medical appraisal policy - royal united hospital · key principles 5.1 appraisal is an annual...

Document name: Medical Appraisal Policy Ref.: Black 172

Issue date: 04 March 2016 Status: Final

Author: Angela Hayday of 22

Medical Appraisal Policy

Reference Number: 172

Author & Title: Angela Hayday Associate Director of Organisational & People Development

Responsible Directorate: Human Resources

Review Date: 17 February 2019

Ratified by (committee): Joint Local Negotiating Committee

Date Ratified: 17 February 2016

Version: 5.0

Related Procedural Documents

Managing Poor Performance Policy

Managing Conduct Policy

Managing Health & Sickness Policy

Recruitment and Selection Policy

Induction Policy

Mandatory Training Policy

Study Leave Policy

Job Planning Policies (Consultant & SAS)

Grievance Policy




Index:

Amendment History ................................................................................................. 3

1. Introduction ...................................................................................................... 4

2. Purpose of this Policy ..................................................................................... 4

2.1 Revalidation _____________________________________________________ 4

2.2 Professional Development _________________________________________ 4

2.3 Organisational priorities ___________________________________________ 4

3. Equality Statement........................................................................................... 5

4. Aims and Objectives of this policy ................................................................ 5

5. Key Principles .................................................................................................. 6

6. Duties / Responsibilities ................................................................................. 7

6.1 Chief Executive___________________________________________________ 7

6.2 Management Board _______________________________________________ 7

6.3 Clinical Governance Committee _____________________________________ 7

6.4 Responsible Officer _______________________________________________ 7

6.5 Medical Appraiser ________________________________________________ 8

6.6 Head of Division __________________________________________________ 8

6.7 Lead Clinician ____________________________________________________ 8

6.8 Doctor being appraised ____________________________________________ 8

6.9 Human Resources department ______________________________________ 9

7. Monitoring Compliance ................................................................................... 9

8. Key Performance Indicators ......................................................................... 10

8.1 Appraisal compliance ____________________________________________ 10

8.2 Number of doctors successfully validated ___________________________ 10

9. Medical Appraisal Process ........................................................................... 11

9.1 Medical Appraisal ________________________________________________ 11

9.2 Essential supporting information requirements _______________________ 12

9.3 Integration with quality improvement, clinical governance and performance monitoring systems _________________________________________________ 13

9.4 Appraisal documentation _________________________________________ 13

9.5 Appraisal records and confidentiality _______________________________ 14

9.6 Allocation of doctors to appraisers _________________________________ 14

9.7 Deferring annual appraisal ________________________________________ 15

9.8 Conflicts of interest or appearance of bias ___________________________ 16

9.9 Complaints arising from the appraisal process _______________________ 16




10. Medical Appraisal: Selection, Training and Support of Medical Appraisers ......................................................................................................................... 17

10.1 Selection Process for Medical Appraisers ________________________ 17

10.2 Role of the Medical Appraiser __________________________________ 17

10.3 Training, Development & support for Medical Appraisers ___________ 18

10.4 Indemnity arrangements for Medical Appraisers __________________ 18

11. References ..................................................................................................... 19

Document Control Information ............................................................................. 20

Ratification Assurance Statement _____________________________________ 20

Consultation Schedule _______________________________________________ 21

Amendment History

Issue Status Date Reason for Change Authorised

1 Draft September 2012

New Policy Lyn Vaughan Director of HR

5.0 February 2016

Policy expired, review required as part of three yearly policy review process

Claire Buchanan, Director of HR




1. Introduction The purpose of this policy is to provide guidance for staff within the Royal United Hospital, Bath NHS Trust (RUH) about the requirements and processes for medical appraisal in the context of revalidation. This policy applies to all medical staff with whom the Royal United Hospital Bath NHS Trust has a prescribed connection, including those with honorary contracts, where they relate to the Responsible Officer for the RUH.

