Appraisal and Revalidation Policy for Doctors at South London and Maudsley NHS Foundation Trust
Version: / 1.0
Ratified By: / TBC
Date Ratified: / TBC
Date Policy Comes Into Effect: / TBC
Author: / Dr Michael Holland
Responsible Director: / Dr Martin Baggaley
Responsible Committee: / TBC
Target Audience: / All Non-Training grade doctors
Review Date: / TBC
Equalities Equality Impact Assessment / Assessor: Dr Michael Holland / Date: TBC
HRA Impact Assessment / Assessor: Dr Michael Holland / Date: TBC

Policy for the Development and Management of Trust-wide Procedural Page 1 of 15

DocumentsVersion 4 – July 2011

Document History

Version Control

Version No. / Date / Summary of Changes / Major (must go to an exec meeting) or minor changes / Author

Consultation

Stakeholder/Committee/ Group Consulted / Date / Changes Made as a Result of Consultation
All Non-training grade doctors
LNC

Plan for Dissemination of Policy

Audience(s) / Dissemination Method / Paper
or
Electronic / Person Responsible

Contents

SectionPage

  1. Introduction5
  2. Definitions5
  3. Purpose and Scope of Policy5
  4. Roles and Responsibilities6
  5. Main Principles of Appraisal6
  6. Appraisals – The Requirements6
  7. Clinical Governance Evidence10
  8. Records and Confidentiality10
  9. Doctors in Difficulty11
  10. Doctors involved in Disciplinary procedures11
  1. Selection, Training, Retention and Review11

of Appraisers

  1. Quality Assurance12
  2. Appraisal – the link with Job Planning13
  3. Appraisal – the Link with CEAs13
  4. Procedure to be Followed for Doctors who14

have not completed an annual Appraisal

  1. Monitoring Compliance14
  2. Associated Documentation14
  3. References15
  4. Freedom of Information Act 200015

Appendices

Appendix 1: Roles and Responsiblities

Appendix 2: Guidelines for the Medical Appraisal process and documentation

Appendix 3: Frequently Asked Questions

Appendix 4: Appraiser Job Description, Person Specification and Application Form

Appendix 5: Medical Appraisal Feedback

Appendix 6: Doctor’s Appraisal Checklist

Appendix 7: RoyalCollege supporting information requirements

Appendix 8: Exit report for locum appointments

Appendix 9: Annual Medical Appraisal Board Report

Appendix 10: Exception Audit template

Appendix 11: Equality Impact Assessment

Appendix 12: Human Rights Act Assessment

Appendix 13: Checklist for the Review and Approval of a Policy

1.Introduction

This policy document states South London and Maudsley Foundation Trust’s requirements and the approach to appraisals for Revalidation to ensure that licensed doctors remain up to date and fit to practise. It is also to support all those involved with appraisals of medical staff.

Revalidation is the process by which licensed doctors.demonstrate that they remain up to date and fit to practise. Revalidation is based both on local clinical governance and appraisal processes. It is designed to improve the quality of patient care.

  • To confirm that licensed doctors practice in accordance with the GMC’s generic standards
  • For doctors on the specialist register and GP register, to confirm that they meet the standards appropriate for their specialty
  • To identify, for further investigation and remediation, poor practice where local systems are not robust enough to do this or do not exist.

All medical staff are expected to go through revalidation every five years. Primary Care organisations (currently Clusters, in the future NCB) are responsible for recommendations on revalidation for doctors on Performers’ Lists. The Deanery will be responsible for such recommendations on the revalidation of doctors in training. NHS Trusts are responsible for recommendations on revalidation for the doctors they employ either directly or through honorary contracts.

2.Definitions

Revalidation – a 5-yearly process that doctors must pass through to maintain their license to practice

Appraisal – an annual review of performance and development of future training needs that is carried out by a trained appraiser.

Responsible Officer – Individual responsible for implementation and management of the appraisal process including appraisal outcomes.

Appraisee – individual doctor for whom the appraisal is being carried out.

