KSS General Practice Programme Local Faculty Group Annual Audit and Review

To be used for:

  • LFG Annual Audit and Review to LAB
  • Report to GP Specialty School

To use this form to create & update your LFG record: go to page 13 - ‘Completing this form’

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LEP Name
Associate GP Dean
GP Programme Directors
MEM(s)
LFG Administrator(s)

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Local Faculty Group (Please list place of meetings)

LFG meeting 1 / LFG meeting 2 / LFG Meeting 3
Attendees / Dates of each meeting
1. / 2. / 3.
Please tick box if person attended meeting
GP Associate Dean or Deputy(Chair)
Specialty Local Programme Administrator
Educational Supervisors teaching on the programme (insert no.)
Postgraduate Doctors representatives from each year
of Specialty
Medical Staffing
Library Services
Careers
GP Programme Directors as appropriate
GP Trainers (Please list by name)*
Clinical Supervisors of GP trainees (please list by name and Specialty)*
Other appropriate work and Specialty areas

*Extend boxes as required

Educational Network

Number of Accredited GP Trainers
Number of FY2 Clinical Supervisors
Number of FY2 Community Educational Supervisors trained
Number of Trainers now left the programme
Number of Trainer Overlaps

Summary of Trainees

See attached spreadsheet

Domain 1 Patient Safety
The Handbook must provide a clear statement, which immediately addresses any concern about patient safety arising from the training of doctors, and the roles and responsibilities of teachers, Postgraduate Doctors and the LFG.
Areas you may wish to comment on:
handover arrangements, ensuring continuity of patient care at the start and end of periods of day or night duties (1.6);
guidelines on taking consent (1.4);
GMC ethical requirements and the Postgraduate Doctors’ understanding of this.
Notable practice
Areas of concern with time-bound targets for action with named responsibility
Areas of improvement since last report

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Domain 2 Quality management review and evaluation
The curriculum and timetable must take appropriate account of working hours including EWTR (2.1) and issues such as avoiding sleep deprivation and providing an appropriate intensity of work in relation to learning.
Areas you may wish to comment on:
The curriculum and timetable;
The European Working Time Directive and rotas;
curriculum evaluation.
Notable practice
Areas of concern with time-bound targets for action with named responsibility
Areas of improvement since last report
Describe any cause for concern last year that has now improved? If none, please write ‘None’

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Domain 3 Equality, diversity and opportunity
All Postgraduate Doctors must have access to information about their employer’s policy and procedures for Equal Opportunities and Diversity (3.1, 3.2).
Additional support must be provided for Postgraduate Doctors identified as vulnerable
and all those who have additional needs in line with the KSS Trainees in Difficulty Guidelines. Those trainees with particular identified needs must have access to independent counselling services and Occupational Health Services as needed (3.4).
In line with the Disability Discrimination Act, it is the LEP’s responsibility to make reasonable adjustments to programmes for Postgraduate Doctors with disabilities in consultation with Foundation programme leads (3.1).
Areas you may wish to comment on:
support for Postgraduate Doctors identified as vulnerable
and any with additional needs;
any adjustments to programmes for Postgraduate Doctors with disabilities;
any other equality and diversity issues.
Notable practice
Areas of concern with time-bound targets for action with named responsibility
Areas of improvement since last report

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Domain 4 recruitment, selection and appointment
The LFG must have an accessible and transparent recruitment policy which outlines requirements for fairness, objectivity and equality of opportunity in selection procedures (4.3).
In consultation with the DME, the LFG Lead must take responsibility for ensuring an appropriate level of recruitment support is provided by the Trust to the KSS recruitment process proportionate to the number of Postgraduate Doctors in training.
Areas you may wish to comment on:
appeals;
recruitment support provided by trust staff to the Deanery;
Notable practice
Areas of concern with time-bound targets for action with named responsibility
Areas of improvement since last report

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Domain 5 Delivery of approved curriculum including assessment
The local curriculum must be appropriate for the National GP programme curriculum framework and must enable Postgraduate Doctors to achieve the competences and professionalism required for them adequately to fulfil their present roles and future career intentions.
Areas you may wish to comment on:
the GP programme handbook and responses to it;
the range of educational and clinical activities as set out in the curriculum;
access to training days, courses, resources and other learning opportunities that form an intrinsic part of the training programme;
the approved assessment system;
changes in regulations and requirements in the reporting year.
Notable practice
Areas of concern with time-bound targets for action with named responsibility
Areas of improvement since last report