2. Purpose of this Policy The purpose of this policy is to describe how medical appraisal will be carried out within the context of revalidation to ensure that licensed doctors remain up to date and fit to practice and meet the appraisal requirements associated with employment by the RUH. Medical appraisal will be used for the following purposes:

2.1 Revalidation

To enable doctors to discuss their practice and performance with their appraiser in order to demonstrate that they continue to meet the principles and values set out in Good Medical Practice (GMC, Nov 2006) and thus to inform the responsible officer’s revalidation recommendation to the GMC.

2.2 Professional Development

To enable doctors to enhance the quality of their professional work by planning their professional development. To enable doctors to consider their own needs in planning their professional development.

2.3 Organisational priorities

To enable doctors to ensure that they are working productively and in line with the priorities and requirements of the Royal United Hospital in accordance with Trust Guidance on Job Planning for Consultants. The two processes of appraisal and job planning are separate although the outputs from each will inform the other.




3. Equality Statement This policy applies to all medical staff with a prescribed connection to the Royal United Hospital (RUH). The RUH is committed to providing equality of opportunity and will not tolerate discrimination on grounds of age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex or sexual orientation. This policy has had an Equality Impact Assessment.

4. Aims and Objectives of this policy 4.1 The aim of the policy is to ensure that, through an effective appraisal mechanism, all medical staff are fit to practice and provide the highest standards of safe care to patients.

4.2 Appraisal is a formative and developmental process. It is about identifying development needs, not performance management. It is a positive process, to give doctors feedback on their past performance, to chart continuing progress and identify development needs.

4.3 During their annual appraisals, doctors will use supporting information to demonstrate that they are continuing to meet the principles and values set out in Good Medical Practice.

4.4 The objectives of medical appraisal are to:

4.4.1 Provide individuals with an opportunity to:

o Reflect on their practice and their approach to medicine. o Reflect on the supporting information they have gathered and what that

information demonstrates about their practice. o Identify areas of practice where they could make improvements or

undertake further development. o Demonstrate that they are up to date.

4.4.2 Provide assurances to the RUH and the public that our doctors are remaining up to date across their whole practice.

4.4.3 Provide a route to revalidation which builds on and strengthens existing systems with minimum bureaucracy.

4.4.4 Provide a mechanism for discussing a doctor’s work in the context of organisational priorities. The job plan and individual service / organisational objectives form a key part of evidence required for the appraisal discussion.

4.5 Appraisal is not the mechanism by which serious concerns regarding health, capability, behaviour or attitude are identified or addressed. Such concerns should be managed in an appropriate and timely manner outside of appraisal.




5. Key Principles 5.1 Appraisal is an annual requirement for all doctors. It should be a positive

process which adds value for the doctor and the RUH without being unnecessarily burdensome.

5.2 Annual appraisal for every doctor will be based on the same core set of

supporting information. This core set of information required for appraisal for the purposes of revalidation is defined by the GMC in their 2011 document Supporting Information for Appraisal and Revalidation. Any additional guidance provided, for example, by the Royal Colleges, is advisory only.

5.3 Every appraisal will result in an agreed summary and Personal Development

Plan which will be accessible to the Responsible Officer to inform their revalidation recommendation.

5.4 Appraisal for every doctor will be based on a system which reflects the GMC’s

Good Medical Practice framework for appraisal and assessment and incorporates the supporting information required by the GMC for the purposes of revalidation.

5.5 By 2013, all appraisers must have received revalidation ready appraisal training. 5.6 All appraisals will consider the whole of the doctor’s practice. 5.7 To ensure all doctors have robust evidence for revalidation, any doctor can only

be appraised by the same appraiser three times within a five year revalidation cycle.

5.8 Over the course of the five year revalidation cycle, appraisals will be carried out

by a trust approved medical appraiser. It is considered good practice for doctors to have their appraisal performed by a medical appraiser from outside of their speciality as well as from within their specialty.




6. Duties / Responsibilities All medical staff have a responsibility for ensuring that the principles outlined within this document are universally applied. This policy applies to all members of staff who are involved in any aspect of medical appraisal. Key organisational duties are identified as follows:

6.1 Chief Executive The Chief Executive (CEO) on behalf of the RUH is responsible for ensuring that the Responsible Officer is provided with appropriate resources to enable him / her to discharge their duties. The CEO will ensure that indemnity is provided for appraisers both internal and external to the trust.

