Presentation Title

36pt Arial Bold

Sub heading 24pt Arial

A Framework of Quality Assurance for

Responsible Officers and Revalidation

Annual Board Report,

Surrey and Sussex Healthcare NHS Trust

August 31st 2017

Mr Adam Stacey-Clear

Responsible Officer for Revalidation

Executive Summary

• This report Follows the NHS England template as outlined in the

Framework for Quality Assurance and is an annual requirement for all

designated bodies.

• The annual Organisation Audit findings for Surrey and Sussex

Healthcare NHS Trust will be presented

• 353 doctors with a GMC connection to The Trust were included in the

audit, April 1st 2016-March 31st 2017

• A statement of compliance confirming compliance with The Medical

Profession (Responsible Officers) regulations 2010 needs to be signed

by either the CEO or Chairman following this report.

Governance Arrangements

• Surrey and Sussex Healthcare NHS Trust (SASH) has a Medical

Appraisal Policy on the Trust website which is available for all doctors

to read

• The Responsible Officer is Adam Stacey-Clear who regularly attends

network RO meetings on a regular basis throughout the year. The RO

and Medical director Des Holden also attend quarterly meetings with

the GMC Liaison Officer, Michael Cotton.

• The human resources dept. maintains a list of employed doctors at the

Trust.

• All completed appraisal forms are read by AS-C.

Access, Security and Confidentiality

• All appraisals are stored in a secure folder on the G drive

• No patient identifiable data is stored in any appraisal folders

• No information management breaches.

• The GMC have provided ASC with a secure link which lists all doctors

with a prescribed connection to the Trust (designated body).

• The list is regularly updated.

• Transfer of information between designated bodies.

Slide 4

Conduct and Performance

• All Trust doctors are subject to the organizational policies e.g. capability

and disciplinary in line with Maintaining High Professional Standards

best practice. The Trust recognizes the BMA code of conduct.

• The Trust reviews doctors performance in the yearly job plan,

supported by the annual appraisal process for all medical and dental

staff. Linking job planning with appraisal is currently being developed

as part of a new Trust strategy.

• The clinical effectiveness strategy supports Medical and Dental staff in

their practice by ensuring evidence is practice based and clinically

effective.

• The complaints procedure is Trust policy. This is part of doctor’s

feedback and concerns are raised at job planning stage to enable

improvement in doctor’s practice and patient care.

Slide 5

Pre-employment background checks

• Medical staffing check qualifications against persons specifications for

the post. DBS (formerly a CRB)

• Photographic ID

• Visa or Biometric card as proof of the right to work in the UK

• 2 proofs of address

• GMC registration check

• Must be on specialist register- substantive consultants

• 2 references

• Occupational health check

Locums employed through medacs

Slide 6

Responding to Concerns

• The Trust responds to concerns in respect of a doctor’s practice by

supporting them with regular and ongoing development opportunities.

• Fitness to practice concerns from The GMC about a doctor are dealt

with following the GMC guidelines.

• The Trust has an active whistleblowing (raising concerns) policy

Slide 7

Risks and Issues

• Medical Practice Information Transfer Form for new/visiting doctors

whose current designated body is not SASH.

• Appraisals in March- cohort of doctors have now been moved to earlier

in the year to offset the March crush.

• Appraisal policy changes to incorporate sanctions imposed for late

appraisals.

• All doctors will be sent a link to the new appraisal policy when

reminders are sent out

• The RO regulations are adhered to as strictly as possible, and the

annual appraiser update meetings enhance this.

Slide 8

Appraisals – Why?

• Revalidation demonstrates that a Doctor is up to date and fit to

practice through Appraisal and Clinical Governance

• This leads to improved Safety and Quality in Healthcare

• Fit for Practice – minimum standards as per GMC guidelines

• Fit for Purpose – above and beyond requirement for GMC –

able to undertake the roles for which they are employed

Hawk

Dove

Pen

Sword

Example

Precept

Horses Courses

Less

More

Moss

Rolling Stone

Appraisal Objectives

•Covering total scope of practice in terms of evidence seen •Documenting review of last year's personal development plans & recording origin of newly identified PDP items •Objective exploration of quality improvement activity •Recording that reflection has occurred & learning shared •Stage of revalidation and any outstanding requirement

•Speciality guidance followed & mandatory training recorded

Appraisers

• 44 trained appraisers in faculty of appraisers.

