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Medical Revalidation and Appraisal

General Information
  • Responsible Officer: Dr Jennifer Armstrong, Medical Director
  • Deputy Responsible Officer (Secondary Care): Dr Christopher Deighan
  • Appraisal Lead (Secondary Care): Dr Andrew Harvey
  • Deputy Appraisal Lead: (Secondary Care): Dr Una Graham
  • Deputy Responsible Officer (Primary Care): Dr Kerri Neylon, Clinical Director, Glasgow City HSCP (North West Locality)

These Medical Revalidation and Appraisal pages provide information for non-training career grade doctors in secondary care who have a substantive, locum or honorary contract with NHS Greater Glasgow and Clyde. This includes non-training Clinical Fellows who do not hold a National Training Number (NTN).  It does not include doctors in training (including Foundation Year trainees, Specialty Registrars, Core Trainees and those who hold Locum Appointment for Training posts), for whom NHS Education for Scotland (NES) is the body responsible for revalidation.  

Please note: General Practitioners (GPs) who carry out the majority of their clinical work within Secondary Care should undertake a single appraisal within Secondary Care, which also covers their Primary Care practice. All GPs are required to work an average of fifty sessions per year to demonstrate that they are maintaining their clinical skills.

Please use the titles below to navigate to the required information and guidance.

If you have a specific query or question regarding Medical Revalidation or Appraisal please email medical.revalidation@ggc.scot.nhs.uk and a member of the Medical Staffing Team will get back to you.

Doctors in training with queries regarding revalidation should contact NES for clarification: trainingcontacts@nes.scot.nhs.uk.

Introduction to Medical Revalidation and Appraisal

Appraisal

All Consultants, SAS doctors and Career Grade doctors employed by NHSGGC must undertake an appraisal once during the period 1st April to 31st March in any given year.  Annual appraisal is a contractual obligation for all Consultants and SAS doctors employed by NHS Boards in Scotland.  It is also a statutory responsibility for all Consultants, SAS doctors and Career Grade doctors, who wish to retain a Licence to Practise, to regularly undertake appraisals in accordance with The General Medical Council (Licence to Practise and Revalidation) Regulations Order of Council 2012.

The appraisal should focus in the main on information gathered during the preceding year using the GMC’s Good Medical Practice Framework as its focus.  If this is a doctor’s first appraisal as a newly qualified Consultant/SAS Grade/Career Grade they should bring along a copy of their Certificate of Completion of Training (CCT), their Annual Review of Competence Progression (ARCP) and any evidence of patient/colleague feedback gathered in the previous 5 years.  If a doctor has been previously employed as a Consultant/SAS Grade/Career Grade and has undertaken a valid appraisal for the preceding year they should bring along a copy of their signed Form 4 to their first Appraisal meeting.

Appraisals should be completed online using the Scottish Online Appraisal Resource (SOAR). This will assist greatly in record keeping and ensure that through audit the process can be quality assured.  To register with SOAR please access the website http://www.appraisal.nes.scot.nhs.uk/.

Your Chief of Medicine / Appraisal Lead is formally responsible for appointing your appraiser. It is not permissible for an appraisee to self-select an appraiser. Where possible, doctors should be appraised by 2 separate appraisers during the 5 year revalidation cycle

Revalidation

Revalidation is the process by which doctors are required to demonstrate on a regular basis that they are up to date and fit to practice.  Doctors will revalidate, usually every five years, based on a recommendation made to the GMC by the Board Medical Director, as Responsible Officer (RO).  The RO will base their recommendation on a doctor’s appraisals over a five year period (i.e. the revalidation cycle), together with information drawn from the local clinical governance systems.  The RO will be required to make a revalidation recommendation in accordance with the doctor’s due date which has been prescribed by the GMC.  Each doctor will be notified directly of their revalidation due date by the GMC.

The RO can make one of three recommendations:

  • Recommendation to revalidate
  • Recommendation to defer
  • Recommendation of non-engagement.

On the basis of the RO’s recommendation, the GMC will decide whether the doctor’s licence to practise should continue to be revalidated for a further 5 years.  For further information on revalidation please access the the following GMC website: http://www.gmc-uk.org/doctors/revalidation.asp.

Should you have any queries in relation to the above please email: medical.revalidation@ggc.scot.nhs.uk.

