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1 Trust Board Meeting Date: 24 September 2015 Accountable Director: Dr Mahadeva Ganesh, Medical Director
SUMMARY REPORT
Meeting Date: 24 September 2015 Agenda Item: 8.3 Enclosure Number:
8
Meeting: Trust Board
Title: Medical Re-Validation: A Framework of Quality Assurance for Responsible Officers and Revalidation – Annual Board Report
Author: Dr Mahadeva Ganesh Accountable Director:
Dr Mahadeva Ganesh
Other meetings presented to or previously agreed at:
Committee Date Reviewed Key Points/Recommendation from that Committee
Quality & Safety Committee
23 July 2015
Purpose of the report
The purpose of this paper is to provide assurance to the Board of the Trust’s progress in implementing the Responsible Officer Regulations. These Regulations are a key part of the revalidation arrangements by which all doctors have to demonstrate that they have up to date skills and competencies and are fit to practice. Providers have a statutory duty to support their Responsible Officers under the regulations, and this report helps the Trust Board to oversee compliance. A copy of this report and its appendices will be sent to the higher level Responsible Officer at NHS England as part of the new Framework of Quality Assurance requirements.
Consider for Action
Approval
Assurance
Information
Strategic goals this report relates to:
To deliver high quality care
To support people to live independently at
home
To deliver integrated care
To develop sustainable community
services
Summary of key points in report
This report describes the progress of the Trust towards the management of medical appraisal & revalidation during 2014/15.
As at 31 May 2015, 17 doctors had a prescribed connection to the Shropshire Community Health NHS Trust, which means that the Trust is their designated body for the purposes of revalidation.
16 out of 17 doctors were appraised during 14/15, with the main reason for the one missed appraisal being long-term sickness absence.
2 doctors were recommended for revalidation during this period and both have been ratified by the GMC. No doctor has been so far deferred and no concerns have been put forward to RO post appraisal.
2 Trust Board Meeting Date: 24 September 2015 Accountable Director: Dr Mahadeva Ganesh, Medical Director
An action plan for future developments can be found in section 11.
The draft Revalidation and Appraisal Report written by internal auditors Baker Tilly, following their recent audit, found that the Trust’s Revalidation and Appraisal processes and controls are adequately designed and were found to be operating effectively. They state that taking account of the issues identified within their report, the Board can take reasonable assurance that the controls in place to manage this risk are suitably designed and consistently applied.
Key Recommendations
The Board is asked to receive and note this report and approve the statement of compliance.
Is this report relevant to compliance with any key standards? YES OR NO
State specific standard or BAF risk
CQC Yes 12 & 14
IG Governance Toolkit No
Board Assurance Framework
Yes Quality risk
Impacts and Implications? YES or NO
If yes, what impact or implication
Patient safety & experience Yes
Financial (revenue & capital) Yes Training budgets and 360 degree feedback.
OD/Workforce Yes
Legal Yes
3 Trust Board Meeting Date: 24 September 2015 Accountable Director: Dr Mahadeva Ganesh, Medical Director
1
A Framework of Quality Assurance for Responsible Officers and Revalidation
Annex D - Annual Board Report Template Version 5, June 2014
2
NHS England INFORMATION READER BOX Directorate
Medical Operations Patients and Information
Nursing Policy Commissioning Development
Finance Human Resources
Publications Gateway Reference: 01142
Document Purpose Guidance
Document Name A Framework of Quality Assurance for Responsible Officers and Revalidation, Annex D - Annual Board Report Template
Author NHS England, Medical Revalidation Programme
Publication Date 10 June 2014
Target Audience All Responsible Officers in England
Additional Circulation List
Foundation Trust CEs , NHS England Regional Directors, Medical Appraisal Leads, CEs of Designated Bodies in England, NHS England Area Directors, NHS Trust Board Chairs, Directors of HR, NHS Trust CEs, All NHS England Employees
Description A template board report for use by designated bodies to monitor their organisation’s progress in implementing the Responsible Officer Regulations.
Cross Reference The Medical Profession (Responsible Officers) Regulations, 2010 (as amended 2013) and the GMC (Licence to Practise and Revalidation) Regulations 2012
Superseded Docs
(if applicable)
A Framework of Quality Assurance for Responsible Officers and Revalidation, Annex D - Annual Board Report Template, version 4, April 2014.
Action Required Designated Bodies to receive annual board reports on the implementation of revalidation and submit an annual statement of compliance to their higher level responsible officers.
