Written evidence from the Royal College
of Physicians (REV 19)|
The Royal College of Physicians (RCP) plays a leading
role in the delivery of high quality patient care by setting standards
of medical practice and promoting clinical excellence. We provide
physicians in the United Kingdom and overseas with education,
training and support throughout their careers. As an independent
body representing over 20,000 Fellows and Members worldwide, we
advise and work with government, the public, patients and other
professions to improve health and healthcare.
- The Royal College of Physicians supports the
introduction of revalidation in the UK in 2012 as a means of promoting
and enhancing the quality of care that physicians provide to their
patients and the public.
- We remain concerned about certain aspects of
the current proposals.
- We agree that the revalidation process should
be simplified and streamlined.
- We consider that the differences between specialties
should be acknowledged and supported within a common framework.
- High quality appraisal is central to the successful
delivery of revalidation.
- Appraisal should remain a predominantly formative
- We consider that it would be simpler, and more
broadly applicable, if specialty supporting information was categorised
under three main headings rather than the 12 Attributes of the
- The current proposals for Strengthened Medical
Appraisal are over-detailed and should be simplified.
- Actual or potential conflicts of interest within
the RO role should be addressed, and steps taken to manage these
if they occur.
- Colleges and Faculties should continue to play
a central role in the revalidation process, including setting
of standards, supporting implementation, and in quality assurance.
- Specialist support and guidance should be provided
by Colleges and Faculties to individual doctors, appraisers and
Responsible Officers, both in routine revalidation processes and
where remediation may be required.
- We wish to continue to work closely with the
GMC, the Revalidation Support Team and other stakeholders to ensure
that revalidation achieves its potential benefits in terms of
improved quality of care for patients.
2.1. The RCP is pleased to have the opportunity
to support the work of this Parliamentary Inquiry. We believe
that revalidation has the potential to yield important benefits
to the public and to the medical profession in the form of improved
healthcare quality and outcomes, and in terms of reinforcing public
confidence in the profession.
2.2. However, significant uncertainties remain
in relation to the planned process and its key components and
we very much welcome the opportunity to contribute evidence to
the Committee on behalf of our Fellows and Members
2.3. In October, the GMC published its analysis
of the response to its public consultation "Revalidation:
The Way Ahead", to which the RCP had submitted a comprehensive
response. We commend the GMC for conducting a thorough and comprehensive
consultation in advance of the introduction of revalidation in
the UK, and welcome the fact that the analysis of responses addressed
a number of key concerns already raised by us and by other royal
colleges. We also welcome the recognition of the need for further
2.4. One of the main conclusions from the GMC's
report is that the process needs to be simplified and streamlined
to provide a better fit with requirements and expectations. We
acknowledge and support this conclusion.
2.5. We also believe that the essential differences
between specialties should continue to be recognised, based within
a common framework. In collaboration with the Academy of Medical
Royal Colleges we are taking steps to streamline the components
of the process that relate to the roles of this College and its
Fellows and Members.
2.6. The Colleges are well placed to establish
standards and to support implementation at local, as well as national,
level. This support should include involvement in quality assurance
of processes and outcomes, as well as the provision of advice
and guidance to physicians, appraisers and Responsible Officers.
3. THE PURPOSE
3.1. Throughout the development process, those
organisations responsible (GMC, Department of Health, NHS and
the Medical Royal Colleges and Faculties) must retain a strong
focus on the purpose of revalidation. In their document "Revalidation:
A Statement of Intent", the GMC, the CMOs for England and
Northern Ireland, the Deputy CMO for Scotland and the Medical
Directors of the NHS in England have all agreed that "the
purpose of revalidation is to assure patients and the public,
employers and other healthcare professionals that licensed doctors
are up to date and fit to practise".
3.2. However, this document also acknowledges
that revalidation "
..should be part of a range of
measures to ensure high quality safe care". The two other
elements are appraisal and robust clinical governance. We believe
that appraisal is the key to bringing the other two elements together
"sensitively and effectively" (Secretary of State)
and we support the view expressed in the CMOs report Medical Revalidation
- Principles and Next Steps (2008) that appraisal "should
remain a predominantly formative process". A great deal
of work has already been done to bring these processes together,
but more is needed in order to avoid a conflict between the processes
of clinical governance (quality control) and revalidation (quality
improvement and regulatory assurance).
3.3. In its submission to the GMC consultation,
the RCP emphasised the relative importance of quality improvement
as the main benefit of revalidation. The public already has high
confidence in the ability their clinicians; a revalidation process
that drives up standards and promotes excellence and quality throughout
the profession will yield significant benefits which are much
broader than just confidence in a regulatory process.
4.1. It is clear that revalidation will depend
on a number of systems and processes working efficiently together
across the healthcare system. Although the GMC owns the last stage
of the process (the point at which the doctor's licence to practise
is renewed for another five year period), a number of processes
that lead up to that point are owned by other organisations (for
example, by employers and the Medical Royal Colleges and Faculties).
