Revalidation of Doctors - Health Committee Contents

Written evidence from the Royal College of Anaesthetists (REV 09)


  • The Royal College of Anaesthetists (RCoA) supports the General Medical Council's (GMC) intention to ensure revalidation is as streamlined, straightforward and proportionate as possible. The call for simplification by some responders to the GMC consultation should not, however, result in a system that is unfit for purpose; namely one that does not adequately provide assurance to the public that doctors are fit to practise with no concerns about quality of care and patient safety.
  • We support current plans from the Department of Health and NHS Revalidation Support Team for a system of strengthened medical appraisal that is both formative and summative. It is important that appraisal adequately considers the generic and specialist standards that doctors are required to meet. A framework and system must also be place that facilitates self-reflection on personal and team practice and performance. The RCoA has already taken steps to support anaesthetists (both appraisers and appraisees) preparing for strengthened medical appraisal through developing guidance and educational resources and activities.
  • The specialist standards set by the Royal Colleges should help define any framework for appraisal and revalidation so that the process is relevant and meaningful for specialty doctors. The anaesthesia, intensive care and pain medicine specialty standards should act as signposts and provide guidance as to the knowledge areas, skills, attitudes and activity levels that all anaesthetists are required to demonstrate, and in doing so, provide assurance to the public that revalidation is robust and fit for purpose. We recognise further work needs to be done as to presentation of the specialty standards in reducing the complexities perceived in revalidation. In particular, in relating the standards to two key areas - in defining the attributes or qualities expected of anaesthetists, intensive care and pain medicine specialists and, secondly, in defining acceptable levels of supporting information in terms of quality, quantity and how it is produced for discussion at appraisal.
  • We support a structured system of peer or colleague feedback in deriving supporting information for revalidation. Workplace colleagues are well placed to offer an informed opinion as to a doctor's professional skills and behaviour and there is clear evidence that this feedback is beneficial for informing on an individual's professional development planning. If an appropriate system is in place it will provide a well informed and balanced source of information and insight about a doctor's professionalism.
  • In regard to patient feedback in revalidation we believe more work needs to be done in establishing an evidence base as to its validity (as a source of information about a doctor's professionalism) and added value (in terms of quality and compared to other, already existing, sources of evidence demonstrating patient satisfaction with health care and services). Specifically, in regard to anaesthesia, it is our current opinion that patient questionnaires are not appropriate in generating supporting information due to the nature of work in this specialty and clinical relationships with patients - they may, however, be more relevant to the practice of pain medicine.
  • The current GMC proposals for quality assurance must be developed to consider both processes and outcomes, adequate sampling sizes and a positive role for the Royal Colleges. In gaining the buy-in or support of doctors for revalidation they must be assured that it is not solely a GMC process but one that has been validated by expert external and independent professional bodies such as the Royal Colleges. Our concept of quality assurance also extends to one of providing specialty specific advice and support to appraisees and appraisers so that appraisal is delivered consistently, equitably and to acceptable levels.
  • We welcome the GMC's statement that the introduction of revalidation is a shared responsibility involving the regulatory authorities, Royal Colleges and other key stakeholders. However such an embracement does necessitate an explicit course of action for each stakeholder involved, which is coordinated and strategic, making best use of individual expertise and at the same time reducing the duplication of effort and work. The GMC will no doubt be at the centre of all this and a good effective working relationship with the Royal Colleges, via the Academy of Medical Royal Colleges, will be essential in introducing revalidation.


1.  The Royal College of Anaesthetists (RCoA) is the professional body responsible for the specialty of anaesthesia throughout the United Kingdom. Our two Faculties of Pain Medicine and Intensive Care Medicine look after the professional interests of doctors in these specialties. The activities of the RCoA are varied, but include the setting of standards of clinical care, organising a system of continuing professional development and the provision of guidance and support to our 14,500 Fellows and Members.

2.  As a specialty anaesthetists, intensive care and pain medicine specialists are the single largest group of hospitals doctors. Their major role lies in providing anaesthesia during surgery, but this role is ever widening and anaesthetists are also involved in the preparation of surgical patients, the relief of post-operative pain, in obstetric units, in cardiac arrest teams, in intensive care units, in accident and emergency departments, in chronic pain management, in acute pain teams, in dentistry, in psychiatry for patients receiving ECT, as well as the provision of sedation and anaesthesia for patients undergoing radiology and radio-therapy procedures. Anaesthetists, intensive care and pain medicine specialists are also widely involved in the teaching and training of undergraduate medical students, postgraduates, nurses and many other paramedics. They may also lead or manage the various departments in which they play a major role such as day surgery, operating theatres, recovery units, high dependency units, critical care services and resuscitation services.


3.  The RCoA supports the GMC's intention to ensure revalidation is as streamlined, straightforward and proportionate as possible. However this intention and calls for simplification should not diminish the robustness of the overall process so that revalidation is no longer fit for purpose. Contextualising this statement is that revalidation must be about providing assurance to the public that doctors are fit to practise with no concerns about quality of care or patient safety; and also the process must be a positive one in motivating formative development within the profession. Over-simplification may well challenge these principles.