Appraisal Year and Phasing

The appraisal year & appraisal process for Secondary Care

The appraisal year

The appraisal year is aligned to the financial year, running from 1st April to 31st March.  The appraisal year aligned to an appraisal is predicated by when the appraisal meeting takes place.  For example, if the appraisal meeting takes place in June 2022, the appraisal will fall under the appraisal year 2022/2023 (1st April 2022 to 31st March 2023).  An Appraisal meeting taking place in April 2023 will fall within the appraisal year 2023/2024 (1st April 2023 to 31st March 2024).

The information to be reviewed at the appraisal meeting should cover all supporting information gathered since the previous appraisal to being the doctor up to date.     

Supporting information for annual appraisal must include evidence of Continuing Professional Development, Quality Improvement Activity, Significant Events Analysis, a review of complaints and compliments and also evidence of Colleague MSF and Patient Feedback, which are GMC requirements for revalidation (in conjunction with at least one appraisal in every 5 year revalidation cycle).

The phased appraisal process for Secondary Care

Within Secondary Care appraisees (other than non training Clinical Fellows) should be appraised in accordance with a rolling structured timetable. Each appraisee will be required to complete an appraisal during a four month period as determined by their GMC revalidation due date (in particular the month). The appraisal phasing system operates as follows:

  • Phase 2:  Doctors who have revalidation months falling during  August, September, October or November, have an appraisal completion window of April – July
  • Phase 3:  Doctors who have revalidation months falling during  December, January, February or March, have an appraisal completion window of August – November
  • Phase 1:  Doctors who have revalidation months falling during April, May, June or July, have an appraisal completion window of December – March
  • Phase 0: If a doctor commences employment within the Board on or after the 1st November in any given appraisal year, and they are not due to revalidate during that appraisal year, they will not be expected to complete an appraisal for that appraisal year, and will fall into their phasing window for the following appraisal year.

Appraisal timings for Non Training Clinical Fellows

The appraisal completion deadline for Clinical Fellows is dependent on their contract end date.  Clinical Fellows with contracts ending in February should complete their appraisal by the end of January, and those with contracts ending in August, should complete their appraisal between April – July.          

Non Training Clinical Fellows Appraisal Process

The appraisal process for Clinical Fellows who do not have a training number within NHSGGC is similar to that of numbered trainees, and requires the doctor’s appraisal to be taken forward by their allocated Educational Supervisor, which should make reference to the ePortfolio that the Clinical Fellow is completing, and should be recorded on the SOAR system.      

Appraisal process guidance for Clinical Fellows working at Foundation Level, ST1+ Level and their Educational Supervisors can be accessed by clicking on the following links.

Please click on following link below to access FAQ’s for non Training Clinical Fellows

Scottish Online Appraisal Resource (SOAR)

All doctors employed by NHSGGC must register with the Scottish Online Appraisal Resource (SOAR).  This will assist greatly in record keeping and ensure that through audit, the Appraisal process can be quality assured.  To register with SOAR please access the following website: http://www.appraisal.nes.scot.nhs.uk/.

SOAR is mandatory for the recording all appraisal information for medical staff employed by NHSGGC.  If you require guidance on how to get started on SOAR, you can access this via the following link: http://www.appraisal.nes.scot.nhs.uk/help-me-with/appraisal/appraisal-this-year/getting-started.aspx.

Patient Feedback Exercise

To support revalidation, doctors are required to gather patient feedback.  Accordingly, it is asked that all doctors with patient contact attempt the patient feedback exercise at least once in every 5 year cycle.  Any exemptions must be discussed and agreed at the Board Wide Revalidation Group (BWRG) which is chaired by the RO.

The Board recommends the use of the NHSGGC Patient Feedback Questionnaire (a version of CARE) or one of two variations of this questionnaire for use by Radiologists and Child Health Specialists. NHS GGC patient questionnaires are also available in the following languages:- Arabic, Polish, Punjabi, Simplified Chinese and Urdu.  Doctors are welcome to use an alternative questionnaire as long as it meets GMC requirements and has the approval of the RO.

To manage the high volume of patient questionnaires, the Board has purchased an electronic scanner which has been specifically set up to read the NHSGGC Patient Feedback Questionnaire plus the two variations above. At this stage the Board is unable to process any other types of questionnaires.  If, therefore, a doctor chooses to use an alternative questionnaire they will be required to make their own administration arrangements.