4.2. The other area of the revalidation process
of which the GMC has taken ownership is the underlying standards
framework. This was adapted from the previous edition of the GMC's
code of practice "Good Medical Practice". The Good Medical
Practice (GMP) Framework consisted of four Domains, 12 Attributes
and over 60 "Standards", and provided a structure by
means of which supporting information from the individual's practice
would enable doctors to demonstrate that they were up to date
and fit to practise.
4.3. In 2008 the GMC approached the Academy of
Medical Royal Colleges with a request that Colleges and Faculties
should develop specialty-specific frameworks that would specify
the supporting information that would enable each medical specialty
(College or Faculty) to demonstrate that they were meeting the
requirements of the twelve Attributes.
4.4. After much consultation each specialty provided
a framework, many of which stipulated "core" and "optional"
supporting information and an accompanying Checklist, since many
elements of the supporting information were relevant to several
Attributes. These specialty frameworks and checklists featured
as an appendix to the GMC's consultation document "Revalidation:
The Way Ahead" (March to June 2010). The Colleges and Faculties
anticipated that these "core" and "option"
frameworks would need more work, and were continuing to review
them on a regular basis.
4.5. The GMC's analysis of the consultation response
suggested that the Colleges and Faculties frameworks were over
complicated. It had already been recognised by the Colleges and
Faculties that the specialty proposals would require modification,
and this work was taking place during the consultation period.
The GMC has now stated that they wish to work with the Colleges
to streamline the specialty-specific frameworks.
4.6. The GMC consultation response also indicated
broad agreement with the proposal that relicensure and specialist
recertification should be combined into one process of "revalidation".
While this makes sense from an administrative perspective we have
concerns about its effect if the concept is combined with too
much simplification and streamlining. This is because reduction
of the required supporting information to a small number of generic
elements will significantly limit the ability of doctors to revalidate
according to the nature of their professional (hence specialist)
4.7. Within the physician Colleges there are
numerous sub-specialties, and therefore potential inconsistencies
may arise. We have addressed this by allowing sub-specialties
to maintain their own "take" on the core elements of
the process, recognising that good practice in some sub-specialties
will require, for example, greater technical or communication
skills than others. This is where the specialist certification
element of revalidation is important.
4.8. The Academy and its constituent Colleges
and Faculties are working on a common core specialty framework
that can be applied to all, while acknowledging essential specialty
differences. This framework will achieve the streamlining that
the GMC recommends, especially if it is structured under three
main headings - Objective Evaluation, Perceptions
and Maintenance of the quality of your work.
4.9. The RCP was closely involved in the first
secondary care pilot in Mersey, and it was recognised through
this pilot that Trust information systems needed upgrading, and
that some of the GMP Attributes were more difficult to provide
supporting information for than others. The proposed specialty
frameworks were not available to test.
5.1. The appraisal process has, rightly in our
view, been placed at the centre of proposals for revalidation.
Appraisal is the process by which an individual doctor will be
able to review the quality of his or her individual professional
practice and will agree a plan for personal development. Dame
Janet Smith considered that "appraisal is patchy and not
fit for purpose" and recommended that it should be strengthened.
We agree that there is wide-spread variation in the way appraisals
are carried out in different organisations and therefore the current
processes may not always be sufficiently robust to base revalidation
5.2. It is because of these challenges that a
new format for appraisal, Strengthened Medical Appraisal (SMA),
is being developed, within which doctors must demonstrate compliance
with the GMP domains and attributes on an annual basis. SMA is
currently being piloted within the "Pathfinder Pilots"
5.3. The RCP recognises the importance of "Good
Medical Practice" as a descriptor of the behaviour to which
all doctors should aspire. Showing that doctors are achieving
these attributes will require supporting information that may
be more conveniently classified under the different headings suggested,
so that specialty variations are more easily understood and acknowledged.
5.4. The process currently proposed for SMA is
complex and detailed, perhaps because of the perceived need to
make decisions based upon it legally defensible. Each item of
supporting information is subject to scrutiny at a number of stages,
and this has made the proposed process time consuming, and challenging
to pilot effectively.
5.5. A number of electronic systems have been,
and are being, developed in an attempt to streamline this process,
but these have brought their own problems and have not always
seemed helpful to their users. We believe that appropriate electronic
systems should be available, but that they, like the process they
are designed to support, should be flexible and streamlined.
5.6. Because of the relatively short (one year)
timescales of the pilots, more work has had to be put in than
may be required when revalidation is rolled out. This needs careful
consideration, since to under-estimate the resource implications
would be disastrous. It is important that doctors understand that
although appraisal must happen every year, revalidation is a five-year
process, and SMA needs to be based firmly on this premise.
