GP Appraisal External Quality Assurance Assessment Programme NHS Orkney January 2009
NHS Quality Improvement Scotland external quality assurance of GP appraisal NHS Orkney Context NHS Quality Improvement Scotland (NHS QIS) developed and published a strategy document Shifting the Focus: Leading on Quality Improvement and Patient Safety in Community and Primary Healthcare Services in October 2007. This strategy document outlines the organisation s commitment to support NHSScotland to continually improve the quality of care and treatment delivered to patients in the community and primary healthcare services. The GP Appraisal Scheme in Scotland is managed by NHS Education for Scotland (NES). It is a medical appraisal scheme that benefits from national management and quality assurance. In Scotland it covers almost 5,000 GPs involving approximately 150 appraisers. As part of the robust quality assurance process, NHS QIS, in collaboration with key stakeholders, established a national steering group to develop a framework and methodology to externally quality assure how NHS boards undertake and manage the GP appraisal process. This work has involved the establishment of an external quality assurance (EQA) programme to assess implementation and management of the GP appraisal process throughout the 14 NHS boards in Scotland. An external review audit tool was piloted in NHS Dumfries & Galloway, NHS Grampian and NHS Greater Glasgow and Clyde in February 2008. The pilot assessment was undertaken using the review methodology defined by the NHS QIS GP Appraisal Steering Group. Feedback received from NHS boards that participated in the pilot review was considered by the steering group, and the review methodology was refined and amended where appropriate. The finalised assessment tool was circulated to conduct a full EQA of the GP appraisal process in 14 NHS boards between May June 2008. This report highlights the outcome of the findings in NHS Orkney. 2
Board background Orkney is an island group situated north of mainland Scotland. It is made up of about 100 islands, of which 17 are inhabited, and has a population of around 19,770. The majority of the population live on the main island where Kirkwall, the administrative centre of Orkney, is located. Further information about the local board can be found at www.ohb.scot.nhs.uk For the purposes of this project, NHS Orkney provided the following breakdown of GPs working in all capacities within the board area: GP Providers 17 Salaried GPs 11 Retainee GPs 0 GPs working in Out of Hours service 19 Sessional GPs 12 Host Sessional GPs not clarified The following figures demonstrate the percentage of GPs, working in each of the capacities, to have been appraised in the past 12 months: GP Providers 76% Salaried GPs 64% Retainee GPs 0 Host Sessional GPs not clarified Rating The following scores in figures relation in to relation core standards to GP Appraisers were also provided: Number of GP Appraisers employed 2 Total number of GP Appraiser sessions per week 2 3
Rating scores in relation to core criteria NHS QIS rating scale: 0 Nothing in place, system or process has not yet been developed 1 Under development or developed but not fully implemented 2 Fully developed and implemented throughout the service 3 Fully developed, implemented and regularly monitored Overview: Q1 Q2 Board rating NHS QIS rating There is a board GP Appraisal Steering Group established with a clearly defined role, remit and membership 1 0 A board GP Appraisal Report is prepared annually by the Local Appraisal Advisor and presented to the board 0 0 Q3 There is a process in place to notify the board GP Appraisal Team when a GP starts work in the board area in any capacity 2 1 Q4 There is a process in place to notify the GP Appraisal Team when a GP ceases to work in the board area 2 1 Q5 There is a process in place for the board to action non-engagement or unsatisfactory engagement in the appraisal process by GPs as identified by the production of form GPScot 5b 1 1 Q6 Support is available at board level to GPs identified through the appraisal system as giving cause for concern 3 1 Q7 Effective communication between GP Appraisal Team and governance structure established 2 1 Q8 The recruitment process for Appraisers is equitable, open and transparent and facilitates representation from the spectrum of Doctors working in General Practice 2 2 Q9 Appropriate support is provided to Appraisers to enable them to carry out their duties effectively 3 2 Q10 Adequate Appraisers are in post to ensure access to the appraisal process for all GPs working in the board area 2 2 Q11 A system is in place to monitor effective management of appraisal scheme by GP Appraisal Team 2 0 Q12 Effectiveness of GP Appraisers being monitored 3 2 Q13 There is a process in place to monitor uptake of GP Appraisal amongst Sessional/Locum GPs working in your board area 2 1 Q14 There is a process in place to ensure uptake of GP Appraisal amongst Sessional/Locum GPs hosted by your board area 2 2 Q15 There is a process in place to monitor uptake of GP Appraisal amongst GPs providing Out of Hours services in your board area 2 1 Total score: 29 17 % score: 64% 38% 4
