SOMERSET PARTNERSHIP NHS FOUNDATION TRUST ANNUAL MEDICAL APPRAISAL AND REVALIDATION REPORT 2016/17. Report to the Trust Board 25 July 2017

Transcription

1 SOMERSET PARTNERSHIP NHS FOUNDATION TRUST ANNUAL MEDICAL APPRAISAL AND REVALIDATION REPORT 2016/17 Report to the Trust Board 25 July 2017 Sponsoring Director: Author: Purpose of the report: Key Issues and Recommendations: Dr Sarah Oke (Medical Director) Head of Medical Services To provide assurance to the Board as part of the Responsible Officer s Regulations. To seek approval of the statement of compliance confirming Somerset Partnership NHS Foundation Trust is in compliance with the regulations. Overall arrangements for ensuring doctors are appraised to a standard that meets the requirements of the Responsible Officer Regulations and are revalidated in a timely manner are working effectively. In 2016/17, 92% of doctors with a prescribed connection to Somerset Partnership had a completed appraisal. A total of four revalidation recommendations were made to the GMC during the same period. An NHS England review of arrangements was completed in Actions designed to address the findings of the review are largely complete. Arrangements for ensuring doctors appointed to the Trust, including locums, are subject to appropriate checks have been strengthened but there is still significant room for improvement. Actions required by the Board: The Board is asked to discuss the report and approve the statement of compliance. July 2017 Public Board - 1 -

2 July 2017 Public Board - 2 -

3 SOMERSET PARTNERSHIP NHS FOUNDATION TRUST ANNUAL MEDICAL APPRAISAL AND REVALIDATION REPORT 2016/17 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 2016 March 2017) In 2016/17, 92% of doctors with a prescribed connection to Somerset Partnership had a completed appraisal. This maintains a good level of performance Revalidation recommendations to the GMC were all carried out in a timely manner. In total fours recommendations were made, all of which recommended revalidation. There were no requests for a deferral and no reports for non-engagement Information the Responsible Officer should have access to before doctors begin work with the Trust is not always recorded. Whilst this continues to be a concern effective action has been taken and performance is improving The result of an NHS England Independent Verification Visit is reported. No significant concerns were raised and action has been taken to address all the recommendations 2. PURPOSE 2.1. This is the seventh 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 Officer (RO) 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 2017 Public Board - 3 -

4 3. BACKGROUND 3.1. 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 system Provider organisations have a statutory duty to support their Responsible Officers in discharging their duties under the Responsible Officer 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. GOVERNANCE ARRANGEMENTS 4.1. The Board has appointed the Medical Director as RO. The RO 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 Revalidation Steering Group (MRSG) The MRSG is part of the Trust s Governance arrangements and reports to the Our Partnership governance group. More routine and regular management of appraisal is undertaken at two-monthly meetings between the Lead Medical Appraiser and the Medical Appraisal and Revalidation Coordinator, who report any issues back to the RO, as well as providing an update to the Medical Revalidation Steering Group. The RO and Medical Appraisal and Revalidation Coordinator also meet regularly about revalidation recommendations that are pending. July 2017 Public Board - 4 -

5 4.3. The Medical Appraisal Lead holds quarterly peer group meetings with the appraisal team, with an agenda that covers appraisal management and appraisal practice. Independent Verification Visit 4.4. In June 2016 NHS England undertook a review of the Trust s arrangements for Medical Appraisal and Revalidation. The review was led by the Associate Medical Director, Revalidation and Quality Lead, NHS England (South), with support from an NHSE Medical Director, a Designated Body Representative and a Regional Representative from NHSE (South) In advance of the verification visit the Trust provided a large quantity of information and completed an extensive self-assessment. The preparations were time consuming but were a valuable exercise in their own right The verification visit itself and the subsequent report were disappointing and frustrating in equal measure. The disappointment came not from criticism about the Trust s arrangements but from the fact very little was learnt as a consequence of the visit. The opportunity for medical appraisal and revalidation arrangements to be independently assessed had been welcomed and the prospect of expert insight into the effectiveness of these arrangements was keenly anticipated. Unfortunately the reality was that the feedback from the review did little more that reflect back what had been reported to the review team as part of the submission of information ahead of the review and the discussions that had taken place during the verification visit. Participants on the day of the review had been left with a sense that the review team considered arrangements to be affective but an equivocal judgement was lacking The structure and content of the report that followed the review added to the confusion. The report presented a number of facts as both good practice and an area for improvement. In addition some recommendation contradicted national guidance Following receipt of the draft report a series of discussions took place between the Somerset Partnership Medical Director and the lead for the review team. This led to a revised version of the report being received in August 2016 (Appendix A). An action plan was prepared and attached at Appendix B. 5. MEDICAL APPRAISAL 5.1. At 31 March 2017, 64 doctors had a prescribed connection to Somerset Partnership. Of this group, 59 (92%) had a completed appraisal during the appraisal year, compared with 98% (59 of 60) in 2015/16. Although July 2017 Public Board - 5 -

