Written evidence from the Royal College
of Surgeons of England (REV 12)
SUMMARY
- The College supports the introduction of a revalidation
system.
- The leadership of and ultimate responsibility
for revalidation must lie with the GMC.
- The GMC needs to set out clearly the remaining
tasks and who has delegated responsibility for them.
- The independence and impartiality of responsible
officers is not assured and more needs to be done to monitor them.
- The move to implement revalidation as organisations
become ready does not represent a risk based approach. The GMC
needs to proactively support lagging organisations.
- Following a risk based approach, further work
is needed to ensure that systems are in place to revalidate appropriately
locum doctors and doctors working solely in the independent sector.
- The importance of specialty difference must not
be lost in the rush to produce a simple system.
- A consistent approach to appraisal must be championed
by the GMC.
- Whole practice appraisal must be supported by
responsible officers and all health organisations.
- Revalidation is an opportunity to improve existing
systems and processes to collect and analyse information about
the outcomes of health care.
- Medical Royal Colleges should have a clear role
in the quality assurance of revalidation.
- The role of PCTs and SHAs within the regulations
needs to be reconsidered in light of changes to these organisations
which the Government has announced.
EVIDENCE
1. The Royal College of Surgeons of England supports
the introduction of a revalidation system Our hope is that revalidation
will:
(a) Provide a way for doctors to prove that they
meet high standards of practice.
(b) Protect patients through early identification
of problems and strong clinical governance.
(c) Reassure patients that their doctor is fit
to practice.
2. The College has supported the work done over
the last 11 years to introduce a revalidation system. The various
set backs have been frustrating but it is clear that even the
anticipation of revalidation has improved the clinical governance
landscape. Nevertheless there is still much more work to be done.
LEADERSHIP
3. The Royal College of Surgeons of England is
clear that revalidation must be led by the profession and to that
end the General Medical Council (GMC) must have overall responsibility.
To date the College has encouraged the GMC to take a leadership
role. However, we have been somewhat disappointed by the GMC's
apparent failure to clearly set out how it expects the revalidation
project to proceed. In particular it has not been clear what the
GMC expects other bodies to do including the role of the Colleges.
It is our opinion that this has led to delays and duplication
and is the reason why the system has been criticised as being
overly complex. It appears that this is now being remedied.
4. We recognise that the four UK departments
of health are concerned about the impact of revalidation on their
health services and have therefore taken a proactive role in preparing
for revalidation. Revalidation should be a UK-wide regulation
system so that any patient in the UK can expect that their doctors
are being revalidated to the same standards in a consistent way.
It is not clear to what extent the GMC has oversight of these
implementation activities. The GMC needs to retain the right to
approve or veto systems in order to ensure that consistency and
fairness is maintained.
5. Looking forward, the GMC urgently needs to
set out in very clear terms, what tasks are left to complete,
who will be responsible for completing them and who will sign
them off. It is only then that broader stakeholders such as Medical
Royal Colleges, specialty associations and patient groups can
identify how and when they can provide input to the development
of standards, rules and systems. This will also minimise any future
duplication.
6. It is clear from the GMC's report on their
consultation that a pragmatic approach is being taken to the implementation
of revalidation focusing on information already widely available.
This is sensible but the risk is that the most relevant types
of supporting information for specialists may be ignored. Revalidation
should be subject to continuous renewal which should make revalidation
even more straightforward. Over time it will be possible for the
profession to develop better forms of supporting information to
replace those currently available. The support of the GMC and
departments of health will be critical.
7. The College, even as an identified partner,
is still unclear what revalidation in its entirety will look like.
Doctors have even less idea about what will happen and what they
need to do to prepare. They are receiving conflicting messages
from a variety of sources further adding to the confusion. The
GMC needs to act authoritatively setting clear timescales for
implementation and needs to make communication with doctors a
priority.
RESPONSIBLE OFFICERS
8. The College remains concerned about the responsible
officer role. We are supportive of revalidation having a local
dimension because it allows local circumstances to be taken into
account and will strengthen clinical governance. However, placing
processes at a local level opens up the potential for the revalidation
process to become conflated with employment issues. Revalidation
is about demonstrating performance against professional standards
and while this overlaps with what an employer requires from its
employees, other dimensions such as revenue raising are simply
irrelevant.
9. As it currently stands the College does not
believe that effective safeguards have been introduced to ensure
that the revalidation process will not be the subject of interference
from employer led processes. We acknowledge that it may be impractical
to change course before implementation but the GMC should make
it a priority to assess, within the first two years of revalidation
if the potential conflict is proving a reality. If this is the
case then the GMC should consider whether an independent network
of locally based responsible officers might prove a better alternative.
