Revalidation of Doctors - Health Committee Contents


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). 
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