6 this represents an increase in the number of appraisals that did not take place, the reasons for this are understood and the number of appraisals that are categorised as 1a (the top category) increased from 52% in 2015/16 to 77% in 2016/ Two of the doctors who did not have an appraisal during 2016/17 were on long-term sickness absence and one was on maternity leave. One doctor had retired earlier in the year, returning part-time at the end of the appraisal year. This doctor needed more time to be able to collect enough supporting information to be appraised in their new post. One further doctor was from overseas and we were unable to determine the date of his last appraisal. He renewed his Licence to Practice with the GMC in His employment with us was on a part-time fixed-term basis where he regularly returned to his home county. It was therefore not possible to appraise him during the year All medical appraisals in 2016/17 were completed by the Trust appraisal team. The appraisal team comprises five Medical Appraisers plus a Medical Appraisal Lead. There has been a change of Medical Appraisal Lead Dr Reenee Barton took over this role in November Appraisers receive specialist training on joining the appraisal team and then regular top-up training The Appraisal Lead regularly attends Regional Appraisal Lead Network meetings. The Appraisal Team are also members of the Trust s Medical Appraiser Peer Group, which meets on a quarterly basis and which provides a platform of support and quality assurance for the appraisers. One appraiser stepped down during and three new appraisers were appointed. All new appraisers completed new appraiser training and have had an induction with the Lead Medical Appraiser. next appraisal year Each Appraiser carried out between 9 and 15 appraisals in 2016/17, which is in line with NHS England guidance of between 5 and 20 appraisals per year. All appraisals were carried out using the Allocate Software e-appraisal system An online appraisal feedback form 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. During the appraisal year 68% of doctors completed an appraisal feedback form for their appraiser An audit of completed appraisals reviewed 50% of appraisals carried out in 2016/17. The results of the audit are presented at Appendix D. The audit adopted a three point scoring system in accordance the NHS England Appraisal Summary and PDP Audit Tool (ASPAT): July 2017 Public Board - 6 -

7 0 = not satisfactory; 1 = needs improvement 2 = satisfactory. The majority of appraisals were assessed as satisfactory, with all appraisals sampled meeting the required standard for reviewing complaints and significant events Thirty-one cases were reviewed for the appraisal year with a random selection of appraisals completed by each appraiser chosen by the Revalidation Coordinator using a board approved audit tool. Following the audit a checklist for supporting information agreed by the Medical Revalidation Steering Group had been incorporated into the Medical Appraisal Policy and may have contributed to improvements in a number of areas: description of the full scope of the doctors work; completion of patient feedback; completion of colleague feedback; completion of appraiser statements for sign off to the RO; reviews of complaints and SIRIs On the downside the audit showed a reduction in CPD compliant with GMC guidance, although this may in part be a reflection of the standards used by the auditors to deem the appraisal documentation as satisfactory. Few doctors had included evidence of Peer Group membership and peer group sign-off of their PDP plan. The Royal College has some useful Peer Group templates for psychiatrists to use, including reflection templates which have now been incorporated into the Medical Appraisal Policy The appraisal policy has been extensively reviewed and updated to incorporate recent guidance from NHS England regarding the scheduling of appraisal dates and requesting postponements of appraisals. Recommendations from Sir Keith Pearson s report Taking Revalidation Forward (January 2017) intended to reduce bureaucracy and strike a better balance between reflection, development and compliance, have also been reflected in the policy More guidance has also been included on reflection, CPD, checklists for supporting information and the four domains of Good Medical Practice and how to demonstrate this in appraisal. A clearer differentiation between the purposes and function of Appraisal (Personal Development and Revalidation) versus Job Planning (Performance) has also been included. There is also more explicit guidance regarding the qualities July 2017 Public Board - 7 -

