Revalidation of Doctors - Health Committee Contents


Written evidence from Dr Allan Cole (REV 17)

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.

SUMMARY

  • The GMC's proposal to use regular annual appraisal as one of the essential elements of revalidation is likely to be effective.
  • 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 revalidation.
  • 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 and effective.
  • 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 WAY IN WHICH THE GMC PROPOSES TO ESTABLISH REVALIDATION

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 the activity.

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 FURTHER DEVELOPMENT OF 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 different individuals.

13.  Feedback

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 for revalidation.

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 cycle.

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 effective revalidation

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.

OTHER COMMENTS

17.  The process of revalidation and conflict of interest

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 absolutely clear.

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).

November 2010


 
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