NLG(15)326. DATE OF MEETING 28 th July Trust Board of Directors Public REPORT FOR. Medical Director REPORT FROM

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1 NLG(15)326 DATE OF MEETING 28 th July 2015 REPORT FOR Trust Board of Directors Public REPORT FROM Medical Director CONTACT OFFICER Mr Lawrence Roberts, Medical Director SUBJECT Annual Revalidation Report 2014/15 BACKGROUND DOCUMENT (IF ANY) N/A REPORT PREVIOUSLY CONSIDERED BY & DATE(S) Trust Governance & Assurance Committee 16 th July 2015 EXECUTIVE COMMENT (INCLUDING KEY ISSUES OF NOTE OR, WHERE RELEVANT, CONCERN AND / OR NED CHALLENGE THAT THE BOARD NEED TO BE MADE AWARE OF) HAVE THE STAFF SIDE BEEN CONSULTED ON THE PROPOSALS? The Report provides an outline of the position regarding Revalidation & Appraisal and provides assurance that the Trust is complying with GMC requirements. The report addresses the following: a. Audit of missed/incomplete appraisals. b. Quality assurance of appraisals. c. Audit of revalidation recommendations. d. Audit of concerns regarding doctors practice. e. Audit of recruitment & engagement background checks. N/A HAVE THE RELEVANT SERVICE USERS/CARERS BEEN CONSULTED ON THE PROPOSALS? N/A ARE THERE ANY FINANCIAL CONSEQUENCES ARISING FROM THE RECOMMENDATIONS? N/A IF YES, HAVE THESE BEEN AGREED WITH THE RELEVANT BUDGET HOLDER AND DIRECTOR OF FINANCE, AND HAVE ANY FUNDING ISSUES BEEN RESOLVED? N/A ARE THERE ANY LEGAL IMPLICATIONS ARISING FROM THIS PAPER THAT THE BOARD NEED TO BE MADE AWARE OF? N/A WHERE RELEVANT, HAS PROPER CONSIDERATION BEEN GIVEN TO THE NHS CONSTITUTION IN ANY DECISIONS OR ACTIONS PROPOSED? N/A WHERE RELEVANT, HAS PROPER CONSIDERATION BEEN GIVEN TO SUSTAINABILITY IMPLICATIONS (QUALITY & FINANCIAL) & CLIMATE CHANGE? N/A THE PROPOSAL OR ARRANGEMENTS OUTLINED IN THIS PAPER SUPPORT THE ACHIEVEMENT OF THE TRUST OBJECTIVE(S) AND COMPLIANCE WITH THE REGULATORY STANDARDS LISTED N/A 1 ACTION REQUIRED BY THE BOARD The Board are asked to note the contents of the Annual Revalidation report

2 Annual Revalidation/Appraisal Report 2014/15 1. Executive summary There were 325 doctors with a prescribed connection to NLaG as at 31 March The number of doctors with a prescribed connected to NLaG fluctuated throughout the year from 312 to 345. Between 1 April 2014 and 31 March doctors completed an appraisal. The main issue for the Trust in respect of appraisal has been non-engagement of doctors and difficulty monitoring the position as this has been done manually by the Revalidation Assistant. The Trust are in the process of procuring a Revalidation Management System (RMS) which is an IT system that will support the Appraisal and Revalidation process, making it largely automated to allow better monitoring and control of the process. The specification for the system has been finalised, and procurement of the system has now gone out to tender with a closing date of 15 July It is anticipated that an appropriate supplier will have been identified by August Purpose of the Paper From December 2012, the GMC implemented its mandatory requirement of appraisal and revalidation as a means of regulating licensed doctors. The mandatory requirement aims to provide confidence to patients that their doctors are up to date and fit to practise. Licensed doctors have to revalidate every five years, based upon the GMC s core guidance for doctors (Good Medical Practice). In accordance with GMC guidelines every doctor should have an annual appraisal which covers the following four domains: 1. Knowledge, skills and performance. 2. Safety and quality. 3. Communication, partnership and teamwork. 4. Maintaining trust. Every 5 years each doctor goes through the process of revalidation, whereby their appraisals are reviewed by the provider organisations Responsible Officer (RO). Upon satisfactory review of a doctors appraisals and supporting documentation the RO will submit a revalidation recommendation to the GMC. Provider organisations have a statutory duty to support their RO s in discharging their duties under the Responsible Officer Regulations 1 and it is expected that executive teams will oversee compliance by: monitoring the frequency and quality of medical appraisals in their organisations; checking there are effective systems in place for monitoring the conduct 1 The Medical Profession (Responsible Officers) Regulations, 2010 as amended in 2013 and The General Medical Council (Licence to Practise and Revalidation) Regulations Order of Council

3 and performance of their doctors; confirming that feedback from patients is sought periodically so that their views can inform the appraisal and revalidation process for their doctors; and Ensuring that appropriate pre-employment background checks (including pre-engagement for Locums) are carried out to ensure that medical practitioners have qualifications and experience appropriate to the work performed. The purpose of this report is to provide the Board with details of the Trusts final position in respect of Appraisal and Revalidation for the period April 2014 March 2015, and to provide assurance that the Trust is complying with the GMC requirements regarding Appraisal and Revalidation. 3. Background The Medical Directors Office produced an update report regarding Appraisal & Revalidation which was presented to TGAC on 18 May 2015, this gave a brief overview of the Trusts position in respect of Appraisal and Revalidation for the previous year, together with a quarterly report (for the period 1st Jan st March 2015). It also outlined the NHS England recommendations and the steps that are being taken to fulfil those recommendations. NHS England requires the Trust to complete & submit an Annual Organisational Audit (AOA). Accordingly this was completed and submitted in both 2014 & Governance Arrangements The Medical Directors Office are responsible for ensuring that all doctors with a prescribed connection to the Trust have an annual appraisal and go through the revalidation process when they are due for revalidation. The Medical Directors Office produced their first report for TGAC on the Revalidation and Appraisal position in May In addition to this, as previously mentioned the Medical Directors Office submitted an Annual Organisational Audit (AOA) as required by NHS England in 2014 & In order to maintain an accurate list of doctors with a prescribed connection to the Trust the Revalidation Assistant runs a fortnightly check on ESR for new-starters and leavers. A process is being put in place so that the Revalidation Assistant will be give notification of new starters at the time of recruitment, this will avoid the delay in waiting for the doctor to be registered on ESR. As a quality assurance measure a monthly revalidation meeting takes place between; the RO, the Appraisal Lead & the Revalidation Assistant in order to review Revalidation submissions before recommendations are made by the RO. 3

4 The Medical Directors Office structure is currently as follows: Medical Director /Responsible Officer Appraisal Lead Deputy Medical Director Associate Medic al Directors AMD - AMD - Medicine Pathology y AMD Surg & Crit Care Medical Directorate Manager AMD - Community AMD W&C Revalidation Assistant PA to the MD Admin Assistant 4

5 a. Policy and Guidance NHS England has issued updated Medical Appraisal Policy (version 2 dated April 2015). Please see annexed document Appendix A. The specification for the Revalidation Management System makes reference to Medical Appraisal Policy (version 2) in order to ensure that the system procured facilitates compliance with NHS England s guidance. Further, the Trusts Medical Appraisal Policy will be reviewed by the Medical Directors Office in light of the new guidance. 5. Medical Appraisal a. Appraisal and Revalidation Performance Data The Medical Directors Office are currently able to report on the group position in respect of completed Appraisals, we are moving towards providing more detail and reporting the information below by specialty. No of Doctors No of completed No of doctors in appraisals remediation/disciplinary processes Clinical Support Services Medicine Surgery W&C Community & Therapy Path Links Details of exceptions i.e. missed appraisals and reasons, incomplete appraisals etc. are outlined in Appendix B; Audit of all missed or incomplete appraisals audit. b. Appraisers The Medical Director s Office facilitated Revalidation Fit Appraiser Training which took place on 25 June 2015 at SGH & 29 June 2015 at DPoW. 48 doctors signed up to attend the training and 46 attended. From 1 July 2015 appraisals will only be carried out by appraisers that attended the 2015 training. The training was provided by Quarteds Ltd an appropriate supplier identified by the Appraisal Lead. Further from 1 July 2015 appraisers have appraisees allocated to them by the Medical Directors Office each year. 5

6 c. Quality Assurance The Revalidation Assistant: Review s appraisal folders to provide assurance that the appraisal inputs; the pre-appraisal declarations and supporting information, is available and appropriate. Review s appraisal folders to provide assurance that the appraisal outputs: PDP, summary and sign offs are complete. Discusses doctors due for revalidation at the Revalidation Meeting held with the RO & Appraisal Lead, and highlights any issues/concerns regarding appraisal paperwork. Collates feedback forms which are completed by Appraisee s in order to review the standard of Appraisers. Aims for the Future: Review of appraisal outputs to provide assurance that any key issues identified pre-appraisal which require discussion during the appraisal are included in the appraisal outputs. AMD s to conduct a random thorough review of a sample of appraisals to ensure consistency and satisfactory standard. This will inform the information that will be presented in Appendix C. For the individual appraiser s: An annual record of the appraiser s reflection on appropriate continuing professional development. An annual record of the appraiser s participation in appraisal calibration events such as reflection on appraisal network meetings. 360 feedback from doctors for each individual appraiser. For the organisation: Audit of timelines of process of appraisal by department. System user feedback. Review of lessons learned from any complaints. Review of lessons learned from any significant events. d. Access, security and confidentiality Once completed by the Appraiser and Appraisee the appraisal documentation is saved on a secure section of the Trust h-drive. The Revalidation Assistant holds data on the position regarding appraisal/revalidation for all doctors with a prescribed connection to the Trust, this is also saved on a secure section of the Trust s h-drive. 6

7 e. Clinical Governance At present doctors are required to pull information together for their appraisal in line with the GMC guidelines. It is intended that the Revalidation Management System will automatically pull information from a number of sources across the Trust (i.e., PALS, ESR etc.) in order to inform the appraisal discussion. 6. Revalidation Recommendations See Annual Report Template Appendix D; Audit of revalidation recommendations 7. Recruitment and engagement background checks Pre-employment background checks are currently dealt with by the Recruitment HUB. Checks on locums are conducted by the supplying agency. See Annual Report Template Appendix F 8. Monitoring Performance The performance of all doctors is monitored by: Annual appraisals. Job planning reviews. 9. Responding to Concerns and Remediation Where concerns are raised about doctors the RO will consider whether an internal investigation into that doctor s practise should take place. Where there is no GMC involvement at the outset, the RO will also consider whether the GMC should be notified of the concerns and the investigation. The Medical Directors Office are in the process of: Drafting a remediation policy to support the RO in dealing with concerns regarding doctors. Facilitating Case Manager training to ensure that the Trust has a number of dedicated case managers and that their approach to case management is consistent. Facilitating Case Investigator training to ensure consistency of approach where internal investigations are considered appropriate. The Medical Directors Office will seek to put in place appropriate process to ensure that data required for Appendix E; Audit of concerns about a doctor s practice can be reported. 7

8 10. Risk and Issues During 2014/15 NHS England put in place an Action Plan which the Trust was required to show progress against in order to retain the ability to revalidate doctors. The Trust s progress against that Action Plan has recently been reviewed by NHS England and it was considered that sufficient progress is being made, such that progress is now being monitored locally. A key part of progress against the NHS England Action Plan is the implementation of a Revalidation Management System which is a robust electronic system which will: Manage appraisal and revalidation for all doctors within the Trust. Mitigate against this risk of doctors failing to revalidate. Ensure a standardised and efficient process to streamline current manual revalidation/appraisal processes. Ensure a consistent and rigorous approach to monitoring and reporting on issues related to revalidation/appraisal in a proactive manner. Allow the Trust to proactively manage the status of each doctor in real time, in an efficient manner using dashboard reporting. Provide quality assurance mechanisms. 11. Executive Team Reflections The Executive Team have considered the Medical Directors proposals regarding the need for a Revalidation Management System and are supportive of the need to identify and procure the system as soon as possible. 12. Corrective Actions, Improvement Plan and Next Steps A specification in respect of the Revalidation Management System has been agreed and is out to tender with a closing date of 15 July It is anticipated that an appropriate supplier will have been identified by 1 August 2015 with a view to prompt implementation thereafter. 13. Statement of Compliance The Statement of Compliance has been signed by the CEO and provides assurance to the Board that the Appraisal and Revalidation systems and processes that are in place are in line with guidance and requirements outlined by NHS England. Please see Appendix G. 14. Recommendations The Board is asked to consider and accept this report. 8

9 Appendix B Audit of all missed or incomplete appraisals audit Doctor factors (total) Number Maternity leave during the majority of the appraisal due window 2 Sickness absence during the majority of the appraisal due window 3 Prolonged leave during the majority of the appraisal due window 1 Suspension during the majority of the appraisal due window 0 New starter within 3 month of appraisal due date 14 New starter more than 3 months from appraisal due date 3 Postponed due to incomplete portfolio/insufficient supporting information 1 Appraisal outputs not signed off by doctor within 28 days 0 Lack of time of doctor 2 Lack of engagement of doctor 3 Other doctor factors 3 Issue of appraisal format for Trust Grade. Resolved. Agreed that all Trust Grades should use MAG Form. Appraiser factors Number Unplanned absence of appraiser 0 Appraisal outputs not signed off by appraiser within 28 days 0 Lack of time of appraiser 0 Other appraiser factors (describe) 0 Organisational factors Number Administration or management factors 0 Failure of electronic information systems 0 Insufficient numbers of trained appraisers 0 Other organisational factors (describe) 0 9

10 ****NOT INCLUDED IN REPORT AS THE TRUST IS NOT CURRENTLY REPORTING IN THIS DETAIL **** Quality assurance audit of appraisal inputs and outputs Appendix C Total number of appraisals completed Number Number of appraisal portfolios sampled (to demonstrate adequate sample size) Number of the sampled appraisal portfolios deemed to be acceptable against standards Appraisal inputs NCR NCR Scope of work: Has a full scope of practice been described? Continuing Professional Development (CPD): Is CPD compliant with GMC requirements? Quality improvement activity: Is quality improvement activity compliant with GMC requirements? NCR NCR NCR NCR NCR NCR Patient feedback exercise: Has a patient feedback NCR exercise been completed? Colleague feedback exercise: Has a colleague feedback NCR NCR exercise been completed? Review of complaints: Have all complaints been included? NCR NCR Review of significant events/clinical incidents/suis: Have all significant events/clinical incidents/suis been included? Is there sufficient supporting information from all the doctor s roles and places of work? Is the portfolio sufficiently complete for the stage of the revalidation cycle (year 1 to year 4)? Explanatory note: For example Has a patient and colleague feedback exercise been completed by year 3? Is the portfolio complete after the appraisal which precedes the revalidation recommendation (year 5)? Have all types of supporting information been included? Appraisal Outputs NCR NCR NCR NCR NCR NCR Appraisal Summary NCR NCR Appraiser Statements NCR NCR Personal Development Plan (PDP) NCR NCR 1 0

11 Appendix D Audit of revalidation recommendations Revalidation recommendations between 1 April 2013 to 31 March 2014 Recommendations completed on time (within the GMC recommendation window) Late recommendations (completed, but after the GMC recommendation window closed) Missed recommendations (not completed) 0 TOTAL 157 Primary reason for all late/missed recommendations For any late or missed recommendations only one primary reason must be identified No responsible officer in post 0 New starter/new prescribed connection established within 2 weeks of revalidation due date New starter/new prescribed connection established more than 2 weeks from revalidation due date 0 0 Unaware the doctor had a prescribed connection 0 Unaware of the doctor s revalidation due date 0 Administrative error 0 Responsible officer error 0 Inadequate resources or support for the responsible officer role 0 Other 1 Reason unknown. Previous RO made recommendation. Previous Revalidation Assistant was employed at the time of late recommendation. TOTAL [sum of (late) + (missed)] 1 10

12 ****NOT INCLUDED IN REPORT AS THE TRUST IS NOT CURRENTLY REPORTING IN THIS DETAIL **** Audit of concerns about a doctor s practice Appendix E Concerns about a doctor s practice Number of doctors with concerns about their practice in the last 12 months Explanatory note: Enter the total number of doctors with concerns in the last 12 months. It is recognised that there may be several types of concern but please record the primary concern Capability concerns (as the primary category) in the last 12 months Conduct concerns (as the primary category) in the last 12 months Health concerns (as the primary category) in the last 12 months Remediation/Reskilling/Retraining/Rehabilitation High level 2 Medium level 2 Low level 2 Numbers of doctors with whom the designated body has a prescribed connection as at 31 March 2014 who have undergone formal remediation between 1 April 2013 and 31 March 2014 Formal remediation is a planned and managed programme of interventions or a single intervention e.g. coaching, retraining which is implemented as a consequence of a concern about a doctor s practice A doctor should be included here if they were undergoing remediation at any point during the year Consultants (permanent employed staff including honorary contract holders, NHS and other government /public body staff) Staff grade, associate specialist, specialty doctor (permanent employed staff including hospital practitioners, clinical assistants who do not have a prescribed connection elsewhere, NHS and other government /public body staff) General practitioner (for NHS England area teams only; doctors on a medical performers list, Armed Forces) Trainee: doctor on national postgraduate training scheme (for local education and training boards only; doctors on national training programmes) Doctors with practising privileges (this is usually for independent healthcare providers, however practising privileges may also rarely be awarded by NHS organisations. All doctors with practising privileges who have a prescribed connection should be included in this section, irrespective of their grade) Total NCR NCR NCR NCR NCR NCR NCR NCR NCR NCR

13 Temporary or short-term contract holders (temporary employed staff including locums who are directly employed, trust doctors, locums for service, clinical research fellows, trainees not on national training schemes, doctors with fixedterm employment contracts, etc.) All Designated Bodies Other (including all responsible officers, and doctors registered with a locum agency, members of faculties/professional bodies, some management/leadership roles, research, civil service, other employed or contracted doctors, doctors in wholly independent practice, etc.) All Designated Bodies TOTALS Other Actions/Interventions NCR NCR NCR Local Actions: Number of doctors who were suspended/excluded from practice between 1 April and 31 March: Explanatory note: All suspensions which have been commenced or completed between 1 April and 31 March should be included Duration of suspension: Explanatory note: All suspensions which have been commenced or completed between 1 April and 31 March should be included Less than 1 week 1 week to 1 month 1 3 months 3-6 months 6-12 months NCR NCR Number of doctors who have had local restrictions placed on their practice in the last 12 months? GMC Actions: Number of doctors who: Were referred by the designated body to the GMC between 1 April and 31 March NCR Underwent or are currently undergoing GMC Fitness to Practice procedures between 1 April and 31 March Had conditions placed on their practice by the GMC or undertakings agreed with the GMC between 1 April and 31 March Had their registration/licence suspended by the GMC between 1 April and 31 March Were erased from the GMC register between 1 April and 31 March National Clinical Assessment Service actions: Number of doctors about whom the National Clinical Advisory Service (NCAS) has been contacted between 1 April and 31 March for advice or for assessment Number of NCAS assessments performed NCR NCR *NCR Not currently recorded 12

14 Total Identity check Past GMC issues GMC conditions or undertakings On-going GMC/NCAS investigations Disclosure and Barring Service (DBS) 2 recent references Name of last responsible officer Reference from last responsible officer Language competency Local conditions or undertakings Qualification check Revalidation due date Appraisal due date Appraisal outputs Unresolved performance concerns Audit of Recruitment & Engagement Background Checks APPENDIX F Number of new doctors (including all new prescribed connections) who have commenced in last 12 months (including where appropriate locum doctors) Permanent employed doctors Number 19 Temporary employed doctors Number 210 Locums brought in to the designated body through a locum agency Number 0 Locums brought in to the designated body through Staff Bank arrangements Number 42 Doctors on Performers Lists Number 0 Other Explanatory note: This includes independent contractors, doctors with practising privileges, etc. For membership organisations this includes new members, for locum agencies this includes doctors who have registered with the agency, etc. Number 0 TOTAL Number 271 For how many of these doctors was the following information available within 1 month of the doctor s starting date (numbers)** Permanent employed doctors Temporary employed doctors Locums brought in to the designated body through a locum agency Locums brought in to the designated body through Staff Bank arrangements NCR NCR NCR NCR NCR 19 NCR 0 NCR NCR NCR NCR NCR NCR NCR NCR NCR 210 NCR 0 NCR NCR NCR NCR NCR NCR NCR NCR NCR NCR NCR 42 NCR 0 NCR NCR NCR NCR 13

15 Doctors on Performers Lists Other (Independent contractors, practising privileges, members, registrants, etc.) NCR NCR NCR NCR NCR NCR NCR NCR NCR NCR NCR NCR NCR NCR NCR NCR NCR NCR Total NCR NCR NCR NCR NCR 271 NCR 0 NCR NCR NCR NCR For Providers of healthcare i.e. hospital trusts use of locum doctors: Explanatory note: Number of locum sessions used (days) as a proportion of total medical establishment (days) The total WTE headcount is included to show the proportion of the posts in each specialty that are covered by locum doctors Locum use by specialty: Total establishment in specialty (current approved WTE headcount) - Total no of Locums used between Consultant: Overall number of locum hours used SAS doctors: Overall number of locum hours used Trainees (all grades): Overall number of locum hours used Total Overall number of locum hours used Surgery (SGH) Surgery (DPoW) 33 different locums used throughout ,179.3 Medicine (SGH) Medicine (DPoW) Psychiatry Obstetrics/Gynaecology (SGH) Paeds (SGH)

16 Anaesthetics (SGH) Anaesthetics (DPoW) Radiology Pathology Other Total in designated body (This includes all doctors not just those with a prescribed connection) Number of individual locum attachments by duration of attachment (each contract is a separate attachment even if the same doctor fills more than one contract) 3 locums used over Total Preemployment checks completed (number) Induction or orientation completed (number) Exit reports completed (number) 2 days or less NCR NCR NCR NCR NCR 3 days to one week NCR NCR NCR NCR NCR 1 week to 1 month NCR NCR NCR NCR NCR 1-3 months NCR NCR NCR NCR NCR 3-6 months NCR NCR NCR NCR NCR 6-12 months NCR NCR NCR NCR NCR More than 12 months NCR NCR NCR NCR NCR Total NCR NCR NCR NCR NCR Concerns reported to agency or responsible officer (number) **We are currently unable to confirm whether data was collected within the 1 st month of the doctors employment with the Trust. NCR Not Currently Recorded 15

17 Appendix F Statement of Compliance Designated Body Statement of Compliance The Executive management team of Northern Lincolnshire & Goole Hospitals NHS Foundation Trust has carried out and submitted an annual organisational audit (AOA) of its compliance with The Medical Profession (Responsible Officers) Regulations 2010 (as amended in 2013) and can confirm that: 1. A licensed medical practitioner with appropriate training and suitable capacity has been nominated or appointed as a responsible officer; Comments: The Medical Director, Mr Lawrence Roberts is the nominated RO. Mr Roberts has completed RO Training. 2. An accurate record of all licensed medical practitioners with a prescribed connection to the designated body is maintained; Comments: Confirmed. This list is maintained by the Revalidation Assistant in the Medical Directors Office. 3. There are sufficient numbers of trained appraisers to carry out annual medical appraisals for all licensed medical practitioners; Comments: Confirmed. Appraiser Training has recently been provided to a cohort of Appraisers. If appropriate training has not been undertaken, a doctor cannot act as a Medical Appraiser. 4. Medical appraisers participate in ongoing performance review and training / development activities, to include peer review and calibration of professional judgements (Quality Assurance of Medical Appraisers or equivalent); Comments: Confirmed. Appropriate training is facilitated by the Medical Directors Office, and feedback on appraisers is collated by the Revalidation Assistant. 5. All licensed medical practitioners 3 either have an annual appraisal in keeping with GMC requirements (MAG or equivalent) or, where this does not occur, there is full understanding of the reasons why and suitable action taken; 3 Doctors with a prescribed connection to the designated body on the date of reporting. 16