8 and standards expected of appraisers which has led to a more robust formal induction of new appraisers and 1:1 review meetings between each appraiser and the Lead Medical Appraiser The system for generating the Quality and Outcome Measures (QOM) reports has been further developed and the layout of the reports has been revised in order to make them more user-friendly. This now includes a traffic-light system for benchmarking, as well as more relevant data for the doctor s specialty. Doctors are now able to view and download their individual report online. 6. REVALIDATION RECOMMENDATIONS 6.1. Four 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 2016/17 can be found at Appendix E. 7. RECRUITMENT AND ENGAGEMENT BACKGROUND 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 G. Enduring problems with these checks have been reported in previous reports to the Board. In an effort to address these problems two new posts were established within the Medical Director s Office. These posts took over responsibility for collecting and recording pre-employment information and the process for booking locums staff from HR There is still much work to be done but the results show that the gaps in the information recorded are decreasing and plans are in place to develop those areas that need improvement (e.g. induction and exit reports). It should be noted that the audit only asks for information that was available within one month of the employee s start date in certain cases, especially regarding references from a previous RO, the information was available, but not within the time frame specified as the response time often exceeded one month. 8. MONITORING PERFORMANCE 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. July 2017 Public Board - 8 -

9 This information is provided to both the doctor and their appraiser and the results of the audit reported at Appendix D shows that it is discussed during appraisals Clinical governance arrangements have been strengthened by the appointment of Clinical Directors within each operational service directorate. 9. RESPONDING TO CONCERNS AND REMEDIATION 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 Concerns were raised about one Somerset Partnership doctor in 2016/17. More information is provided at Appendix F. 10. RISKS AND ISSUES The risk associated with failure to comply with medical appraisal and revalidation regulations is recorded within the Medical Directorate Risk Register. 11. LESSONS LEARNED The ability to undertake or record certain pre and post-employment checks in a timely manner continues to be a concern and is a focus for further development The quality of appraisal is improving but further scope for development is evident. 12. CORRECTIVE ACTIONS, IMPROVEMENT PLAN AND NEXT STEPS Complete any outstanding actions resulting from the independent varication visit Continue to develop systems for collecting and recording preemployment checks for permanent and temporary doctors Ensure results of language competency assessment is documented. July 2017 Public Board - 9 -

10 12.4. Provide an opportunity for the appraisers to reflect on their own performance and progress as an appraiser by Introducing annual appraisal review meetings between the Appraisal Lead and each member of the Appraisal Team Make completion of the online appraisal feedback form mandatory Provide a session on reflective practice for doctors in collaboration with the GMC. 13. RECOMMENDATION The Board is asked to receive the report, which will be shared with the higher level Responsible Officer at NHS England and to approve the statement of compliance confirming Somerset Partnership is complying with the Responsible Officer regulations (Appendix H). MEDICAL DIRECTOR July 2017 Public Board

11 Appendix A Higher Level Responsible Officer Quality Review Summary Date of Review: Wednesday 1 June 2016 Designated Body: Somerset Partnership NHS FT Designated Body: Somerset Partnership NHS Foundation Trust Review Team: Type/sector of Designated Body Community and Mental Health Vicky Banks, Associate Medical Director, Responsible Officer Dr Andrew Dayani Revalidation and Quality Lead, NHS Appraisal Lead Dr Sunil Ram England (South), Regional representative Anita Hamilton, Business Manager, Revalidation Manager Jeremy Smith Regional Representative, NHS England HR Lead Nick Macklin (South) Clinical Governance Lead Dr Andrew Dayani Karen Matthews-Shard, Group Clinical Patient Safety Lead Paul Milverton Director, Independent Clinical Services, Patient Experience Lead Lucy Nicholls Designated Body Representative Revalidation Administrator Claire Bennett Caroline Gamlin, Medical Director, NHS England South (South West), Local Office Representative Summary: The county of Somerset is situated in South-West England, bordering Bristol and Gloucestershire to the north, Devon to the South and West, Dorset to the south-east and Wiltshire to the east. The county is rural in nature and geographically wide-spread. It is home to around 530,000 citizens and its main towns include Taunton, Yeovil and Bridgwater. Somerset Partnership manages and provides Community and Mental Health services to the people of Somerset, which includes 13 Community Hospitals, 8 mental health inpatient wards, and numerous county-wide community-based physical and mental health services. It is the largest employer in the county, with around 4000 members of staff. The Trust s Medical Directorate employs around 60 doctors in the fields of Psychiatry, Palliative Medicine, Community Hospital medical services and Sexual Health services. These doctors have a prescribed connection to Somerset Partnership and Dr Andrew Dayani, the Trust Medical Director, is their Responsible July 2017 Public Board

