Written evidence from Dr Allan Cole (REV
This submission is from Dr Allan Cole as an individual.
He is an experienced Medical Director, having been in such a post
in one of the largest acute Trusts (University Hospitals of Leicester)
in the country from 1993-2009. In this post, he was one of the
first to introduce appraisal to consultant medical staff. He is
the lead and pilot Responsible Officer for the Pathfinder pilot
of revalidation in Leicester, which is one of the 10 pilot sites.
He is a past Chairman of the British Association of Medical Managers.
He is now a Medical Director within the Revalidation Support Team.
- The GMC's proposal to use regular annual appraisal
as one of the essential elements of revalidation is likely to
- The proposal to use Responsible Officers in Designated
Organisations (usually the Medical Director) is fully supported.
- The 12 attributes and four Domains of Good Medical
Practice as defined by the GMC should remain the principle behind
- The GMC's opinion that the supporting evidence
provided by doctors should directly map to the 12 attributes may
be difficult to work in practice.
- To ensure clarity, there is a need to be more
specific about the mandatory evidence required.
- The pathfinder pilot must be allowed to be completed
and inform the final form of appaisal.
- It is essential that the formative and supportive
part of appraisal is not over-shadowed by the demands of revalidation.
- It is important that the governance and accountability
arrangements for the implementation of revalidation are clear
- Training of appraisers and Responsible Officers
is important to assure both quality and consistency.
- How the process of appraisal and revalidation
is quality assured needs to be addressed.
- There is a need to identify what organisations
will be "Designated" (and thus who the Responsible Officer
will be) for GP's in primary care after the changes proposed in
the recent white paper.
- The extra year for implementation is strongly
supported as being likely to improve the quality and effectiveness
of the process.
THE GMC PROPOSES
1. Appraisal for medical staff was adopted as
a desirable activity for doctors more than 15 years ago and since
then, as the benefits have been recognized, various initiatives
from employers and professional organisations have been intended
to make appraisal a necessary activity for several different purposes.
However, there was little agreement about how appraisal should
be undertaken and the implementation of appraisal has been patchy
with some organisations and individuals having a reasonably comprehensive
system while others have played little more that lip-service to
2. The GMC has proposed
that appraisal should be one of the key components of the revalidation
process. However, those that first developed medical appraisal,
found that a supportive, developmental and formative process was
the most beneficial and acceptable method of implementing it.
Such an appraisal system though does not lend itself immediately
to the more summative and judgmental process that is required
for revalidation. However, it was widely agreed that the use
of appraisal for revalidation was a sound and sensible proposal
and work was therefore started to adapt medical appraisal to be
fit for purpose for revalidation.
3. The term Strengthened Medical Appraisal (SMA)
was coined to describe the improvements that were required in
the medical appraisal process in order to support revalidation.
A paper was prepared in November 2009 by the Revalidation Support
Team (RST) which proposed a methodology which was to be used during
the pilot project for revalidation called the Pathfinder Project
which started in early 2010.
4. The Pathfinder pilot will not formally report
on its findings until June 2011 although there will be an interim
report in the coming months. The findings of the pilot must be
allowed to inform the final form of appraisal although the need
for streamlining and simplification as well as the evolving debate
within the profession has allowed work to start on developing
the SMA into a Medical Appraisal Framework (MAF). This work is
currently being undertaken by the Revalidation Support Team, who
are working in conjunction with all stakeholder organisations.
This will include coordination as far as possible with similar
work in the devolved administrations of the UK. and will be complete
by the time revalidation is expected to go live in 2012.
THE GMC PROPOSALS
5. There are two distinct aspects of medical
appraisal and this needs to be recognised:
- the parts of appraisal which are intended to
help individual doctors develop themselves, their career and their
strive towards excellence. In this part, there will be challenge
but there will not primarily be judgement. Partaking in this aspect
of appraisal might become mandatory but the content will not lend
itself to the type of judgement that will be required for revalidation.
- the part of appraisal needed for revalidation,
will be judgemental about the appropriateness of education and
training, reflection and quality assurance activity that an individual
is involved in compared to their particular practice. The aim
is to make a judgement that an individual doctor is appropriately
safe and up to date.
