provided as part of its self-assessment. A process is in place to track appraisals, with the appraisal lead monitoring progress of appraisals on SOAR. Appraisals are spread throughout the year in three groups of 4 months. The appraisers are responsible for setting up appraisal meetings in line with the timetable. This process is then backed up with the appraisal lead contacting the appraiser if an interview is not completed on time. The NHS board confirmed that the RO checks Form 4s (or relevant documentation) for all new appointments within the organisation. Where doctors are employed by more than one organisation the NHS board makes sure that any governance concerns are shared between organisations at the time when they arise. Appraisal rates The graph below demonstrates the appraisal rates for National Waiting Times Centre Board for to Figure 1: National Waiting Times Centre Board percentage of completed appraisals compared with the Scottish mean appraisal rate National Waiting Times Centre Board Scotland Appraisal year Information for appraisal Supporting information: The NHS board reported that all appraisers are aware of their obligation to discuss all aspects of a doctor s practice at appraisal, including any disciplinary issues. All Form 4s are reviewed by the appraisal lead and, if necessary, they provide feedback to the appraiser. The panel highlighted this as an area of good practice. Doctors are provided with sufficient up-to-date clinical activity data for inclusion in their appraisal portfolio. The NHS board provides this in a variety of forms, for example theatre cases are logged on the OPERA system which can produce reports specifically for each doctor. Complaints, compliments and concerns: Complaints or concerns are managed through the clinical governance department which can supply summary details on request. Compliments are usually addressed directly to the doctors involved. The NHS board 85

86 Medical revalidation in Scotland: local reports reported that it uses the DATIX system to record all critical incidents. This is managed by the clinical governance team and summary reports can be supplied to doctors upon request. The NHS board reported that, in , it will introduce a formal clinical governance report for each doctor which will include all this information. Multi-source feedback: Doctors access WASP through the SOAR system to gather multisource feedback and this is discussed during the appraisal. The NHS board reported that other sources of feedback are also accepted such as those conducted during training exercises. Patient satisfaction: A process is in place to manage patient feedback. The NHS board initiates the process by identifying doctors 6 months in advance of their revalidation date. Patient questionnaires are then distributed independently from the doctor and responses are collated by the human resources department which provide a report to the doctor. The report is then discussed at the appraisal. All doctors use the CARE questionnaire to collect feedback. The NHS board reported a good rate of return on patient questionnaires. Remediation, rehabilitation and targeted support The NHS board reported that due to its size it does not have a great need for remediation services, therefore, it does not have a formal policy in place. However, it is able to provide remediation as appropriate on an ad-hoc basis and to consider external requests on their merit. Self-reported assessment on progress to meet medical revalidation requirements During the self-assessment process, we asked organisations to reflect on their progress to meet medical revalidation requirements. NHS National Waiting Times Centre reported that it has well-developed systems and processes and can demonstrate sustainable improvement throughout the organisation. The panel agreed with this assessment. Good practice, improvements and challenges We asked for feedback on examples of good practice in relation to implementing medical revalidation. The NHS board reported that due to its size the appraisal lead is able to make personal contact to make sure all requirements are in place for doctors approaching revalidation. The RO and deputy RO meet every month to jointly consider forthcoming revalidation recommendations. We also asked about challenges and the NHS board reported that succession planning for appraisers, rotation of appraiser/appraisee pairings and appraiser/appraisee ratios remains a challenge. Action points from 215 review Continue to monitor the number of annual appraisals Implement the local remediation policy Implement the medical education strategy Action points for consideration during No action points were identified by the panel for Fully actioned Ongoing 86

87 Medical revalidation in Scotland: local reports Scottish Ambulance Service Data tables Number of doctors with a prescribed connection Number of doctors with a prescribed connection on 31 March 216 Number of doctors eligible for appraisal in Number of completed appraisals Appraisal results Not available Appraisal results Not available Appraisal results Not available Appraisal results (1%) Appraisal results Not applicable Appraisal results Revalidation results Number of doctors eligible for revalidation in Number of positive recommendations Number of deferral requests Revalidation Number of doctors identified for revalidation in Number of doctors identified for revalidation in who had an appraisal between 1 April 212 and 31 March 213 between 1 April 212 and 31 March 213 Number of doctors identified for revalidation in who had an appraisal between 1 April 213 and 31 March 214 between 1 April 213 and 31 March 214 Number of doctors identified for revalidation in who had an appraisal between 1 April 214 and 31 March 215 between 1 April 214 and 31 March 215 Number of doctors identified for revalidation in who had an appraisal between 1 April 215 and 31 March 216 between 1 April 215 and 31 March 216 Number of NES-trained appraisers Number of NES-trained appraisers in organisation 87

88 Medical revalidation in Scotland: local reports Findings of the evaluation panel Scottish Ambulance Service is a designated body and has one doctor, who has a prescribed connection to Scottish Government. The doctor is the RO and their appraisal is managed through the Scottish Government RO revalidation arrangements. Scottish Ambulance Service reported it had no doctors to appraise during the reporting period 1 April March 216. However, the organisation confirmed that in the future, it would outsource appraisal support, if it had any doctors with a prescribed connection to it. The panel suggested that Scottish Ambulance Service should aim to put in place arrangements for outsourcing appraisal support before recruiting any doctors. The panel queried whether Scottish Ambulance Service needed to be a designated body, given that there is only one doctor involved and the doctor has a prescribed connection to Scottish Government. If, in the future, Scottish Ambulance Service increases the number of doctors with a prescribed connection to it, the panel suggested that RO support and appraisal services could both be outsourced. Scottish Ambulance Service confirmed that this is still under consideration, as there has been no change to its number of doctors in the last year. Governance relevant to revalidation Scottish Ambulance Service reported that it has no formal arrangements in place to support the appraisal process. However, the organisation confirmed that the outsourcing of the appraisal and the associated governance arrangements such as the audit and tracking of missed or incomplete appraisals would be arranged, if required. Scottish Ambulance Service confirmed that a report on the status of medical revalidation is being prepared and will be submitted to its clinical governance committee. Scottish Ambulance Service reported it does not currently have arrangements in place for checking Form 4s (or relevant documentation) for new appointments. It also reported that, where doctors are employed by more than one organisation, there are no formal systems in place for the sharing of information with other organisations. As this was an action point from the 215 review, Scottish Ambulance Service confirmed that this is now being taken forward and an update will be included in the report to its clinical governance committee. Information for appraisal Supporting information: Scottish Ambulance Service reported it does not have a process in place to make sure doctors are aware of their responsibility to include supporting information that reflects the whole of their practice. It confirmed that this will be covered as part of the report to its clinical governance committee. Scottish Ambulance Service reported that a formal system for providing doctors with up-todate clinical activity data will be developed in partnership with the relevant staff groups. Complaints, compliments and concerns: Scottish Ambulance Service reported that it is developing a process to feed complaints, compliments and comments into the appraisal system. Multi-source feedback: Scottish Ambulance Service confirmed that doctors would use the multi-source feedback tool on SOAR for gathering multi-source feedback. Patient satisfaction: Scottish Ambulance Service confirmed that there is no requirement for it to have a process in place for managing patient feedback questionnaires. Remediation, rehabilitation and targeted support Scottish Ambulance Service reported that it currently does not have a formal process in place for providing remediation, rehabilitation and targeted support. 88

89 Medical revalidation in Scotland: local reports Self-reported assessment on progress to meet medical revalidation requirements During the self-assessment process, we asked organisations to reflect on their progress to meet medical revalidation requirements. Scottish Ambulance Service reported that it is aware of the improvements that need to be made and has prioritised them, but are not yet able to demonstrate meaningful action. The panel was unable to provide an assessment of the progress made due to the limited amount of activity reported by Scottish Ambulance Service. Good practice, improvements and challenges We asked for feedback on examples of good practice in relation to implementing medical revalidation. Scottish Ambulance Service did not provide any feedback on good practice. Scottish Ambulance Service reported that revalidation has contributed to local improvement indirectly through supporting and quality assuring doctors. Action points from 215 review Consider whether it needs to be a designated body or whether RO could be outsourced. Confirm that appraisal will be outsourced. Report at least annually through formal governance arrangements to provide an assurance that appraisal and medical revalidation is proactively managed and implemented. Complete and implement the medical appraisal and revalidation policy. Put in place information-sharing arrangements to support ScotSTAR staff and BASICS responders in their appraisal and professional development. Set out the CPD requirements and arrangements for ScotSTAR staff and BASICS responders RO to attend RO network meetings. Fully actioned Ongoing Action points for consideration during Consider whether it needs to be a designated body or whether RO could be outsourced. Set up formal arrangements to outsource appraisal support. Report at least annually through formal governance arrangements to provide an assurance that appraisal and medical revalidation is proactively managed and implemented. The panel did note that this will be reported to Scottish Ambulance Service s clinical governance committee. Complete and implement the medical appraisal and revalidation policy. Put in place information-sharing arrangements to support ScotSTAR staff and BASICS responders in their appraisal and professional development. Set out the CPD requirements and arrangements for ScotSTAR staff and BASICS responders. RO to attend RO network meetings. 89

90 Medical revalidation in Scotland: local reports The State Hospitals Board for Scotland Data tables Number of doctors with a prescribed connection Number of doctors with a prescribed connection on 31 March Number of doctors eligible for appraisal in Number of completed appraisals Appraisal results (1%) Appraisal results (1%) Appraisal results (1%) Appraisal results (71%) Appraisal results (1%) Appraisal results (82%) Revalidation results Number of doctors eligible for revalidation in Number of positive recommendations 3 (1%) Number of deferral requests Revalidation Number of doctors identified for revalidation in Number of doctors identified for revalidation in who had an appraisal between 1 April 212 and 31 March 213 between 1 April 212 and 31 March 213 Number of doctors identified for revalidation in who had an appraisal between 1 April 213 and 31 March 214 between 1 April 213 and 31 March 214 Number of doctors identified for revalidation in who had an appraisal between 1 April 214 and 31 March 215 between 1 April 214 and 31 March 215 Number of doctors identified for revalidation in who had an appraisal between 1 April 215 and 31 March 216 between 1 April 215 and 31 March (5%) 1 (1%) Number of NES-trained appraisers Number of NES-trained appraisers in organisation 3 9

91 Medical revalidation in Scotland: local reports Findings of the evaluation panel Governance relevant to revalidation The State Hospitals Board for Scotland is a designated body with an RO. NHS Lanarkshire provides an external appraiser to the NHS board. There is an informal agreement between the two NHS boards for this service. The panel suggested the NHS board considers exploring the benefits of having a partnership for appraisal services. The NHS board has arrangements in place to track the appraisal record of each doctor. The appraisal and revalidation administrator monitors and tracks information regarding missed or incomplete appraisals, giving the appraisers regular updates. The NHS board provided a copy of its audit of medical staff appraisals for the appraisal year and confirmed that no appraisals had been missed during this appraisal cycle. The NHS board also has arrangements in place to check Form 4s (or relevant documentation) for new appointments and this is managed by the human resources department. It has a process in place to send letters to relevant medical managers as its doctors also work in other NHS board areas. These letters are sent before each appraisal to request appraisal information. They include a standard list of items that are relevant to doctors working at the State Hospitals Board for Scotland. Information for appraisal Supporting information: The NHS board uses various methods to prompt doctors to include relevant supporting information that supports the whole of their practice. This is outlined in its draft revalidation and appraisal policy, which includes a list of mandatory evidence that doctors require to present at their appraisal. Variance tools are also used to provide data on the clinical care of patients from their admission into hospital through to intermediate care and annual case review. This information is sent to the RO and the appraisal and revalidation administrator every 3 months. Clinical audits are also analysed and sent to the appropriate consultant as well as the appraisal and revalidation administrator. The information is also uploaded onto SOAR. Complaints, compliments and concerns: The NHS board has a process to feed information on complaints, compliments, concerns or critical incidents into the appraisal system. The complaints officer collates all positive and negative feedback. A standard letter is then sent to the appraisers in the lead up to appraisal outlining all compliments and complaints, including whether any of the complaints are urgent. Appraisers are also informed if no complaints have been received. Multi-source feedback: The NHS board reported that it has a system to provide multisource feedback into personal and professional development plans. The NHS board highlighted that it offers different formats for collecting feedback including those administered by the Royal College of Psychiatrists. Multi-source feedback can also be obtained from SOAR. Patient satisfaction: The CARE questionnaire is used to manage the patient satisfaction process. The appraisal and revalidation administrator sends the CARE questionnaire to all patients along with a self-addressed return envelope to ensure that patient feedback remains anonymous. A summary of feedback is provided every year to individual doctors in relation to their patients. The NHS board noted that due to the nature of patients and workload, it is unable to gather a large number of responses. The NHS board further explained that it is considered inappropriate to use these questionnaires in a prison setting or when seeing an individual for the purposes of a court report. The panel commended the NHS board for the processes and procedures it had in place to manage the information required for appraisal. 91

92 Medical revalidation in Scotland: local reports Remediation, rehabilitation and targeted support The NHS board has a process for managing remediation and rehabilitation. It also provides support in line with its management of employee capability policy which is based on national guidelines. The NHS board can also source services externally depending on the required need or level of support required. Self-reported assessment on progress to meet medical revalidation requirements During the self-assessment process, we asked organisations to reflect on their progress to meet medical revalidation requirements. The NHS board reported that it has well-developed systems and processes and can demonstrate sustainable improvement throughout the organisation. The panel agreed with this assessment. Good practice, improvements and challenges We asked for feedback on examples of good practice in relation to implementing medical revalidation and the State Hospitals Board for Scotland highlighted its standardised list of evidence for appraisal. The list was developed jointly with the medical group and allows appraisees and appraisers to gain an understanding of standard practice. The NHS board indicated that revalidation has contributed to local improvement in the organisation and provided the following examples: introduction of an adapted CARE questionnaire and a review of patients feedback extension of the standardised audit and sharing of data system review of complaints and critical incident reviews during a doctor s appraisal, and improved information sharing and openness. We also asked about challenges and the NHS board indicated one ongoing challenge. Doctors employed by the State Hospitals Board for Scotland also provide clinical sessions to other organisations. The NHS board reported that it is difficult to obtain feedback on doctors performance from other NHS boards despite sending standard letters requesting this information. Action point from 215 review Add review dates to medical revalidation policy document following approval process. Fully actioned Ongoing Action points for consideration during Finalise draft medical revalidation policy document. Explore benefits for outsourcing appraisers for appraisal. 92

93 Medical revalidation in Scotland: local reports 2.2 Hospices Accord Hospice Data tables Number of doctors with a prescribed connection Number of doctors with a prescribed connection on 31 March Number of doctors eligible for appraisal in Number of completed appraisals Appraisal results (1%) Appraisal results (67%) Appraisal results (1%) Appraisal results (1%) Appraisal results (1%) Appraisal results (1%) Revalidation results Number of doctors eligible for revalidation in Number of positive recommendations 1 (1%) Number of deferral requests Revalidation Number of doctors identified for revalidation in Number of doctors identified for revalidation in who had an appraisal between 1 April 212 and 31 March 213 between 1 April 212 and 31 March 213 Number of doctors identified for revalidation in who had an appraisal between 1 April 213 and 31 March 214 between 1 April 213 and 31 March 214 Number of doctors identified for revalidation in who had an appraisal between 1 April 214 and 31 March 215 between 1 April 214 and 31 March 215 Number of doctors identified for revalidation in who had an appraisal between 1 April 215 and 31 March 216 between 1 April 215 and 31 March 216 Number of NES-trained appraisers Number of NES-trained appraisers in organisation 1 93

