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
We are pleased to respond to this consultation. This
consultation was prepared by Dr Laurence Mynors-Wallis: Registrar.
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
- 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
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
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
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
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
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;
(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
5. THE SPEED
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.
6.1 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
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
7. ROLE OF
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.