NHS QIS comments in relation to criteria Q1 There is a board GP Appraisal Steering Group established with a clearly defined role, remit and membership NHS QIS rating = 0 There is no formal GP Appraisal Steering Group in place. However, the board reported that informal meetings take place 3 times per year between the Local Appraisal Advisor (LAA) and the NHS Orkney Primary Care Manager and that any issues on GP appraisal would be addressed at these meetings. However, NHS QIS recommends the establishment of a formal GP Appraisal Steering Group with a remit for discussing and developing GP Appraisal in NHS Orkney. Q2 A board GP Appraisal Report is prepared annually by the Local Appraisal Advisor and presented to the board NHS QIS rating = 0 The board submitted no evidence or details regarding a GP Appraisal Annual Report and, therefore, NHS QIS is unable to establish whether GP Appraisal annual reports are produced or whether there are plans to produce annual reports in the future. NHS QIS recommends that an annual report be produced to give an accurate reflection of the performance of the appraisal process within the NHS Orkney board area. Q3 There is a process in place to notify the board GP Appraisal Team when a GP starts work in the board area in any capacity The board reported that there is a process in place whereby the Primary Care Manager notifies GP Appraisers of any new GPs practicing in the NHS Orkney board area. However, from the evidence supplied, NHS QIS was unable to establish whether there is a formal process for notifying the GP Appraisal Team. Q4 There is a process in place to notify the GP Appraisal Team when a GP ceases to work in the board area NHS Orkney reported that the Primary Care Manager notifies the board s Public Service Division and local GP Appraisers when a GP ceases to practice within the board area. However, there does not appear to be a formal process for notifying the GP Appraisal Team and, therefore, a score of 1 was provided to reflect this. 5
Q5 There is a process in place for the board to action non-engagement or unsatisfactory engagement in the appraisal process by GPs as identified by the production of form GPScot 5b The board reported that 5 GPScot 5bs were issued in the year 2007 2008. However, the board did not provide a specific anonymised example of the board s actions as evidence. The board did outline the informal process followed on production of a GPScot 5b stating the Primary Care Manager investigates initially and any unresolved issues are escalated to the Medical Director and GP Appraisal Team. NHS QIS recommends that the LAA is involved in any investigation or decision to escalate to board level. Q6 Support is available at board level to GPs identified through the appraisal system as giving cause for concern The board reported that all GPs are assessed by Occupational Health prior to starting employment in the board area. However, the board did not outline referral pathways or detail how the service is accessed by GPs highlighted through the appraisal process as giving cause for concern. The board reported that the Training and Development Department ensures as much access as possible to training for GPs and publishes a training diary to highlight upcoming training courses. Funding is also available for courses outwith NHS Orkney, where appropriate. The board informed NHS QIS that it has an arrangement with NHS 24 to provide cover for practices allowing 7 afternoons per year for protected learning time. Study leave is also available and the use of this is monitored by the Primary Care Manager. NHS QIS recommends that specific supported learning time is made available for GPs identified as giving cause for concern through a clinical support structure with links to GP Appraisal. Q7 Effective communication between GP Appraisal Team and governance structure established The board demonstrated an informal link between the clinical governance structure and the LAA directly through the Primary Care Manager. An example of board intervention was provided but no evidence of any monitoring was submitted. NHS QIS recommends that a formal process linking GP Appraisal to the board clinical governance structure be developed. 6
Q8 The recruitment process for Appraisers is equitable, open and transparent and facilitates representation from the spectrum of Doctors working in General Practice NHS QIS rating = 2 NHS Orkney confirmed that all appraisers are recruited following the NES national recruitment process. However, the board did not provide a breakdown by gender, age, ethnicity or GP status of the Appraisers currently in post or any evidence of monitoring to ensure that Appraisers reflect the GP population in the board area. NHS QIS notes the high percentage of salaried GPs in the NHS Orkney area and recommends that demographic data are collected to enable the board to facilitate appropriate representation for future recruitment purposes. Q9 Appropriate support is provided to Appraisers to enable them to carry out their duties effectively NHS QIS rating = 2 The board reported that the LAA organises and leads four meetings of Grampian Appraisers per year, although the board did not submit any evidence that the meetings involve discussions on appraisal activity in Orkney. The board does however, provide administrative support as and when required and premises are made available which have online computer and printing facilities. Q10 Adequate Appraisers are in post to ensure access to the appraisal process for all GPs working in the board area NHS QIS rating = 2 NHS Orkney reported no shortfall in the number of Appraiser sessions provided as two sessions are required and two sessions are currently provided. While there are adequate appraisers in place, there is a shortfall in the number of GP appraisals being undertaken. NHS QIS concludes that while there are adequate Appraisers in place, the system is not monitored. 7