94 Medical revalidation in Scotland: local reports Findings of the evaluation panel Accord Hospice is a designated body and has two doctors with a prescribed connection to it. The hospice outsources appraisal and RO support to NHS Greater Glasgow and Clyde. A Memorandum of Understanding is in place between the two organisations detailing the arrangements. Governance relevant to revalidation The hospice has arrangements in place to support appraisal and medical revalidation for each doctor. This includes one trained NES appraiser. The appraiser and chief executive officer review the appraisal and revalidation records and seek feedback from the individual doctors. An annual audit of appraisal and revalidation records is undertaken and is reported to the clinical governance committee and RO at NHS Greater Glasgow and Clyde. The hospice reported that Form 4s (or relevant documentation) for all new appointments are checked by the chief executive officer. Information for appraisal Supporting information: The hospice uses various methods to prompt doctors to include relevant supporting information that is relevant to the whole of their practice. As well as encouraging doctors to be active in management and strategic governance meetings, doctors are encouraged to either chair or attend a variety of clinical and governance groups. Doctors also lead and participate in educational audits, and feedback is provided through the hospice s governance structures and processes. The clinical administration staff support doctors to record their clinical activity on the patient administration system. This system can be used to produce clinical activity reports for the whole organisation or for individual doctors. The system has recently been improved to allow doctors to track outpatient and community activity. Complaints, compliments and concerns: The hospice follows NHS Greater Glasgow and Clyde s guidance on the completion of appraisal documents and related procedures. This includes a process for feeding information on complaints, compliments, concerns and critical incidents into the appraisal system. A local agreement is also in place with the clinical lead for palliative care to share information with the NHS board about any concerns they have. Multi-source feedback: All arrangements for gathering multi-source feedback and incorporating it into personal and professional development plans are provided by NHS Greater Glasgow and Clyde as part of the agreement between the two organisations. Patient satisfaction: All doctors with patient contact must try to gather a certain number of completed patient questionnaires. Following guidance received from NHS Greater Glasgow and Clyde, the hospice s clinical administration staff distribute the patient questionnaires and these are collated centrally for analysis by the NHS board, which ensures impartiality. The patient feedback is ed to the doctor and appraiser directly. The hospice described its experience with the use of patient questionnaires to date as very positive. The review panel commended this process as good practice. Remediation, rehabilitation and targeted support The hospice has not yet had to manage any doctors requiring training or retraining. However, should the need arise, advice would be sought from NHS Greater Glasgow and Clyde about the appropriate procedures. The hospice has a service level agreement with the NHS board s occupation health services to support doctors who require rehabilitation. A process is in place for monitoring doctors conduct, performance and fitness to practise. The hospice has developed a policy statement for remediation, rehabilitation and targeted support for medical staff to access. 94

95 Medical revalidation in Scotland: local reports Self-reported assessment on progress to meet medical revalidation requirements During the self-assessment process, we asked organisations to reflect on their progress to meet medical revalidation requirements. Accord Hospice reported that it can demonstrate sustained good practice and innovation that is shared throughout the organisation and which others can learn from. The panel agreed with this assessment. Good practice, improvements and challenges We asked for feedback on examples of good practice in relation to implementing medical revalidation. The hospice reported that one of its consultants has been fully supported to train as an NES enhanced appraiser. This has developed the doctor s skills and allows the doctor to participate in NHS Greater Glasgow and Clyde s secondary care appraisal process. The hospice is also now fully engaged with the NHS board s appraisal system and all medical staff have participated in enhanced medical appraisal. Action points from 215 review No action points were identified in the 215 review. Action points for consideration during No action points were identified by the panel for

96 Medical revalidation in Scotland: local reports Ardgowan Hospice Data tables Number of doctors with a prescribed connection Number of doctors with a prescribed connection on 31 March Number of doctors eligible for appraisal in Number of completed appraisals Appraisal results (8%) Appraisal results (6%) Appraisal results Appraisal results (1%) Appraisal results Appraisal results (1%) Revalidation results Number of doctors eligible for revalidation in Number of positive recommendations Number of deferral requests Revalidation Number of doctors identified for revalidation in Number of doctors identified for revalidation in who had an appraisal between 1 April 212 and 31 March 213 between 1 April 212 and 31 March 213 Number of doctors identified for revalidation in who had an appraisal between 1 April 213 and 31 March 214 between 1 April 213 and 31 March 214 Number of doctors identified for revalidation in who had an appraisal between 1 April 214 and 31 March 215 between 1 April 214 and 31 March 215 Number of doctors identified for revalidation in who had an appraisal between 1 April 215 and 31 March 216 between 1 April 215 and 31 March 216 Number of NES-trained appraisers Number of NES-trained appraisers in organisation 96

97 Medical revalidation in Scotland: local reports Findings of the evaluation panel Ardgowan Hospice reported that it is not a designated body. The hospice outsources appraisal and RO support to NHS Greater Glasgow and Clyde and a Memorandum of Understanding is in place between the two organisations detailing the arrangements. Governance relevant to revalidation The hospice takes advice on all aspects of the appraisal process from the local appraisal lead at NHS Greater Glasgow and Clyde. The hospice reported that an annual appraisal audit had been performed and reported that there were no missed or incomplete appraisals. The human resources department maintains a spreadsheet to monitor and track appraisal information. The hospice reported that medical revalidation is a standing agenda item on the healthcare governance committee and is included in the annual report to the Board. Form 4s (or relevant documentation) for new appointments are checked by the hospice s chief executive and lead consultant. The chief executive will inform the RO at NHS Greater Glasgow and Clyde if there are any concerns. Information for appraisal Supporting information: The hospice reported that its doctors are aware of the GMC requirements to provide supporting evidence that reflects the whole of their practice. Clinical activity data are captured routinely within the hospice s balanced scorecard and the data manager provides an analysis. This information is also reported every 3 months to NHS Greater Glasgow and Clyde. Complaints, compliments and concerns: The hospice reported it has a system in place to manage, track and report information about complaints, compliments, concerns or critical incidents. These are managed by the healthcare governance committee and risk management committee. Feedback is provided to the individual doctor at the time that the complaint or incident takes place. Any incidents would be reported to NHS Greater Glasgow and Clyde. Multi-source feedback: The hospice reported that its doctors use the multi-source feedback resource on SOAR. Feedback is discussed at the appraisal meeting and included in the personal development plans. Patient satisfaction: The hospice uses a modified version of the Voices questionnaire and the CARE patient feedback questionnaires to gather patient feedback. Nurses and reception staff distribute and collect the questionnaires and forward them to Stobhill Hospital, Glasgow for analysis. This feedback is discussed during appraisals. The hospice reported that patients and their families find the Voices questionnaire easier to complete as the CARE questionnaire involves more paperwork. Remediation, rehabilitation and targeted support The hospice confirmed that it follows NHS Greater Glasgow and Clyde s policy for remediation, rehabilitation and targeted support. It reported that staff training is discussed at the education and training group and implemented as required. The lead clinician monitors doctors conduct, performance and fitness to practise on an ongoing basis. Self-reported assessment on progress to meet medical revalidation requirements During the self-assessment process, we asked organisations to reflect on their progress to meet medical revalidation requirements. Ardgowan Hospice reported that it has welldeveloped systems and processes and can demonstrate sustainable improvement throughout the organisation. The panel considered that the hospice can demonstrate sustained good practice and innovation that is shared throughout the organisation and which others can learn from. 97

98 Medical revalidation in Scotland: local reports Good practice, improvements and challenges We asked for feedback on examples of good practice in relation to implementing medical revalidation and the hospice reported it has an education and training group which meets regularly to set out the training plans for its staff. There is also an educational facilitator in post to recommend appropriate CPD for its staff. The hospice has implemented processes for more data related to outcomes as further supporting evidence. Action points from 215 review No action points were identified in the 215 review. Action points for consideration during No action points were identified by the panel for

99 Medical revalidation in Scotland: local reports Ayrshire Hospice Data tables Number of doctors with a prescribed connection Number of doctors with a prescribed connection on 31 March Number of doctors eligible for appraisal in Number of completed appraisals Appraisal results (1%) Appraisal results (1%) Appraisal results (1%) Appraisal results (1%) Appraisal results (1%) Appraisal results (1%) Revalidation results Number of doctors eligible for revalidation in Number of positive recommendations 1 (1%) Number of deferral requests Revalidation Number of doctors identified for revalidation in Number of doctors identified for revalidation in who had an appraisal between 1 April 212 and 31 March 213 between 1 April 212 and 31 March 213 Number of doctors identified for revalidation in who had an appraisal between 1 April 213 and 31 March 214 between 1 April 213 and 31 March 214 Number of doctors identified for revalidation in who had an appraisal between 1 April 214 and 31 March 215 between 1 April 214 and 31 March 215 Number of doctors identified for revalidation in who had an appraisal between 1 April 215 and 31 March 216 between 1 April 215 and 31 March 216 Number of NES-trained appraisers Number of NES-trained appraisers in organisation 1 (1%) 99

100 Medical revalidation in Scotland: local reports Findings of the evaluation panel Ayrshire Hospice is a designated body. It has a formal agreement in place for outsourcing appraisal and RO support from NHS Ayrshire & Arran. Governance relevant to revalidation The hospice indicated that access to leadership and advice on all aspects of the appraisal process is provided through the NHS Ayrshire & Arran appraisal and revalidation team. Ayrshire Hospice reported that it did not perform an audit of missed or incomplete appraisals. However, information regarding missed or incomplete appraisals is provided by the NHS Ayrshire & Arran appraisal and revalidation team on a continuous basis. The hospice s lead consultant provides a report on appraisal and revalidation to the hospice s chief executive and clinical services director. The clinical services director reports on medical revalidation to the hospice s Board and clinical governance committee. This provides the Board with an assurance that all doctors working in the organisation are fit to practise. Ayrshire Hospice reported that it does not check Form 4s (or relevant documentation) and advised that this is done by NHS Ayrshire & Arran. The hospice also reported that where hospice s doctors (those employed by the medical out of hours team) are employed by more than one organisation, it is expected that they take responsibility for transfer of information between organisations. Information for appraisal Supporting information: The hospice encourages all doctors to be mindful of their responsibility to include supporting information that reflects the whole of their practice. Ayrshire Hospice reported that clinical activity data for the hospice inpatient unit and community and acute hospitals are collected and disseminated to doctors by the Ayrshire Hospice quality department. Complaints, compliments and concerns: The clinical services director issues a written confirmation to each doctor advising whether or not any complaints or concerns were received during the appraisal period. The hospice reported that NHS Ayrshire & Arran provides this information for any of the doctors who have clinical sessions in the hospital setting. This information is also recorded on SOAR. Multi-source feedback: The hospice reported that all doctors undertake multi-source feedback once every 5 years as part of the appraisal process. Patient satisfaction: Ayrshire Hospice explained that obtaining patient feedback for medical appraisal and revalidation within the hospice follows the recommendations of the Association for Palliative Medicine. The hospice added that this is part of the medical appraisal and revalidation process which is required to take place once every 5 years. In addition the patient satisfaction questionnaires and surveys are also used to reflect on a spectrum of domains of care provided by the multidisciplinary team rather than an individual clinician. The collation and analysis of patient questionnaire results is carried out by the hospice quality improvement facilitator and a summary report can be produced if requested. Dissemination of this information within the organisation is supported by the hospice clinical governance structure. The panel noted a range of tools used for the management of patient questionnaires and commended the hospice on this. The tools used by the hospice include the following: hospice wide: Care Opinion hospice lymphoedema questionnaire respite and response service feedback 1

101 Medical revalidation in Scotland: local reports inpatient unit: Tell Us What You Think, Just One Word, patient and relative questionnaire, and carer s café questionnaire (carer feedback/assessment). The hospice reported that it is currently encouraging patients and carers to use Care Opinion as a means of providing feedback on their experience of hospice services. The hospice explained that this system enables patients and carers to track the changes that have resulted from their comments. The feedback obtained from patient questionnaires informs both clinical practice and service evaluation. Person Centred Outcome Measures refer to measures which focus on the domains known to be prioritised by patients with advanced illness. If the patient is too frail or sick to report the measures themselves, they may be reported by proxies (family members or professionals) on the patient s behalf. Remediation, rehabilitation and targeted support The hospice indicated that it has a process in place for its doctors to undergo training or retraining. This support would be tailored to an individual doctor's needs and supported by the Ayrshire Hospice human resources policy, management of employee capability. The hospice would also seek advice and guidance from NHS Ayrshire & Arran, human resources, NHS Education for Scotland and the Medical Royal Colleges. Self-reported assessment on progress to meet medical revalidation requirements During the self-assessment process, we asked organisations to reflect on their progress to meet medical revalidation requirements. Ayrshire Hospice reported that it has welldeveloped systems and processes and can demonstrate sustainable improvement throughout the organisation. The panel agreed with this assessment. Good practice, improvements and challenges We asked for feedback on examples of good practice in relation to implementing medical revalidation. The hospice reported that all doctors currently employed by the organisation participate in annual appraisal and revalidation supported by the NHS Ayrshire & Arran appraisal and revalidation team. The hospice also reported that it provides support to its lead consultant in their role as a NES-trained appraiser. The hospice reported that medical revalidation provides continuous assurance that all licensed doctors employed by the organisation are fit to practise. The panel commended the hospice for using patient feedback more widely on a routine basis and the additional work undertaken to give documentation and feedback to doctors for revalidation purposes. Action points from 215 review No action points were identified from the 215 review. Action points for consideration during No action points were identified by the panel for

102 Medical revalidation in Scotland: local reports Bethesda Hospice Data tables Number of doctors with a prescribed connection Number of doctors with a prescribed connection on 31 March Number of doctors eligible for appraisal in Number of completed appraisals Appraisal results (1%) Appraisal results (1%) Appraisal results (1%) Appraisal results (1%) Appraisal results (1%) Appraisal results (1%) Revalidation results Number of doctors eligible for revalidation in Number of positive recommendations Number of deferral requests Revalidation Number of doctors identified for revalidation in Number of doctors identified for revalidation in who had an appraisal between 1 April 212 and 31 March 213 between 1 April 212 and 31 March 213 Number of doctors identified for revalidation in who had an appraisal between 1 April 213 and 31 March 214 between 1 April 213 and 31 March 214 Number of doctors identified for revalidation in who had an appraisal between 1 April 214 and 31 March 215 between 1 April 214 and 31 March 215 Number of doctors identified for revalidation in who had an appraisal between 1 April 215 and 31 March 216 between 1 April 215 and 31 March 216 Number of NES-trained appraisers Number of NES-trained appraisers in organisation 12

103 Medical revalidation in Scotland: local reports Findings of the evaluation panel Bethesda Hospice is a charity which provides a range of palliative care services for patients. The hospice receives RO and appraisal support from NHS Western Isles. Governance relevant to revalidation The panel noted that there is no formal audit process in place to provide assurance on missed or incomplete appraisals. Instead, due to the very small number of doctors in the hospice, the hospice manager requests written confirmation that doctors have received an annual appraisal. The self-assessment states that the RO provides a detailed annual report to NHS Western Isles. However, the panel noted that this report makes no reference to Bethesda Hospice. Bethesda Hospice confirmed that it has a process in place for the RO to review Form 4s (or relevant documentation) for all new appointments for whom they have responsibility. The RO takes responsibility for the management of sharing information for doctors who work across organisations. Information for appraisal Supporting information: Doctors within the hospice are aware of their responsibility to include items of supporting information that reflects the whole of their practice for appraisal purposes. Doctors meet regularly with hospice senior staff to review complaints, compliments and significant events data and these meetings are minuted. Up-to-date clinical activity information is shared with doctors during senior management team meetings. The results of patient satisfaction questionnaires are audited and displayed in a newsletter issued to all doctors every 2 months. Complaints, compliments and concerns: The general manager ensures all complaints, concerns and compliments are copied to the hospice doctors to add to their appraisal portfolios. Doctors have access to significant events and complaints data. The appraiser also requests this information from the doctor to discuss at appraisal. Multi-source feedback: The hospice reported that doctors complete at least one multisource feedback exercise in each 5-year revalidation cycle. Patient satisfaction: The hospice uses its own patient questionnaire to gain feedback. These are issued to patients, family and friends. The hospice noted in its self-assessment that the questionnaire is currently being reviewed and updated to encourage an increase in the response rate. Remediation, rehabilitation and targeted support The hospice has no process in place for doctors to undergo training or re-training. There have been no concerns to date; any future concerns would be looked at jointly with NHS Western Isles. There is no rehabilitation provision in place for doctors within the hospice. Instead, support would be sought from NHS Western Isles. Self-reported assessment on progress to meet medical revalidation requirements During the self-assessment process, we asked organisations to reflect on their progress to meet medical revalidation requirements. Bethesda Hospice reported that it is developing plans and processes and can demonstrate sustainable improvement throughout the organisation. The panel agreed with this assessment. Good practice, improvements and challenges We asked for feedback on examples of good practice in relation to implementing medical revalidation. The hospice reported that it has good links with NHS Western Isles which provides the hospice with excellent advice and support. The panel also highlighted the arrangements the hospice manager has in place to receive written confirmation that doctors 13