We would recommend that, where possible, doctors aim to undertake the patient feedback exercise during the first 3 years of the revalidation cycle.  This is a precautionary measure in case it is necessary to repeat the exercise, perhaps due to low return rates, or the doctor in discussion with his/her Appraiser wishes to repeat the exercise.  The patient feedback exercise must be completed prior to the revalidation due date.

Doctors will be required to distribute 25 patient questionnaires across the whole of their practice and where possible should capture both inpatients and outpatients.  It is accepted that some questionnaires may not be returned.  The questionnaire should be distributed randomly and without influence from the doctor to patients who are competent and well enough to complete the proforma.  It is also possible for parents or carers to complete the questionnaire  instead of the patient.  

Please follow the guidance below to obtain your NHSGGC Patient Feedback Questionnaire:

  1. Request the patient questionnaire by e-mailing medical.revalidation@ggc.scot.nhs.uk at least 2 weeks prior to when you wish to commence the exercise;
  2. Indicate in your e-mail if you wish the NHSGGC Patient Feedback questionnaire, the adapted Radiology or Child Health Care Questionnaire.  Please also advise if you require these questionnaires in any of following languages:- Arabic, Polish, Punjabi, Simplified Chinese and Urdu
  3. On receipt of your email, the Medical Staffing team will post out 25 patient questionnaires with instructions for distribution by a third party.  Please note that it is a GMC requirement that the patient questionnaire be distributed independently of the doctor, i.e. by a third party;
  4. Once the questionnaires have been returned, Medical Staffing will scan the completed returns and generate a summary report.  To obtain this report, please contact Medical Staffing by e-mailing medical.revalidation@ggc.scot.nhs.uk at least 2 weeks prior to your appraisal meeting;
  5. We would recommend commencing the patient feedback exercise at least 2 months prior to your appraisal meeting, to allow time for the patient questionnaires to be distributed, completed and returned and report produced.

Please note: requests for the NHSGGC Patient Feedback Questionnaire must be made through medical staffing.  This enables the team to administer the process and produce the required summary reports.  The electronic scanner can only read the copies of the questionnaires issued by the Medical Staffing team, so please do not photocopy, scan or downloaded copies from another website.  

For any queries in relation to Patient Feedback Questionnaires please telephone 0141 201 0780

Colleague Multi-Source Feedback (MSF)

To support revalidation, doctors are required to gather colleague feedback.  This is also referred to as Multi-Source Feedback (MSF).  All doctors are requested to complete the colleague feedback exercise at least once in every 5 year cycle.  Any exemptions must be discussed and agreed at the Board Wide Revalidation Group (BWRG) which is chaired by the RO.

The colleague feedback exercise should be used formatively:

  • as a learning and development tool to identify strengths and areas for improvement in a doctor’s practice, to inform continuing professional development; and
  • as one of several pieces of information which, when considered together, will inform the decision as to whether a doctor should be recommended for revalidation.

The Scottish Government Health Department commissioned NES to develop a colleague questionnaire that would be suitable for all General Practitioners and career grade doctors in Scotland. This questionnaire is available as a web resource and is free to use for doctors registered with SOAR.

Please click the following link to access the colleague questionnaire:https://www.appraisal.nes.scot.nhs.uk/what-is/faqs/msf/

It is recommended that the doctor seeking feedback invites 15 colleagues to complete the short questionnaire, selected from across the whole of their practice.  For example, colleagues from other specialties, junior doctors, nurses, allied healthcare professionals, management and clerical staff.  Doctors are also encouraged to score themselves as this helps to facilitate a more meaningful discussion in terms of how the doctor views themselves compared to their colleagues.  The results are then collated and a summary report is provided to the doctor (the NES MSF tool does this electronically).  Doctors should aim to complete the colleague feedback exercise in the 4 weeks leading up to their appraisal meeting, to ensure that they have the necessary feedback to form part of their appraisal discussion.

Review of Complaints and Compliments

Information on Complaints Certificates

Feedback is often provided by patients and others by way of complaints and compliments, which should also be reviewed as part of the Appraisal process.   The GMC definition of a complaint is “a formal expression of dissatisfaction or grievance.  It can be about an individual doctor, the team or about the care of patients where a doctor could be expected to have had influence or responsibility”.  The doctor may also choose to bring any compliments they have received to their Appraisal meeting.