18 Comments: Confirmed. The Medical Directors Office has communicated to all doctors the requirement to complete an annual appraisal using the MAG Form. Reasons for failing to have an annual appraisal are recorded & reported using the quarterly and annual revalidation reports. 6. There are effective systems in place for monitoring the conduct and performance of all licensed medical practitioners 1, which includes [but is not limited to] monitoring: in-house training, clinical outcomes data, significant events, complaints, and feedback from patients and colleagues, ensuring that information about these is provided for doctors to include at their appraisal; Comments: Conduct & performance is reviewed at the Annual Appraisal Meeting. A more robust system of compiling and reviewing this information will ensue with the implementation of the Revalidation Management System, which is expected to be in place by the end of December There is a process established for responding to concerns about any licensed medical practitioners 1 fitness to practise; Comments: Currently concerns are dealt with under the Maintaining High Professional Standards Policy. The Medical Directors Office has in hand the drafting of a Remediation Policy which will work in conjunction with and support the Maintaining High Professional Standards Policy. 8. There is a process for obtaining and sharing information of note about any licensed medical practitioners fitness to practise between this organisation s responsible officer and other responsible officers (or persons with appropriate governance responsibility) in other places where licensed medical practitioners work; Comments: This is dealt with by the RO via the Revalidation Assistant. 9. The appropriate pre-employment background checks (including pre-engagement for Locums) are carried out to ensure that all licenced medical practitioners 4 have qualifications and experience appropriate to the work performed; and Comments: GMC registration is checked at the time of employment. 10. A development plan is in place that addresses any identified weaknesses or gaps in compliance to the regulations. 4 Doctors with a prescribed connection to the designated body on the date of reporting. 17

19 Comments: Progress against the NHS England Action Plan confirms that identified weaknesses or gaps in compliance are being addressed. Signed on behalf of the designated body Name: Karen Jackson Chief Executive Officer Signed: Date: 18

20 Medical Appraisal Policy Policy for the appraisal of licensed medical practitioners who have a prescribed connection to NHS England Version 2.0, April 2015

21 OFFICIAL NHS England INFORMATION READER BOX Directorate Medical Commissioning Operations Patients and Information Nursing Finance Trans. & Corp. Ops. Commissioning Strategy Publications Gateway Reference: Document Purpose Guidance Document Name Medical Appraisal Policy (v2) Author NHS England, Medical Directorate (Revalidation) Publication Date May 2015 Target Audience Responsible Officers, Medical Appraisal Leads, Medical Appraisers Additional Circulation List Description Medical Directors, Doctors with a prescribed connection to NHS England, DH, BMA, GMC, Royal College of GPs, NHS Employers, Academy of Medical Royal Colleges, Regional HR and Finance Leads, NHS England Regional Directors Policy for appraisal of licensed medical practitioners who have a prescribed connection to NHS England (circa 42,000 doctors from circa 700 designated bodies). It describes the framework for appraisal, with tools to support implementation contained within the annexes. Cross Reference The Medical Profession (Responsible Officers) Regulations, 2010/2013 and the GMC (Licence to Practice and Revalidation) Regulations 2012 Superseded Docs (if applicable) Action Required Timing / Deadlines (if applicable) Contact Details for further information Document Status Medical Appraisal Policy (v1) published October 2013 Responsible officers to ensure that Doctors with a connection to NHS England are appraised in accordance with this policy To be implemented as soon as reasonably practicable Dr Maurice Conlon england.revalidation-pmo@nhs.net This is a controlled document. Whilst this document may be printed, the electronic version posted on the intranet is the controlled copy. Any printed copies of this document are not controlled. As a controlled document, this document should not be saved onto local or network drives but should always be accessed from the intranet. The NHS Commissioning Board (NHS CB) was established on 1 October 2012 as an executive non-departmental public body. Since 1 April 2013, the NHS Commissioning Board has used the name NHS England for operational purposes. Document number: Medical Issue/approval date: 07/05/2015 Version number: 2.0 Appraisal Policy Status: Approved Next review date: 01/04/2016 Page 2

22 OFFICIAL NHS England Medical Appraisal Policy Policy for the appraisal of licensed medical practitioners who have a prescribed connection to NHS England Version number: 2 First published: March 2013 Updated: October 2013 (v1) Prepared by: Dr Maurice Conlon National Appraisal Lead This is a controlled document. Whilst this document may be printed, the electronic version posted on the intranet is the controlled copy. Any printed copies of this document are not controlled. As a controlled document, this document should not be saved onto local or network drives but should always be accessed from the intranet. Document number: Medical Issue/approval date: 07/05/2015 Version number: 2.0 Appraisal Policy Status: Approved Next review date: 01/04/2016 Page 3

23 OFFICIAL 1 Contents 1 Policy statement Introduction Policy aim and objectives Aim Objectives Background General Responsible officer regulations Revalidation Medical appraisal NHS England as a designated body... 7 Figure 1: Prescribed connections to NHS England (from Prescribed connections to NHS England)... 8 Figure 2: Identifying the relevant NHS England responsible officer for a doctor with a prescribed connection to NHS England Scope Roles and responsibilities NHS England responsible officer Chief Executive Officer Clinical appraisal leads and senior appraisers Medical appraisers Doctors Procedural document development process Responsible officer regulations A single NHS England policy for medical appraisal Sponsor and Lead Author Framework for medical appraisal Leadership of medical appraisal Appraisers Recruitment, training, support and review of appraisers Specific operational details The medical appraisal Specific operational details Organisation and governance of medical appraisal Specific operational details Distribution and implementation Target audience and circulation Implementation Monitoring Equality and Health Inequalities Analysis Section 1: Equality analysis Section 2: Health Inequalities Analysis Equality Impact Assessment screening involvement Signatures Associated documentation and references Annexes Document number: Medical Issue/approval date: 07/05/2015 Version number: 2.0 Appraisal Policy Status: Approved Next review date: 01/04/2016 Page 4

24 OFFICIAL 1 Policy statement NHS England is responsible for planning, securing and monitoring services commissioned by them in respect of primary care, offender health, military health and specialised commissioning. It is also responsible for holding Clinical Commissioning Groups (CCGs) to account for the services they plan, secure and monitor on behalf of local populations. NHS England will ensure services commissioned by them and others improve patient outcomes and meet the requirements of the Commissioning Framework. This document is underpinned by the values of NHS England: A clear sense of purpose. A commitment to putting patients, clinicians and carers at the heart of decisionmaking. An energised and proactive organisation, offering leadership and direction. A focused and professional organisation, easy to do business with. An objective culture, using evidence to inform the full range of its activities. A flexible organisation. An organisation committed to working in partnership to achieve its goals. An open and transparent approach. An organisation with clear accountability arrangements. This NHS England policy for medical appraisal seeks to embody these values, as well as ensure that medical appraisal is undertaken in a way that drives up quality and safety of healthcare and that NHS England discharges its statutory obligations in relation to its function as a designated body. Document number: Medical Issue/approval date: 07/05/2015 Version number: 2.0 Appraisal Policy Status: Approved Next review date: 01/04/2016 Page 5

25 OFFICIAL 2 Introduction 2.1 Policy aim and objectives Aim The aim of this policy is to ensure that all licensed medical practitioners (doctors) with a prescribed connection to NHS England 1 undergo a high quality and consistent form of annual medical appraisal. As described in the NHS Revalidation Support Team Medical Appraisal Guide, medical appraisal can be used for four purposes: 1) To enable doctors to discuss their practice and performance with their appraiser in order to demonstrate that they continue to meet the principles and values set out in the GMC document Good Medical Practice and thus to inform the responsible officer s revalidation recommendation to the GMC. 2) To enable doctors to enhance the quality of their professional work by planning their professional development. 3) To enable doctors to consider their own needs in planning their professional development. and may also be used 4) To enable doctors to ensure that they are working productively and in line with the priorities and requirements of the organisation they practise in Objectives NHS Revalidation Support Team Medical Appraisal Guide v4, March 2013 (re-issued with updated hyperlinks September 2014) NHS England has the following objectives for medical appraisal: to support the delivery of safe, high quality, committed, compassionate and caring services to patients; to help supervise and support its doctors in achieving continual professional improvement; to support the process of medical revalidation; to contribute to the achievement of the values of NHS England. 1 There may be other doctors employed or contracted to NHS England who have a prescribed connection to another designated body. Their professional medical appraisal for revalidation should be performed within their designated body but an annual structured review of their performance in their NHS England role will be performed and will where relevant be informed by this policy. Document number: Medical Issue/approval date: 07/05/2015 Version number: 2.0 Appraisal Policy Status: Approved Next review date: 01/04/2016 Page 6

26 OFFICIAL 2.2 Background General Medical appraisal has been a requirement for consultants since 2001 and for general practitioners (GPs) since Responsible officer regulations The Medical Profession (Responsible Officers) regulations 2010 and the Medical Profession (Responsible Officers) (Amendment) regulations 2013 require each body designated under the regulation to appoint a responsible officer who must monitor and evaluate the fitness to practise of doctors with whom the designated body has a prescribed connection Revalidation Revalidation is the process by which licensed doctors demonstrate to the GMC that they are up to date and fit to practise. One cornerstone of the revalidation process is that doctors will participate in annual medical appraisal. On the basis of this and other information available to the responsible officer from local clinical governance systems, the responsible officer will make a recommendation to the GMC, normally every five years, about the doctor s revalidation. The GMC will consider the responsible officer s recommendation and decide whether to continue the doctor s licence to practise. There is extensive guidance and information on the revalidation process available from many sources. The key references are listed below in Section 10 Associated documentation and references. Other information is also available from other sources, chief among which are the General Medical Council website ( and the NHS England Revalidation webpage ( Medical appraisal Medical appraisal is the appraisal of a doctor by a trained appraiser, informed by supporting information defined by the GMC, in which the doctor demonstrates that they are practising in accordance with the GMC guidance Good Medical Practice across the whole of their scope of practice. In 2013 the NHS Revalidation Support Team published a piloted and tested model of medical appraisal, the Medical Appraisal Guide, which complies with the needs of revalidation. This guide was updated in NHS England as a designated body NHS England is the largest designated body under the regulations. It has a prescribed connection with approximately 45,000 doctors. The usual means by which a doctor has a prescribed connection to NHS England are described in the NHS England published document Prescribed Connections to NHS England and are illustrated in Figure 1. The rules for establishing which NHS England responsible officer a doctor relates to are illustrated in Figure 2. Document number: Medical Issue/approval date: 07/05/2015 Version number: 2.0 Appraisal Policy Status: Approved Next review date: 01/04/2016 Page 7

27 Figure 1: Prescribed connections to NHS England (from Prescribed connections to NHS England) 2 The prescribed connection for doctors within the blue line is to NHS England Department of Health RO NHS England National Office RO* Government Departments, Non- Departmental Public Bodies & Executive Agencies ROs Health Education England (HEE) RO 13 Local Education and Training Boards (LETB) ROs NHS Trust Development Authority (NHS TDA) RO c290 Other NHS ROs** 4 x Regional Office ROs* c330 Non- NHS ROs** NHS Litigation Authority (NHS LA) RO 27 Area Team ROs* c200 Doctors c30 DH Doctors c46,000 Trainees c60,000 Doctors c11,000 Doctors c42,000 GPs * Denotes NHS England Responsible Officers (ROs) ** Responsible officer of other NHS or non-nhs designated bodies including ROs from medical defence organisations, RMO organisations, British College of Aesthetic Medicine, NHS Blood & Transplant, NHS Leadership Academy, Faculty of Homeopathy, Defence Deanery, non-nhs organisations and armed forces (on the basis of the address of the Designated Bodies' headquarters) 2 In the NHS England structural revision in 2015, the 27 Area Teams are replaced by 12 appraisal teams across the four regions.

28 Figure 2: Identifying the relevant NHS England responsible officer for a doctor with a prescribed connection to NHS England 3. 3 In the NHS England structural revision in 2015, the 27 Area Teams are replaced by 12 appraisal teams across the four regions.

29 OFFICIAL 3 Scope This policy applies to the appraisal of licensed medical practitioners who have a prescribed connection to NHS England. 4 Roles and responsibilities 4.1 NHS England responsible officer 4 The national responsible officer (the NHS England National Medical Director) is accountable to the NHS England Chief Executive for the provision of medical appraisal for regional responsible officers and doctors directly employed by NHS England in national roles. The national responsible officer also has responsibility for ensuring all other doctors with a prescribed connection to NHS England who are linked to the national responsible officer (the responsible officers of the NHS Trust Development Authority, Health Education England and the NHS Litigation Authority) have a suitable medical appraisal and by agreement this may need to be directly provided by NHS England. The regional responsible officers (regional medical directors) are accountable to the national responsible officer. The regional responsible officers also have responsibility for ensuring all other doctors with a prescribed connection to NHS England who are linked to the regional responsible officer (for example external responsible officers) have a suitable medical appraisal and by agreement this may need to be directly provided by NHS England. The NHS England responsible officers within the NHS England regions (normally the equivalent NHS England medical directors) are accountable to their regional responsible officer for the provision of medical appraisal to all the doctors for whom they are responsible. These include doctors on medical and ophthalmic performers lists, doctors employed in local locations and secondary care locum doctors who are registered with a locum agency which is not on the Government Procurement Service framework. 4 In addition to being accountable for the provision of medical appraisal, the responsible officer is also accountable for: ensuring the provision of processes for supervision of the quality of medical practice; intervening, should concern arise about medical practice; making recommendations about revalidation to the GMC for doctors with a prescribed connection to the designated body; whilst retaining statutory responsibilities at all times, NHS England responsible officers will normally delegate many operational tasks to members of their team. Actions ascribed to the responsible officer in this policy should be taken to indicate the responsible officer or person with appropriately delegated authority. Document number: Medical Issue/approval date: 07/05/2015 Version number: 2.0 Appraisal Policy Status: Approved Next review date: 01/04/2016 Page 10

30 OFFICIAL 4.2 Chief Executive Officer The Chief Executive Officer of NHS England is accountable to the Board for supporting the function of the responsible officers in respect of all their statutory duties, including the provision of medical appraisal as described by this policy. 4.3 Clinical appraisal leads and senior appraisers Owing to the scale involved for most NHS England responsible officers, it will be the norm for the responsible officer to put an appraisal support team in place to manage the appraisal system on their behalf. Where an NHS England responsible officer appoints a clinical appraisal lead, senior appraiser(s) 5 and/or non-clinical manager(s), those persons are accountable to the appointing NHS England responsible officer for providing leadership in respect of the medical appraisal process, in collaboration with the responsible officer, local appraisers, those doctors linked to the responsible officer, and other individuals and groups as locally determined. Illustrative job descriptions and person specifications for a clinical appraisal lead and senior appraiser are set out in annex G. 4.4 Medical appraisers Medical appraisers are accountable to their NHS England responsible officer (via their clinical appraisal lead and senior appraiser if appropriate) for providing medical appraisals as described by this policy, and for engaging with training, support and review processes as described in this policy. 4.5 Doctors Doctors with a prescribed connection to an NHS England responsible officer are individually professionally accountable for their engagement with the medical appraisal process as described by this policy. 5 A review of provision of support to appraisal across NHS England in 2014 found that in addition to appointing a clinical appraisal lead to support their overall appraisal system, it is widespread practice for NHS England responsible officers to engage a number of appraisers to support local groups of appraisers within their system. A variety of terms is in use to denote these persons. For simplicity and to make clear the distinction between the two roles, this policy uses the term senior appraiser to denote a medical appraiser who offers support and supervision to a designated local group of appraisers. Document number: Medical Issue/approval date: 07/05/2015 Version number: 2.0 Appraisal Policy Status: Approved Next review date: 01/04/2016 Page 11

31 OFFICIAL 5 Procedural document development process 5.1 Responsible officer regulations NHS England is a designated body under the terms of the Medical Profession (Responsible Officers) regulations 2010 and the Medical Profession (Responsible Officers) (Amendment) regulations These regulations require the provision of a suitable appraisal process for licenced medical practitioners who have a prescribed connection to NHS England. 5.2 A single NHS England policy for medical appraisal Prior to the formation of NHS England, the responsibility for the provision of medical appraisal rested with Primary Care Trusts, each of which had their own appraisal policy. The creation of NHS England therefore necessitated the creation of a single NHS England-wide medical appraisal policy, so that appraisal for doctors connected to NHS England is performed to a consistent manner throughout the organisation. Publication of version 1.0 of this policy harmonised and replaced all previous medical appraisal policies of those individual bodies. This version (version 2.0) represents an update of version 1.0, reflecting developments in the area of appraisal in the intervening time. All parts of NHS England should now be working consistently to this updated NHS England Medical Appraisal Policy. 5.3 Sponsor and Lead Author The NHS England Deputy Medical Director, by way of delegation from the national responsible officer (the NHS England National Medical Director), is the sponsor for the NHS England Medical Appraisal Policy. The NHS England National Appraisal Lead, Dr Maurice Conlon, is the Lead Author. Document number: Medical Issue/approval date: 07/05/2015 Version number: 2.0 Appraisal Policy Status: Approved Next review date: 01/04/2016 Page 12

32 OFFICIAL 6 Framework for medical appraisal There are four aspects to the framework for medical appraisal described in this policy: 1) Leadership of medical appraisal. 2) Appraisers. 3) The medical appraisal. 4) Organisation and governance of medical appraisal. 6.1 Leadership of medical appraisal NHS England responsible officers are responsible for the clinical leadership of medical appraisal in the relevant part of NHS England as described in this policy. Each NHS England responsible officer will be able to describe how the leadership and accountability of medical appraisal is expressed within their part of NHS England. Essential components of this will include: Description of the structure for leadership of medical appraisal, with identified personnel and description of any delegated functions. In areas where this is not currently established, the principles and functions described in annex I are intended to be of help in developing a suitable local structure. Provision by each NHS England responsible officer of periodic reporting as defined in the NHS England framework for the quality assurance of revalidation (FQA) (of which the quality management of appraisal is a key component), and a description of the process for addressing actions arising. As well as being of value to the responsible officer producing it, such reporting will serve to support quality monitoring processes within NHS England as a whole. These in turn will contribute to external assurance of the quality of appraisal and revalidation within NHS England. Support for the provision and participation in the All England Appraisal Network ( ) by appropriate personnel, at local, regional and national level. 6.2 Appraisers Recruitment, training, support and review of appraisers Given that the large majority of doctors with a prescribed connection to NHS England are general practitioners, NHS England will continue the existing practice of recruiting the large majority of its appraisers from this population. NHS England responsible officers will arrange to recruit, train, support and review the performance of medical appraisers in line with the NHS Revalidation Support Team guidance Quality Assurance of Medical Appraisers. The appendices to Quality Assurance of Medical Appraisers and the tools listed in Annex J of this policy will be the operational Document number: Medical Issue/approval date: 07/05/2015 Version number: 2.0 Appraisal Policy Status: Approved Next review date: 01/04/2016 Page 13

33 OFFICIAL tools for this, unless by specific agreement of the relevant NHS England responsible officer. This will be the case regardless of the model by which NHS England appraisers are engaged. These tools may be adapted and other tools may be incorporated from time to time as agreed by NHS England Specific operational details All England Appraisal Network NHS England will continue to support the participation of relevant persons in the All England Appraisal Network at local, regional and national level, as described in the proposal document All England appraisal network v1.0, November 2013 (available on request from Local appraisers will attend local meetings, clinical and administrative appraisal leads will attend regional meetings and the regional appraisal leads and national lead will attend national meetings. Attendance at such meetings will assist with calibration of approach within NHS England as a designated body. Because the network is open to all designated bodies in England, it will also facilitate increasing consistency across the healthcare sector in England as a whole Individual appraiser activity In normal circumstances, an individual appraiser should undertake between 5 and 20 appraisals a year, to maintain an appropriate level of quality and consistency. If an appraiser undertakes fewer or more than this, the reasoning and arrangements for supervision of this will be recorded as part of the quality monitoring process. An appraiser should not undertake more than two appraisal meetings on the same day Number of appraisers Responsible officers will ensure that they engage enough suitable appraisers to complete the necessary appraisal meetings on a timely basis. Where the ratio of appraisers to doctors is lower than 1:20 or higher than 1:5, the justification for this will be recorded as part of the overall governance review of the appraisal process Managing concerns about performance of appraisers Where concern arises about the performance of a medical appraiser, which cannot be addressed by the normal processes described in Quality Assurance of Medical Appraisers, this will be managed according to the relevant NHS England human resource policies and in keeping with the contractual arrangement between NHS England and the appraiser in question Appraiser indemnity Medical appraisers are relevant persons for the purposes of the NHS Litigation Authority Third Party Liability Scheme and as such are covered by this scheme in terms of liability for their actions whilst acting in the role of appraiser. Appraisers who are licensed medical practitioners should note that this cover does not extend to representing them in the case of a challenge to their licence or registration and should therefore consider whether they also need to maintain appropriate professional insurance. Document number: Medical Issue/approval date: 07/05/2015 Version number: 2.0 Appraisal Policy Status: Approved Next review date: 01/04/2016 Page 14

34 OFFICIAL 6.3 The medical appraisal Medical appraisal for doctors with a prescribed connection to NHS England will be carried out in accordance with the GMC guidance: Supporting information for appraisal and revalidation, and be based on the GMC s Good Medical Practice Framework for appraisal and revalidation. Medical appraisal for doctors with a prescribed connection to NHS England will conform to the model of appraisal described in the NHS Revalidation Support Team Medical Appraisal Guide Specific operational details Format of appraisal There is a variety of appraisal formats in place across NHS England, based on previously established arrangements. In several areas, the use of one appraisal vehicle predominates. NHS England will accept appraisals undertaken in any format which has previously been agreed and properly procured, where these are demonstrably in keeping with the NHS Revalidation Support Team Medical Appraisal Guide and are also agreed by the relevant NHS England responsible officer. Where no such arrangement has been made, medical appraisals for doctors with a prescribed connection to NHS England may be undertaken using the NHS Revalidation Support Team Medical Appraisal Guide Model Appraisal Form (MAG form) or another format which, as a minimum, replicates the information presented in the MAG form. There is a link to the MAG form in Section 10 (Associated Documentation and References). The NHS Revalidation Support Team MAG form illustrates the functional requirements for a medical appraisal vehicle, consistent with the NHS Revalidation Support Team Medical Appraisal Guide. The MAG form also functions as a suitable no-cost option for an appraisal vehicle accepted and recognised by NHS England. NHS England is happy to make the specification of the MAG form available to appraisal vehicle providers, to facilitate the design of their products as closely to this specification as possible. At such time as NHS England makes revision to the MAG form or the specification of its content, this will be shared with interested providers. NHS England will not procure an appraisal vehicle for doctors connected to it, nor will it seek to further extend existing contracts once they expire. NHS England will continue to work to define the functional requirements of appraisal vehicle(s) in the future, whether pdf-based, on-line or in some other format, and in line with NHS England requirements. NHS England does not accept appraisal documentation provided in paper format. Where individual doctors have chosen their own vehicle, whether from a commercial provider or a college or other professional body, they must ensure that the information from this is presented in a format compatible with the required GMC Domains and Medical Appraisal Guide outputs, and which is agreed by their responsible officer. In addition, doctors choosing to use a personally sourced vehicle (including from commercial providers, colleges and other professional bodies) do so at their own risk in terms of the Document number: Medical Issue/approval date: 07/05/2015 Version number: 2.0 Appraisal Policy Status: Approved Next review date: 01/04/2016 Page 15

35 OFFICIAL security of their information. NHS England does not accept liability for the functioning of any appraisal vehicle provided by any external organisation. NHS England may revise these arrangements as appropriate from time to time. In all cases the structured outputs of appraisal, including the final sign-off statements, should be those listed in the NHS Revalidation Support Team Medical Appraisal Guide: The appraiser s statements should confirm that: 1) An appraisal has taken place that reflects the whole of a doctor s scope of work and addresses the principles and values set out in Good Medical Practice. 2) Appropriate supporting information has been presented in accordance with the Good Medical Practice Framework for Appraisal and Revalidation and this reflects the nature and scope of the doctor s work. 3) A review that demonstrates appropriate progress against last year s personal development plan has taken place. 4) An agreement has been reached with the doctor about a new personal development plan and any associated actions for the coming year. The appraiser must remain aware when conducting an appraisal of their duty as a doctor, as laid out in Good Medical Practice. The appraisal summary should include a confirmation from the appraiser that they are aware of those duties. I understand that I must protect patients from risk of harm posed by another colleague s conduct, performance or health. The safety of patients must come first at all times. If I have concerns that a colleague may not be fit to practise, I am aware that I must take appropriate steps without delay, so that the concerns are investigated and patients protected where necessary. This provides the context for a further statement that: 5) No information has been presented or discussed in the appraisal that raises a concern about the doctor s fitness to practise. The appraiser and the doctor should both confirm that they agree with the outputs of appraisal and that a record will be provided to the responsible officer. If agreement cannot be reached the responsible officer should be informed. In this instance, the appraiser should still submit the outputs of the appraisal, but the responsible officer should take steps to understand the reasons for the disagreement. NHS Revalidation Support Team Medical Appraisal Guide version Personal information The supporting information used for appraisal and revalidation must be anonymised by doctors to ensure that all personal identifiers, including names, dates of birth, addresses, Document number: Medical Issue/approval date: 07/05/2015 Version number: 2.0 Appraisal Policy Status: Approved Next review date: 01/04/2016 Page 16