104 Medical revalidation in Scotland: local reports working in the hospice have received an annual appraisal and are up to date and fit to practise as an example of good practice. The hospice reported no challenges faced with regards to implementing medical revalidation. Action points from 215 review Fully actioned Ongoing Implement a process for RO to check Form 4s (or relevant documentation). Provide RO report, at least annually, through formal governance arrangements. Action points for consideration during Provide RO report, at least annually, through formal governance arrangements. Include details of progress with medical appraisal and the revalidation status of doctors working at Bethesda Hospice in the RO s annual report to NHS Western Isles. 14

105 Medical revalidation in Scotland: local reports Children s Hospice Association Scotland Data tables Number of doctors with a prescribed connection Number of doctors with a prescribed connection on 31 March Number of doctors eligible for appraisal in Number of completed appraisals Appraisal results (1%) Appraisal results (1%) Appraisal results (75%) Appraisal results Appraisal results Appraisal results (1%) Revalidation results Number of doctors eligible for revalidation in Number of positive recommendations 1 (1%) Number of deferral requests Revalidation Number of doctors identified for revalidation in Number of doctors identified for revalidation in who had an appraisal between 1 April 212 and 31 March 213 between 1 April 212 and 31 March 213 Number of doctors identified for revalidation in who had an appraisal between 1 April 213 and 31 March 214 between 1 April 213 and 31 March 214 Number of doctors identified for revalidation in who had an appraisal between 1 April 214 and 31 March 215 between 1 April 214 and 31 March 215 Number of doctors identified for revalidation in who had an appraisal between 1 April 215 and 31 March 216 between 1 April 215 and 31 March 216 Number of NES-trained appraisers Number of NES-trained appraisers in organisation 15

106 Medical revalidation in Scotland: local reports Findings of the evaluation panel Governance relevant to revalidation The Children s Hospice Association Scotland (CHAS) has outsourced RO support and appraisal services to NHS Tayside. There is an agreement between CHAS and NHS Tayside confirming the arrangements in place which covers both of the organisation s hospices, Rachel House and Robin House. Leadership and advice on appraisal arrangements are provided by the appraisal lead at NHS Tayside, the CHAS medical director and chief executive. CHAS has a system to monitor and track information about missed or incomplete appraisals. An audit of doctors revalidation status is undertaken and an annual report is prepared for the chief executive, clinical governance committee and the board of directors. CHAS has a process in place for checking Form 4s (or relevant documentation). This is undertaken for all substantive posts by the CHAS human resources team and the RO. In situations where a doctor s substantive post is with another organisation and sessional services are provided to CHAS, the CHAS human resources team request and check previous appraisal documentation. This is viewed by the organisation s medical director. Additionally, the CHAS medical director has regular communications and meetings with the medical directors for paediatrics from NHS Lothian and NHS Greater Glasgow and Clyde to discuss medical consultant work plans and appraisals. The CHAS medical director also uses the SOAR website to check that all sessional GPs who undertake their annual appraisals outwith CHAS, have undertaken annual appraisal and subsequent revalidation in their host organisations. Information for appraisal Supporting information: There is a system in place to provide doctors with information on their clinical activity for their annual appraisals. Regular training sessions are held including significant event analysis sessions which provide doctors with a good range of up-to-date information. After any significant event, CHAS holds an internal multidisciplinary debrief session at which discussions take place to identify what went well and what could have been done better. Clinical incidents are also discussed at the monthly medicine management group meeting. Complaints, compliments and concerns: CHAS has a formal process in place to provide doctors with information on complaints, compliments or concerns in advance of their appraisal. A policy for this process has been developed. All complaints are discussed at the CHAS senior management team meeting and investigations are carried out and feedback is provided to relevant staff. The medical director cascades feedback within the medical team, if the complaint involved the medical director, the chief executive would provide feedback directly to the medical director. CHAS reported that it values feedback as it considers it a useful tool which helps to ensure that patient care is maintained to a high standard. Multi-source feedback: CHAS confirmed that its doctors use the multi-source feedback resource on SOAR. Patient satisfaction: CHAS reported that its doctors use the Paediatric Carers of Children Feedback Tool developed by the Royal College of Paediatrics and Child Health (RCPCH) as a patient questionnaire. For the purposes of avoiding any bias, administrators manage the patient feedback process. Once completed, the administrator returns the questionnaires to the RCPCH for analysis and feedback. Remediation, rehabilitation and targeted support CHAS is an employer of a small number of medical doctors and, as such, it does not consider it necessary to have a policy in place for remediation and support. Instead, there is process in place which requires each doctor to have a 6-monthly review. The medical 16

107 Medical revalidation in Scotland: local reports director s review is carried out by the chief executive and the doctor s review is undertaken by the medical director. This review process is used to identify if any of the doctors require support. Any issues would be discussed with the RO and support would be provided accordingly. Self-reported assessment on progress to meet medical revalidation requirements During the self-assessment process, we asked organisations to reflect on their progress to meet medical revalidation requirements. CHAS reported that it has well-developed systems and processes and can demonstrate sustainable improvement throughout the organisation. The panel agreed with this assessment. Good practice and challenges We asked for feedback on examples of good practice in relation to implementing medical revalidation. CHAS reported that it has a formal process and documentation in place to update the chief executive, clinical governance committee and the board of directors about the revalidation status of its doctors. The panel also considered the use of the feedback tool to be an area of good practice. We also asked about challenges however, CHAS confirmed it did not have any to report. Action point from 215 review Annual report to include details to provide assurance to the clinical governance committee that arrangements for appraisal are in place as well as information on the fitness to practice of its doctors. Fully actioned Ongoing Action points for consideration during No action points were identified by the panel for

108 Medical revalidation in Scotland: local reports Highland Hospice Appraisal and revalidation data for doctors working in Highland Hospice are included in NHS Highland s report as all doctors working in the hospice have their prescribed connection with NHS Highland. Findings of the evaluation panel Highland Hospice is a registered charity in Scotland. All of the doctors working at Highland Hospice have a prescribed connection to NHS Highland. Therefore, the NHS board is responsible for carrying out the annual appraisal of these doctors and there is no requirement for the hospice to formally outsource medical appraisal. NHS Highland also provides the hospice with RO support. The panel noted that the hospice was not aware that the national agreement template, to formalise arrangements for outsourcing external appraisal services and or RO support, had been issued in October 214. Governance relevant to revalidation The hospice indicated that access to leadership and advice on all aspects of the appraisal process is provided through NHS Highland which provide support and advise staff when they are preparing for appraisal. The hospice reported that although it had not carried out a formal audit of missed or incomplete appraisals. However, the appraisal status of its doctors is monitored closely by the medical staffing department at NHS Highland. Highland Hospice does not provide an annual report or briefing paper to its governing body or relevant subcommittee. Highland Hospice explained that its RO would report any difficulties to the hospice s chief executive officer and these would also be brought to the attention of the Board by the human resources sub-committee. Highland Hospice reported that checking Form 4s (or relevant documentation) for new appointments has not been a routine part of its appointment process to date. The NHS board stated that the medical staffing department at NHS Highland requires copies of Form 4s, before they will grant honorary contracts. Information for appraisal Supporting information: The hospice explained that the appraisal service provided by NHS Highland makes sure that doctors are aware of the requirements to provide supporting information that reflects the whole of their practice. Complaints, compliments and concerns: Highland Hospice reported that each doctor is given an annual report, produced by NHS Highland, which provides details of any complaints or critical incidents that they have been involved in and, the report must be made available to their appraiser. The hospice reported that there is no formal channel of communication between the hospice chief executive officer and the medical staffing department at NHS Highland to inform the appraisal process of any in-house complaints or concerns. Multi-source feedback: The hospice indicated that it has arrangements in place to provide multi-source feedback. A brief explanation was provided to confirm that multi-source feedback is provided on a frequency that satisfies the requirements for revalidation. Patient satisfaction: Highland Hospice explained that it uses the Hospice UK patient feedback questionnaires and these are distributed by nominated staff members. The hospice reported that the patient questionnaire provides them with limited value due to the frailty of the majority of its patients. However, the hospice does seek verbal feedback from families, after the passing of a family member and on an ongoing basis from individuals receiving carer support. The panel noted that the hospice indicated that it had experienced difficulties meeting the required number of completed questionnaires, in a reasonable time period. 18

109 Medical revalidation in Scotland: local reports Remediation, rehabilitation and targeted support Highland Hospice reported that it uses NHS Highland s policy for remediation, rehabilitation and support to support any of its doctors with additional training needs or requiring rehabilitation. Self-reported assessment on progress to meet medical revalidation requirements During the self-assessment process, we asked organisations to reflect on their progress to meet medical revalidation requirements. Highland Hospice reported that it has welldeveloped systems and processes and can demonstrate sustainable improvement throughout the organisation. The panel agreed with this assessment. Good practice, improvements and challenges The hospice did not report any areas of good practice in relation to the implementation of medical revalidation. It explained that it is a small organisation, with a small number of doctors and that medical revalidation had not had any significant impact on the hospice. The hospice highlighted that medical appraisal and revalidation is administered through NHS Highland and beyond making sure that there is ongoing communication between the NHS board and the hospice, there had not been any other issues identified. Action points from 215 review Fully actioned Ongoing Provide an RO report, at least annually, through formal governance arrangements. Continue to monitor the appraisal rate. Action points for consideration during Formalise the arrangement, based on the national agreement template, with NHS Highland for the provision of RO support to the hospice. Provide assurance in the form of an annual report or briefing paper, to the hospice s governing body that all doctors working in the hospice are up to date with appraisal and revalidation arrangements and are fit to practise. 19

110 Medical revalidation in Scotland: local reports Marie Curie Hospice, Edinburgh Data tables Number of doctors with a prescribed connection Number of doctors with a prescribed connection on 31 March Number of doctors eligible for appraisal in Number of completed appraisals Appraisal results Not available Appraisal results Not available Appraisal results Not available Appraisal results Not available Appraisal results (71%) Appraisal results (1%) Revalidation results Number of doctors eligible for revalidation in Number of positive recommendations 2 (1%) Number of deferral requests Revalidation Number of doctors identified for revalidation in Number of doctors identified for revalidation in who had an appraisal between 1 April 212 and 31 March 213 between 1 April 212 and 31 March 213 Number of doctors identified for revalidation in who had an appraisal between 1 April 213 and 31 March 214 between 1 April 213 and 31 March 214 Number of doctors identified for revalidation in who had an appraisal between 1 April 214 and 31 March 215 between 1 April 214 and 31 March 215 Number of doctors identified for revalidation in who had an appraisal between 1 April 215 and 31 March 216 between 1 April 215 and 31 March 216 Number of NES-trained appraisers Number of NES-trained appraisers in organisation 1 (1%) 11

111 Medical revalidation in Scotland: local reports Findings of the evaluation panel Governance relevant to revalidation Marie Curie Hospice, Edinburgh is a designated body and outsources appraisal services and RO support to NHS Lothian. The hospice also has an arrangement with St Columba s Hospice to undertake appraisals for each other. The hospice has agreements in place to formalise these arrangements with NHS Lothian and St Columba s Hospice. Marie Curie Hospice is supported by the appraisal and SOAR teams at NHS Lothian to provide its doctors with leadership and advice on the appraisal process. The RO and executive medical director for Marie Curie Hospice also contribute to this. Marie Curie Hospice reported that it has a team of eight doctors and that engagement with appraisal is well monitored. The hospice confirmed that any missed or incomplete appraisals and deferrals would be picked up by the hospice monitoring system. The RO provides the Marie Curie Board of Trustees with an annual update on its progress with appraisal and revalidation. Marie Curie Hospice stated that Form 4s (or relevant documentation) for new appointments are requested and checked by the line manager for medical staff; any issues are reported to the RO and NHS Lothian and escalated accordingly. The hospice indicated that it had no process in place to share information, where doctors are employed by more than one organisation and said it was not something that was relevant for any of its staff at the time. Information for appraisal Supporting information: The hospice explained that it directs its doctors to guidance on SOAR which makes them aware of their responsibility to include items of supporting information that reflects the whole of their practice. Clinical activity data for the hospice is produced every month and made available to doctors through hospice quality assurance monitoring. Complaints, compliments and concerns: Marie Curie Hospice reported that discussion at individual meetings between the doctor and their line manager encourages the inclusion of information on complaints, compliments, concerns or critical incidents in the appraisal system. However, the panel noted that this process was very doctor dependent and agreed that it did not provide any assurance of the governance arrangements. Multi-source feedback: The doctors at Marie Curie Hospice all use the multi-source feedback system on SOAR. The hospice reported that the results of the feedback are discussed with the doctor s line manager and used in the appraisal process. Patient satisfaction: Marie Curie Hospice reported that is has a number of ways to gather feedback from patients and families, such as gathering real-time feedback on a patient s care and experience in the hospice using ipads. The results of this feedback are reviewed every month at the hospice s quality assurance meetings. The hospice uses the CARE questionnaire to gather patient feedback and it described how patients are provided with a covering letter, along with the questionnaire to explain the feedback process. The hospice reported that completed questionnaires are returned to the doctor s line manager. Marie Curie Hospice reported that the majority of questionnaires that it distributes are issued to outpatients, as it considers its inpatient population too frail. The panel would encourage the hospice to use patient feedback more evenly across inpatient and outpatient care by considering options for gathering feedback from inpatients. The results drawn from patient feedback are included in the doctor s annual appraisal in order to comply with revalidation. Remediation, rehabilitation and targeted support Marie Curie Hospice reported that any plans for the training or re-training of doctors would be designed to meet the needs of the individual and work within the relevant guidance and policies of Marie Curie Hospice and NHS Lothian. 111

112 Medical revalidation in Scotland: local reports Self-reported assessment on progress to meet medical revalidation requirements During the self-assessment process, we asked organisations to reflect on their progress to meet medical revalidation requirements. Marie Curie Hospice reported that it has welldeveloped systems and processes and can demonstrate sustainable improvement throughout the organisation. However, the panel considered that the hospice was developing plans and processes and can demonstrate sustainable improvement throughout the organisation. Good practice, improvements and challenges We asked for feedback on examples of good practice in relation to implementing medical revalidation and Marie Curie Hospice made reference to the agreement it has with St Columba s Hospice to provide appraisal services for one another s doctors. The hospice highlighted that revalidation complimented the existing person-centred culture work being done in the hospice. The hospice added that it considered the appraisal and revalidation process invests in the doctor, as an individual, as well as his or her part of the wider hospice team. The panel acknowledged that Marie Curie Hospice is still in a period of transition and has complied with what was asked for as part of this year s external quality assurance review. The panel was pleased to see the progress that the hospice had made since last year s review and noted the areas of improvement. Action point from 215 review Implement a system or process for checking Form 4s (or relevant documentation). Fully actioned Ongoing Action points for consideration during No action points were identified by the panel for