12 Officer for appraisal and revalidation purposes. The Trust also contracts GP practices to provide medical services to several of the community hospitals, although these doctors do not have a prescribed connection to SomPar. The Trust s Medical Appraisal team consists of a Medical Appraisal Lead and five Medical Appraisers. They are supported administratively by the Head of Medical Services and the Directorate s two Personal Assistants. Our appraisal rates are generally positive: all appraisals (62) were undertaken and signed off during the 2015/16 appraisal year, except for one, due to long-term sickness absence. The Trust also performed well during 2014/15, with the completed appraisal percentage a little higher than the national average. The RO made a total of 20 revalidation recommendations to the General Medical Council (GMC) during 2015/16. All 20 were on time and made a positive recommendation to the GMC to revalidate the doctor. There were no requests for deferral. An annual report on Medical Appraisal and Revalidation was submitted to the Trust Board in July The Board subsequently made the required declaration of compliance to NHS England by the deadline of August Self-assessment has continued to be an important part of the management and development of medical appraisal and revalidation. An Annual Organisational Audit was completed in May The CQC assessed the Trust in September The report concluded that the Trust needs improvement, although this related mainly to the areas of Learning Disabilities and District Nursing, and there were no issues raised with the Trust s appraisal and revalidation processes. The main challenges facing the Medical Directorate are related to staffing, due to several retirements in the past year and a general shortage of applicants for vacant posts, leading to a reliance on locums. The restructuring of the Human Resources department has also led to a lack of HR personnel with medical staffing expertise, and HR engagement with and support for the Directorate has been largely lacking over the past year. The Trust has recently undergone a significant staff restructure, but we are positively looking to the future under the leadership of a new Chief Executive. On the day of the review meetings were held with: Andrew Dayani, MD/RO Sunil Ram, Clinical Appraisal Lead Revalidation Manager, Jeremy Smith Revalidation Administrator, Claire Bennett Lucy Nicholls, patient experience Lead Nick Macklin, HR/Medical Staffing Drop in sessions 3 Doctors and 2 Appraisers July 2017 Public Board

13 Examples of good practice Areas for development Resources that may be helpful The Designated Body and Responsible Officer There has been significant change within the Directorate with two Associate Medical Directors stepping down from their roles. With recent staff restructuring this has led to an increased workload for the Medical Management Team. There are plans to introduce Divisional Clinical Directors, but this many take a few months before implemented. As part of the new Clinical Director Model two years ago, the HAY Group were appointed to facilitate organisational change through including the new clinical director model. Vocare covers out of hours for the Community Hospitals with meetings every 3 or 6 months. For Drs working in hours regular contract/performance review meetings are held with visits to the Community Hospitals to meet the teams. Four of the hospitals have directly employed Drs who the MD/RO line manages. Friday afternoons the MD/RO goes out on the wards giving welcomed visibility. Ensuring new business partnerships (HR partner/clinical director/service manager) will evolve as the medical leadership structure comes to fruition, this should lessen the load on the MD/RO and provide clear leadership, line management and governance within division. This needs to take place. The new Clinical Leadership Structure will also assist/support the MD/RO and Revalidation processes and include a RO advisory group. Ensure the new structures are in place to take forward and support medical engagement, strengthening clinically led governance. External organisation leading a piece of work on medical engagement, starting in July 2016 with an 18 month plan that will result in ground up clinical led governance. The GP practices are more complex to manage but have moved to a contracting model whereby contracting with one organisation. There have been a couple of incidents which have been managed with the GPs and there is an assumption Suggested challenging questions for the Board: Challenging Questions for Boards. If responses to requests for information are not forthcoming from other ROs the regional team are available to help. July 2017 Public Board