Doctors should discuss any change in their practice that has been made as a result of any complaints or compliments received since the last Appraisal, either individually or across the team.

The Board is able to provide doctors with a Complaints Certificate, which confirms the number of complaints a doctor has been involved in within the previous year (this data is extracted from the Datix System).  The reports are run three times a year in keeping with the ‘phased’ Appraisal timetable:

  • doctors due to be appraised between 1st April and 31st July will be issued with a complaints certificate covering the period 1st April to 31st March;
  • doctors due to be appraised between 1st August  and 30th November will be issued with a complaints certificate covering the period 1st August to 31st July; and
  • doctors due to be appraised between 1st December and 31st March will be issued with a complaints certificate covering the period 1st December to 30th November.

Please follow the guidance below to obtain a copy of your Complaints Certificate:

  1. request a Complaints Certificate at least two weeks before your Appraisal meeting by emailing medical.revalidation@ggc.scot.nhs.uk; and
  2. on receipt of your e-mail you will be e-mailed one of two certificates stating either:
  • there have been no complaints in the previous year; or
  • you have been involved in “x” complaints and the outcome of each complaint e.g. upheld, partially upheld, not upheld and so on.

For any queries in relation to complaints certificates please telephone 0141 201 0780

Significant Clinical Incidents

To support revalidation doctors are required to discuss any Serious Clinical Incidents (SCIs) at their Appraisal, with a particular emphasis on those that have led to a specific change in practice or demonstrate learning.  The Appraiser will be interested in any actions that the doctor has taken or any changes which have been implemented to prevent such events or incidents happening again.  

Areas for further learning and development should be reflected in the doctor’s personal development plan and CPD.  Doctors should bring along their own log of any SCIs recorded in the preceding year up to the date of the Appraisal meeting.  

If you require further information regarding an SCI or SCI’s that you have been involved in, please contact your Clinical Director.      

NES Appraiser Training

If you wish to apply to be an Appraiser, you need to complete the application form and equal opportunities form, which can be found along with appraiser training dates on the NES website: https://www.appraisal.nes.scot.nhs.uk/appraiser-training/

The completed forms must be sent to NES by email: Medical.Appraisal@nes.scot.nhs.uk.  A copy of the forms should also be forwarded to the Medical Staffing Team to ensure that a central record of applications is maintained: medical.revalidation@ggc.scot.nhs.uk.

Please note: your application must be authorised by your Medical Manager before submission to NES.

Click on the following link to access the Scottish Medical Appraiser Handbook: http://www.appraisal.nes.scot.nhs.uk/i-want-access-to/resources-for-appraisers/appraiser-handbook.aspx.

Making a Recommendation

There are 5 steps to support the Responsible Officer (RO) in making a revalidation recommendation:

  1. The Appraiser and Appraisee should ensure that the Form 4 is completed online using the SOAR system, which allows the RO to review/access the Form 4(s) when it comes to making a revalidation recommendation to the GMC;
  2. The Chiefs of Medicine (COMs) are advised by the Revalidation Team which doctors are due to revalidate within their Directorate/Sector in the coming month and are asked if they know of any reasons which may preclude a doctor from being revalidated.  For example, there may be ongoing HR processes, which need to be finalised before a recommendation can be made.  Another extenuating circumstance, which could prevent a recommendation being made, is if an individual has not completed an appraisal;
  3. The Deputy Responsible Officer quality reviews the Form 4s submitted to ensure that all the information required has been included, for example CPD, MSF/Patient Questionnaire.  If the Form 4 is incomplete the DRO will make contact with both the Appraisee and Appraiser to advise.  If the Form 4 needs to be edited, arrangements are made by the the Revalidation Team to have SOAR unlock the Form 4;
  4. The RO meets the Deputy Responsible Officer, Board Appraisal Lead and Revalidation Team on a monthly basis to review and sign off the Form 4s for those Appraisees who are due to revalidate in the proceeding month.  The RO will make one of three disposals: Recommendation to Revalidate; Deferral; or Non-Engagement.
  5. Further to the monthly meeting, the Revalidation Team notifies the GMC of the recommendations that have been made.  Once the GMC has received the RO recommendation they will make a decision about your recommendation and will write to let you know.
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