Medical Appraisal & Revalidation System

Terms and conditions for use of the NHS Wales Medical Appraisal and Revalidation System - Version 6

 

1. Nomenclature and feedback

The Medical Appraisal Revalidation System is managed, developed and supported by the E-Learning Unit and Revalidation Support Team at the Wales Deanery, Cardiff University.  MARS is provided to GPs in Wales as part of the overall GP appraisal process which is managed by the Revalidation Support Unit.  MARS is provided to other doctors in Wales as a system to support the appraisal process managed by the Designated Body and to help ensure consistency in the appraisal process across Wales.

MARS is provided by the Wales Deanery to Health Education South West as a supported service under the SAT instance.  Health Education South West offer the system to GPs in the areas of Bristol, North Somerset, Somerset, and South Gloucester (the BNSSSG Area Team) and Bath, Gloucestershire, Swindon and Wiltshire (the BGSW Area Team).  Health Education South West also provides SAT access to members of the Area Teams with a responsibility for appraisal and revalidation.

MARS consists of a number of independent sites; they cover the hospital sector, the independent sector and general practice, the latter functioning both in Wales and in Severn. The main structures of the sites are identical but the text has been changed as appropriate. It is likely in the first few years of use that some of the nomenclature may cross between the systems. We have tried to avoid this where possible and are always happy to take feedback via nhswalesappraisal@cf.ac.uk for users in Wales and Severn.GPAppraisal@southwest.hee.nhs.uk for users in Severn.  We will be constantly adapting the sites in line with feedback, Quality Assurance reviews and external pressures including for example developments within revalidation.

 

2. Appraisal information

The personal information held within these sites is treated in accordance with the Data Protection Act 1998 (DPA). For the purposes of the Act, Cardiff University is the Data Controller.  Principles of access are outlined below.

The appraisal information you enter into MARS will be available to your appraiser once a meeting has been negotiated. Your personal and professional details (including the range and scope of your work), will be available to your appraiser once: -

  • you have chosen him/her from a list of approved, trained appraisers,
  • your request has been accepted by that appraiser.

In the unlikely event that your appraiser identifies a concern during the appraisal process about your performance or fitness to practice they would have a duty to report this in line with GMC guidance.  In Wales, any such concerns relating to GPs would be managed in line with the agreed ‘communication protocol for managing information flows between appraisal and clinical governance’ (which is available via the MARS library) and concerns relating to other doctors would be managed in line with existing local clinical governance systems.  In Severn, such concerns will be managed in line with your Area Team’s local protocol.  This management process may require that aspects of your appraisal information would be made available to other clinicians involved in the process.

Your appraisal summary and PDP (form 4) will be available to your medical director/ Responsible Officer under NHS appraisal rules.  For the purposes of revalidation this information may be shared with those with delegated RO responsibilities, and for Quality Assurance purposes.

Wales Deanery, Health Education South West and Designated Body staff members have access to data entered into MARS as appropriate to enable effective management of the appraisal process.  Reports will be produced automatically through the online system which will provide management information about engagement with appraisal.  This access is in line with local policies and in accordance with the Data Protection Act 1998.

Additionally aggregated reports will be produced detailing the learning needs and constraints identified by doctors. No individuals will be identified in these reports.  These aggregated reports will be made available to the relevant staff within the Designated Body/Area Team and appraisal management team. In Wales, relevant staff within the Designated Body and the Welsh Government will receive annual reports containing aggregated data for the purposes of planning educational provision and considering how any lack of provision might be addressed.  In Severn, relevant Education Provider Organisations will have access to aggregated reports for the same purpose.

 

3. Quality assurance

A range of Quality Assurance (QA) activities are carried out to assess whether the appraisal process is meeting specified standards and remains fit for purpose, and to inform the performance management and development of Appraisers.  This QA does not relate to the evidence provided by individual doctors nor to their clinical performance or fitness to practice.  Key QA activities are described below.

In Wales, a random sample of appraisal evidence, summaries and PDPs will be generated automatically each year for quality assurance (QA) purposes in order to review whether the appraisal process is meeting specified standards. This is an essential aspect of managing the appraisal process. All such materials will be anonymised by the Revalidation Support Unit (Wales Postgraduate Deanery) and access to them will be restricted to those participating in the QA. Any items of a particularly sensitive nature or from which individuals could be identified will be omitted. Individuals will not be identified in QA reports. Previous reports on QA of GP appraisal can be accessed at https://nhswalesappraisal.org.uk/default/library

Additionally in Wales, GP Appraisal Co-ordinators have access to appraisal summaries and PDPs in order to routinely quality assure a sample of these on an on-going basis.  This routine QA is used to provide specific feedback to individual Appraisers and to review whether the appraisal process is meeting specified standards in the local area.

In Severn, Lead Appraisers will have access in order to review whether the appraisal process is meeting specified standards in the Area Team.

 

4. Use of e-mail

As part of the registration process you are required to enter a live e-mail address. This will be used for the purposes of appraisal and communication about the process of appraisal. You will receive automated e-mail reminders from the system when your appraisal is due. You will also receive e-mails that inform you at various stages during the appraisal process. You also may receive e-mails about educational events, appraisal or revalidation from the Designated Body /Area Team or the Revalidation Support Unit. Your e-mail address will not be passed on to any third parties unless we have your explicit consent or unless required to do so by law.

 

5. All users

The website is subject to copyright and the contents, process and functionality cannot be shown, described or demonstrated to any parties that are not directly engaged with the project process (unless formally agreed by the Welsh Revalidation Delivery Board appraisal lead).

 

5a. If you are an appraisee you should remember that the data you enter must not breach patient confidentiality rules. You are asked to agree the following statements:-

  • I agree not to enter patient identifiable data into this database
  • I agree not to use images of patients without prior consent or under normal NHS rules of data processing
  • I understand that information entered on this database will be fully accessible to my appraiser for the year in question once I have agreed an appraisal date
  • Where information could foreseeably be associated with an identifiable patient even when a name is not used, consent for inclusion should be obtained in advance.

I understand and accept the principles of access and confidentiality described in this statement.

 

5b. If you are an Appraiser you must agree to the following conditions:-

I understand that the information I have access to on the database is personal data as defined by the Data Protection Act 1998, and that I therefore have specific responsibilities to it.

Therefore I agree:

  • To hold this data securely and use it only for the purposes for which it has been submitted to me.
  • To securely destroy any data that I may download and/or print from the database once the appraisal is complete. In keeping with best practice hard copy data should be shredded and/or disposed of in confidential waste.

 

5c. If you are another user (Designated Body staff, system/IT administrator, Wales Postgraduate Deanery staff/Severn Postgraduate Medical Education staff etc.) you must agree to the following conditions:

I understand and accept the principles of access and confidentiality described in the statements below and recognise and accept my own responsibilities in relation to them. I therefore agree:

  • To hold this data securely and use it only for the purposes for which it has been submitted to me.
  • To destroy any data that I may download from the database securely once the appraisal is complete. In keeping with best practice this data should be shredded and/or disposed of in confidential waste.