D:\116097075.doc
Terms and conditions for use of the Medical Appraisal and Revalidation
System (MARS) including the Severn Appraisal Toolkit (SAT)
Version 6
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.
D:\116097075.doc
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.
D:\116097075.doc
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.
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.
D:\116097075.doc
In Severn, Lead Appraisers will have access in order to review whether the
appraisal process is meeting specified standards in the Area Team.
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.
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).
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
D:\116097075.doc
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.
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.