6.1. The Responsible Officer (RO) is the person
who will have statutory responsibility for bringing together the
outcomes of the annual appraisals and other information about
the performance of a doctor, and making a positive recommendation
to the GMC in favour of revalidation. The equivalent role within
the NHS at present is that of Medical Director, and it has been
recommended that the two roles should be carried out by the same
6.2. The competencies required of an RO have
been set out in Guidance, and the ROs will themselves be subject
to appraisal. However, some of the competency frameworks that
have been suggested as a basis for this process appear over-complicated
6.3. The joining of the Medical Director role
(clinical governance and performance management) with the Responsible
Officer role (revalidation and quality improvement) may give rise
to real or perceived conflict of interest, particularly where
Trusts are under financial or target-related pressure. Proper
mechanisms to support ROs, and to ensure that such conflicts of
interest are avoided, must be developed.
6.4. This will form part of the quality assurance
process that needs to be applied to revalidation, for the reassurance
of doctors, and for the reassurance of the public. We believe
that the Colleges and Faculties should be equal partners in this
process with other key stakeholders. We have a responsibility
not only to our members and Fellows to advise and support them,
but also to our patients and the wider public to ensure that the
doctors treating them are fairly judged.
6.5. Input from patients, carers and the lay
public has been a central part of the way that we have approached
the development of the recommendations for revalidation for physicians.
The same is true for other Colleges and Faculties. Patient and
carer participation and feedback should be obtained not only through
patient questionnaires relating to individual doctors, but also
through their continued involvement in the roll-out and quality
assurance of the system.
6.6. The future role of GMC Affiliates (or the
equivalent under new terminology) will need careful consideration.
Even if, as "lay Affiliates", they are not medically
qualified, they will still be employees of the GMC. Thus while
they will have an important role in ensuring consistency of decision
making and engagement with relevant stakeholders they will not
be best placed to provide the independent view normally associated
with lay representatives.
7. ROLE OF
7.1. The Medical Royal Colleges and their specialist
organisations were tasked, in "Trust, Assurance and Safety"
with developing the standards for specialist practice and developing
the means to demonstrate that they were being met. The great majority
of doctors are "specialists" (including General Practitioners)
and therefore we believe that the Colleges and Faculties, and
thus the Academy, must remain key contributors to a revalidation
process that is designed to support doctors in demonstrating their
professional competence within their specialist field.
7.2. We consider that the Colleges and Faculties
are well-placed to train and advise appraisers and ROs on the
requirements for revalidation in our specialties.
7.3. We consider that the Colleges should be
involved in the quality assurance of revalidation. This will be
important in order to provide an external perspective to that
of the GMC, who would otherwise be solely responsible for the
quality assurance of their own decision-making processes.
7.4. We recognise the central role of the Revalidation
Support Team (England) (RST) in the development and implementation
of revalidation. We have worked closely with the RST throughout
the process so far, but are concerned that they may become linked
mainly with NHS employers. This could create an excessively performance-managed
approach to revalidation that risks polarisation and would not
serve the process well. We consider that the RST, as representatives
of the Department of Health, and the Colleges and Faculties, with
the Academy, should work closely together to achieve a revalidation
programme that meets all of the aspirations of all parties concerned.
7.5. We consider that, as specialist organisations,
the Colleges and their specialist associations should be closely
involved n the processes of remediation, where this is required.
We are in a good position to provide advice to individual physicians
and to their ROs regarding the skills and standards required.
There will be individuals whose needs are relatively minor, when
referral to a Clinical Advisory Service or the regulator will
not be required. Adequate funding will need to be identified for
the supportive remediation of these individuals, and Colleges
will have an important role in its delivery.
7.6. WHAT WILL
7.7. The current Pathfinder "whole system"
pilots are due to complete in March 2011. We agree with the GMC
that the data gathered from these must (a) address the many key
questions that are being asked and (b) be properly analysed and
learned from prior to the roll-out of revalidation.
7.8. Additional pilot projects through 2011 should
be targeted at any remaining critical areas. We consider that
the revalidation of locum doctors and revalidation of those with
"portfolio" job plans have not yet been adequately addressed.
7.9. The cost-benefit analysis, planned for the
second quarter of 2011, must be realistic, honest and robust,
and sources of funding to support revalidation must be identified
and agreed by all. The GMC proposes to roll-out revalidation according
to "organisation readiness", and this implies, we think
correctly, that there is uneven "readiness" across the
UK. This being so, the cost analysis must address those organisations
where appraisal and IT systems are currently poor as well as those
where they are already excellent.
8.1. We recommend that there is continued close
co-operation between the Academy of Medical Royal Colleges, individual
Colleges and the GMC in the further planning and implementation
8.2. We recommend that the Colleges / Academy
and the Revalidation Support Team (England) continue to work closely
together in areas of mutual interest.
8.3. We recommend that all elements of the revalidation
process should be streamlined, but at the same time that the process
should continue to acknowledge that trained doctors practice in
many different ways, and therefore the details of individual revalidation
requirements will differ.
8.4. We recommend that the learning from the
Pathfinder Pilots, and from the work in other areas that has already
been carried out, is taken into account in the remaining time
available before revalidation roll-out.
8.5. We recommend that the cost implications
of revalidation are honestly and openly considered, and that proper
and manageable arrangements are made to meet these costs.