14 Examples of good practice Areas for development Resources that may be helpful Appraisal this will be discussed at their appraisal. Ensure processes are in place to ensure this happens which may be through the use of the local office structured reference (see later in summary). The Trust has moved to an electronic platform for Appraisal and Revalidation. The Revalidation Administrator works closely with the Clinical Appraisal Lead using the Zircadian system. A traffic light system of red, amber and green is used which shows quantity for appraisal and the MD/RO checks quality. The system can request feedback which is currently sought from the appraisees, but not the appraisers. Revalidation recommendations take around minutes and checks have been put into place to ensure GMC information is accessed. The Medical Appraisal Lead was supported by 4 appraisers in with refresher training provided in February Whilst the number of appraisers are small, around 5/6, there are more allocated and there is hope that an SAS Dr will join. The Clinical Appraisal lead organises Steering Group Meetings and Appraiser Peer Group Meetings every 3 months. MIAD provide the training and updates. To look at appointing more appraisers. Appraisal Logistics Handbook link to website: Quality Assurance of medical appraisal: guidance notes: raisers/qa-guidance-notes/. Appraisal QA Tools - ASPAT, Progress & Excellence: _MAPS A1 PROGRESS QA App1_ASPAT form dratemplate Sept 2012.d Excellence QA tool Oct 2013 v2.doc Link to Appraiser Training and Support: July 2017 Public Board

15 Examples of good practice Areas for development Resources that may be helpful The Revalidation Support Group reviews performance during the year with appraisals completed, those to be carried out, and also the revalidations that are due. Following 2 years of development, Quality and Outcome Measure reports have been produced from RIO. The next stage is the introduction of a portal so Drs can access their own. Training was originally provided on the report as it is a basis for conversation not a judgement on individuals, ie, not used for performance management. Build on the very positive approach to presenting Drs with outcome data etc. In mental health this is more challenging but gives Drs an opportunity to reflect on their own and team s practice. Consider: a) a more user friendly version of the data summary, b) this is an opportunity to involve Drs in medical engagement with the divisional business partnership model and c) extra training and/or support when and where required. Provide more training and communication on the Quality and Outcome Measure reports. Develop a more user friendly version of the data summary. ers/app-train-sup/ Examples of good appraisal Primary care: Summary of 3. Summary of the appraisal discussion - appraisal discussion - Examples of good appraisal Secondary care & leadership roles: Summary of RO appraisal appraisal discussion - summary example (go Link to appraiser skills videos cal appraisal skills video workshops QwMACXkj1zbMA27JZs9SgPXOuwgPWm Below are a couple of examples capturing a range of governance data including performance/activity data, which may be useful: July 2017 Public Board

16 Examples of good practice Areas for development Resources that may be helpful Consultant Data Pack - Urology.pdf Consultant Data Pack - Respiratory Me QSA Jabb De-Hutt ( ) Jun 2016.p Appraisal Text.docx A guidance document on inputs to appraisal: raisers/improving-the-inputs-to-medicalappraisal/ GMC Case Studies on collecting patient feedback: k.asp Monitoring Performance and Responding to Concerns The MD/RO usually discusses any concerns with his contact at the GMC Liaison, Paul Jones. There are quarterly meetings combined with the RO Joint Appraisal Days a good opportunity to peer review and benchmark. If the matters are about noncompliance with appraisal they would go to RSG, but if more complex it may go to the GMC as to whether a deferral/referral. If matters progress to a Strengthen the team of investigators and develop support for new investigators. Liaise with regional team, AMD (Vicky Banks) to explore opportunities for support and development across organisations. Risk assessment for establishing levels of concerns: Establishing Levels of concerns.pdf July 2017 Public Board

