Written evidence from The Royal College
of General Practitioners (REV 34)
SUMMARY
(a) The Royal College of General Practitioners
supports the principle of the introduction of revalidation for
doctors. Revalidation can offer the public, health professionals,
managers, employers and the state reassurance that every doctor
is keeping up to date and remains fit to practise; encourage doctors
to reflect on their standards of care and to strive for improvement;
and identify any underperformance at an early stage when intervention
is most likely to be effective and feasible.
(b) In supporting revalidation, we recognise
some significant challenges. Revalidation for doctors must be
fit for the purpose; fair and equitable to all doctors; achievable
with minimal disruption to the delivery of healthcare; and applicable
to all doctors whatever their chosen career pathway.
(c) Revalidation must be as simple and explicable
as possible, while still achieving its stated objectives. For
this reason we wish to achieve:
- A common definition of the supporting information
normally required from all doctors regardless of their speciality.
- The simplification of mapping of the supporting
information for revalidation and the appraiser sign off.
- The processes and tools for Colleague Surveys
and Patient Surveys should be clarified.
(d) Annual appraisal is evolving, but it must
become a more robust assessment of information on a doctor's performance,
using a common set of supporting information.
(e) Local clinical governance must be an effective
system that responses appropriately to concerns raised through
appraisals or through other routes.
(f) There are a number of unresolved issues arising
from Equity and Excellence: Liberating the NHS that could
threaten the overall integrity of revalidation. Detail is lacking
on many facets, including the location and organisation of:
- The maintenance of the Performers List (the local
register of GPs)
- data collection and analysis for clinical governance
to support patient safety
- The Responsible Officer
- Processes for addressing concerns about the performance
of individual doctors or teams, including a definition of the
nature of the problem and the actions to address it, support/remediation
and reintegration
BODY OF
EVIDENCE
1. The Royal College of General Practitioners
(RCGP) is the largest membership organisation in the United
Kingdom solely for GPs. It aims to encourage and maintain the
highest standards of general medical practice and to act as the
"voice" of GPs on issues concerned with education, training,
research, and clinical standards. Founded in 1952, the RCGP has
over 38,000 members who are committed to improving patient care,
developing their own skills and promoting general practice as
a discipline.
2. The RCGP welcomes the opportunity to provide
written evidence to the Select Committee on the Revalidation of
Doctors. The RCGP has been a leading organisation within the movement
to revalidation for over a decade and we continue to offer leadership
both to the half of the profession in general practice and, through
our membership of the Academy of Medical Royal Colleges, to the
profession generally. We have previously consulted the GP profession
and relevant organisations to produce the Guide to Revalidation
for General Practitioners,[34]
which contains the RCGP's proposals for the processes and standards
for the revalidation of GPs.
3. The RCGP supports the introduction of revalidation.
We do so because we believe that patients, the public, health
professionals, managers, employers and the state expect and deserve
reassurance that every doctor is keeping up to date and remains
fit to practise; all doctors should be encouraged to reflect on
their standards of care and be encouraged to strive for improvement;
and that we should identify any underperformance at an early stage
when intervention is most likely to be effective and feasible.
4. In supporting revalidation, we recognise some
significant challenges. Revalidation for doctors must be fit for
the purpose described in paragraph 3; it must be fair and equitable
to all doctors; it must be achievable with minimal disruption
to the delivery of healthcare; and it must be applicable to all
doctors whatever their chosen career pathway. In the latter case,
general practice especially provides a plethora of career choices
(such as working as a peripatetic locum or out of hours; in secure
environments or the defence medical services; providing extended
clinical services; in medical management; teaching; undertaking
research) which must be accommodated within proposals for revalidation.
We do not want to inhibit good doctors from providing innovative,
high quality services but we do wish to see all doctors demonstrate
that such services are safe and of high quality.
5. The RCGP does therefore recognise that revalidation,
when introduced, must be as simple and explicable as possible,
while still achieving its stated objectives. For this reason we
are supportive of the GMC's aim, as one outcome of its consultation,
to streamline proposals for revalidation. We wish to achieve:
- A common definition of the supporting information
normally required from all doctors regardless of their speciality.