It is this second part that required strengthening
when SMA was introduced. The word "strengthened" has
been interpreted as the provision of a greater volume of evidence
but it would be better interpreted as the need to provide certain
information on a mandatory basis.
6. The use of the Domains and Attributes of
Good Medical Practice - the GMC has defined four domains and
12 attributes which form the core of what constitutes "Good
Medical Practice" (GMP) and expects that recommendations
for revalidation from Responsible Officers on individual doctors,
will essentially confirm adherence to these. It is entirely logical
therefore that SMA proposed that appraisal should be informed
by evidence collected by individual doctors which would directly
map to one or more of these attributes. However in practice this
appears to be more difficult and less precise than at first envisioned.
It may be difficult therefore to support the GMC's view that
evidence should be directly mapped to the 12 attributes.
7. This difficulty emanates from the nature of
the attributes which are of necessity quite general and subjective
because they are required to describe the principles of Good Medical
Practice applying in all circumstances. As an example, whilst
it is obviously entirely correct that a doctor must adhere to
this attribute - "apply knowledge and experience to practice",
providing specific evidence of this is unlikely to be comprehensive
and will tend to result in superficiality. The other extreme which
has also been found is that some have felt the necessity to produce
extraordinary amounts of information in an attempt to be comprehensive
which has become far too onerous for all (and probably counter-productive).
8. There is a need therefore when practically
implementing appraisal for revalidation, to have a clearer understanding
of the type of evidence that is expected in order to fulfill the
expectations of the GMC for the purpose of revalidation against
the 12 attributes.
9. To this end, the MAF is likely to propose
that evidence is separated into areas which should apply to all
doctors in whatever activity they are engaged:
- A summary/description of all activity within
their practice as a doctor;
- A record of activity in training and keeping
up to date;
- A description of contribution to quality assurance
systems for an individual's practice, outcome data where feasible;
- Feedback from patients, colleagues and staff:
(a) Patient questionnaires;
(b) Colleague feedback; and
(c) A record of all complaints and serious incidents.
- Self-declaration regarding health and probity.
10. A summary/description of all activity
within their practice as a doctor
The importance of this is that in order to assess
effectively a doctor's safety and fitness to practice, it is essential
that an appraiser has a complete view of the type(s) of practice
the appraiser is engaged in and this has to be in some detail.
While a job plan may be helpful information in this regard, it
is unlikely to be sufficient. There is a need to know the types
of patients, the volume of cases and the medical techniques used.
This description should be inclusive of private work of all sorts,
teaching, research, professional duties, management etc.
In some specialties a log book could be provided
but may be over-detailed for the purpose - a summary of work would
be easier for an appraiser to assimilate. Thought needs to be
given to the best format or formats for this information.
11. A record of activity in training and keeping
up to date
The purpose of this is for the appraiser to be able
to assess whether the doctor is undertaking sufficient continuing
education and mandatory training to enable the individual's practice
to remain safe and up to date.
Many of the Medical Royal Colleges are producing
guidance on what they consider appropriate in their specialties.
However, many individuals over time, practice in quite narrow
areas of the specialty or even in areas which are not directly
within the remit of their own specialty. This means that the assessment
of adequacy of education and training needs to be done locally
by the appraiser. When necessary, the appraiser will of course
be able to take advice from colleagues in or outside a Trust to
help support this assessment.
12. A description of how an individual ensures
their practice is quality assured
It is necessary that all doctors consider how their
practice is measured. There is a huge variation in how this is
done in different areas of medical practice.
The term Clinical Audit has often been used to describe
some of these activities but it means different things to different
people. The type of activities include:
- Contribution to a national register.
- Individual outcome data.
- Team outcome data - this may be gathered formally
through hospital data but can also be less formal when doctors
work in teams:
- Attendance at specialty and inter-disciplinary
meetings could be included where applicable (eg MDT's).
- Specific QA activity (eg in Pathology).
- Individual collection of complications and compared
with published evidence.
- Etc. etc.
An appraiser will need to assess the appropriateness
of the quality assurance activity for the appraisees' particular
practice. Where a practice involves a very high risk of serious
consequences, it is likely that the requirement for QA will be
more rigorous than in a practice with less risk of serious consequences.