17 Examples of good practice Areas for development Resources that may be helpful disciplinary, a non-executive, lay member and HR are involved. Managing Concerns goes through a separate group appointed as necessary and has only been used once in the last 3/4 years. Complaints and incidents all medical Datix currently go to the MD/RO to review and only a few of those need to be progressed. The issues are kept on word/excel with soft data on personnel files. There are quality outcome measures as well for benchmarking and to aid discussions. A Case Investigator is shared across AWP and Devon Partnership. There is a SUI and Mortality Review Group which is very positive as the Trust co-ordinates the multiagency safe guarding hub based at the HQ at the local Police station which co-ordinates social, health and Police responses. Information is fed up and disseminated down for consistency and any required resources. The Trust employs a number of doctors connected to the performers list. Aiming to appoint five to six Medical Clinical Directors for across the division and then they provide the first tier of investigating staff complaints. Refresher training available for Case Investigators and this can be discussed with the Regional Revalidation Team. Each division will have a triumvirate which will be the basic structure for governance and SUIs and complaints and will be managed locally with their own Governance Board. Put in place robust structure and processes to ensure consistency across divisions. Use the Local Office structured reference in line with the information flows paper. fo-flows/ A proforma has been developed by the local office to support this function: July 2017 Public Board

18 Examples of good practice Areas for development Resources that may be helpful Recruitment and Engagement Recent appointment of a new HR Director, recognising the paucity of medical HR expertise, is leading a move towards a more integrated knowledgeable workforce. The HR director has commissioned additional resource from an HR Business Partner to review medical staff and the processes and put in place some actions and earning to take forward across the wider teams. Work is underway with Taunton and Somerset NHS FT (Musgrove) to share HR Business Advisers. Current reporting of concerns of locum agencies is under review. Currently a traditional consultant panel is used for recruiting non-locums but looking to moving towards an assessment centre. The amount of work has on job planning has been limited but the new roles will co-ordinate job planning so effectively job planning and the appraisal will be linked. Other - Public and Patient Involvement etc The MD/RO is involved with the Leading Together Programme (LTP) now undertaking 2 projects as his partner on the LTP is involved in Learning The processes will be reviewed and taken forward by the Business Partners. Continue to develop mental HR expertise and build on this relationship to strengthen medical HR processes. Strengthen and consider formalising links and processes with Taunton and Somerset which are already in place. Put in place template documentation to support the existing reporting mechanisms for feedback. Ensure successful new consultant appointments through performance management with a six month probationary period. There is a real opportunity to involve the Patient Experience Lead with the LTP which could develop and embrace live Structured reference for GP's in other roles Link to NHS Employment Check Standards: Suggested opportunities for involving patients & public: July 2017 Public Board

19 Examples of good practice Areas for development Resources that may be helpful Disabilities. Secretaries disseminate the forms for patient feedback which are loaded onto Zircadian. A variety of colleagues are sought for individual feedback and the list is approved. Public Engagement sits within corporate governance and works with the MD/RO and Director of Nursing. Friends and Family (F&F) is available in every service and is asked of every patient at different parts of their pathway depending on appropriateness. F&F Trust Level Summary report goes to clinical governance groups and issues are discussed. Information from PALS (Patient Advice and Liaison Service), complaints, Healthwatch and any ad hoc reports/surveys goes to the PPI Group. The PPI provides a lay person s viewpoint. The PALs has 2 members of staff based in Bridgwater who will work in the patch and speak to patients on wards providing reassurance and signposting. Monthly Have Your Say meetings are held on wards. In order to gain feedback from out of hours Vocare all the complaints managers meet on a quarterly basis having signed up to a joint protocol for handling complaints. During June there is an event for 46 Drs for training on Equality and Diversity. patient feedback, for example, using an ipad. Good examples of this are found in North Devon Healthcare Trust (Stuart Kyle, Appraisal and Revalidation Lead, stuartkyle@nhs.net) Circulate the Healthwatch leaflet to encourage patients to provide feedback. Vicky Banks discussed the postcard system that is used for patients at the Royal Devon & Exeter NHS FT which could be another method employed. Opportunities for Patient and Public Eng Leaflets - information for patients Hapia & GMC: Revalidation_Leaflet- AUGUST MI GMC Patient feedback.pdf July 2017 Public Board

