Revalidation of Doctors - Health Committee Contents


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.

1.  EXECUTIVE SUMMARY

  • 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 process.
  • 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 GMP Framework.
  • 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.  INTRODUCTION

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 testing.

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 OF REVALIDATION

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.  FRAMEWORKS AND SUPPORTING INFORMATION

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) practice.

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.  APPRAISAL

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 upon them.

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" in England.

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.  DECISION-MAKING PROCESS

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 person.

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 and aspirational.

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 THE MEDICAL ROYAL COLLEGES AND FACULTIES

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 HAPPEN NEXT

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.  RECOMMENDATIONS

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 of revalidation.

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.

November 2010


 
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