36 OFFICIAL hospitals and NHS numbers, are removed and that patients, carers, relatives and staff are not directly identifiable. It is possible that in some circumstances the information contained in appraisal and revalidation portfolios would allow those with local knowledge to identify individuals. However, access is limited and risks can be reduced to acceptable levels by putting in place the limited access safeguards set out on pages of the Information Commissioner s Anonymisation: managing data protection risks code of practice. Patients should be notified in leaflets, notices and on practice websites that all records are stored and processed confidentially. They should also be notified that patient information may be used for purposes of professional development and revalidation of doctors. Patients should also be informed that such information will be anonymised and the robust safeguards required by the Information Commissioner put in place Assigning an appraiser to a doctor NHS England responsible officers will take the following guidance from the NHS Revalidation Support Team document Quality Assurance of Medical Appraisers, into account when considering the suitability of an appraiser for a particular doctor: Appraiser suitability The appraiser will normally be a licensed doctor with knowledge of the context in which the doctor works. This is particularly important for doctors in clinical roles. However, doctors work in many different roles and settings and there are situations where it may be more appropriate for the appraiser to be from a non-medical background. This already occurs, for example, for some doctors in senior management positions who do no clinical work. It would be inappropriate to compel such doctors to have a second appraisal by a licensed doctor purely to satisfy the requirements of revalidation. In essence, the appraiser should therefore: be the most appropriate appraiser for the doctor, taking into account their full scope of work; understand the professional obligations placed on doctors by the GMC; understand the importance of appraisal for the doctor s professional; development; have suitable skills and training for the context in which the appraisal is taking place. The GMC has made it clear that to satisfy the requirements of revalidation, appraisers do not need to be licensed doctors and that local decisions should determine the overall suitability of the appraiser workforce, but it is important that both the doctor and their responsible officer have confidence in the appraiser s ability to carry out the role to the required standard. In addition to this there must be no conflict of interest or appearance of bias between a doctor and their appraiser, to ensure the objectivity of the appraisal. Also, to maximise Document number: Medical Issue/approval date: 07/05/2015 Version number: 2.0 Appraisal Policy Status: Approved Next review date: 01/04/2016 Page 17

37 OFFICIAL achievement of all the purposes of appraisal stated earlier, the doctor should be in agreement with the assigned appraiser Allocation process The NHS England approach is for a doctor s appraiser to be allocated by the relevant appraisal office. All NHS England responsible officers should adopt an allocation method by the end of March In allocating an appraiser NHS England responsible officers will need to ensure the suitability and objectivity of the appraiser. This would include checking the allocation for suitability and objectivity before the appraisal takes place, and ensuring that the appraiser is aware of their responsibility to make a declaration that there is no potential conflict of interest or appearance of bias prior to an appraisal. If the doctor or another person objects to the allocated appraiser they should complete an appeal form explaining their reasons (annex B) and send it to the responsible officer. If the appeal is accepted, the doctor should be allocated a different appraiser. The appeal process should be repeated once if there is still no agreement after the first appeal. In cases where the responsible officer and the doctor cannot agree a suitable appraiser after two appeals, an external appraiser will be allocated by the regional responsible officer; their decision will be final. A doctor should normally have no more than three consecutive appraisals with the same appraiser and must then have a period of at least three years before being appraised again by the same appraiser. If, in exceptional circumstances, it is deemed appropriate for a doctor to have the same appraiser for more than three consecutive appraisals, the justification for this will be recorded within the governance review processes. Equally, an allocated pairing of a doctor with an appraiser should normally be for three consecutive appraisals. Where a doctor wishes to change appraiser early, the doctor must complete the form to appeal against appraiser allocation in annex B. The responsible officer or other person with delegated authority must be fully clear about the justification for the re-allocation and whether any other action is appropriate in relation to the matter, before allowing the appeal. A doctor should not act as appraiser to a doctor who has acted as their appraiser within the previous five years. Similarly, a doctor who has entered the NHS England appraisal process from a training programme should not be allocated their educational supervisor as their appraiser for the first three years after exiting training Conflict of interest or appearance of bias between a doctor and their appraiser As stated above, the process of assigning an appraiser to a doctor should take into account the need to ensure the objectivity of the appraiser. NHS England responsible officers should follow the process described in annex B for managing situations where a concern is expressed from any source about a risk of conflict of interest or appearance of bias between a doctor and their assigned appraiser. Document number: Medical Issue/approval date: 07/05/2015 Version number: 2.0 Appraisal Policy Status: Approved Next review date: 01/04/2016 Page 18

38 OFFICIAL Appraisal of responsible officers A responsible officer should be appraised by a trained appraiser who is: appointed or agreed by that responsible officer s own responsible officer; not a doctor for whom they have statutory responsibilities. NHS England regional responsible officers will maintain a list of appraisers with the skills required to undertake appraisal of responsible officers whose prescribed connection is to NHS England 6 and the responsible officers of Health Education England, NHS Trust Development Authority and the NHS Litigation Authority, and other doctors as necessary Medical appraisal process and timescales Each doctor is expected to undertake an appraisal in every appraisal year (1 April to 31 March). Each doctor will have an agreed, fixed appraisal date each year (the appraisal due date ). Where not already otherwise established, and where a different date is not agreed to be more appropriate, a doctor s appraisal due date will be the last day of the month of their birthday (their appraisal month ). Doctors will be expected to participate in their appraisal meeting on or before the stipulated appraisal due date, unless by specific, written agreement of the relevant NHS England responsible officer. For the avoidance of doubt, should a doctor have an appraisal later than their appraisal due date (whether or not by agreement with their responsible officer), their next appraisal should revert to their original appraisal month. In order to manage their appraisal scheduling in the final month of the appraisal year, NHS England responsible officers may exercise discretion to minimise the number of doctors who are allocated an appraisal due date in March. A doctor s appraisal due date may be changed by agreement between the doctor and the responsible officer or other person with delegated authority. The process and timescales are set out in annex A Interrupting an appraisal On very rare occasions, an unexpected serious concern may come to light in the course of an appraisal. In such circumstances the appraiser should suspend the conversation, should not complete the appraisal outputs, and should notify the responsible officer as soon as reasonably practicable, so that the matter may be addressed. The responsible officer will decide within a timescale appropriate to the circumstances and no later than 28 days after being notified when the appraisal process should be reinstated and how the issues raised are to be addressed. 6 The NHS England national responsible officer holds their prescribed connection outside NHS England. Their appraisal is therefore to be undertaken in accordance with the appraisal policy of the body to which the national responsible officer is connected. Document number: Medical Issue/approval date: 07/05/2015 Version number: 2.0 Appraisal Policy Status: Approved Next review date: 01/04/2016 Page 19

39 OFFICIAL 6.4 Organisation and governance of medical appraisal NHS England responsible officers will manage an appraisal system that is subject to effective governance and ensures that all doctors with a prescribed connection to NHS England are accounted for annually Specific operational details Administrative support for appraisal An NHS England model for administrative support for medical appraisal is described at Annex I. This is not intended to be prescriptive and the relevant responsible officer is free to define their own team differently as appropriate. It may be noted that the appraisal network referred to in section provides a forum for mutual calibration of levels of managerial and administrative support for appraisal and a mechanism whereby issues identified may be fed back to NHS England centrally Maintenance of an accurate list of doctors requiring appraisal NHS England has procured a national Revalidation Management System (RMS) as the means by which responsible officers will maintain an accurate list of doctors requiring appraisal, and implementation of the RMS across NHS England commenced in The RMS replaces the locally developed mechanisms previously used by NHS England responsible officers, including the NHS Revalidation Support Team Responsible Officer Dashboard. As well as maintaining the responsible officer s list of doctors, it provides several organisational benefits, including: maintaining a list of appraisers, allocating appraisers, sending programmed reminders, providing secure storage of appraisal outputs, populating a dashboard showing the status of doctors in respect of their revalidation, linking with the GMC revalidation system (GMC Connect), supporting quality assurance processes including the FQA and feedback from the doctors being appraised, and allowing seamless migration of doctors between different responsible officers in NHS England. It is expected that all NHS England responsible officers will have made the transition to using RMS for their doctors by March Arrangements for information management NHS England responsible officers will follow the NHS Revalidation Support Team guidance Information Management for Medical Revalidation in England. In particular, they will ensure that the process flows for handling, storage and sharing of the appraisal documentation in Annex H are followed Monitoring the quality of medical appraisal In its role as Senior Responsible Owner of revalidation in England, NHS England has developed a single framework for quality assurance of medical revalidation (FQA), applicable to all designated bodies in England. A significant component of this is the quality monitoring arrangements for medical appraisal. NHS England responsible officers will continue to comply with the requirements of this framework Data for the responsible officer Pending the development of IT processes that permit the automated extraction of salient information from appraisal documentation for use by the appraisal office in populating the responsible officer information system, NHS England responsible officers will require Document number: Medical Issue/approval date: 07/05/2015 Version number: 2.0 Appraisal Policy Status: Approved Next review date: 01/04/2016 Page 20

40 OFFICIAL appraisers assistance in transferring certain key items of information from appraisals to the RMS (section ), for example by completion of a checklist at each appraisal. Annex C lists these items of information. This list will be reviewed regularly, on at least an annual basis The appraisal year and definition of completed annual medical appraisal For the purpose of auditing the appraisal system, the NHS England appraisal year is 1 April to 31 March. NHS England responsible officers will use the definition of completed medical appraisal as set out in the NHS England framework for quality assurance in the following sections ( and ). Should the definitions in the NHS England framework for quality assurance change, then the amended definitions will be adopted by NHS England Completed medical appraisal Category 1a completed annual medical appraisal A Category 1a completed annual medical appraisal is one where the appraisal meeting has taken place between 9 and 15 months of the date of the last appraisal, the outputs of appraisal have been agreed and signed-off by the appraiser and the doctor within 28 days of the appraisal meeting, and the entire process occurred between 1 April and 31 March. Category 1b completed annual medical appraisal A Category 1b completed annual medical appraisal is one in which the appraisal meeting took place in the appraisal year between 1 April and 31 March, and the outputs of appraisal have been agreed and signed-off by the appraisal and the doctor, but one or more of the following apply: - a period of time of less than 9 months or greater than 15 months from the last appraisal has elapsed; - the outputs of appraisal have been agreed and signed-off by the appraiser and the doctor between 1 April and 28 April of the following appraisal year; - the outputs of appraisal have been agreed and signed-off by the appraiser and the doctor more than 28 days after the appraisal meeting. However, in the judgement of the responsible officer, the appraisal has been satisfactorily completed to the standard required to support an effective revalidation recommendation. Where the organisational information systems of the designated body do not permit the parameters of a Category 1a completed annual medical appraisal to be confirmed with confidence, the appraisal should be counted as a Category 1b completed annual medical appraisal. It should be noted that these definitions in sections and are relevant to the quality assurance of the appraisal process and do not directly relate to the process and timescales for arranging appraisal, arrangements for which are described in section and Annex A. Document number: Medical Issue/approval date: 07/05/2015 Version number: 2.0 Appraisal Policy Status: Approved Next review date: 01/04/2016 Page 21

41 OFFICIAL Annual audit of missed or incomplete appraisals NHS England responsible officers will use the definitions of incomplete or missed medical appraisal as set out in the NHS England framework for quality assurance, as follows: Approved incomplete or missed appraisal (Category 2) An approved incomplete or missed annual medical appraisal is one where the appraisal has not been completed according to the parameters of either a Category 1a or 1b completed annual medical appraisal, but the responsible officer has given approval to the postponement or cancellation of the appraisal. The responsible officer must be able to produce documentation in support of the decision to approve the postponement or cancellation of the appraisal in order for it to be counted as an approved incomplete or missed annual medical appraisal. Unapproved incomplete or missed appraisal (Category 3) An unapproved incomplete or missed annual medical appraisal is one where the appraisal has not been completed according to the parameters of either a Category 1a or 1b completed annual medical appraisal, and the responsible officer has not given approval to the postponement or cancellation of the appraisal. Where the local organisational information systems do not retain documentation in support of a decision to approve the postponement or cancellation of an appraisal, the appraisal should be counted as an unapproved incomplete or missed annual medical appraisal. NHS England responsible officers will use the process set out in the NHS England framework for quality assurance of revalidation to audit those appraisals which are missed or incomplete. The RMS referred to earlier in section is specifically designed to support this. NHS England responsible officers will arrange their processes so as to maximise the number of doctors having a Category 1a completed medical appraisal, and minimise the number with unapproved incomplete or missed medical appraisal (Category 3). A missed or incomplete appraisal should not lead to a change to a doctor s agreed appraisal month, unless the responsible officer deems this to be necessary Reinstating appraisal A doctor who is seeking to return to practice after a period of absence should discuss their circumstances with their NHS England responsible officer at the earliest opportunity. The timing of their first appraisal will be determined to some extent by their individual circumstances, including whether they can demonstrate that they have maintained fitness to practise in the relevant areas during their absence and hence whether a bespoke retraining programme or period of supervision is required prior to resuming practice. The first appraisal should take place between 6 and 12 months after re-entry to practice. The NHS England responsible officer may also exercise discretion as to whether, within this range, it occurs earlier to support the doctor s return to practice, or later to facilitate the accrual of Document number: Medical Issue/approval date: 07/05/2015 Version number: 2.0 Appraisal Policy Status: Approved Next review date: 01/04/2016 Page 22

42 OFFICIAL supporting information 7. Where possible and practical, if the doctor had a previously agreed appraisal month this should be reinstated. Also, if the doctor has had an appraisal previously and circumstances permit, their first appraisal should be undertaken within 15 months of the last one. Suitable arrangements must always be made to manage a doctor s return to practice after a significant break. Such arrangements are independent of this medical appraisal policy Appraiser engagement and payment In order to achieve consistency, NHS England standardised the arrangements for engaging and paying appraisers during 2013/14. The ongoing mechanisms are as follows: Independent contractor model NHS England now has a standard approach of engaging medical appraisers using a single independent contractor model, with payment calculated on the basis of one standard payment per appraisal. Almost all new appraisers have been engaged on this basis from 1 November 2013, and this will continue to be the standard approach from April The payment takes into account aspects such as normal appraiser expenses, and the appraiser s requirements to maintain and develop their skills and cooperate with NHS England assurance processes. Details of this as well as the standard contractor agreement and the rate of payment are published separately. Appraisal role incorporated into a broader employed position A small number of NHS England appraisers undertake their appraisal function as a component of a broader employed role within NHS England. Their terms and conditions, including remuneration for the role, are covered by their overall job description and contract of employment. Seconded appraisers A small number of NHS England appraisers are employed elsewhere in the NHS, and undertake their appraisal work under the terms of a secondment arrangement between NHS England and their base organisation. Their terms and conditions are defined in the secondment arrangement, and their remuneration is provided to their source organisation. This model applies predominantly to appraisers in the regional pools, who may, for example, be doctors in NHS Trusts in their main role. Employed appraisers A very small number of medical appraisers continue to hold employment contracts, carried over from their arrangements prior to their transfer to NHS England. Work will continue to review and ratify these arrangements. Commissioned appraisal service NHS England also accepts the model of appraiser engagement where the responsible officer commissions appraiser services from an external organisation. Where this model is 7 If a doctor is undertaking any professional duties within their scope of work, they must continue to have annual appraisal as defined above. However, if this work falls outside the remit of their work on the Performers List, it may be that their prescribed connection lies somewhere other than with NHS England. Document number: Medical Issue/approval date: 07/05/2015 Version number: 2.0 Appraisal Policy Status: Approved Next review date: 01/04/2016 Page 23

43 OFFICIAL used, the relevant NHS England responsible officer retains accountability for the quality of the appraisal process. Assurance must be obtained from the provider organisation that the terms of this policy apply. This will include adhering to the NHS Revalidation Support Team guidance Quality Assurance of Medical Appraisers. It also includes using the same rate of payment as NHS England. Other arrangements From time to time NHS England may exert discretion in engaging medical appraisers via a model which may differ from those listed above. In such cases, the content of annex K, which describes medical appraiser role expectations, will apply, to ensure that the appraiser performs to the requirements of this policy and associated guidance and regulations Direct payment to doctors undergoing appraisal Whilst NHS England is committed to resourcing an appraisal system which is accessible for all doctors with a prescribed connection to NHS England within the terms of the relevant regulations, it does not make direct payments to doctors being appraised Arrangements for agreeing the postponement of appraisal NHS England responsible officers will use the process for recording and approving requests for postponement of appraisal set out in annex D Management of apparent non-participation by a doctor NHS England responsible officers will use the process and documentation set out in annex E if a doctor appears not to be actively and effectively participating in the appraisal process Management of complaints about the appraisal process NHS England responsible officers will use the complaints process set out in annex F to address complaints raised as part of the appraisal process Supporting information for appraisals Doctors with a prescribed connection to NHS England are personally responsible for presenting their own supporting information, including anonymised patient information and colleague feedback, in line with the requirements of the GMC guidance Supporting Information for Appraisal and Revalidation 8. NHS England medical appraisers will have regard to suitable resources pertaining to the assessment of supporting information as directed by NHS England from time to time. 8 NHS England recognises that there are mutual benefits to NHS England and to doctors if there is consensus about the nature of the supporting information a doctor presents at appraisal and cooperation in respect of the gathering this information. NHS England endorses the collaborative document from the healthcare regulators Effective governance to support medical revalidation - a handbook for boards and governing bodies and will participate in discussions to ensure it has reasonable arrangements to support doctors in collecting supporting information for appraisal. Document number: Medical Issue/approval date: 07/05/2015 Version number: 2.0 Appraisal Policy Status: Approved Next review date: 01/04/2016 Page 24

44 OFFICIAL Equality and diversity awareness NHS England responsible officers will ensure that all appraisers undergo appropriate equality and diversity training on a regular basis in line with its requirements for employees and other workers Patient and public involvement NHS England is committed to securing patient and public involvement in the medical appraisal policy and its processes, in keeping with the NHS England overall approach to patient and public involvement. The methods by which this is achieved in the context of medical appraisal and the means of monitoring these will be as described in the overall NHS England approach for securing patient and public involvement Joint appraisal NHS England responsible officers will make provision for joint appraisal where this may be appropriate; for example, in the appraisal of clinical academics according to the Follett Review principles. In cases of joint appraisal, at least one of the appraisers, who will be responsible for the final sign-off statements, will have been recruited, trained, supported and reviewed in accordance with the NHS Revalidation Support Team guidance: Quality Assurance of Medical Appraisers Emerging developments in medical appraisal NHS England will take into account emerging thinking on aspects of medical appraisal in recognition of the continuing development of medical appraisal and the need to work towards increased consistency both within NHS England as a designated body, and across all designated bodies. NHS England will therefore participate in the discussion and adoption of approaches described by the All England Appraisal Network in their Medical Appraisal Position Statements (MAPS). The list of MAPS as they currently exist at publication of this document can be found in Annex L. Document number: Medical Issue/approval date: 07/05/2015 Version number: 2.0 Appraisal Policy Status: Approved Next review date: 01/04/2016 Page 25

45 OFFICIAL 7 Distribution and implementation 7.1 Target audience and circulation This target audience of this policy is: NHS England responsible officers, NHS England appraisal leads, and doctors with a prescribed connection to NHS England. It will also be circulated to the following persons and organisations: NHS England medical directors, NHS England regional directors, NHS England regional leads, NHS England finance leads, Department of Health, General Medical Council, Academy of Medical Royal Colleges, Royal College of General Practitioners, NHS Employers, British Medical Association. It will be available on the NHS England website medical revalidation page at It may also be of interest to other designated bodies across the United Kingdom. 7.2 Implementation Responsibility for implementation of this policy is shared according to the accountabilities described in section 4. Day to day operational implementation will be undertaken by the NHS England responsible officers and their teams. Document number: Medical Issue/approval date: 07/05/2015 Version number: 2.0 Appraisal Policy Status: Approved Next review date: 01/04/2016 Page 26

46 OFFICIAL 8 Monitoring The application and effectiveness of this policy will be monitored and assessed in partnership with doctors, appraisers and relevant partners and stakeholders. Q1. Element to be monitored i.e. measurable policy objective 1. The application and effectiveness of key aspects of this policy, as defined through the Framework for Quality Assurance (FQA) for responsible officers and revalidation described below, will be monitored. Such aspects include: a. Measurement of appraisal rates b. Maintenance of a cohort of suitable appraisers c. Adherence to the agreed format of medical appraisal 2. Other aspects may also be monitored from time to time, according to levels of priority identified by NHS England. 3. The policy in its entirety will be subject to day to day discussion and review via the network arrangements described below. Q2. Position responsible for monitoring The NHS England Deputy Medical Director, by means of delegation from the responsible officer for the NHS England national office, is responsible for monitoring adherence to this policy. Q3. Method 1. Monitoring will be primarily undertaken via the NHS England Framework for Quality Assurance (FQA) of revalidation processes. This framework is led by NHS England for all designated bodies in England, in its role as Senior Responsible Owner for the implementation of the responsible officer regulations in England, in order to ensure that NHS England is discharging its statutory functions. 2. Monitoring of other aspects pertaining to efficiency and consistency may take place, as determined on the basis of emerging priorities, by the NHS England Revalidation Programme Board. 3. Monitoring of routine compliance and effectiveness of this policy is also achieved through discussion and calibration within the Responsible Officer Calibration and Operational Network, and the All England Appraisal Network. These are effective in monitoring the policy in its everyday use across NHS England. Q4. Frequency 1. Monitoring of key aspects of this policy will occur at the frequency set out by the FQA. This will include an annual organisational audit undertaken by each NHS England responsible officer. It will also include other aspects such as an independent verification process, which may itself include local visits from a verification team. Again, the frequency of these is determined by the FQA. 2. The frequency of monitoring of other aspects pertaining to efficiency and consistency will be determined by the NHS England Revalidation Programme Board. 3. Monitoring via the networks described above occurs on a continual basis, with feedback across and between these networks supported by a variety of meetings and other means of communication. Document number: Medical Issue/approval date: 07/05/2015 Version number: 2.0 Appraisal Policy Status: Approved Next review date: 01/04/2016 Page 27

47 OFFICIAL Q5. Reporting arrangements Committee/Group that monitoring is reported to, including responsibility for action plans 1. The results of the annual organisational audit are fed back to each NHS England responsible officer, who is responsible for generating a suitable action plan in response to the findings. The overall outputs from the FQA are reported to the NHS England Revalidation Programme Board, which in turn reports to the England Revalidation Implementation Board and to ministers. 2. Any monitoring commissioned by the NHS England Revalidation Programme Board will be reported to that board, which will be responsible for implementing any resulting action plans. 3. Any feedback on the compliance or effectiveness of this policy which arises from the networks described above will be channelled to the NHS England Revalidation Programme Board, which will be responsible for implementing any resulting action plans. Document number: Medical Issue/approval date: 07/05/2015 Version number: 2.0 Appraisal Policy Status: Approved Next review date: 01/04/2016 Page 28