113 Medical revalidation in Scotland: local reports Marie Curie Hospice, Glasgow Data tables Number of doctors with a prescribed connection Number of doctors with a prescribed connection on 31 March Number of doctors eligible for appraisal in Number of completed appraisals Appraisal results Not available Appraisal results Not available Appraisal results Not available Appraisal results Not available Appraisal results Not available Appraisal results (88%) Revalidation results Number of doctors eligible for revalidation in Number of positive recommendations 2 (1%) Number of deferral requests Revalidation Number of doctors identified for revalidation in Number of doctors identified for revalidation in who had an appraisal between 1 April 212 and 31 March 213 between 1 April 212 and 31 March 213 Number of doctors identified for revalidation in who had an appraisal between 1 April 213 and 31 March 214 between 1 April 213 and 31 March 214 Number of doctors identified for revalidation in who had an appraisal between 1 April 214 and 31 March 215 between 1 April 214 and 31 March 215 Number of doctors identified for revalidation in who had an appraisal between 1 April 215 and 31 March 216 between 1 April 215 and 31 March 216 Number of NES-trained appraisers Number of NES-trained appraisers in organisation 2 113

114 Medical revalidation in Scotland: local reports Findings of the evaluation panel Marie Curie Hospice, Glasgow reported that it is not a designated body. The hospice confirmed that it receives RO support and appraisal services from NHS Greater Glasgow and Clyde. The hospice provided a copy of the formal agreement for the provision of these services as part of its self-assessment submission. Governance relevant to revalidation The hospice reported that its medical director keeps a log of all due appraisals and revalidation dates and regularly meets with medical staff to ensure that there are no missed or incomplete appraisals. The hospice reported that it follows the NHS Greater Glasgow and Clyde revalidation governance procedures. The hospice reported that all appraisal and revalidation activity for doctors is presented in an annual report to the Marie Curie Board of Trustees. The purpose of this report is to provide assurance on its adherence with appraisal and revalidation obligations. The hospice had no deferrals for the period The medical director checks all Form 4s (or relevant documentation) for new appointments for whom they have responsibility. When a doctor is employed by more than one organisation, the hospice confirmed that there is a process in place for sharing information between the organisations. Doctors share their Form 4s with their line manager within the hospice and it is expected that any information or concerns that the RO has would be shared with the hospice. Information for appraisal Supporting information: The medical director for the hospice regularly meets with doctors and they are reminded of their responsibility to include items of supporting information that reflects the whole of their practice within their appraisal documentation. The hospice reported it has a system in place for providing doctors with up-to-date clinical activity. Hospice doctors have responsibilities within different clinical governance groups and they are able to access minutes from these groups and the monthly clinical activity statistics. The hospice reported that reported incidents are fed back and discussed with medical staff at regular meetings and at the quality group. Complaints, compliments and concerns: The hospice reported that all doctors are encouraged to feed information on complaints, compliments, concerns or critical incidents into their appraisal. The monitoring of this is done by NHS Greater Glasgow and Clyde as part of the appraisal services provided. Multi-source feedback: All doctors use the NHS Greater Glasgow and Clyde appraisal system to gather multi-source feedback for appraisal. Patient satisfaction: The hospice uses NHS Greater Glasgow and Clyde patient questionnaires to gather patient feedback and the hospice administration team assist with the distribution of questionnaires to patients. NHS Greater Glasgow and Clyde then analyses the questionnaires and provides a report to the appraisee and appraiser for discussion at appraisal. The hospice reported that its doctors occasionally face difficulties in being able to gather a high number of responses due to patients being too frail to complete questionnaires. Remediation, rehabilitation and targeted support The hospice reported that it does not have a process in place to provide doctors with training or re-training. However, if this was required, the hospice would seek advice from human resources, the clinical director, medical lead, NHS Greater Glasgow and Clyde colleagues and NES in order to provide individual support to doctors. Doctors employed by the hospice also have access to the occupational health service for any rehabilitation needs. 114

115 Medical revalidation in Scotland: local reports Self-reported assessment on progress to meet medical revalidation requirements During the self-assessment process, we asked organisations to reflect on their progress to meet medical revalidation requirements. Marie Curie Hospice, Glasgow reported that it has well-developed systems and processes and can demonstrate sustainable improvement throughout the organisation. The panel agreed with this assessment. Good practice, improvements and challenges We asked for feedback on examples of good practice in relation to implementing medical revalidation. The hospice reported that its appraisal process is robustly integrated with NHS Greater Glasgow and Clyde s appraisal system. This ensures that there is external objective input into the appraisal of the hospice doctors. The hospice did not identify any challenges faced with the implementation of medical revalidation. Action points for consideration during No action points were identified by the panel for

116 Medical revalidation in Scotland: local reports St Columba s Hospice Data tables Number of doctors with a prescribed connection Number of doctors with a prescribed connection on 31 March Number of doctors eligible for appraisal in Number of completed appraisals Appraisal results (1%) Appraisal results (1%) Appraisal results (1%) Appraisal results (1%) Appraisal results (1%) Appraisal results (1%) Revalidation results Number of doctors eligible for revalidation in Number of positive recommendations 5 (1%) Number of deferral requests 1 (2%) Revalidation Number of doctors identified for revalidation in Number of doctors identified for revalidation in who had an appraisal between 1 April 212 and 31 March 213 between 1 April 212 and 31 March 213 Number of doctors identified for revalidation in who had an appraisal between 1 April 213 and 31 March 214 between 1 April 213 and 31 March 214 Number of doctors identified for revalidation in who had an appraisal between 1 April 214 and 31 March 215 between 1 April 214 and 31 March 215 Number of doctors identified for revalidation in who had an appraisal between 1 April 215 and 31 March 216 between 1 April 215 and 31 March 216 Number of NES-trained appraisers Number of NES-trained appraisers in organisation 1 116

117 Medical revalidation in Scotland: local reports Findings of the evaluation panel St Columba s Hospice provides a comprehensive range of palliative care services for patients, as well as support for relatives and carers. A formal agreement is in place for outsourcing RO support from NHS Lothian. An appraisal support service is provided on a reciprocal, formal agreement basis between St Columba s Hospice and Marie Curie Hospice, Edinburgh. The panel commended the hospice on progress made with appraisal services. However, it did note that the current agreement does not meet the criteria of having two different appraisers within the 5-yearly cycle. The panel acknowledged that the medical director s report contained a potential option for appraisal support. Governance relevant to revalidation The hospice reported that due to the small number of doctors employed, appraisal dates are easily monitored without the need for a formal audit process. A copy of the medical director s annual report to the hospice s governing body was provided to the panel. This report referred to the agreement with Marie Curie Hospice, Edinburgh for reciprocal appraisal support. The report also referred to the current appraisal arrangements for the medical director outwith the agreement with Marie Curie Hospice, Edinburgh. The hospice stated that Form 4s (or relevant documentation) for all new appointments are reviewed by the hospice medical director. Information for appraisal Supporting information: The hospice reported that the medical director holds pre-appraisal meetings with doctors to help them identify the type of supporting information that will be needed to provide evidence for their appraisals. The personal development plan from the previous year is also reviewed by the medical director at this meeting. The hospice also encourages doctors to keep up to date with the guidelines on the SOAR website. A patient information system called Crosscare is used by the hospice to generate activity data relevant to all aspects of clinical service. These reports are generated by hospice medical administration staff. Complaints, compliments and concerns: Doctors involved in a complaint investigation will receive appropriate feedback from the medical director and are encouraged to reflect on this as part of the appraisal process. Compliments are passed on to doctors directly so that the information can be kept in their appraisal portfolio. The hospice reported that critical incidents are discussed with the relevant multidisciplinary team. Doctors involved are then encouraged to reflect on their practice using a standard critical incident pro-forma which is retained for reference during their appraisal. Multi-source feedback: The hospice reported that multi-source feedback is provided from the SOAR website and incorporated into personal and professional development plans. Patient satisfaction: The Royal College of Physicians, patient feedback questionnaire is used by the hospice to gather patient feedback. Patients from the inpatient unit and day hospice are given questionnaires by an appropriately trained member of staff or volunteer. The panel noted the hospice response on its self-assessment that, due to the nature of the hospice, it is unable to gather a large number of respondents and would encourage the hospice to explore other feedback options. Remediation, rehabilitation and targeted support There is a process in place for remediation and rehabilitation services. This is supported by the medical director and human resources department. The hospice provided the review panel with a copy of its capability policy as part of its medical revalidation submission. Doctors have access to the services of an occupational health doctor as well as the services of a confidential staff counsellor. 117

118 Medical revalidation in Scotland: local reports Self-reported assessment on progress to meet medical revalidation requirements During the self-assessment process, we asked organisations to reflect on their progress to meet medical revalidation requirements. St Columba s Hospice reported that it has welldeveloped systems and processes and can demonstrate sustainable improvement throughout the organisation. The panel noted improvement on the previous year. However, due to the management of patient feedback, the panel considered the hospice to be at the stage where it is developing plans and processes and can demonstrate sustainable improvement throughout the organisation. Good practice, improvements and challenges We asked for feedback on examples of good practice in relation to implementing medical revalidation. St Columba s Hospice provided various examples in its self-assessment. The hospice has governance structures which enable staff involvement in quality and service improvement. Doctors are actively encouraged to reflect on practice through reflective cases and the use of significant event analysis. The hospice has an organisational-wide approach to continuing professional development. The hospice reported that the only challenge it faced is how it will creatively collect patient and family satisfaction information. Action points from 215 review Report at least annually, through formal governance arrangements. Outsource medical appraisal services. Fully actioned Ongoing Action points for consideration during Establish a process to rotate appraisers to ensure doctors do not have the same appraiser for more than 3 years. Consider options for gathering patient feedback from inpatients. 118

119 Medical revalidation in Scotland: local reports St Margaret of Scotland Hospice Data tables Number of doctors with a prescribed connection Number of doctors with a prescribed connection on 31 March Number of doctors eligible for appraisal in Number of completed appraisals Appraisal results (5%) Appraisal results (6%) Appraisal results (75%) Appraisal results (1%) Appraisal results (1%) Appraisal results (1%) Revalidation results Number of doctors eligible for revalidation in Number of positive recommendations 1 (1%) Number of deferral requests Revalidation Number of doctors identified for revalidation in Number of doctors identified for revalidation in who had an appraisal between 1 April 212 and 31 March 213 between 1 April 212 and 31 March 213 Number of doctors identified for revalidation in who had an appraisal between 1 April 213 and 31 March 214 between 1 April 213 and 31 March 214 Number of doctors identified for revalidation in who had an appraisal between 1 April 214 and 31 March 215 between 1 April 214 and 31 March 215 Number of doctors identified for revalidation in who had an appraisal between 1 April 215 and 31 March 216 between 1 April 215 and 31 March (1%) 1 (1%) 1 (1%) 1 (1%) 1 (1%) 1 (1%) 1 (1%) 1 (1%) Number of NES-trained appraisers Number of NES-trained appraisers in organisation 1 119

120 Medical revalidation in Scotland: local reports Findings of the evaluation panel St Margaret of Scotland Hospice is a designated body and has four doctors with a prescribed connection to it. The hospice outsources appraisal and RO support to NHS Greater Glasgow and Clyde. A Memorandum of Understanding is in place between the two organisations detailing the arrangements. Governance relevant to revalidation The hospice reported that there are governance structures in place for medical revalidation. The hospice confirmed that there were no missed or incomplete appraisals and no deferrals during the reporting period 1 April 215 to 31 March 216, therefore, an audit of missed or incomplete appraisals was not necessary. A copy of the hospice s annual report to its governing body was provided as part of the self-assessment. The RO does not check Form 4s (or relevant documentation) for all newly appointed doctors. A process has been embedded within the hospice s safe recruitment policy where the human resources department requests a copy of the completed appraisal and evidence of revalidation within the last 5 years, if applicable, for all new appointments. The hospice reported that it has no doctors who are employed by more than one organisation, therefore, it does not currently have a process to share information between organisations. Information for appraisal Supporting information: The hospice reported that appraisal and revalidation is discussed regularly at senior management meetings. All doctors are aware of their responsibility to provide items of supporting information at appraisal that reflects the whole of their practice and this is discussed regularly at the monthly medical team meetings. Up-to-date clinical activity is collected and distributed to doctors by the medical secretary every month for inclusion in their appraisal. Complaints, compliments and concerns: The hospice confirmed that it has a process in place to feed information on complaints, compliments, concerns or critical incidents into the appraisal system. Multi-source feedback: The hospice reported that doctors identify 3 individuals to complete multi-source feedback using the WASP and e-portfolio systems for inclusion in their appraisal. Patient satisfaction: The hospice uses the CARE and GMC approved questionnaires to gather patient feedback. The medical secretary will distribute and collect validated questionnaires from inpatients, outpatients and day hospice patients in a random distribution process. Thereafter, the medical secretary collates the information which is analysed independently from the doctor before being fed into the appraisal process. The hospice reported that the process had been very successful with outpatients. Remediation, rehabilitation and targeted support The hospice reported that remediation, rehabilitation and targeted support would be provided in-house if possible. Otherwise, a suitable external resource would be used. Any requirements for additional training would be identified and doctors would be supported to attend courses. The hospice reported that occupational health advice would be sought by the hospice if required. However, to date, this has not been needed. Self-reported assessment on progress to meet medical revalidation requirements During the self-assessment process, we asked organisations to reflect on their progress to meet medical revalidation requirements. The hospice reported that it can demonstrate sustained good practice and innovation that is shared throughout the organisation and which others can learn from. The panel agreed with this assessment. 12

121 Medical revalidation in Scotland: local reports Good practice, improvements and challenges We asked for feedback on examples of good practice in relation to implementing medical revalidation. The hospice reported that it has shown successful collaborative working between the medial and senior management teams to establish a structure for revalidation. Hospice doctors are encouraged to develop their knowledge base and clinical practice through participation in the education programme for healthcare professionals. The hospice reported that revalidation has improved existing processes which were already in place by formalising them such as significant event analysis. We also asked about challenges the organisation faces in relation to medical revalidation. The hospice reported that the resource and time required to prepare for appraisal submissions was challenging for both appraisers and appraises. Action points from 215 review No action points were identified in the 215 review. Action points for consideration during No action points were identified by the panel for

122 Medical revalidation in Scotland: local reports St Vincent s Hospice Data tables Number of doctors with a prescribed connection Number of doctors with a prescribed connection on 31 March Number of doctors eligible for appraisal in Number of completed appraisals Appraisal results (33%) Appraisal results (1%) Appraisal results (5%) Appraisal results (1%) Appraisal results (1%) Appraisal results (1%) Revalidation results Number of doctors eligible for revalidation in Number of positive recommendations Number of deferral requests Revalidation Number of doctors identified for revalidation in Number of doctors identified for revalidation in who had an appraisal between 1 April 212 and 31 March 213 between 1 April 212 and 31 March 213 Number of doctors identified for revalidation in who had an appraisal between 1 April 213 and 31 March 214 between 1 April 213 and 31 March 214 Number of doctors identified for revalidation in who had an appraisal between 1 April 214 and 31 March 215 between 1 April 214 and 31 March 215 Number of doctors identified for revalidation in who had an appraisal between 1 April 215 and 31 March 216 between 1 April 215 and 31 March 216 Number of NES-trained appraisers Number of NES-trained appraisers in organisation 122

