board of directors (public) 5.2 dr koye odutoye, deputy

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Report to: Board of Directors (Public) Paper number: 5.2 Report for: Information Date: 17 September 2020 Report author: Dr Koye Odutoye, Deputy Medical Director & Appraisal Lead Report of: Dr Vincent Kirchner, Medical Director FoI Status:

Report can be made public

Strategic Priority Supported:

Keeping our service users, carers and staff safe

Cultural Pillar Supported:

We value each other / We are empowered / We keep things simple / We are connected

Title: Annual Medical Appraisal and Revalidation Board Report

Executive Summary Introduction: Medical appraisal comprises a summative and formative review of a doctor’s clinical practice and professional development. GMC Revalidation builds on the appraisal process, reviewing performance over a 5-year period, thus assuring the public, employers and colleagues that the revalidated doctor meets agreed standards of practice. Our Trust medical appraisal and revalidation processes are well developed with clear leadership and governance structures. Summary of achievements/performance:

Completion of internal Trust quality assurance audit of appraisal (assessing 29% of all outputs). Results Once again very encouraging. Previous good practice is sustained and areas requiring improvement have improved.

Successful embedding of new appraisal software (L2P) system. This is quicker and more intuitive to use and offers better administrative oversight of process, aiding governance and report generation. Have now completed first year of active use in the last appraisal cycle with excellent overall feedback from appraiser and appraised doctors.

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Revalidation Advisory Group now well embedded with settled membership. Group continues to meet flexibly 4-6 times a year, supporting revalidation decisions and ensuring a clear audit trail.

We maintained a 98% rate of engagement with appraisal for all our doctors. This engagement has consistently remained above the national average rates.

Quality Assurance continues with NHSE quarterly and annual organisational self-audits on process and our yearly internal quality assurance audit of appraisal outputs.

We have further updated appraisal policy to incorporate new GDPR rules and other national guidance.

We have formalised mentoring processes for new consultants, created guidance and trained new mentors.

Challenges:

We still do not have comparative clinical activity and performance data that is sufficiently tailored to individual clinical settings to inform meaningful discussion within appraisal. Further progress with this process has been disrupted by the recent Covid-19 crisis.

Due to the COVID-19 crisis, all appraisals for this year’s 2020/21 annual cycle have been cancelled and deferred until 2021. This decision has been supported by NHSE and GMC directives and is fully compliant with national guidance.

Also consequent to the COVID-19 crisis, all revalidation recommendations from March 2020 to March 2021 have been postponed for 12 months at the direction of the GMC.

The year ahead:

Explore ways of capturing clinical activity with ICT and clinical directors.

Use of the new L2P Software to develop and improve the medical job-planning process.

Clear plan to sustain and achieve further quality improvements for appraiser outputs. Continued yearly internal audit.

Recommendation to the Board The Board of Directors is requested to:

• RECEIVE and ACCEPT the provided Annual Medical Appraisal and Revalidation Board Report.

ANNUAL BOARD REPORT MEDICAL APPRAISAL AND REVALIDATION

DR VINCENT KIRCHNER JULY 2020

Annual Board Report – Medical Appraisal and Revalidation (2019/20)

Purpose of the paper This paper is to provide the Board with information about processes in place in C&I for

medical appraisals, revalidation recommendations, remediation and governance. It also reports on current positive achievements and challenges as well as planned future developments over the next year.

Introduction Medical appraisal comprises of a summative and formative review of a doctor’s clinical

practice and professional development. It incorporates important feedback from patients and colleagues. It helps encourage doctors to plan and ensure continued professional development through an agreed personal development plan. GMC Revalidation builds on the appraisal process, reviewing a doctor’s performance (and evidence of keeping up to date) over a 5-year period. All non-training doctors (trainee doctors have a separate process under their training programmes) are contractually obliged to participate in this process. It aims to strengthen the way doctors are regulated and consists of Doctors taking part in appraisal, collating portfolio evidence over a five-year period to show they meet the standards set by the GMC; it increases public trust and confidence in the medical system. Our Trust medical appraisal and revalidation processes are well developed with clear leadership, policy, quality assurance and governance structures.

