medical appraisal policy elibrary id reference no: clin-pol-003-12

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Version number: 1.0 Trust-wide CBR Title: Medical Appraisal Policy

Medical Appraisal Policy

eLibrary ID Reference No: CLIN-POL-003-12

Newly developed Trust-wide CBRs will be allocated an eLibrary reference number following submission of eform for

registering on eLibrary. Reviewed Trust-wide CBRs must retain the original eLibrary reference id number.

Version: 1.0

Date Approved by Corporate Business

Records Committee (CBRC):

28th November 2012

Date Approved by Trust Board (if Applicable) N/A

Review Date: November 2014

Title of originator/author: Deputy Medical Director

Title of Relevant Director: Chief Medical Officer

Target audience: Medical Staff

If printed, copied or otherwise transferred from eLibrary, Trust-wide Corporate

Business Records will be considered ‘uncontrolled copies’. Staff must always

consult the most up to date PDF version which is registered on eLibrary.

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This Trust-wide CBR has been developed / reviewed in accordance

with the Trust approved ‘Development & Management of Trust-

wide Corporate Business Records Procedure (Clinical and Non-

clinical strategies, policies and procedures)’

Version

9.0

Summary of Trust-wide CBR: (Brief summary of the Trust-wide Corporate Business Record)

The Medical Appraisal Policy outlines the process

of how Medically qualified staff conduct their

appraisal process.

Purpose of Trust-wide CBR: (Purpose of the Corporate Business Record)

Medical Appraisals are required in order to make a

decision on whether or not to revalidate a doctor. If

doctors are not revalidated they cannot continue to

practice medicine.

Trust-wide CBR to be read in conjunction with: (State overarching/underpinning Trust approved CBRs)

N/A

Relevance: (State one of the following: Governance, Human Resource, Finance, Clinical, ICT, Health & Safety, Operational)

Human Resource, Governance, Clinical

Superseded Trust-wide CBRs (if applicable): (Should this CBR completely override a previously approved Trust-wide CBR, please state full title and eLibrary reference number and the CBR will be removed from eLibrary)

N/A

Author’s Name, Title & email address: Dr. Michael Iredale – Deputy Medical Director

[email protected]

Reviewer’s Name, Title & email address: Mrs. Meghana Pandit – Chief Medical Officer

[email protected]

Responsible Director’s Name & Title: Mrs. Meghana Pandit – Chief Medical Officer

[email protected]

Department/Specialty: Trust Corporate Services

Version Title of Trust Committee/Forum/Body/Group consulted

during the development stages of this Trust-wide CBR

Date

1.0 Medical Negotiating Committee September 2012

1.0 HRED Committee September 2012

1.0 Corporate Business Records Committee November 2012

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Table of Contents

Paragraph

Number Description

Page

Number

1.0

Scope

4

2.0

Introduction

4

3.0

Statement of Intent

5

4.0

Definitions

6

5.0

Duties/Responsibilities

7

6.0

Details of the Policy

10

7.0

Dissemination and Implementation

19

8.0

Training

19

9.0

Monitoring Compliance

9.4 Monitoring Table

19

20

10.0

Staff Compliance Statement

21

11.0

Equality and Diversity Statement

21

12.0

References and Bibliography

21

13.0

UHCW Associated Records

22

14.0

Appendices

23

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1.0 SCOPE

This policy applies to all doctors and Dentists employed by University Hospitals

Coventry and Warwickshire NHS Trust with the exception of Doctors in Training who

will be appraised through separate means relating to their training, co-ordinated by

the West Midlands Deanery. Where doctors are employed through joint appointments

with the University of Warwick, appraisal will be undertaken in a joint process.

2.0 INTRODUCTION

Medical Appraisal was first introduced for NHS consultants in 2001 and for general

practitioners in 2002. It has been generally well regarded by doctors and it has also

provided organisations with an opportunity to align individual professional

development with service and organisational development.

The White Paper ‘Trust Assurance and Safety (1) has positioned strengthened

annual medical appraisal as the cornerstone of revalidation. The new model of

appraisal will involve quality assurance and effective supporting clinical governance

systems. Current appraisal systems and content are based on GMC’s ‘Good Medical

Practice’ as a framework (2).

Revalidation of licensed doctors will be required every five years and is based on

comprehensive appraisals undertaken over that five year period. It is designed to

improve the quality of patient care by ensuring that licensed doctors remain up to

date and continue to be fit to practice:

• To confirm that licensed doctors practice in accordance with the GMC’s

generic standards

• For doctors on the specialist register and GP register, to confirm that they

meet the standards appropriate for their specialty

• To identify, for further investigation and remediation, poor practice where local

systems are not robust enough to do this or do not exist.