20 July 2017 Public Board

21 ACTION PLAN TEMPLATE Appendix B Higher Level Responsible Officer Quality Review (HLROQR) This template is provided for documenting actions if desired. Designated Body: Responsible Officer: Area for development identified at HLROQR Somerset Partnership NHS Foundation Trust Dr Andrew Dayani Date of HLROQR: 1 June 2016 Action Responsibility Timescale Strengthen Medical Management Team following loss of two AMDs and staff restructuring within HR department. The Medical Directorate has introduced Clinical Directors for each of the five Trust Divisions. Andrew Dayani / Jeremy Smith October 2016 Complete Assess the level of Medical Engagement within the Trust. Doctors and managers to undertake the (Warwick) Medical Engagement Scale survey,. Andrew Dayani / Claire Bennett December 2016 Complete Clinical Governance for GPs providing medical services to our community hospitals Concerns about GPs working in community hospitals are identified through Trust clinical governance Claire Bennett 31 December 2016 Complete July 2017 Public Board

22 ensure that information on any incident that involves a GP who is not a Trust employee but who is working within Trust services, is communicated to the local office s RO. arrangements. Where required these are raised directly with the contractor by the Medical Director or Clinical Director responsible for the community hospital where concerns have been raised. If appropriate an RO to RO information transfer will also take place. Aim to appoint more appraisers. Review the number of appraisers within the appraisal team and ensure the number of appraisals completed remains within the range recommended by NHSE. Employ additional appraisers as necessary to meet all the requirements set out within the Medical Appraisal Policy. Dr Reenee Barton, Trust Medical Lead Appraiser December 2016 Complete- Additional appraisers appointed from April Make the Quality and Outcome Measures (QOM) report and other appraisal data supplied to doctors more useable. Work with IT to ensure the QOM reports are more user-friendly and develop a template for providing the other information. Chris Mortimore / Dan Arrigoni / David Nation / Claire Bennett 31 March 2017 Complete Strengthen the Trust s team of investigators. We believe the current arrangements for investigating concerns are adequate. The Trust N/A N/A July 2017 Public Board

23 investigator has spare capacity which is shared with other Trusts. Review current reporting of concerns of locum agencies. Ensure successful new consultants appointed are performance managed with a six month probationary period. Conduct a review of the arrangements for booking medical locums. Review to include ensuring locum bookings are employed for capped rates, appropriate pre-employment checks are completed and concerns are communicated back to the agency. The Trust does not employ staff on probationary periods. Existing policies and procedures are used to address concerns about conduct or performance at any July 2017 Public Board Jonathan Shoebridge, Medical Staffing Lead N/A 31 March 2017 Complete. The lack of capacity with HR to support the management of locums has led to the appointment of a Medical Staffing Coordinator within the Medical Directorate, who has established more effective systems for The arrangements for booking locums have recently been subject to an audit by NHS Counter Fraud. The Medical Appraisal and Revalidation Coordinator has established new systems for collecting preemployment information about locums. N/A

24 stage of a doctor s employment with the Trust. Involve the Patient Experience Lead with the LTP, which could develop and embrace live patient feedback, for example, using an ipad. Review arrangements for obtaining patient feedback. Reenee Barton (Trust Medical Lead Appraiser) / Lucy Nicholls (Patient Experience Manager) 31 March 2017 On going Wider patient feedback mechanisms are under review as part of a national Patient Experience Collaborative. I confirm that the action plan above has been discussed and agreed with my Board or equivalent Responsible officer - Signature & Date July 2017 Public Board

25 Audit of all missed or incomplete appraisals Appendix C Doctor factors (total) 5 Maternity leave during the majority of the appraisal due window 1 Sickness absence during the majority of the appraisal due window 2 Prolonged leave during the majority of the appraisal due window 0 Suspension during the majority of the appraisal due window 0 New starter within 3 month of appraisal due date 0 New starter more than 3 months from appraisal due date 1 Postponed due to incomplete portfolio/insufficient supporting information 0 Appraisal outputs not signed off by doctor within 28 days 0 Lack of time of doctor 0 Lack of engagement of doctor 0 Other doctor factors (describe) Doctor retired shortly before appraisal due date, then returned to work at end of appraisal year. 1 Appraiser factors 0 Unplanned absence of appraiser 0 Appraisal outputs not signed off by appraiser within 28 days 0 Lack of time of appraiser 0 Other appraiser factors (describe) 0 Organisational factors 0 Administration or management factors 0 Failure of electronic information systems 0 Insufficient numbers of trained appraisers 0 Other organisational factors (describe) 0 July 2017 Public Board