Similarly, where doctors are working in teams and where the quality
of the whole team is measured and known to be good, then there
may be less need to provide information on an individual (and
indeed it may not be very easy either).
Again, the Medical Royal Colleges will provide helpful
advice on this but the assessment will need to be made individually
by an appraiser because of the heterogeneity of practice between
Appraisees will need to provide feedback on their
practice. It has been agreed that a formal MSF will normally only
be required every five years and there is not yet clarity about
how this should fit in with other forms of patient questionnaires.
Negative feedback in the form of complaints will
also need to be presented to appraisers, who need to ensure that
appropriate actions and reflection have resulted and whether there
is any untoward pattern to the complaints
14. Health and Probity
An assessment of health and probity will be required
15. The developmental part of Appraisal
The requirements of revalidation have made it necessary
to make considerable changes to the appraisal that was originally
developed for medical practitioners. It is of great importance
that the demands for the more basic and judgmental part of appraisal
for revalidation, do not displace the beneficial and supportive
part of appraisal that has been developed previously.
Much has been written about how the more formative
appraisal should be undertaken and how this helps doctors develop
and improve their practice and how it augurs excellence. The continued
development and strengthening of this is important for the profession
and the patients. The more subjective nature of the contents of
this, does not lend itself to the black and white judgments needed
If the GMC decided, it might be possible to make
participation in such activity mandatory but it is unlikely to
be feasible to make qualitative assessment of such appraisal -
in other words all that could realistically be recorded was whether
it was done or not done.
16. The questions that need to be answered by
an appraiser in each year and at the end of a five year revalidation
At the end of an appraisal, the key outputs are a
summary, a professional development plan and a series of set statements
made by the appraiser. These statements are designed to apply
to all practitioners but they may be too general and non-specific
to allow an effective assessment summary of doctors in different
specialties. The MAF will address this issue and work with others
to define the questions that need answering in order to support
This approach will require professional skill and
judgement which underlines the need to have effective training
for appraisers, which will not only ensure the quality of the
process but also contribute to consistency. The appraiser may
ask for guidance from elsewhere - Colleges or local colleagues.
17. The process of revalidation and conflict
Revalidation will be informed by Responsible Officers
(RO's) in "Designated Organisations". The plan is that
RO's will be doctors in a Board level position which inevitably
means that they are likely to be the Medical Director. Arguments
have been put forward that this could become a conflict of interest
but as the MD's themselves are accountable to the GMC, this conflict
is likely to be minimal except iin some exceptional cases, such
as with relatives. On the other hand there is a great advantage
in the Medical Director being the RO because that will ensure
that the responsibility for clinical governance and revalidation
will coincide. This is of over-riding importance. the proposed
process of revalidation is therefore fully supported.
18. Doctors employed in other ways
There are a significant number of doctors working
independently, as locums or in other situations. All will require
an RO and testing is being undertaken on how the process will
work in these various situations. Indeed there is a question as
to who will be the RO for primary care doctors after the planned
demise of PCT's which Is proposed in the recent white paper and
this issue will need to be addressed in the near future.
19. Leadership for Revalidation - there
is a need to ensure there is complete clarity about responsibility
and leadership of the implementation of revalidation. There are
many stakeholders in the process which provides ample opportunity
for confusion. The GMC as regulator may be the obvious organisation
to lead on the implementation but it may not have the skills to
implement revalidation without great dependence on many different
partners - particularly the DH. The accountability needs to be
20. Quality Assurance - there is a need
to identify the most appropriate and cost-effective methodology
of external quality assurance and who will undertake this.
21. The extra year- The extension of piloting
by a further year announced by the Secretary of State in June
has been of great importance in allowing the proposals and work
so far to be adapted into a practical, affordable and effective
tool for the revalidation of doctors. Without the extra year the
Pathfinder pilot would not have been completed and its findings
incorporated into the final methodology. It is not intended to
use the extra year to extend the existing Pathfinder pilot but
to use the time to ensure that its results can be used properly
and to test specific aspects further (such as Multi-source feedback).