48 OFFICIAL 9 Equality and Health Inequalities Analysis This procedural document forms part of NHS England s commitment to create a positive culture of respect for all individuals including staff, patients, their families and carers as well as community partners. The intention is to identify, remove or minimise discriminatory practice in the areas of race, disability, gender, sexual orientation, age and religion, belief, faith and spirituality as well as to promote positive practice and value the diversity of all individuals and communities. Where any aspect of this policy is identified as contravening the principles of equality and diversity in respect of any individual(s), the relevant responsible officer will raise this with their higher level responsible officer with a view to both correcting this matter for the individual(s) concerned, and making appropriate amendments to this policy. 9.1 Section 1: Equality analysis Evidence What evidence have you considered? This NHS England Medical Appraisal Policy is founded on guidance relating to revalidation and appraisal from the Department of Health, GMC and the NHS Revalidation Support Team, and is intended to discharge NHS England s statutory responsibilities as described elsewhere in this document. It has been shared with the British Medical Association for comment and no significant detriment relating to equality has been raised. The medical appraisal process is set out to be applicable equally and fairly to all licenced medical practitioners with a prescribed connection, and is seen as a mechanism for supporting and supervising these individuals. There are no identified matters in relation to the relevant guidance and legislation, nor from the discharge of this policy to date, that indicate any detriment in relation to equality that requires attention in a general manner. Where a NHS England responsible officer becomes aware of any such issue in relation to an individual, they are empowered to consider this, discuss it with colleagues as appropriate and make appropriate arrangements to accommodate the needs of the individual in question. Age No general issue in relation to this protected characteristic has been identified. Where a NHS England responsible officer becomes aware of any such issue in relation to an individual, they are empowered to consider this, discuss it with colleagues as appropriate and make appropriate arrangements to accommodate the needs of the individual in question. Disability No general issue in relation to this protected characteristic has been identified. Reasonable adjustments will be made to allow doctors with a disability to fully participate in the appraisal process. Where a NHS England responsible officer becomes aware of any such issue in relation to an individual, they are empowered to consider this, discuss it with colleagues as appropriate and make appropriate arrangements to accommodate the needs of the individual in question. Document number: Medical Issue/approval date: 07/05/2015 Version number: 2.0 Appraisal Policy Status: Approved Next review date: 01/04/2016 Page 29

49 OFFICIAL Gender reassignment (including transgender) No general issue in relation to this protected characteristic has been identified. Whilst recognising the primacy of patient safety, there is clear information governance guidance referred to within this policy, which makes clear the right to confidentiality of the doctor being appraised. Where a NHS England responsible officer becomes aware of any such issue in relation to an individual, they are empowered to consider this, seek advice and support as appropriate and make appropriate arrangements to accommodate the needs of the individual in question. Marriage and civil partnership No general issue in relation to this protected characteristic has been identified. Where a NHS England responsible officer becomes aware of any such issue in relation to an individual, they are empowered to consider this, discuss it with colleagues as appropriate and make appropriate arrangements to accommodate the needs of the individual in question. Pregnancy and maternity No general issue has been identified in relation to this protected characteristic. Arrangements are included in the policy to allow for the postponement of appraisals for doctors on maternity, paternity or adoption leave and those on long-term absence as a result of sickness. Where a NHS England responsible officer becomes aware of any such issue in relation to an individual, they are empowered to consider this, discuss it with colleagues as appropriate and make appropriate arrangements to accommodate the needs of the individual in question. Race No general issue has been identified in relation to this protected characteristic. Where a NHS England responsible officer becomes aware of any such issue in relation to an individual, they are empowered to consider this, discuss it with colleagues as appropriate and make appropriate arrangements to accommodate the needs of the individual in question. Religion or belief No general issue has been identified in relation to this protected characteristic. Where a NHS England responsible officer becomes aware of any such issue in relation to an individual, they are empowered to consider this, discuss it with colleagues as appropriate and make appropriate arrangements to accommodate the needs of the individual in question. Sex No general issue has been identified in relation to this protected characteristic. Where a NHS England responsible officer becomes aware of any such issue in relation to an individual, they are empowered to consider this, discuss it with colleagues as appropriate and make appropriate arrangements to accommodate the needs of the individual in question. Sexual orientation No general issue has been identified in relation to this protected characteristic. Where a NHS England responsible officer becomes aware of any such issue in relation to an individual, they are empowered to consider this, discuss it with colleagues as appropriate and make appropriate arrangements to accommodate the Document number: Medical Issue/approval date: 07/05/2015 Version number: 2.0 Appraisal Policy Status: Approved Next review date: 01/04/2016 Page 30

50 OFFICIAL needs of the individual in question. Carers No general issue has been identified in relation to carers in the context of this policy. Arrangements are included in the policy to allow for the postponement of appraisals for doctors with carer s obligations as appropriate. Where a NHS England responsible officer becomes aware of any such issue in relation to an individual, they are empowered to consider this, discuss it with colleagues as appropriate and make appropriate arrangements to accommodate the needs of the individual in question. Other identified groups No other detriment has been identified in relation to any other identified group. The processes relating to medical appraisal and revalidation are designed to be applicable to all doctors regardless of specialty, location in the UK or context of engagement, such that, if the doctor is capable of practising in a particular specialty, location or context of engagement, they are also capable of complying with the appraisal process. Whilst bearing in mind the primacy of patient safety, where a NHS England responsible officer becomes aware of any such issue in relation to any other identified group, they are empowered to consider this, discuss it with colleagues as appropriate and make appropriate arrangements to accommodate the needs of the individual in question. Engagement and involvement How have you engaged stakeholders with an interest in protected characteristics in gathering evidence or testing the evidence available? Engagement of this nature was undertaken in the development of the guidance and legislation underpinning this policy. Version 1.0 of this policy was shared with the British Medical Association for comment and this version will also be shared on publication. How have you engaged stakeholders in testing the policy or programme proposals? The NHS Revalidation Support Team undertook a three stage pilot process to develop the model of appraisal which underpins this policy. This policy includes a formal feedback/complaint process whereby any individual or group of individuals who have comments or observations about its impact in relation to any of the protected characteristic may submit these to the responsible officer so that they may be addressed. For each engagement activity, please state who was involved, how and when they were engaged, and the key outputs: The most comprehensive of the three stage pilot processes, known as the Pathfinder Pilots, involved testing the proposed model of appraisal with a group of 3000 doctors, from across England and reported in July The recommendations from this report led to the appraisal process subsequently defined by the NHS Revalidation Support Team in their Medical Appraisal Guide, which underpins this policy. Document number: Medical Issue/approval date: 07/05/2015 Version number: 2.0 Appraisal Policy Status: Approved Next review date: 01/04/2016 Page 31

51 OFFICIAL Summary of Analysis From the above, it can be confirmed that no issue has been identified, whether in the design of the appraisal process, or in the enactment of this policy to date, that adversely impacts on any of the protected characteristics. Even bearing this in mind, there is a mechanism in place whereby individuals with an observation of this nature may share this with their responsible officer so that this may be considered and addressed. This is a useful safety net to ensure that any such issue, as yet unrecognised, may be raised and addressed in the future. Eliminate discrimination, harassment and victimisation The NHS England Medical Appraisal Policy presents a consistent model of appraisal for all doctors with a prescribed connection to NHS England; as such, it is a vehicle for eliminating discrimination, harassment and victimisation by ensuring that every individual is subject to the same level of scrutiny and entitled to the same level of support. It is also flexible to the possible needs of an individual with one or more than one protected characteristic, in that NHS England responsible officers have the discretion to amend processes where appropriate, and where considerations of patient safety permit, in order to accommodate the needs of that individual. Advance equality of opportunity The NHS England Medical Appraisal Policy presents a consistent model of appraisal for all doctors with a prescribed connection to NHS England; as such it is a vehicle for advancing equality of opportunity by ensuring that every individual is subject to the same level of scrutiny and entitled to the same level of support. It is also flexible to the possible needs of an individual with one or more than one protected characteristic, in that NHS England responsible officers have the discretion to amend processes where appropriate, and where considerations of patient safety permit, in order to accommodate the needs of that individual. Promote good relations between groups The NHS England Medical Appraisal Policy presents a consistent model of appraisal for all doctors with a prescribed connection to NHS England; as such it is a vehicle for promoting good relations between groups by ensuring that every individual is subject to the same level of scrutiny and entitled to the same level of support and thus making visible the fact that a level playing field is available to all individuals. It is also flexible to the possible needs of an individual with one or more than one protected characteristic, in that NHS England responsible officers have the discretion to amend processes where appropriate, and where considerations of patient safety permit, in order to accommodate the needs of that individual. Evidence based decision-making In the implementation of this policy and in evaluation reviews of equality monitoring, NHS England will remain alert to the identification of issues of equality in relation to this policy as described above. Findings will be evaluated to identify any negative impact and Document number: Medical Issue/approval date: 07/05/2015 Version number: 2.0 Appraisal Policy Status: Approved Next review date: 01/04/2016 Page 32

52 OFFICIAL address these accordingly. Additionally, where a NHS England responsible officer identifies any issue relating to equality, this will be shared with their higher level responsible officer so that it can be captured, analysed and, where appropriate, lead to refinement/correction of this policy with a view to ensuring fair outcomes. This equality analysis will be published as a component of this policy, and as such will be shared with all those listed in the circulation, and any person or body who accesses it from the NHS England revalidation web page. Comments and observations in relation to equality matters will be welcomed by the sponsor and the lead author. Document number: Medical Issue/approval date: 07/05/2015 Version number: 2.0 Appraisal Policy Status: Approved Next review date: 01/04/2016 Page 33

53 OFFICIAL 9.2 Section 2: Health Inequalities Analysis Evidence What evidence have you considered to determine what health inequalities exist in relation to your work? The content of this policy is underpinned by guidance from the Department of Health, General Medical Council, and by legislation, the purpose of which is to reduce health inequalities by making more consistent the assurance of the professional behaviour of doctors in the United Kingdom. Impact What is the potential impact of your work on health inequalities? The purpose of this policy is to reduce health inequalities by making more consistent the assurance of the professional behaviour of doctors with a prescribed connection to NHS England, regardless of their specialty, location or context of engagement. How can you make sure that your work has the best chance of reducing health inequalities? The full enactment of this policy will provide the greatest likelihood that it will have maximum impact in terms of reducing health inequalities by making more consistent the degree to which doctors with a prescribed connection to NHS England are maintaining their standards of practice. Monitor and Evaluation How will you monitor and evaluate the effect of your work on health inequalities? NHS England and the GMC have programmes in place to assess the degree to which the benefits of medical appraisal and revalidation are realised, and this includes the degree to which medical appraisal and revalidation contribute to the reduction of health inequalities. Evaluation from this work will be of value in monitoring and evaluating the effectiveness of this policy in reducing health inequalities. For your records Name of person(s) who carried out these analyses: Dr Maurice Conlon Name of Sponsor Director: Dr Mike Bewick Date analyses were completed: 7 April 2015 Review date: 1 April 2016 Document number: Medical Issue/approval date: 07/05/2015 Version number: 2.0 Appraisal Policy Status: Approved Next review date: 01/04/2016 Page 34

54 OFFICIAL 9.3 Equality Impact Assessment screening involvement Signatures Managers Signature: Date: 7 April 2015 Document number: Medical Issue/approval date: 07/05/2015 Version number: 2.0 Appraisal Policy Status: Approved Next review date: 01/04/2016 Page 35

55 OFFICIAL 10 Associated documentation and references A guide to confidentiality in health and social care (HSCIC, 2013) A Framework of Quality Assurance for Responsible Officers and Revalidation (Department of Health, NHS England, 2014) A Review of Appraisal, Disciplinary and Reporting Arrangements for Senior NHS and University Staff with Academic and Clinical Duties: A report to the Secretary of State for Education and Skills, by Professor Sir Brian Follett and Michael Paulson-Ellis (Department for Education and Skills, 2001) All England appraisal network proposal v1.0 (NHS England, 2013) Available on request from: england.revalidation-pmo@nhs.net Anonymisation: managing data protection risks code of practice (ICO, 2012) Appraisal for consultants working in the NHS: guidance (Department of Health, 2001) ublications/publicationspolicyandguidance/dh_ Appraisal for general practitioners: guidance (Department of Health, 2002) ublications/publicationspolicyandguidance/dh_ Code of practice on confidential information (HSCIC, 2014) Confidentiality: NHS Code of Practice (Department of Health, 2003) ance/dh_ Effective governance to support medical revalidation: A handbook for boards and governing bodies (A collaboration of healthcare regulators, 2013) Information Management for Medical Revalidation in England (NHS Revalidation Support Team, 2013) Document number: Medical Issue/approval date: 07/05/2015 Version number: 2.0 Appraisal Policy Status: Approved Next review date: 01/04/2016 Page 36

56 OFFICIAL Introduction and link to Anonymisation Standard for the publication of health and social care data (HSCIC, 2013) Standard-for-the-publication-of-health-and-social-care-data-becomes-effective-on-30-April Joint Funding Council's Libraries Review Group: Report (The Follett Report) Medical Appraisal Guide: A guide to medical appraisal for revalidation in England, version 4 (NHS Revalidation Support Team, 2013 (reissued with updated hyperlinks September 2014)) Medical Appraisal Guide Model Appraisal Form (NHS Revalidation Support Team, 2012) Medical Appraisal Guide Model Appraisal Form: User guide (NHS Revalidation Support Team, 2012) Medical Appraisal Position Statements (NHS England) Available on request from: england.revalidation-pmo@nhs.net. Prescribed Connections to NHS England (NHS England, 2013) Quality Assurance of Medical Appraisers: Engagement, training and assurance of medical appraisers in England, version 5 (NHS Revalidation Support Team, 2014) Supporting information for appraisal and revalidation (GMC, 2012) The Good medical practice framework for appraisal and revalidation (GMC, 2013) The Medical Profession (Responsible Officers) (Amendment) Regulations The Medical Profession (Responsible Officers) Regulations 2010 (Her Majesty s Stationery Office, 2010) The National Health Service (Performers Lists) (England) Regulations Document number: Medical Issue/approval date: 07/05/2015 Version number: 2.0 Appraisal Policy Status: Approved Next review date: 01/04/2016 Page 37

57 OFFICIAL 11 Annexes A B C D E F G H I J K L M N Appraisal process Appealing against appraiser allocation Data for the responsible officer Requesting postponement of appraisal Non-participation in appraisal Complaints process Clinical appraisal lead job description and person specification Information governance Suggested appraisal team structure the appraisal office Routine appraiser assurance tools Appraiser role expectations All England appraisal network medical appraisal position statements Glossary Working group Document number: Medical Issue/approval date: 07/05/2015 Version number: 2.0 Appraisal Policy Status: Approved Next review date: 01/04/2016 Page 38

58 OFFICIAL NHS England Medical Appraisal Policy Annex A: Medical appraisal process and timescales NHS England Medical Appraisal Policy Version 2, April 2015 Annex A: Medical appraisal process and timescales Page 1

59 NHS England INFORMATION READER BOX Directorate Medical Commissioning Operations Patients and Information Nursing Finance Trans. & Corp. Ops. Commissioning Strategy Publications Gateway Reference: Document Purpose Guidance Document Name Medical Appraisal Policy (v2) Author NHS England, Medical Directorate (Revalidation) Publication Date May 2015 Target Audience Responsible Officers, Medical Appraisal Leads, Medical Appraisers Additional Circulation List Description Medical Directors, Doctors with a prescribed connection to NHS England, DH, BMA, GMC, Royal College of GPs, NHS Employers, Academy of Medical Royal Colleges, Regional HR and Finance Leads, NHS England Regional Directors Policy for appraisal of licensed medical practitioners who have a prescribed connection to NHS England (circa 42,000 doctors from circa 700 designated bodies). It describes the framework for appraisal, with tools to support implementation contained within the annexes. Cross Reference The Medical Profession (Responsible Officers) Regulations, 2010/2013 and the GMC (Licence to Practice and Revalidation) Regulations 2012 Superseded Docs (if applicable) Action Required Timing / Deadlines (if applicable) Contact Details for further information Document Status Medical Appraisal Policy (v1) published October 2013 Responsible officers to ensure that Doctors with a connection to NHS England are appraised in accordance with this policy To be implemented as soon as reasonably practicable Dr Maurice Conlon england.revalidation-pmo@nhs.net This is a controlled document. Whilst this document may be printed, the electronic version posted on the intranet is the controlled copy. Any printed copies of this document are not controlled. As a controlled document, this document should not be saved onto local or network drives but should always be accessed from the intranet. The NHS Commissioning Board (NHS CB) was established on 1 October 2012 as an executive non-departmental public body. Since 1 April 2013, the NHS Commissioning Board has used the name NHS England for operational purposes. NHS England Medical Appraisal Policy Annex A: Medical appraisal process and timescales Version 2, April 2015 Page 2

60 OFFICIAL Annex A: Medical appraisal process and timescales The flow chart below describes the process and timescales for undertaking an annual appraisal. At least 56 days prior to the last day of the doctor s appraisal month, the appropriate appraisal office confirms name of agreed appraiser to the doctor. At least 28 days prior to last day of the doctor s appraisal month, doctor and appraiser notify a mutually agreed appraisal date to the appropriate appraisal office. At least 14 days prior to agreed appraisal date, doctor submits pre-appraisal documentation to appraiser. At least seven days prior to agreed appraisal date, appraiser reviews pre-appraisal documentation and clarifies any necessary aspects with the doctor. If necessary, doctor and appraiser agree a new date. Doctor and appraiser hold appraisal discussion. Appraiser and doctor draft summary and PDP. No later than 28 days after appraisal meeting, doctor and appraiser sign off agreed appraisal documentation, and complete the appraisal outputs*. No later than 28 days after appraisal meeting, appraiser sends one copy of the completed appraisal documentation to the appropriate appraisal office, and one to the doctor. * For every medical appraisal the structured outputs of appraisal including the final signoff statements for the appraisal should be those listed in the RST Medical Appraisal Guide. NHS England Medical Appraisal Policy Annex A: Medical appraisal process and timescales Version 2, April 2015 Page 3

61 OFFICIAL NHS England Medical Appraisal Policy Annex B: Appealing against appraiser allocation NHS England Medical Appraisal Policy Version 2 April 2015 Annex B: Appealing against appraiser allocation Page 1

62 NHS England INFORMATION READER BOX Directorate Medical Commissioning Operations Patients and Information Nursing Finance Trans. & Corp. Ops. Commissioning Strategy Publications Gateway Reference: Document Purpose Guidance Document Name Medical Appraisal Policy (v2) Author NHS England, Medical Directorate (Revalidation) Publication Date May 2015 Target Audience Responsible Officers, Medical Appraisal Leads, Medical Appraisers Additional Circulation List Description Medical Directors, Doctors with a prescribed connection to NHS England, DH, BMA, GMC, Royal College of GPs, NHS Employers, Academy of Medical Royal Colleges, Regional HR and Finance Leads, NHS England Regional Directors Policy for appraisal of licensed medical practitioners who have a prescribed connection to NHS England (circa 42,000 doctors from circa 700 designated bodies). It describes the framework for appraisal, with tools to support implementation contained within the annexes. Cross Reference The Medical Profession (Responsible Officers) Regulations, 2010/2013 and the GMC (Licence to Practice and Revalidation) Regulations 2012 Superseded Docs (if applicable) Action Required Timing / Deadlines (if applicable) Contact Details for further information Document Status Medical Appraisal Policy (v1) published October 2013 Responsible officers to ensure that Doctors with a connection to NHS England are appraised in accordance with this policy To be implemented as soon as reasonably practicable Dr Maurice Conlon england.revalidation-pmo@nhs.net This is a controlled document. Whilst this document may be printed, the electronic version posted on the intranet is the controlled copy. Any printed copies of this document are not controlled. As a controlled document, this document should not be saved onto local or network drives but should always be accessed from the intranet. The NHS Commissioning Board (NHS CB) was established on 1 October 2012 as an executive non-departmental public body. Since 1 April 2013, the NHS Commissioning Board has used the name NHS England for operational purposes. NHS England Medical Appraisal Policy Annex B: Appealing against appraiser allocation Version 2 April 2015 Page 2

63 OFFICIAL Annex B: Appealing against appraiser allocation 1.1 Background The most important reasons for appealing against the allocation of a specific appraiser are where there is a potential conflict of interest or appearance of bias between the doctor and the appraiser, and appraiser suitability. These may most commonly be raised by the doctor but may also be raised by other personnel, such as the appraiser, the appraisal lead, the responsible officer, or colleagues of the doctor. 1.2 Potential conflict of interest or appearance of bias Instances where potential conflict of interest or appearance of bias between doctor and appraiser most commonly occur, include: 1.3 Personal relationships where there is a personal relationship such as marriage or partnership between an appraiser and a doctor or where the two are related in any other way; where there is a financial or business relationship between an appraiser and a doctor (for example partners in a primary care partnership); instances where a third party is involved e.g. an affair or marriage breakdown; where there is significant breakdown in the relationship between an appraiser and a doctor. 1.4 Professional relationship The different roles of the appraiser and the doctor might create a situation where a conflict of interest or appearance of bias might need further consideration: where there is an inverted line management relationship (for example where the doctor is the clinical director/responsible officer/employer to the appraiser in the doctor s main role or in any other place of work. where the direct line management relationship creates potential risk of conflict or appearance of bias. For example, a doctor s employer or responsible officer should not act as their appraiser. where there is a clinical relationship between the doctor and the appraiser. where there is reciprocal appraisal where two doctors appraise each other. where an appraiser receives direct payment from a doctor for carrying out an appraisal. NHS England Medical Appraisal Policy Annex B: Appealing against appraiser allocation Version 2 April 2015 Page 3

64 OFFICIAL The risk of conflict of interest or appearance of bias is greatest when the matter is current. However some historical matters may still create a potential conflict of interest or appearance of bias. These should be raised so that an objective judgement can be made by the responsible officer. 1.5 Appraiser suitability The appraiser will normally be a licensed doctor with knowledge of the context in which the doctor works. This is particularly important for doctors in clinical roles. However, doctors work in many different roles and settings and there are situations where it may be more appropriate for the appraiser to be from a non-medical background. This already occurs, for example, for some doctors in senior management positions who do no clinical work. It would be inappropriate to compel such doctors to have a second appraisal by a licensed doctor purely to satisfy the requirements of revalidation. In essence, the appraiser should therefore: be the most appropriate appraiser for the doctor, taking into account their full scope of work ; understand the professional obligations placed on doctors by the GMC; understand the importance of appraisal for the doctor s professional development have suitable skills and training in the context in which the appraisal is taking place. The GMC has made it clear that to satisfy the requirements of revalidation, appraisers do not need to be licensed doctors and that local decisions should determine the overall suitability of the appraiser workforce, but it is important that both the doctor and their responsible officer have confidence in the appraiser s ability to carry out the role to the required standard. All appeals against the allocation of a specific appraiser should be recorded, along with the outcome, whether the risk is deemed to be significant or not, using the template below. In many circumstances the matter can be resolved by discussion, openness and agreement. This should be documented in the interests of transparency. When the matter cannot be resolved, then an alternative appraiser should be allocated. In cases where the responsible officer and the doctor cannot agree a suitable appraiser, an external appraiser will be allocated by the regional responsible officer and their decision will be final. A review of appeals against the allocation of a specific appraiser should be included by the NHS England responsible officer as part of the medical appraisal quality assurance process. NHS England Medical Appraisal Policy Annex B: Appealing against appraiser allocation Version 2 April 2015 Page 4

65 OFFICIAL Form for appealing against the allocation of a specific appraiser. Part A to be completed by person making the appeal Doctor: Doctor s GMC number: Appraiser: Reason(s) for appealing against the allocation (tick all that apply): Potential conflict of interest or appearance of bias: Close personal or family relationship (past or present) Close financial or business relationship Professional relationship Known or longstanding personal animosity Appraiser suitability Other (please describe under further details below) Further details: Name of person making the appeal (if not the doctor): Designation: Contact details (in case appraisal office needs more information): Part B to be completed by appraisal office Decision: Decision approved by: Name: Position: Date: NHS England Medical Appraisal Policy Annex B: Appealing against appraiser allocation Version 2 April 2015 Page 5

66 OFFICIAL NHS England Medical Appraisal Policy Annex C: Data for the responsible officer NHS England Medical Appraisal Policy Version 2 April 2015 Annex C: Data for the responsible officer Page 1