Timings / Deadline From April 2014
Contact Details for further information
http://www.england.nhs.uk/revalidation/
Document Status 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
3
Annex D – Annual Board Report Template 2014/15
1. Executive summary
Shropshire Community NHS Trust employs or has working in its buildings a large number of doctors, most however do not have the Trust as their Designated Body for the purposes of revalidation (see background below) as they are generally GPs providing cover to the Community Hospitals, consultants from SATH providing outpatient clinics or GPs with Special interest. Currently, the Trust is the Designated Body for 17 doctors, most are either CAMHs clinicians or Community Paediatricians, and the remainder are the equivalent of GPs with Special Interest but are no longer on the GP register. Every year, all doctors will have an annual appraisal by the end of May and it is anticipated that all Doctors will have completed this process where the Trust is their Designated Body. If this is not the case, an audit will take place to look at why the appraisal has not occurred. Currently 2 of the Trust doctors have been put forward for approval by the Trust to the General Medical Council (GMC) and the decision has been ratified.
2. Purpose of the Paper
The purpose of this paper is to provide assurance to the Board of the organisations progress in implementing the Responsible Officer Regulations. A copy of this report and its appendices will be sent the higher level Responsible Officer at NHS England as part of the new Framework of Quality Assurance requirements. The report is based on a framework document provided by NHS England.
3. Background
Revalidation is the process by which doctors will have to demonstrate to the General Medical Council (GMC) that they are compliant with relevant professional standards, have up to date skills and competencies and are fit to practise. Annual appraisal is the process which ensures consultants and non-consultant career grade medical staff are up to date and continue to be fit to practise. Appraisal should be supportive and effective and informed by valid and verifiable supporting evidence that reflects the breadth of the individual doctor’s practice. It should result in a Personal Development Plan prioritising the doctor’s development needs for the coming year. Annual appraisal will provide the basis for revalidation in the future. The process of revalidation will involve two strands: relicensing (confirming that doctors practise in accordance with the General Medical Council’s (GMC) generic standards) and recertification (confirming that doctors on the specialist and GP registers conform to standards appropriate for their specialty) Revalidation involves a 5 year cycle of approval by the GMC. The process should be viewed as developmental in that different aspects of work and data can be collected in each year concentrating on different areas which is brought together in a portfolio for approval.
4
For most doctors revalidation is a developmental process to enable doctors to improve and increase the quality of their work, identify areas for improvement and evidence good practice. It will be a rare occurrence for the process to cause doctors not to be revalidated. The purpose of this report is to update the Board on the revalidation process within the Trust, to highlight any areas of concern that need to be improved on and to consider the assurance document required (see Annexe E - Statement of Compliance). The report is based on a framework document provided by NHS England.
Medical Revalidation was launched in 2012 to strengthen the way that doctors are regulated, with the aim of improving the quality of care provided to patients, improving patient safety and increasing public trust and confidence in the medical system.
Provider organisations have a statutory duty to support their Responsible Officers in discharging their duties under the Responsible Officer Regulations1 and it is expected that provider boards will oversee compliance by:
Monitoring the frequency and quality of medical appraisals in their organisations; in our trust it is conducted annually.
Checking there are effective systems in place for monitoring the conduct 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.
Previous reports and documents have been provided to the Board, namely:-
• Medical Revalidation Review of the Process in the Trust June 2013 • Review of ORSA November 2013. • A Framework of Quality Assurance for Responsible Officers and
Revalidation May 2014
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 2012’
5
4. Governance Arrangements
Given the small number of doctors that have the Trust as their designated body, the number of people involved in the process of appraisal and revalidation is relatively small. This can bring with it some difficulties and challenges as well as advantages. Most doctors know the other doctors they work with very well; maintaining objectivity in the appraisal process can therefore be difficult. The trust is also reviewing the current medical leadership model and this may impact on the current governance arrangements.
a) Trust organisational structure The Trust’s organisational structure for medical appraisal and revalidation is shown in Figure 1.
Associate Medical Directors
Dr A Neale Dr P Zubkowski Dr E Peer
Quality Assurance
Appraisal Leads
Dr M Ganesh
Responsible Officer (RO)
6
b) Governance reporting structure The Trust’s governance reporting structure for medical appraisal and revalidation is shown in Figure 2.
