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Page 1 of 27
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.
Page 2 of 27
Version number: 1.0 Trust-wide CBR Title: Medical Appraisal Policy
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Superseded Trust-wide CBRs (if applicable): (Should this CBR completely override a previously approved Trust-wide CBR, please state full title and eLibrary reference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
Reviewer’s Name, Title & email address: Mrs. Meghana Pandit – Chief Medical Officer
Responsible Director’s Name & Title: Mrs. Meghana Pandit – Chief Medical Officer
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
Page 3 of 27
Version number: 1.0 Trust-wide CBR Title: Medical Appraisal Policy
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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Version number: 1.0 Trust-wide CBR Title: Medical Appraisal Policy
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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Version number: 1.0 Trust-wide CBR Title: Medical Appraisal Policy
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 :