The General Medical Council allocates all licensed doctors to a Designated Body. Doctors in training will have their Deanery as Designated Body and are therefore not included in this report. Camden and Islington Foundation Trust is the Designated Body for all our non-training doctors. Dr Vincent Kirchner is the Responsible Officer and Dr Koye Odutoye is the Appraisal lead for the Trust.

1. Achievements for 2019-2020

• Good engagement with appraisal and revalidation for this year from both appraisers & appraisees.

• Successful implementation of a new electronic Medical Appraisal system, the “Licence to Practice” (L2P) system. All doctors, including locums and LAS are registered on the system. This generates automated audit information for more accurate reporting. It also incorporates a job plan management system and automatically issues prompts regarding appraisal requirements and relevant deadlines thus ensuring a more streamlined process. Our doctors have reported the system to be easier and very user friendly. Reports have been generated for quarterly audits.

• Completion of another Trust quality assurance audit in early 2020: The appraisal lead, Dr Koye Odutoye, audited 25 of 85 or 29% of all appraisal outputs and also incorporated appraisals carried out on locum trainees. It provides a robust and reliable picture of the current state of quality within the process. On the whole results were very encouraging and demonstrate continuing improvements in target areas identified in the previous year’s audit as well as maintaining standards in established areas of excellent practice. Showing ongoing excellent adherence to NHSE appraisal standards by both our appraisers and doctors appraised. (See appendix B for details). Across the16 appraisal domains audited (see details for domains in the attached appendix) there were no domains in the red/unsatisfactory zone. There has been further improvement in making reference to the previous personal development plan (PDP) and providing an adequate overall summary of the appraisee’s progress and work context. There were many good examples of summaries of the appraisal discussion that struck the right balance between a brief overview and necessary additional individualised detail.


i. Previous improved practice in 11 domains (including reflection, completing agreed PDPs and challenging appraisees) have been maintained and further embedded as standard practice. 23 of 25 appraisers or 92% had excellent overall output quality scores. This represents a maintenance of standards (indeed a further slight improvement) compared with 20/22 (91%) in the 2018/19 and 19/23 or 83 % in the 2017/18 cycle. Two appraisers were in the “amber zone” and could improve further (although had actually improved significantly from the previous year’s performance following extra training provided.) Other Improvements such as reference to quality improvement activity, evidence of “smart” agreed PDP objectives and reference to patient safety/risk systems and learning from serious incidents were also sustained or improved. Finally, the two appraisals completed by non-trained appraisers (on their locum trainees) audited both achieved excellent appraiser quality scores in the green zone, demonstrating that our e-learning appraisal modules provide sufficient training for occasional ad hoc appraisers.

ii. There were however 3 domains—making comments on the quality of portfolio and references to mandatory training, probity and health—which were still in amber range with a more or less static quality score and could improve further and there are plans to address this with appraisers. There is also scope for further improvement in the use of the other place of work form, (required for doctors with work responsibilities outside our Trust.)

• Quality Assurance also remains well established with NHSE driven quarterly and annual organisational self-audits on process and our yearly internal quality assurance audit on quality of appraisal outputs.

• We have improved our process of ensuring all locums/temporary employees are routinely appraised as appropriate and incorporated their appraisals into the electronic management system so as to ensure that these are now part of the main body of all appraisals being monitored for quality assurance.

• We have further updated the Trust appraisal policy to include use of the new L2P process; other new national developments including new GDPR guidance and, finally, tighter guidelines one ensuring timely completion of the required 360 MSF feedback process within a 5-year revalidation cycle.

Completion and embedding of the new Revalidation Advisory Group (as recommended by last NHSE review) to support the Responsible Officer in making revalidation recommendations. This arrangement is now well established. The group has now met on 4 occasions and will continue to meet flexibly 4-6 times a year. 25 revalidations recommendations were made over the last year. Three deferrals were made, two with acceptable reasons – two doctors needed more time to prepare and one deferral was due to prolonged sickness. By March 2019 we had maintained a 95.7% rate of completion of yearly appraisals and 100% of engagement with the appraisal process for all of our doctors. This level of engagement has consistently remained above the national and London regional average rates for appraisal engagement (91.57% and 92.6% respectively based on the last NHSE national report, July 2019). Short-term locum doctors are consistently being offered the opportunity of having an NHS appraisal if appropriate. • We have further formalised mentoring arrangements for new consultants, trained more

mentors and developed handbooks and feedback/quality assurance structures for the mentoring process.