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All non-training grade Medical Staff (GPs, Consultants, SAS grades and any other

non-training grade posts) are expected to go through revalidation every five years.

The Deanery will be responsible for the revalidation of doctors in training.

University Hospitals Coventry and Warwickshire NHS Trust will to support all

employees within the Trust to ensure that they receive an appraisal on an annual

basis; this includes all doctors and dentists within the Trust. Appraisal for doctors and

dentists is a professional process of constructive dialogue, in which the doctor being

appraised has a formal structured opportunity to reflect on his or her work and to

consider how his or her effectiveness might be improved. Medical appraisal has been

identified as the cornerstone of the revalidation process and will be used to support

the decision by the Responsible Officer whether or not to recommend revalidation.

3.0 STATEMENT OF INTENT

It is the policy of the Trust that medical revalidation, and the processes to enable it,

will be implemented in the Trust in order to assure patients, public and staff (including

clinicians, support staff, managers and the Trust Board), that doctors are up to date

and fit to practice, and are being supported in the continuous improvement of the

quality of their practice and services. Revalidation will be underpinned through a

robust, equal, fair and transparent annual appraisal system informed by enhanced

information flows and delivered by quality assured appraisers. All medical staff will

participate in annual appraisal and the revalidation process, and in the essential

contributory activities of clinical governance, audit, and the obtaining of patient and

colleague feedback.

The Trust requires all doctors and dentist working within the organisation to have an

appraisal on an annual basis. There is a requirement for the organisation to make the

necessary provision for all members of staff to have an appraisal and the appraisee

to have a responsibility to participate in appraisal process and any joint

recommendations which may be derived from the appraisal. Additionally it must be

noted that it is a contractual requirement of doctors to retain a licence to practice,

revalidation which is the mechanism for this will be facilitated through annual

appraisal.

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4.0 DEFINITIONS

4.1 Appraisal – Provides the framework to ensure that all doctors have annual two

way discussions which includes the areas specified under Good Medical Practice

(GMP) relating to their practice and career development.

4.2 Completed appraisal – Is one where the appraisal meeting has taken place

within the appraisal year and the summary of the appraisal discussions and Personal

Development Plan (PDP) have been signed off by the appraiser and appraisee.

4.3 Appraisal Year – The appraisal year, like a financial year runs from 1st April to

31st March. Defining the appraisal year in this way aims to assist the management

and monitoring of the appraisal process and to allow comparators and benchmarking

between organisations.

4.4 Relicensing – Since November 2009, all doctors in the United Kingdom have

been required by law to be registered and hold a licence to practice with the GMC in

order to practice medicine. Revalidation is the process by which this licence is

renewed.

4.5 Revalidation – Is the process by which doctors will demonstrate to the GMC that

they remain up to date and fit to practise. All doctors will be required to undertake

revalidation on a five year cycle in order to retain their licence to practise.

Revalidation is based upon information generated from yearly appraisals during the

five year cycle. Multi-source feedback is required at least once during each doctor’s

five year review cycle.

4.6 Recertification - Licensed doctors on the Specialist or GP register will in addition

be required to recertify against the standards that apply to their specialty or area of

practice, set by the relevant medical Royal College or Faculty and approved by the

GMC.

4.7 Suitable Appraiser – For a consultant this would be another consultant in the

same specialty or related specialty as the appraisee who has received appropriate

training in conducting appraisals.

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For an SAS doctor this could be a either a consultant or SAS doctor in the same or

related specialty as the appraisee who is included on the appropriate specialist

register and who has received appropriate training in conducting appraisals. This

does not have to be the educational consultant or Clinical Director.

4.8 Revalidation Lead – This individual will oversee the operational implementation

and maintenance of matters relating to revalidation on behalf of the Chief Medical

Officer and Responsible Officer.

4.9 Revalidation Coordinator – This individual will coordinate aspects connected to

revalidation as instructed by the Chief Medical Officer and Responsible Officer.

5.0 Duties / Responsibilities

5.1 Chief Executive

The Chief Executive on behalf of UHCW NHS Trust is responsible for ensuring that

the Responsible Officer is provided with appropriate resources to allow him/her to

discharge his/her duties. The Chief Executive will ensure that indemnity is provided

for appraisers both internal to the trust and appraisers that are external to the trust.

5.2 Responsible Officer

The Responsible Officer (normally the Chief Medical Officer) has overall

responsibility for the effective implementation and operation of appraisals for all non-

training grade Medical Staff within the organisation (Consultants, SAS, Trust Doctors

and all non-training grade posts) and is personally accountable to the Board. The

Responsible Officer will be supported by the Revalidation Lead.

The Responsible Officer will make a recommendation to the GMC on a doctor’s

fitness for revalidation based on an assessment of their practise through annual

appraisals over five years.