NHS England
(Quarterly and Annually)
Trust Board
(Annually)
Trust Quality & Safety Committee
(Annually)
Revalidation Steering Group with Associate Medical
Directors
(Quarterly)
Revalidation Local Group
(As and when required)
7
c) Reporting
NHS England
• Quarterly- Medical appraisal compliance • Annually – Annual Organisational Audit findings (AOA) [Appendix F] • Annually – Annual Trust Board Report
Trust Board
• Annually- Annual Organisational Audit findings (AOA) [Appendix F] –assurance/approval.
• Annually – Annual Trust Board Report – assurance/approval.
Quality & Safety Committee
• Annually- Annual Organisational Audit findings (AOA) [Appendix F] –assurance/approval.
• Annually – Annual Trust Board Report – assurance/approval. • As required- Policy change for approval- Approval.
Revalidation Steering Group
• Quarterly- Medical Appraisal/Revalidation update – monitoring.
Revalidation local group
• As required – management of apparent non-engagement with medical
appraisal/revalidation
GMC Connect
Connect is the General Medical Councils (GMC) database used by designated bodies to view and manage the list of doctors who have a prescribed connection to their organisation.
The database is maintained by the Trust’s Responsible Officer. The Trusts Electronic Staff Record management system (ESR) is used as its main information source in relation to starters and leavers, and is updated in ‘real time’.
GMC Connect also allows doctors to directly add themselves onto the system, where this happens, contact is made with the doctor through the Revalidation Office, to check the validity of the prescribed connection, which is done by using the NHS England prescribed connection algorithm.
8
5. Policy and Guidance
There are no new changes in current policy or guidance on medical revalidation or appraisal.
6. Medical Appraisal
a) Appraisal and Revalidation Performance Data
Detailed activity levels of appraisal outputs in individual departments:- • There are 17 doctors with the Trust as their designated body • 16 doctors have already completed their appraisals • Last year, one doctor had an incomplete appraisal due to long-term sick leave
(See appendix A).
b) Appraisers
There are currently 13 trained appraisers in the Trust. This number is sufficient, however, there are some clinicians who have an appraisal by an appraiser who is employed outside the Trust where there is a need for particular knowledge; the RO has approved this. In July 2014, appraisal training was provided to train new appraisers, non-consultant grade doctors and update current practice. This was an approved course and was very successful.
c) Quality Assurance
Responsible Officer to ensure that:
For the appraisal portfolio:-
• There is a review of appraisal folders to provide assurance that the appraisal inputs: the pre-appraisal declarations and supporting information provided is available and appropriate.
• There is a review of appraisal folders to provide assurance that the appraisal outputs: PDP, summary and sign offs are complete and to an appropriate standard.
• There is a review of appraisal outputs to provide assurance that any key items identified pre-appraisal as needing discussion during the appraisal are included in the appraisal outputs.
9
For the individual appraiser:-
• An annual record of the appraiser’s reflection on appropriate continuing professional development is recorded in the appraiser’s own appraisal documentation.
• An annual record of the appraiser’s participation in appraisal calibration events such as reflection on ASG (Appraisal Support Group) meetings. Last year’s appraisal training was held to increase calibration of the process. Following the completion of appraisals in May, there will be meetings between appraisers to improve practice and share learning; these meetings will be recorded.
• 360 feedbacks from doctors for each individual appraiser have been completed. There were no areas of concerns reported to the RO by the appraisers.
For the organisation:-
• System user feedback - At the end of May when all appraisals have been completed, all appraises will be sent a feedback form and information collated to help move the process forward.
• Review of lessons learned from any complaints - There have been no complaints in the current year concerning the appraisal process.
(See Annual Report Template, Appendix B; Quality assurance audit of appraisal inputs and outputs)
d) Access, security and confidentiality
All appraisers and appraises are aware that confidential information cannot be kept within the appraisal portfolio.
This is reviewed as part of the appraisal.
Where a doctor has been involved in a security breach, they are mandated to discuss the situation in their appraisal. No such potential breach has occurred within the last year.
e) Clinical Governance
Individual doctors will have performance data that can be used in the appraisal document. The information available to them will include complaints, SUIs and rates of performance that are reported to the Board, division and local team. They will also be able to use data and information from reports such as the mortality reviews, and relevant audits. The Medicines Management Team can provide useful data for doctors detailing some prescribing behaviours. Currently, however, the Trust does not have one single operating platform for information and data. This makes it very hard to compare the practice of doctors across specialities and some of the data systems provide more information than others, for example Graphnet as used in CAMHs can provide much more information on a doctor’s activity than the system used in Community Paediatrics.
