SOMERSET PARTNERSHIP NHS FOUNDATION TRUST ANNUAL MEDICAL APPRAISAL AND REVALIDATION BOARD REPORT 2015/16. Report to the Trust Board 26 July 2016

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1 SMERSET PARTNERSHIP NHS FUNDATIN TRUST ANNUAL MEDICAL APPRAISAL AND REVALIDATIN BARD REPRT 215/16 Report to the Trust Board 26 July 216 Sponsoring Director: Author: Purpose of the report: Dr Andrew Dayani (Medical Director). Head of Medical Services. To provide assurance to the Board as part of the Responsible fficer s Regulations. To seek approval of the statement of compliance confirming Somerset Partnership NHS Foundation Trust is in compliance with the regulations. Key Issues and Recommendations: Arrangements for ensuring doctors are appraised to a standard that meets the requirements of the Responsible fficer Regulations and are revalidated in a timely manner are working effectively. In 215/16, 98% of doctors with a prescribed connection to Somerset Partnership had a completed appraisal. A total of 2 revalidation recommendations were made to the GMC during the same period. Arrangements for ensuring doctors appointed to the Trust, including locums, are subject to appropriate checks are not working as well. Information the Responsible fficer should have access to before doctors begin work with the Trust is not always ed. Whilst this continues to be a concern, there have been improvements compared with previous years. Actions have been identified that should address all of the issues identified. Actions required by the Board: To receive the report and to approve the statement of compliance. July 216 Public Board - 1 -

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3 SMERSET PARTNERSHIP NHS FUNDATIN TRUST ANNUAL MEDICAL APPRAISAL AND REVALIDATIN BARD REPRT 215/16 1. EXECUTIVE SUMMARY 1.1 The purpose of this report is to provide assurance to the Board that the arrangements for medical appraisal and Revalidation have been operating effectively over the last year (April 215 March 216). 1.2 In 215/16, 98% of doctors with a prescribed connection to Somerset Partnership had a completed appraisal. This maintains the level of performance achieved in 214/15 and confirms that the steps to improve compliance, introduced in 214, have been effective. 1.3 Revalidation recommendations to the General Medical council (GMC) were all carried out in a timely manner. In total 2 recommendations were made, all of which recommended revalidation. There were no requests for a deferral and no reports for non-engagement. 1.4 Information the Responsible fficer should have access to before doctors begin work with the Trust is not always ed. Whilst this continues to be a concern, improvements compared with previous years are evident. 1.5 Actions are identified that should address all of the issues identified. 2. PURPSE 2.1 This is the sixth annual report to the Trust Board on the development and operation of systems to support the appraisal and revalidation of medical staff. The format of the report follows the Annual Board Report Template provided by NHS England. The report is intended to provide assurance that appraisal systems are robust, support revalidation and are operating effectively. The report forms part of the Medical Director s duties as Responsible fficer (R). 2.2 Revalidation is a key component of a range of measures designed to improve the quality of care for patients. It is the process by which the General Medical Council confirms the continuation of doctors licences to practice in the UK. It provides assurance to patients and the public, employers and other healthcare professionals that licensed doctors are up to date and fit to practice. July 216 Public Board - 3 -

4 3. BACKGRUND 3.1 Medical Revalidation was launched in 212 to strengthen the way that doctors are regulated, with the aim of improving the quality of care provided to patients, improving patient safety and increasing public trust and confidence in the medical system. 3.2 Provider organisations have a statutory duty to support their Responsible fficers in discharging their duties under the Responsible fficer Regulations and it is expected that provider boards will oversee compliance by: monitoring the frequency and quality of medical appraisals in their organisations; checking there are effective systems in place for monitoring the conduct and performance of their doctors; confirming that feedback from patients is sought periodically so that their views can inform the appraisal and revalidation process for their doctors; and ensuring that appropriate pre-employment background checks (including pre-engagement for Locums) are carried out to ensure that medical practitioners have qualifications and experience appropriate to the work performed. 4. GVERNANCE ARRANGEMENTS 4.1 The Board has appointed the Medical Director as Responsible fficer (R). The R is responsible for the delivery of the arrangements needed to support revalidation. Arrangements, including monitoring completion of appraisals and validation of the list of doctors with a prescribed connection to the Trust, are overseen by the Medical Appraisal Steering Group (MASG). 4.2 In ctober 215 the MASG was renamed the Medical Revalidation Steering Group (MRSG), in order to better reflect the role of the group. The terms of reference were also reviewed and updated. The MASG / MRSG was part of the Trust Integrated Governance Framework and reported on a quarterly basis to the Workforce Governance Group, which in turn provided assurance to the Trust Board. The Work Governance Group was dissolved in late 215 and alternative arrangements are yet to be confirmed. 4.3 More routine and regular management of appraisal and revalidation is undertaken at monthly medical managers meetings, at which appraisal and revalidation is a standing agenda item. The Medical Appraisal Lead July 216 Public Board - 4 -