The Responsible Officer will provide an annual report to the trust board.

The Responsible Officer will ensure that arrangements are in place so that

information held by the organisation on each doctor’s practice within the organisation

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is made available to them on an annual basis and in a timely manner.

UHCW NHS Trust will provide a description of the selection process for appraisers,

together with a Job Description of the required competencies (Appendix 1). It will

arrange for training, in line with the guidelines, for all new appraisers; and updated

training for existing appraisers. UHCW NHS Trust will produce on an annual basis a

list of suitably trained appraisers for appraisees to select from. It will obtain appraisee

feedback on the performance of all its appraisers.

5.3 Clinical Directors

Clinical Directors have responsibility over their Specialty Group and will retain an

oversight of appraisals within their respective specialty(s), including tracking timely

completion for all medical staff.

Clinical Directors will participate in the appraisal process where they are selected as

an appraiser, and adhere to the principles of GMP relating to appraisal.

Clinical Directors will comply with agreed recommendations derived from appraisals

relating to individual’s development needs where compatible with the needs of the

department and service. Where these recommendations are not, further discussion

with the appraiser and appraisee may be required.

Clinical Directors are responsible for raising any concerns in relation to the appraisal

process should they occur.

5.4 Appraisers

Appraisers will participate in the appraisal process where they are selected as an

appraiser if agreed and adhere to the principles of GMP relating to appraisal.

Appraisers will make adequate provision to undertake appraisal of those designated

as their appraisees (this will be reflected in their job plan). They will adhere to the

Medical Appraisal Policy and:

• Organise all their appraisals within the appraisal timeframe

• Review appraisal documentation and evidence at least 2 weeks before the

appraisal interview takes place, identifying key areas for discussion

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• Ensure all paperwork is processed as required on completion of the appraisal

interview, including the signing off of the PDP by both parties (using the

agreed Trust template documentation).

• Report on the outcome of their appraisals to the Responsible Officer and

inform the Clinical Director that an appraisal has taken place.

• When the successful appraisal has been completed they will forward details

to the email address [email protected] so that it can be

recorded electronically on the appriasee’s record for future reference. For

those areas live on ESR Self Service, the details of the appraisal can be

entered directly at source by the relevant manager.

• Undertake appraisal training and attend refresher training on a 3 yearly basis

• Take part in a performance review, including feedback on performance in

their role

• Organise for their own appraisal in a timely manner

• Ensure their statutory and mandatory training is up to date.

Appraisers will highlight any serious performance issues as necessary to the relevant

Clinical Director and / or Chief Medical Officer.

Should an appraiser feel there is a conflict of interest which prevents them

undertaking appraisal with an individual then this will be discussed with the Clinical

Director and Chief Medical Officer as required.

5.5 Appraisees

Appraisees are responsible for ensuring that they participate in the annual appraisal

cycle to meet the requirements of Revalidation. They are required to maintain a

professional portfolio including feedback from each of their employers (whole practice

review) including the independent sector, records of their training, reflective practice

and additional documentation as specified by the GMC. This evidence must be

available to their Appraiser at least 2 weeks before the date of the appraisal.

Appraisees will identify a suitable appraiser from the trust approved list, and inform

the appraisal co-ordinator. They will appropriately prepare for the appraisal meeting

including review of supporting information and adhere to the principles of GMP

relating to appraisal.

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Appraisees will use the agreed Trust appraisal documentation, which will be available

on the intranet.

Appraisees will comply with agreed recommendation derived from appraisals.

Appraisees will raise any concerns in relation to the appraisal process should they

occur.

5.6 Appraisal Co-ordinator

• Will ensure that all doctors have a confirmed date for their appraisal

• Will highlight deviations from the agreed appraisal timetable to Clinical

Director for the relevant area and the Chief Medical Officer where necessary

• Will receive and log completed appraisal documentation

5.7 Reporting and Recording

Once completed, appraisal information should be sent through for recording on the

Electronic Staff Records (ESR) system. The appraiser should email the ESR &

Workforce Information Team ([email protected]) to confirm the

details of the appraisal that has been conducted.

For those areas live on ESR Self Service, the details of the appraisal can be entered

directly at source by the relevant manager.

The ESR & Workforce Information Team will produce monthly reports on compliance

rates and these will be distributed as part of the Key Performance Indicators for

Specialty Groups so that these can be monitored.

6.0 DETAILS OF THE POLICY

6.1 Principles of Appraisal

Appraisal should be a positive process that gives doctors feedback on their past

performance, to chart their continuing progress and to identify their development al

needs. It is a forward-looking process, essential in identifying the developmental and

educational needs of individuals. Appraisal is at its heart a reflective process

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allowing the doctor to review his/her development professionally with a trained

colleague as appraiser - involving challenge where necessary. It has the dual aim of

ensuring high quality patient care and assisting the individual to achieve his or her full

professional potential.