10. The GMC has not fully expressed how it will
interact with responsible officers. Responsible officers will
be supervised to some extent by their own responsible officers;
but these will be provided by the four departments of health rather
than by the GMC. Therefore it is not clear how the GMC will monitor
the work of responsible officers directly in order to ensure that
local systems and the revalidation recommendations made by the
responsible officers are in line with GMC expectations.
RISK BASED
APPROACH
11. The GMC is understandably keen to implement
revalidation as soon as it can. To this end their approach is
to begin revalidation in the healthcare environments when they
are ready. By definition those organisations with the best systems
where doctors are likely need the least monitoring by the GMC
will be first. The organisations with the poorest systems will
begin revalidation much later even though the doctors working
in those systems may be currently less well monitored and as a
consequence pose a greater risk. In order to mitigate the effects
of poor systems leading to greater risk due to delay the GMC should
proactively identify such organisations and work with them to
improve their systems and implement revalidation as early as possible.
An agreed "start by" date is essential so that organisations
can be held to account.
12. It is relatively easy to identify some of
the key groups that pose a risk because they work outside of the
"managed" healthcare environment. These groups are sometimes
termed orphan groups. Several groups concern us, in particular:
peripatetic locum doctors, doctors working wholly in the independent
sector (particularly those in the cosmetic sector) and doctors
coming to the UK from overseas for limited periods of time.
Locum doctors
13. Peripatetic locum doctors provide a vital
service to the UK healthcare system. They provide cover at times
of pressure and the service relies on their flexibility. However
it is clear that they are not adequately covered by trust clinical
governance systems and that locum agencies provide variable monitoring
based on reports received from trusts. It will be much more difficult
for peripatetic locum doctors to gather information for revalidation
and for this information to be verified. The College has recognised
this problem and is working on gathering together standards for
locum surgeons. The GMC needs to work with the Colleges and others
to consider what advice can be given to locums, and their appraisers,
about acceptable adaptations to the revalidation process.
14. We are especially concerned about locum doctors
who do not have NHS practice and are not registered with an approved
locum agency through which to obtain their responsible officer
and appraisal. These doctors are supposed to be served by their
Primary Care Trust or Local Health Board. Apart from the fact
that these organisations are not familiar with surgical practice,
in England Primary Care Trusts will soon cease to exist. The GMC
and government urgently need to address this.
Independent Sector
15. The College has established a working party
to draw together standards for cosmetic surgery, both for the
individual and for surgical services. Revalidation will be included
as a regulatory mechanism for upholding these standards. This
work is due to conclude in Summer 2011.
16. The broader issues related to doctors working
wholly in the independent sector are yet to be fully addressed.
We welcome the pilot work undertaken by Independent Healthcare
Advisory Services (IHAS)[3]
but we are concerned that the responsibilities of healthcare organisations
are not fully understood and compliance will be low. It is important
that advice be given to the independent sector to ensure that
they make suitable provision for the introduction of revalidation,
including supporting whole practice appraisal. Revalidation does
present costs but it is not acceptable for organisations to put
off enhancing clinical governance systems. The GMC and Care Quality
Commission need to work together to address this.
DOCTORS COMING
TO THE
UK FROM OVERSEAS
FOR LIMITED
PERIODS OF
TIME
17. The GMC has stated that doctors coming to
the UK will need to be licensed and are therefore subject to revalidation.
However there is almost no detail on how this will work in practice.
The issues are similar to those concerning peripatetic locum doctors
where their work is not subject to a continuous regime of clinical
governance. These doctors pose a particular risk that must be
addressed as a priority.
SPECIALTY DIFFERENCES
18. Following the publication of the white paper,
Trust, assurance and safety, the Medical Royal Colleges
were quite clear that revalidation would contain a significant
specialty element and that their responsibility was to set relevant
standards complementary to the generic Good Medical Practice standards.
Quite quickly it became apparent that the separation of relicensure
and recertification was cumbersome and confusing. Rightly it was
abolished in favour of something more streamlined. We supported
the reunification in the belief that all surgeons, not those just
on the specialist register, would be covered by standards relevant
to surgeons.
19. However, we are increasingly worried that
the push towards simplification marks a move away from specialty
standards and towards a one-size-fits-all approach. This must
be resisted. We support the efforts to ensure consistency of terminology
and the identification of essential items of supporting information
across medicine. However specialty specific difference must be
accepted. For example we have determined that outcomes data form
an integral part of a surgeon's revalidation portfolio but such
data would not be so relevant for other specialties and it is
right that they not be required to replicate this. We would not
approve of a move to make outcomes data an optional form of supporting
information for surgeons. Where available it must be presented.