6.2 Management Board Management Board is responsible for monitoring and approving the framework to support the appraisal and revalidation of permanent medical staff that is compliant with all relevant legislation, guidelines and NHS best practice standards.

6.3 Clinical Governance Committee The committee is established as a sub-committee to the Trust Board. The committee is an assurance committee of the Board and is responsible for the review of the effectiveness of the process of appraisal and revalidation for permanent medical staff.

6.4 Responsible Officer The Responsible Officer (RO) is accountable for ensuring that:

A medical appraisal system, which complies with national guidance and requirements, is in place and maintained.

There are sufficient numbers of trained medical appraisers.

Doctors undertake annual appraisals.

Medical appraisals take account of relevant information relating to the doctor’s roles.

Systems are in place to record and collate all the necessary information, including a record of any practice undertaken by the doctor outside of the organisation.




6.5 Medical Appraiser The Medical Appraiser is responsible for:

Adequate preparation for appraisal meetings.

Maintaining their own skills in the role of medical appraiser through participation in approved development activities.

Participating in the quality assurance process for medical appraisers.

Using the Trust’s approved process for sending the outputs of appraisal to the Responsible Officer within 28 days of the appraisal meeting.

6.6 Head of Division Within their division the Head of Division is responsible for:

Ensuring all doctors have an annual appraisal through an effective divisional performance management process.

6.7 Lead Clinician Within their speciality the Lead Clinician is responsible for:

Monitor and encourage compliance with the divisional performance management process for appraisal.

Providing feedback into the appraisal process through the completion of the Trust’s approved ‘Clinical Lead Template for Appraisal of Permanent Member of Staff’.

6.8 Doctor being appraised The doctor being appraised is responsible for:

Maintaining a portfolio of supporting information to demonstrate the maintenance of their clinical and professional standards and, where applicable, their specialist skills.

Undertaking appraisal once per year within the appraisal year.

Choosing an appraiser in accordance with the principles described in this policy and agreeing a date to meet with the appraiser. A list of trained medical appraisers is available on the Medical Appraisal intranet page.




Using the Trust’s approved process for completing an annual appraisal.

Ensuring that the time required to comply with revalidation requirements including preparation for and participation in the annual appraisal process is met within the SPA allocated in each consultant’s job plan.

.

6.9 Human Resources department

Producing and publishing procedural documents and guidelines to support the implementation of Medical Revalidation. Responsible for communicating with the Responsible Officer to make sure that the RO is aware of any doctor who is under formal investigation for conduct / capability issues. This information should also be shared with the Director of Medical Education about any doctor in training. Responsible for producing and distributing appraisal compliance reports in a timely manner for discussion at divisional performance management meetings. Responsible for providing information to the Equality & Diversity Committee about equality monitoring so that any potential discrimination can be identified and prevented.

7. Monitoring Compliance The Responsible Officer will be responsible for monitoring compliance with this policy. Details of all appraisal completion figures and exception reports will be recorded in a database and reported annually to the Board by the Responsible Officer.




8. Key Performance Indicators

8.1 Appraisal compliance

The number of medical appraisals completed as a percentage of the number of those doctors eligible for appraisal within the appraisal year. A completed appraisal is one where the appraisal meeting has taken place within the appraisal year (1 April to 31 March) and the outputs of appraisal have been agreed and signed off by the appraiser and doctor within 28 days of the appraisal meeting.

8.2 Number of doctors successfully validated

The number of eligible doctors recommended for revalidation by the RO to the GMC whose recommendation is successful.




9. Medical Appraisal Process

9.1 Medical Appraisal

Medical appraisal differs fundamentally from appraisal in other settings due to its link with external professional regulation and revalidation. Medical appraisals are based on a doctor’s performance as described in the GMC’s Good Medical Practice. There are 3 stages in the medical appraisal process described in detail in the Medical Appraisal Guide, A guide to medical appraisal for revalidation in England, (RST, version 3, March 2012) these are inputs to appraisal, the confidential appraisal discussion and outputs of appraisal.