The primary aim of appraisal is to help doctors consolidate and improve on good

performance, aiming towards excellence. In doing so, it should identify areas where

further development may be necessary or useful; the purpose is to improve

performance right across the spectrum. It can help to identify concerns over

performance at an early stage and also to recognise factors, which may have lead to

performance problems, such as ill health.

Appraisal is underpinned by continuing professional development and if used

properly can help to develop a reflective culture within service and training. In time it

is expected that regular successful annual appraisal will provide the foundation stone

upon which a positive affirmation of continued fitness to practice can be made every

five years by the doctor’s Responsible Officer (3).

The aims of appraisal are to:

• Set out personal and professional development needs and agree plans for

these to be met

• Regularly review a doctor's work and performance, utilising relevant and

appropriate comparative operational data from local, regional and national

sources

• Consider the doctor’s contribution to the quality and improvement of services

and priorities delivered locally

• Optimise the use of skills and resources in seeking to achieve the delivery of

general and personal medical services

• Identify the need for adequate resources to enable any service objectives in

the agreed job plan review to be met

• Provide an opportunity for doctors to discuss and seek support for their

participation in activities for the wider NHS

• Utilise the annual appraisal process and associated documentation to meet

the requirements for GMC revalidation against the nine headings of ‘Good

Medical Practice’.

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6.2 Appraisal process

The content of appraisal is based on the GMC guidance published in ‘Good Medical

Practice’.

A list of trained appraisers will be sent to the Chief Medical Officer on an annual

basis. Individuals on the medical appraiser list will be suitably trained to conduct

appraisals and are informed of the necessary processes of reporting their

completion.

The list of agreed appraisers will be published on the intranet so that an appraisee

can contact their appraiser and confirm they have capacity to appraise them. Once

the appraiser/appraisee relationship has been agreed, the appraisers must inform the

appraisal co-ordinator. Once confirmed, a record of this relationship will be kept

centrally by the appraisal co-ordinator.

• The appraisal year runs from 1st April to 31st March.

• It is expected that all appraisals will be carried out between April and June of

the following appraisal year i.e. the appraisal will review a complete year’s

activity. It is acceptable to start the process towards the end of the annual

cycle e.g. holding the appraisal meeting in February/March.

• The appraisee must choose an appraiser from the list of trained appraisers

that is available from the Appraisal Co-ordinator

• The appraisee should agree a date with the appraiser that is usually at least

six weeks in advance of the appraisal meeting.

• The appraisal documentation should normally be available to the appraiser

two weeks prior to the appraisal meeting (one week being the absolute

minimum).

• The information required for appraisal, and responsibility for provision is listed

in appendix 2

• The doctor being appraised should prepare for the appraisal by identifying

issues to discuss with the appraiser, collecting relevant evidence and by

preparing a draft personal development plan (PDP).

• The appraiser should review the portfolio of evidence in advance of the

meeting. If evidence is missing there should be an opportunity for the

appraiser to request that the evidence is provided in advance of the meeting.

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• The appraiser should prepare and agree an agenda of items that are to be

discussed and reviewed one week before the meeting.

• The appraisal meeting must be held in an appropriate environment. This will

involve a quiet room and both the appraiser and appraisee must ensure that

they are not disturbed during the appraisal meeting.

• The appraiser must complete summary of appraisal (form 4). The appraisee

should complete the agreed personal development plan.

• On completion of the appraisal signed off copies of the appraisal

documentation i.e. the summary of appraisal and the personal development

plan, must be returned to the Chief Medical Officer’s office in an electronic

format by the appraisee.

• The appraisee is responsible for completing the annual appraiser feedback

form and for returning this to the Appraisal Co-ordinator.

• The appraisal process is only completed when the Chief Medical Officer’s

office issues a certificate of satisfactory completion of appraisal.

• Multi-source feedback must be undertaken at least once during the five year

revalidation cycle. When multi-source feedback is undertaken, it must be

taken into account during that year’s appraisal.

A flow chart summarising the process is shown in Appendix 3.

6.3 Approach to appraisal and revalidation of clinical academic staff

Follett principles will apply to the appraisal of clinical academics. This means that

appraisal and revalidation processes will involve “joint working to integrate separate

responsibilities”. Details are given in Appendix 4.

6.4 Private practice

Where a doctor carries out private practice, supporting information from that work

should be provided to allow for a full appraisal of clinical practice. If no evidence is

provided then a clear statement must be made that clinical practice from non-NHS

work has not been appraised. It is expected however that strengthened medical

appraisal for the purposes of revalidation will be based on whole practice appraisal.

Absence of supporting information from other practice settings may therefore risk the

satisfactory completion of annual appraisal when revalidation is implemented.