123 Medical revalidation in Scotland: local reports Findings of the evaluation panel St Vincent s Hospice is a designated body and has a Memorandum of Understanding in place with NHS Greater Glasgow and Clyde to outsource both appraisal and RO support. Governance relevant to revalidation The hospice gets advice on all aspects of the appraisal process from the local appraisal lead and a designated human resources adviser at NHS Greater Glasgow and Clyde. The hospice has arrangements in place to track the appraisal records of its doctors. The chief executive officer and medical consultant report on appraisal and revalidation to the clinical governance committee every 3 months. Minutes and action points from the meetings of the group are reported to St Vincent s Board of Trustees. The hospice confirmed that it is the medical consultant s responsibility to check Form 4s (or relevant documentation) for new appointments. The hospice reported that it has an informal process for sharing information, if a doctor is employed by more than one organisation. The panel recommended that a formal process is put in place for sharing information between organisations. Information for appraisal Supporting information: The medical consultant meets regularly with the doctors to make sure that they are aware of their responsibility to include supporting information relating to the whole of their practice in their appraisal. Complaints, compliments and concerns: The hospice described the process it has in place to feed information on complaints and concerns in to the appraisal system. Complaints are managed by the director of care who liaises with the appropriate line manager (the consultant if the complaint relates to medical staff or the chief executive if the complaint relates to the consultant).the chief executive officer, director of care or consultant will make this information available to the medical team. Each doctor is expected to include relevant information in their appraisal file using SOAR. Any concerns about a specific member of the medical team will be discussed with NHS Greater Glasgow and Clyde s appraisal lead and advice sought about further escalation, if required. Multi-source feedback: The hospice reported that doctors request multi-source feedback using the process supported by SOAR. Patient satisfaction: The hospice uses NHS Greater Glasgow and Clyde s adapted CARE patient feedback questionnaire for gathering patient feedback. The hospice s inpatient unit nursing staff or the clinical administration staff distribute the questionnaires to patients for completion. The analysis of patient feedback is administered by NHS Greater Glasgow and Clyde. The hospice reported that it took a minimum 3 months to generate enough responses to be valid. It also reported that doctors had reservations about the appropriateness of using patient satisfaction questionnaires with a very vulnerable patient population. However, the feedback to date has been gathered only from patients. The hospice may consider gathering feedback from relatives or carers to increase the number of responses received. Remediation, rehabilitation and targeted support The hospice does not have a process in place for doctors to undergo training or re-training. Any concerns would be managed by seeking advice from the NHS Greater Glasgow and Clyde s appraisal lead. The hospice does not offer its doctors rehabilitation services. It reported that it would seek advice from NHS Greater Glasgow and Clyde s appraisal lead about access to appropriate support, when necessary. 123

124 Medical revalidation in Scotland: local reports Self-reported assessment on progress to meet medical revalidation requirements During the self-assessment process, we asked organisations to reflect on their progress to meet medical revalidation requirements. The hospice reported that it has well-developed systems and processes and can demonstrate sustainable improvement throughout the organisation. The panel agreed with this assessment. Good practice, improvements and challenges We asked for feedback on examples of good practice in relation to implementing medical revalidation. The hospice highlighted that medical revalidation is a standing item at its clinical governance committee to ensure that its profile remains high at both senior management and board of trustees level. We also asked if revalidation supported or contributed to local improvement. The hospice reported that since the introduction of revalidation, the hospice has implemented a more robust structure for monitoring the appraisal and revalidation process for doctors. The hospice reported that it had no specific challenges at this time. Action points from 215 review No action points were identified from the 215 review. Action point for consideration during Implement a formal process for sharing information between organisations if a doctor is employed by more than one organisation. 124

125 Medical revalidation in Scotland: local reports Strathcarron Hospice Data tables Number of doctors with a prescribed connection Number of doctors with a prescribed connection on 31 March Number of doctors eligible for appraisal in Number of completed appraisals Appraisal results (1%) Appraisal results (1%) Appraisal results (75%) Appraisal results (1%) Appraisal results (78%) Appraisal results (91%) Revalidation results Number of doctors eligible for revalidation in Number of positive recommendations 4 (1%) Number of deferral requests Revalidation Number of doctors identified for revalidation in Number of doctors identified for revalidation in who had an appraisal between 1 April 212 and 31 March 213 between 1 April 212 and 31 March 213 Number of doctors identified for revalidation in who had an appraisal between 1 April 213 and 31 March 214 between 1 April 213 and 31 March 214 Number of doctors identified for revalidation in who had an appraisal between 1 April 214 and 31 March 215 between 1 April 214 and 31 March 215 Number of doctors identified for revalidation in who had an appraisal between 1 April 215 and 31 March 216 between 1 April 215 and 31 March (1%) 1 (1%) 1 (1%) 1 (1%) 1 (1%) 1 (1%) 1 (1%) Number of NES-trained appraisers Number of NES-trained appraisers in organisation 1 125

126 Medical revalidation in Scotland: local reports Findings of the evaluation panel Strathcarron Hospice is a designated body and outsources appraisal and RO support to NHS Forth Valley. It also provides appraisal support to NHS Forth Valley and has a formal Memorandum of Understanding in place with the NHS board detailing this arrangement. The panel commended the agreement in place between the two organisations. Governance relevant to revalidation Due to the small number of doctors employed, the hospice did not carry out an audit to determine if there were any missed or incomplete appraisals during However, it reported that a record of all appraisals is maintained and any issues would be highlighted at an early stage. The hospice reported that it reports annually to the clinical governance committee to confirm progress with medical revalidation. The hospice confirmed that there were no deferrals for the period The hospice reported it has arrangements in place to check Form 4s (or relevant documentation) for new appointments and that this is done at the recruitment stage by the human resources department. Any concerns identified would be raised with the appropriate member of the senior management team. The hospice does not have any doctors that are employed by more than one organisation. Information for appraisal Supporting information: The hospice reported that doctors are aware of their responsibility to include items of supporting information in their appraisal which reflects the whole of their practice. Complaints, compliments and concerns: The hospice reported that it has a process in place to add information on complaints to the appraisal system. The chief executive writes to the appraiser detailing any complaints that involved a specific doctor. Information on complaints is also readily available to doctors for reflection and inclusion in their appraisal portfolio. Multi-source feedback: Strathcarron Hospice has arrangements in place to provide multisource feedback to doctors. Doctors are required to incorporate this into the appraisal system, specifically for inclusion within their personal development plans. Patient satisfaction: The hospice uses a patient questionnaire which has been adapted to suit the hospice requirements and has been approved by NHS Forth Valley. Completed patient questionnaires are forwarded to NHS Forth Valley for analysis and then made available to doctors. Remediation, rehabilitation and targeted support Strathcarron Hospice doctors are supported with training or re-training needs. Each doctor is assigned to a consultant who assists them in identifying appropriate training. Attendance at external training events is supported by the hospice. To date there have been no requirements for doctors to undergo rehabilitation. The hospice reported that it would seek advice from NHS Forth Valley should this need arise. Self-reported assessment on progress to meet medical revalidation requirements During the self-assessment process, we asked organisations to reflect on their progress to meet medical revalidation requirements. Strathcarron Hospice reported that it can demonstrate sustained good practice and innovation that is shared throughout the organisation and which others can learn from. The panel agreed with this assessment. Good practice, improvements and challenges We asked for feedback on examples of good practice in relation to implementing medical revalidation. Strathcarron Hospice highlighted a few areas of good practice in its self- 126

127 Medical revalidation in Scotland: local reports assessment submission for example the hospice has an audit programme for medical revalidation in place and completed audits are presented to the clinical governance committee. We also asked about challenges and the hospice highlighted that due to the limited patient population, it is difficult to gather enough patient feedback. This is especially difficult when the hospice has more than one doctor due for medical revalidation at the same time. Action points from 215 review Fully actioned Ongoing Revise arrangements for checking Form 4s (or relevant documentation). Continue to monitor the appraisal rate. Continue to develop medical revalidation processes, procedures and plans. Action point for consideration during Continue to develop medical revalidation processes, procedures and plans. 127

128 Medical revalidation in Scotland: local reports The Prince and Princess of Wales Hospice Data tables Number of doctors with a prescribed connection Number of doctors with a prescribed connection on 31 March Number of doctors eligible for appraisal in Number of completed appraisals Appraisal results (5%) Appraisal results (1%) Appraisal results (1%) Appraisal results (1%) Appraisal results (78%) Appraisal results (1%) Revalidation results Number of doctors eligible for revalidation in Number of positive recommendations Number of deferral requests Revalidation Number of doctors identified for revalidation in Number of doctors identified for revalidation in who had an appraisal between 1 April 212 and 31 March 213 between 1 April 212 and 31 March 213 Number of doctors identified for revalidation in who had an appraisal between 1 April 213 and 31 March 214 between 1 April 213 and 31 March 214 Number of doctors identified for revalidation in who had an appraisal between 1 April 214 and 31 March 215 between 1 April 214 and 31 March 215 Number of doctors identified for revalidation in who had an appraisal between 1 April 215 and 31 March 216 between 1 April 215 and 31 March 216 Number of NES-trained appraisers Number of NES-trained appraisers in organisation 128

129 Medical revalidation in Scotland: local reports Findings of the evaluation panel The Prince and Princess of Wales Hospice is a designated body and has three doctors with a prescribed connection to it. The hospice outsources appraisal and RO support to NHS Greater Glasgow and Clyde. A Memorandum of Understanding is in place between the two organisations detailing the arrangements. Governance relevant to revalidation The hospice has robust governance arrangements in place to track the appraisal record of each doctor. The hospice confirmed that the human resources department and lead consultant carry out an annual audit of medical appraisals. The audit identifies any missed or incomplete appraisals and the reasons for these, and subsequent actions are documented. The audit is submitted to the staff governance group for information. The hospice reported that the RO does not check Form 4s (or relevant documentation) for all new appointments for whom they have responsibility. However, at interview, candidates are asked for details of their recent appraisals, revalidation information and Medical Defence Union certification. This is then followed up formally with successful candidates. The lead consultant discusses the most recent appraisal documentation to confirm its contents with the newly appointed doctor during the induction period. For those doctors who are employed by more than one organisation, honorary contracts are in place to make sure they are aware of their responsibilities to both organisations. Information for appraisal Supporting information: The hospice reported that the collection of appraisal evidence is a regular item on the agenda at the medical team meetings. Doctors are able to raise any issues on the appraisal process at these meetings and receive support if required. The hospice uses a variety of methods to provide doctors with sufficient up-to-date and relevant information about clinical activity, including job plans, rotas, diary cards and weekly meetings. Clinical activity is discussed at the clinical governance committee meeting which takes place every 2 months and is reported to the hospice s Board and NHS Greater Glasgow and Clyde. Complaints, compliments and concerns: The hospice reported that complaints, compliments, concerns and critical incidents are forwarded to the chief executive, who would liaise with the lead consultant who would discuss these with the individual concerned. The doctor would keep a record of their information to feed it into appraisal. The lead consultant would liaise with the appropriate person in NHS Greater Glasgow and Clyde to ensure that information is shared, as appropriate. Where necessary, the doctor, in consultation with the lead consultant, would record a significant learning event about the critical incident or complaint. Multi-source feedback: The hospice confirmed that multi-source feedback for doctors is managed using the SOAR system. Patient satisfaction: The hospice uses NHS Greater Glasgow and Clyde s CARE patient questionnaires to gather patient feedback. The hospice provides doctors with appropriate support to approach patients for feedback, ensuring anonymity and confidentiality are maintained. Feedback cards are available for patients and carers to complete while they are in the hospice and feedback is gathered on the hospice s website. A patient survey is conducted every year and all feedback is regularly monitored and displayed in public areas. Remediation, rehabilitation and targeted support The hospice follows NHS Greater Glasgow and Clyde s medical appraisal policy. However, the hospice has its own personal and people development policies to support staff in their role. The hospice actively supports doctors with training opportunities and encourages shadowing opportunities, role exchanges and joint working as a way of developing staff. 129

130 Medical revalidation in Scotland: local reports Where there are gaps in performance, the hospice supports staff by discussing concerns and agreeing and setting performance objectives. It also supports them to address these concerns and meet their objectives. Where necessary, doctors may be referred to occupational health services or receive counselling support or clinical or managerial supervision. Self-reported assessment on progress to meet medical revalidation requirements During the self-assessment process, we asked organisations to reflect on their progress to meet medical revalidation requirements. The Prince and Princess of Wales Hospice reported that it has well-developed systems and processes and can demonstrate sustainable improvement throughout the organisation. The panel considered that The Prince and Princess of Wales Hospice can demonstrate sustained good practice and innovation that is shared throughout the organisation and which others can learn from. Good practice improvements and challenges We asked for feedback on examples of good practice in relation to implementing medical revalidation. The hospice reported that it continues to have a close working relationship with NHS Greater Glasgow and Clyde to support the medical appraisal and revalidation process. We also asked if revalidation had contributed to local improvement within the organisation. The hospice reported that revalidation has made sure that a programme of multi-source feedback and patient feedback is embedded into the culture of the organisation. It has encouraged a framework on which to discuss appraisal with doctors in a positive manner and has led to improved reflective practice as a learning tool. We also asked about challenges and two areas were identified by the hospice: the fact that appraisals take place externally makes giving formal feedback to doctors more challenging, and as an independent organisation, the hospice does not have access to SOAR which would facilitate an easier audit of data collected. Action points from 215 review No action points were indentified in the 215 review. Action points for consideration during No action points were identified by the panel for

131 Medical revalidation in Scotland: local reports 2.3 Regulated independent healthcare services Castle Craig Hospital Data tables Number of doctors with a prescribed connection Number of doctors with a prescribed connection on 31 March Number of doctors eligible for appraisal in Number of completed appraisals Appraisal results (1%) Appraisal results (1%) Appraisal results (83%) Appraisal results (7%) Appraisal results (1%) Appraisal results (1%) Revalidation results Number of doctors eligible for revalidation in Number of positive recommendations 2 (1%) Number of deferral requests Revalidation Number of doctors identified for revalidation in Number of doctors identified for revalidation in who had an appraisal between 1 April 212 and 31 March 213 between 1 April 212 and 31 March 213 Number of doctors identified for revalidation in who had an appraisal between 1 April 213 and 31 March 214 between 1 April 213 and 31 March 214 Number of doctors identified for revalidation in who had an appraisal between 1 April 214 and 31 March 215 between 1 April 214 and 31 March 215 Number of doctors identified for revalidation in who had an appraisal between 1 April 215 and 31 March 216 between 1 April 215 and 31 March 216 Number of NES-trained appraisers Number of NES-trained appraisers in organisation 131

132 Medical revalidation in Scotland: local reports Findings of the evaluation panel Castle Craig Hospital is a designated body. It has an RO and appraisal services are provided by NHS Borders. A formal agreement co-signed by the chief executive officers of both Castle Craig Hospital and NHS Borders is in place. A copy of this agreement was provided as part of the hospital s self-assessment submission. Governance relevant to revalidation An audit was carried out for the period and the hospital reported no missed or incomplete appraisals. The organisation s clinical governance group monitors the progress of doctors appraisals on a monthly basis and senior managers and doctors are alerted to any issues with appraisal. An annual report is provided to the governing body of Castle Craig Hospital to give assurance that the organisation is meeting its obligations for medical revalidation. The hospital reported that there were no deferrals during The RO for Castle Craig Hospital checks all Form 4s (or relevant documentation) for new appointments. Doctors who are employed by more than one organisation are responsible for providing relevant information relating to all aspects of their practice to the RO and appraisal lead. The hospital reported that this is clearly outlined within the organisation s policy for revalidation. Information for appraisal Supporting information: Castle Craig Hospital reported that due to the small number of doctors it employs, the RO meets with doctors regularly. Through these meetings, doctors are reminded of their responsibility to provide information on all aspects of their practice at appraisal. In addition, this is regularly discussed at internal CPD meetings. Doctors are encouraged to attend governance meetings where all clinical activity is discussed. Minutes of senior staff meetings are also readily available to doctors. Doctors are also encouraged to use the organisation s internal systems to access up-to-date clinical activity data. Complaints, compliments and concerns: The RO reviews all complaints and concerns raised about individual doctors. In line with the hospital s revalidation policy, doctors are responsible for providing information relating to complaints, compliments and concerns as part of their appraisal portfolio. All critical incidents are reviewed by the clinical governance committee every month. The hospital employs an external consultant to work with the chief executive to undertake an annual report on critical incidents. Multi-source feedback: Castle Craig Hospital doctors use the Royal College of Psychiatrists ACP36 system to gather multi-source feedback for appraisal. This feedback is then used to inform doctors personal development plans. Patient satisfaction: There are two processes in place to gather patient feedback at Castle Craig Hospital: Process one involves patient satisfaction surveys being issued to patients as part of their admission to hospital. There are two surveys used by the hospital, one for patients receiving intensive treatment and one for the extended care unit. These surveys are confidential and are therefore supplied with a sealable envelope to make sure that they are handled appropriately. The governance department is then responsible for collating all information gathered from these surveys for reporting purposes. Any areas of improvement identified are considered and implemented by the quality assurance manager. The hospital also produces a report on patient satisfaction every 2 years. Process two involves the hospital gathering feedback through patient focus groups. Each group meets to discuss a specific topic or questions which attendees are made aware of in advance of the meeting. Minutes of these meetings are taken and any concerns raised are followed up by the hospital. The panel encourages the hospital to make sure elements of patient feedback are specific to individual doctors. The hospital reported a positive 132