5 also holds quarterly meetings with the appraisal team, with an agenda that covers appraisal management and appraisal practice. 5. MEDICAL APPRAISAL 5.1 At 31 March 216, 6 doctors had a prescribed connection to Somerset Partnership. f this group, 59 (98%) had a completed appraisal during the appraisal year, compared with 97% (62 of 64) in 214/15. The only doctor who did not have an appraisal during 215/16 was on long-term sickness absence and so was unable to be appraised during the year. 5.2 All medical appraisals in 215/16 were completed by the Trust appraisal team. The appraisal team comprises five Medical Appraisers plus a Medical Appraisal Lead. Appraisers receive specialist training on joining the appraisal team and then regular top-up training. Refresher session was delivered to all Trust Appraisers in February The Appraisal Lead regularly attends Regional Appraisal Lead Network meetings. The Appraisal Team are also members of the Trust s Medical Appraisal Peer Group, which meets on a quarterly basis and which provides a platform of support and quality assurance for the appraisers. ne new appraiser has joined the team for the next appraisal year and it is planned to further increase the number of medical appraisers to provide continuity and greater resilience in future years. 5.4 Each Appraiser carried out between ten and 17 appraisals in 215/16, which is in line with NHS England guidance of between five and 2 appraisals per year. All appraisals were carried out using the Allocate Software e-appraisal system. 5.5 An online appraisal feedback form that doctors complete after their appraisal meeting was introduced during the appraisal year. This feature within the Allocate Software e-appraisal system allows feedback reports to be generated for each appraiser. The reports are sent to the appraiser at year-end and reviewed by the Appraisal Lead. 5.6 An audit of completed appraisals reviewed 5% of appraisals carried out in 215/16 (a total of 32). The results of the audit are presented at Appendix B. The audit adopted a three point scoring system in accordance the NHS England Appraisal Summary and PDP Audit Tool (ASPAT): = not satisfactory; 1 = needs improvement 2 = satisfactory. 5.7 The majority of appraisals were assessed as satisfactory, with all appraisals sampled meeting the required standard for reviewing complaints and significant events. The audit showed that the areas July 216 Public Board - 5 -

6 needing most improvement were the compilation of supporting information, writing of appraisal summaries and supporting comments to the appraiser statements. 5.8 The appraisal policy has been reviewed and updated to incorporate recent guidance from NHS England regarding the scheduling of appraisal dates and requesting postponements of appraisals. 5.9 Systems for providing information on complaints, sickness, SIRIs and compliance with mandatory training to individual appraisees and appraisers are now well-established. A revised report on Quality of utcome Measures (QM) was made available for doctors to use from 215/16. This contains a wide range of indicators at individual and speciality level, including benchmarks. These reports have been adapted several times over the year to ensure optimal relevance for the individual doctor s work. The system for generating the QM reports is being further developed to make it easier for doctors to access and interpret the results. 6. REVALIDATIN RECMMENDATINS 6.1 Twenty recommendations were made to the GMC during the reporting period. All recommendations were made on time and all were positive recommendations. There were no requests to defer a recommendation and no notifications to the GMC for non-engagement. A summary of the recommendations made in 215/16 can be found at Appendix C. 7. RECRUITMENT AND ENGAGEMENT BACKGRUND CHECKS 7.1 Policies are in place to govern the recruitment process for permanent and temporary staff and set out the pre-employment checks that should be completed. An audit of compliance with pre-employment checks can be found at Appendix E. The results show that gaps in the information recoded are still widespread and that significant improvements are still needed, particularly in relation to the information collected prior to the appointment of locums. However, it should be noted that the results of the audit this year still represent significant progress compared with previous years. 7.2 Steps to strengthen systems and processes around recruitment that were set out in the action plan presented in last year s report, were delayed by the absence of substantive senior HR/D leadership and the lack of dedicated Medical Staffing resources within the HR Directorate. Plans are in place to introduce a revised and enhanced transactional HR service which will include all recruitment related activity and the proposed new Clinical Management Model will further strengthen interactions between Corporate Services and perational July 216 Public Board - 6 -