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6.5 Outcomes of Appraisal

For most doctors the appraisal process will result in a positive outcome with the

development of an agreed personal development plan. The maximum benefit from

the appraisal process can only be realised where there is openness between the

appraisee and appraiser. The appraisal should identify individual needs, which will

be addressed through the personal development plan. All records will be held on-line

and any printed copies to be kept on a secure basis and access/use must comply

fully with the requirements of the Data Protection Act. The following forms must be

completed:

• Summary of Appraisal – The key points of discussion and outcome must be

fully documented. Both parties must sign the appraisal summary sheet (form

4) to confirm that this is an accurate reflection of the appraisal meeting and

send in confidence to the Chief Medical Officer’s Office by the appraisee. This

should happen within two weeks of the appraisal meeting. A copy should also

be sent to the Clinical Director for storage on the personal file.

• Personal Development Plan – As an outcome of the appraisal, key

development objectives for the following year and subsequent years should

be set. These objectives may cover any aspect of the appraisal such as

personal development needs, training goals and organisational issues,

keeping up to date, CPD e.g. acquisition/consolidation of new skills and

techniques. The personal development plan should be finalised within two

weeks of the appraisal meeting. The personal development plan will need to

be agreed with the clinical director and appraisees must send the signed off

personal development plan immediately to their clinical director for approval.

Following the completion of a successful appraisal, confirmation of this completion

will be sent to through to Workforce Information

([email protected]) so that it can be recorded on the appraisee’s

record. For those areas live on ESR Self Service, the details of the appraisal can be

entered directly at source by the relevant manager.

The last sheet of the appraisal (Form 4) where both the appraisee and appraiser sign

to confirm the outcome of the appraisal, should be submitted submitted to the Clinical

Director for recording on the personal file.

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Should any concerns or development needs be identified through the appraisal

process these will be communicated to the Chief Medical Officer as appropriate for

oversight as the Responsible Officer.

6.6 What is an unsatisfactory appraisal?

Guidance is given in the appendices on what is considered to be essential and

optional documentation that should be detailed in the portfolio (Appendix 2).

If any part of the essential documentation is not identified in a portfolio (unless a

satisfactory explanation can be offered by the appraisee) then this must be brought

to the attention of the appraisee prior to the appraisal meeting. This should provide

an opportunity for the appraisee to produce the relevant piece of information. If the

information is not forthcoming and there is no satisfactory explanation offered then

the appraisal meeting should not go ahead and the Chief Medical Officer should be

informed.

An unsatisfactory outcome of appraisal may also arise from:

• failure to address issues that have been previously raised about clinical

performance or personal behaviour

• the appraiser’s judgement that there is inadequate evidence in any section of

the appraisal information.

• failure to make adequate progress against the previous years PDP without

adequate explanation.

Part of the developmental approach to appraisal should be in supporting the

appraisee in improving the quality of evidence year on year in the appraisal portfolio.

It is only when there has been a clear failure to respond to actions outlined in

previous Form 4s that the appraisal could be considered as being unsatisfactory. If

the issues cannot be resolved with the appraisee then the matter should be referred

to the Chief Medical Officer.

6.7 Disagreement of appraisal outcome

Should there be a disagreement between the appraiser and appraisee regarding the

outcome of an appraisal, this should be identified to the Deputy Medical Director

(Non-elective care) for resolution. Soundings on the issue may be taken from a

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number of appraisers and an opinion on the merits of the case will be conveyed to

the appraisee and the appraiser by the Trust Lead. Where the Consultant continues

to disagree with the content of the appraisal or the process that has been followed

and a certificate of satisfactory completion of appraisal cannot be issued then the

Consultant will be advised of his/her right to raise their concern formally in

accordance with the Trust’s Grievance Procedure.

6.8 When an appraisal meeting should be adjourned?

Where it becomes apparent during the appraisal process that there is a potentially

serious performance, health or conduct issue (not previously identified) that requires

further discussion or investigation, the appraisal meeting must be stopped. The

matter must be referred by the appraiser immediately to the Chief Medical Officer to

take appropriate action.

6.9 Exemption from appraisal

Consultants, SAS doctors and locums who have been in post for less than six

months prior to the end of an appraisal year will be exempt from the appraisal

process for that year but will be expected to meet with the Clinical Director / Clinical

lead and General Manager to agree relevant service related objectives within the first

job planning meeting.

All other consultants / SAS doctors that have been in post for more than six months

(including locums) will be expected to participate fully in the appraisal process. The

six months includes time spent in previous posts in UHCW NHS Trust. It is the

responsibility of the individual doctor (including locums) to ensure that they

participate in the appraisal process.