Figure 1

INPUTS

Personal information

Scope and nature of work

Supporting information

Review of last year’s development

plan

Achievements, challenges and

aspirations

Confidential appraisal discussion

OUTPUTS

Doctors personal development plan

Summary of appraisal

Appraiser’s statements

Post-appraisal sign-off by doctor and appraiser

Each of the components in Figure 1 is described in detail in Medical Appraisal Guide, A guide to medical appraisal for revalidation in England.




9.2 Essential supporting information requirements

The supporting information should relate to the doctor’s complete scope and nature of work. The GMC document, Supporting Information for Appraisal and Revalidation describes the six types of supporting information that a doctor will be expected to provide and discuss at appraisal at least once in each five-year cycle. These are:

1. Continuing professional development 2. Quality improvement activity 3. Significant events 4. Feedback from colleagues 5. Feedback from patients 6. Review of complaints and compliments

Supporting information

Timescale Responsibility to provide

Continuing professional development

Must relate to the 12 month period prior to the appraisal that precedes any revalidation recommendation

Appraisee

Quality improvement activity

Must be considered at each appraisal. Appraisee

Significant events e.g. incidents, formal HR investigations

Must relate to the 12 month period prior to the appraisal that precedes any revalidation recommendation

Appraisee

Feedback from colleagues

Must have been undertaken no earlier than 5 years prior to the first revalidation recommendation. The doctor will need to nominate 20 colleagues (10 medical, 10 non-medical if possible) and collect a minimum of 15 completed questionnaires

Appraisee to initiate, organisational support to collect

Feedback from patients

Must have been undertaken no earlier than 5 years prior to the first revalidation recommendation. The questionnaire must be administered to 45 consecutive patients (or carers) and a minimum of 34 completed questionnaires collected.

Appraisee to initiate, organisational support to collect

Review of complaints

Must relate to the 12 month period prior to the appraisal that precedes any revalidation recommendation.

Appraisee

Review of compliments

Must relate to the 12 month period prior to the appraisal that precedes any revalidation recommendation.

Appraisee

This enables the doctor to demonstrate their practice in the four domains of the Good Medical Practice Framework for Appraisal and Revalidation. These four domains are:

1. Knowledge, skills and performance 2. Safety and quality 3. Communication, partnership and teamwork 4. Maintaining trust




9.3 Integration with quality improvement, clinical governance and performance monitoring systems

9.3.1 Clinical governance information plays a key role in the supporting information for appraisal and revalidation. Doctors are required to include quality improvement activity including audit, significant event analysis, a review of complaints, and clinical performance data, where this is available. It is the doctor’s role to ensure this information is included in their supporting information, but the organisation has a role to play in ensuring this information is as accessible as possible.

9.3.2 Appraisal, performance management and conduct / capability

are separate systems which fulfil separate purposes, while all contributing to overall clinical governance and the wider quality and safety agenda. However, for doctors to be properly supported and for revalidation as a whole to operate effectively and fairly it is essential that there are clear, consistent, transparent links and information flows between these systems.

9.3.3 The operational HR team will notify the Responsible Officer and

the Director of Medical Education about any doctors / doctors in training who are under formal investigation for conduct / capability issues.

9.3.4 All supporting information will be shared in accordance with

Information Management for Medical Revalidation in England (NHS RST, March 2012). Doctors are entitled to view information held about them in clinical governance or responsible officer systems (unless there is an exemption under the Data Protection Act 1998) and they may request that this information is amended, where there are factual inaccuracies, qualified, so that their comments are attached, or deleted, if appropriate.

9.4 Appraisal documentation

Doctors should record the information required for appraisal using the Trust’s approved process. Information about the process is available on the intranet, follow link below: http://webserver.ruh-bath.nhs.uk/Training/appraisals/medical_staff.asp?menu_id=9 It is important to remember that any information provided in support of the appraisal process will be shared with your appraiser and responsible officer. Therefore you should take care to abide by

http://webserver.ruh-bath.nhs.uk/Training/appraisals/medical_staff.asp?menu_id=9

http://webserver.ruh-bath.nhs.uk/Training/appraisals/medical_staff.asp?menu_id=9




confidentiality, data security and information governance protocols. In particular you should remove all personally identifiable data.