3.Purpose and Scope of the Policy

The purpose of this policy is to outline the requirements and arrangements for conducting the Appraisal and Revalidation of Medical Staff in South London and Maudsley Foundation Trust following direction by the General Medical Council and other relevant bodies. This policy is not exhaustive and is not intended to contain information on all aspects of Appraisal and Revalidation. Appraisal is not a new concept, however, the approach and use of information is clarified and strengthened.

The policy defines the responsibilities of key staff involved in appraisal including medical staff, managers, HR etc. The aim of the policy is to ensure that, through an effective appraisal mechanism, all medical staff are fit to practise and provide the highest standards of safe care to patients. The policy statement is supplemented by separate documents providing more information about appraisal processes.

Annual appraisal for consultants and those on the new Associate Specialist and Specialty doctor contracts is already a contractual requirement. This policy applies to all non-training grade medical staff, including those with honorary contracts, where they relate to the Responsible Officer for this organisation. Annual appraisal is a requirement, as part of revalidation, for all medical staff including: Clinical Fellows, Trust doctors, research fellows with clinical commitments, SAS grades on the old contract, and locums.

4.Roles and Responsibilities

There are several key roles in the successful application of this policy and achieving effective appraisals. The primary role is that of the Responsible Officer. In South London and Maudsley NHS Foundation Trust this will be incorporated into the Medical Director’s role as the senior medical professional within the organisation, who is personally accountable to the Trust Board and to the GMC.

He/She will be responsible for ensuring that all medical staff are appraised, that any follow up action is taken, that comprehensive records are kept of all appraisals and for making recommendations for Revalidation to the General Medical Council. Further information on this and other roles is included in Appendix 1.

5.MAIN PRINCIPLES OF APPRAISAL

Appraisal is a supportive mechanism focusing on enhancing local systems of quality improvement. It is designed to recognise good performance, provide feedback, and assist in the identification of performance issues so they can be dealt with at an early stage. The appraiser will review various sources of supporting information with the doctor to gain a rounded impression of that doctor’s practice and inform a mutually agreed Personal Development Plan (PDP). Appraisal will identify doctors who are struggling to provide the supporting information that is needed to demonstrate achievement of generic and specialist standards. It will assist those doctors in identifying support and developmental needs at an early stage, before there is any question of concerns about patient safety.

Every doctor is responsible for ensuring that they are appraised annually on their whole practice, so will need to make arrangements to share information from each of their employers, including private practice,on an annual basis.

Appraisals happen on an annual basis within each appraisal year. An appraisal is not considered to have been completed without timely sign off (within 28 days of the appraisal meeting). Revalidation will require a cumulative review of appraisals over a 5 year period.

6APPRAISALS – THE REQUIREMENTS

6.1Medical appraisal (see Appendix 2)

Medical appraisal differs fundamentally from appraisal in other settings due to its elemental link with external professional regulation and revalidation. Medical appraisals are based on a doctor’s performance as described in the GMC’s Good Medical Practice:

Inputs to appraisal

  • Doctor’s contact details
  • Scope and nature of work
  • Supporting Information
  • Continuing professional development
  • Quality Improvement Activity
  • Significant events
  • Feedback from colleagues
  • Feedback from patients
  • Review of complaints and compliments

This enables the doctor to demonstrate their practice in the four domains of the Good Medical Practice Framework for Appraisal and Revalidation. These four domains are:

  1. Knowledge, skills and performance
  2. Safety and quality
  3. Communication, partnership and teamwork
  4. Maintaining trust

The supporting information is important in itself, bu it is also the doctor’s reflectionon the information and the record of that reflection that informs the appraisal discussion. This allows the appraiser and the doctor to discuss the doctor’s practice and performance.

6.2Appraisal Protocol

The Appraisal process comprises of threephases:

  • Phase 1: Inputs to appraisal (as described above)
  • Phase 2: Confidential Appraisal discussion
  • Phase 3: Outputs of appraisal

6.3 The Annual Appraisal Cycle

Appraisals are carried out between April and June each year. Doctors joining the organisation outside of this period will be contacted and an appraisal organised at the earliest opportunity if they have not had an appraisal within that appraisal year.