This portfolio of information will need to be varied for exceptional
cases and augmented in some specialities (for example surgical
outcomes for the surgical specialities). This will mean that all
doctors are being expected to provide similar information promoting
cross-discipline equity; all doctors can be clearer about the
information required; doctors moving speciality will not be disadvantaged;
and Responsible Officers will be presented with similar information
regardless of the speciality of the doctor.
- The mapping of the supporting information for
revalidation needs to be simplified (and in many instances removed)
and the appraiser sign off should be clearer.
- The processes and tools for Colleague Surveys
and Patient Surveys should be clarified. We believe it should
be the responsibility of the Colleges to assess available tools
for their appropriateness within their working environment (most
good tools can be applied in most settings); and for the GMC to
oversee the organisations that administer and analyse the results
in order to ensure confidentiality, appropriate feedback to the
doctors and involvement of the clinical governance processes when
there is cause for concern.
6. At the centre of revalidation for doctors
lie two key systems: annual appraisal and clinical governance.
Annual appraisal is evolving, but it must become a more robust
assessment of information on a doctor's performance, using a common
set of supporting information as described above. The RCGP does
not wish to disable the formative element of an effective appraisal,
and for most good doctors the checking of supporting information
to ensure it is "fit for revalidation" should take only
a small proportion of the time available. However, in those cases
where the supporting information cannot give the appraiser the
assurances they seek, the focus of the appraisal will need to
be on that information.
7. The second key system is local clinical governance.
There will be a requirement for an effective system that responses
appropriately to concerns raised through appraisals or through
other routes.
8. While the RCGP has welcomed the overall thrust
of the Coalition Government's White Paper Equity and Excellence:
Liberating the NHS, there are still a number of unresolved
issues that could threaten the overall integrity of revalidation,
especially in general practice. It is not yet clear to us where
the following functions will sit, the priority and resources that
will be available to them and the quality assurance regimen that
will be applied:
- The maintenance of the Performers List (the local
register of GPs).
- Data collation and analysis for clinical governance
and patient safety.
- The Responsible Officer.
- Processes for addressing concerns about the performance
of individual doctors or teams, including a definition of the
nature of the problem and the actions to address it, support/remediation
and reintegration.
9. This evidence will now respond to the specific
requests for information from the Select Committee.
THE WAY
IN WHICH
THE GMC PROPOSES
TO ESTABLISH
REVALIDATION
10. With the caveats above, the RCGP believes
that the current proposals are proportionate and appropriate.
We support both the direction of travel and the broad means towards
achievement being proposed by the GMC. The RCGP has been conducting
pilots to assess the feasibility of current proposals (see Appendix)
and is broadly satisfied with the outcomes.
THE RESPONSES
TO THE
CONSULTATION AND
THE GMC AND
UK HEALTH DEPARTMENTS'
STATEMENT OF
INTENT ISSUED
ON 18 OCTOBER
11. The RCGP strongly welcomes both the GMC's
summary of the responses to its consultation and the joint statement
of intent. In particular the latter provides considerable reassurance
of political intent to carry the revalidation project through
to a successful conclusion.
THE EXPERIENCES
OF THOSE
INVOLVED IN
THE PILOTS
IN LONDON
AND WEST
YORKSHIRE
12. The RCGP assumes that these are references
to two of the Pathfinder Pilots being conducted by the Revalidation
Support Team in England. The RCGP is not involved in the Pathfinder
Pilot in West Yorkshire but it does have a representative on the
steering group for the London Pathfinder Pilot. The latter is
progressing satisfactorily, although the numbers of completed
"revalidation ready" appraisals is behind schedule.
One recurrent theme concerns the use of the Pathfinders Revalidation
Toolkit which seems to be challenging to use. This pilot should
provide useful information for the continuing refinement of the
both the supporting information and the processes for revalidation.