133 Medical revalidation in Scotland: local reports experience in the use of patient feedback tools and identifies this as an important part of quality management for Castle Craig Hospital. Patients are actively encouraged to provide feedback by staff before being transferred or discharged from the hospital. The hospital also produces a formal report to its Board on patient satisfaction every year. Remediation, rehabilitation and targeted support Castle Craig Hospital reported that it provides support to doctors through CPD. The hospital s remediation policy was provided as part of the self-assessment submission. Doctors may have access to rehabilitation services through occupational health, if required. Self-reported assessment on progress to meet medical revalidation requirements During the self-assessment process, we asked organisations to reflect on their progress to meet medical revalidation requirements. Castle Craig Hospital reported that it has welldeveloped systems and processes and can demonstrate sustainable improvement throughout the organisation. The panel considered that the hospital can demonstrate sustained good practice and innovation that is shared throughout the organisation and which others can learn from. Good practice, improvements and challenges We asked for feedback on examples of good practice in relation to implementing medical revalidation. Castle Craig Hospital reported that due to the size of the organisation, the RO has a good understanding of all doctors CPD. It also reported that, due to the implementation of revalidation, doctors have been actively pursuing CPD. We also asked about challenges and the hospital reported that one doctor works equal sessions across two organisations and that the RO will contact the other organisation to discuss the best way of sharing information on this doctor s practice. Action points for consideration during No action points were identified by the panel for

134 Medical revalidation in Scotland: local reports Surehaven Glasgow Hospital Data tables Number of doctors with a prescribed connection Number of doctors with a prescribed connection on 31 March 216 Number of doctors eligible for appraisal in Number of completed appraisals Appraisal results Not available Appraisal results Not available Appraisal results Not available Appraisal results Not available Appraisal results Appraisal results Revalidation results Number of doctors eligible for revalidation in Number of positive recommendations Number of deferral requests Revalidation Number of doctors identified for revalidation in Number of doctors identified for revalidation in who had an appraisal between 1 April 212 and 31 March 213 between 1 April 212 and 31 March 213 Number of doctors identified for revalidation in who had an appraisal between 1 April 213 and 31 March 214 between 1 April 213 and 31 March 214 Number of doctors identified for revalidation in who had an appraisal between 1 April 214 and 31 March 215 between 1 April 214 and 31 March 215 Number of doctors identified for revalidation in who had an appraisal between 1 April 215 and 31 March 216 between 1 April 215 and 31 March 216 Number of NES-trained appraisers Number of NES-trained appraisers in organisation 134

135 Medical revalidation in Scotland: local reports Findings of the evaluation panel Surehaven Glasgow Hospital is a specialist subsidiary company of Shaw Healthcare. The hospital employs one doctor who also works within NHS Dumfries & Galloway. The doctor has their prescribed connection to NHS Dumfries & Galloway and they arrange their appraisal, which Surehaven Glasgow Hospital feeds into. The RO at NHS Dumfries & Galloway confirmed the NHS board has a process in place to ensure that the doctor will have access to different appraisers in the 5 year appraisal cycle. Governance relevant to revalidation Surehaven Glasgow Hospital reported that the clinical director of mental health services at NHS Dumfries & Galloway provides leadership and advice on all aspects of the appraisal process. The hospital confirmed that it liaises closely with NHS Dumfries & Galloway to make sure appraisals are completed. Any missed or incomplete appraisals are included in NHS Dumfries & Galloway s audit system. The hospital confirmed that the organisation s Scottish director provides an update annually on the revalidation process to the hospital s Board of directors. The hospital reported it has no arrangements in place to check Form 4s (or relevant documentation) as there have been no any new appointments. Information for appraisal Supporting information: Surehaven Glasgow Hospital has adopted the process already established in NHS Dumfries & Galloway to make sure doctors are aware of their responsibility to include in their appraisal items of supporting information that reflect the whole of their practice. The hospital listed a range of clinical data that the senior administrator keeps for the doctor. Complaints, compliments and concerns: Surehaven Glasgow Hospital reported that information on complaints, compliments, concerns or critical incidents is added to the appraisal system through direct communication with the RO at NHS Dumfries & Galloway. The hospital manager and the RO are reviewing the current system to make sure it is robust and effective. Multi-source feedback: The hospital reported it follows NHS Dumfries & Galloway s protocol for providing multi-source feedback using the WASP system on SOAR. Patient satisfaction: The hospital reported it follows NHS Dumfries & Galloway s protocol to gather patient feedback. The results of the questionnaires are forwarded to the RO who provides feedback to the hospital s manager if there are any concerns raised. Remediation, rehabilitation and targeted support The hospital reported it follows NHS Dumfries & Galloway s processes and policies for remediation, rehabilitation and targeted support. Self-reported assessment on progress to meet medical revalidation requirements During the self-assessment process, we asked organisations to reflect on their progress to meet medical revalidation requirements. Surehaven Glasgow Hospital reported that it is developing plans and processes and can demonstrate sustainable improvement throughout the organisation. The panel agreed with this assessment. Good practice, improvements and challenges We asked for feedback on examples of good practice in relation to implementation of medical revalidation. Surehaven Glasgow Hospital reported that medical revalidation has provided a positive reporting structure in what could potentially be an isolated post, encompassing closer scrutiny of current practice. 135

136 Medical revalidation in Scotland: local reports We also asked about challenges. Surehaven Glasgow Hospital reported that being a small organisation with only one doctor is challenging and was grateful to NHS Dumfries & Galloway for its collaboration and support in the appraisal process and medical revalidation. Action points from 215 review Fully actioned Ongoing Implement a formal agreement, based on the national template, for the provision of external appraisal and RO services. Continue to monitor the number of annual appraisals. Continue to work with NHS Dumfries & Galloway to strengthen the governance arrangements for appraisal and revalidation. Not applicable Action point for consideration during Continue to work with NHS Dumfries & Galloway to strengthen the governance arrangements for appraisal and revalidation. 136

137 Medical revalidation in Scotland: local reports 2.4 Non-regulated healthcare services AbleMed Health Ltd Data tables Number of doctors with a prescribed connection Number of doctors with a prescribed connection on 31 March Number of doctors eligible for appraisal in Number of completed appraisals Appraisal results Not available Appraisal results Not available Appraisal results Not available Appraisal results Not available Appraisal results Appraisal results (1%) Revalidation results Number of doctors eligible for revalidation in Number of positive recommendations 1 (1%) Number of deferral requests Revalidation Number of doctors identified for revalidation in Number of doctors identified for revalidation in who had an appraisal between 1 April 212 and 31 March 213 between 1 April 212 and 31 March 213 Number of doctors identified for revalidation in who had an appraisal between 1 April 213 and 31 March 214 between 1 April 213 and 31 March 214 Number of doctors identified for revalidation in who had an appraisal between 1 April 214 and 31 March 215 between 1 April 214 and 31 March 215 Number of doctors identified for revalidation in who had an appraisal between 1 April 215 and 31 March 216 between 1 April 215 and 31 March 216 Number of NES-trained appraisers Number of NES-trained appraisers in organisation 1 137

138 Medical revalidation in Scotland: local reports Findings of the evaluation panel AbleMed Health Ltd is an occupational health provider. It is a designated body with an RO. Appraisal services are outsourced to RS Occupational Health and there is formal agreement between the two organisations for the provision of this service. The RO is appraised as part of the Scottish Government s RO network. The organisation reported that its RO has provided appraisal support to the Glasgow Memory Clinic and RS Occupational Health. Governance relevant to revalidation The organisation reported that it had no missed or incomplete appraisals for the period It also reported that there were no deferrals during this time. Due to it only having a small number of doctors with a prescribed connection to it, AbleMed Health Ltd can support its doctors through the appraisal process without the need for formal audits. The RO provides an annual report to the governing body of AbleMed Health Ltd to provide assurance that it is meeting the obligations required for medical revalidation. The RO checks all Form 4s (or relevant documentation) for all new appointments. Where doctors are employed by more than one organisation, AbleMed Health Ltd reported that it would expect the doctor to advise the appraiser and provide a note of this activity to include in their appraisal to reflect the whole their practice. Information for appraisal Supporting information: The organisation provides doctors with GMC guidance on supporting information. It also reported that the medical director supports doctors with the collection of information required for appraisal. Up-to-date clinical activity can be obtained from the organisation s IT system. This includes summary data on assessments and outcomes as well as oil and gas offshore medicals completed. Complaints, compliments and concerns: AbleMed Health Ltd reported that it has a process to include information relating to complaints, compliments and concerns into the appraisal system. This process is carried out by the medical director, who provides doctors with a summary of information required for appraisal. Multi-source feedback: The organisation supports doctors to collect multi-source feedback required for appraisal. This is done by using an online survey system (Survey Monkey). Information gathered through the survey is then summarised and a report is provided to the doctor for appraisal. Patient satisfaction: The online survey system is also used by the organisation to gather patient feedback. Administration staff provide patients with either a paper copy or electronic link to the survey dependent on their requirements. Patients are asked to provide feedback following assessment. The organisation reported that the questions included in the survey are in line with GMC standards. AbleMed Health Ltd reported that it experienced good results in gathering patient feedback. Remediation, rehabilitation and targeted support The organisation supports doctors with training requirements in order to maintain up-to-date knowledge in this industry. It also reported that its doctors maintain registration by attending the oil and gas UK conference on a bi-annual basis. Doctors are supported with rehabilitation, if required. Self-reported assessment on progress to meet medical revalidation requirements During the self-assessment process, we asked organisations to reflect on their progress to meet medical revalidation requirements. AbleMed Health Ltd reported that it has welldeveloped systems and processes and can demonstrate sustainable improvement throughout the organisation. The panel agreed with this assessment. 138

139 Medical revalidation in Scotland: local reports Good practice, improvements and challenges We asked for feedback on examples of good practice in relation to implementing medical revalidation. AbleMed Health Ltd reported that it has outsourced appraisal services for its doctors and its own RO is appraised as part of the Scottish Government RO network. The organisation also highlighted its support of internal and external CPD and training as areas of good practice. AbleMed Health Ltd also reported that the implementation of medical revalidation has contributed to improvements within the organisation. The organisation reported no challenges with the implementation of medical revalidation. Action points from 215 review Consider outsourcing appraisal and RO support. An action plan should be developed by December 215 to address these requirements. Support with this will be provided from the RO network. AbleMed Health Ltd will be asked to confirm it has made arrangements to use NES-trained appraisers and that appraisal is outsourced, although it is recognised that this may take time to arrange. Action plan should be followed up and further action taken if necessary. NES-trained appraisers should carry out appraisals. RO to attend RO network meetings RO should provide assurance, at least annually, through formal governance arrangements that doctors working in AbleMed Health Ltd are fit to practise and have a licence to practise. AbleMed Health Ltd staff should have access to soar Fully actioned Ongoing Action points for consideration during No action points were identified by the panel for

140 Medical revalidation in Scotland: local reports Glasgow Centre for Reproductive Medicine Data tables Number of doctors with a prescribed connection Number of doctors with a prescribed connection on 31 March Number of doctors eligible for appraisal in Number of completed appraisals Appraisal results Not applicable Appraisal results Not applicable Appraisal results Not applicable Appraisal results Not applicable Appraisal results Not applicable Appraisal results Revalidation results Number of doctors eligible for revalidation in Number of positive recommendations 1 (1%) Number of deferral requests Revalidation Number of doctors identified for revalidation in Number of doctors identified for revalidation in who had an appraisal between 1 April 212 and 31 March 213 between 1 April 212 and 31 March 213 Number of doctors identified for revalidation in who had an appraisal between 1 April 213 and 31 March 214 between 1 April 213 and 31 March 214 Number of doctors identified for revalidation in who had an appraisal between 1 April 214 and 31 March 215 between 1 April 214 and 31 March 215 Number of doctors identified for revalidation in who had an appraisal between 1 April 215 and 31 March 216 between 1 April 215 and 31 March 216 Number of NES-trained appraisers Number of NES-trained appraisers in organisation 14

141 Medical revalidation in Scotland: local reports Findings of the evaluation panel Glasgow Centre for Reproductive Medicine is an independent fertility clinic and designated body. The centre reported that it receives RO support and appraisal services as part of the Scottish Government RO appraisal cohort. Governance relevant to revalidation The centre reported that as it is a small organisation with very few doctors there is no audit or tracking mechanism required. The centre manager submits a 6-monthly report to the centre s Board for assurance which includes information on staff licence to practise, renewal dates and personal development plans as part of the appraisal process. The RO is responsible for checking all Form 4s (or relevant documentation) for all new appointments. The centre reported that it does not have a process in place to share information on doctors who are employed by more than one organisation. The doctors who provide services to the centre are primarily employed by the NHS, therefore, it relies on the appraisal outcome to provide assurance on fitness to practise. Information for appraisal Supporting information: Glasgow Centre for Reproductive Medicine encourages doctors to use the SOAR system to gather information for appraisal which reflects the whole of their practice. The centre reported that it has a robust quality management system which provides doctors with all clinical activity data required for appraisal. In addition, this data is analysed and regularly discussed with doctors outwith the appraisal cycle. In its self-assessment, the centre reported that doctors are encouraged to attend conferences and provide feedback to medical staff on their specialist area. Complaints, compliments and concerns: The centre reported that there is a process in place to include information on complaints, compliments and concerns into the appraisal system. The quality manager collates all information and provides summary reports to doctors for their appraisal portfolios. The senior management team also reviews information on a quarterly basis to identify any recurring themes and areas for improvement. Multi-source feedback: Doctors are signposted to the SOAR system to gather multi-source feedback for appraisal. Patient satisfaction: Patients are provided with questionnaires to complete following consultations. The centre manager then gathers all responses and provides doctors with reports which can be used to inform personal development plans. Currently, the questionnaire used is an in-house developed set of questions which are multiple choice, ranging from poor to excellent. The centre reported that it will be adopting the GMC patient questionnaire for appraisals. The centre also highlighted that it had an excellent return rate for patient feedback during Remediation, rehabilitation and targeted support Glasgow Centre for Reproductive Medicine has a process in place to provide training or retraining to doctors. This is an internal system which produces key performance indicator reports on a 12-day cycle to help identify any issues relating to a particular doctor. The centre uses this data to implement any additional training needs on an individual basis. The centre does not provide its doctors with rehabilitation services as doctors providing services to the centre are primarily employed by the NHS and would therefore be supported through the NHS board s rehabilitation policy. Self-reported assessment on progress to meet medical revalidation requirements During the self-assessment process, we asked organisations to reflect on their progress to meet medical revalidation requirements. Glasgow Centre for Reproductive Medicine reported that it can demonstrate sustained good practice and innovation that is shared 141

