Case study 4 - Nottingham University NHS Trust

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Introduction

Formed in 2006, Nottingham University Hospitals NHS Trust (NUH) is one of the biggest and busiest acute trusts in England, employing some 13,000 staff. NUH is responsible for ensuring 643 of its doctors receive annual appraisals and are supported with their revalidation.

Challenges

NUH found that the greatest challenge in preparing for revalidation was ensuring that all of its doctors participated in a quality annual appraisal and that they understood they needed to have a regular appraisal to revalidate and maintain their licence to practise.

Four years ago when the Trust began considering its readiness for revalidation, it established that around half of the consultants and non-consultant career grade doctors were participating in appraisal. However, the Trust was unable to establish how many of those doctors had been appraised in the last year or how thorough those appraisals had been.

There was also a lack of clarity regarding the supporting information that would be required for revalidation, and who would be responsible for collecting this.

Ensuring that adequate resources and support were in place to develop the Trust’s guidance and procedures for appraisal and revalidation was also critical; and it was crucial that procedures were flexible enough to incorporate different policies produced by individual medical royal colleges and faculties and by individual departments within the hospital.

Action

In response to these challenges, the Trust formed a Medical Appraisal and Revalidation Committee (MARC). This included representatives from the medical royal colleges, medical staff side, the University of Nottingham, and directorate management teams.

In November 2008, this committee published a report recommending a series of actions that would ensure the Trust would be ready for the roll out of revalidation in late 2012. The report looked at three key areas: policy and procedures; developing an intranet site where doctors could arrange appraisals and maintain records; and training and developing a group of appraisers.

These actions were taken forward by Mr Nigel Beasley, Deputy Medical Director with responsibility for appraisal and revalidation. Mr Beasley explains: ‘Establishing the committee was a really important step forward in our readiness.

Following the report, we made significant progress in our policies and procedures, and we appointed and trained 65 new appraisers. But our key challenge has been developing an intranet system which our doctors can use to manage their appraisals and access information about the plans we have for revalidation.’

In 2009, the Trust appointed a dedicated medical workforce project manager, Louise Dexter, who was tasked with coordinating the processes around appraisals. Louise worked closely with Dr Shafique Ahmad, a consultant in the Emergency Department and member of MARC, who was instrumental in building and developing the intranet site.

The site has been refined over the last two years and now allows doctors to easily identify an appraiser and arrange an appraisal.

Doctors can select an appraiser from a list of names in their department and the site automatically sends an email to notify that doctor of a request for an appraisal.

Prior to 2008, doctors who wanted to have an appraisal could choose any doctor within the Trust as their appraiser. Following the appointment of 65 dedicated appraisers, the Trust decided that, from then on, only those 65 appraisers could conduct appraisals.

This was to ensure appraisals were carried out in a consistent way and to a high quality. The number of appraisers has now grown to 120 to help ensure there are enough appraisers with a good mix across hospital departments.

Once doctors have had their appraisal, they can upload their completed Form 4s to the site and use it to maintain an appraisal record. Importantly the site is open to everyone, and anyone in the Trust can log in and see when a colleague last completed an appraisal.

As Mr Beasley explains, transparency was vital: ‘We felt it was important that clinical directors, for example, could use the intranet site to look at when their consultants last had an appraisal, or other staff in the Trust could look to see when doctors they work with last had one.’

Dr Shafique Ahmad explains the implementation process thus far: ‘In today’s world, if information is not available in one click, people won’t stay tuned. As such, we focus on keeping the service simple, targeted at its audience and consistent with GMC messaging.

Crucially, our systems are underpinned by a dedicated support team that assists doctors who are struggling to find what they need.’ The challenge still remaining is to improve access and availability to supporting information, and to quality assure the appraisal process while retaining engagement levels.

MARC also worked with representatives of the medical royal colleges to analyse the GMC’s Good Medical Practice framework for appraisal and the colleges’ guidance for doctors to create a single portfolio template to help doctors collate supporting information and identify the correct sources for feedback, including the clinical director or head of service, the HR team and the education and training team.

Results and benefits

The overall appraisal rate for doctors within NUH has improved significantly and is now over 98%. Mr Beasley confirms: ‘We are definitely ready for the roll out of revalidation and we are already seeing great benefits across the Trust. As a doctor I found it exceptionally useful to sit down with another colleague, reflect on my current practice and develop a personalised action plan.

This also provides direct benefits for patients, who for the first time will have assurance that their doctors regularly reflect on quality of care, and that someone has checked doctors are competent and fit to practise.

’This is a view supported by Dr Ivan Le Jeune, Consultant Physician in the Departments of Acute and Respiratory Medicine, who has recently completed the appraiser training: ‘Previously, when I have had appraisals, I have been unsure about what the outcomes were or how I can apply them to my practice.

With the upcoming introduction of revalidation, appraisals have become much more focused on developing a clearer personal development plan and more achievable planned goals that will offer direct benefits to me and the overall service.’

Dr Le Jeune continues: ‘I think most doctors have an in-built desire to offer the best service they can for their patients, but sometimes I think in the past we have assumed that we are doing this. Appraisal and revalidation make doctors really reflect on their practice, and challenge and analyse the service we are offering, allowing us to develop our practice more confidently.’

Key findings

• Setting up a Medical Appraisal and Revalidation Committee (MARC) helped NUH to involve the right people within the organisation from the start. The committee has been critical in ensuring clear and consistent processes are established right the way across the organisation. This has led to high levels of internal buy-in.
• NUH ensured its revalidation project had strong governance and leadership by making its deputy medical director responsible for appraisal and revalidation. It also appointed a dedicated project manager.
• NUH has kept its doctors engaged with appraisal and revalidation by developing its own portfolio system and running a programme of open seminars over the last two years. These events have given doctors a forum to share and discuss their views and concerns.