10
The ability of the Trust to provide information and data is a well-recognised area of concern and a move towards an Electronic Patient Record is already in progress and is likely to help resolve this issue of data quality.
f) Revalidation Recommendations
• 2 doctors have been recommended for revalidation by the RO to the GMC. Both recommendations have been approved.
• There have currently been no deferral requests
• There have been no non-engagement notifications
(See Annual Report Template Appendix C; Audit of revalidation recommendations)
g) Recruitment and engagement background checks
There is a clear process and protocol for managers to follow to ensure all new doctors and locums appointed are checked in terms of their capability to fulfil their roles. This is undertaken via the HR process. Recently, there has been an increase in medical locums used due to difficulties to recruit in CAMHs and some gaps between doctors leaving and being replaced in Community Paediatrics.
A random audit is to take place to ensure that this process in place robust.
Currently the request for a RO reference is not part of the NHS recruitment guidelines and is not requested routinely.
New doctors, including locums, will now be asked for their most recent appraisal outputs and asked about progress against this once they have been in post for 2 weeks. Currently we have 5 Locum doctors with us and all have their appraisal completed for this year and no concerns have been reported to the RO.
(See Annual Report Template Appendix E; Audit of recruitment and engagement background)
h) Monitoring Performance
Alongside the appraisal, all doctors have a job plan and a management structure under which their performance is monitored. Any concerns about their performance are dealt with by the manager but there is good communication between managers and the RO who is kept informed of any concerns.
i) Responding to Concerns and Remediation
• The Trust currently uses the standard responding to concerns policy in line with
the GMC. • There are no doctors currently on a remediation programme.
11
j) Risk and Issues
Being a small Trust makes it difficult to put in a process that keeps the revalidation process completely objective. Recent recruitment difficulties have meant that there has been an increase in the number of locum agency medical staff employed. The trust has invited an external Auditor to quality assure or revalidation process and governance around it. It will hopefully enlighten us to improve our existing process.
k) Board Reflections
To be included following the Board discussion.
l) Corrective Actions, Improvement Plan and Next Steps
Doctors in the Trust have the ability to revalidate; the process of assurance needs to be strengthened. In order for this to occur the following actions need to be put in place:
Reference Action
Lead Completion Date
12.1 To devise Local Medical Appraisal (MA)Policy
RO and AMD Nov 2015
12.2 To develop a QA monitoring tool for MA
AMD Dec 2015
12.3 To develop an Induction programme for Locum doctors and for Substantive posts in the Trust
Community Paeds- Dr I. Mahabeer. CAMHS- Dr A. Neal. Community Hospitals- Dr Emily Peer and Dr Ganesh
Completed Nov 2015 Nov 2015
12.4 To devise a feedback questionnaire when Locums leave the Trust.
RO Jan 2016
12.5 ESR to develop a process for sharing centrally held supporting information with appraisers and appraises ahead of their appraisal meeting.
John Snell and HR Jan 2016
12
The Board is asked to:-
a) Accept the report (noting it will be shared, along with the annual audit, with the higher level Responsible Officer) and to consider any needs/resources.
b) To approve the ‘statement of compliance’ confirming that the organisation, as a designated body, is in compliance with the regulations
13
Annual Report Template Appendix A Audit of all missed or incomplete appraisals audit
Doctor factors (total) Number
Maternity leave during the majority of the ‘appraisal due window’ 0
Sickness absence during the majority of the ‘appraisal due window’ 1
Prolonged leave during the majority of the ‘appraisal due window’ 0
Suspension during the majority of the ‘appraisal due window’ 0
New starter within 3 month of appraisal due date 0
New starter more than 3 months from appraisal due date 0
Postponed due to incomplete portfolio/insufficient supporting information
0
Appraisal outputs not signed off by doctor within 28 days 0
Lack of time of doctor 0
Lack of engagement of doctor 0
Other doctor factors 0
(describe)
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
(describe)
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
14
Annual Report Template Appendix B Quality assurance audit of appraisal inputs and outputs Total number of appraisals completed Number
Number of appraisal portfolios sampled (to demonstrate adequate sample size) 10
Number of the sampled appraisal portfolios deemed to be acceptable against standards 10
Appraisal inputs 10 10
Scope of work: Has a full scope of practice been described?
10 10
Continuing Professional Development (CPD): Is CPD compliant with GMC requirements?
10 10
Quality improvement activity: Is quality improvement activity compliant with GMC requirements?
10 10
Patient feedback exercise: Has a patient feedback exercise been completed?
No
Colleague feedback exercise: Has a colleague feedback exercise been completed?
