� Statement of Compliance is based on the Annual Organisational Audit (submitted on 14/5/2014) of compliance with the Medical Profession (Responsible Officers) Regulations 2010 (as amended in 2013).

� Medical appraisal and revalidation are designed to show that doctors are up to date and fit to practice, providing safe quality healthcare. This will improve patient safety and increase public trust and confidence in the medical system.

� Provider organisations have a statutory duty to support the RO to discharge their duty and will oversee compliance by;

1. monitoring the frequency and quality of medical appraisals

2. effective mechanisms are in place to monitor the conduct and performance of their doctors

3. confirming that patient feedback is sought periodically

4. appropriate pre-employment checks are carried out to ensure experience and qualifications relevant to the work performed

� Adam Stacey-Clear appointed as RO

� Qualified 1978 St Thomas’s Hospital

� Appointed consultant surgeon East Surrey Hospital 1993

� Received RO training May 2011and 6 further training modules.

� The GMC have provided the RO with a secure link which lists all doctors with a prescribed connection to the Trust

� This list is regularly updated and additions/deletions are communicated to the RO by email

� In addition the RO keeps a list of the entire non-training medical workforce to cross check with the GMC list in a secure site on G-drive.

� Currently 48 trained appraisers for 159 consultants and 84 SAS doctors (ratio 1:5)

� The total number of doctors does fluctuate all the time depending on retirement/leaving the Trust for another position/new appointments.

� Appraiser top-up training Nov 2012 and 2013

� Appraiser support group meeting Feb 2013; next meeting 18 September

� Appraisal folders all reviewed and signed off by AS-C. Insufficient appraisal evidence returned for additional SI

� PDP’s all reviewed by AS-C. Now to include at least one objective from Trust Quality Strategy (Des Holden presentation to Board Jan 2014)

� Quality assurance of appraisals as per external audit review RSM Tenon 2013-rated green

� Introduction of appraise feedback survey monkey-Sept 2014

� Participation in Benefits realisation group survey for impact of appraisal on culture and behaviour December 2013 organised by King’s Fund.

� Database established to keep track of all appraisal dates. Late appraisals for year ending March 2014 recorded and declared in AOA report for the Trust (4)

� Reasons for late appraisal not adequate and not including e.g. illness or maternity leave

� Option to use form REV6 to request a non-engagement concern letter from GMC (after discussion with GMC employer liaison officer)

� Next appraisal backdated to previous due date

� Might not be able to revalidate if not

� 102 revalidation recommendations since March 2013 (10 deferred), none late

� No non engagement recommendations

� All Trust doctors are subject to the organisational policies, e.g. capability and disciplinary. The Trust recognises the BMA code of conduct to performance manage all doctors at Surrey and Sussex Healthcare NHS Trust.

� The Trust regularly reviews all doctors performance in the yearly job plan and this is supported by the appraisal process for all Trust Medical and Dental staff.

� The clinical effectiveness strategy supports the Medical and Dental staff in their practice by ensuring evidence is practice based and clinically effective.

� The complaints procedure is Trust Policy. This is part of a doctor’s feedback and concerns are raised at the job planning stage to enable improvement in doctor’s practice and patient care.

� The Trust responds to concerns in respect of doctor’s practice by supporting them with regular and ongoing development opportunities.

Fitness to practice recommendations from the GMC procedure for concerns or complaints made against a practicing doctor within the Trust are followed.

� Use Transfer of Information Template (confidential)

� Template approved by NHS England

� Have communicated by phone and email (for non confidential information) with some RO’s in other designated bodies requesting information.

� Medical staffing check qualifications against persons specifications for the post

� Ask for photographic ID (passport)

� Ask for right to work in UK e.g. visa if necessary

� 2 proofs of address

� GMC registration-check no conditions

� Must be on specialist register

� 2 references

� Occupational health check

� Non fixed term locums employed through Medacs (pasaapproved) and substantive consultant approves CV

� RO has applied for installation of risk management software on PC in order to cross check and ensure that doctors declare all complaints/SI’s in their MAG form

� Appraisee feedback survey monkey to be installed towards quality assurance of appraisers.

� The biggest challenge for patient feedback cards (your care matters) is that patients don’t know who their consultant is. Some patients don’t know the difference between a consultant and any other doctor.

� June 2014-introduction of revalidation relevant questions to the cards.

� Consultants need to drive this and make sure the patients know their consultant’s name.