Doctors who have not completed their appraisal between April and June will be contacted to confirm that an appraisal date has been made with an appraiser. If no date has been made for their appraisal they will be contacted to find out the reason. If there is evidence that they have not fully engaged in the process they will be given a 28 day period to arrange their appraisal and a letter will be sent to them to confirm that they are obliged to have an annual appraisal for both regulatory and contractual purposes. If after 28 days no appraisal has been organised a further letter will be sent for their appraisal to happen in the next 7 days. Following this they will be referred to the RO to consider contacting the GMC and indicate that the doctor is not engaging.

6.4Appraisal Process & Administration (Appendix 6, 7 and 8)

The appraisal documentation is contained within the electronic appraisal system Zircadian. Details of generic supporting information requirements are made clear in“Ready for Revalidation: Supporting Information for appraisal and Revalidation.” GMC 2012. Specific guidance on appropriate content for MSF is available from Doctors are expected to sign up to the Datix system which will allow incidents to be automatically forwarded to them as reported and CAGs will share Factfinder reports with their doctors. Insight can provide reports on other quality metrics. Specialty-specific guidance on supporting information has been published by the Academy of Medical Royal Colleges. Scheduling of appraisals is carried out by the appraisers and will be monitored by the Medical Directors’ office.

Appraisers will be allocated by the Medical Director’s office. Appraisers will be randomly allocated to appraisees and attempts will be made to allocate appraisers from within an appraisee’s CAG. If an appraisee/appraiser notes a conflict of interest:

  • personal/family relationship
  • Paired appraisals where two doctors appraise each other
  • An appraiser receiving direct payment from an appraisee for performing the appraisal.

They should inform the Medical Director’s office and the appraisal will be reallocated.

6.5 Exceptions

There are no exceptions for appraisal, all doctors who are connected to SLaM as their designated body will be expected to have an annual appraisal.

6.6 Locums

Locums working at the Trust will be contacted by the Medical Director’s office to determine when their appraisal is due and organise for this to be carried out within South London and Maudsley NHS Foundation Trust if this occurs during their period of employment with the organisation. Locums who work at the Trust for short periods and have an up to date appraisal should have a brief exit appraisal (see Appendix 11 for exit form). This should facilitate such doctors to maintain high standards of medical care and to prepare for revalidation.

6.7 What is an unsatisfactory appraisal?

Guidance is given in the above policy on what is considered to be essential and optional documentation that should be detailed in the portfolio (see Appendices 9 and 10).

If any part of the essential documentation is not identified in a portfolio (unless a satisfactory explanation can be offered by the appraisee) then this must be brought to the attention of the appraisee prior to the appraisal meeting as indicated in Appendix 7 (the Appraisal Process). This should provide an opportunity for the appraisee to produce the relevant piece of information. If the information is not forthcoming and there is no satisfactory explanation offered then the appraisal meeting should not go ahead and the Medical Director should be informed.

An unsatisfactory outcome of appraisal may also arise from:

  • failure to address issues that have been previously raised about clinical performance or personal behaviour
  • the appraiser’s judgement that there is inadequate evidence in any section of the appraisal documentation.
  • failure to complete the previous years PDP without adequate explanation.

It is only when there has been a clear failure to respond to actions outlined in previous outputs from appraisals that the appraisal could be considered as being unsatisfactory. If the issues cannot be resolved with the appraisee then the matter should be referred to the Medical Director.

6.8 Complaints

Any consultant who has concerns about the process of their appraisal should raise the issue directly with the Medical Director. Formal complaints will be handled via the trust’s Grievance Policy. Consultant appraisees will be surveyed annually for feedback on the quality of their appraisal.

7CLINICAL GOVERNANCE EVIDENCE

South London and Maudsley NHS Foundation Trust will ensure that effective and supported systems of clinical governance arrangements are available to enable doctors’ CPD.