4.  The robustness of the process is, in our opinion, dependent on the specialty standards that doctors will need to consider when revalidating. The specialty standards set by the Royal Colleges represent the core values held by specialty doctors and the minimum levels of practice expected of them. Diminishing the recognition of these specialty standards during appraisal will represent an over-simplification of the revalidation process. Whatever framework for appraisal and assessment is finally decided upon the specialty standards should define the main elements or attributes that make up that framework. Without consideration of the specialty standards, appraisal will be meaningless and not relevant to a doctor and their specialist practice.


5.  The RCoA agrees that a strengthened form of annual appraisal should be the vehicle in delivering revalidation for doctors. We are monitoring the Department of Health/NHS Revalidation Support Team's work and proposals for strengthened medical appraisal and have taken proactive steps in supporting appraisers and appraisees within such a system. This includes:

  • Producing interim guidance on supporting information for presentation at appraisal. The items of supporting information listed are benchmarked against specialty standards set by the College. We have identified which items are "core" and therefore providing a minimum data-set and checklist to help anaesthetists prepare for appraisal.
  • Developing series of online video clips demonstrating how the summative (assessment) and formative (professional development) elements will work within a single appraisal process. The videos also demonstrate how specialty specific issues can be discussed within the framework provided by the generic GMC attributes.
  • Through focus groups we have also developed opening and supplementary questions for each of the 12 GMC attributes covered in appraisal. The questions should encourage reflection and responses from appraisees to confirm that they are meeting the generic and specialty standards that define each attribute. These questions are generic enough to be used in the appraisal of doctors practising in other specialties. We have informed the GMC as to this work and for their consideration in producing national guidance on appraisal.
  • Developing a training programme to enable Lead Appraisers to train and provide advice to appraisers in their departments (at a local Trust level) as to the anaesthesia specific requirements and standards in appraisal. The training will consider the quality of supporting information presented and the specialty benchmarks against which the information will be evaluated.

6.  The interim guidance, video clips and questions are freely available from the RCoA website:

7.  The overall focus of this work is to consider the necessary anaesthesia specific requirements in strengthened medical appraisal. The appraisal will be specialty specific as the discussion will focus around what an individual anaesthetist, intensive care and pain medicine specialist does in their practice and the supporting information presented. In evaluating this information and performance, an appraiser will need make a judgement by considering the specialty standards set by the College and that all anaesthetists, intensive care and pain medicine specialists are expected to meet. The outcomes of five successful appraisals, all based on what a doctor actually does in practice and benchmarked against specialty standards, will provide a robust platform upon which a Responsible Officer can make a positive recommendation to the GMC for a doctor to revalidate. It will also provide robust re-assurance to the public that a doctor is fit to practise in their specialist area.


8.  The specialty standards set the parameters for acceptable practice in anaesthesia, intensive care and pain medicine. The standards represent the minimum benchmarks that all are expected to meet, rather than levels of excellence; although in striving for this higher level anaesthetists, intensive care and pain medicine specialists can use these standards to reflect on practice and identify knowledge areas, skills and attitudes for professional development. The specialist standards therefore exists for summative (assessment of performance against predefined and explicit benchmarks) and formative (professional development towards excellence) purposes - both of which are mirrored in the principles underpinning revalidation. The specialist standards should not be neglected therefore in the simplification and streamlining of revalidation.

9.  Work does need to be undertaken, however, in presenting these specialist standards so that it is made clear what is expected of doctors when revalidating and in reducing the complexities associated with the process. There is a need, we believe, to clearly distinguish the applicability of specialty standards to two different areas:

  • In defining the attributes or qualities of a doctor in our specialty.
  • In defining acceptable levels of supporting information in terms of quality, quantity and how it is produced.

10.  In the first instance, we have mapped the specialty standards from The Good Anaesthetist and The Good Pain Medicine Doctor (RCoA, 2010) against the 12 GMC attributes so that the GMC's framework for appraisal and assessment is meaningful for anaesthetists and related to their specialty practice. The standards from these documents are themselves derived from standards of practice documents published by the RCoA, Association of Anaesthetists of Great Britain and Ireland and specialists societies. These are key documents specifying standards of acceptable and safe levels of practice in the specialty.

11.  In presenting items of supporting information for appraisal, specialty standards also exist in determining the content, quality and how these items should be produced. The RCoA publication Raising the Standard (2006), for example, prioritises those audits that should be undertaken within departments of anaesthesia, intensive care and pain medicine, details the best standards as to data collection, stipulates benchmarks and recommends actions to be taken to complete the audit learning cycle. Whilst the methodology is generic, specialty elements must be considered in relation to data collected, benchmarks and acceptable targets in the specialty. Another example is supporting information derived from colleague multi-source feedback (MSF). Specialty guidance will be published recommending who and how many (i.e. surgeons, nurses, operating department practitioners, trainees) should provide feedback to anaesthetists, to capture a representative picture of an anesthetist's skills and performance in the workplace. Specialty standards will therefore provide an objective benchmark for appraisers in judging whether supporting information, which is likely to be specialty specific, is acceptable or not. Our next task is to present these standards in a way that is succinct and easy to understand for the purposes of revalidation.