Appraisal and CPD are closely linked. Doctors are required to provide evidence of CPD relating to their practice at their appraisal, and one of the key outputs of appraisal is the Personal Development Plan.

Peer and patient feedback systems will be validated and comply with the GMC’s criteria.

Doctors should provide evidence of compliance with organisational mandatory training requirements at their annual appraisal.

9.5 Appraisal records and confidentiality

The information within a doctor’s appraisal and revalidation portfolio is confidential and access is limited to the doctor, appraiser and the responsible officer. The details of discussions during the appraisal interview would generally be considered to be confidential to the appraiser and the doctor being appraised. However within the context of appraisal for revalidation, the appraiser will report to the Responsible Officer on the general outcomes of appraisal. Therefore the appraiser will need to escalate any concerns about appraisal that arise during the appraisal discussion, in accordance with the RUH’s relevant policies and guidelines. This includes any significant concerns or patient safety issues arising within appraisal.

The RUH and the doctor being appraised will need to retain copies of the appraisal documentation over a five year period.

9.6 Allocation of doctors to appraisers

Doctors can choose their appraiser from an approved list of medical appraisers. The appraiser should meet the following criteria:

Be a licenced doctor with knowledge of the context in which the doctor works.

Be an appropriate appraiser for the doctor taking into account their full scope of work.

Understand the professional obligations placed on doctors by the GMC.

Understand the importance of appraisal for the doctor’s professional development.

Have suitable skills and training.




9.7 Deferring annual appraisal

Trust policy requires all staff to participate in an annual appraisal. The appraisal year runs from April to March. This is also a requirement for successful revalidation. There are exceptional circumstances when a doctor may request that an appraisal is deferred which mean that an appraisal will not take place during one appraisal year. These are breaks in clinical practice due to:

Sickness or maternity leave.

Absence abroad or sabbaticals

Suspension from clinical work as a result of the doctor being investigated due to concerns raised about performance / behaviour.

Doctors who think they may need to defer their appraisal should make a formal request in writing to the Divisional Board Chair who will make a decision in consultation with the Associate Medical Director. The decision can be appealed and appeals will be dealt with by the Medical Director. A request to defer should be made at the earliest opportunity and in the year in which the appraisal was due. A decision to allow deferment will depend on a number of factors including:

How many appraisals have or will be missed in a 5 year period.

If further breaks from clinical practice are anticipated in the near future.

If there have been problems with evidence in previous appraisals.

If the doctor is undergoing any investigation about his / her performance.

The above list is not exhaustive. In situations where a doctor has not completed an annual appraisal and has not requested a deferment the Medical Director will investigate the reasons why a doctor has not completed an appraisal and take appropriate action to resolve the situation. Doctors who choose not to engage with the appraisal process will not be dealt with by deferral, discussions with the doctor and the Medical Director will take place to address non engagement, this may include invoking formal conduct or capability procedures, where appropriate.




9.8 Conflicts of interest or appearance of bias

It is important that the evaluation of a doctor’s fitness to practise is fair, honest and evidence based if it is to provide the assurances that patients and doctors require from the system. In some circumstances, doctors will find there is a conflict of interest or appearance of bias with their appraiser or responsible officer. The following are examples of where a conflict of interest or appearance of bias may occur:

Personal or family relationships

An appraiser and doctor sharing close business or financial interests

Reciprocal appraisal, where two doctors appraise each other

An appraiser appraising a doctor who acts as their line manager in the same or in a different organisation

A responsible officer or a doctor’s direct employer acting as appraiser

If a conflict of interest or appearance of bias is identified between appraisee and appraiser, the responsible officer should be informed in writing, explaining the conflict and providing as much background information as is necessary and relevant. It may be appropriate for the responsible officer to request that another appraiser is assigned. The responsible officer will not themselves assign the new appraiser. It will be the responsibility of the appropriate clinical lead or appraisal lead to assign a new appraiser in such cases. If a conflict of interest or appearance of bias exists between a doctor and a responsible officer, the Chief Executive should be informed in writing giving as much information as possible. It is important that every attempt is made to resolve the issue using the existing mediation procedures. If, after all processes are exhausted, a satisfactory resolution is not possible the evaluation of fitness to practise may be overseen by another responsible officer. In such circumstances, the designated body should seek advice from the responsible officer’s own responsible officer and the decision should be recorded in writing.