2. Challenges

• Clinical activity: We still do not have accurate comparative clinical activity and performance data that is sufficiently tailored to individual clinical service settings to facilitate a meaningful discussion on these areas. This is still in part due to poor/unreliable data pulled through by the ICT department, but we also need to further develop more meaningful comparative data individualised for each clinical division/area. We hope this will be made easier when a more reliable and comprehensive clinical dashboard comes into operation. This has been put on hold in recent months, consequent to the recent Covid-19 crisis but will be prioritised over the next year.

• Due to the COVID-19 crisis, all appraisals for this year’s 2020/21 annual cycle have been cancelled until 2021. This decision has been supported by NHSE and GMC directives and is fully compliant with national guidance. It has lifted additional pressures and enabled doctors to focus fully on clinical activity during a challenging period which included numerous sick absences in the medical trainee (and consultant) workforce and various new clinical pressures and adjusted ways of working.

• Revalidation recommendations for March 2020 to March 2021 have all been postponed for 12 months at the direction of the GMC. This decision, together with our decision to defer appraisals until next year, will mean that some doctors will need to be revalidated on the basis of 4, rather than the usual 5 appraisals over a 5-year revalidation cycle. The GMC has confirmed that this will be acceptable as long as there are no other concerns and the doctor is otherwise fully engaged with the local appraisal process.

3. Objectives for 2019-2020

• Further explore ways of capturing clinical activity with ICT and clinical directors. • Appraisers to work on areas for improvement identified by Appraisal lead’s audit 2019-

2020, making use of available resources, i.e. refresher training, appraiser workshops, appraiser peer groups. The main target areas for improvement will be improving reference is made to mandatory training, probity and health; raising the profile and use of the new external work form; reviewing uncompleted PDPs and improving the appraisal summary.

• Planned use of the new Medical Appraisal and job-planning L2P Software to develop and improve the medical job-planning process

4. Appraisal and Revalidation Performance Data

See Appendix C for a more detailed report

Overview Data for 2019 – 2020 Appraisals Performed

Appraisers Leavers Starters Revalidations made

85 25 12 18 25


5. Concerns & Remediation

• One doctor has been off work with a prolonged period of sickness but there have been also been longstanding concerns about this doctor’s conduct, engagement with appraisal and reliable fulfilment of their job responsibilities. There has been a further failed phased return to work and continued poor communication and engagement with occupational health. This is being managed under the Trust absence and disciplinary policies.

• One doctor has been off on prolonged sick absence since late October 2019 but has maintained appropriate communication. We have ensured that he has been fully supported through this process and has availed himself of access to support through the NHS Practitioner support program. He is currently in the process of commencing a phased and supported return to work in July 2020.

Appendix A Annual Organisational Audit 2019/20 (NOT submitted/ requested by NHSE due to COVID-19)

AOA Reference Item

Number of prescribed

connections

Completed appraisals

(1)

Optional completed appraisals

(1a)

Approved incomplete or missed

appraisal (2)

Unapproved incomplete or

missed appraisal (3)

Total

2.1.1 Consultants 86 73 49 12 1 86

2.1.2 Staff grade, associate specialist, specialty doctor 12 7 5 5 0 12

2.1.3 Doctors on Performers Lists 0 0 0 0 0 0

2.1.4 Doctors with practising privileges 1 0 0 1 0 1

2.1.5 Temporary or short-term contract holders 1 1 1 0 0 1

2.1.6 Other doctors with a prescribed connection 8 0 0 7 1 8

2.1.7 Total of 2.1.1 - 2.1.6 108 81 55 25 2 108


Appendix B Internal Audit results 2019/20


The results of this audit (2019/’20) on the quality of medical appraisal within the Trust are summarized below. The audit was based on 25 appraisal outputs out of 85 appraisals or 29% of appraisal outputs.