12.  A valid and reliable system of colleague multi-source feedback (MSF) providing informed supporting information about a doctor's practice will no doubt contribute, in a positive sense, to their professional development. Feedback identifying areas to address, against the relevant GMC attributes, through the personal development plan will be a positive aspect of the appraisal and revalidation process. However underpinning this rationale is one of validity and reliability of the supporting information. Developing a valid and reliable MSF for the medical profession is an ongoing concern for many stakeholders, including the GMC and the Royal Colleges. Setting the ground rules, for example, as to the selection of appropriate colleagues to provide valid and reliable feedback as to an anaesthetist's skills and behaviours is an important part of the overall process.

13.  We question, however, the applicability of patient questionnaires in providing an informed, valid and reliable source of supporting information of a doctor's performance in some specialties such as anaesthesia and intensive care medicine. In anaesthesia, situations where it may be seen as appropriate to capture patients' views are at the pre-operative stage, i.e. immediately after a pre-operative assessment or visits, yet this may not be the case in practice. For example, anaesthetists involved in high turnover operating lists, where patients have already been pre-assessed by others in an out-patient clinic setting, will have an average of 20-30 minutes to see 6-8 patients during their very brief pre-op visit; the two types of encounter are so different it is impossible to expect the anaesthetists to have comparable feedback. It may not be appropriate to ask a patient to fill in a questionnaire at the early post-operative stage either, as their judgement may be impaired as a result of the effects of their anaesthetic. It will difficult for patients in intensive care, for obvious reasons, to provide any response as to a doctor's skills and performance. There are more general concerns, regardless of specialty, about patient questionnaires in revalidation. For example, patient feedback may reflect shortfalls in the overall health care experience due to problems related to nursing care and organisational issues causing lack of continuity in medical care rather than due to the performance of an individual doctor. We also question the added value of patient questionnaires, in terms of the quality of supporting information it provides against other, already existing, sources of evidence demonstrating patient satisfaction with their health care.

14.  Our current opinion, therefore, is that current patient questionnaires are not appropriate in generating informed, valid and reliable supporting information for doctors in anaesthesia or intensive care medicine. The RCoA does, however, intend to try and develop appropriately validated and reliable patient feedback questionnaires.


15. We are disappointed that the GMC proposals for quality assurance (QA) envisages a role for the Royal Colleges that is restricted to providing information and data and defines these organisations, who set the specialty standards for the profession, as a contributor and not as a partner with a positive role in the QA process. The GMC will in effect be quality assuring a process by which they are also responsible for making the decision as to whether to revalidate a doctor. Denying the Royal Colleges a positive role will arguably make it more difficult to convince doctors about the benefits of revalidation that are broader than patient safety. It can be argued that to gain the buy-in of doctors, they must be assured that it is not solely a GMC process but one that has been validated through QA by expert (specialist standards setters) external and independent professional bodies such as the Royal Colleges.

16.  We welcome the GMC's proposals to quality assure the organisational processes and frameworks involved in revalidation. We would welcome more details, however, as to how individual outcomes and decisions to revalidate will be quality assured. Revalidation is after all a high-stakes process involving an individual's license to practise on one hand and on the other, assurance, to the public, that doctors are practising to acceptable levels with due regard to patient safety issues. We accept that quality assuring 100% of outcomes may not be possible, due to logistical and financial reasons, but serious consideration should be paid to arriving at a sufficient sample size to reassure the profession and public that revalidation is fit for purpose.

17.  The GMC should consider the involvement of a panel of senior RCoA representatives in reviewing a sample of anonymised portfolios and decisions in regard to anaesthetists being revalidated. If there was significant disagreement as to the number of positive revalidation decisions in the sample this might highlight deficiencies and problems in the system. A similar arrangement should be in place for other specialties involving the relevant Royal Colleges.

18.  Quality assurance is also about ensuring that the specialty elements of appraisal are delivered consistently, equitably and to acceptable levels, locally and nationally. To achieve this, our interpretation of a positive role in QA therefore includes providing advice and support as to specialty issues to individual anaesthetists, intensive care and pain medicine specialists, appraisers (who may not be from the same specialty) and Responsible Officers (likewise). We are planning to develop our existing national network of clinical Regional Advisors or develop a new network of Regional Professional Advisors to provide on the ground expert advice and support. In implementing this plan will require adequate resourcing so that our advisors are fully trained and systems are put into place and managed.

Dr Andy Tomlinson
Senior Vice President and Revalidation Lead

November 2010

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