7 Divisions including clear processes for the appointment and engagement of substantive and locum staff alike. 7.3 Finance resources have been made available by the Director of Workforce and rganisational Development to engage on a just time basis, an extremely experienced Medical HR Manager. In addition to supporting the Trust with the implementation of the Junior Doctor s contract, this individual will conduct a comprehensive review of all processes and procedures relating to the Trust s Medical Workforce, including best practice in respect of the conduct and ing of background checks. 8. MNITRING PERFRMANCE 8.1 The performance of doctors is monitored using an array of information, including information on sickness, complaints, SIRIs and mandatory training compliance. The majority of doctors (Mental Health staff) also receive reports containing a variety of activity and quality indicators. This information is provided to both the doctor and their appraiser and the results of the audit reported at Appendix B shows that it is discussed during appraisals. 8.2 utside the appraisal process, performance information is regularly reviewed by medical managers. Clinical governance arrangements highlight potential concerns and ensure the Responsible fficer is sighted on relevant issues. As part of these arrangements, Datix reports involving Medical Staff are reviewed by the Medical Director. 9. RESPNDING T CNCERNS AND REMEDIATIN 9.1 Concerns about medical staff are dealt with through the Disciplinary Policy for Medical Staff. If a doctor requires additional support to function effectively and safely this can be provided through the arrangements set out in the Remediation, Re-skilling and Rehabilitation Policy. 9.2 Concerns were raised about one Somerset Partnership doctor in 215/16. More information is provided at Appendix D. 1. RISKS AND ISSUES 1.1 The risk associated with the use of temporary staff if background checks are not adequate. July 216 Public Board - 7 -

8 11. LESSNS LEARNED 11.1 Failure to undertake or certain pre and post-employment checks in a timely manner continues to be a concern. Some re-assurance is provided by the knowledge that doctors working within Somerset Partnership but with prescribed connections elsewhere are still subject to Revalidation and the R regulations An independent verification visit was undertaken by NHS England in June 216. The date of the visit falls outside the period covered by this report and at the time of writing the findings from the visit have not been confirmed. Initial feedback at the end of the visit and draft findings received so far indicate the verification team had no significant concerns about the arrangements for medical appraisal and revalidation in Somerset Partnership. The findings and accompanying action plan will be reported in detail in the Board report for 216/ CRRECTIVE ACTINS, IMPRVEMENT PLAN AND NEXT STEPS 12.1 Steps to strengthen HR support in respect of the recruitment of substantive and locum medical staff were outlined at 7.3. As an interim measure for ing background checks, arrangements have been made between HR and the Medical Directorate to share details of all new substantial and locum positions to the Medical Director s PA, who will create and maintain a comprehensive spreadsheet of all checks required including those related to appraisal and revalidation, for each new position. The latter will be checked against s held on GMC Connect and the general GMC Doctor s Register Re-establish governance arrangements that enable the Medical Revalidation Steering Group to report to a relevant Governance Group Use the Appraisal Summary and PDP Audit Tool (ASPAT) to provide a more in depth assessment of the quality of medical appraisals Implement all actions in response to findings from the NHS England verification visit. 13. RECMMENDATIN 13.1 The Board is asked to receive the report, which will be shared with the higher level Responsible fficer at NHS England and to approve the statement of compliance confirming Somerset Partnership is complying with the Responsible fficer regulations (Appendix F). MEDICAL DIRECTR July 216 Public Board - 8 -