THE SECRETARY
OF STATE'S
DECISION IN
JUNE TO
EXTEND THE
PILOTING OF
REVALIDATION BY
A YEAR,
MEANING THAT
IT WILL
NOT NOW
BE FULLY
IMPLEMENTED UNTIL
2012 AT THE
EARLIEST
13. The RCGP welcomed and continues to welcome
this announcement. Although it believed that the proposals for
supporting information would have been ready in time for the original
launch date of April 2011, it was clear that NHS processes (in
both primary care and hospital settings) would not have been sufficiently
developed. The processes in non-NHS settings will remain a concern
even in 2012. We urge all departments of health to use the extra
time to ensure that local systems are in place and effective as
soon as possible in order to achieve the go-ahead in the summer
of 2012 with the phased introduction of revalidation in all sectors
following that decision.
November 2010
APPENDIX
SUMMARY OF
THE OUTCOME
OF THE
RCGP REVALIDATION PILOTS
The RCGP has the responsibility, on behalf of all
GPs, to propose the standards and methods for the revalidation
of GPs. To ensure that its proposals are realistic, proportionate
and achievable for all GPs, the RCGP has commissioned a number
of pilots. As well as testing its proposals on mainstream GPs,
the RCGP has tested its proposals on specific groups, including
sessional and remote rural GPs. A summary of the findings of the
completed Warwick, Sessional, Tayside and Prescribing Indicators
pilots can be found below. Two further pilots are currently underway
- one for doctors working in the Defence Medical Services (i.e.
outside the NHS) and one for doctors who work in Secure Environments,
such as prisons, custody suites and immigration removal centres.
Learning from these pilots is incorporated into the
RCGP Guide to Revalidation on an ongoing basis.
WARWICK PILOT
The objectives of this pilot were as follows:
- To assess the feasibility of a representative
sample of English and Welsh general practitioners (principal and
sessional GPs, full-time and part-time) collecting supporting
information as required for the RCGP's proposed revalidation portfolio.
- To compare the rating of the contents of the
RCGP's proposed revalidation portfolio with an alternative source
of evidence for revalidation (an applied knowledge test).
- To explore the feasibility of GP appraisers and
Responsible Officers rating the contents of the RCGP's proposed
revalidation portfolio.
- To identify GP and GP appraisers' views on revalidation
and the RCGP's proposed GP revalidation portfolio and to gather
their suggestions on how the process might be improved.
The methodology used was as follows:
- A sample of GPs from three Primary Care Organisations
(two in England & one in Wales) collected 12 month's of supporting
information in a project portfolio guided by criteria and standards
as detailed in the RCGP Revalidation Guide.
- Participants mapped their supporting information
against the GMC Good Medical Practice four domains &
12 attributes.
- A reflective issues log, an on-line questionnaire
and focus groups were used to obtain participants' views on the
proposed revalidation process and the associated logistics.
- A group of these GPs was recruited to sit an
nMRCGP Applied Knowledge Test (AKT) assessment and the results
were correlated with the contents of their portfolios.
- Project assessors rated the contents of participants'
portfolios.
- Assessors were interviewed and focus groups were
arranged to gather their feedback.
Main findings:
- 50 GP principals, 18 sessional GPs and one GP
registrar submitted project portfolios. (520 GPs were invited
to participate in the project, 118 consented to participate -
Numbers of portfolios submitted may have been affected by the
swine flu epidemic coinciding with the project recruitment period
and the temporary withdrawal of the NHS Appraisal Toolkit in the
last month of the data collection period).
- Just over two-thirds (68%) of the portfolios
submitted by the GPs contained evidence of sufficient quantity
and quality to meet the proposed RCGP revalidation standard for
at least four out of the eight to ten supporting information areas.
- The study suggested that the principal factors
that affected a GP's ability to submit quality supporting
information were a lack of automatic access to practice data (i.e.
access to practice files and invitations to practice meetings)
plus lack of colleague and patient continuity.
- Salaried GPs scored comparably in all supporting
information areas with the GP principals. GP locums, however,
compared less favourably with GP principals and salaried GPs on
SEA, colleague MSF survey, and the full-cycle clinical audit supporting
information areas.
