Revalidation of Doctors - Health Committee Contents


Written evidence from the Royal College of Psychiatrists (REV 16)

The Royal College of Psychiatrists is the leading medical authority on mental health in the United Kingdom and is the professional and educational organisation for doctors specialising in psychiatry.

We are pleased to respond to this consultation. This consultation was prepared by Dr Laurence Mynors-Wallis: Registrar.

1.  SUMMARY

1.1  The Royal College of Psychiatrists strongly supports revalidation. College members, whilst having understandable concerns about bureaucracy and potential time taken from direct patient care, have accepted revalidation guided by the aims set by the College which are listed below:

  • revalidation must command the confidence of patients, the public and the profession;
  • revalidation should facilitate improved practice for all College members and fellows;
  • the process should identify those whose practice falls below acceptable standards and give advice and monitoring to allow revalidation to be reconsidered; there should be early warning of potential failure so remedial action can be taken;
  • the process should allow those who are working to College standards to revalidate without undue difficulty or stress;
  • there must be equity across the specialties, independent of differing areas of practice, working environments and geographical location;
  • revalidation should be affordable and flexible, starting simple to allow further development; and
  • the process should incorporate as far as possible information already being collected in clinical work and use existing tools and standards where available.

1.2  The College is clear that revalidation is not, and should not be, about identifying the few bad doctors. Whilst this may happen in a few cases, other governance systems should pick up failing doctors and concerns should immediately be addressed.

1.3  Revalidation must be about supporting doctors in their endeavour to deliver high quality and improving healthcare. The success or failure of revalidation will depend to what extent this aim is achieved.

2.  GMC PROPOSALS FOR REVALIDATION

2.1  Revalidation for psychiatrists will involve a robust annual review with an experienced colleague (an appraisal) at which the doctor being appraised will provide evidence that they are meeting professional standards. The appraiser will use this evidence to identify any necessary developmental actions and discuss evidence required for future appraisals. It is expected that this process will be collaborative with the professionals working together.

2.2  The purpose of collecting supportive evidence for appraisals, over the five-year cycle, is not to tick boxes showing that a particular standard has been met, but rather to enable the psychiatrist to collect a body of meaningful information that will demonstrate continuing fitness to practise. It is expected that this process will facilitate ongoing professional development, the aim of which is to improve the standard of care that each psychiatrist provides for patients.

2.3  It will be clear from this description of revalidation that the role of the appraiser will be crucial. The appraiser must be an experienced doctor, trained to assess the standards expected for psychiatrists and mindful of the significant obligations that appraisal places upon him or her to undertake a robust and rigorous process. Appraisers must be supported in this important role with both training time and access to peer review.

3.  COLLEGE CONCERNS

3.1  Revalidation and the medical member of the tribunal reviewing detention under the Mental Health Act

3.11  The College has a particular concern about the revalidation proposals with regard to doctors who sit as a medical member on mental health review tribunals. It is proposed at present that these doctors will not need to be revalidated but that they will simply need to be registered doctors.

3.12  The College believes this is wrong. Doctors who make important decisions about detention and hence liberty of patients must be revalidated. This will assure patients and their carers that the doctors being asked to make important decisions about continuing detention under the Mental Health Act are up to date and fit to practice.

3.13  It is difficult to know to know what credibility a medical member would have in going against the decision made by the treating psychiatrist, if the treating psychiatrist is a revalidated doctor and the review tribunal panel doctor is not.

3.14  We believe that patients should have a choice; they may not wish to be assessed by a non revalidated doctor. The College believes it unlikely that many detained patients, who are often significantly unwell, will be unable to make the distinction between a registered doctor without a license to practice and a revalidated doctor, even if this is explained.

3.2  Responsible Officers

3.21  In England there continues to be some uncertainty as to whether responsible officers in managed care organisations will be the medical director. The Royal College of Psychiatrists believes the medical director is well placed to be the responsible officer. He or she already has a responsibility for ensuring good clinical governance within their organisation and this involves ensuring that the doctors within their organisation are fit to practice. The College is aware that there could be a concern about potential conflicts of interest. However it is already the case that the medical director is expected to highlight clinical concerns. Medical directors will be readily aware of the difference between a colleague in their organisation meeting the professional requirements of revalidation and the different requirements of a Trust wishing a doctor to work in a different way.

