CENTRAL MANCHESTER UNIVERSITY HOSPITALS NHS FOUNDATION TRUST

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1 CENTRAL MANCHESTER UNIVERSITY HOSPITALS NHS FOUNDATION TRUST Agenda Item 10.2 Report of: Paper prepared by: Professor R C Pearson, Medical Director Miss S Rowlands, Trust Assurance Manager (Operational) Date of paper: 10 th March 2014 Subject: Purpose of Report: Update Report to the Board of Directors: Management of Medical Appraisal and Revalidation Indicate which by Information to note Support Resolution Approval Consideration of Risk against Key Priorities (Impact of report on key priorities and risks to give assurance to the Board that its decisions are effectively delivering the Trust s strategy in a risk aware manner) The issues contained in this report have an impact on medical staff employment and organisational reputation. Recommendations Part 2 submission (meeting in private) Executive Summary This report describes the Trust s progress towards the management of Medical Appraisal and Revalidation, since Revalidation commenced in December Summary of key points: the Trust s Responsible Officer (RO) has been revalidated by the GMC all doctors employed by the Trust are expected to undertake annual appraisal compliance with medical appraisal is 41% (as at 21 st February 2014) there are 175 trained appraisers within CMFT all doctors with a prescribed connection must engage in Revalidation every five years all doctors must undertake 360 degree appraisal (multi-source feedback) at least once in each five year revalidation cycle

2 there are currently 907 doctors with a prescribed connection to CMFT (as per data from GMC Connect, the GMC s secure partner portal) 234 doctors with a prescribed connection to CMFT have received a recommendation to the GMC. Of these, 214 were positive recommendations and 20 were requests for deferral (6 long term sickness or maternity leave, the rest awaiting further information e.g. multisource feedback). Introduction Medical Revalidation has been introduced to help re-assure patients, the public and the medical profession that doctors are up to date and fit to practise. It also functions to support doctors development. It is a legal requirement for all doctors, practising in the UK, to be registered with the General Medical Council (GMC) and to hold a licence to practise. Revalidation applies to all licensed doctors, including trainees, and clinical academics in the UK and in all sectors (NHS and private). CMFT appointed the Medical Director to the statutory role of Responsible Officer (RO) with responsibility for implementing the Revalidation process within the Trust. Management of Appraisal and Revalidation at CMFT The RO for CMFT is the Medial Director and he is responsible for making recommendations to the GMC at the end of a doctor s five year Revalidation cycle with regards to that doctor s suitability for Revalidation. He is supported by an Associate Medical Director with oversight of Revalidation and Appraisal, the Director of Clinical Effectiveness, Trust Assurance Manager (Operational) and Head of Medical Staffing. Appraisal The first Revalidation cycle started in December 2012 (Year 0) with an expectation that the majority of licensed doctors will have been through a first Revalidation by March Appraisal is a key element of Revalidation, forming the basis for the recommendation made by the RO. Therefore, the GMC requires all doctors to have an annual appraisal, based on the GMC s Good Medical Practice (GMP) framework, signed off by both Appraiser and Appraisee, in order to allow the RO to make a positive recommendation to the GMC for Revalidation. The Trust s appraisal policy has been reviewed to ensure that it complies with the requirements of the enhanced medical appraisal for Revalidation. CMFT Appraisal process All doctors and dentists must ensure that they undergo appraisal within each financial year and are responsible for the continuous collection of their portfolio evidence, for the whole of their practice, over the course of their 5 year Revalidation cycle. This should be in accordance with the GMC s GMP framework and any specialty evidence should be in accordance with the recommendations made by the College or Specialty in their respective guidance. Historically, appraisals were organised by Divisions on an ad-hoc basis throughout the financial year. However, this inevitably resulted in the majority of appraisals being performed in the last quarter of the year, putting a strain on appraisers, the Medical Director and the Medical Staffing Department, and the current pressure at year end.

3 Appraisal Activity Levels Medical appraisal underpins the Revalidation process. Doctors are required to have 5 appraisals within the Revalidation Cycle (one per year in the 5 year cycle). Table 1 demonstrates the number of doctors, employed by CMFT, that have completed their appraisal in the period 1 st April st February 2014, those that are in progress/scheduled and the number of appraisals outstanding and not scheduled. It should be noted that the numbers stated below do not include numbered training grade doctors, as these are the responsibility of the North West Deanery. Table 1 no. doctors who have completed an appraisal (1 st April st Feb 2014) No. Medical Staff/Dentists % compliance Number of appraisals completed % Number of appraisals in progress or scheduled Number of appraisals outstanding and not scheduled Total % % Outstanding appraisals Table 2 shows the numbers of appraisals that are outstanding within each clinical Division. This is the position as at 21 st February 2014; weekly updates will be provided to the Medical Director. Please note that the numbers include Trafford doctors who have been aligned to their respective Divisions. Table 2 no. appraisals outstanding by Division (as of 21 st Feb 2014) Division No. Appraisals Outstanding CSS 52 Dental 15 Eye Hospital 13 Medicine and Community 83 Research 4 RMCH 79 Specialist Medicine 77 SMH 30 Surgery 78 Divisions are working through the list of doctors without a current appraisal, with a view to meeting the end of year target of 95% completion by 31 st March This is monitored weekly. Future Actions The Medical Staffing department will all doctors who have not completed an appraisal in the 2013/14 financial year after 1 st April 2014, as per GMC requirements for Revalidation and nonengagement. Doctors who have not completed an appraisal must be made aware of breaches of Trust Terms & Conditions of employment, that investigations will be undertaken to establish why they have not had an appraisal and that they have failed to follow Trust Policy. With regards to Consultant staff, this will impact on their pay progression and eligibility for Clinical Excellence Awards.