- For seven of the 10 supporting information areas
required for the project GP portfolio, more than three-quarters
of the respondents reported that this was appropriate evidence
for assessing their performance as a GP. The GPs were less convinced
that the extended roles (59%) and colleague MSF and PSQ questionnaires
(57%, and 55% respectively) were appropriate supporting evidence
to assess a GP's performance.
- More than three-quarters of the respondents reported
that they could collect supporting information for seven out of
the 10 evidence areas in a five-yearly cycle. These respondents
were most concerned about providing supporting information for
extended practice, learning credits and patient satisfaction questionnaires.
- There was considerable variation in the time
taken by GPs to produce portfolios - the four sections that the
GPs found most demanding time-wise to produce, reflect and write
up were the learning credits, PSQ, clinical audits and colleague
MSF.
- The vast majority of problems reported by the
GPs centred on the new types of supporting information areas of
learning credits and colleague MSF surveys.
- Three out of the ten doctors passed the AKT test;
seven out of the nine GPs who submitted portfolios were marked
satisfactory and five out were marked satisfactory for their portfolio
learning credit evidence. The numbers were too small to be of
statistical significance for correlation with the ratings of their
portfolio contents.
- The time taken by the GP appraisers to rate a
paper-based GP portfolio with the evidence sorted into the eight
to ten supporting information areas ranged from 10-75 minutes
with an average time of 21 minutes. There was variation between
scores when "double marked" suggesting that benchmarking
is very important.
- The project ROs were impressed with the quantity
of information that the GPs had been able to submit over a relatively
short period of time. However, they considered that the quality
of the evidence could be improved. The absence of self-reflection
was notable in some cases.
CONCLUSIONS/MAIN
RECOMMENDATIONS:
- Participants' portfolios contained quality supporting
information that with training and support should develop into
evidence that could be recommended for the proposed RCGP revalidation.
- There should be a gradual introduction of revalidation
process to allow GPs, other colleagues and organisations involved
to fully understand the process.
- GPs require clear, practical guidance on how
to collect areas of supporting information.
- GPs require access to a user-friendly electronic
portfolio.
- Appraisers will require initial face-to-face
training.
- Alternate revalidation methods and support networks
need to be explored for sessional GPs who experience reduced access
to practice data.
- Colleague and patient feedback should be performed
out of house to increase the objectivity of the process.
- High quality training is required for Responsible
Officers and appraisers to promote the standardisation of the
rating of GP portfolios.
- GP assessors' rating of portfolios must be quality
assured to ensure consistency.
SESSIONAL AND
LOCUM DOCTORS
PILOT
Objectives and methodology:
- This study set out to explore the experience
of locum, salaried and remote GPs in collecting supporting information
in the proposed RCGP revalidation portfolio.
- 53 sessional or remote GPs took part in focus
groups or interviews and attempted to collect items of supporting
information - clinical audit, significant event analysis, colleague
and patient feedback - over a three month period.
Key findings:
- The sessional GPs in this study who felt most
able to collect the RCGP's proposed supporting information were
mainly those with a fixed practice base for at least one session
a week over a period of time. GPs who experienced the most difficulty
tended to be peripatetic locums and Out of Hours (OOH) GPs with
no permanent practice base.
- Remote rural GPs in small practices highlighted
issues relating to the limited practice list size for clinical
and significant event audit and having insufficient colleagues
to elicit colleague feedback.
- Locums felt that they were perceived to have
a lower status than other GPs and that this translated into a
lack of engagement and support from practices for appraisal and
revalidation activities.
- OOH and remote GPs also experienced isolation
and felt relatively unsupported.
- The availability of a peer group of supportive
colleagues would help the completion of supporting information
requirements by providing the opportunity for reflective discussion.
- Remote rural GPs were generally able to complete
clinical and significant event audit, although there were concerns
about small sample sizes for both SEAs and some audits.