26 July 2017 Public Board

27 Appendix D Quality assurance audit of appraisal inputs and outputs Total number of appraisals completed 59 Appraisal inputs Scope of work: Has a full scope of practice been described? Continuing Professional Development (CPD): Is CPD compliant with GMC requirements? Quality improvement activity: Is quality improvement activity compliant with GMC requirements? Patient feedback exercise: Has a patient feedback exercise been completed? Colleague feedback exercise: Has a colleague feedback exercise been completed? Number of appraisal portfolios sampled (to demonstrate adequate sample size) Number of the sampled appraisal portfolios deemed to be acceptable against standards (3 needed improvement) (12 needed improvement) (12 needed improvement; 1 not satisfactory) (7 needed improvement; 2 not satisfactory) (7 needed improvement) Review of complaints: Have all complaints been included? (1 needed improvement) 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 5)? Have all types of supporting information been included? (1 needed improvement) (13 needed improvement; 1 not satisfactory) (13 needed improvement; 1 not satisfactory) July 2017 Public Board

28 Appraisal Outputs Appraisal Summary (8 needed improvement) Appraiser Statements (5 needed improvement) PDP (3 needed improvement) July 2017 Public Board

29 Audit of revalidation recommendations Appendix E Revalidation recommendations between 1 April 2015 to 31 March 2016 Recommendations completed on time (within the GMC recommendation window) Late recommendations (completed, but after the GMC recommendation window closed) 4 0 Missed recommendations (not completed) 0 TOTAL 4 Primary reason for all late/missed recommendations For any late or missed recommendations only one primary reason must be identified No responsible officer in post 0 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 0 0 Unaware the doctor had a prescribed connection 0 Unaware of the doctor s revalidation due date 0 Administrative error 0 Responsible officer error 0 Inadequate resources or support for the responsible officer role 0 Other 0 Describe other TOTAL [sum of (late) + (missed)] 0 July 2017 Public Board

30 July 2017 Public Board

31 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 record 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 High level Medium level Low level Health concerns (as the primary category) in the last 12 months Remediation/Reskilling/Retraining/Rehabilitation Numbers of doctors with whom the designated body has a prescribed connection as at 31 March 2016 who have undergone formal remediation between 1 April 2015 and 31 March 2016 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 0 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 0 locums who are directly employed, trust doctors, locums for service, clinical research fellows, trainees not on national training schemes, doctors with fixedterm employment contracts, etc.) All Designated Bodies. Other (including all responsible officers, and doctors registered with a locum 1 July 2017 Public Board Appendix F Total

32 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. TOTALS 1 Other 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 2015 and 31 March 2016 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 0 National Clinical Assessment Service actions: 0 Number of doctors about whom the National Clinical Advisory Service (NCAS) 0 has been contacted between 1 April and 31 March for advice or for assessment Number of NCAS assessments performed 0 1 Locum doctor, whose contract was terminated early July 2017 Public Board

33 Audit of recruitment and engagement background checks Appendix G Number of new doctors (including all new prescribed connections) who have commenced in last 12 months (including where appropriate locum doctors) Permanent employed doctors 6 Temporary employed doctors 4 Locums brought in to the designated body through a locum agency 36 Locums brought in to the designated body through Staff Bank arrangements 1 Doctors on Performers Lists 0 Other 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 TOTAL 47 For how many of these doctors was the following information available within 1 month of the doctor s starting date (numbers) 0 Total Identity check Past GMC issues GMC conditions or undertakings On-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 Permanent employed doctors Language competency is assessed during interview but has not been formally documented. July 2017 Public Board

34 Temporary employed doctors 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 Other (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 Consultant: Overall number SAS doctors: Overall Trainees (all grades): Overall Total Overall number of locum July 2017 Public Board

35 approved WTE headcount) of locum days used number of locum days used number of locum days used Surgery Medicine Psychiatry Obstetrics/Gynaecology Accident and Emergency Anaesthetics Radiology Pathology Other 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) days used Concerns reported to agency or responsible officer (number) 2 days or less 0 0 No record No record No record 3 days to one week No record No record No record 1 week to 1 month No record No record No record 1-3 months 8 7 No record No record No record 3-6 months 8 7 No record No record No record July 2017 Public Board