Q11 A system is in place to monitor effective management of appraisal scheme by GP Appraisal Team NHS QIS rating = 0 The board reported the appraisal of its LAA is undertaken by NES and NHS Grampian and that the previous appraisal took place in February 2004. However, it was reported that a performance appraisal is scheduled for July 2008. NHS QIS acknowledges that the LAA for Orkney is based in Grampian where appraisal takes place, although no evidence was submitted to demonstrate that the LAA s performance in NHS Orkney was part of this appraisal process. NHS QIS would recommend that a separate appraisal is undertaken specific to the LAA s role in NHS Orkney. Q12 Effectiveness of GP Appraisers being monitored NHS QIS rating = 2 The board described the process by which appraisal outcome measures are reviewed during Appraiser appraisal. NHS QIS noted that NHS Orkney GP Appraisers have undergone appraisal in their role as NHS Grampian Appraisers and would strongly recommend that this appraisal process includes a specific discussion on the appraisal work undertaken on behalf of NHS Orkney. The board did not provide any evidence of monitoring of the process. Q13 There is a process in place to monitor uptake of GP Appraisal amongst Sessional/Locum GPs working in your board area NHS Orkney reported that 3 Sessional GPs are hosted on its Performers List and that all 3 GPs have been appraised in the 12 months prior to 31 March 2008. Reference to these GPs being on the board payroll leads NHS QIS to the conclusion that these Sessional GPs are employed by board administered GP practices and the situation regarding other Sessional GPs hosted on the board s Performers List has not been clarified. The board does not report any system in place to monitor current appraisal status of Sessional GPs hosted by other boards but also on NHS Orkney s Performers List. 8
Q14 There is a process in place to ensure uptake of GP Appraisal amongst Sessional/Locum GPs hosted by your board area NHS QIS rating = 2 A description of the process to notify Sessional/Locum GPs of their responsibility to undergo an annual appraisal was provided for NHS and independent GP practices within NHS Orkney. The Primary Care Manager updates the list of appraisees and this is also given to the LAA. No financial support is made available to Sessional/Locum GPs undergoing appraisal. However, arrangements are made by the board to cover their workload. Single-handed practitioners on remote islands are provided with workload cover and transport costs to leave their base for appraisal. NHS QIS identified this as an area of good practice. Q15 There is a process in place to monitor uptake of GP Appraisal amongst GPs providing Out of Hours services in your board area The board reported that there is no separate process for monitoring uptake of GP Appraisal among GPs providing Out of Hours services within NHS Orkney as these GPs have other roles in general practice and are appraised within these roles. The process by which Host Sessional GPs working in independent practices are appraised remains unclear and, therefore, NHS QIS was unable to conclude if the board has a process in place to monitor uptake of GP Appraisal among GPs providing Out of Hours services. 9
Summary of good practice points Workload cover and transport costs are provided by NHS Orkney for single handed practitioners on remote islands to leave their base for appraisal. Summary of recommended actions NHS QIS recommends that NHS Orkney implements the following specific action points: Q1 Q2 Q5 Q6 Q7 Q11 and Q12 Establish a formal GP Appraisal Group. Produce an annual report to reflect the performance of the GP Appraisal process within the NHS Orkney board area. Formalise a process to involve the LAA in any investigation or decision regarding the non-engagement or unsatisfactory engagement in the appraisal process by GPs identified by the issue of a GPScot 5b form. Provide specific supported learning time for GPs identified as giving cause for concern through a clinical support structure with links to GP Appraisal. Develop a formal process to link the GP Appraisal team to the board s clinical governance structure. Establish a separate appraisal for the LAA s role in NHS Orkney. NHS QIS would like to thank NHS Orkney for its participation and involvement in this EQA of the GP Appraisal process. NHS QIS contacts: Ms Kirsteen Eydmann, Project Officer, Performance Assessment Ms Sharon Keane, Programme Manager, Performance Assessment Dr Patricia Moultrie, GP Appraisal EQA Project Manager 10
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