142 Medical revalidation in Scotland: local reports throughout the organisation and which others can learn from. The panel agreed with this assessment. Good practice, improvements and challenges We asked for feedback on examples of good practice in relation to implementing medical revalidation and the Glasgow Centre for Reproductive Medicine highlighted its internal system for identifying training needs as an area of good practice. The centre reported that the requirement for the medical director to be appraised externally results in this meeting having to take place in Aberdeen. For a small organisation, the extensive travel required for one appraisal was highlighted as a challenge in the implementation of medical revalidation. Action points for consideration during No action points were identified by the panel for

143 Medical revalidation in Scotland: local reports Glasgow Memory Clinic Data tables Number of doctors with a prescribed connection Number of doctors with a prescribed connection on 31 March Number of doctors eligible for appraisal in Number of completed appraisals Appraisal results Not available Appraisal results Not available Appraisal results Not available Appraisal results Not available Appraisal results Appraisal results (1%) Revalidation results Number of doctors eligible for revalidation in Number of positive recommendations Number of deferral requests Revalidation Number of doctors identified for revalidation in Number of doctors identified for revalidation in who had an appraisal between 1 April 212 and 31 March 213 between 1 April 212 and 31 March 213 Number of doctors identified for revalidation in who had an appraisal between 1 April 213 and 31 March 214 between 1 April 213 and 31 March 214 Number of doctors identified for revalidation in who had an appraisal between 1 April 214 and 31 March 215 between 1 April 214 and 31 March 215 Number of doctors identified for revalidation in who had an appraisal between 1 April 215 and 31 March 216 between 1 April 215 and 31 March 216 Number of NES-trained appraisers Number of NES-trained appraisers in organisation 1 143

144 Medical revalidation in Scotland: local reports Findings of the evaluation panel Glasgow Memory Clinic is an independent research organisation and a designated body. The panel noted that the RO for the clinic is appraised as part of the NHS National Services Scotland pool of appraisers. RO support and appraisal services for the clinic doctor are provided by AbleMed which is an external occupational health provider. Governance relevant to revalidation The review panel noted that there is no requirement for an audit process or tracking mechanism to identify any missed or incomplete appraisals due to the small number of doctors involved. Glasgow Memory Clinic reported that its clinic doctor had completed the appraisal process for the period Glasgow Memory Clinic reported that it does not have a process in place for the RO to check Form 4s (or relevant documentation) as doctors chose to opt out of providing a copy to the clinic due to the confidentiality of the document. The panel recommended that the organisation sources and implements a process for requesting information on fitness to practise relating to all doctors who provide a service to the clinic from primary employers. Glasgow Memory Clinic reported that apart from referencing at the recruitment stage, it has not got a process for sharing information on doctors employed by more than one organisation. It also stated in its self-assessment that it welcomes any advice the panel can offer about how this can be achieved. Information for appraisal Supporting information: The human resources department for Glasgow Memory Clinic assists its doctors to collect supporting information for appraisal portfolio s which reflects the whole of their practice. Doctors are provided with up-to-date clinical activity data by means of an audit of the clinic which is provided externally. Complaints, compliments and concerns: Any complaints, compliments and concerns relating to the Glasgow Memory Clinic are reported to the managing director and the human resources manager is responsible for receipting and recording of all relevant information. Doctors are then supported by the human resources manager to gather all information relating to them for their appraisal portfolio. Multi-source feedback: The process to gather multi-source feedback is managed by the human resources manager. A questionnaire is distributed and the HR manager collates anonymous feedback and provides a report to the doctor. The report is included in the doctor s personal development plan and discussed at appraisal Patient satisfaction: Glasgow Memory Clinic reported that as its doctors do not provide direct patient care; it is exempt from the patient feedback requirement for appraisal. Remediation, rehabilitation and targeted support Due to the nature of work carried out by the Glasgow Memory Clinic, it reported that all doctors must complete the requirements of training in a particular area before being approved to commence research. The clinic reported that it does not have a policy in place to provide rehabilitation services to doctors as this has not been a requirement to date. Self-reported assessment on progress to meet medical revalidation requirements During the self-assessment process, we asked organisations to reflect on their progress to meet medical revalidation requirements. Glasgow Memory Clinic reported that it is developing plans and processes and can demonstrate sustainable improvement throughout the organisation. The panel agreed with this assessment. 144

145 Medical revalidation in Scotland: local reports Good practice, improvements and challenges We asked for feedback on examples of good practice in relation to implementing medical revalidation. Glasgow Memory Clinic highlighted the continuous scrutiny of its practice and outcomes as an example. Glasgow Memory Clinic reported that revalidation has resulted in local improvements within the organisation. This has resulted in clear processes being put onto place which require doctors to evidence their fitness to practise. The clinic has also witnessed a more focused approach to personal development plans. We also asked about challenges and one was identified by the clinic. The organisation reported that it is a small centre in comparison to other designated bodies and it struggles to implement the processes required for medical revalidation. It did note that it is progressing and processes are becoming more refined. Action points from 215 review Fully actioned Ongoing Consider RO and appraisal arrangements NES-trained appraisers to be used in future. RO to attend RO network meetings. RO should provide assurance by reporting, at least annually, through formal governance arrangements that doctors working in the clinic are fit to practise and that any issues are managed. Medical staff should have access to SOAR. Action points for consideration during RO should provide assurance by reporting, at least annually, through formal governance arrangements that doctors working in the clinic are fit to practise and that any issues are managed. Medical staff should have access to SOAR. Request Form 4 (or relevant documentation) relating to all doctors who provide a service to the clinic from the doctor s primary employer. Develop a process for sharing information for doctors who work across more than one organisation. 145

146 Medical revalidation in Scotland: local reports MP Locums Data tables Number of doctors with a prescribed connection Number of doctors with a prescribed connection on 31 March Number of doctors eligible for appraisal in Number of completed appraisals Appraisal results Not available Appraisal results Not available Appraisal results Not available Appraisal results Not available Appraisal results (42%) Appraisal results (65%) Revalidation results Number of doctors eligible for revalidation in Number of positive recommendations 7 (1%) Number of deferral requests Revalidation Number of doctors identified for revalidation in Number of doctors identified for revalidation in who had an appraisal between 1 April 212 and 31 March 213 between 1 April 212 and 31 March 213 Number of doctors identified for revalidation in who had an appraisal between 1 April 213 and 31 March 214 between 1 April 213 and 31 March 214 Number of doctors identified for revalidation in who had an appraisal between 1 April 214 and 31 March 215 between 1 April 214 and 31 March 215 Number of doctors identified for revalidation in who had an appraisal between 1 April 215 and 31 March 216 between 1 April 215 and 31 March (67%) Number of NES-trained appraisers Number of NES-trained appraisers in organisation

147 Medical revalidation in Scotland: local reports Findings of the evaluation panel MP Locums is an independent recruitment agency that supplies locum doctors to NHSScotland through the NHSScotland Framework Contract. It is a designated body with RO support and appraisal services outsourced to the Medical Support Union (MEDSU). There is a formal agreement in place between the two organisations confirming these arrangements. Governance relevant to revalidation MP Locums reported that it uses Eclipse software to monitor and track information on appraisals. The system generates automatic reminders for appraisal dates. The organisation has also undertaken an audit of appraisal and deferrals. MP Locums has a process to check Form 4s (or relevant documentation) for all new appointments. There is also a process in place to share information where doctors are employed by more than one organisation. MP Locums is part of the Health Professionals Alert Notices (HPAN) system. This is a system where NHS bodies and others can be notified of a doctor s conduct or performance issue should there be a concern that there is a risk that the doctor may pose a threat to patients or staff. MP Locums uses formal documentation for the transfer of statements from current and previous employers to facilitate the handover of information from one organisation to another. Information for appraisal Supporting information: Doctors are made aware on appointment that they have to provide supporting information for their appraisal portfolios which reflects the whole of their practice. This is stated in the organisation s welcome pack which is provided to all doctors. MP Locums has implemented a new training and appraisal policy for its doctors. This allows the organisation to track a summary of appraisal discussions as well as record all mandatory and agreed CPD requirements. Complaints, compliments and concerns: MP Locums issues placement feedback forms to doctors and to the department in which the doctor has provided a locum service. The information gathered from the placement feedback form is used to inform the appraisal process. Any complaints, concerns or incidents raised are managed by the organisation s medical director in line with its complaints policy which was provided to the panel. This process includes notifying the doctor s appraiser and RO. Multi-source feedback: A portal for doctors to record and manage multi-source feedback is provided by MEDSU for all MP Locum doctors. The placement feedback forms also contain information to support doctors with feedback from colleagues. Patient satisfaction: The placement feedback also supports this process. Locum doctors have allocated space on the MEDSU portal to record and track their patient satisfaction survey directly onto the system. Remediation, rehabilitation and targeted support MP Locums provides remediation, rehabilitation and support for its doctors. The support provided is outlined in the organisation s remediation policy and responding to concerns policy. Any necessary further monitoring of a doctor s performance, conduct or fitness to practise is undertaken by agreeing appropriate action plans between the appraiser and appraisee which are followed up at agreed intervals. Any concerns of a more serious nature would be managed on an individual basis and referred to the GMC, if necessary. Self-reported assessment on progress to meet medical revalidation requirements During the self-assessment process, we asked organisations to reflect on their progress to meet medical revalidation requirements. MP Locums reported that it has well-developed 147

148 Medical revalidation in Scotland: local reports systems and processes and can demonstrate sustainable improvement throughout the organisation. The panel agreed with this assessment. Good practice, improvements and challenges We asked for feedback on examples of good practice in relation to implementing medical revalidation. MP Locums reported that it has entered into an agreement with MEDSU to ensure that all doctors who have a prescribed connection to MP Locums receive a full, comprehensive support system for all their appraisal and revalidation requirements. The organisation reported that the way it has provided this resource, structure and process empowers its doctors working in any setting and enables them to manage their professional lives and meet their regulatory and compliance requirements. In terms of supporting local improvement in the organisation, MP Locums reported that following feedback from the previous review, it has implemented a training and appraisal policy to better track and support its doctors in their CPD. We also asked about challenges. Ensuring the collection of sufficient information for revalidation for doctors who only work part time in the UK was highlighted by MP Locums as an area of challenge. However, MP Locums reported that the GMC Revalidation Support Team is working with all agencies concerned to help address this issue. Action points from 215 review Fully actioned Ongoing Clarify the current outsourcing arrangements. Healthcare Improvement Scotland to arrange a meeting to discuss current requirements in Scotland and the support that can be provided. RO to attend RO Network meetings, as part of the Scottish Revalidation RO community. We recognise the RO currently attends RO Network meetings in England. MP Locums should have access to SOAR subject to further discussion, as noted above (the individual Boards would need to agree to this as they have refused in the past). Action points for consideration during RO to attend RO Network meetings as part of the Scottish Revalidation RO community. Consider the benefits of becoming part of the NES-trained appraiser system by having NEStrained appraisers and entering into a reciprocal agreement with another organisation to provide and receive appraisal services. 148

149 Medical revalidation in Scotland: local reports RS Occupational Health Data tables Number of doctors with a prescribed connection Number of doctors with a prescribed connection on 31 March Number of doctors eligible for appraisal in Number of completed appraisals Appraisal results Not available Appraisal results Not available Appraisal results (78%) Appraisal results Appraisal results (64%) Appraisal results (1%) Revalidation results Number of doctors eligible for revalidation in Number of positive recommendations 1 (1%) Number of deferral requests Revalidation Number of doctors identified for revalidation in Number of doctors identified for revalidation in who had an appraisal between 1 April 212 and 31 March 213 between 1 April 212 and 31 March 213 Number of doctors identified for revalidation in who had an appraisal between 1 April 213 and 31 March 214 between 1 April 213 and 31 March 214 Number of doctors identified for revalidation in who had an appraisal between 1 April 214 and 31 March 215 between 1 April 214 and 31 March 215 Number of doctors identified for revalidation in who had an appraisal between 1 April 215 and 31 March 216 between 1 April 215 and 31 March 216 Number of NES-trained appraisers Number of NES-trained appraisers in organisation 2 149

150 Medical revalidation in Scotland: local reports Findings of the evaluation panel RS Occupational Health (RSOH) is an independent occupational health services provider. The organisation is a designated body and has its own RO and NES-trained appraisers. It reported that there is a reciprocal arrangement in place between RSOH and Ablemed Health Ltd. The ROs and appraisers carry out appraisals for doctors in each other s organisations. The panel noted that there was no formal agreement in place between the two organisations for appraisal services. Governance relevant to revalidation The organisation carried out an audit of all appraisals for the period and reported that there were no missed or incomplete appraisals. There is a process in place to track appraisals on an ongoing basis. RSOH holds an appraisal planning meeting each year in early February, thereafter, all doctors are formally advised of the deadline for completing appraisals. The RO is also aware of this process and would be required to intervene if any doctors did not comply with the deadline. The organisation reported that no issues were raised with the RO throughout this appraisal year and that all doctors were appraised on time. RSOH also reported no deferrals for the period There is a process in place for the RO to check relevant documentation for all new appointments. RSOH reported that it does not use Form 4s instead it uses a specific transfer information document to carry out this check. Where doctors are employed by more than one organisation, the RO is required to make contact with the other organisation as appropriate. Information for appraisal Supporting information: Doctors are responsible for including supporting information at appraisal which reflects all aspects of their practice. RSOH reported that this is clearly outlined in its appraisal documentation for doctors. RSOH reported that as it does not provide direct clinical care, the requirement to collect up-to-date clinical activity data is not applicable for its doctors appraisal portfolios. A statistical report is made available to doctors as part of the information provided to support appraisal. Complaints, compliments and concerns: The RO, in collaboration with the business support unit, keeps a record of all complaints, compliments and concerns. This is provided to doctors for inclusion in their appraisal portfolio. Multi-source feedback: RSOH doctors use an electronic system to gather multi-source feedback and incorporate the findings into their personal development plan. The organisation also reported that it uses a secondary source in the form of a medical report feedback document. Patient satisfaction: Patient questionnaires which are personalised to individual doctors are distributed by the business support manager following an appointment with the doctor. All responses, which are anonymous, are collated by the business support manager who enters the data into the system. Once 5 responses have been logged, the system will then generate a report for the doctor. Remediation, rehabilitation and targeted support RSOH doctors are supported with training and re-training requirements. Doctors are also supported on an individual basis with any rehabilitation needs. Self-reported assessment on progress to meet medical revalidation requirements During the self-assessment process, we asked organisations to reflect on their progress to meet medical revalidation requirements. RSOH reported that it has well-developed systems and processes and can demonstrate sustainable improvement throughout the organisation. The panel agreed with this assessment. 15

151 Medical revalidation in Scotland: local reports Good practice, improvements and challenges We asked for feedback on examples of good practice in relation to implementing medical revalidation. RSOH reported that its appraisal process matches the SOAR process for NHS doctors. Also, the organisation reported that its approach to appraisal planning has resulted in an improved appraisal completion times. The RO also uses a revalidation checklist to ensure that the RO has personally discussed the appraisal and other relevant documentation with the appraiser before making a recommendation for revalidation. RSOH reported that medical revalidation has contributed to the continuation of its high-quality service to clients. We also asked about challenges and no areas were identified by RSOH. Action points from 215 review Consider that RSOH has considered outsourcing appraisals in future and that NES-trained appraisers will be used. Consider its status as a designated body and consider outsourcing RO support. RO to continue to attend RO network meetings. Annual appraisal rate needs to be maintained. RO should provide a report, at least annually, through formal governance arrangements to give assurance to the governing body that doctors working in RSOH are fit to practice and have a licence to practise. Action points for consideration during No action points were identified by the panel for Fully actioned Ongoing 151