67 NHS England INFORMATION READER BOX Directorate Medical Commissioning Operations Patients and Information Nursing Finance Trans. & Corp. Ops. Commissioning Strategy Publications Gateway Reference: Document Purpose Guidance Document Name Medical Appraisal Policy (v2) Author NHS England, Medical Directorate (Revalidation) Publication Date May 2015 Target Audience Responsible Officers, Medical Appraisal Leads, Medical Appraisers Additional Circulation List Description Medical Directors, Doctors with a prescribed connection to NHS England, DH, BMA, GMC, Royal College of GPs, NHS Employers, Academy of Medical Royal Colleges, Regional HR and Finance Leads, NHS England Regional Directors Policy for appraisal of licensed medical practitioners who have a prescribed connection to NHS England (circa 42,000 doctors from circa 700 designated bodies). It describes the framework for appraisal, with tools to support implementation contained within the annexes. Cross Reference The Medical Profession (Responsible Officers) Regulations, 2010/2013 and the GMC (Licence to Practice and Revalidation) Regulations 2012 Superseded Docs (if applicable) Action Required Timing / Deadlines (if applicable) Contact Details for further information Document Status Medical Appraisal Policy (v1) published October 2013 Responsible officers to ensure that Doctors with a connection to NHS England are appraised in accordance with this policy To be implemented as soon as reasonably practicable Dr Maurice Conlon england.revalidation-pmo@nhs.net This is a controlled document. Whilst this document may be printed, the electronic version posted on the intranet is the controlled copy. Any printed copies of this document are not controlled. As a controlled document, this document should not be saved onto local or network drives but should always be accessed from the intranet. The NHS Commissioning Board (NHS CB) was established on 1 October 2012 as an executive non-departmental public body. Since 1 April 2013, the NHS Commissioning Board has used the name NHS England for operational purposes. NHS England Medical Appraisal Policy Annex C: Data for the responsible officer Version 2 April 2015 Page 2

68 Annex C: Data for the responsible officer 1.1 Background NHS England responsible officers will require certain items of information to enable them to make a recommendation about a doctor's fitness to practice. A significant proportion of this information will be generated via the appraisal process. Until technical solutions resolve the challenge of transferring the relevant information, responsible officers will be reliant on appraisers to record this information and to assist with its transfer into the responsible officer's information system. The specific information required may vary according to the doctor's scope of work, as well as local requirements. This annex contains the current set of information that NHS England responsible officers will need, for doctors whose scope of work includes general practice, and for doctors whose scope of work includes being a responsible officer. It is envisaged that, through a process of experience and dialogue both locally, across NHS England and with relevant partners and stakeholders, the content of this data set will be developed further, and will include greater detail relating to these and other roles. 1.2 Core information Doctor s name. Doctor s GMC number. Appraiser s name. Appraiser s GMC number. Date of appraisal. Doctor s responsible officer. Revalidation due date. NHS England Medical Appraisal Policy Annex C: Data for the responsible officer Version 2 April 2015 Page 3

69 Section Generic items This section contains items which apply to all doctors with a prescribed connection to NHS England. They must be completed over a revalidation cycle to fulfil the requirements of revalidation General Appraiser statement on conflict of interest or appearance of bias between the doctor and the appraiser. At each appraisal. Record "none" if none to declare. Performance concern events. All events since last appraisal and any previously declared, if still relevant to scope of work. Includes, but not limited to: local processes, NCAS and GMC processes. Record "none" if none to declare. Breaks from work. Any significant breaks from work since last appraisal, including maternity leave, sickness absence, sabbatical leave. Record "none" if none to declare. GMC status events. Any GMC assessments and undertakings since last appraisal, and any not previously declared. Record "none" if none to declare. Practice status events. Any restrictions on practice in any aspect of scope of work applied since last appraisal, and any not previously declared. Record "none" if none to declare. Satisfactory statement of scope of work in appraisal documentation. Confirmation by appraiser that the doctor has confirmed that their written scope of work is complete. Roles listed in scope of work. A simple list of the roles the doctor has described in their appraisal form. The appraiser should identify any of these which have not been reviewed in the course of the appraisal Appraiser statements Confirmation at each appraisal by the appraiser whether they have indicated "Agree" or "Disagree" to each of the RST Medical Appraisal Guide (MAG) appraiser statements, with explanatory comment and a description of agreed corrective action. NHS England Medical Appraisal Policy Annex C: Data for the responsible officer Version 2 April 2015 Page 4

70 1.2.4 Supporting information The appraiser should confirm the presence of the following "in the round", across the whole of the doctor's scope of work, drawing the attention of the responsible officer to any particular area within the scope of work from which items of information are absent. Absence of specific items of supporting information relating to a particular role should be noted in section 2. Continuing professional development (CPD). Quality improvement (QI). Significant events. Patient feedback. Colleague feedback. Complaints. Probity statement. Health statement. NHS England Medical Appraisal Policy Annex C: Data for the responsible officer Version 2 April 2015 Page 5

71 Section Specific items expected in relation to a specific role declared in a doctor's scope of work This section should be developed where national agreement determines items of information for doctors undertaking specific roles in their scope of work throughout NHS England to present at their appraisal. Absence of such nationally agreed information at the doctor's appraisal should then be flagged for the attention of the responsible officer. Such items of information are not necessarily directly relevant to the doctor's revalidation recommendation. Items included in the table below should be viewed as examples, as the processes by which these items are to be agreed have yet to be established. Scope of work: responsible officer General Confirmation of appointment as RO by the organisation (for all organisations where they are the RO). Required once, at commencement of appointment to role of RO. Supporting information CPD: RO training undertaken. The doctor has confirmed to the appraiser that they have attended suitable responsible officer training. CPD: evidence of compliance with designated body mandatory training. The doctor has confirmed to the appraiser that they have complied with their organisations requirements for mandatory training. CPD: Evidence of attendance at RO network events annually (expectation to attend all; minimum three annually). The doctor has confirmed to the appraiser within their CPD log the RO Network activities that they have participated in since their last appraisal. Scope of work: general practitioner General Works a minimum of one clinical session per week. Annually. Appraiser should make comment if a doctor declaring general practice as a component of their scope of work is undertaking less than this. Supporting information CPD: Basic Life Support training. Annually. Certification of CPR training. Comment if not present. CPD: Log or diary of CPD activity in keeping with RCGP definition and recommendation of 50 CPD credits per year. Comment if not presented or if not sufficient. Annually. Comment if level of CPD activity deviates significantly below that recommended by the RCGP. NHS England Medical Appraisal Policy Annex C: Data for the responsible officer Version 2 April 2015 Page 6

72 QI: Revalidation quality management report(s) and action plan presented and discussed. The doctor has presented the revalidation quality management report(s) relating to their designated body (including ORSA or its superceding equivalent), the resulting action plan(s), and these have been discussed in the appraisal. Record "none" when no such reports are presented. QI: External reviews and reports (including. CQC), and resulting action plans presented and discussed. The doctor has presented any other relevant quality management report(s) (including but not limited to CQC reports), the resulting action plan(s), and these have been discussed in the appraisal. Record "none" when no such reports are presented. Further columns to be added to the above table as agreement on the information associated with other specific roles develops. Rows to be amended or added as items of information within a specific role are agreed or discarded. NHS England Medical Appraisal Policy Annex C: Data for the responsible officer Version 2 April 2015 Page 7

73 Section Locally agreed aspects This section should be developed where local agreement determines items of information for doctors in geographical areas of NHS England to present at their appraisal. Absence of such locally agreed information should then be flagged for the attention of the responsible officer. Such an approach might be helpful if a particular area has a local driving need. One example of this is where a regional responsible officer might be asked to provide information about national locum agencies, which are concentrated in one region. Another might be where one local area team is piloting the inclusion of a new item of supporting information which might go on to become standardised across NHS England, such as a requirement for general practitioners to present evidence of CPD in relation to children s safeguarding. As in Section 2, such items of information are not necessarily directly relevant to the doctor's revalidation recommendation. Again as in Section 2, items included in this section of the table below should be viewed as examples, as the processes by which these items are to be agreed have yet to be established. Scope of work: regional responsible officer Review of compliance of locum agency responsible officers with revalidation processes. Scope of work: general practitioner CPD: Children's safeguarding training. Further columns to be added to the above table as agreement on the information associated with other specific roles develops. Rows to be amended or added as items of information within a specific role are agreed or discarded. NHS England Medical Appraisal Policy Annex C: Data for the responsible officer Version 2 April 2015 Page 8

74 OFFICIAL NHS England Medical Appraisal Policy Annex D: Requesting postponement of appraisal NHS England Medical Appraisal Policy Version 2 April 2015 Annex D: Requesting postponement of appraisal Page 1

75 NHS England INFORMATION READER BOX Directorate Medical Commissioning Operations Patients and Information Nursing Finance Trans. & Corp. Ops. Commissioning Strategy Publications Gateway Reference: Document Purpose Guidance Document Name Medical Appraisal Policy (v2) Author NHS England, Medical Directorate (Revalidation) Publication Date May 2015 Target Audience Responsible Officers, Medical Appraisal Leads, Medical Appraisers Additional Circulation List Description Medical Directors, Doctors with a prescribed connection to NHS England, DH, BMA, GMC, Royal College of GPs, NHS Employers, Academy of Medical Royal Colleges, Regional HR and Finance Leads, NHS England Regional Directors Policy for appraisal of licensed medical practitioners who have a prescribed connection to NHS England (circa 42,000 doctors from circa 700 designated bodies). It describes the framework for appraisal, with tools to support implementation contained within the annexes. Cross Reference The Medical Profession (Responsible Officers) Regulations, 2010/2013 and the GMC (Licence to Practice and Revalidation) Regulations 2012 Superseded Docs (if applicable) Action Required Timing / Deadlines (if applicable) Contact Details for further information Document Status Medical Appraisal Policy (v1) published October 2013 Responsible officers to ensure that Doctors with a connection to NHS England are appraised in accordance with this policy To be implemented as soon as reasonably practicable Dr Maurice Conlon england.revalidation-pmo@nhs.net This is a controlled document. Whilst this document may be printed, the electronic version posted on the intranet is the controlled copy. Any printed copies of this document are not controlled. As a controlled document, this document should not be saved onto local or network drives but should always be accessed from the intranet. The NHS Commissioning Board (NHS CB) was established on 1 October 2012 as an executive non-departmental public body. Since 1 April 2013, the NHS Commissioning Board has used the name NHS England for operational purposes. NHS England Medical Appraisal Policy Annex D: Requesting postponement of appraisal Version 2 April 2015 Page 2

76 Annex D: Requesting postponement of appraisal This annex sets out the procedure which NHS England will adopt with regard to an application for a postponement of appraisal of doctors who have a prescribed connection to NHS England. As described in the main body of this policy, all doctors with a prescribed connection to NHS England are obliged to undergo annual appraisal. This should take place during the doctor s appraisal month (as defined in the main policy document). There are circumstances when a doctor may request that an appraisal is deferred such that no appraisal takes place during one appraisal year (which runs 1 April to March 31), or that the appraisal is postponed to take place later than the last day of their appraisal month. Doctors may request a postponement of an appraisal due to: breaks in practice due to sickness, maternity or adoption leave; breaks in practice due to absence abroad or sabbaticals; delay of an appraisal beyond the last day of their appraisal month due to unforeseen personal or work related issues. It may be appropriate to postpone appraisal if a doctor is suspended or excluded from work, but it may also be appropriate to continue with appraisal and the individual circumstances in such situations should be considered on their own merit by the relevant NHS England responsible officer. This list is not exhaustive and other reasons may also be identified. A doctor who is seeking to return to practise after a period of absence should discuss their circumstances with their new responsible officer at the earliest opportunity. Guidance is also available from their specialty body. The timing of their first appraisal will be determined to some extent by their individual circumstances, including whether they can demonstrate that they have maintained fitness to practise in the relevant areas during their absence and hence whether a bespoke re-training programme or period of supervision is required prior to resuming practice. In general, the first appraisal should take place between 6 and 12 months after re-entry to professional practice. Where possible and practical, if the doctor had a previously agreed appraisal month this should be reinstated. Also, if the doctor has had an appraisal previously and circumstances permit, their first appraisal should be undertaken within 15 months of the last one. No doctor will be disadvantaged or unfairly penalised as a result of protected characteristics. NHS England Medical Appraisal Policy Annex D: Requesting postponement of appraisal Version 2 April 2015 Page 3

77 1.1 Process for requesting a postponement Prior to submitting a formal request for postponement of appraisal, a doctor may choose to seek informal advice from their local clinical lead for appraisal. A doctor who thinks they may need to postpone their appraisal should complete a formal request and submit this to the relevant responsible officer. Postponement applications should be submitted at the earliest possible opportunity and in most circumstances no later than 28 days before the last day of the doctor s appraisal month (i.e. the date by which the doctor should normally have notified the agreed date of their appraisal to the appraisal office (See Annex A)). The NHS England responsible officer or other person with delegated authority will consider postponement requests and applicants will be informed in writing of the decision within seven working days. NHS England Medical Appraisal Policy Annex D: Requesting postponement of appraisal Version 2 April 2015 Page 4

78 Appraisal postponement application form Section A Doctor s details and request for postponement Doctor s name: GMC number: Telephone number(s): Mobile: Practice: Home: Doctor s appraisal month: Date of last appraisal: Name of last appraiser: Revalidation due date: Reason for request for postponement of appraisal: Proposed date for next appraisal: Date of request: Section B Local decision Name of person considering request: Position: Postponement agreed: Yes No Comment: Agreed new appraisal due date: Date of decision: NHS England Medical Appraisal Policy Annex D: Requesting postponement of appraisal Version 2 April 2015 Page 5

79 OFFICIAL NHS England Medical Appraisal Policy Annex E: Non-participation in appraisal NHS England Medical Appraisal Policy Version 2 April 2015 Annex E: Non-participation in appraisal Page 1

80 NHS England INFORMATION READER BOX Directorate Medical Commissioning Operations Patients and Information Nursing Finance Trans. & Corp. Ops. Commissioning Strategy Publications Gateway Reference: Document Purpose Guidance Document Name Medical Appraisal Policy (v2) Author NHS England, Medical Directorate (Revalidation) Publication Date May 2015 Target Audience Responsible Officers, Medical Appraisal Leads, Medical Appraisers Additional Circulation List Description Medical Directors, Doctors with a prescribed connection to NHS England, DH, BMA, GMC, Royal College of GPs, NHS Employers, Academy of Medical Royal Colleges, Regional HR and Finance Leads, NHS England Regional Directors Policy for appraisal of licensed medical practitioners who have a prescribed connection to NHS England (circa 42,000 doctors from circa 700 designated bodies). It describes the framework for appraisal, with tools to support implementation contained within the annexes. Cross Reference The Medical Profession (Responsible Officers) Regulations, 2010/2013 and the GMC (Licence to Practice and Revalidation) Regulations 2012 Superseded Docs (if applicable) Action Required Timing / Deadlines (if applicable) Contact Details for further information Document Status Medical Appraisal Policy (v1) published October 2013 Responsible officers to ensure that Doctors with a connection to NHS England are appraised in accordance with this policy To be implemented as soon as reasonably practicable Dr Maurice Conlon england.revalidation-pmo@nhs.net This is a controlled document. Whilst this document may be printed, the electronic version posted on the intranet is the controlled copy. Any printed copies of this document are not controlled. As a controlled document, this document should not be saved onto local or network drives but should always be accessed from the intranet. The NHS Commissioning Board (NHS CB) was established on 1 October 2012 as an executive non-departmental public body. Since 1 April 2013, the NHS Commissioning Board has used the name NHS England for operational purposes. NHS England Medical Appraisal Policy Annex E: Non-participation in appraisal Version 2 April 2015 Page 2

81 Annex E: Non-participation in appraisal 1.1 Background All doctors with a licence to practise are required to participate meaningfully in annual appraisal in accordance with GMC revalidation regulations. In addition, doctors on the NHS England Performers List are required to do so under the NHS (Performers Lists) Regulations Doctors employed or engaged under different means by NHS England are required to do so within the terms of their contract of employment or terms of engagement. In the majority of cases, most doctors participate actively in the system. In some cases, a process of dialogue between the doctor and responsible officer may be necessary to establish agreement about what constitutes meaningful appraisal within the terms of the guidance that exists. For a small minority who do not participate, clear processes are required to handle such non-participation under: the provisions of the National Health Service (Performers Lists) (England) Regulations 2013 if appropriate, in respect of their breach of the undertakings agreed and implicit in their inclusion in the Medical Performers List; the regulations and rules relevant to the relevant contract of employment or terms of engagement; the General Medical Council (Licence to Practise and Revalidation) Regulations The procedure below: identifies the sequence of actions which will be taken to support participation with the appraisal system when there is apparent non-participation by a doctor. reminds practitioners of their professional responsibilities. advises practitioners as to the potential implications in the case of doctors: - where they are included in the Medical Performers List - where they hold employment contracts - where they are engaged under other terms of engagement - regarding revalidation and their licence to practise. Failure to participate meaningfully in the process will place a doctor s inclusion on the Performers List, and/or their employment/engagement status, and potentially their GMC licence to practise at risk. 1.2 Procedure The following procedure describes how NHS England operates in relation to apparent non-participation with medical appraisal. NHS England Medical Appraisal Policy Annex E: Non-participation in appraisal Version 2 April 2015 Page 3

82 1. Each year, each doctor will be made aware of the requirement to have their annual appraisal by the last day of their agreed appraisal month (appraisal deadline). Doctors whose prescribed connection to NHS England is new will be made aware of the identity of their responsible officer, and the relevant appraisal officer. Account will be taken of the date of the most recent appraisal in determining the doctor s appraisal month, the last day of this being their appraisal due date. Where not already otherwise established, and where a different month is not agreed to be more appropriate, a doctor s appraisal due date will be the last day of their birth month. 2. In keeping with the appraisal process described in annex A, a doctor will receive at least one reminder (normally electronic) of the need to arrange their appraisal at least 56 days prior to the last day of the doctor s appraisal month (Reminder letter 1 is an example of such a letter). 3. If 28 days following the end of the doctor s appraisal month the appraisal officer has not received the appraisal output documents, the local systems will be checked to verify the current, or most recent, and registered address for the doctor. After a further 7 days a second reminder letter will then be sent out by to the address held on record for the doctor, and by letter to the address given to NHS England as designated body by the doctor. (Reminder letter 2 is an example of such a letter) 4. If a response is received within 5 working days to the second reminder letter, and the doctor has either requested or has booked their appraisal within 28 days, the normal process is resumed. A new appraisal date will be set and the normal process resumed. 5. If no response is received to the second reminder letter, or a response is received advising that no appraisal has been booked, a third reminder letter (Reminder letter 3 is an example of such a letter) will be sent to the doctor 7 working days after the date of the second reminder letter (or as soon as the response is received). This letter will be sent from the responsible officer and will remind the doctor of their responsibilities, the potential consequences of failing to participate in the appraisal system, and the steps the responsible officer will take should the doctor continue to fail to engage. The third reminder letter will be sent by to the address held on record for the doctor, and by letter (recorded delivery) to the address given to NHS England as designated body by the doctor. 6. If a response is received to the third reminder letter, and the doctor has either requested or has booked their appraisal within 28 days, the normal process is resumed. A new appraisal date will be set and the normal process is resumed. NHS England Medical Appraisal Policy Annex E: Non-participation in appraisal Version 2 April 2015 Page 4

83 7. If no response is received to the third reminder letter or a response is received advising that no appraisal has been booked, a fourth and final letter (Final reminder letter 4 is an example of such a letter) will be sent to the doctor 7 working days after the date of the third reminder letter (or as soon as the response is received). This letter will be sent from the responsible officer. It will advise that formal action under the NHS (Performers Lists) (England) Regulations 2013 disciplinary procedures/contract of employment disciplinary procedures, and/or notification of non-participation to the GMC is being considered and/or that because of failure to engage in the appraisal process, the doctor has been referred into the local NHS England practitioner performance processes. The fourth and final reminder letter will be sent by e- mail to the address held on record for the doctor, and by letter (recorded delivery) to the address given to NHS England as designated body by the doctor. 8. Having considered the facts, the relevant decision making group will then determine the appropriate course of action which may involve engaging the (Performers List) Regulations, disciplinary procedures, other locally or contractually appropriate processes and/or notification of non-participation to the GMC. NHS England Medical Appraisal Policy Annex E: Non-participation in appraisal Version 2 April 2015 Page 5

84 1.2.1 Reminder letter 1 sent at 56 days before deadline for appraisal meeting LOGO Local office address and contact details Date Dear Dr xxxx REMINDER: Your appraisal 20XX-XX This is to remind you that are due to have your appraisal at the latest by xxxx. For your appraisal to be considered complete, your post appraisal paperwork needs to be in the office by xxxx + 28days. If you do not think you need an appraisal this year please inform the office of the reasons in writing or by at the above address to avoid you receiving further reminders. You must inform us and/or Medical Performers List administrators about the circumstances that mean that you do not need to have your appraisal. If you have mitigating circumstances, please advise the office so that we can consider invoking the formal process to postpone your appraisal. The enclosed document (Medical Appraisal Policy Annex D: Requesting postponement of appraisal) will help you to decide how to proceed. Should you have any queries, please do not hesitate to contact me. Yours sincerely Xxxxx xxxxx Appraisal and Revalidation Office Enclosed Medical Appraisal Policy Annex D: Requesting postponement of appraisal NHS England Medical Appraisal Policy Annex E: Non-participation in appraisal Version 2 April 2015 Page 6

85 1.2.2 Reminder letter 2 sent seven days after paperwork due (i.e days after deadline for appraisal meeting) LOGO Local office address and contact details Dear Dr xxxx Failure to participate in the NHS England appraisal system Our records indicate that you should have had your 20xx-20xx appraisal by DD/MM/YYYY. To date we have not received confirmation that your appraisal has been undertaken. Please can you inform me if your appraisal has been undertaken and if so confirm the date and the name of your appraiser so we can follow up the documentation. If you have not had your appraisal please inform me of the reason for this by within the next 5 working days. My address/contact details are as shown at the top of this letter. I also attach details of the non-participation in the appraisal escalation process for your information (Figure 1). As your local appraisal officer, I have to inform you that participation in the appraisal system provided by NHS England is a regulatory and/or contractual requirement for all doctors with a prescribed connection to the NHS England. Failure to participate without agreed postponement places you at risk of action being taken against you under the various provisions of the regulations and/or your contract. Annual appraisal is viewed by NHS England as a valuable component of a doctor s professional development. Participation in annual appraisal is also a requirement to remain on the Medical Performers List of NHS England. In addition, a satisfactory annual appraisal is now a GMC requirement for revalidation and non-participation places you at risk of the matter being referred to the GMC. This letter has been sent by and hard copy to the most recent address you have supplied to the NHS England XXX appraisal team. Yours sincerely XXXX XXXXX Title (Appraisal Office to Responsible Officer) cc Xxx Xxxx: Responsible Officer NHS England Medical Appraisal Policy Annex E: Non-participation in appraisal Version 2 April 2015 Page 7

86 1.2.3 Reminder letter 3 sent seven days after reminder letter 2 LOGO Local office address and contact details Date Dear Dr xxxx Failure to participate in the NHS England appraisal system Further to the letter dated INSERT DATE from INSERT NAME, Appraisal Officer, I am writing to express my concern that you have failed to respond and participate in the annual appraisal process. I would remind you that it is a GMC requirement that you participate in the appraisal system provided by NHS England. You will also be aware that with the introduction of revalidation I will be required as your responsible officer to make a recommendation on your fitness to be relicensed. One of the questions I will be obliged to answer will be in relation to your participation with the appraisal process. I therefore urge you to book your appraisal within 7 working days of the date of this letter and to make the necessary arrangements for your appraisal to be carried out as a matter of urgency. If there are any practical problems in arranging your appraisal please contact the local office without delay. I have requested the appraisal office to advise me should you fail to do so. If I do not receive confirmation from you that you are taking urgent steps to arrange your appraisal by DD/MM/YYYY. I intend to refer your case to the INSERT NAME OF RELEVANT LOCAL DECISION MAKING GROUP to consider formal regulatory and/or contractual action as appropriate. If I do not receive confirmation from you that you are taking urgent steps to arrange your appraisal, your failure to participate will also be recorded in the local revalidation system and I will begin discussions with the local GMC Employer Liaison Adviser about your non-participation with the appraisal system. As annual appraisal is a GMC requirement I have to inform you that you are at risk of a formal referral to the GMC in respect of your revalidation. I look forward to being advised that you have taken the appropriate steps to remedy the situation. This letter has been sent by and hard copy by registered mail to the most recent address you have supplied to NHS England XXX appraisal team. Should you have any queries, please do not hesitate to contact me. Yours sincerely Xxxxx xxxxx Responsible Officer NHS England Medical Appraisal Policy Annex E: Non-participation in appraisal Version 2 April 2015 Page 8

