Written evidence from the British Cardiovascular
Society (REV 10)
SUMMARY
- The British Cardiovascular Society supports the
concept of revalidation as a "streamlined, straightforward
and proportionate process".
- We believe that there is a danger that the process
as currently outlined could result in expenditure of considerable
unnecessary effort by individual doctors.
- The BCS has developed a simple template for revalidation
of cardiologists.
- National clinical audits provide a potential
mechanism for the development of risk stratified and benchmarked
clinical outcome data that could be used to support revalidation
and more generally to drive quality improvement.
- Funding of some important national clinical audits
is at risk.
- The BCS believes that key national clinical audits
should be centrally funded.
- Professional societies have a key role to play
in the development of risk stratified outcome models from national
audit data and need academic and financial support to do so.
- The cost of supporting national audits and development
of outcome models will be a small fraction of commissioning expenditure
for any specialty.
- For specialties where national audit data is
not readily available, accreditation of services against nationally
agreed standards could provide an alternative means of providing
supporting information on objective assessment of performance
for individual doctors.
- Professional societies should have a role in
assisting Responsible Officers in evaluating doctors who are at
risk of failing to achieve revalidation.
1.0 BACKGROUND
The British Cardiovascular Society (BCS) is the Professional
Society representing all those working within cardiovascular health,
science and disease management. Its members who are cardiologists
and cardiovascular physicians support the concept of revalidation
as a "streamlined, straightforward and proportionate"
process. A key aim of the Society is to improve the quality of
cardiac services within the UK and we see revalidation as an important
component of this process. The Society and its affiliated subspecialty
groups have a strong track record of national data collection
through the Central Cardiac Audit Database (CCAD) and we believe
that so far as is possible supporting evidence for revalidation
should be derived from validated national audit data.
2.0 EVIDENCE
2.1 There is a widespread perception that current
proposals for revalidation are too complicated and could result
in expenditure of considerable extra time and effort by individual
practitioners. This has been highlighted in the responses to the
GMC consultation. We agree with this concern and view it as a
strong argument for the use of routinely collected national audit
datasets where these are available.
2.2 The BCS has developed a template for revalidation
of cardiologists based on the three domains of knowledge, skills
and professionalism:
http://www.bcs.com/pages/page_box_contents.asp?navcatID=34&PageID=523
These proposals were widely supported by the membership.
It is likely that our proposals will require some modification
as the process of revalidation matures but we believe that the
underlying principles are sound.
2.3 Central to the skills based domain is a hierarchy
of supporting evidence such that provision of appropriate risk
stratified outcomes benchmarked against national audit data and
demonstrating continuing competence removes the requirement for
any additional locally collected data.
2.4 There are currently seven national clinical
audits (NCA) of cardiac topics with varying degrees of data completeness.
Some such as the database on cardiovascular interventions of the
British Cardiovascular Intervention Society and the MINAP database
have extremely high rates of data submission. These were not initially
set up to provide supporting evidence for revalidation but provide
a rich resource of data that can be routinely collected at low
cost.
2.5 The White Paper "Liberating the NHS"
states that existing NCAs should be expanded to a wider range
of conditions and to increase their validity, collection and use.
It also indicates that NCAs should produce clinical outcome data
as well as process data. Many existing NCAs could in principle
be adapted to serve the purposes of revalidation by providing
risk stratified outcome data. Since in many cases the mechanisms
to collect such data already exist little additional local infrastructure
would be required to make these audits universal. This would be
a highly cost efficient way to provide high quality supporting
professional information.
2.6. Funding of NCAs is currently haphazard.
Identification of a number of mandatory core NCAs with secured
central funding is essential for the agenda outlined in "Liberating
the NHS" and would greatly assist the development of revalidation.
2.7 The active engagement of Professional Societies
such as the BCS is key to the success of both revalidation and
more generally the provision of meaningful outcome data. Professional
Societies have a role in defining datasets and appropriate outcome
measures. Societies will need academic and statistical input to
build and apply risk models against which individual performance
can be benchmarked and will need to be supported financially to
do this. However the cost of such analysis will be only a small
fraction of the overall commissioning expenditure for a specialty
and cheaper than the alternative of multiple duplicative processes
at local level. There is an expanding evidence base that high
quality care is cost effective care.
2.8 There is a public expectation that doctors
demonstrate their continuing competence. The BCS supports the
publication of appropriately risk stratified benchmarked individual
outcome data where this is applicable. This is only possible with
full data collection, sophisticated modelling and agreement on
what constitutes an outlier.
2.9 Some medical specialities do not lend themselves
so easily to provision of robust outcome data and other measures
need to be used. In cardiology this includes cardiac imaging.
The imaging groups affiliated to the BCS have developed departmental
quality assessment and improvement processes, otherwise referred
to as accreditation. It is our view that a cardiologist practicing
in an imaging department that has met nationally agreed standards
including systematic quality control should meet the requirements
under the skills domain (or objective assessment of performance)
without the need to provide additional supporting evidence in
this domain. Since these processes are standardised they remove
the requirement for duplicative local efforts and will be cost
effective. There are many other areas where appropriate use of
standardised accreditation or peer review processes could be used
to provide supporting information in this way.
2.10 The BCS believes that the structures of
revalidation should be as simple as possible. Some general information,
such as description of practice and statements on health and probity
are mandatory for all doctors. In our view confirmation of ongoing
competence in the skills domain as described above accompanied
by evidence of completion of CPD against the full range of clinical
activity (knowledge domain) and satisfactory completion of peer
and patient feedback (Professionalism) will in the great majority
of instances provide all the additional information required for
revalidation.
2.11 The GMC has not yet fully defined the process
for handling the situation where a Responsible Officer has concerns
about an individual doctor's fitness for revalidation. The BCS
believes that Professional Societies should have a role in supporting
the Responsible Officer by providing expert advice and evaluation
where required.
November 2010
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