Case study 2 - NHS Berkshire

This page is aimed at employers, responsible officers and organisations.

You can download our case study for NHS Berkshire (pdf).

Introduction

NHS Berkshire is a cluster of two primary care trusts - NHS Berkshire East and NHS Berkshire West - spanning a region from Hungerford in the west to Slough in the east. The Cluster incorporates 107 GP practices and is responsible for the revalidation of 710 doctors, including 150 locum doctors.

Challenges

As a primary care commissioner, one of the major revalidation challenges facing NHS Berkshire is that it does not employ its doctors directly. In contrast to hospital doctors, who are employed by the NHS, a GP is contracted to provide care by a primary care trust.

While these contracts stipulate that an annual appraisal is required, managing the process and ensuring they happen regularly is a challenge. This is because the authority of line management lies within each self-contained practice.

This challenge is exacerbated by the fact that NHS Berkshire is currently in transition ahead of the formation of clinical commissioning groups (CCGs) in 2013. This has made it harder to focus minds on the importance of revalidation.

Another challenge facing NHS Berkshire is that the performers’ list for the region includes some 150 locum GPs, several of whom spend months at a time located outside of the Berkshire region.

Some locum GPs are based in Australia for more than six months of the year, while those who practise sports medicine can be difficult to pin down during the summer due to the nature of their work. This can make it challenging for locum doctors to collect the supporting information required for appraisal and revalidation, because of the changing nature of their practice.

There is also the issue of a very small minority of doctors that have proved to be unreachable – either because they have failed to notify the organisation of changes in their address or circumstances or because they have simply refused to engage with appraisal.

NHS Berkshire has also found that, while the vast majority of doctors are engaging with appraisal, there are many doctors who leave having their appraisal until March, the final month of the appraisal calendar. This leaves open the possibility of them being rushed or failing to be appraised if, for example, they become ill.

Action

From the outset, NHS Berkshire decided it should create a structure centred on a team approach, to ensure revalidation was given the right amount of time and support.

As well as Dr David Buckle, Medical Director and Responsible Officer for NHS Berkshire, the team includes a revalidation manager and two appraisal leads, one based in the east of the region and one based in the west. ‘Re-training appraisers was vital and something we worked on from the outset,’ explains Dr Buckle, ‘as we felt this was key to ensuring doctors had the support they needed to receive annual appraisals and ultimately revalidate.’ He confirms that 98% of appraisers have now received or booked top up training.

Dr Buckle and his team have worked with practice managers, forging relationships and encouraging them to remind their doctors of their revalidation responsibilities.

Knowing that their doctors must complete the process to ensure the practice’s ongoing success, practice managers can play a crucial role in emphasising the importance of doctors engaging with appraisal and revalidation, and may also help in the gathering of supporting information, as Dr Buckle explains: ‘Practice managers can encourage doctors to get patient feedback, to review complaints and ensure a steady stream of information is being collected.’

This role is something Dr Buckle can see being taken on by locum agencies in the future, further strengthening that group’s engagement with medical appraisal. ‘You don’t have this problem in hospitals, where there are systems in place as part of the line management process. In Berkshire we have developed a file which collates all the information we hold for an individual GP in one place.

When that doctor is revalidated or there is a performance concern, we have the information at hand.’ Dr Buckle’s team has also worked closely with CCG leads ahead of the changes next year. The CCG leads view appraisal and revalidation as essential as they also want quality primary care.

NHS Berkshire is encouraging practices to use the RCGP tool for recording supporting information, as the transition to clinical commissioning groups makes the development of bespoke tools more challenging.

However, Dr Buckle stresses that he will be supporting his GPs by funding a colleague and patient feedback tool: ‘Appraisal is the most important thing in this whole process,’ he says, ‘and you simply won’t get good 360° feedback in a small surgery without an electronic, validated process that asks the right questions, so we are looking to bring that in very soon.’

NHS Berkshire has also decided to tackle any lack of engagement from doctors head on. If any doctor fails to engage with appraisal and revalidation for a long period of time, they will be sent a hand-delivered letter explaining that continued lack of engagement will result in their removal from the performers’ list.

Meanwhile, NHS Berkshire has also decided to stop holding appraisals in March, the last month of the appraisal year, to encourage doctors not to leave their appraisal until the last minute.

Results and benefits

Since preparations for the roll out of revalidation began, the number of doctors in the region engaging in appraisal has steadily increased. One PCT now has an appraisal rate of 95%, while another is at 98%. These are figures which Dr Buckle feels are reflective of a realisation that revalidation is happening and a growing recognition of the importance of appraisal.

Overall Dr Buckle feels that preparations for revalidation are progressing well: ‘Revalidation is a new process but there are elements, such as appraisal, which are an improvement to what we were doing before – and for which GPs are well equipped.

The process is becoming more sophisticated; and is getting better all the time. It’s much bigger than ticking boxes – it’s about continuously improving quality and performance, and providing reassurance for patients that we are as good as we say we are.’

Key findings

• NHS Berkshire has worked in partnership with practice managers and CCG leaders in the area to communicate the importance of appraisal and revalidation, positioning them as ‘quality’ issues. This has helped to strengthen doctors’ engagement with appraisal.
• Practice managers have an important role in helping GPs to collect supporting information for their appraisal and revalidation.
• NHS Berkshire wanted to make sure it had the right level of support in place for its doctors from the outset. One of its first priorities was to complete its training of appraisers.
• Organisations need to think about how they manage and time their appraisals of doctors in the future. NHS Berkshire has stopped holding appraisals in March, to encourage doctors not to leave appraisal to the last minute.