4.  CURRENT GMC PILOTS IN LONDON AND WEST YORKSHIRE

4.1  The Royal College of Psychiatrists is participating in the current revalidation pilots. Whilst we support many aspects of what the GMC is piloting, the College has two concerns:-

4.11  The current system of dividing good medical practice (the generic standards for all doctors) into four domains and twelve attributes is not ideal. There are some attributes that can easily be measured, others are more subjective or can only be measured when they don't occur. The College in its submission to the GMC consultation recommended reducing the number of areas being assessed at appraisal. The three key headings are as follows:

(a)  Demonstrating good clinical care;

(b)  Relationships with patients and colleagues; and

(c)  Continuing Professional Development.

4.12  The supporting technology. It will be crucial if revalidation is to work for there to be a working electronic portfolio within which revalidation information can be collected and stored, both for clarity of information required and quality assurance. The College is concerned that the current electronic system used within the NHS in England has been withdrawn as a free service for doctors. This seems a retrograde step. It cannot be the case that appraisal information should continue to be stored in lever arch files on doctors' shelves. Nor should it be the case that each College develops a separate system for collecting information.

5.  THE SPEED OF IMPLEMENTATION

5.1  Whilst the College understands the desire to ensure that information from the current revalidation pilots is collected and analysed before revalidation is implemented, on balance the College believes that revalidation should start soon. There have been discussions about revalidation for well over a decade. The proposals as they exist should not be a surprise for any individual doctor, and indeed should ensure that all doctors practice at what should be seen as minimum standards.

6.  STANDARDS SET FOR PSYCHIATRISTS

6.1  Revalidation and appraisal provide the opportunity for a psychiatrist to reflect upon their work with an experienced colleague and to develop a plan for subsequent professional development in the subsequent year.

6.2  The Royal College of Psychiatrists has established a clear framework of evidence that psychiatrists will present at appraisal. The College has been mindful of the need to start with a simple and readily understood process, building on what is already in place. The standards expected for psychiatrists over a five-year cycle are as follows:-

6.21  Providing evidence of good clinical practice. The College is recommending that this is done in two ways; firstly via at least two audits, per five-year revalidation cycle, of significant areas of clinical practice. The purpose of this is to demonstrate within key areas of practice the extent to which the doctor and multi-disciplinary colleagues are meeting agreed standards, providing the opportunity to correct these standards and then re-evaluate them the subsequent year.

On an individual level, each doctor will be required to discuss clinical cases, chosen at random, with a colleague, the colleague providing feedback and identifying good areas of clinical practice and areas for improvement. This is known as case-based discussion and in pilot work has been viewed enthusiastically by consultant psychiatrists.

6.22  Feedback from patients. The patient experience is a key aspect of healthcare quality. The College has developed and evaluated a robust system of seeking anonymised feedback from patients. It is expected that this will be used at least once in a five yearly cycle, alongside local collection of patient feedback. It is expected at appraisal that the psychiatrist will demonstrate how they have adapted their practice according to feedback received.

6.23  Feedback from Colleagues. Almost all psychiatrists work within a multi-disciplinary team. Feedback from colleagues within the team, as to strengths and weaknesses, is helpful in developing the psychiatrist to be a key player and clinical leader within the team.

6.24  Clinical outcomes will become increasingly important over the coming years. The Royal College of Psychiatrists is recommending a range of outcomes to be used across mental health. The routine use of outcomes to inform the patient's progress and the practice of the doctor is an important measure to improve patient care.

6.25  Reflections upon complaints or serious untoward incidents. Each psychiatrist will be expected to reflect upon, learn lessons as appropriate and take any necessary action following a complaint or adverse incident. This will be reviewed at appraisal.

6.26  Continuing Professional Development. Each psychiatrist will be expected to demonstrate that they are fully compliant with the College's standards for continuing professional development.

7.  ROLE OF MEDICAL ROYAL COLLEGES

7.1  The Royal College of Psychiatrists will have an important role in ensuring the success of revalidation, in the following areas:-

7.11  Leadership. The College has been clear that it supports the processes of revalidation and hence has sought to allay the concerns of its members. This has been achieved by focusing on the aims set out above.

7.12  Setting clear and measurable standards for revalidation. The College updated the standards expected for all psychiatrists (Good Psychiatric Practice, Third Edition) in 2008 in order to ensure that the professional standards set were measurable and provided a clear foundation for revalidation.

7.13  Provide training and support for appraisers. Although appraisal can be seen as a generic activity, the interpretation of the College standards requires specialist expertise.

7.14  Supporting employers in assisting doctors who require remediation and further training.

November 2010


 
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Prepared 8 February 2011