APPRAISAL
20. Strengthened medical appraisal is the core
process for revalidation. Existing appraisal needs to be enhanced
and extended to include an assessment element for revalidation.
The College is concerned that the GMC appears to have left the
four UK departments of health to undertake this task without guidance
from the GMC about what it expects. In order to make sure that
revalidation applies equally all over the UK appraisal must be
designed with a consistent philosophy and with common elements.
For example the Revalidation Support Team for England has developed
an appraisal system that promotes a small number of items of supporting
information being put forward for inspection by the appraiser.
An alternative approach might be that the appraiser chooses items
to review from a long list of available information. The College
has concerns about the Revalidation Support Team's approach but
it is not clear if our lobbying on this issue should be directed
at the Department of Health or the GMC.
21. The College has long advocated whole practice
appraisal. Patients need to be assured that their surgeon's work
is of a high quality in all areas of their practice across all
sectors. This means that information for appraisal is drawn from
all places of work providing an overall picture. We are pleased
that the GMC makes note of this in its documents but we are concerned
that there is less commitment to this on the ground. We were disappointed
that the responsible officer regulations did not include a duty
to provide information to facilitate whole practice appraisal.
We believe that the GMC should issue guidance to responsible officers
making it explicit that the GMC expects whole practice appraisal
to take place.
OPPORTUNITY TO
IMPROVE SYSTEMS
THAT RECORD
OUTCOME DATA
22. The College would like to inform the committee
about the College's aspirations for the use of outcome data. Revalidation
presents a unique opportunity to commit surgeons and their employers
to enhancing participation in clinical audit and to bring surgeons
closer to the routine data collected on their behalf in order
to develop this into a more clinically meaningful resource. In
the NHS in England Hospital Episode Statistics (HES) is the largest
and most complete data set about healthcare. Initially developed
for administrative purposes, it has become far more reliable over
recent years due to the focus on payment for activity within the
NHS. Revalidation presents the opportunity to further develop
this data set to better understand NHS activity and the quality
of care provided to patients. This is in line with the coalition
government's agenda to widen access and openness about NHS data
as outlined in the current consultation Liberating the NHS:
an Information Revolution.
23. Understanding health outcomes is never easy.
There are always numerous factors to take into account and results
are rarely clear cut. Nevertheless, the College has worked with
the surgical specialty associations to identify for the first
time particular sets of operative procedures that describe the
practice of specialist surgeons, along with a simple range of
outcome indicators that can be derived from HES. This will enable
comparison and benchmarking between units and between individual
surgeons and will provide an essential source of supporting information
for revalidation. Much support from the Department of Health and
the NHS Information Centre will be required to realise the potential
of this work which , if implemented, will further the aims of
the government in its information strategy.
24. The College believes that, even in the short
term, outcomes data can form a part of revalidation through a
combination of national and local clinical audits, routinely collected
data (HES) and self collected data (personal log books). However,
for surgeons and the public to have confidence in these data,
there must be a commitment from the government, the GMC and the
profession to invest time and effort into improving the quality
of information to support outcome measurement. We are clear that
the drive to streamline the revalidation process must preserve
specialty difference and the standards the profession has set.
QUALITY ASSURANCE
25. A transparent and robust quality assurance
process is essential to ensuring the success of revalidation.
The revalidation process itself is mostly devolved with very little
GMC involvement. For that reason the quality assurance process
must be thorough and involve routine checks as well as investigations
triggered by anomalies. We understand why the GMC is keen to work
with systems regulators in order to not duplicate and create a
burden but the GMC must retain control of quality assurance overall.
26. The quality assurance process should focus
on two elements:
(a) Revalidation systems in organisations
(b) Individual revalidation recommendations and
decisions
The GMC should take a risk based approach to this,
targeting identified high risk institutions but retaining an appropriate
degree of randomisation in its approach.
27. The Medical Royal Colleges are guardians
of the specialty standards and as a result must be party to the
quality assurance system in order to retain the confidence of
medical professionals that the standards are being upheld. The
Royal College of Surgeons has engaged the GMC in discussions about
how this might be undertaken but we are not confident that the
role of Medical Royal Colleges is firmly embedded. Colleges can
provide support in a number of ways such as reviewing information
to trigger further investigation, providing service reviews with
specialist input.
November 2010
3 Assuring the quality of medical appraisal for
Revalidation, Strengthening Medical Appraisal: A Report of the
study in the Independent Sector (England), Independent Healthcare
Advisory Services, 2010. Back
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