CONCLUSIONS/MAIN
RECOMMENDATIONS
- Revalidation would require a culture change:
sessional GPs to be supported in their professional development
by both practices and Primary Care Organisations.
- OOH organisations should provide their regular
GPs with specific systems to carry out clinical audit; identify
and discuss SEAs and elicit colleague and patient feedback, as
well as offering some educational updates
- A number solutions were identified for areas
of supporting information which proved to be problematic - these
are incorporated into the RCGP Guide to Revalidation.
TAYSIDE
Objectives and methodology:
- 60 Tayside GPs were recruited into a revalidation
study which aimed to explore the value of a prescribed portfolio
of feedback information about the doctor's individual practice
and information from the environment in which the doctor worked
(i.e. the GP practice).
- The prescribed portfolio contained both personal
and practice based feedback information. Personal feedback information
was provided from Multi-Source Feedback (MSF), Patient Survey
Questionnaire (PSQ), analysis of written complaints and a self
assessed open book knowledge test (RCGP Scotland PEP).
- Practice feedback information was provided from
QOF plus data and data on 12 potentially dangerous co-prescriptions.
- In order to assess whether the prescribed feedback
information covered the four GMC domains and 12 attributes, the
pilot team carried out a mapping exercise using feedback formats
which were mapped to the four domains and 12 attributes.
- At the start of the project participants were
asked to map the feedback formats based on how they thought they
would map to the GMC framework. As most would have had no previous
expertise of using these feedback formats, this was a measure
of their perceptions.
- At completion of the study participants were
asked to complete the mapping exercise a second time - on this
occasion their responses would be based on their experience
of the feedback formats (which involved receiving the
feedback, reflecting on the feedback and using the feedback at
their appraisal discussion).
Key findings:
- A high level of agreement by participants over
how the feedback formats mapped to the GMC framework.
- MSF as a feedback format was thought most likely
to test most of the GMC framework.
- Following experience of using the feedback formats
- the only significant changes from their initial perceptions
were that knowledge testing and patient surveys tested more of
the GMC framework than they had though using their perceptions
alone.
- The open book knowledge test was valued by participants.
- The open book knowledge test seems to act as
a catalyst for further reading and learning.
- MSF and PSQ feedback was particularly valued
if it included comments about the doctor.
- Provision of the 12 potentially dangerous co-prescriptions
was valued by most participants and this data was used as a source
of further exploration into the practice prescribing.
CONCLUSIONS/MAIN
RECOMMENDATIONS:
- The feedback tools used demonstrated that MSF,
PSQ and open book knowledge testing were perceived by participants
to map best to the GMC revalidation framework. The open book knowledge
test was valued and can be a catalyst to promote further learning.
PRESCRIBING INDICATORS
Objectives and methodology:
- To develop and test a set of indicators of prescribing
and medicines management that could be used for the purposes of
quality improvement in General Practice and feed into Revalidation
processes.
- A list of potential prescribing safety indicators
were identified through a literary search and a series of consensus
panel meetings.
- The indicators which were deemed appropriate
were tested to see if they could be turned into computer queries.
- Those which could be turned into computer queries
were tested on two types of clinical system
Key findings:
- The process demonstrated that it was possible
to develop a mechanism for data extraction, indicator encoding
and data assessment based on those indicators. It also showed
that there is inter-practice variation in prescribing.
CONCLUSIONS/MAIN
RECOMMENDATIONS
- Electronic prescribing currently only exists
in general practice and it is the combination of that and the
clinical record which made this project possible. If electronic
records (clinical and prescribing) develop in other sites, such
as hospitals, there may be scope for such information gathering
for revalidation by other disciplines.
- Individual prescribing numbers should be introduced
for GPs - this would be essential to enable the use of prescribing
indicators as supporting information for revalidation.
- Any such data generated from prescribing indicators
would need to be interpreted in an appropriate way.
34 Guide to the Revalidation of General Practitioners
- Version 3 (RCGP, January 2010:
http://www.rcgp.org.uk/PDF/PDS_Guide_to_Revalidation_for_GPs.pdf). Back
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