Appendix C

Appraisal & Revalidation Performance data 2019/20

Revalidation data 2019/20 Revalidation due for the year 26 Deferral for the year 3* Positive recommendations for the year 25

*Deferral was to allow more time for preparation only. Two were subsequently recommended within the year and one doctor has been on long term sick and deferred.


Appendix D

Governance Arrangements

Current overarching governance structure summarised as follows:

Clinical Governance

The medical appraisal system currently ensures that general clinical governance and performance measures across the clinical divisions in the Trust also inform the process. The inputs are tabled below. Serious incident investigation outcomes and clinical performance activity are automatically uploaded to each doctor’s portfolio.

Supporting Documents for clinical governance

Audits Doctors to perform one audit or quality improvement project each revalidation cycle (5 yearly) and upload in appraisal portfolio

Complaints & Compliments

Collected, anonymised and uploaded to appraisal portfolios.

Serious Investigations & Datix

Collected, anonymised and uploaded to appraisal portfolio with emphasis on learning potential and areas for improvement within the doctor’s individual practice or clinical service.

Clinical activity

Gathered by IT dept, reported on to show average markers for each consultant in each division. Uploaded in appraisal portfolio.

Other place of work form

Helps identify any issue at ‘other place of work beyond the trust’ during the appraisal year; it is to be signed by the ‘other RO or manager’.

There is a self-declaration option as well for private practice.


Appendix E

Quality Assurance Structures A range of quality review processes are all well embedded and are tabulated below. We have now conducted two internal audits led by the appraisal lead. We anticipate that once areas for improvement are further fine-tuned we can then cut down the internal audit frequency to a biennial arrangement. All other interventions and NHSE audits will continue in a yearly cycle to ensure continued maintenance of knowledge and practice amongst appraisers.

Measures Appraisal & Revalidation Software - L2P (Licence to Practice) onwards.

Generates reports for Responsible officer & appraisal lead.

Generates appraiser feedback; which in turn is used to further develop of our medical appraisal process and for yearly audits.

Appraiser workshops Appraisal lead chairs three workshops yearly to share experiences, discuss quality assurance reviews, set standards and prepare for the next appraisal cycle.

Appraiser Training All appraisers receive initial training and refresher training every 3 years through an approved trainer recommended by the NHSE revalidation team.

Peer group mailing list Appraisers to communicate and share ideas during the cycle.

Documentation Doctors are sent a list of recommended documentation covering the 6 domains** required by the GMC, to include in their portfolios. This is also available on the intranet. (**Feedback from patients and colleagues; significant events; continuous professional development activity; audit and quality improvement work and complaints/incidents over the appraisal year)

NHSE Audits Quarterly audits are sent to NHSE.

Annual Organisational audits are done yearly, 2019-2020 was completed in May 2020 – (see extract in appendix A).

Internal Audit - A of output samples

In keeping with NHSE and GMC directives, there is an internal system in place for quality assurance of an appropriate sample of the outputs of the medical appraisal process to ensure that they comply with GMC requirements and other national guidance. The Appraisal lead prepares a yearly audit based on feedback generated from the software L2P; these findings are individualised and uploaded to each appraiser’s portfolio for discussion in their own appraisal. This is also presented and discussed on our Quality Assurance workshop. (See appendix B for audit results 2019-2020)


Appendix F

Pre-employment checks The following routine employment checks and requirements were performed on all doctors joining C&I in 2019-2020 by the Medical Staffing Team:

DBS Clearance Proof of GMC registration Fitness to Practice form to declare criminal

convictions Self-declaration of health and probity Occupational Health Clearance Relevant qualifications Photographic identification Most recent NHS payslip if applicable Right to work in the UK Two proofs of address

Proof of Section 12/Approved Clinician status. 1 reference from current employer if working

for the NHS with no gaps in service. Otherwise 3 references covering the last 3 years and 3 references for Consultants.

RO to RO information transfer. All new Doctors are asked to upload their last

appraisal outputs to RMS including previous PDP. (Appraisal revalidation software)