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Domain 6 Support and development of trainees, trainers and local faculty
Policies and procedures for induction to LEPs, departments and clinical teams. There must be an Education Supervisor for each trainee and a named Clinical Supervisor for each point of their training. Supervisors must have sufficient time to carry out their duties and access to support and training. Postgraduate doctors have an entitlement to regular, ongoing educational supervision, including an agreed minimum allocation of time for educational supervision meetings and a timetable for clinical supervision meetings. All LFGs must adhere to the KSS Trainees in Difficulty Policy and be able to demonstrate how this works in practice. LFGs must implement and monitor policies and incidents of grievance and discipline, bullying and harassment. Postgraduate doctors must have academic and study leave opportunities, and the opportunity to learn from and with other healthcare professionals.
Areas you may wish to comment on:
induction;
educational and clinical supervision including supervisor moderation, appraisal training and support;
bullying and harassment and grievance and disciplinary issues (which should be generic and preserve anonymity);
the provision of timetabled, organised educational meetings, including training in generic professional skills;
opportunities to learn with, and from, other healthcare professionals;
study leave and academic opportunities;
Notable practice
Areas of concern with time-bound targets for action with named responsibility
Areas of improvement since last report

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Domain 7 Management of education and training
To publish and make clearthrough transparent processes who is responsible for each element and at each stage of the training programme;
to manage processes for identifying, supporting and managing Trainees in Difficulty (7.3).
Areas you may wish to comment on:
The responsibilities of all Trust and hospital staff involved in the GP programme;
TiD and the TiD policy.
Notable practice
Areas of concern with time-bound targets for action with named responsibility
Areas of improvement since last report

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Domain 8 Educational resources and capacity
There must be sufficient resources to provide the opportunity for all postgraduate doctors to achieve the educational outcomes specified in the curriculum and to receive full teaching. LFGs must establish effective mechanisms to provide high-quality career advice, guidance, support and referral for postgraduate doctors.
Areas you may wish to comment on:
the availability of resources;
the appropriateness of educational facilities;
the work of the careers lead and the effectiveness of careers advice, support and guidance.
Notable practice
Areas of concern with time-bound targets for action with named responsibility
Areas of improvement since last report

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Domain 9 Outcomes
Postgraduate Doctors must have access to an analysis of outcomes of assessments, benchmarked against other programmes (9.1).
Areas you may wish to comment on:
an analysis of outcomes of assessments;
comparators and benchmarks derived from other GP programmes.
Notable practice
Areas of concern with time-bound targets for action with named responsibility
Areas of improvement since last report
Comment on any difficulties in securing full membership here:
Comment here on any issues relating to the LFG procedural regulations; difficulties, steps taken to resolve them:
Confirm that trainees are represented on LFGs and LAB. Describe and comment on their induction. Monitor attendance at the KSS Deanery Postgraduate Doctors Representatives Workshops
Signed by Local Faculty Lead
Date signed

LFG/ LAB Report Form

Overview

The overall lay-out of this form must remain unchanged as it is the standard record used by all specialities/ LFGs to submit their annual report to the Deanery. However, the“one cap fits all” approach can makeit difficult to understand what each section is looking for. Previous forms were much more GP specific and clearer to use.
The next several pages of this form are a duplicate version where the wording has been changed to make it more clear what each section is looking for:
- includes an overall comment on how much detail each section requires.
- includes some suggestions on where to find information
- includes some suggestions on the type of answer that is required

Your entries in this next part of the form are automatically copied into the standard Deanery version above.

Completing the Form

The nine sections that follow should be updated 3-4 times during the year – after each LFG, after the PMETB survey is published, after an inspection visit.The first pass will probably take 45-60 minutes. Each subsequent update should take much less time.

This process will be much easier if you set the agenda items in your LFG meetings to match the 9 GMC domains.

The document is locked and this should restrict you to entering replies only in the grey boxes

Please use <TAB> to move from one box to the next (above <Caps Lock> at the left of the keyboard)

This will ensure thatcomments are automatically copied into the right place in the standard version of the form

Year-end

At the very start of the form are three pages that record basic information about the LFG and Educational Network. They need to be completed before the final submission of the year in June/ July. Hopefully, an administrator at your Post-graduate Centre could complete these pages.

The rest should all be done!

Explain the Layout

The layout reflects the GMC document “Generic Standards for Specialty Including GP Training”

Some Domains are more important than others. The most detail is required in:

Domain 1 – Patient Safety
Safe working practices & supervision of trainees

Domain 5 – Delivery of Approved Curriculum
Education programme & assessments

Domain 6 – Support and Development of Trainees & Trainers
Includes work of trainer group

Domain 7 – Management of Education & Training
What you do for Trainees in Difficulty

Domain 1 Patient Safety
The duties, working hours and supervision of trainees must be consistent with the delivery of high-quality, safe patient care. There must be clear procedures to address immediately any concerns about patient safety arising from the training of doctors.
This domain is concerned with the essential safeguards on any action by trainees that affects the safety and wellbeing of patients.
.