9.9 Complaints arising from the appraisal process

If a doctor has a complaint about their appraiser or the appraisal process this will be dealt with in accordance with the trust Grievance Procedure.




10. Medical Appraisal: Selection, Training and Support of Medical Appraisers

The Responsible Officer must ensure that the medical appraisal system is of sufficient quality to support their recommendations; the quality of the medical appraiser workforce is a major determinant in this. Quality Assurance of Medical Appraisers (NHS RST, version 3, March 2012).

10.1 Selection Process for Medical Appraisers

Appraisers will be recruited through a written request for expressions of interest from the Responsible Officer to doctors. The Divisional Heads will be responsible for overseeing the recruitment process. Lead clinicians will be responsible for identifying sufficient numbers of suitable medical appraisers for their speciality. Medical Appraisers will be required to complete the medical appraiser competency self-assessment tool to identify their development needs which will be addressed through on-going support and development activities. These should be discussed at their appraisal and reflected in their personal development plan. Medical appraisers will be appointed subject to satisfactory completion of initial Medical Appraisal training and production of an agreed personal development plan (PDP).

10.2 Role of the Medical Appraiser

Role description / person specification The role description and person specification for medical appraisers described in Assuring the Quality of Appraisers (NHS RST, 2011) will be adopted. Appraiser capacity Each appraiser is expected to carry out 6 appraisals per year.

No appraiser will carry our appraisal for the same doctor for more than 3 consecutive years.

Those undertaking appraisals as an appraiser will be afforded time within the ‘corporate’ SPA’ to undertake initial and on-going appraiser training and support, prepare for and undertake appraisals, complete appraisal documentation, participate in an annual process to review appraiser performance.




For guidance on the amount of time allocated please refer to the relevant Trust Job Planning Policy (Consultant & SAS doctors). An appraiser should not receive direct payment from a doctor for performing appraisal; appraisers are contracted to, and paid by the designated body i.e. the RUH

10.3 Training, Development & support for Medical Appraisers

All medical appraisers will undertake initial medical appraisal training which complies with the Training Specification for Medical Appraisers in England (NHS, RST, April 2012. In addition, those medical appraisers who have not previously undertaken any form of appraisal training will be required to undertake additional appraisal training. The arrangements for support and on-going development for medical appraisers will be led by the Responsible Officer with support from the Associate Director of Organisational & People Development and the Medical Appraisal Lead. Medical appraisers are required to:

1. Review and update their PDP annually using the appraiser self-assessment competency tool to inform items relating to the role of appraiser.

2. Participate in any on-going support and development provided to address development needs including any appraisal update training and equality and diversity awareness training.

3. Seek feedback from appraisee’s about their performance in the role of medical appraiser using a structured feedback questionnaire provided by the organisation.

An annual review of performance will be carried out for all medical appraisers to ensure that medical appraisers are appropriately supported, their development needs are being addressed and that appraisals are being performed to the required standard. This will be incorporated into the individual appraisal process.

10.4 Indemnity arrangements for Medical Appraisers

Doctors working as appraisers on behalf of the RUH will be indemnified for their actions in the pursuance of their work as part of their usual indemnity arrangements with the Trust.




11. References The Equality Act 2010 Organisational Readiness Self-Assessment, RST, March 2012 The Medical Profession (Responsible Officer) Regulations 2010, Her Majesty’s Stationery Office, 2010 The Role of the Responsible Officer, Closing the Gap in Medical Regulation, Responsible Officer Guidance, Department of Health, 2010 Good Medical Practice, GMC, 2006 The Good Medical Practice framework for appraisal and revalidation, GMC, 2011 Supporting information for appraisal and revalidation, GMC, 2011 Medical Appraisal Guide, A guide to medical appraisal for revalidation in England, RST, Version 3, March 2012 Quality Assurance of Medical Appraisers, Recruitment, training, support and review of medical appraisers in England, RS, Version 3, March 2012 Medical Appraisal Guide: Model appraisal form, RST, March 2012 Training Specification for Medical Appraisers in England, RST, Version 2 April 2012




Document Control Information

Ratification Assurance Statement

Dear Lynn

Please review the following information to support the ratification of the below named document.