87 1.2.4 Final reminder letter 4 LOGO Local office address and contact details Date Dear Dr xxxx Failure to participate in the NHS England appraisal system Further to my letter dated INSERT DATE, a copy of which is attached for your information, I have been advised that you have still failed to comply with your regulatory requirement to engage in the annual appraisal system provided by NHS England in accordance with the provisions of Regulation 9(7) of the NHS (Performers Lists) Regulations 2004 and/or the GMC Revalidation Regulations I am therefore writing to advise you that I have referred your case into the local NHS England practitioner performance processes to consider formal regulatory and/or Performers List and/or contractual or other action as appropriate. In addition, your failure to participate will also be recorded in the local revalidation system. As annual appraisal is a GMC requirement, I have to inform you that I will now discuss your case with the local GMC Employer Liaison Adviser, and that you are at risk of a formal referral to the GMC in respect of your revalidation. I urge you to make immediate contact with me so that this matter can be resolved. This letter has been sent by and hard copy to the most recent address you have supplied to the Medical Performers List and to the local GMC Employer Liaison Advisor. Yours sincerely Xxxxx xxxxx Responsible Officer cc Local GMC Employer Liaison Advisor NHS England Medical Appraisal Policy Annex E: Non-participation in appraisal Version 2 April 2015 Page 9

88 1.3 Figure 1 Non-participation flowchart Letter 1 Reminder of Appraisal 56 Days Appraisal due Birth month Agreed month Appraisal Month Check contact details are correct Appraisal taken place on time End of appraisal month Appraisal not taken place or no contact 28 days 7 days AFTER 28 day deadline Letter 2 sent New appraisal month Postponement agreed Postponement requested Postponement NOT agreed 7 working days Response Received Yes No Documents received Appraisal booked within 7 days Letter 3 sent 7 working days Appraisal complete Response Received No 7 working days Engage Performance/Disciplinary GMC Notification Letter 4 sent NHS England Medical Appraisal Policy Annex E: Non-participation in appraisal Version 2 April 2015 Page 10

89 OFFICIAL NHS England Medical Appraisal Policy Annex F: Complaints process NHS England Medical Appraisal Policy Version 2 April 2015 Annex F: Complaints process Page 1

90 NHS England INFORMATION READER BOX Directorate Medical Commissioning Operations Patients and Information Nursing Finance Trans. & Corp. Ops. Commissioning Strategy Publications Gateway Reference: Document Purpose Guidance Document Name Medical Appraisal Policy (v2) Author NHS England, Medical Directorate (Revalidation) Publication Date May 2015 Target Audience Responsible Officers, Medical Appraisal Leads, Medical Appraisers Additional Circulation List Description Medical Directors, Doctors with a prescribed connection to NHS England, DH, BMA, GMC, Royal College of GPs, NHS Employers, Academy of Medical Royal Colleges, Regional HR and Finance Leads, NHS England Regional Directors Policy for appraisal of licensed medical practitioners who have a prescribed connection to NHS England (circa 42,000 doctors from circa 700 designated bodies). It describes the framework for appraisal, with tools to support implementation contained within the annexes. Cross Reference The Medical Profession (Responsible Officers) Regulations, 2010/2013 and the GMC (Licence to Practice and Revalidation) Regulations 2012 Superseded Docs (if applicable) Action Required Timing / Deadlines (if applicable) Contact Details for further information Document Status Medical Appraisal Policy (v1) published October 2013 Responsible officers to ensure that Doctors with a connection to NHS England are appraised in accordance with this policy To be implemented as soon as reasonably practicable Dr Maurice Conlon england.revalidation-pmo@nhs.net This is a controlled document. Whilst this document may be printed, the electronic version posted on the intranet is the controlled copy. Any printed copies of this document are not controlled. As a controlled document, this document should not be saved onto local or network drives but should always be accessed from the intranet. The NHS Commissioning Board (NHS CB) was established on 1 October 2012 as an executive non-departmental public body. Since 1 April 2013, the NHS Commissioning Board has used the name NHS England for operational purposes. NHS England Medical Appraisal Policy Annex F: Complaints process Version 2 April 2015 Page 2

91 Annex F: Complaints process Doctors with a prescribed connection to NHS England who undergo appraisal can expect their appraisal to be conducted under the terms of this policy. The process should be well organised and professionally carried out by the staff supporting the process, the appraiser and any other personnel contributing to the process. This annex describes the process by which a doctor may make a complaint about the appraisal process, where they believe that the terms of this policy have not been followed, or that their appraiser or any other personnel involved in the process has not undertaken their duties in a proper and professional manner. Complaints should be resolved: as quickly as possible, fairly and non-judgementally, at a local level, and using any outcomes to formulate lessons learned and to improve the quality of the service. Common categories under which a complaint may be made about the appraisal process by a doctor include, but are not limited to: the standard of service provided by an individual appraiser; deviation from agreed standard appraisal procedures; the actions or behaviour of any appraisal team members; actions or inactions deemed detrimental to an individual doctor or their practice; failures in the administration system, including communication; appraiser allocation and payments; breaches of confidentiality; dissatisfaction or disagreement with decisions reached or matters pertaining to professional or clinical judgement. If an individual doctor has concerns regarding their appraisal this should be raised in the first instance with the individual concerned. If the doctor feels unable to raise the matter with the individual or the doctor remains unhappy with the response they have received, they should complain to the local appraisal clinical lead or appraisal manager. Complaints should be made in writing. Figure 1 contains a suitable template for this. The local appraisal officer is responsible to the relevant responsible officer for managing the complaints process, with input from the local clinical appraisal lead. On receipt of a complaint, the local appraisal manager should log the complaint, notify the responsible officer, acknowledge receipt of the complaint to the doctor within 1 working week, and undertake an information gathering exercise to establish the facts. The doctor should be made aware that further help, advice and support are available, for example from the BMA. NHS England Medical Appraisal Policy Annex F: Complaints process Version 2 April 2015 Page 3

92 The local appraisal manager and the clinical appraisal lead should then review the facts and develop a response to the complaint. A written response to the doctor making the complaint should be made within 28 days. This should contain: a summary of the complaint; description of the facts as they have been established; a summary of the outcome; an apology where appropriate; details of any changes implemented as a result of the complaint information on further support and advice if the complainant remains dissatisfied. If the doctor is not satisfied by the response to their complaint, they should raise the matter with the responsible officer. If the doctor s complaint relates to the actions of their responsible officer, it may still be possible to use this form but it should be submitted to the responsible officer s responsible officer. All complaints relating to the NHS England medical appraisal process will be collated by NHS England responsible officers in the context of the quality assurance process, and a review with outcomes included in the medical appraisal governance processes. Confidentiality of all personnel should be maintained at all times. This process does not aim to address issues around: anonymous or unofficial complaints including whistle blowing; dissatisfaction with regionally or nationally agreed appraisal policies. NHS England Medical Appraisal Policy Annex F: Complaints process Version 2 April 2015 Page 4

93 Figure 1: Standard complaint template Template for complaint about the appraisal process by a doctor Responsible officer: Doctor: Doctor s GMC number: Appraiser: Date of incident: Subject of complaint: Details of complaint: Date of complaint: Thank you for raising a complaint about the appraisal process. You should submit this to your local appraisal office. You should receive an acknowledgement within seven days and a written response within 28 days. Appraisal office use Date of final response: Signed off by: Outcome and action taken: NHS England Medical Appraisal Policy Annex F: Complaints process Version 2 April 2015 Page 5

94 OFFICIAL NHS England Medical Appraisal Policy Annex G: Clinical appraisal lead and senior appraiser job descriptions and person specifications NHS England Medical Appraisal Policy Version 2 April 2015 Annex G: Clinical appraisal lead and senior appraiser job descriptions and person specifications Page 1

95 NHS England INFORMATION READER BOX Directorate Medical Commissioning Operations Patients and Information Nursing Finance Trans. & Corp. Ops. Commissioning Strategy Publications Gateway Reference: Document Purpose Guidance Document Name Medical Appraisal Policy (v2) Author NHS England, Medical Directorate (Revalidation) Publication Date May 2015 Target Audience Responsible Officers, Medical Appraisal Leads, Medical Appraisers Additional Circulation List Description Medical Directors, Doctors with a prescribed connection to NHS England, DH, BMA, GMC, Royal College of GPs, NHS Employers, Academy of Medical Royal Colleges, Regional HR and Finance Leads, NHS England Regional Directors Policy for appraisal of licensed medical practitioners who have a prescribed connection to NHS England (circa 42,000 doctors from circa 700 designated bodies). It describes the framework for appraisal, with tools to support implementation contained within the annexes. Cross Reference The Medical Profession (Responsible Officers) Regulations, 2010/2013 and the GMC (Licence to Practice and Revalidation) Regulations 2012 Superseded Docs (if applicable) Action Required Timing / Deadlines (if applicable) Contact Details for further information Document Status Medical Appraisal Policy (v1) published October 2013 Responsible officers to ensure that Doctors with a connection to NHS England are appraised in accordance with this policy To be implemented as soon as reasonably practicable Dr Maurice Conlon england.revalidation-pmo@nhs.net This is a controlled document. Whilst this document may be printed, the electronic version posted on the intranet is the controlled copy. Any printed copies of this document are not controlled. As a controlled document, this document should not be saved onto local or network drives but should always be accessed from the intranet. The NHS Commissioning Board (NHS CB) was established on 1 October 2012 as an executive non-departmental public body. Since 1 April 2013, the NHS Commissioning Board has used the name NHS England for operational purposes. NHS England Medical Appraisal Policy Version 2 April 2015 Annex G: Clinical appraisal lead and senior appraiser job descriptions and person specifications Page 2

96 Annex G: Clinical appraisal lead and senior appraiser 1 job descriptions and person specifications The job descriptions and person specifications contained in this annex are illustrative and based on the NHS England HR arrangements as understood at the time of publication of this version of the NHS England Medical Appraisal Policy. They should be customised and adapted at the time of appointment of persons to these roles in light of local requirements combined with the requirement to maintain consistency of approach across NHS England. The requirements of NHS England HR and other relevant policies should also be considered as they apply at that time. 1.1 Clinical appraisal lead job description Job title Clinical appraisal lead Reference number Directorate Medical directorate Pay band Medical Salary Responsible to Responsible officer: Accountable to Responsible officer: Responsible for Promoting medical appraisal and revalidation. Coordinating effective arrangements for medical appraisal. 1 A review of provision of support to appraisal across NHS England in 2014 found that in addition to appointing a clinical appraisal lead to support their overall appraisal system, it is widespread practice for NHS England responsible officers to engage a number of appraisers to support local groups of appraisers within their system. A variety of terms is in use to denote these persons. For simplicity and to make clear the distinction between the two roles, this policy uses the term senior appraiser to denote a medical appraiser who offers support and supervision to a designated local group of appraisers. NHS England Medical Appraisal Policy Version 2 April 2015 Annex G: Clinical appraisal lead and senior appraiser job descriptions and person specifications Page 3

97 Providing leadership for the medical appraiser workforce, including appropriate quality assurance and performance review. Base Clinical appraisal lead job purpose/summary The role of Clinical Appraisal Lead is to provide overall leadership and support to the whole medical appraiser workforce of the appraisal office, coordinating guidance, educational and benchmarking opportunities and performance review to all appraisers engaged by the office. Working closely with the Medical Appraisal Manager, senior appraisers and other appraisal office colleagues, the post holder will promote, support and facilitate the implementation of national appraisal policies and ensure a robust quality assurance process is implemented for medical appraisals. Key job specific responsibilities Managing the activity of medical appraisers to defined and quality assured standards, including, but not exclusive to: Promoting excellence in medical appraisal to deliver robust revalidation recommendations and quality improvements in patient care through the professional development of doctors. Recruiting and selecting medical appraisers. Organising and/or delivering competency based new appraiser training. Lead and support the senior appraisers of the appraisal office. Supporting new appraisers through a probationary period, such as the first three appraisals, providing feedback on their performance. Monitoring performance of existing appraisers, ensuring that appraisals are conducted in line with national, regional and local guidance, and that regular feedback is provided. Promoting and supporting the continuing professional development (CPD) of medical appraisers. Promoting the benchmarking of professional judgements between medical appraisers through the provision of resources and opportunities to learn with and from others. Supporting and facilitating local medical appraiser support group meetings, directly or indirectly. Answering queries from doctors and appraisers. Supporting the role of the responsible officer (RO) by ensuring that the outputs of appraisal provide the required information to enable robust revalidation recommendations to be made. NHS England Medical Appraisal Policy Version 2 April 2015 Annex G: Clinical appraisal lead and senior appraiser job descriptions and person specifications Page 4

98 Ensuring appraisals are carried out before the end of year deadline. Producing and promoting appropriate evaluation, reports and summaries, Dealing with significant events and complaints, with the medical appraisal manager. Keeping abreast of local and national developments in appraisal and revalidation. Promoting a quality assured appraisal and revalidation process to doctors and appraisers. Representing the appraisal team at local, regional and national initiatives relating to the development and implementation of appraisal. Networking with other clinical appraisal leads and their teams to maintain standards of delivery of medical appraisal across NHS England. Liaising with medical educators and their networks on issues relating to continuing professional development (CPD) for doctors being appraised. Ensuring compliance with all confidentiality and governance requirements. Working at all times to promote equality and reduce inequalities, promote the health, safety and well-being of all staff and champion the NHS Constitution. Key accountabilities The clinical appraisal lead will be accountable to the relevant NHS England responsible officer. Communications and key working relationships Responsible officer. Medical appraisal manager. Medical appraisal administrative team. Other clinical appraisal leads. Senior appraisers. Medical appraisers. Doctors being appraised. Key stakeholders, including GMC, the Academy of Medical Royal Colleges, NHS England, RST. Training and performance review The clinical appraisal lead will be required to undertake training and performance review appropriate to the role, including, but not restricted to, health and safety, equality and diversity and information governance training. This job description and person specification are an outline of the tasks, responsibility and outcomes required of the role. The job holder will carry out any other duties that may reasonably be required by their line manager. The job description and person specification may be reviewed on an on-going basis in accordance with the changing needs of the organisation and any changes in national policies or guidance. NHS England Medical Appraisal Policy Version 2 April 2015 Annex G: Clinical appraisal lead and senior appraiser job descriptions and person specifications Page 5

99 Additional Responsibilities for all staff NHS England is committed to providing a safe, healthy and fair working environment and to providing staff with opportunities to maximise their contribution through involvement and professional development. In addition to the specific responsibilities set out above, NHS England has the following expectations of all staff: Safeguarding Within their sphere of competence, each member of staff is responsible for promoting and safeguarding the welfare of the children, young people and / or vulnerable adults for whom they are responsible or may come into contact with, in the job role. Health & Safety NHS England aims to provide all staff, visitors and service users with a safe environment, in which to be able to work or visit, without suffering any personal injury or ill health. Each member of staff is responsible for ensuring that they work in such a way as to ensure their own health and safety, and that of other staff, clients, patients and members of the public. Information Quality All staff must ensure complete and accurate data is collected and recorded in a timely manner. Equality & Diversity NHS England recognises the diversity of its staff and undertakes to treat them equitably and fairly irrespective of gender, gender identity, disability, race age, sexual orientation, religion or belief. NHS England recognises its duty to each and every individual employee and will respect their human rights. It also expects that its employees will treat other staff, patients and members of the public with dignity and respect. Probationary period The job description would normally be for a probationary period of 3 months initially and subject to satisfactory performance review. Job description agreement NHS England Medical Appraisal Policy Version 2 April 2015 Annex G: Clinical appraisal lead and senior appraiser job descriptions and person specifications Page 6

100 Job holder s signature: Head of department s signature: Date: Date: NHS England Medical Appraisal Policy Version 2 April 2015 Annex G: Clinical appraisal lead and senior appraiser job descriptions and person specifications Page 7

101 1.2 Clinical appraisal lead person specification Core elements of a person specification for clinical appraisal lead No distinction has been made between essential and desirable as the importance of each of these qualities should be determined by the responsible officer in relation to local context. Qualifications Medical degree Licensed medical practitioner Entry on the medical performers list Experience Knowledge Trained and experienced medical appraiser Experience of managing time to ensure deadlines are met Experience of applying principles of quality improvement Experience of management of medical appraisals for revalidation, at a senior level Knowledge of the role and responsibilities of the medical appraiser and clinical appraisal lead Knowledge of the purpose and process of medical appraisal Knowledge of the purpose and principles of revalidation Knowledge of responsibilities of doctors as described in Good Medical Practice Knowledge of the GMC Framework for medical appraisal and revalidation and the GMC supporting information for appraisal and revalidation Knowledge of the Medical Appraisal Guide (RST, 2013) Knowledge of principles of clinical governance, evidence based medicine and clinical effectiveness Knowledge of relevant local and national healthcare context Knowledge of current NHS structures, including the role of regulators Understanding and application of principles of equality and diversity Understanding and application of principles of information governance Understanding and application of legislation and guidance relating to data protection and confidentiality Knowledge of relevant speciality specific elements, including Royal College guidance on continuing professional development requirements and quality improvement activities Skills Motivating, influencing and negotiating skills Good oral communication skills, including active listening skills, the ability to understand and summarise a discussion, ask appropriate questions, provide constructive challenge and give effective feedback Good written communication skills, including the ability to summarise clearly and accurately NHS England Medical Appraisal Policy Version 2 April 2015 Annex G: Clinical appraisal lead and senior appraiser job descriptions and person specifications Page 8

102 Objective evaluation skills Appropriate IT skills for the role (familiarity with web-based appraisal support systems, on-line resources, web based discussion forums, reliable electronic communication skills) Proven leadership skills, including delegation, time-management, and networking skills Attributes Excellent personal integrity, personal effectiveness and selfawareness Motivated, enthusiastic, positive role model Able to adapt behaviour to meet the needs of the group and in the light of feedback Significant commitment to on-going personal education and development Able to work independently and autonomously Able to manage own workload and make timely and informed decisions Demonstrates a commitment to and focus on quality Promotes high standards to consistently improve patient outcomes Values diversity and difference Operates with integrity and openness Uses evidence to make improvements Looks for collective success, listens and learns from the contribution of others Good working relationships and credibility with professional colleagues and relevant stakeholders Able to work effectively in a team Able to build wide support networks with key stakeholders, including doctors and appraisers NHS England Medical Appraisal Policy Version 2 April 2015 Annex G: Clinical appraisal lead and senior appraiser job descriptions and person specifications Page 9

103 1.3 Senior appraiser job description Job Title Reference Number Directorate Pay Band Senior appraiser To be completed by HR Medical directorate Medical Salary Responsible to Accountable to Responsible for Responsible officer or nominated deputy (e.g. clinical appraisal lead) Responsible officer or nominated deputy (e.g. clinical appraisal lead) Promoting medical appraisal and revalidation Directly managing and supporting medical appraisers Base Senior appraiser job purpose/summary The role of senior appraiser is to provide leadership and support to a nominated number of the engaged medical appraisers of the appraisal office, coordinating guidance, educational and benchmarking opportunities and performance review to these appraisers. Working closely with the clinical appraisal lead, the medical appraisal manager, other senior appraisers and other colleagues in the appraisal office, the post holder will promote, support and facilitate the implementation of national appraisal policies and ensure a robust quality assurance process is implemented for medical appraisals. A senior appraiser will undertake the programme as outlined below; Job Purpose: Aims to continuously improve the standard of care provided by doctors connected to NHS England. Aims to support the responsible officer for medical revalidation. Aims to support the medical appraisal process for NHS England. To support the performance review process. To support and work closely with the medical appraisal co-ordinator/administrator office. To be responsible for the continuing assurance of appraisers. To participate in or implement quality assurance process and give feedback to appraisers regarding their performance as an appraiser. NHS England Medical Appraisal Policy Version 2 April 2015 Annex G: Clinical appraisal lead and senior appraiser job descriptions and person specifications Page 10

104 To review and contribute to regular appraisal review on every appraiser. To be the first point of contact for issues arising out of appraisals. To contribute and adhere to the appraisal policies processes and procedures. To keep the responsible officer (or nominated deputy) informed of developments and initiatives in appraisal, revalidation, professional regulation and related matters. To contribute to the recruitment process for medical appraisers. To deliver and contribute to a comprehensive training and support package provided for all new appraisers. To raise performance concerns identified through the appraisal process with the responsible officer or nominated deputy. Contribute to other specific function related activity in relation to appraisals as agreed with the responsible officer. To support the appraisal and revalidation process for NHS England. To support individual doctors to improve their standard of care. Key result areas To assist NHS England in its compliance with the requirements of medical revalidation. To ensure the NHS England medical appraisal scheme is in line with national and local policies and that it is responsive to the evolving requirements of revalidation. To ensure appropriate assurance of appraisers and that there is an appropriate appraiser/doctor ratio and representative appraiser mix. To ensure that all doctors connected to NHS England are appraised in accordance with regulations, policies and procedures. Deputise for the responsible officer or nominated deputy as required. Managerial responsibilities Together with the medical appraisal co-ordinator/administrator implement the policies and procedures required for medical appraisal in NHS England, consistent with the requirements of medical revalidation. Undertake regular appraiser assurance reviews with medical appraisers. To raise performance concerns identified through the appraisal process with the medical director/responsible officer or nominated deputy. Administrative responsibilities Ensure that all documentation in respect of medical appraisal is completed in a timely fashion by the appraisers for whom the senior appraiser has responsibility. Regularly review and evaluate the documentation associated with the medical appraisal scheme. Communication and liaison responsibilities Improve awareness and understanding of medical appraisal and revalidation to doctors, including any changes to policy or processes. Promote an environment of trust and support between the NHS England and its NHS England Medical Appraisal Policy Version 2 April 2015 Annex G: Clinical appraisal lead and senior appraiser job descriptions and person specifications Page 11

105 doctors. Training and development responsibilities Keep up to date with current developments in the NHS. Ensure new medical appraisers have undertaken an appropriate training programme and that they participate in regular support and educational development activities to ensure all appraisers are up to date with issues related to medical appraisal and revalidation. Additional Responsibilities for all staff NHS England is committed to providing a safe, healthy and fair working environment and to providing staff with opportunities to maximise their contribution through involvement and professional development. In addition to the specific responsibilities set out above, NHS England has the following expectations of all staff: Safeguarding Within their sphere of competence, each member of staff is responsible for promoting and safeguarding the welfare of the children, young people and / or vulnerable adults for whom they are responsible or may come into contact with, in the job role. Health & Safety NHS England aims to provide all staff, visitors and service users with a safe environment, in which to be able to work or visit, without suffering any personal injury or ill health. Each member of staff is responsible for ensuring that they work in such a way as to ensure their own health and safety, and that of other staff, clients, patients and members of the public. Information Quality All staff must ensure complete and accurate data is collected and recorded in a timely manner. Equality & Diversity NHS England recognises the diversity of its staff and undertakes to treat them equitably and fairly irrespective of gender, gender identity, disability, race age, sexual orientation, religion or belief. NHS England recognises its duty to each and every individual employee and will respect their human rights. It also expects that its employees will treat other staff, patients and members of the public with dignity and respect. NHS England Medical Appraisal Policy Version 2 April 2015 Annex G: Clinical appraisal lead and senior appraiser job descriptions and person specifications Page 12

106 Confidentiality All staff must at all times be aware of the importance of maintaining confidentiality on information gained in the course of their duties. This may well include access to personal information relating to service users and NHS England staff. Information Governance All staff have a personal responsibility to ensure that person identifiable, confidential or sensitive information is processed in line with the Data Protection Act, the NHS Records Management Code and the NHS Code of Confidentiality. All staff should be aware of the requirements of the Freedom of Information Act 2000 and the NHS England procedures for dealing with requests for information in a timely manner. Access to Health Records All staff who contribute to patients health records are expected to be familiar with, and adhere to the NHS England Records Management policy. Staff should be aware that patients records throughout NHS England will be subject to regular audit. In addition, all health professionals are advised to compile records on the assumption that they will be accessible to patients in line with the Data Protection Act All staff that have access to patients records have a responsibility to ensure that these are maintained and that confidentiality is protected in line with PCT Policy. This job description is not intended to be an exhaustive list of duties but to give a guide to the objectives and responsibilities of the post. It will be reviewed in line with any organisational change and annually as part of the post holder s job review process. Probationary period The job description would normally be for a probationary period of 3 months initially and subject to satisfactory performance review Job description agreement Job holder s signature: Head of department s signature: Date: Date: NHS England Medical Appraisal Policy Version 2 April 2015 Annex G: Clinical appraisal lead and senior appraiser job descriptions and person specifications Page 13