6.10 New staff members

Clinical Managers must inform new employees of the requirement to undertake

annual appraisal should they not already be aware. In addition they must ensure that

employees within their area of responsibility comply with this policy.

6.11 Deferment of an annual appraisal

UHCW NHS Trust requires all consultants and SAS doctors to undergo an appraisal

annually and will remain a formal requirement for revalidation once it is introduced.

There are however exceptional circumstances when a doctor may request that an

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appraisal is deferred such that no appraisal takes places during one appraisal year.

Instances when a doctor may request a deferment:

• Breaks in clinical practice due to sickness or maternity.

• Breaks in clinical practice due to absence abroad or sabbaticals.

• Breaks due to compulsory mobilisation or service.

Doctors who have a break from clinical practice may find it harder to collect evidence

to support their appraisal, particularly if being appraised soon after their return to

clinical practice. An appraisal however can often be useful when timed to coincide

with a doctor’s re-induction to clinical work to help plan their re-entry.

Appraisers will use their discretion when deciding the minimum evidence acceptable

for these exceptional appraisals.

As a general rule it is advised that doctors having a career break:

• In excess of 6 months should try to be appraised within 6 months of returning

to work.

• Less than 6 months should try to be appraised no more than 18 months after

the previous appraisal and wherever possible so that an appraisal year is not

missed altogether.

Each case can be dealt with on its merits and UHCW NHS Trust is mindful that no

doctor must be disadvantaged or unfairly penalised as a result of pregnancy,

sickness or disability. Doctors are likely to have to produce the required total amount

of CPD credits stipulated for the five year revalidation cycle, even if they have had

some periods of leave during these five years.

UHCW NHS Trust has the right to take action against a doctor if they do not undergo

an annual appraisal without having good reason. This policy aims to ensure that

these circumstances are dealt with in an appropriate, timely, and consistent manner,

minimising bureaucracy and ensuring that all doctors benefit from appraisal at a time

which meets their professional needs.

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Doctors who think they may need to defer their appraisal should discuss their

deferment with their Clinical Lead / Clinical Director in the first instance and inform

the Chief Medical Officer.

Appraisals may be deferred at the specific request of the Chief Medical Officer where

a doctor is already under investigation for concerns that have been raised.

6.12 Procedure to be followed for doctors who have not completed an annual

appraisal

The Clinical Director will be asked by the Chief Medical Officer to carry out an

investigation as to the reasons why the individual doctor has not completed an

appraisal. A report on the investigation will be submitted to the Chief Medical Officer

and appropriate action will be taken.

Doctors who have not completed an annual appraisal will not be eligible for routine

pay progression or local clinical excellence awards unless deferment on exceptional

grounds has been agreed with UHCW NHS Trust.

6.13 Complaints arising from the appraisal process

Complaints and grievances arising from the appraisal process should be addressed

in the first instance to the Deputy Medical Director (non-elective care) responsible for

revalidation, or, if they concern the Deputy Medical Director, to the Chief Medical

Officer.

Receipt of complaints will be acknowledged within seven days. Complaints will be

investigated and where possible resolved by the recipient within twenty eight days. A

written reply will be provided to the complainant at this time.

Complaints and grievances may be discussed with the Chief HR Officer or Associate

Director of HR, with the agreement of the complainant, if necessary to determine the

best course of action or to assure the complainant of the integrity of the process.

Complainants who are not satisfied with the outcome can refer the complaint to the

Chief Executive of UHCW NHS Trust.

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7.0 DISSEMINATION AND IMPLEMENTATION

The Medical Appraisal policy will be implemented with effect from <insert date>

effect. In addition to being updated on the E-Library the dissemination of this policy

will be supported by training of appraisers undertaken by Learning and Development.

It is also expected that this policy will be communicated out to all affected employees

through all user communications.

8.0 TRAINING

The Trust will provide training and guidance for medical staff on the Medical

Appraisal Policy and will also ensure that all staff required to undertake medical

appraisal are made aware of this policy as appropriate.

9.0 MONITORING COMPLIANCE WITH THE PROCEDURAL DOCUMENT

9.1 Quality assurance programme for appraisal

Internal Quality Assurance (QA) of appraisal comprises:

• Assurance of the process.

• Assurance of work of appraisers.

Compliance with this policy and the completion of annual appraisals will be a key

performance indictor used by the specialty groups to track compliance with this

policy.

9.2 Assurance of the Process

Assurance of the process will be carried out as part of the annual report to the Board

of UHCW NHS Trust produced by the Chief Medical Officer.

Regular review of UHCW NHS Trust’s appraisal system, policy and supporting

guidance will be undertaken each year by the Trust revalidation Lead (Deputy

Medical Director). This will include regular formal feedback from both appraisers and

appraisees on the management of the appraisal system as a whole. For appraisees

this will be achieved through the use of the routine Appraisee Feedback

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Questionnaire (Appendix 5). Appraisers will be asked for feedback as part of their

review process.