0 0
Review of complaints: Have all complaints been included? 10 10
Review of significant events/clinical incidents/SUIs: Have all significant events/clinical incidents/SUIs been included?
10 2
Is there sufficient supporting information from all the doctor’s roles and places of work?
10 10
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?
10 10
Appraisal Outputs
Appraisal Summary 10 10
Appraiser Statements 10 10
Personal Development Plan (PDP) 10 10
15
Annual Report Template Appendix C Audit of revalidation recommendations
Revalidation recommendations between 1 April 2014 to 31 March 2015
Recommendations completed on time (within the GMC recommendation window)
2
Late recommendations (completed, but after the GMC recommendation window closed)
0
Missed recommendations (not completed) 0
TOTAL 2
Primary reason for all late/missed recommendations
For any late or missed recommendations only one primary reason must be identified
0
No responsible officer in post 0
New starter/new prescribed connection established within 2 weeks of revalidation due date
0
New starter/new prescribed connection established more than 2 weeks from revalidation due date
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 0
Describe other 0
TOTAL [sum of (late) + (missed)] 0
16
Annual Report Template Appendix D Audit of concerns about a doctor’s practice
Concerns about a doctor’s practice High level2
Medium level2
Low level2
Total
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
0
Capability concerns (as the primary category) in the last 12 months
0
Conduct concerns (as the primary category) in the last 12 months
0
Health concerns (as the primary category) in the last 12 months
1 1 2
Remediation/Reskilling/Retraining/Rehabilitation
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
0
Consultants (permanent employed staff including honorary contract holders, NHS and other government /public body staff)
0
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)
0
General practitioner (for NHS England area teams only; doctors on a medical performers list, Armed Forces)
0
Trainee: doctor on national postgraduate training scheme (for local education and training boards only; doctors on national training programmes)
0
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)
0
Temporary or short-term contract holders (temporary employed staff including locums who are directly employed, trust doctors, locums for service, clinical
0
2 http://www.england.nhs.uk/revalidation/wp‐
content/uploads/sites/10/2014/03/rst_gauging_concern_level_2013.pdf
17
research fellows, trainees not on national training schemes, doctors with fixed-term employment contracts, etc) All Designated Bodiess
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 Bodiess
0
TOTALS 0
Other Actions/Interventions
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
0
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
0
Number of doctors who have had local restrictions placed on their practice in the last 12 months?
0
GMC Actions:
Number of doctors who:
0
Were referred by the designated body to the GMC between 1 April and 31 March
0
Underwent or are currently undergoing GMC Fitness to Practice procedures between 1 April and 31 March
0
Had conditions placed on their practice by the GMC or undertakings agreed with the GMC between 1 April and 31 March
0
Had their registration/licence suspended by the GMC between 1 April and 31 March
0
Were erased from the GMC register between 1 April and 31 March 0
National Clinical Assessment Service actions: 0
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
0
Number of NCAS assessments performed 0
18
Annual Report Template Appendix E
Audit of recruitment and engagement background checks
Number of new doctors (including all new prescribed connections) who have commenced in last 12 months (including where appropriate locum doctors)
Permanent employed doctors 1
Temporary employed doctors 0
Locums brought in to the designated body through a locum agency 5
Locums brought in to the designated body through ‘Staff Bank’ arrangements 0
Doctors on Performers Lists 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
0
TOTAL 6
For how many of these doctors was the following information available within 1 month of the doctor’s starting date (numbers)
Tot
al
Iden
tity
chec
k
Pas
t GM
C
issu
es
GM
C c
ondi
tions
or
un
dert
akin
gs
On-
goin
g G
MC
/NC
AS
in
vest
igat
ions
D
iscl
osur
e a
nd
Bar
ring
Ser
vice
(D
BS
)
2 re
cent
re
fere
nces
Nam
e of
last
re
spon
sibl
e of
ficer
Ref
eren
ce fr
om
last
res
pons
ible
of
ficer
Lan
guag
e co
mpe
tenc
y
Loca
l con
ditio
ns
or u
nde
rtak
ings
Qua
lific
atio
n ch
eck
Rev
alid
atio
n du
e da
te
App
rais
al d
ue
date
App
rais
al
outp
uts
Unr
esol
ved
perf
orm
ance
co
ncer
ns
Permanent employed doctors
1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 1
Temporary employed doctors
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Locums brought in to the designated body through a locum agency
5 5 5 5 5 5 5 5 0 5 5 5 1 1 1 5
19
Locums brought in to the designated body through ‘Staff Bank’ arrangements
