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A Framework of Quality Assurance for Responsible Officers and Revalidation

Annual Board Report,

Surrey and Sussex Healthcare NHS Trust

September 24th 2015

Adam Stacey-Clear

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

• 245 doctors with a GMC connection to The Trust were included in the audit, April 1st 2014-March 31st 2015

• 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.

• A record of all doctors connected with the Trust is maintained

• The Responsible Officer is Adam Stacey-Clear who regularly attends network RO meetings, and attended as visiting Peer review RO to Portsmouth Hospitals NHS Trust on 8th September 2015.

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

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

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 4

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 5

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.

• 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 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

Recommendations submitted to the GMC

• 114 revalidation recommendations made.

• 14 deferrals

• 100 positive recommendations

• Deferrals mainly due to lack of supporting information

Slide 8

Medical Appraisal

• 245 doctors were included in this audit, 166 consultants and 79 associate specialists/Trust doctors

• 161 consultants completed an annual appraisal between 1/4/2014 and 31/3/2015, of which 2 were approved and 3 unapproved.

• 78 associate specialists/Trust doctors completed an appraisal, the late appraisal being unapproved.

• Audit sheet for late appraisals is maintained.

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

Slide 9

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:

• Measure 1a- Appraisal took place 9-15 months from previous appraisal, signed off , all between 1 April and 31 March

• 1b-1 April-31 March but less than 9 months or more than 15, or signed off 1 April-28 April of following appraisal year, or signed off more than 28 days after appraisal meeting

• 2-approved incomplete appraisal- neither 1a or 1b-but RO gave prospective approval for cancellation or postponement

• 3- unapproved incomplete or missed appraisal-1a,1b or 2 do not apply.

• Trust is going to stick with annual appraisals, +/- one month.

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Appraisal number

DISTRIBUTION OF APPRAISALS

Comparator Report

• Nationally 731 designated bodies (ALL), 58 in same sector (SS)= NHS England south.

• SASH compared with both groups.

• Completed appraisal consultants 97% SASH, ALL 87%, SS 87%

• Completed appraisal SAS/Trust doctors 98% SASH, ALL 84%, SS 81%.

• Approved late appraisals consultants 1.2% SASH, ALL 6.3%, SS 6.7%

• Approved late SAS/Trust doctors 0% SASH, ALL 8.6%, SS 9.1%

• Unapproved appraisals consultants 1.8% SASH, ALL 6.5%, SS 5.6%

• Unapproved SAS/Trust doctors 1.3% SASH, ALL 7.5%, SS 5.6%.

Slide 12

Are doctors organised?

• Some are

• The good ones are excellent ambassadors for the Trust and proud of their achievements

• Some need direction

• Brownian (Robert Brown) motion-random movement of water vapour particles, bumping into each other.

• Wilson’s cloud chamber (Charles Thomson Rees Wilson)- water vapour condenses on ionizing particles from a powerful alpha emitting source (MW)

Slide 13

http://www-outreach.phy.cam.ac.uk/camphy/cloudchamber/cloudchamber1_1.htm

http://www-outreach.phy.cam.ac.uk/camphy/cloudchamber/cloudchamber4_1.htm

http://www-outreach.phy.cam.ac.uk/camphy/cloudchamber/cloudchamber9_1.htm

Slide 14

Famous Michael Wilsons

• Michael Henry Wilson (1901-1985) British anthroposophist and founder of Sunfield Children's Home, Clent

• Michael Wilson (writer) (1914-1978), Hollywood screenplay writer

• Michael Wilson (Australian politician) (born 1934), member of the South Australian House of Assembly

• Michael Wilson (Canadian politician) (born 1937), Canadian politician and diplomat

• Michael G. Wilson (born 1942), producer and screenwriter of James Bond films

• Michael Wilson (guitarist) (born 1952), Jamaican guitarist for Burning Spear from 1977 to 1984

• Michael Wilson (cyclist) (born 1960), Australian cyclist

• Michael Wilson (director) (born 1964), artistic director of Hartford Stage

• Michael Wilson (Australian footballer) (born 1976), Australian rules footballer for Port Adelaide

• Michael Wilson (New Zealand footballer) (born 1980), New Zealand association football player

• Michael Wilson (ice hockey) (born 1987), Canadian ice hockey defenceman

• Michael Wilson (presenter), British journalist and business presenter (formerly on Sky News)

• Michael Wilson (basketball), former player of the Harlem Globetrotters aka 'Wild Thing'

Slide 15

Quality assurance

• Currently conducting an external review of appraisers using an NHS England toolkit concentrating on the appraisal outputs and PDP.

• External verification visit due soon from NHS England south.

• Appraisee feedback working well, reliant on appraisal sign off certificate.

• Six month PDP review working well

• Appraiser support group meetings carried out in June 2015 (three sessions spread over 2 days)

• PDP includes a Trust quality improvement activity

Slide 16

Risks and Issues

• Information transfer for visiting doctors whose designated body is not SASH.

• Appraisals in March

• Feedback for locums

• Patient feedback-database setup.

Slide 17

Board Reflections

• Working party to explore patient and public involvement in revalidation

• PDP six month check

• Verification visit

• Appraiser quality assurance audit

• Transfer of information form between SASH and other organisations

• Improved appraisee feedback

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