107 1.4 Senior appraiser person specification Core elements of a person specification for senior appraiser No distinction has been made between essential and desirable as the importance of each of these qualities should be determined by the responsible officer in relation to local context. Qualifications Medical degree Licensed medical practitioner Entry on the medical performers list Higher medical qualification (e.g. MRCGP or equivalent qualification) Experience Experience and understanding of NHS England and Primary Care Organisations Active medical appraiser GP Education e.g. as a Trainer or Teacher Knowledge Skills Attributes Medical appraisal and medical revalidation Change Management skills Relevant educational qualification Motivating, influencing and negotiating skills Good oral communication skills, including active listening skills, the ability to understand and summarise a discussion, ask appropriate questions, provide constructive challenge and give effective feedback Good written communication skills, including the ability to summarise clearly and accurately Objective evaluation skills Appropriate IT skills for the role (familiarity with web-based appraisal support systems, on-line resources, web based discussion forums, reliable electronic communication skills) Proven leadership skills, including delegation, time-management, and networking skills Excellent personal integrity, personal effectiveness and self-awareness Motivated, enthusiastic, positive role model Able to adapt behaviour to meet the needs of the group and in the light of feedback Significant commitment to on-going personal education and development Able to work independently and autonomously Able to manage own workload and make timely and informed decisions Demonstrates a commitment to and focus on quality Promotes high standards to consistently improve patient outcomes Values diversity and difference Operates with integrity and openness Uses evidence to make improvements Looks for collective success, listens and learns from the contribution of others Good working relationships and credibility with professional colleagues and relevant stakeholders Able to work effectively in a team Able to build wide support networks with key stakeholders, including doctors and appraisers NHS England Medical Appraisal Policy Version 2 April 2015 Annex G: Clinical appraisal lead and senior appraiser job descriptions and person specifications Page 14

108 OFFICIAL NHS England Medical Appraisal Policy Annex H: Information governance NHS England Medical Appraisal Policy Version 2 April 2015 Annex H: Information governance Page 1

109 NHS England INFORMATION READER BOX Directorate Medical Commissioning Operations Patients and Information Nursing Finance Trans. & Corp. Ops. Commissioning Strategy Publications Gateway Reference: Document Purpose Guidance Document Name Medical Appraisal Policy (v2) Author NHS England, Medical Directorate (Revalidation) Publication Date May 2015 Target Audience Responsible Officers, Medical Appraisal Leads, Medical Appraisers Additional Circulation List Description Medical Directors, Doctors with a prescribed connection to NHS England, DH, BMA, GMC, Royal College of GPs, NHS Employers, Academy of Medical Royal Colleges, Regional HR and Finance Leads, NHS England Regional Directors Policy for appraisal of licensed medical practitioners who have a prescribed connection to NHS England (circa 42,000 doctors from circa 700 designated bodies). It describes the framework for appraisal, with tools to support implementation contained within the annexes. Cross Reference The Medical Profession (Responsible Officers) Regulations, 2010/2013 and the GMC (Licence to Practice and Revalidation) Regulations 2012 Superseded Docs (if applicable) Action Required Timing / Deadlines (if applicable) Contact Details for further information Document Status Medical Appraisal Policy (v1) published October 2013 Responsible officers to ensure that Doctors with a connection to NHS England are appraised in accordance with this policy To be implemented as soon as reasonably practicable Dr Maurice Conlon england.revalidation-pmo@nhs.net This is a controlled document. Whilst this document may be printed, the electronic version posted on the intranet is the controlled copy. Any printed copies of this document are not controlled. As a controlled document, this document should not be saved onto local or network drives but should always be accessed from the intranet. The NHS Commissioning Board (NHS CB) was established on 1 October 2012 as an executive non-departmental public body. Since 1 April 2013, the NHS Commissioning Board has used the name NHS England for operational purposes. NHS England Medical Appraisal Policy Annex H: Information governance Version 2 April 2015 Page 2

110 Annex H: Information governance The RST guidance Information Management for Medical Revalidation in England, and the guidance and legislation on which this is based, applies. As a consequence of this, the following specific arrangements apply: All relevant records should be maintained by the doctor and the responsible officer. The appraiser requires access to the doctor s portfolio and appraisal forms for the purpose of carrying out the appraisal. The appraiser is not allowed to maintain or keep personal records about a doctor s appraisals for any purpose. All the appraiser s records of the doctor s appraisal portfolio and appraisal form should therefore be destroyed when the appraisal has been completed and the outputs have been received by the doctor and the responsible officer. Drafts of a doctor s appraisal documentation may be exchanged by between a doctor and their appraiser only using secure means which are compliant with the NHS confidentiality code of practice. When it is necessary to send appraisal documentation by , the most straightforward means of achieving this is for the documentation to be sent between nhs.net accounts. Where the doctor does not have a secure nhs.net account, further advice should be sought from the responsible officer as to whether an alternative account is acceptable or a suitable alternative method of exchanging the documentation should be used. At such time as NHS IT encryption methods facilitate the secure sharing of appraisal documentation with hitherto unsecure destinations, these methods may be adopted within the parameters set out in formal guidance and policy at that time. Such alternatives of exchanging a doctor s appraisal documentation between a doctor and their appraiser include exchanging it using a securely encrypted mass storage device (memory stick), or using a local intranet facility which has been shown to meet the requirements of the NHS confidentiality code of practice. When in possession of a memory stick containing a doctor s appraisal documentation, the appraiser is responsible for its security in the same way as for a private and confidential paper document. After the appraisal is complete, the appraiser must send a copy of the final appraisal documentation to the doctor for their records, and upload a copy to the NHS England Revalidation Management System. Where the RST Medical Appraisal Guide Model Appraisal Form ( MAG form ) is used, this should be the Locked down version of the form. The appraiser must then delete or destroy all other electronic and other copies of the doctor s appraisal documentation, no later than one calendar month NHS England Medical Appraisal Policy Annex H: Information governance Version 2 April 2015 Page 3

111 after the date on which the appraisal has been received by the responsible officer. This includes deletion from: - all files and folders on their computer hard drive, including from the computer recycle bin ; - the Sent items on their ; - the Deleted items folder on their ; - any securely encrypted mass storage device (memory stick) on which a copy has been stored; - any other place where the appraiser has stored the form. receipts for sent items may be retained by the appraiser. The responsible officer and their team will make arrangements for safe and secure storage of the appraisal documentation and other relevant information in accordance with the RST guidance Information Management for Medical Revalidation in England. The responsible officer will also maintain a written protocol for access to the doctor s appraisal and revalidation portfolio and to the information held on the responsible officer s local revalidation dashboard, with named personnel and criteria for access. 1.1 Confidentiality of appraisal information The appraisal discussion is an important opportunity for a confidential open discussion between a doctor and a trained appraiser. The responsible officer will normally base their decision to recommend for revalidation on the basis of the appraisal outputs, i.e. the summary of discussion, the new personal development plan, and the appraiser s statements. However, the responsible officer may view any relevant information to assure their recommendation about the doctor s fitness to practise. In the context of appraisal this may on occasion include the completed full appraisal documentation and the doctor s supporting information. More guidance on this can be found in the NHS Revalidation Support Team document: Information management for medical revalidation in England. NHS England Medical Appraisal Policy Annex H: Information governance Version 2 April 2015 Page 4

112 OFFICIAL NHS England Medical Appraisal Policy Annex I: Suggested appraisal team structure the appraisal office NHS England Medical Appraisal Policy Version 2 April 2015 Annex I: Suggested appraisal team structure the appraisal office Page 1

113 NHS England INFORMATION READER BOX Directorate Medical Commissioning Operations Patients and Information Nursing Finance Trans. & Corp. Ops. Commissioning Strategy Publications Gateway Reference: Document Purpose Guidance Document Name Medical Appraisal Policy (v2) Author NHS England, Medical Directorate (Revalidation) Publication Date May 2015 Target Audience Responsible Officers, Medical Appraisal Leads, Medical Appraisers Additional Circulation List Description Medical Directors, Doctors with a prescribed connection to NHS England, DH, BMA, GMC, Royal College of GPs, NHS Employers, Academy of Medical Royal Colleges, Regional HR and Finance Leads, NHS England Regional Directors Policy for appraisal of licensed medical practitioners who have a prescribed connection to NHS England (circa 42,000 doctors from circa 700 designated bodies). It describes the framework for appraisal, with tools to support implementation contained within the annexes. Cross Reference The Medical Profession (Responsible Officers) Regulations, 2010/2013 and the GMC (Licence to Practice and Revalidation) Regulations 2012 Superseded Docs (if applicable) Action Required Timing / Deadlines (if applicable) Contact Details for further information Document Status Medical Appraisal Policy (v1) published October 2013 Responsible officers to ensure that Doctors with a connection to NHS England are appraised in accordance with this policy To be implemented as soon as reasonably practicable Dr Maurice Conlon england.revalidation-pmo@nhs.net This is a controlled document. Whilst this document may be printed, the electronic version posted on the intranet is the controlled copy. Any printed copies of this document are not controlled. As a controlled document, this document should not be saved onto local or network drives but should always be accessed from the intranet. The NHS Commissioning Board (NHS CB) was established on 1 October 2012 as an executive non-departmental public body. Since 1 April 2013, the NHS Commissioning Board has used the name NHS England for operational purposes. NHS England Medical Appraisal Policy Annex I: Suggested appraisal team structure the appraisal office Version 2 April 2015 Page 2

114 Annex I: Suggested appraisal team structure the appraisal office These arrangements will vary according to the shape and size of the population of doctors of a given responsible officer. This annex therefore sets out the principles and common features which all responsible officers should expect to have in place for leading and supporting effective appraisal in their setting. It is necessary to note that a responsible officer is likely to need other staff in support of the other statutory functions of the responsible officer, such as monitoring performance, responding to concerns about a doctor s practice and making revalidation recommendations to the GMC. 1.1 Principles NHS England responsible officers should ensure they have access to the following: dedicated professional/peer leadership for appraisal in their area; access to a learning network for appraisal leaders (e.g. that shares good practice for appraisal implementation); management and administrative support that enables communication, coordination, assurance and audit of appraisal quality and completion, troubleshooting / Q&A service; access to training support and resources to ensure that all appraisers keep up-to-date with current developments in appraisal practice; and financial management for the elements of running appraisal that require this (e.g. paying and invoicing). 1.2 Specific arrangements The appraisal team described here is a generic structure which will enable a NHS England responsible officer to deliver a high quality appraisal system. It is recognised that the needs of the national, regional and other NHS England responsible officers are different in scale and other aspects. Some flexibility is therefore expected in terms of how the appraisal team is structured in an individual appraisal office. Nevertheless the structure described is applicable to a significant degree in the differing contexts. Professional/peer leadership should be divided into an overall and supporting structure. Overall leadership should be delivered by a dedicated clinician who has paid time in their role to undertake this work (the clinical appraisal lead). They should be supported by clinical colleagues taking responsibility for the assurance of appraiser performance of groups of NHS England Medical Appraisal Policy Annex I: Suggested appraisal team structure the appraisal office Version 2 April 2015 Page 3

115 appraisers within the team (the senior appraiser 1 ). It is expected that most NHS England appraisal teams will choose to do this. Given the scale of the task for each NHS England appraisal office, the person with overall responsibility for revalidation should not normally also undertake the role of clinical appraisal lead. A senior manager should oversee the running of all aspects of appraisal. This role may overlap and integrate with other revalidation and quality improvement roles. A number of supporting managers and administrators will be required to underpin the tasks of: - communications - appraiser recruitment/commissioning and allocation - appraisal scheduling and reminders - answering operational questions - connecting appraisal outputs with revalidation systems to enable recommendations to GMC - managing the appraisal and revalidation management systems - IT support - co-ordination of doctor feedback to appraisers (meetings with appraisers to discuss impact) and appraiser performance review - setting up and running of events for doctors (e.g. awareness raising, user updates) - administration of training programmes for appraisers - quality assurance systems (feedback, output review, audit of compliance with standards) maintenance and report writing - complaints handling - conflict resolution - financial processing and reporting - support process of supporting information provision. 1 A review of provision of support to appraisal across NHS England in 2014 found that in addition to appointing a clinical appraisal lead to support their overall appraisal system, it is widespread practice or NHS England responsible officers to engage a number of appraisers to support local groups of appraisers within their system. A variety of terms is in use to denote these persons. For simplicity and to make clear the distinction between the two roles, this policy uses the term senior appraiser to denote a medical appraiser who offers support and supervision to a designated local group of appraisers. NHS England Medical Appraisal Policy Annex I: Suggested appraisal team structure the appraisal office Version 2 April 2015 Page 4

116 OFFICIAL NHS England Medical Appraisal Policy Annex J: Routine appraiser assurance tools NHS England Medical Appraisal Policy Version 2 April 2015 Annex J: Routine appraiser assurance tools Page 1

117 NHS England INFORMATION READER BOX Directorate Medical Commissioning Operations Patients and Information Nursing Finance Trans. & Corp. Ops. Commissioning Strategy Publications Gateway Reference: Document Purpose Guidance Document Name Medical Appraisal Policy (v2) Author NHS England, Medical Directorate (Revalidation) Publication Date May 2015 Target Audience Responsible Officers, Medical Appraisal Leads, Medical Appraisers Additional Circulation List Description Medical Directors, Doctors with a prescribed connection to NHS England, DH, BMA, GMC, Royal College of GPs, NHS Employers, Academy of Medical Royal Colleges, Regional HR and Finance Leads, NHS England Regional Directors Policy for appraisal of licensed medical practitioners who have a prescribed connection to NHS England (circa 42,000 doctors from circa 700 designated bodies). It describes the framework for appraisal, with tools to support implementation contained within the annexes. Cross Reference The Medical Profession (Responsible Officers) Regulations, 2010/2013 and the GMC (Licence to Practice and Revalidation) Regulations 2012 Superseded Docs (if applicable) Action Required Timing / Deadlines (if applicable) Contact Details for further information Document Status Medical Appraisal Policy (v1) published October 2013 Responsible officers to ensure that Doctors with a connection to NHS England are appraised in accordance with this policy To be implemented as soon as reasonably practicable Dr Maurice Conlon england.revalidation-pmo@nhs.net This is a controlled document. Whilst this document may be printed, the electronic version posted on the intranet is the controlled copy. Any printed copies of this document are not controlled. As a controlled document, this document should not be saved onto local or network drives but should always be accessed from the intranet. The NHS Commissioning Board (NHS CB) was established on 1 October 2012 as an executive non-departmental public body. Since 1 April 2013, the NHS Commissioning Board has used the name NHS England for operational purposes. NHS England Medical Appraisal Policy Annex J: Routine appraiser assurance tools Version 2 April 2015 Page 2

118 Annex J: Routine appraiser assurance tools It is important that medical appraisers maintain and develop their skills on an ongoing basis. This is primarily the responsibility of the appraiser, but the designated body has a share in this responsibility. There are a variety of means by which medical appraisers can maintain and develop their skills, but core activities include: 1. CPD: attendance at local update and appraisal network meetings, in addition to other types of continuing professional development, including peer review 2. Quality improvement activity: review of appraisal outputs, in particular the appraisal summary and PDP that are recorded in the appraisals they carry out 3. Significant events: noting and recording for reflections events from their appraisal work from which learning and development can be derived 4. Feedback: obtaining and reflecting on feedback from doctors whom they appraise, and from colleagues in their appraisal role 5. Appraiser assurance review meetings with a senior appraiser or appraisal lead. 6. Discussing and reflecting upon their performance as an appraiser at their own appraisal. Using a simple framework to review a doctor s appraisal submission is another means of supporting appraiser consistency, especially in situations where appraisers are faced with a variety of appraisal formats used by doctors. This appendix supplements the Quality assurance of medical appraisers guidance (QAMA) issued by the NHS Revalidation Support Team in setting out further detail and providing useful tools around the on-going process of appraiser assurance. This position is underpinned by the following principles: a) The patient safety benefits of revalidation and the professional development benefits of appraisal depend on all doctors receiving a consistently good quality appraisal experience. b) Medical appraisers have a professional responsibility to maintain and develop their appraisal skills. c) Designated bodies have a responsibility to support their appraisers in the maintenance and development of their skills, and to assure the quality of medical appraisals. d) Attendance at network meetings and other forms of shared learning interactions is a key component of appraisers maintaining and developing their skills and of calibrating their behaviours and decisions. NHS England Medical Appraisal Policy Annex J: Routine appraiser assurance tools Version 2 April 2015 Page 3

119 e) Quality assurance audit of appraisal outputs and feedback from doctors helps to identify individual and group appraiser learning needs. f) Periodic assurance review meetings with a senior appraiser or appraisal lead, or with a peer appraiser is of benefit to all appraisers, and in particular new appraisers and appraisers requiring additional development. In addition, undertaking appraisals is part of a doctor s whole practice, which should therefore be discussed at the appraisers own appraisal for revalidation. g) There is also a role for self-review, although the involvement of a second person in the process adds to assurance and objectivity. The tools that follow have been developed from experience in different parts of NHS England: The Appraisal Summary and PDP Audit Tool (ASPAT) has been developed by doctors from the primary, secondary and independent sector and is a generic tool that may be used to audit the appraisal summary and PDP of all doctors in England. It may also be useful as a reference for appraisers as they write their appraisal summaries. The ASPAT has been written after reviewing other available appraisal audit tools such as PROGRESS, EXCELLENCE, the East Midlands tool and the Oxford tool. This audit tool covers many similar areas to its predecessors and offers further development in certain areas. Whilst the ASPAT is not specifically intended to replace other tools where these are being used to good effect, it may act as a suitable standard tool in places where no such process has been in place before. The Medical appraisal feedback questionnaire has been reproduced from appendix 5 of Quality Assurance of Medical Appraisers (QAMA), and is the standard tool used for this purpose in NHS England. The Appraiser assurance review template is a means of recording a review of the appraiser role according to the categories of supporting information set out by the GMC. It is intended to support one-to-one meeting between an appraiser and their senior appraiser of appraisal lead, but may also be used in peer-to-peer or selfreview. The appraisal summary preparatory notes template can provide a useful method for an appraiser to prepare for an appraisal, especially if the appraisal vehicle being used by the doctor does not clearly follow the format set out in the Medical Appraisal Guide Model Appraisal Form (MAG form). It is not of itself an assurance tool but is presented here as an optional appraiser support tool. NHS England Medical Appraisal Policy Annex J: Routine appraiser assurance tools Version 2 April 2015 Page 4

120 1.1 Appraisal Summary and PDP Audit Tool Appraiser identifier Doctor identifier Date of appraisal Organisation Auditor (usually the senior appraiser) Click here to enter text. Click here to enter text. Click here to enter a date. Click here to enter text. Click here to enter text. Scale: 0 Unsatisfactory 1 Needs improvement 2 Good Score each item out of two Setting the scene and overview of supporting information a) The appraiser sets the scene summarising the doctor s scope of work Choose an item. b) The evidence discussed during the appraisal is listed (not all senior appraisers feel that this is necessary, so if not required score 2) c) There is documentation of whether the supporting information covers the whole scope of work Choose an item. Choose an item. d) Specific evidence is summarised with a description of what it demonstrates Choose an item. e) Objective statements about the quality of the evidence are documented Choose an item. f) All statements made by the appraiser are supported by evidence Choose an item. g) Appraiser comments about evidence refer/fit in to the four GMC domains and associated attributes set out in the GMC guidance Good medical practice framework for appraisal and revalidation h) Reference is made to whether speciality specific guidance for appraisal has been followed e.g. college recommendations for CPD and quality improvement activity (this is not a GMC requirement so if the senior appraiser does not feel that this is necessary, score 2) Choose an item. Choose an item. NHS England Medical Appraisal Policy Annex J: Routine appraiser assurance tools Version 2 April 2015 Page 5

121 i) Reference to completion of locally agreed required training (e.g. safeguarding training, basic life support training) is made (please insert agreed requirements, score 2 if none agreed) Comments: Click here to enter text. Choose an item Reflection and effective learning a) There is documentation of evidence showing that reflection on learning has taken place or that the appraiser has discussed how the doctor should document their reflection b) There is documentation of evidence showing that learning has been shared with colleagues or that the appraiser has challenged the doctor to do so c) There is documentation of evidence showing that learning has improved patient care/practice or that the appraiser has explored how this might be taken further with the doctor Comments: Click here to enter text. Choose an item. Choose an item. Choose an item The PDP and developmental progress a) There is positive recording of strengths, achievements and aspirations in the last year Choose an item. b) There is documentation of appropriate challenge in the discussion and PDP e.g. significant issues discussed and new suggestions made Choose an item. c) The completion (or not) of last year's PDP is recorded Choose an item. d) Reasons why any PDP learning needs that were not followed through are stated (if the PDP was completed then score 2) e) There are clear links between the summary of discussion and the agreed PDP f) The PDP has SMART objectives (specific, measurable, achievable, relevant, timely) Choose an item. Choose an item. Choose an item. NHS England Medical Appraisal Policy Annex J: Routine appraiser assurance tools Version 2 April 2015 Page 6

122 g) The PDP covers the doctor's whole scope of work and personal learning needs and goals Choose an item. h) The PDP contains between 3-6 items Choose an item. Comments: Click here to enter text General standards and revalidation readiness a) The documentation is typed and uploaded onto an electronic toolkit in clear and fluent English Choose an item. b) There is no evidence of appraiser bias or prejudice or information that could identify a patient/third party information Choose an item. c) The stage of the revalidation cycle is commented on Choose an item. d) There is documentation regarding revalidation readiness relating to supporting information (e.g. states that feedback and satisfactory QIA are already done). Any outstanding supporting information/other requirements for revalidation are commented on with a plan of action to address them e) Appraisal statements (including health and probity) have been signed off or if not, an explanation given (if signed off score 2) Comments: Click here to enter text. Choose an item. Choose an item. General comments from the senior appraiser: Click here to enter text. TOTAL SCORE (OUT OF 50) Click here to enter text. NHS England Medical Appraisal Policy Annex J: Routine appraiser assurance tools Version 2 April 2015 Page 7

123 1.2 Medical Appraisal Feedback Questionnaire (from Quality Assurance of Medical Appraisers v5, appendix 5) Dear Doctor Now that your recent appraisal has been signed-off as complete, I would be very grateful if you will complete the following questionnaire. It will be used to provide information to the responsible officer about the quality of the appraisal and feedback to help your appraiser. All feedback will be collated so that it is anonymous before being fed back to the appraiser. Please note that if you have a serious concern about the conduct of your appraisal, do not use this form but please contact Click here to enter text. directly, at: Click here to enter text.. If you answer no to any of the yes/no questions below, please use the relevant comments box to provide an explanation and constructive suggestions for improvement. Medical appraisal feedback questionnaire Name of designated body Name of doctor Name of medical appraiser Date of appraisal discussion NHS England Click here to enter text. Click here to enter text. dd/mm/yyyy Duration of appraisal discussion Hours < >4 Was there sufficient protected time for the appraisal discussion? Was the venue private and professional? Yes No Yes No Comments Click here to enter text. NHS England Medical Appraisal Policy Annex J: Routine appraiser assurance tools Version 2 April 2015 Page 8

124 Poor Borderline Satisfactory Good Very good The administration and management of the appraisal system Is the appraisal process satisfactory? Did you have access to all necessary forms and materials for your appraisal? Were you able to collect the necessary supporting information from the organisation(s) where you work? Did the administrative support for the appraisal process meet your needs? Yes No Yes No Yes No Yes No Any comments about the administration or management of your appraisal system Click here to enter text. The appraiser (Please give your appraiser feedback for their personal development) Please rate your appraiser s skills in Establishing rapport Demonstrating thorough preparation for your appraisal Listening to you and giving you time to talk Giving constructive and helpful feedback Supporting you Challenging you Helping you to review and reflect on your practice Helping you to identify gaps and improve your portfolio of supporting information for revalidation Helping you to review your progress against your last personal development plan (PDP) Helping you to produce a new PDP that reflects your development needs Managing the appraisal process and paperwork NHS England Medical Appraisal Policy Annex J: Routine appraiser assurance tools Version 2 April 2015 Page 9

125 Would you be happy to have the same appraiser again? Yes No Any other comments about your appraiser Click here to enter text. The appraisal overall Was the appraisal useful overall for Your personal development? Your professional development? Your preparation for revalidation? Promoting quality improvements in your work? Improving patient care? (where applicable) Yes No Yes No Yes No Yes No Yes No Any other comments about your appraisal overall Click here to enter text. Thank you for taking the time to complete this questionnaire. Please return it to Click here to enter text. NHS England Medical Appraisal Policy Annex J: Routine appraiser assurance tools Version 2 April 2015 Page 10

