Case study 5 - Hywel Dda Health Board

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Introduction

Hywel Dda Health Board provides healthcare services to 372,320 people throughout Carmarthenshire, Ceredigion and Pembrokeshire, in Southern and Western Wales. It provides Acute, Primary, Community, Mental Health and Learning Disabilities services via General and Community Hospitals, Health Centres, GP's, Dentists, Pharmacists and Optometrists and other sites. The Health Board is responsible for the revalidation of 777 doctors across both primary and secondary care.

Challenges

In terms of preparing for revalidation, the greatest challenge facing the organisation is replicating for hospital doctors the system it has in place for GPs. The appraisal system in Wales is well developed for GPs as they can only retain their status on the performers’ list if they take part in appraisal.

Primary care in Wales also benefits from a close relationship with the Wales Deanery. All GPs have access to the Deanery’s online system, which informs them when their appraisal is due and provides them with a space where they can store the supporting information they need for appraisal and, in turn, revalidation. As the appraisal process has been up and running for some time, primary care in Wales has also been able to recruit a bank of appraisers which GPs can choose from.

In comparison, appraisals in secondary care are less well developed and the engagement of doctors has previously been limited, so demonstrating the value of appraisal going forward is a priority. Secondary care has historically relied on a paper based system, which is not so standardised and provides more scope for an appraisal to be missed or insufficient supporting information to be collected. In addition, hospital doctors are appraised predominantly by line managers, who may not always be the most suitable appraiser, so developing a bank of appraisers similar to those in primary care is a key challenge.

The sheer size of the organisation is also a challenge. Keeping track of 777 doctors from a broad range of specialties across four general hospitals, eight community hospitals and 14 health centres is difficult, especially when doctors may change roles and locum doctors tend to move around a lot due to the nature of their work.

Another challenge across the whole Health Board is obtaining multi-source feedback. Even in primary care, with a robust appraisal process in operation, the requirements for revalidation mean more information will need to be collected than previously. In addition, at the centre of the challenges faced by the Health Board has been the issue of personnel – finding the right team to lead and manage the introduction of revalidation within the organisation.

Action

The priority for the Health Board was to build an infrastructure for appraisal to support its secondary care doctors. It has done this by copying and implementing the best measures from primary care, which include an online system to help manage doctors’ appraisals and building a strong network of appraisers. It also brought in an Associate Medical Director for Workforce to lead the project, making revalidation the central point of this newly created role.

Responsible Officer and Medical Director Dr Sue Fish explains: “We had to make our work on revalidation a priority and so we appointed Dr June Picton as Associate Medical Director for Workforce, predominantly to oversee its implementation. June has been tasked with improving the appraisal processes within secondary care and her appointment has been critical in ensuring revalidation is understood across the organisation.” A revalidation manager is currently being recruited to further strengthen the revalidation team.

Since beginning her role, Dr Picton has been busy preparing secondary care doctors for an enhanced form of appraisal: “I’m going out and meeting specialist departments to let them know what is required,” she says. “I’ve personally trained 56 hospital doctors in how to be appraisers and the next stage is to create a list of appraisers from which doctors can select. The challenge in secondary care is keeping this bank of appraisers engaged – in primary care appraisers are paid for this role but this is not the case in secondary, so we need to incentivise doctors by highlighting the professional development benefit for them.” This face-to-face training process is “very time consuming” but is ultimately essential in ensuring the appraisal system is based on strong foundations.

The challenge of keeping appraisees motivated can also be overcome by stressing the opportunities appraisal provides, according to Dr Graham Boswell, Hospital Director for Clinical Care, who works alongside Dr Picton on the implementation of revalidation: “Appraisal and development is fundamentally linked to education – doctors need to be made aware that annual appraisal is a chance to plot your next learning steps.”

Dr Fish emphasises that the Wales Deanery’s online system – Medical Appraisal and Revalidation System (MARS) – has been vital in helping Welsh GPs participate in appraisal and will be rolled out across the secondary care system in Wales over the next twelve months. “This will be a vital step forward in ensuring doctors are prepared for revalidation.”

Dr Picton agrees. “The Deanery’s online system is excellent for storing supporting information and for providing users with a revalidation readiness dashboard, which clearly highlights gaps that need filling. When MARS is rolled out to secondary care doctors it will be an enormous help.”

To best support locum doctors with revalidation the Health Board again works closely with the Deanery, cross referencing their appraisal database with the performers’ list to ensure no doctor is unaccounted for. For locum doctors who work in hospitals, the Health Board is utilising its relationship with locum agencies to make sure that regular appraisal is taking place.

In terms of multi-source feedback, a decision has been taken by the Wales Revalidation Delivery Board to procure a tool on a pan-Wales level. This will ensure that feedback is gathered in a consistent way across Wales.

Results & Benefits

Dr Fish feels that the Health Board is in good shape ahead of the commencement of revalidation: “Obviously, we need to get the multi-source feedback tool up and running, but after conversations with the relevant Welsh authorities and the GMC I am confident that we will have at least 20% of doctors with supporting information from the required amount of sources, which will mean we can commence revalidation as scheduled.”

Dr Picton explains that initial changes implemented have had a positive effect and evidences this by explaining that over 90% of doctors across both primary and secondary care have had an appraisal in the past twelve months – a much improved figure. For Dr Picton, it is now vital to “keep the ball rolling” in the run up to revalidation.

Both doctors feel that revalidation will be of significant benefit to doctors and patients, with Dr Fish explaining that, in her role of Responsible Officer, revalidation will crucially give her feedback about individual doctors as opposed to practices. Revalidation, they stress, will ensure effective appraisals are completed on time, underlining its importance for professional development. Dr Boswell concurs, emphasising that revalidation will also provide patients with assurances that their doctors are fit to practise, and increase patient confidence in the medical profession.

Key Findings

• Build on your strengths – if the appraisal process is strong in one area of your organisation, look to share and copy best practice in other areas
• Emphasise professional development opportunities – promoting the role of appraisals in professional development can incentivise doctors, helping to engage appraisees and support the recruitment of appraisers
• Provide doctors with effective tools – robust systems for securing supporting information and a suitable tool for multi-source feedback are vital to making the process as easy as possible for doctors