9.3 Assurance of the Work of Appraisers

QA of appraiser work is delivered through:

1. Recruitment and selection – through the Chief Medical Officer / Revalidation

Lead.

2. Review of established appraisers’ performance through regular feedback

questionnaires from appraisees (Appendix 5).

3. Annual appraiser paper-based review – using analysis of form 4 / PDPs

produced

4. Three yearly face to face formal appraiser reviews.

5. Annual appraiser updates (formal group training and appraiser support)

External assurance of appraisal systems will be undertaken as and when agreement

is reached nationally on mechanisms for conducting this in line with CQC regulation

and inspectorate responsibilities.

9.4 Monitoring Table

Aspect of compliance or effectiveness being monitored

Monitoring method

Individual department responsible for the monitoring

Frequency of the monitoring activity

Group / committee which will receive the findings / monitoring report

Group / committee / individual responsible for ensuring that the actions are completed

Completion of

appraisal

ESR KPI Relevant

Clinical

Director

Quarterly

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10.0 STAFF COMPLIANCE STATEMENT

All staff must comply with this Trust-wide Corporate Business Record and failure to

do so may be considered a disciplinary matter leading to action being taken under

the Trust-s Disciplinary Procedure. Actions which constitute breach of confidence,

fraud, misuse of NHS resources or illegal activity will be treated as serious

misconduct and may result in dismissal from employment and may in addition lead to

other legal action against the individual/s concerned.

A copy of the Trust’s Disciplinary Procedure is available from eLibrary.

11.0 EQUALITY & DIVERSITY STATEMENT

Throughout its activities, the Trust will seek to treat all people equally and fairly. This

includes those seeking and using the services, employees and potential employees.

No-one will receive less favourable treatment on the grounds of sex/gender

(including Trans People), disability, marital status, race/colour/ethnicity/nationally,

sexual orientation, age, social status, their trade union activities, religion/beliefs or

caring responsibilities nor will they be disadvantaged by conditions or requirements

which cannot be shown to be justifiable. All staff, whether part time, full-time,

temporary, job share or volunteer; service users and partners will be treated fairly

and with dignity and respect.

12.0 REFERENCES AND BIBLIOGRAPHY

1. www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_065

946

2. http://www.gmc-uk.org/guidance/good_medical_practice.asp

3. http://www.gmc-uk.org/doctors/revalidation/5786.asp

4. www.gmc-uk.org/doctors/revalidation/revalidation_gmp_framework.asp

5. www.gmc-uk.org/doctors/revalidation/revalidation_information.asp

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13.0 UHCW ASSOCIATED RECORDS

13.1 Appraisal documentation to support medical appraisal within UHCW NHS Trust

conforms to advice given in ‘The Good medical Practice Framework for appraisal and

revalidation’ (4) and ‘Supporting information for appraisal and revalidation’ (5).

Documentation is shown in Appendix 6, and will be reviewed on an annual basis, that

review informed by feedback from both appraisers and appraisees.

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Appendix 1:

Medical Appraisers

Selection:

Consultants are asked to put themselves forward to become Medical Appraisers. They will be expected to perform appraisals in their own and related specialties. They will be expected to undertake up to 8 appraisals each year. A list of appraisers will be approved by the Revalidation Lead and the Responsible Officer. If there are any issues or concerns these will be discussed with the appraiser by the Revalidation Lead. A list of approved appraisers will be published on the trust intranet, and held by the Appraisal Co-ordinator.

Key Tasks and Responsibilities of a Medical Appraiser

• To attend appropriate appraiser training

• To participate in ongoing training and support to address the development needs in the role of

appraiser

• To participate in performance review in the role of the appraiser

• To undertake pre appraisal preparation and appraisal discussion in line with the Trust’s

Appraisal Policy, alongside national guidance and quality standards

• To complete post appraisal documentation in line with the Trust’s policy, alongside national

guidance and quality standards, and to submit this to the Responsible Officer or delegated staff

member.

