Medical Revalidation Responsible Officer Report¹

Size: px

Start display at page:

Download "Medical Revalidation Responsible Officer Report¹"

Nancy Reed
5 years ago
Views:

1 Medical Revalidation Responsible Officer Report¹ 1. EXECUTIVE SUMMARY LTHT is a designated body with 1247 doctors assigned to it for the appraisal year, of whom 96% completed their yearly appraisal on time. The Trust is maintaining its high appraisal completion rates. Doctors with incomplete appraisals are actively managed by the Chief Medical Officer and Responsible Officer. 2. PURPOSE OF THE PAPER To update on progress and improvement plans for medical revalidation. 3. BACKGROUND Medical Revalidation was launched in 2012 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 profession. Designated Bodies have a statutory duty to support their Responsible Officers in discharging their duties under the Responsible Officer Regulations² and it is expected that their 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 preengagement for locums) are carried out to the required standards. 3. GOVERNANCE ARRANGEMENTS Progress in implementing a high-quality system for revalidation is overseen by the Revalidation and Appraisal Steering Group. A working group and a number of other groups contribute to this overview. The Steering Group is chaired by the Responsible Officer (RO) and its membership includes the Chief Medical Officer (CMO), medical leads for operations, professional development and medical workforce, as well as front-line clinicians who have volunteered to help the Group with its work. The Group reports to the board through this annual report. Through this structure, revalidation has been designed, developed and implemented by numerous clinicians and lead appraisers, supported by HR but in a way that conforms to national requirements and standards. 3 ¹ The structure and content of the report is, in significant part, mandated by NHS England ²The Medical Profession (Responsible Officers) Regulations, 2010 as amended in 2013 and The General Medical Council (Licence to Practise and Revalidation) Regulations Order of Council 2012

2 4. MEDICAL APPRAISAL 4.1 Appraisal Figures 2016/2017 A detailed breakdown is attached at Appendix 3, key points are: Total Completed Special Circumstances No Appraisal (96%) (92%) (89%) (90%) (88%) (2%) (3%) (3%) (2%) (3%) (2%) (5%) (8%) (8%) (9%) New Starters An audit has been completed and all doctors that failed to complete an appraisal in have been identified and written to. Of the 29 doctors who did not complete an appraisal 11 of these were consultants. Those doctors that have since completed their appraisal or disclosed mitigating circumstances have been advised that they have a gap in their appraisal history but no further action is needed. Those doctors that have not completed an appraisal have been set an appraisal deadline of the 30th September A further audit will be run in October to ensure that all the outstanding appraisals have been completed; further action will be undertaken if necessary, such as notifying the GMC of failure to engage in the process. 4.2 Appraisal Re-Alignment Appraisal re-alignment began in the appraisal year where we aimed to simplify the Trust-wide task of ensuring appraisal completion, and enable a more reflective process. The Trust has moved away from the rush of medical appraisals that take place every year between January and March in order to relieve the pressure on many staff at year-end, and this mirrors similar action taken by NHS England. This approach has increased our overall appraisal compliance rates. 4.3 Appraisers There are currently 224 active appraisers within the Trust. CPD workshops are now being run on a bi-monthly basis. All active appraisers are required to attend two workshops in 3 years to maintain their competence. Following feedback from NHS England we developed a networking appraiser conference which was well received. This conference will be repeated again this appraisal year with an emphasis upon Quality Improvement. 4.3 Appraisal toolkit The web-based appraisal toolkit (PReP) has been in use across the Trust for five years and all medical appraisals are now completed on this system. The PReP contract expires on the 31st March 2018, and we are currently in the process of reviewing a business case to appoint a supplier. 5

3 4.4 Quality Assurance NHS England s Appraisal Summary and PDP Audit Tool (ASPAT) has been implemented by LTHT. The audit tool enables LTHT to score the appraisal outputs to ensure that the appraisal process is meeting the required standards. The ASPAT forms part of a new feedback structure to our appraisers in order to increase quality in the appraisal system. A Wayfinder campaign was run on the Trust platform asking What can we stop, start, do differently to improve medical appraisal? and How would you say appraisal has benefited your patients? The responses have now been analysed and have been fed into the Quality Improvement plan. Our whole appraisal and revalidation system has been externally reviewed by the NHS leadership team for the North. The review endorsed our existing improvement plan and made 2 additions. NHS England paired LTHT with County Durham and Darlington NHS Trust, based upon appraisal system and location. County Durham and Darlington have since completed a peer review and LTHT and we are awaiting the results. 4.5 Clinical Governance Assurance and performance in this area are reported elsewhere, overseen by the Chief Medical Officer (CMO) and Chief Nurse. Key aspects of clinical governance for the RO at LTHT are the collection and use of clinical information and systems to assist clinicians in their annual appraisal and more rarely to trigger the raising of concerns about a doctor s practice from our clinical risk management systems. Both are the subject of new approaches being taken in the current year and there are high levels of collaboration between the relevant departments and the RO s team. We have been unable to respond positively to statement 6 of the assurance statements (Appendix 4). Whilst there are effective systems for monitoring conduct and performance these data are not routinely provided to doctors for inclusion in their annual appraisal portfolios. We are currently looking into ways that clinical governance information could regularly be uploaded to a doctor s individual appraisal portfolio for discussion at the appraisal meeting. We believe that our performance in this area is not significantly different to peer trusts. Alternatives could include a self service model. 5. MEDICAL REVALIDATION 5.1 Revalidation Recommendations The revalidation recommendation panel (RO, CMO, Senior Medical Managers, Trust Medical Appraisal Lead and HR) has reviewed portfolios resulting in 1016 recommendations to the GMC since revalidation started in The frequency of each recommendation and comparison to England as a whole is shown below. 5