• Rather unequal distribution of appraisals from those who responded to request for

number of appraisals carried out.

• Appraisal year runs from April 1st to March 31st.

• Recent guidelines from NHS England recommend new appraisal categories:

Slide 12

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Number

Number

Number of appraisals carried out by Dr – April 2016: March 2017

NHS England appraisal guidelines

Medical Appraisal

• 353 doctors were included in this audit, 178 consultants and 175

associate specialists/Trust doctors/staff grade.

• 166 consultants completed an annual appraisal between 1/4/2016 and

31/3/2017.

• 7 late consultant appraisals were approved, 5 were not

• 165 associate specialists/Trust doctors completed an appraisal.

• 8 late SAS appraisals were approved, 2 were not.

• Audit sheet for late appraisals is maintained.

• Late appraisals default to the original due date the next year

Slide 15

Slide 16

2016/17 AOA indicator

SECTION 2: Appraisal

Your

organisation’s

response

Same sector:

DBs in sector: 54

All sectors:

Total DBs: 821

No. of doctors

(in organisation)

Total no. of doctors

(in SAME sector)

Total no. of doctors

(across ALL sectors)

Consultants 178 15381 50102

Staff grade, associate

specialist, specialty doctor

175 4084 11974

Slide 17

Completed appraisals (Measure 1a & 1b)

Your

organisation’s

response and (%)

calculated

appraisal rate

Same sector

appraisal rate

ALL sectors

appraisal rate

166 (93.3%) 93.6% 91.7%

165 (94.3%) 87.5% 87.0%

Slide 18

Approved incomplete or missed appraisal (Measure 2)

Your

organisation’s response

and (%) calculated

appraisal rate

Same sector

appraisal rate

ALL sectors

appraisal rate

7 (3.9%) 3.5% 4.7%

8 (4.6%) 6.6% 7.4%

Slide 19

Unapproved incomplete or missed appraisal (Measure 3)

Your organisation’s

response and (%)

calculated appraisal

rate

Same sector

appraisal rate

ALL sectors

appraisal rate

5 (2.8%) 2.9% 3.5%

2 (1.1%) 5.9% 5.6%

Recommendations submitted to GMC

• 22 revalidation recommendations made.

• 4 deferrals

• 18 positive recommendations

• Deferrals mainly due to lack of supporting information

• 108 doctors left the Trust

• 45 doctors were correctly connected to the Trust.

• 6 doctors were in training posts (and therefore not AS-C’s

responsibility) but had told the GMC that we were their DB.

• 7 doctors were found to be GPs

• 1 doctor died

• 49 doctors told GMC they were here but we could not get information

from them

Slide 20

Slide 21

Late appraisals without prior permission

Dr Michael Wilde Dr Matthew Cowan Dr Helena Wright Dr Rahi Yallapragada Dr Usha Limbu Miss Jean Arikosamy Dr Domo Kiss

WHAT’S GONE WELL

• New form for Locums with scope for feedback

• Attachment of Achievement Reviews to Appraisals

• Embedding Trust Values and Behaviours into Appraisal

• Reasonable good appraisal rates obtained

• Majority of doctors respond to e-mails confirming dates of booked-

in appraisals

• Updated e-mails in relation to reminders / new doctors / 360◦s

• New doctors acceptance letter includes requests to give Jenny

Cawthorne details of current RO and DB

• Good relations with St Catherine’s Hospice

Slide 23

WHAT’S NOT GONE WELL

• Doctors do not always respond to their SaSH e.mails so now including a “read

receipt” on their reminders

• Uneven response rate to feedback survey following an appraisal

• Doctors seem unaware that they have to update their own GMC details

• Some doctors not happy that appraisals moved from March to earlier date

• Public / Patient Involvement

• Repeat offenders

• Appraisal date drift

• Mood of reduced engagement and constant chasing required

• Some summaries not adequate

• Uneven distribution of appraisals

• Date of appraisal

Slide 24

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