126 Appraiser Assurance Review Template 1.3 Using this template It is good practice for the senior appraiser (or appraisal lead) to hold a periodic assurance review meeting with individual appraisers. This template is intended to guide this process and provide a record of the meeting for the appraiser and the appraisal office. Whilst initially designed to support an assurance review meeting between an appraiser and their senior appraiser, this template can also be used alone by an appraiser as a self-review tool, or by an appraiser and a fellow appraiser as a peerfacilitated review tool, in a networking or buddying context. The intended procedure is as follows: 1. The reviewer or appraisal office part-populates the template, and prepares the appraiser s audit of appraisal outputs, doctor feedback and any other relevant information, as available. 2. The appraiser completes remaining items in Section A. 3. The appraiser and reviewer hold the review meeting, structured along the lines of the information in the template. 4. The appraiser and reviewer agree the content of Section B, and complete the sign-off in Section C. 5. The appraiser and the appraisal office each retain a copy of the final template. Note: Appraisers who are themselves licenced medical practitioners should present a copy of the completed template at their own medical appraisal, as supporting information indicating their participation in effective governance processes in relation to their appraisal work. 1.4 Section A Appraiser s name: Click here to enter text. Reviewer s name: Click here to enter text. Reviewer s role: Click here to enter text. Date of review meeting: Click here to enter a date General Specialty: Click here to enter text. Other roles: Click here to enter text. Start date as appraiser: Click here to enter text. Have you signed a contract/consultancy agreement? Choose an item. Date of signature of contract/consultancy agreement: Click here to enter text. Number of appraisals in the last year: Click here to enter text. Number of appraisals you would like to do next year: Click here to enter text. Scope of appraisal work (e.g. primary care, secondary care, private, responsible officer appraisals): Click here to enter text. NHS England Medical Appraisal Policy Annex J: Routine appraiser assurance tools Version 2 April 2015 Page 11

127 1.4.2 Headlines Looking at your last review s development themes/objectives in relation to your role as appraiser, to what extent did you get to fulfil these? Click here to enter text. As an appraiser, what do you consider you did well in the last year? Click here to enter text. What is your approach to preparation and appraisal summaries completion? Click here to enter text. What difficulties/ barriers have you come across as an appraiser? Click here to enter text. How well does your appraisal work fit in with your other professional duties? Click here to enter text. Do you have any helpful tips/good practice to share? Click here to enter text. Do you have any suggestions for appraisal workshop topics? Click here to enter text. How would you like your appraisal work to develop? Click here to enter text CPD for your appraisal work Local appraiser groups/appraiser network meetings attended: Click here to enter text. Comments on these, and any other CPD activities you have undertaken in relation to your appraisal work; possible development plans: Click here to enter text Quality improvement activity for your appraisal work (Appraisal office should provide the audit of appraisal summaries and PDPs if available) Comments on the audit of your appraisal summaries and PDPs and any other quality improvement activity relating to your appraisal work; possible development plans: Click here to enter text Significant events in your appraisal work (Consider, for example, unexpected concerns, interrupted appraisal, failure to agree outputs with doctor) Comments; possible development plans: Click here to enter text Maintaining professional relationships with doctors you have appraised (Appraisal office to provide doctor feedback if available,) Comments on doctor feedback provided by the appraisal office and any other feedback from the doctors you have appraised; possible development plans: Click here to enter text. NHS England Medical Appraisal Policy Annex J: Routine appraiser assurance tools Version 2 April 2015 Page 12

128 1.4.7 Maintaining professional relationships with colleagues in your appraisal work Comments; possible development plans: Click here to enter text Your health in relation to your appraisal work Comments; possible development plans: Click here to enter text Maintaining probity in relation to your appraisal work (Consider, for example, identification of conflict of interest or appearance of bias with doctors you are asked to appraise, delivering a professional appraisal through diligent preparation and personal organisation.) Comments, possible development plans: Click here to enter text Complaints and compliments in relation to your appraisal work (Appraisal office to provide information about complaints if available) Comments; possible development plans: Click here to enter text Any other comments before the discussion Reviewer: Click here to enter text. Appraiser: Click here to enter text. 1.5 Section B Comments/summary following discussion Reviewer: Click here to enter text. Appraiser: Click here to enter text. Personal development themes for your appraisal work Click here to enter text. Actions by reviewer/appraisal office Click here to enter text. NHS England Medical Appraisal Policy Annex J: Routine appraiser assurance tools Version 2 April 2015 Page 13

129 1.6 Section C Sign-off We agree that the above is an accurate summary of the review discussion and agreed personal development themes/actions. Signature: May be agreed by if both parties consent, in which case names sufficient: Click here to enter text. Date of sign-off: Click here to enter a date. NHS England Medical Appraisal Policy Annex J: Routine appraiser assurance tools Version 2 April 2015 Page 14

130 1.7 Appraisal Summary Preparatory Notes Template This form is designed for the appraiser s use only, to make relevant preparatory notes. Sections may be copied and pasted into the doctor s appraisal following the appraisal meeting as appropriate. This form is designed for the appraiser s use only, to make relevant preparatory notes. Sections may be copied and pasted into the doctor s appraisal following the appraisal meeting as appropriate. Doctor s name Date of appraisal Revalidation date SETTING THE SCENE AND SCOPE OF WORK SUPPORTING INFORMATION (list what is provided under the following headings. Include the action plan for any supporting information that is missing) Continuing professional development (may include college recommendations) Quality improvement activity (e.g. audit/case reviews) Quality Improvement Activity 1. Clinical audit 2. Review of clinical outcomes 3. Case review 4. Audit teaching programme 5. Evaluate health policy or management practice Significant events (if applicable) Feedback from colleagues (5 yearly) Feedback from patients (where applicable and 5 yearly) Review of complaints and compliments Significant Events Significant events are reserved for the rare cases where there was a serious incident (for example unexpected death or permanent harm) and a significant untoward incident (SUI) process was initiated The systems around SUIs are rarely activated in primary care but less serious significant event analyses may still be submitted for learning NHS England Medical Appraisal Policy Annex J: Routine appraiser assurance tools Version 2 April 2015 Page 15

131 Reference to any other clinical supervision/specialty appraisal also submitted/ro evidence LAST YEAR S PDP Was it completed? If not, document why not Reflection prompt: What went well? What could have been done better? How has this learning affected the doctor personally? How has it improved their patient care? Did they objectively demonstrate this? Did they disseminate this learning to colleagues? Refer to the doctor s strengths and areas for development Domain 1: Knowledge, skills and performance Domain 1 Knowledge, skills and performance Attribute 1 - Maintain your professional performance Attribute 2 - Apply knowledge and experience to practice Attribute 3 - Ensure that all documentation (including clinical records) formally recording your work is clear, accurate and legible Domain 2: Safety and quality Domain 2 Safety and Quality Attribute 1 - Contribute to and comply with systems to protect patients Attribute 2 - Respond to risks to safety Attribute 3 - Protect patients and colleagues from any risk posed by your health NHS England Medical Appraisal Policy Annex J: Routine appraiser assurance tools Version 2 April 2015 Page 16

132 Domain 3: Communication, partnership and teamwork Domain 3 Communication, Partnership and Teamwork Attribute 1 - Communicate effectively Attribute 2 - Work constructively with colleagues and delegate effectively Attribute 3 - Establish and maintain partnerships with patients New: Teaching, training, supporting and assessing Continuity and coordination of care Domain 4: Maintaining trust Domain 4 Maintaining Trust Attribute 1 - Show respect for patients Attribute 2 - Treat patients and colleagues fairly and without discrimination Attribute 3 - Act with honesty and integrity NHS England Medical Appraisal Policy Annex J: Routine appraiser assurance tools Version 2 April 2015 Page 17

133 Summarising Comments Appraiser: Date: Now copy and paste the text in each of the boxes to the relevant areas of your online toolkit. NHS England Medical Appraisal Policy Annex J: Routine appraiser assurance tools Version 2 April 2015 Page 18

134 OFFICIAL NHS England Medical Appraisal Policy Annex K: Appraiser role expectations NHS England Medical Appraisal Policy Version 2 April 2015 Annex K: Appraiser role expectations Page 1

135 NHS England INFORMATION READER BOX Directorate Medical Commissioning Operations Patients and Information Nursing Finance Trans. & Corp. Ops. Commissioning Strategy Publications Gateway Reference: Document Purpose Guidance Document Name Medical Appraisal Policy (v2) Author NHS England, Medical Directorate (Revalidation) Publication Date May 2015 Target Audience Responsible Officers, Medical Appraisal Leads, Medical Appraisers Additional Circulation List Description Medical Directors, Doctors with a prescribed connection to NHS England, DH, BMA, GMC, Royal College of GPs, NHS Employers, Academy of Medical Royal Colleges, Regional HR and Finance Leads, NHS England Regional Directors Policy for appraisal of licensed medical practitioners who have a prescribed connection to NHS England (circa 42,000 doctors from circa 700 designated bodies). It describes the framework for appraisal, with tools to support implementation contained within the annexes. Cross Reference The Medical Profession (Responsible Officers) Regulations, 2010/2013 and the GMC (Licence to Practice and Revalidation) Regulations 2012 Superseded Docs (if applicable) Action Required Timing / Deadlines (if applicable) Contact Details for further information Document Status Medical Appraisal Policy (v1) published October 2013 Responsible officers to ensure that Doctors with a connection to NHS England are appraised in accordance with this policy To be implemented as soon as reasonably practicable Dr Maurice Conlon england.revalidation-pmo@nhs.net This is a controlled document. Whilst this document may be printed, the electronic version posted on the intranet is the controlled copy. Any printed copies of this document are not controlled. As a controlled document, this document should not be saved onto local or network drives but should always be accessed from the intranet. The NHS Commissioning Board (NHS CB) was established on 1 October 2012 as an executive non-departmental public body. Since 1 April 2013, the NHS Commissioning Board has used the name NHS England for operational purposes. NHS England Medical Appraisal Policy Annex K: Appraiser role expectations Version 2 April 2015 Page 2

136 Annex K: Appraiser role expectations The content of this annex is based on the schedule in the NHS England Consultancy Agreement for engaging appraisers as independent contractors, which, as described in the main body of this policy, is the main method by which NHS England engages medical appraisers. For medical appraisers engaged via other models, the expectations listed in this annex provide a suitable basis for the agreement between NHS England and the appraiser. This applies most commonly to appraisers engaged via the regional appraisal offices, and in particular where an appraiser is engaged on a non-remunerated basis. NHS England regional medical appraiser role expectations 1. A NHS England regional medical appraiser is expected to: (a) (b) (c) (d) (e) (f) (g) (h) (i) remain fully registered with the General Medical Council (the GMC ) with a licence to practise where the Individual is a medical practitioner fully licensed with the GMC and remain included on the Medical Performers List where the Individual is included on the Medical Performers List. For the avoidance of doubt, if the Individual is a retired medical practitioner or non-medical appraiser then the requirements of this clause 1(a) do not apply; perform Services in accordance with the NHS England Medical Appraisal Policy; perform the Services with reasonable skill and care and to the best of their ability; perform such duties in relation to the provision of the Services as NHS England may reasonably request; provide to NHS England such written or oral advice or information regarding any of the Services as NHS England may reasonably require; exercise such powers as may from time to time be vested in or given to the individual by NHS England; not hold themselves out as an employee of NHS England or as having authority to bind NHS England; not incur any expenditure in the name of or for the account of NHS England; comply with any statutory or other reasonable rules, guidance or obligations as may be amended from time to time including but not limited to: i. those relating to health and safety while providing the Services and to take all reasonable steps to safeguard their own safety and the safety of any NHS England Medical Appraisal Policy Annex K: Appraiser role expectations Version 2 April 2015 Page 3

137 other person who may be affected by the Individual s actions in performing the Services; ii. the requirements of data protection legislation; iii. NHS England s Equal Opportunities, Discrimination and Harassment policies (when finalised and as may be amended from time to time thereafter); iv. the NHS England Medical Appraisal Policy; v. the GMC Principles of Good Medical Practice where applicable; vi. the Seven Principles of Standards in Public Life (Nolan Principles); and vii. NHS England s Information Governance Policy; (j) (k) (l) not engage in any conduct detrimental to the interests of NHS England or contrary to the instructions of NHS England; comply with NHS England appraiser quality assurance processes, as described under the NHS England Medical Appraisal Policy and other relevant national guidance; use an nhs.net address for all electronic communications or such other secure address as may be authorised by NHS England from time to time; (m) inform the relevant appraisal officer if any material fact should arise in relation to their professional standing which could compromise their ability or credibility in relation to the performance of the Services under the terms of this Agreement (including but not limited to being the subject of a GMC investigation, having restrictions placed on their practice or receiving a criminal conviction); and (n) provide the Services at an appropriate location that is agreed with the Doctor or at such other premises as the parties agree from time to time are appropriate for the performance of the Services. 2. Confidential Information and Property 2.1 It is acknowledged that to enable the individual to provide the services NHS England will provide the Individual with information of a highly confidential nature which is or may be private, confidential or secret, being information or material which is the property of NHS England or which NHS England is obliged to hold confidential including, without limitation, all official secrets, information relating to the working of any project carried on or used by NHS England, research projects, strategy documents, tenders, financial information, reports, ideas and know-how, employee confidential information and patient confidential information (any and all of the foregoing being Confidential Information ). 2.2 The Individual agrees to adopt all such procedures as NHS England may reasonably require and to keep confidential all Confidential Information and the individual shall not (save as required by law) disclose the Confidential Information in whole or in part to anyone and agrees not to disclose the Confidential Information other than in connection with the provision of the Services. NHS England Medical Appraisal Policy Annex K: Appraiser role expectations Version 2 April 2015 Page 4

138 2.3 The obligations apply to all and any Confidential Information whether the Confidential Information was in or comes into the possession of the individual such obligations shall continue for the term of the association and at all times following the termination of that agreement but shall cease to apply to information which may come into the public domain otherwise than through unauthorised disclosure by the Individual. 2.4 The individual shall not copy, retain or otherwise utilise, unless engaged upon NHS England s business, any documentation, computer disks, tapes or correspondence which relates to NHS England s business, unless specifically authorised by NHS England to do so. NHS England has strict policies and controls in relation to the movement of information and data and the individual is required to comply with NHS England s Information Governance Policy. 2.5 The individual shall not, without the express permission of NHS England, remove any property, documents, computer disks, tapes or files belonging to NHS England from NHS England s premises for any purpose. 2.6 The individual shall not disclose or permit to be disclosed any information relating to NHS England s business to a third party unless requested or authorised to do so by NHS England. 3 Data Protection 3.1 NHS England may from time to time in the course of administering its activities need to process both personal data and sensitive personal data. The individual agrees and acknowledges that this information will be used and processed fairly for the operation of NHS England s activities. 3.2 NHS England is registered in accordance with the requirements of the data protection legislation. The individual shall not at any time use personal data held by NHS England for any purpose not described in its register entry or disclose such data to a third party or act otherwise in contravention of the data protection legislation. 4 Termination 4.1 Either NHS England or the individual may terminate this Agreement at any time by giving to the other one month s notice in writing. 4.2 NHS England may by written notice terminate this Agreement or suspend the performance of all or any of its obligations under it immediately and without liability for compensation or damages if: (a) the individual is, in the reasonable opinion of NHS England, incompetent, guilty of gross misconduct and/or any serious or persistent negligence in the provision of the Services hereunder; NHS England Medical Appraisal Policy Annex K: Appraiser role expectations Version 2 April 2015 Page 5

139 (b) (c) (d) (e) (f) the individual fails after written instruction to provide the Services reasonably and properly required of him/her the individual is guilty of fraud or dishonesty or conducts himself in any manner which, in the reasonable opinion of NHS England, brings or is likely to bring NHS England into disrepute by association or would in any way damage public or professional confidence in the appraisal process governed and operated by NHS England; The individual is suspended, removed or resigns from the Performer s List for clinical practice save where in the event that the individual resigns from the Performer s List, but is deemed to remain fit to practise by the GMC; The individual is suspended by the GMC; the individual is convicted of a criminal offence (other than a road traffic offence for which he is not sentenced to imprisonment); 4.3 Where the individual is referred to the GMC for a fitness to practise issue or any other issue related to the performance of the Individual s clinical duties, the individual shall immediately notify the relevant NHS England Appraisal Office in writing of such referral. In these circumstances, NHS England reserves the right to take such action as it deems reasonably necessary in relation to their engagement in the capacity of Appraiser 5 Notice 5.1 Any notice to be served on any of the parties by the other shall be sent by recorded delivery or registered post or by fax or and shall be deemed to have been received by the addressee within 48 hours of posting or 24 hours if sent by fax or to the correct fax number or address of the addressee. 5.2 Notices to the individual shall be sent to the address at the head of this Agreement. 5.3 Notices to NHS England shall be sent to the address of the HR Director. Period of engagement These expectations are agreed for a maximum period of 12 months, renewable on 1 April annually, subject to satisfactory performance review. NHS England Medical Appraisal Policy Annex K: Appraiser role expectations Version 2 April 2015 Page 6

140 Role expectations agreement Appraiser s signature: Name: Head of department s signature: Name: Date: Date: NHS England Medical Appraisal Policy Annex K: Appraiser role expectations Version 2 April 2015 Page 7

141 OFFICIAL NHS England Medical Appraisal Policy Annex L: Medical Appraisal Position Statements Index NHS England Medical Appraisal Policy Version 2 April 2015 Annex L Medical Appraisal Position Statements index Page 1

142 NHS England INFORMATION READER BOX Directorate Medical Commissioning Operations Patients and Information Nursing Finance Trans. & Corp. Ops. Commissioning Strategy Publications Gateway Reference: Document Purpose Guidance Document Name Medical Appraisal Policy (v2) Author NHS England, Medical Directorate (Revalidation) Publication Date May 2015 Target Audience Responsible Officers, Medical Appraisal Leads, Medical Appraisers Additional Circulation List Description Medical Directors, Doctors with a prescribed connection to NHS England, DH, BMA, GMC, Royal College of GPs, NHS Employers, Academy of Medical Royal Colleges, Regional HR and Finance Leads, NHS England Regional Directors Policy for appraisal of licensed medical practitioners who have a prescribed connection to NHS England (circa 42,000 doctors from circa 700 designated bodies). It describes the framework for appraisal, with tools to support implementation contained within the annexes. Cross Reference The Medical Profession (Responsible Officers) Regulations, 2010/2013 and the GMC (Licence to Practice and Revalidation) Regulations 2012 Superseded Docs (if applicable) Action Required Timing / Deadlines (if applicable) Contact Details for further information Document Status Medical Appraisal Policy (v1) published October 2013 Responsible officers to ensure that Doctors with a connection to NHS England are appraised in accordance with this policy To be implemented as soon as reasonably practicable Dr Maurice Conlon england.revalidation-pmo@nhs.net This is a controlled document. Whilst this document may be printed, the electronic version posted on the intranet is the controlled copy. Any printed copies of this document are not controlled. As a controlled document, this document should not be saved onto local or network drives but should always be accessed from the intranet. The NHS Commissioning Board (NHS CB) was established on 1 October 2012 as an executive non-departmental public body. Since 1 April 2013, the NHS Commissioning Board has used the name NHS England for operational purposes. NHS England Medical Appraisal Policy Annex L Medical Appraisal Position Statements index Version 2 April 2015 Page 2

143 Appendix L: Medical Appraisal Position Statements NHS England medical appraisal position statements are a means by which issues pertinent to consistency and quality are captured, discussed and developed, so as to develop an agreed approach across all relevant parties. Issues are passed to the All England Appraisal Network (National) group in the first instance. The network develops an initial position statement based on preliminary discussion. This statement is shared for wider discussion as appropriate, then re-drafted and recirculated. Depending on the nature of the issue, formal approval may be obtained from various bodies or relevant individuals. The degree to which a position statement has been shared and/or approved is detailed in the governance table at the end of the document. A position statement should be seen as a fluid document to facilitate discussion and debate. It aims to capture current thinking on an issue and describe the best agreed approach available at the time. Incremental levels of sign off and approval occur after appropriate consensus-building efforts have occurred. A position statement may therefore eventually be consolidated as policy, but while it remains a position statement it remains a vehicle for debate and discussion. NHS England medical appraisal position statement relevance NHS England has a dual function in relation to revalidation and appraisal: firstly as a designated body in its own right, and secondly as Senior Responsible Owner for the revalidation programme in England as a whole. A NHS England medical appraisal position statement may therefore be relevant to NHS England only or to all designated bodies in England. The relevance of an individual position statement is indicated in the title of the statement. Position statements which are NHS Englandonly may still be of interest to other designated bodies. The list of position statements in existence at the point of publication of version 2.0 of the NHS England Medical Appraisal Policy is contained in the table below. The most recent version of any position statement may be obtained from england.revalidationpmo@nhs.net. NHS England Medical Appraisal Policy Annex L Medical Appraisal Position Statements index Version 2 April 2015 Page 3

144 Reference number Topic Title Relevance Status at 31/12/14 L1 Logistics MAPS: Appraisal vehicles for doctors connected to NHS England NHS England v0.11 L2 Logistics MAPS: Career breaks All designated bodies v0.2 L3 Logistics Guidelines for the deferral of a revalidation recommendation NHS England v1.0 Gateway L4 Logistics MAPS: Handling late sign off of appraisal All designated bodies v0.2 L5 Logistics MAPS: Postponement of appraisal All designated bodies v0.3 L6 Logistics MAPS: Scheduling medical appraisals All designated bodies (specific ref NHS England) v0.3 L7 Logistics MAPS: Appraisal of doctors who temporarily exit training All designated bodies v0.14 L8 Logistics MAPS: Technology-assisted appraisal All designated bodies v0.11 L9 Logistics MAPS: Interrupting appraisal All designated bodies v0.6 NHS England Medical Appraisal Policy Annex L Medical Appraisal Position Statements index Version 2 April 2015 Page 4

145 L10 Logistics MAPS: Timing first patient feedback after change in role All designated bodies v0.4 L11 Logistics MAPS: Allocating SPA time within job plan for appraisers in secondary/mental/community health sectors All designated bodies v0.3 L12 Logistics MAPS: Achieving high medical appraisal uptake All designated bodies v0.2 A1 Appraisers MAPS: Routine appraiser assurance review All designated bodies v0.4 S1 Supporting information MAPS: Inclusion of key information at appraisal All designated bodies v0.4 S2 Supporting information MAPS: Information about practice and supervision in non-training posts for doctors connected to Local Education and Training Boards All designated bodies v0.9 S3 Supporting information MAPS: Sharing information to support appraisal All designated bodies v0.6 S4 Supporting information MAPS: Demonstration of safeguarding competence by GPs NHS England v0.5 S5 Supporting information MAPS: Amplification of CPD credits in primary care NHS England v0.5 S6 Supporting information MAPS: Principles for training of doctors with a prescribed connection to NHS England NHS England v0.3 NHS England Medical Appraisal Policy Annex L Medical Appraisal Position Statements index Version 2 April 2015 Page 5

146 S7 Supporting information MAPS: Patient feedback in non-standard situations All designated bodies v0.4 S8 Supporting information MAPS: Quality improvement information for general practitioners NHS England v0.3 S9 S10 S11 S12 Supporting information Supporting information Supporting information Supporting information MAPS: Scope of work and appropriate supporting information for a General Practitioner MAPS: Incorporating locally generated supporting information into medical appraisal MAPS: Supporting information for medical appraisal: the role of the designated body MAPS: Assessing supporting information for appraisal in the context of the volume of a doctor s work NHS England v0.2 All designated bodies All designated bodies All designated bodies v0.8 v0.4 v0.5 S13 Supporting information MAPS: Principles for assessing a doctor's supporting information All designated bodies v0.2 S14 Supporting information MAPS: Principles of CPD for revalidation All designated bodies v0.3 S15 Supporting information Spreadsheet of SI vs Scope of work All designated bodies v0.1 S16 Supporting information MAPS: Principles when mandatory training incomplete All designated bodies v0.2 NHS England Medical Appraisal Policy Annex L Medical Appraisal Position Statements index Version 2 April 2015 Page 6

147 OFFICIAL NHS England Medical Appraisal Policy Annex M: Glossary Annex N: Working group NHS England Medical Appraisal Policy Version 2 April 2015 Annexes M & N Page 1