Name of document: Medical Appraisal Policy – Ref: Black 172

Name of author: Angela Hayday

Job Title: Associate Director of Organisational & People Development

I, the above named author confirm that: The Policy presented for ratification meets all legislative, best practice and other

guidance issued and known to me at the time of development of the Policy;

I am not aware of any omissions to the Policy, and I will bring to the attention of the Executive Director any information which may affect the validity of the Policy presented as soon as this becomes known;

The Policy meets the requirements as outlined in the document entitled Trust-wide Policy for the Development and Management of Policies (v4.0);

The Policy meets the requirements of the NHSLA Risk Management Standards to achieve as a minimum level 2 compliance, where applicable;

I have undertaken appropriate and thorough consultation on this Policy and I have documented the names of those individuals who responded as part of the consultation within the document. I have also fed back to responders to the consultation on the changes made to the Policy following consultation;

I will send the Policy and signed ratification checklist to the Policy Coordinator for publication at my earliest opportunity following ratification;

I will keep this Policy under review and ensure that it is reviewed prior to the review date.

Name of Author: Angela Hayday Date: 05 February 2016

Name of Person Ratifying this policy: Claire Buchanan

Job Title: Director of Human Resources

Signature: Date: 17 February 2016

To the person approving this policy:

Please ensure this page has been completed correctly, then print, sign and post this page only to: The Policy Coordinator.

The whole policy must be sent electronically to: [email protected]

mailto:[email protected]




Consultation Schedule

Name and Title of Individual Date Consulted

Members of Task & Finish Group (v1) 25th June 2012

Tim Craft, Medical Director 25th June 2012

Carol Peden, Associate Medical Director 12th July 2012

Lynn Vaughan, Director of Human Resources 12th July 2012

Adam Malin, Director of Medical Education 12th July 2012

Monica Baird, Divisional Head, Surgery 12th July 2012

William Hubbard, Divisional Head, Medicine 12th July 2012

Lead Clinicians 12th July 2012

Clare O’ Farrell, Divisional Manager, Medicine 12th July 2012

Suzanne Wills, Divisional Manager, Surgery 12th July 2012

Local Medical Negotiating Committee (LMNC) 12th July 2012

Strategic Workforce Committee (SWC) 12th July 2012

Trust Policy Group 12th July 2012

Noleen Foley, Chair, LMNC 6th September 2012

Members of the Joint Local Negotiating Committee (LNC)

4th January 2016

Medical Appraisers 5th January 2016

Name of Committee Date of Committee

Local Medical Negotiating Committee (LMNC) 30th August 2012

Strategic Workforce Committee (SWC) 12th July 2012

Local Medical Negotiating Committee LMNC) 27th September 2012

Joint LNC (via email) 15th February 2016




Equality Impact Assessment (EIA) Template

1. Title of document for assessment Medical Appraisal Policy

2. Date of assessment 5th February 2016

3. Date for review 5th February 219

4. Directorate/Service Human Resources

5. Approval Committee Joint Local Negotiating Committee (LNC)

12.

6. Does the document/service affect one group less or more favourably than another on the basis of:

Protected characteristic: Yes/No Rationale

Age No

Disability No

Gender reassignment No

Pregnancy and maternity No

Race No

Religion and belief No

Sex No

Sexual orientation No

Marriage and civil partnership

No

7. If you have identified potential discrimination, are the exceptions valid, legal and/or justified?

8. If the answers to the above question is ‘no’ then adjust the element of the document / service to remove the disadvantage identified.

9. If neither of the above is possible, take no further action until you have contacted your EIA Divisional / Directorate link for review and support

13.

Signature of person completing the Equality Impact Assessment

Name Angela Hayday

Time 11.20 am

Date Friday 5th February 2016

Chair of decision making Board / Group / Committee approval and sign off

Name Noeleen Foley

Time 17.00

Date Monday 8th February 2016