9 Audit of all missed or incomplete appraisals Appendix A Doctor factors (total) 1 Maternity leave during the majority of the appraisal due window Sickness absence during the majority of the appraisal due window Prolonged leave during the majority of the appraisal due window 1 Suspension during the majority of the appraisal due window New starter within three months of appraisal due date New starter more than three months from appraisal due date Postponed due to incomplete portfolio/insufficient supporting information Appraisal outputs not signed off by doctor within 28 days Lack of time of doctor Lack of engagement of doctor ther doctor factors (describe) Appraiser factors Unplanned absence of appraiser Appraisal outputs not signed off by appraiser within 28 days Lack of time of appraiser ther appraiser factors (describe) rganisational factors Administration or management factors Failure of electronic information systems Insufficient numbers of trained appraisers ther organisational factors (describe) July 216 Public Board - 9 -

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11 Quality assurance audit of appraisal inputs and outputs Total number of appraisals completed 63 Number of appraisal portfolios sampled (to demonstrate adequate sample size) Appendix B Number of the sampled appraisal portfolios deemed to be acceptable against standards Appraisal inputs Scope of work: Has a full scope of practice been described? (four needed improvement) Continuing Professional Development (CPD): Is CPD compliant with GMC requirements? (five needed improvement; one not satisfactory) Quality improvement activity: Is quality improvement activity compliant with GMC requirements? (eight needed improvement; one not satisfactory) Patient feedback exercise: Has a patient feedback exercise been completed? Colleague feedback exercise: Has a colleague feedback exercise been completed? Review of complaints: Have all complaints been included? Review of significant events/clinical incidents/suis: Have all significant events/clinical incidents/suis been included? Is there sufficient supporting information from all the doctor s roles and places of work? Is the portfolio sufficiently complete for the stage of the revalidation cycle (year 1 to year 4)? Explanatory note: For example has a patient and colleague feedback exercise been completed by year 3? is the portfolio complete after the appraisal which precedes the revalidation recommendation (year five)? gave all types of supporting information been (12 needed improvement; three not satisfactory) (eight needed improvement) included? Appraisal utputs Appraisal Summary (nine needed improvement) Appraiser Statements (19 needed improvement) PDP (five needed improvement) July 216 Public Board

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13 Appendix C Audit of revalidation recommendations Revalidation recommendations between 1 April 215 to 31 March 216 Recommendations completed on time (within the GMC recommendation window) Late recommendations (completed, but after the GMC recommendation window closed) 2 Missed recommendations (not completed) TTAL 2 Primary reason for all late/missed recommendations For any late or missed recommendations only one primary reason must be identified responsible officer in post New starter/new prescribed connection established within 2 weeks of revalidation due date New starter/new prescribed connection established more than 2 weeks from revalidation due date Unaware the doctor had a prescribed connection Unaware of the doctor s revalidation due date Administrative error Responsible officer error Inadequate resources or support for the responsible officer role ther Describe other TTAL [sum of (late) + (missed)] July 216 Public Board

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15 Appendix D Audit of concerns about a doctor s practice Concerns about a doctor s practice Number of doctors with concerns about their practice in the last 12 months Explanatory note: Enter the total number of doctors with concerns in the last 12 months. It is recognised that there may be several types of concern but please the primary concern Capability concerns (as the primary category) in the last 12 months Conduct concerns (as the primary category) in the last 12 months Health concerns (as the primary category) in the last 12 months Remediation/Reskilling/Retraining/Rehabilitation High Medium Low Total level level level Numbers of doctors with whom the designated body has a prescribed connection as at 31 March 216 who have undergone formal remediation between 1 April 215 and 31 March 216 Formal remediation is a planned and managed programme of interventions or a single intervention e.g. coaching, retraining which is implemented as a consequence of a concern about a doctor s practice A doctor should be included here if they were undergoing remediation at any point during the year Consultants (permanent employed staff including honorary contract holders, NHS and other government /public body staff) Staff grade, associate specialist, specialty doctor (permanent employed staff including hospital practitioners, clinical assistants who do not have a prescribed connection elsewhere, NHS and other government /public body staff) General practitioner (for NHS England area teams only; doctors on a medical performers list, Armed Forces) Trainee: doctor on national postgraduate training scheme (for local education and training boards only; doctors on national training programmes) Doctors with practising privileges (this is usually for independent healthcare providers, however practising privileges may also rarely be awarded by NHS organisations. All doctors with practising privileges who have a prescribed connection should be included in this section, irrespective of their grade) Temporary or short-term contract holders (temporary employed staff including locums who are directly employed, trust doctors, locums for service, clinical research fellows, trainees not on national training schemes, 1 1 July 216 Public Board