152 Medical revalidation in Scotland: local reports 2.5 Mental Welfare Commission for Scotland Data tables Number of doctors with a prescribed connection Number of doctors with a prescribed connection on 31 March Number of doctors eligible for appraisal in Number of completed appraisals Appraisal results (1%) Appraisal results (1%) Appraisal results (1%) Appraisal results (67%) Appraisal results (8%) Appraisal results (1%) Revalidation results Number of doctors eligible for revalidation in Number of positive recommendations 2 (1%) Number of deferral requests Revalidation Number of doctors identified for revalidation in Number of doctors identified for revalidation in who had an appraisal between 1 April 212 and 31 March 213 between 1 April 212 and 31 March 213 Number of doctors identified for revalidation in who had an appraisal between 1 April 213 and 31 March 214 between 1 April 213 and 31 March 214 Number of doctors identified for revalidation in who had an appraisal between 1 April 214 and 31 March 215 between 1 April 214 and 31 March 215 Number of doctors identified for revalidation in who had an appraisal between 1 April 215 and 31 March 216 between 1 April 215 and 31 March 216 Number of NES-trained appraisers Number of NES-trained appraisers in organisation 1 152

153 Medical revalidation in Scotland: local reports Findings of the evaluation panel The Mental Welfare Commission for Scotland is a designated body with an RO and has four doctors who have a prescribed connection to it. The organisation manages all appraisals inhouse and has a NES-trained appraiser. Due to the small numbers of doctors it employs, the panel would recommend that appraisals are fully outsourced to another organisation. This will ensure that doctors are not allocated to the same appraiser more than 3 years in a row. Governance relevant to revalidation The Mental Welfare Commission for Scotland reported that there were no missed or incomplete appraisals in As it is a small organisation, it reported that it is easy to monitor any missed or incomplete appraisals without the need for a formal audit. Instead, appraisal progress is regularly discussed at the monthly medical meetings. An annual report is also provided to the organisation s governing body. The organisation reported that there have been no deferrals in The RO checks Form 4s (or relevant documentation) for all new appointments. The Mental Welfare Commission for Scotland also reported that it has a process in place to share information on doctors who are employed by more than one organisation. This is done by agreeing in advance which organisation will be the lead for appraisal and then information is shared between organisations to support the appraisal process. Information for appraisal Supporting information: Doctors are supported to provide information on all aspects of their practice at appraisal by using the organisation s appraisal and revalidation policy, which is based on GMC guidance. The organisation reported that this has been adapted to take account of the non-clinical function of doctors that it employs. There is an electronic information management system in place to provide clinical activity data to doctors for their appraisal portfolios. The organisation confirmed that it audits telephone advice and visit reports and feeds this back to doctors if necessary. Complaints, compliments and concerns: All complaints and critical incidents involving medical staff are brought to the attention of the RO who makes sure that these are included in the appraisal process. Multi-source feedback: The organisation reported that all doctors participate in multisource feedback at least once in the 5-yearly revalidation cycle. This information is discussed at appraisal and used to inform the doctor s personal and professional development plans. Patient satisfaction: The organisation confirmed that doctors do not carry out a clinical role, and therefore, they do not use patient questionnaires. Remediation, rehabilitation and targeted support The Mental Welfare Commission for Scotland reported that it uses information from the doctor s personal development plan to inform training needs. Doctors are encouraged and supported to use internal and external training resources as required. There is currently no service for rehabilitation for doctors within the organisation. The Mental Welfare Commission for Scotland reported that it would engage with external agencies to provide this. Self-reported assessment on progress to meet medical revalidation requirements During the self-assessment process, we asked organisations to reflect on their progress to meet medical revalidation requirements. The Mental Welfare Commission for Scotland reported that it has well-developed systems and processes and can demonstrate sustainable improvement throughout the organisation. The panel agreed with this assessment, however, noted a concern about the vulnerability of not outsourcing appraisals. 153

154 Medical revalidation in Scotland: local reports Good practice, improvements and challenges We asked for feedback on examples of good practice in relation to implementing medical revalidation. The Mental Welfare Commission for Scotland reported that after the initial use of the multi-source feedback tool, it was suggested that it may be used for other staff groups in the future. The Mental Welfare Commission for Scotland reported that due to the small number of doctors employed, it faces challenges implementing medical revalidation. Action points from 215 review Appraisal should be outsourced due to the small number of doctors and appraisers within the organisation. Continue to monitor the appraisal rate. Fully actioned Ongoing Action points for consideration during Appraisal should be outsourced due to the small number of doctors and appraisers within the organisation. Continue to monitor the appraisal rate. 154

155 Medical revalidation in Scotland: local reports 2.6 Scottish Government Data tables Number of doctors with a prescribed connection Number of doctors with a prescribed connection on 31 March Number of doctors eligible for appraisal in Number of completed appraisals Appraisal results Not available Appraisal results Not available Appraisal results (1%) Appraisal results (9%) Appraisal results (97%) Appraisal results (97%) Revalidation results Number of doctors eligible for revalidation in Number of positive recommendations 5 (1%) Number of deferral requests Revalidation Number of doctors identified for revalidation in Number of doctors identified for revalidation in who had an appraisal between 1 April 212 and 31 March 213 between 1 April 212 and 31 March 213 Number of doctors identified for revalidation in who had an appraisal between 1 April 213 and 31 March 214 between 1 April 213 and 31 March 214 Number of doctors identified for revalidation in who had an appraisal between 1 April 214 and 31 March 215 between 1 April 214 and 31 March 215 Number of doctors identified for revalidation in who had an appraisal between 1 April 215 and 31 March 216 between 1 April 215 and 31 March (1%) 1 (1%) 1 (1%) 1 (1%) 1 (1%) Number of NES-trained appraisers Number of NES-trained appraisers in organisation 2 155

156 Medical revalidation in Scotland: local reports Findings of the evaluation panel Scottish Government is a designated body and the chief medical officer (CMO) is the RO. The CMO is the RO for the doctors directly employed by Scottish Government and the ROs in Scotland and this includes NHS and non-nhs bodies. Scottish Government reported it has outsourced appraisal services and administrative support for the ROs to NHS National Services Scotland (NSS). Although there is no formal written agreement in place with NSS, Scottish Government provided a copy of the letter between Scottish Government and NSS agreeing to provide these arrangements. Governance relevant to revalidation Scottish Government reported that its Senior Revalidation Adviser provides the organisation with effective leadership and advice on the appraisal process. NES and NSS also provide advice on appraisals and training. Scottish Government reported that it carried out a manual audit for missed or incomplete appraisals. Scottish Government and NSS administrators use the SOAR system and reporting tools to monitor and check the appraisal progress for directly employed doctors and ROs respectively. Scottish Government reported that it had no deferrals to date but confirmed it would be able to carry out an audit, if required. Scottish Government confirmed the process it has in place with NSS for appraisal support. NSS allocates a NES-trained appraiser to the RO independently of Scottish Government. NSS keeps records of the pairings for each appraisal year and makes sure that each RO has at least two different appraisers over the 5-year cycle. Doctors directly employed by Scottish Government are also allocated a NES-trained appraiser by NSS. There are currently two NES-trained appraisers within Scottish Government. Scottish Government is aware that the majority of ROs have attended NES training as part of their role but it does not hold statistics to confirm how many ROs are NEStrained appraisers. Scottish Government confirmed that it presents the Healthcare Improvement Scotland annual report on progress with medical revalidation to a Scottish Government senior management team, which includes the chief medical officer, the deputy chief medical officer, director general for health and the director of health workforce and strategic change. Scottish Government reported it has arrangements in place for the RO to check Form 4s (or relevant documentation) for all new appointments for whom they have responsibility. Scottish Government reported it does not have a process in place for sharing information between organisations for doctors who are employed by more than one organisation. Instead, it reported that the evidence detailed in the Form 4 can assure appropriate organisations as a source of whole practice appraisal. Information sharing also happens by probity of ROs and doctors employed by Scottish Government. Information for appraisal Supporting information: Scottish Government has a process in place to prompt doctors to include relevant supporting information within their appraisal documentation that supports the whole of their practice. This is based on the guideline A Guide to Appraisal for Medical Revalidation, which was developed by the national appraisal leads group on behalf of Scottish Government and NHSScotland. However, it acknowledged that further reminders and encouragement should be directed to its appraisees to ensure that this happens. Scottish Government reported that it does not have a system in place for providing doctors with clinical activity information as Scottish Government has no clinical role or activity. The few doctors, who have clinical roles elsewhere, are required to obtain clinical activity information from their employing organisation. This is presented at their appraisal as part of 156

157 Medical revalidation in Scotland: local reports their CPD and personal and professional development plans and is discussed as part of their whole practice appraisal. Complaints, compliments and concerns: Scottish Government reported that for doctors directly employed by Scottish Government, information on complaints, compliments, concerns or critical incidents are fed through internal human resources processes. If appropriate, these would also be managed through the revalidation processes by the CMO as RO, the appraiser and other regulatory bodies. Information on any complaints, compliments, concerns or critical incidents about the ROs are fed through the RO s internal human resources and revalidation processes. In addition, if the CMO receives information regarding complaints, concerns or critical incidents they would assess and involve the appropriate stakeholders where necessary. Multi-source feedback: Scottish Government reported that all doctors are encouraged to follow the guidelines detailed in the guideline A Guide to Appraisal for Medical Revalidation and other appropriate guidelines and documentation for incorporating multi-source feedback into personal and professional development plans. It confirmed that the multi-source feedback tool on SOAR is available to its doctors. The ROs follow local practices and guidelines of their employing body for gathering multi-source feedback. Patient satisfaction: As very few of Scottish Government doctors have a clinical role, the organisation does not have a specific questionnaire for gathering patient feedback. Scottish Government confirmed that the few doctors with clinical roles elsewhere follow the guidelines of the employing body. The ROs follow local arrangements and where appropriate, patient feedback is incorporated into their whole practice appraisal. Remediation, rehabilitation and targeted support Scottish Government reported it does not have formal processes in place for providing remediation and rehabilitation services. However, it confirmed that it would apply internal human resources procedures for its directly employed doctors who require training or retraining or rehabilitation services. If these doctors undertake clinical work elsewhere and concerns have been raised about them, then this would be dealt in conjunction with the NHS board that employs them. The ROs would be subject to their employing body s internal arrangements for training, re-training or rehabilitation services. In the event of an issue relating to RO performance, the CMO would deal with this on an individual basis. Scottish Government confirmed it has a process in place for monitoring doctors conduct performance or fitness to practise. Its directly employed doctors are managed under the appropriate human resources, appraiser and line management procedures. This may be either internal Scottish Government processes or for clinical aspects, this may fall under the employing body procedures with the agreement of the CMO as RO. Scottish Government reported that further monitoring of the ROs is subject to their employing body s internal arrangements. The expectations of this are that the CMO (as RO for the ROs) would be informed where appropriate, so that revalidation considerations or decisions are fully met. The CMO is dependent upon the appraisal arrangements organised by NSS and the submission of Form 4 documents. Self-reported assessment on progress to meet medical revalidation requirements During the self-assessment process, we asked organisations to reflect on their progress to meet medical revalidation requirements. Scottish Government reported that it can demonstrate sustained good practice and innovation that is shared throughout the organisation and which others can learn from. The panel considered that the Scottish Government has well-developed systems and processes and can demonstrate sustainable improvement throughout the organisation. 157

158 Medical revalidation in Scotland: local reports Good practice, improvements and challenges We asked for feedback on examples of good practice in relation to implementing medical revalidation. Scottish Government referred to its leadership of the development and implementation of medical revalidation in Scotland. Scottish Government is also a major stakeholder in the Scottish RO Network and UK Revalidation Advisory Board (RAB) and chairs the Revalidation Delivery Board for Scotland. Scottish Government has collaborated on and funds appropriate training opportunities run by NES, including an RO training day in 215, which is anticipated to become an annual event. It also contributes towards ongoing improvements to SOAR which is hosted by NES. Scottish Government confirmed that revalidation has supported improvements in the organisation. Appraisal rates have increased year on year and have become embedded as part of the annual performance cycle. Indications are that that the appraisal and revalidation process is a valued, reflective forward planning toolset allowing appraisees, appraisers and ROs to consider the requirements to demonstrate they are up to date and fit to practise. We also asked about challenges. A particular challenge that Scottish Government identified is dealing with cross-border issues, such as Scottish designated bodies having an Englishbased RO, who may be RO for a number of other designated bodies in England. It is determining which higher level RO the Scottish designated body should connect with to monitor the RO governance and duties and safeguard patient safety. Scottish Government confirmed local arrangements have been put in place between the higher level ROs to achieve this. This is in line with guidance documentation being developed by the Department of Health in England which has had UK wide stakeholder input, along with GMC participation. The overall process is to exchange a fitness to practise statement between higher level ROs in each country at annual appraisal. Action points from 215 review Fully actioned Ongoing Set up a formal agreement with NHS National Services Scotland for appraisal arrangements for ROs. Review the Scottish Government arrangements for making GMC revalidation recommendations to the GMC. Continue the work under way on providing RO arrangements for non regulated organisations. Continue to provide strong leadership on revalidation, particularly in relation to the CMO role of RO to the ROs. Action points for consideration during Although appraisal arrangements have been formalised with NSS for the appraisal services it provides, the panel would encourage Scottish Government to set up a written formal agreement for the support it receives. Continue the work under way on providing RO arrangements for non regulated organisations. Continue to provide strong leadership on revalidation, particularly in relation to the CMO role of RO to the ROs. 158

159 Medical revalidation in Scotland: local reports Appendix 1 Glossary annual appraisal designated body Form 4 General Medical Council (GMC) independent healthcare provider licence to practise multi-source feedback positive recommendation prescribed connection The process of preparing, collating and reflecting on information, followed by a discussion with an appraiser at a formal, confidential meeting. The appraisal meeting between the appraisee and appraiser should take place every year. The appraisal year for both primary and secondary care has been aligned to the financial year (1 April 31 March). An appraisal is considered to be completed when the summary of the appraisal discussion and personal development plan have been signed off by the appraiser and appraisee, within 28 days of the appraisal meeting. An organisation that employs or contracts with doctors and is designated in The Medical Profession (Responsible Officer) Regulations 21, as amended by The Medical Profession (Responsible Officer) (Amendment) Regulations This form sets out an agreed summary of the appraisal discussion and a description of the actions agreed, including those forming the appraisee s personal development plan. This form is completed by the appraiser and agreed by the appraisee. A public body that maintains the official register of medical practitioners within the UK. Its chief responsibility is to protect, promote and maintain the health and safety of the public by controlling entry to the register and suspending or removing members when necessary. An NHS term for a healthcare services provider (a term which, as used in the UK, refers to an organisation, not an individual healthcare professional) that operates independently of the NHS. To practise medicine in the UK, all doctors are required by law to be both registered and hold a licence to practise. This applies to practising full time, part time, as a locum, privately or in the NHS, or employed or self-employed. Licences are issued, renewed and withdrawn by the GMC. At least 15 colleagues must provide anonymous feedback on each doctor s behaviour and approach. This is required once in each fiveyear period. A recommendation to revalidate is a formal declaration from a RO to the GMC that a licensed doctor remains up to date and fit to practise. The RO has to be assured that doctors have: met the GMC s requirements for revalidation participated in systems and processes to support revalidation, and collected the required supporting information for revalidation. The formal link between a doctor and their designated body. It is the route by which doctors are able to find their RO. Regulation 1 and 12 in The Medical Profession (Responsible Officer) Regulations 21 set out the prescribed connection between designated bodies and doctors and these are explained in more detail in the RO guidance

160 Medical revalidation in Scotland: local reports remediation Responsible Officer (RO) Scottish Online Appraisal Resource (SOAR) The overall process agreed with a practitioner to redress identified aspects of underperformance. Remediation is a broad concept varying from informal agreements to carrying out some re-skilling, to more formal supervised programmes of remediation or rehabilitation. A licensed doctor with a least five years experience who has been nominated or appointed by a designated body. In Scotland, medical directors have been appointed as Responsible Officers and they have a key role in developing more effective liaison between organisations and the GMC as the regulatory body for all doctors. They also oversee the arrangements for medical revalidation, including all methods of evaluating fitness to practise. The GMC will make the final decision on revalidation of any doctor. The national database used to record appraisal for trainees and doctors in primary and secondary care. 16

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