Doctors must also be able to monitor their practice through performance information, including clinical indicators relating to patient outcomes, through feedback from patients and colleagues etc.

South London and Maudsley is currently working on developing systems to collate datasets for Doctors for dissemination.

7.1Multi Source Feedback (MSF)

The GMC recommends that feedback from both colleagues and patients is obtained at least once in each five year appraisal cycle. South London and Maudsley Foundation Trust provides a 360 for both colleagues and patients through the Zircadian system that can be accessed by all doctors. If this is not considered suitable as a tool then this should be discussed with the Medical Director’s office to agree for another 360, that complies with the GMC, to be used.

8RECORDS AND CONFIDENTIALITY

The detail of discussions during the appraisal interview would generally be considered to be confidential to the appraisee and appraiser. However within the context of appraisal for revalidation, the appraiser will be reporting to the Responsible Officer on the general outcomes of their appraisals. Therefore the appraiser will need to escalate any concerns about performance that arise during the appraisal discussion, in line with South London and Maudsley NHS Foundation Trust’s relevant policies and guidelines.

Both South London and Maudsley NHS Foundation Trust and the appraisee will need to retain copies of the appraisal documentation over a five year period. The appraisee should retain and add to their supporting documentation in an appraisal folder. An electronic database to facilitate appraisal for revalidation will be implemented within South London and Maudsley NHS Foundation Trust by March 2013. This database will be:

  • secure
  • allow for documents to be both imported and exported to and from the system
  • able to adapt to the full GMC requirements for revalidation when these are known.

9DOCTORS IN DIFFICULTY

In the event that the appraisal process indicates that a doctor is ‘in difficulty’, the appraiser must escalate this to the relevant Clinical Director without delay, who will deal with the issues in accordance with the South London and Maudsley NHS Foundation Trust’s relevant policies and guidelines.

However, organisations need to deal with performance issues as they arise, and not to wait until the appraisal.It may be appropriate to delay an appraisal under such circumstances, but a doctor’s appraisal for revalidation has to take place annually within the financial year. Arrangements should be made as quickly as possible for the appraisal to be rescheduled. Where this is not possible records must be kept and timescales clearly documented. Audits of any delayed or deferred appraisals will be carried out and summary information will be included in appraisal and revalidation reports to the Trust Board

10Doctors involved in disciplinary procedures

Appraisal is important for all doctors, but crucial for those facing performance or disciplinary procedures. Regular appraisal should continue for such doctors. It must be kept separate from any performance or disciplinary procedures, and a medical manager directly involved in such procedures should not also appraise the doctor concerned. Another appraiser should take on this role in these circumstances.

11SELECTION, TRAINING, RETENTION AND REVIEW OF APPRAISERS

The process for the selection of appraisers will ensure that doctors with the appropriate expertise, skills and commitment are selected for this important role. The Responsible Officer should scope the number of appraisals that will be needed and ensure there is a sufficient pool of trained appraisers within the organisation to carry out these appraisals. There will be a database of appraisers which will be maintained by the Responsible Officer and deputy. The selection and training of new appraisers will be carried out as and when required.

National guidelines (GMC, Revalidation Support Team, etc) will be followed regarding curriculum and approved training.

It is recommended that, to ensure fairness, equity and to mitigate against conflicts of interest, an appraisee will not be appraised by the same appraiser for more than three appraisal cycles.

Medical staff with appraiser responsibilities will have this included in their own appraisal to ensure their competence and performance is satisfactory. The team of appraisers will have periodic meetings to ensure consistent standards are maintained. It is expected that appraisers will perform at least 3 appraisals per year in order to maintain expertise.

Appraisers must declare any conflicts of interest with their appraisee and vice versa. This could be:

  • A personal or family relationship
  • Paired appraisals where two doctors appraise each other
  • An appraiser receiving direct payment from an appraisee for performing the appraisal.

11.1 Responsible Officer’s appraisal