16 doctors with fixed-term employment contracts, etc.) All Designated Bodies. ther (including all responsible officers, and doctors registered with a locum agency, members of faculties/professional bodies, some management/leadership roles, research, civil service, other employed or contracted doctors, doctors in wholly independent practice, etc.) All Designated Bodies. TTALS 1 ther Actions/Interventions Local Actions: Number of doctors who were suspended/excluded from practice between 1 April and 31 March: Explanatory note: All suspensions which have been commenced or completed between 1 April and 31 March should be included Duration of suspension: Explanatory note: All suspensions which have been commenced or completed between 1 April and 31 March should be included Less than 1 week 1 week to 1 month 1 3 months 3-6 months 6-12 months Number of doctors who have had local restrictions placed on their practice in the last 12 months? GMC Actions: Number of doctors who: Were referred by the designated body to the GMC between 1 April 215 and 31 March 216 Underwent or are currently undergoing GMC Fitness to Practice procedures between 1 April and 31 March Had conditions placed on their practice by the GMC or undertakings agreed with the GMC between 1 April and 31 March Had their registration/licence suspended by the GMC between 1 April and 31 March Were erased from the GMC register between 1 April and 31 March National Clinical Assessment Service actions: Number of doctors about whom the National Clinical Advisory Service (NCAS) has been contacted between 1 April and 31 March for advice or for assessment Number of NCAS assessments performed months July 216 Public Board

17 Total Identity check Past GMC issues GMC conditions or undertakings n-going GMC/NCAS investigations Disclosure and Barring Service (DBS) 2 recent references Name of last responsible officer Reference from last responsible officer Language competency Local conditions or undertakings Qualification check Revalidation due date Appraisal due date Appraisal outputs Unresolved performance concerns Audit of recruitment and engagement background checks Appendix E Number of new doctors (including all new prescribed connections) who have commenced in last 12 months (including where appropriate locum doctors) Permanent employed doctors 5 Temporary employed doctors 8 Locums brought in to the designated body through a locum agency 31 Locums brought in to the designated body through Staff Bank arrangements 3 Doctors on Performers Lists ther Explanatory note: This includes independent contractors, doctors with practising privileges, etc. For membership organisations this includes new members, for locum agencies this includes doctors who have registered with the agency, etc TTAL 47 For how many of these doctors was the following information available within one month of the doctor s starting date (numbers) Permanent employed doctors Temporary employed doctors July 216 Public Board

18 Locums brought in to the designated body through a locum agency Locums brought in to the designated body through Staff Bank arrangements Doctors on Performers Lists ther (independent contractors, practising privileges, members, registrants, etc) Total For Providers of healthcare i.e. hospital trusts use of locum doctors: Explanatory note: Number of locum sessions used (days) as a proportion of total medical establishment (days) The total WTE headcount is included to show the proportion of the posts in each specialty that are covered by locum doctors Locum use by specialty: Total establishment in specialty (current approved WTE headcount) Consultant: verall number of locum days used SAS doctors: verall number of locum days used Trainees (all grades): verall number of locum days used Surgery Medicine Psychiatry bstetrics/gynaecology Total verall number of locum days used July 216 Public Board

