Written evidence from the Royal College
of Anaesthetists (REV 09)
SUMMARY
- 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.
BACKGROUND TO
THE RCOA
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.
SIMPLIFICATION AND
STREAMLINING
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.
STRENGTHENED MEDICAL
APPRAISAL
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:
http://www.rcoa.ac.uk/revalidation.
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.
SPECIALIST STANDARDS
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.
COLLEAGUE AND
PATIENT FEEDBACK
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.
QUALITY ASSURANCE
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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