4 LTHT England 4 Recommendations made to the GMC Positive Recommendations 888 (87.4%) (80.3%) Deferrals 126 (12.4%) (19.4%) Failure to Engage 2 (0.2%) 542 (0.3%) LTHT has a much lower deferral rate than the rest of England and we are committed to reducing the deferral rate further, in particular for those doctors where the reason for deferral was due to incomplete 360 feedback, either from patients or colleagues. To date LTHT has made seven late recommendations to the GMC, 5 of these recommendations were completed within 24 hours of the deadline. The 2 remaining late recommendations are due to the way the GMC record late revalidation recommendations. Overall Leeds Teaching Hospitals has a lower error rate of making late revalidation recommendations at 0.69% compared to England which has an error rate of 1.20%. An analysis of the causes of our late returns revealed nonsystematic human error. 5.2 Policy and guidance The medical revalidation policy has been reviewed and updated and will be discussed at the next JCNC in September RECRUITMENT AND ENGAGEMENT BACKGROUND CHECKS All doctors employed by LTHT are subject to the NHS mandatory preemployment recruitment checks prior to appointment, including locum doctors. In April 2014, a new category of fitness to practise impairment 'not having the necessary knowledge of English' was introduced by the GMC, requiring Trusts to ensure that doctors have sufficient knowledge of the English language necessary for their work to be performed in a safe and competent manner. The pre-employment checks carried out on all doctors provide this assurance at LTHT. 7. MONITORING PERFORMANCE The approach taken in LTHT is to use existing routine systems to monitor the fitness to practise of all doctors. This includes Mortality and morbidity reviews Clinical governance forums and meetings in specialties Participation in national and local audits Whistleblowing systems Never Events 6 4 Figures taken from

5 Clinical directors hold responsibility for identifying and managing concerns about performance, or escalating them where it is felt that they may be serious. 8. RESPONDING TO CONCERNS AND REMEDIATION The Trust s approach to identifying and responding to concerns is covered by the Principles for Responding to Concerns and the Guidance and Principles for Remediation 8.1 Doctors at Risk The table below contains data regarding the numbers of doctors at risk during that required formal action by the GMC, or by the Trust internally, where there was an outcome other than case closed with no further action. Doctors at Risk - Categorisation and Level of Concern 5 Low Risk Moderate Risk High Risk Totals Conduct Capability Health Totals Doctors in training Doctors in training have their RO at the Health Education Yorkshire and Humber Deanery (HEYH). The process for providing HEYH with reports has been agreed with them and implemented. 9. RISKS AND ISSUES There are no risks or issues that need to be escalated for the Board s attention. 10. IMPROVEMENT PLAN The full structured improvement plan is published on the Doctors Information Board. The three key areas that we will be focussing upon over the next 12 months are: Improving the role of the lead appraiser - Clarifying the role of the lead appraiser to enable clinical directors (through that role) to ensure that LTHT employed doctors are able to reflect actively on their practice via an effective appraisal system. Accessing clinical outcomes - Enable all doctors to understand the clinical outcomes that they personally contribute to and to reflect on what they need to change and improve on as a practitioner. In the first year this will be about using easily accessible data to feedback to doctors, for example returns to theatre. 6 4 Figures taken from

6 Highlighting our quality improvement activity - Doctors routinely collect information about their quality improvement activity, often this is in the form of participating in clinical audit. Increasingly doctors are making contributions to the LTHT Quality Improvement Strategy as part of the Leeds Improvement Method. This contribution to improving service quality by our medical staff needs to be identified and highlighted in future. 7 5 The level of concern refers to the risk of harm to patients, staff or the doctor in question; the risk to the doctor s career or employment status; and / or the risk to the reputation of the Trust. It is based on the NHS England document Supporting Doctors to Provide Safer Healthcare: Establishing the level of concern (March 2012). Available at:

7 11. RECOMMENDATIONS Board Members are asked to: Note the excellent progress being made in this area Confirm commitment to supporting the progress of this work Confirm that the Chief executive should sign the Board assurance statement relevant to this report Dr Phil Ayres Responsible Officer, Associate Medical Director August 2017 G:\Execs_Support_Team\General\Trust Board\ \Board\Formal Meetings\03 28 September 2017\Public\Final\Blue Box\14.3 Medical Revalidation Report - Appendices.docx

Revalidation Annual Report

Paper 31 14 Revalidation Annual Report 2013-14 Purpose of Document: To provide the Board with a report on the first year s experience with medical revalidation in Public Health Wales. Board/Committee to-