19 Accident and Emergency Anaesthetics Radiology Pathology ther Total in designated body (This includes all doctors not just those with a prescribed connection) Number of individual locum attachments by duration of attachment (each contract is a separate attachment even if the same doctor fills more than one contract) Total Preemployment checks completed (number) Induction or orientation completed (number) Exit reports completed (number) Concerns reported to agency or responsible officer (number) 2 days or less days to one week week to 1 month months months months 5 5 More than 12 months 1 1 Total July 216 Public Board

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21 Appendix F Designated Body Statement of Compliance The Board of Somerset Partnership NHS Foundation Trust has carried out and submitted an annual organisational audit (AA) of its compliance with The Medical Profession (Responsible fficers) Regulations 21 (as amended in 213) and can confirm that: 1. A licensed medical practitioner with appropriate training and suitable capacity has been nominated or appointed as a responsible officer; Comments: 2. An accurate of all licensed medical practitioners with a prescribed connection to the designated body is maintained; Comments: 3. There are sufficient numbers of trained appraisers to carry out annual medical appraisals for all licensed medical practitioners; Comments: 4. Medical appraisers participate in ongoing performance review and training / development activities, to include peer review and calibration of professional judgements (Quality Assurance of Medical Appraisers or equivalent); Comments: 5. All licensed medical practitioners 1 either have an annual appraisal in keeping with GMC requirements (MAG or equivalent) or, where this does not occur, there is full understanding of the reasons why and suitable action taken; Comments: 6. There are effective systems in place for monitoring the conduct and performance of all licensed medical practitioners 1, which includes [but is not limited to] monitoring: in-house training, clinical outcomes data, significant events, complaints, and feedback from patients and colleagues, ensuring that information about these is provided for doctors to include at their appraisal; Comments: 1 Doctors with a prescribed connection to the designated body on the date of reporting. July 216 Public Board

22 7. There is a process established for responding to concerns about any licensed medical practitioners 1 fitness to practise; Comments: 8. There is a process for obtaining and sharing information of note about any licensed medical practitioners fitness to practise between this organisation s responsible officer and other responsible officers (or persons with appropriate governance responsibility) in other places where licensed medical practitioners work; Comments: 9. The appropriate pre-employment background checks (including preengagement for Locums) are carried out to ensure that all licenced medical practitioners 2 have qualifications and experience appropriate to the work performed; and Comments: 1. A development plan is in place that addresses any identified weaknesses or gaps in compliance to the regulations. Comments: Signed on behalf of the designated body Name: _ Signed: [Chief Executive or Chairman a Board member (or Executive if no Board exists)] Date: 2 Doctors with a prescribed connection to the designated body on the date of reporting. July 216 Public Board

23 Links to Strategic Themes: Identify to which of the Somerset Partnership NHS Foundation Trust strategic themes this report relates by including a cross behind the relevant theme(s) Quality and Safety X Sustainability and Transformation Service Delivery Culture and People X Links to the Assurance Framework: the Trust fails to effectively involve patients and carers in the development and delivery of services and care; the Trust fails to improve engagement with the medical workforce, which means medical staff do not play a leading role in the development and delivery of high quality patient care. Links to the NHS Constitution and Trust Values: Links to CQC Domains: Identify the Values to which the issues raised in this report relate by including a cross behind the relevant value(s) Working together for patients Respect and dignity Commitment to quality of care X Compassion Improving lives Everyone counts Identify which of the CQC domains are covered by this report by including a cross behind the relevant domain(s) Is it safe? X Is it caring? Is it well-led? X Is it effective? Is it responsive to people s needs? July 216 Public Board

24 Equality: Identify whether the report has an impact on the protected characteristics set out below, including risks, and if so, say how these risks are to be managed. nly tick the relevant box for which there is an impact. Z Age Gender re-assignment Pregnancy and maternity Religion or Belief Sexual rientation Disability Marriage and Civil Partnership Race Sex Learning Disabilities Legal or statutory implications/ requirements: Public/Staff Involvement History: Previous Consideration: Responsible fficer Regulations none not previously reviewed; report follows Medical Appraisal and Revalidation Board Report 214/15 presented to the Board in May 215. July 216 Public Board