Detailed & important section– issues around working practices & supervision especially in hospital posts

Sources of information:
PMETB survey
Trainee representative feedback
Informal feedback from trainees
Areas you may wish to comment on:
Supervision & support of trainees in training posts *
Compliance with EWTR *
Handover arrangements *
Workload intensity *
*These are all areas scored in the PMETB Survey
Please enter a comment that mentions the positive aspects of the four areas listed above
This could includegreen triangles from the PMETB Survey, changes made to hand-over or rotas
Describe any areas of sufficient concern that they will be discussed at the LFG/ LAB
This should include any red triangles from the PMETB Survey.If none, please write ‘None’
For major concerns, include time-bound targets for action and named responsibility
Describe any cause for concern last year that has now improved? If none, please write ‘None’
Domain 2 Quality management review and evaluation
Specialty, including GP, training must be quality managed, reviewed and evaluated
This domain deals with governance issues and how the GMC’s standards will be used in GMC quality assurance. It refers to the quality management systems and procedures of postgraduate deaneries.

Little detail required, mainly confirming that you sign-up to this domain

Sources of Information:
Incidental information
Deanery visits
Areas you may wish to comment on:
Programme engages with the Deanery review programme (example inspections & visits)
Programme complies with legal requirements like EWTR, Data Protection, Freedom of Information
Any examples from this year where you have been involved in the above?
Describe any areas of sufficient concern that they will be discussed at the LFG/ LAB.
If none, please write ‘None’
For major concerns, include time-bound targets for action and named responsibility
Describe any cause for concern last year that has now improved? If none, please write ‘None’
Domain 3 Equality, diversity and opportunity
Specialty, including GP, training must be fair and based on principles of equality.
This domain deals with equality and diversity matters pervading all aspects training:
- widening accessand participation
- fair recruitment & the provision of information,
- programme design and job adjustment.

Simple domain about VTSinformation you provide andsupport for trainees with additional needs/ LTFTs.
NOT“generaltrainees in difficulty” (TiDs) - see later

Areas you may wish to comment on:
Faculty handbook & Deanery details being up-to-date,other information sources (VTS website)
Number of LTFT posts being supported
Support for doctors with other additional needs e.g. ill-health & disability
Comment about the positive steps you have take in the above areas:
Describe any areas of sufficient concern that they will be discussed at the LFG/ LAB.
If none, please write ‘None’
For major concerns, include time-bound targets for action and named responsibility
Describe any cause for concern last year that has now improved? If none, please write ‘None’
Domain 4 recruitment, selection and appointment
Processes for recruitment, selection and appointment must be open, fair and effective.
The LFG must take responsibility for ensuring an appropriate level of recruitment support is provided to the KSS recruitment process proportionate to the number of Postgraduate Doctors in training.

Simple domain requiring you to confirm that your group does participate in the selection process

Areas you may wish to comment on:
Support provided by your Trainer Group to the recruitment & selection process
Comment about the positive steps you have take in the above area:
Describe any areas of sufficient concern that they will be discussed at the LFG/ LAB.
If none, please write ‘None’
For major concerns, include time-bound targets for action and named responsibility
Describe any cause for concern last year that has now improved? If none, please write ‘None’
Domain 5 Delivery of approved curriculum including assessment
The requirements set out in the approved curriculum must be delivered and assessed.
The approved assessment system must be fit for purpose.

Detailed & important section – quality, access & appropriateness of education; use of assessments

Sources of information:
PMETB survey
Trainee representative feedback
Informal feedback from trainees
Areas you may wish to comment on:
1) Education & training
- GP programme/ faculty handbook
- Range of educational and clinical activities for ST1/2 and ST3
- Access to training days, courses, resources and other learning opportunities
- Any curriculum mapping exercises
- Hour education score *
- Adequate experience score *
- Local teaching score *
- Other learning opportunities score *
*These are all areas scored in the PMETB Survey
2) Assessments
the approved assessment system is implemented (not calibration – see later)
Please enter a comment that mentions positive steps in the areas listed above
This should include green triangles from the PMETB Survey, changes to teaching programmes etc.
Should also include a statement about implementation of the assessment system
Describe any areas of sufficient concern that they will be discussed at the LFG/ LAB
This should include any red triangles from the PMETB Survey.If none, please write ‘None’
For major concerns, include time-bound targets for action and named responsibility
Describe any cause for concern last year that has now improved? If none, please write ‘None’
Domain 6 Support and development of trainees, trainers and local faculty
Trainees must be supported to acquire the necessary skills and experience through induction, effective educational supervision, an appropriate workload, personal support and time to learn.
Trainers must be supported in their role

Some overlap with previous domains so mainly “required statements” & information about Trainer Group
Still NOT “general trainees in difficulty” (TiDs) - see later