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Appendix 2:

Information to support appraisal Supporting information (more detailed information can be found in ‘Supporting information for appraisal and revalidation (GMC 2011)’ (5). The supporting information that you will need to bring to your appraisal will fall under four broad headings:

General information - providing context about what you do in all aspects of your work Keeping up to date - maintaining and enhancing the quality of your professional work Review of your practice - evaluating the quality of your professional work Feedback on your practice - how others perceive the quality of your professional work

There are six types of supporting information that you will be expected to provide and discuss at your appraisal at least once in each five year cycle. They are:

1. Continuing professional development 2. Quality improvement activity 3. Significant events 4. Feedback from colleagues 5. Feedback from patients 6. Review of complaints and compliments

The nature of the supporting information will reflect your particular specialist practice and your other professional roles. For example, an appropriate quality improvement activity will vary across different specialties and roles. Responsibility for Information UHCW NHS Trust is responsible for providing information on:

• Activity

• Complaints

• Incidents

UHCW NHS Trust will facilitate arrangements for completion of Multi-source feedback for all non-training grade doctors Consultants are responsible for providing information on:

• CPD

• Multi-source feedback

• Clinical Audit activity

• Audit of personal clinical outcomes

• Reflection on complaints

• Reflection on incidents

• Compliments

• Evidence from private practice

• Evidence of activity for external bodies

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Appendix 3:

Appraisal Process Flow Chart

1. Appraisee selects Appraiser from UHCW list of approved Appraisers held by

Appraisal Co-ordinator

2. Appraisee agrees date with Appraiser (ideally 6 weeks in advance)

3. Appraisee sends Appraiser appraisal documentation at least 2 weeks in advance

4. Appraisal meeting – from 4 and personal development plan (PDP) agreed

5. Appraisee

a. sends signed copy of Form 4 & PDP to Appraisal Co-ordinator

b. Appraisee completes feedback form

6. Appraiser will inform CD and workforce information that appraisal has taken place

7. Appraisee receives Certificate of Completion of Appraisal

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Appendix 4:

Approach to appraisal and revalidation of clinical academic staff

Follett principles will apply to the appraisal of clinical academics. This means that appraisal

and revalidation processes will involve “joint working to integrate separate responsibilities”

The Follett report suggests that the process should:

1. Involve a decision on whether a single or joint appraisal is appropriate for every

senior NHS and University staff member with academic and clinical responsibilities

2. Ensure joint appraisal for clinical academics holding honorary consultant contracts

and for NHS staff undertaking substantial roles in Universities

3. Define joint appraisal as two appraisers, one from the University and one from the NHS, working with one appraisee on a single occasion

4. Require structured input from the other partner where a single appraiser acts

5. Be based on a single set of documents

The Follett principles were articulated in response to concerns at the possibilities that doctors

with substantial roles in both NHS and University might on the one hand be subjected to

unreasonable and unmanageable demands from the two employers each acting individually,

and on the other hand might not be held accountable by either, each thinking that the other

was overseeing activity or managing the doctor.

In considering the need for a joint appraisal, consideration will be given to the interpretation

of recommendation 2 above, in particular the meaning of the term “substantial roles in

Universities”

All substantive University employees with Honorary clinical contracts (“Academic Doctors”)

require a Trust appraisal process that meets the requirements of revalidation (the Trust, but

not the University, is a Designated Body and the Academic Doctor’s Responsible Officer is

the Trust RO).

The University and the Trust will work to ensure joint appraisal through collaboration between

the relevant University administration and the Chief Medical Officer.

NHS consultants with academic commitments with the University that equal or exceed 50% of

the job plan should also have a joint appraisal conducted by a Trust and a University

appraiser.

A consultant undertaking academic work (of more than 2 PA s per week) may request a joint

appraisal if s/he is concerned that a single Trust appraiser cannot reconcile the conflicting

demands of academic and clinical work. The Responsible Officer will determine whether to

agree to a joint appraisal and will ask the University to provide an academic appraiser. The

Responsible Officer’s decision in this regard is final.

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Appendix 5:

Appraisal Feedback Questionnaire

Concerning your most recent appraisal (mark with a X as appropriate)

Strongly agree

Strongly disagree

My appraiser had read my evidence folder

My appraiser encouraged me to reflect on my practice

My appraiser listened well

There was sufficient time to discuss the issues that were important to me

My appraisal was a constructive experience

My appraisal helped me think about new ways to tackle challenging aspects of work

My appraisal recognised my achievements and progress

My appraisal helped me to identify areas to work on during the coming year

The appraisal process allowed me to formulate a PDP for the next year

My appraiser was able to give me useful, constructive feedback

My appraiser developed ideas and issues from last year’s appraisal

My appraiser helped me identify evidence I need to produce for next year

My appraiser produced an accurate Form 4 a good summary of the appraisal interview

Overall, I felt that my appraisal was a worthwhile experience

Please add any comments you may wish to make about your appraisal, your appraiser or the Appraisal process: Organisation of appraisal in the Trust: Provision of information about appraisal: Personal experience of this appraisal for me: strengths and weaknesses:

Thank you for completing this questionnaire. The results of the survey will be used to

influence future appraiser training and selection and help inform review of the appraisal process.

Please return this questionnaire to Angie Barnet, Chief Medical Officer’s Office

Appraisee name:

Appraiser name :

medical appraisal policy elibrary id reference no: clin-pol-003-12

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