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Doctors on Performers Lists
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Other
(independent contractors, practising privileges, members, registrants, etc)
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Total 6 6 6 6 6 6 6 6 6 6 6 6 2 2 1` 6
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)
Consultant:
Overall number of locum days
used
SAS doctors: Overall
number of locum days
used
Trainees (all grades): Overall number of locum
days used
Total Overall number of locum
days used
Surgery
Medicine
Psychiatry 4 WTE(1440) 900450 0 0 900 450
Obstetrics/Gynaecology
Accident and Emergency
Anaesthetics
Radiology
20
Pathology
Other 1wte 230 0 0 230
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)
Total
Pre-employment
checks completed (number)
Induction or orientation completed (number)
Exit reports completed (number)
Concerns reported to agency or
responsible officer (number)
2 days or less 0 0 0 0 0
3 days to one week 0 0 0 0 0
1 week to 1 month 0 0 0 0 0
1-3 months 0 0 0 0 0
3-6 months 0 0 0 0 0
6-12 months 2 2 2 0 0
More than 12 months 3 3 3 0 0
Total 5 5 5 0 0
OFFICIAL
A Framework of Quality Assurance for Responsible Officers and Revalidation
Annex E - Statement of Compliance
OFFICIAL
2
Statement of Compliance Version number: 2.0 First published: 4 April 2014 Updated: 22 June 2015 Prepared by: Gary Cooper, Project Manager for Quality Assurance, NHS England Classification: OFFICIAL Publications Gateway Reference: 03432
NB: The National Health Service Commissioning Board 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.
OFFICIAL
3
Designated Body Statement of Compliance
The board / executive management team – [delete as applicable] of [insert official name of DB] can confirm that
an AOA has been submitted, the organisation is compliant 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;
Yes
2. An accurate record of all licensed medical practitioners with a prescribed connection to the designated body is maintained;
Comments: GMC connect list regularly reviewed and doctors advised to contact GMC to be added or removed.
3. There are sufficient numbers of trained appraisers to carry out annual medical appraisals for all licensed medical practitioners;
Comments: 10 appraisers trained in summer 2014. Number is sufficient.
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 Appraisers1 or equivalent);
Comments: All appraisers had an appraisal update in summer 2014.
Ro updates all team members on the current knowledge on appraisals and revalidation.
5. All licensed medical practitioners2 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;
Comments:
This year’s appraisals have been completed by the end of May.
MAG- appraisal tool used.
Last year’s late appraisal audit complete
6. There are effective systems in place for monitoring the conduct and performance of all licensed medical practitioners1 (which includes, but is not limited to, monitoring: in-house training, clinical outcomes data, significant events, complaints, and feedback from patients and colleagues) and ensuring
1 http://www.england.nhs.uk/revalidation/ro/app-syst/ 2 Doctors with a prescribed connection to the designated body on the date of reporting.
OFFICIAL
4
that information about these matters is provided for doctors to include at their appraisal;
Comments: Systems are in place to monitor performance; this would be made efficient with a single data system which is likely to be operational across the Trust from June 2016.
7. There is a process established for responding to concerns about any licensed medical practitioners1 fitness to practise;
Comments: Policies in place and are being implemented.
8. There is a process for obtaining and sharing information of note about any licensed medical practitioner’s fitness to practise between this organisation’s responsible officer and other responsible officers (or persons with appropriate governance responsibility) in other places where the licensed medical practitioner works;3
Comments: Networking with the Local Ro and medical leads are well established for information sharing
9. The appropriate pre-employment background checks (including pre-engagement for locums) are carried out to ensure that all licenced medical practitioners4 have qualifications and experience appropriate to the work performed;
Comments: Pre-employment checks are in place as part of routine practice.
10. A development plan is in place that ensures continual improvement and addresses any identified weaknesses or gaps in compliance.
Comments: Plan to increase assurance is part of the current Board Annual Report by the Responsible Officer
Signed on behalf of the designated body
[(Chief executive or chairman (or executive if no board exists)]
Official name of designated body: _ _ _ _ _ _ _ _ _ _ _
Name: _ _ _ _ _ _ _ _ _ _ _ Signed: _ _ _ _ _ _ _ _ _ _
Role: _ _ _ _ _ _ _ _ _ _ _
Date: _ _ _ _ _ _ _ _ _ _
3 The Medical Profession (Responsible Officers) Regulations 2011, regulation 11: http://www.legislation.gov.uk/ukdsi/2010/9780111500286/contents