4 A new system of appraisal is in place from 1 st April 2014, which requires that appraisal is to be undertaken in the doctor s birthday month. This will enable the Divisions and the corporate departments to monitor appraisal on a monthly basis and address non-compliance at an early stage. Communication The requirements for annual appraisal, planning these across the year and the need to allocate dates have been raised at every Clinical Head of Division Forum and Clinical Director Forum. These requirements have also been highlighted in two Medical Revalidation and Appraisal newsletters, sent to doctors from the revalidation@cmft.nhs.uk address in May 2013 and December 2013 respectively. 360-degree Feedback Activity Levels The GMC requires all doctors to undertake 360-degree feedback at least once in their five year Revalidation cycle. The Trust has invested in an electronic 360 degree feedback system, provided by Equiniti 360 Clinical. As clinicians will be going through their revalidation cycles at different times, the organisation of 360 degree feedback has been staggered to reflect the dates when each clinician needs to have completed this process, relative to their Revalidation date. Table 3 demonstrates the number of doctors registered for 360 degree feedback using Equiniti, and their progress to date. This is based on a rolling number, which will increase as more and more doctors are registered as part of the requirements of their Revalidation cycle. Table 3 no. doctors who have been registered for 360-degree feedback and progress to date Total no. doctors registered for 360 degree feedback using Equiniti 360 Clinical No. 360 feedback completed No. 360 feedback in progress No. 360 feedback not started % 360 degree feedback completed % Revalidation Recommendations The GMC has now provided all licensed doctors with notice of when their Revalidation date will be and has allocated each doctor to an Organisation with which they have a prescribed connection. It should be noted that numbered trainees, locum agency doctors and dentists are excluded from this database. There are currently 907 doctors with a prescribed connection to CMFT, as per data received from GMC Connect. In 2012, the Trust was asked to submit a trajectory for submission of Revalidation recommendations to the GMC in Years 0 3 of the implementation period. This is shown in the following table. Year 0 (2012/13) Year 1 (2013/14) Year 2 (2014/15) Year 3 (2015/16) % total recommendations by 31 st March % 26% 35% 35% 100%

5 There are three potential outcomes for a recommendation to revalidate. These are: Agenda Item 10.2 positive recommendation for Revalidation deferral this is a neutral act and is usually related to a doctor who has engaged with the process of appraisal but needs to defer in order to provide further information. It may also be used when a doctor is on maternity leave, sabbatical or long-term sick leave non-engagement this can be linked to a performance process through HR and will prevent a doctor s continued practice beyond their Revalidation date. It can also be linked to any doctor who refuses to fulfil requirements for both annual appraisal and Revalidation. Table 4 demonstrates the number of Revalidation recommendations made by the RO between 3 rd December 2012 and 21 st February 2014, for all doctors with a prescribed connection to CMFT. Table 4 Total no. of recommendations made to date since 3 rd December 2012 Total no. doctors with a prescribed connection to CMFT (as per GMC Connect) Total no. recommendations made % recommendations made % Table 5 represents the number and percentage of recommendations (of the total 234 made between 3 rd December 2012 and 21 st February 2014) that fall into each of the three recommendation categories. Table 5 types of recommendation made to the GMC by CMFT s RO to date since 3 rd December 2012 Recommendation type No. recommendations made % of total recommendations (n=234) Positive % Deferral 20 9% Non-engagement 0 N/A Quality Assurance of appraisal and Revalidation Process In order to ensure that CMFT meets the requirements set out by the GMC with regards to appraisal and Revalidation, the Equiniti Revalidation Management System (RMS) was procured in November In summary, the RMS: allows doctors to collect and store their supporting information for appraisal and Revalidation electronically and in one central place enables the appraiser to check the appraisee s supporting information prior to the appraisal interview. The appraiser only proceeds when they are happy that the information is sufficient and appropriate (i.e. meets the requirements of the GMC s GMP framework) allows the appraisal to be completed and signed off electronically. This ensures that the RO has remote access to all relevant information and assurances are given that the appraisal has been completed in full.

6 Performance Review, Support and Development of Appraisers The RO must be confident that each appraisal is undertaken fairly and that the evidence presented has been reviewed. This should both encourage reflection but also provide challenge. As such, CMFT has a group of 175 appraisers who have received training on the enhanced appraisal system, which includes the top-up training for Revalidation. The next in-house training session for CMFT appraisers is in March It is expected that each appraiser will: have undergone approved training and refresh this at 3 yearly intervals be assessed in the role once no less than every 3 years be supported by the Medical Director/ AMD for Appraisal and Revalidation, meeting as a group once a year. Feedback on every appraisal and appraiser is requested from all appraisees annually, following their appraisal. This is discussed with appraisers individually and as a group. Challenges There are a number of challenges to be faced in the coming year with regards to appraisal and revalidation. These include: continued implementation of and engagement with Equiniti RMS achievement of 97% annual appraisal compliance rate by end of 2013/14 collation and maintenance of robust and accurate data with which to report appraisal compliance on both Trust and Divisional levels Recommendations The Board is asked to note the contents of this paper, progress made to date and the challenges to be faced in the coming year.