FIPO Revalidation Conference Summary

Royal College of Physicians - London - 24th November 2009

Introduction

The GMC first mooted the idea of periodic revalidation for doctors in 1998 following the investigation into the provision of cardiac surgery in Bristol. The original concept was based on a portfolio of evidence demonstrating fitness to practise. The portfolio would include annual appraisals based on Good Medical Practice as well as evidence of CPD during the five year period.

From 1998 to date progress has been slow due to the criticisms made of the GMC proposals during the Shipman Inquiry. Giving evidence to the Inquiry Sir Graeme Catto, the then President of the GMC, referred to revalidation as an MOT test for doctors. Dame Janet Smith chairing the Inquiry said that the plans did not test doctors, and that a more rigorous system utilising available data on performance was required.

The fifth report of the Shipman Inquiry made over 100 recommendations for change at the GMC and in response the Government tasked the Chief Medical Officer, Sir Liam Donaldson with reviewing the structure, role and function of the GMC. His report “Good Doctors Safer Patients” was published in July 2006, and recommended that revalidation should comprise two elements: recertification and relicensure.

The Government’s response to the CMO’s report, “Trust, Assurance and Safety” was published in February 2007, and set out a programme of reform to the United Kingdom’s system for the regulation of health professionals.

FIPO conference on Revalidation brought together representatives of the major bodies involved in implementing revalidation. Over 100 delegates from a broad range of backgrounds but in particular doctors practising in the independent sector attended. All were aware of the basic proposals but seeking clarification on the practicalities of strengthened medical appraisal, revalidation, and the roles of responsible officers, royal colleges and specialist associations

The conference clarified some issues but left other questions unanswered.

Professor Peter Rubin

Professor Rubin the newly appointed President of the General Medical Council confirmed that revalidation was a GMC initiative, and was from the Council’s perspective a major exercise with as many as 218,000 doctors having a licence to practise and therefore submitting themselves for revalidation in due course.

A key point is that revalidation is to be based on a doctor’s current practice.

To make the system workable revalidation should build on local systems, many of which are already in place. For many the process will simply draw together existing systems of appraisal and multisource feedback, for these doctors revalidation will be just a small step from what they do already, but for others the systems are no where near so well developed, requiring a quantum leap before revalidation can be introduced.

The GMC is determined to avoid another MTAS and so revalidation will not start until the necessary systems are in place and so will be phased in from 2011, and the systems will be tested in pilots before going live.

From October 2010 responsible officers will be in post. They will have a range of responsibilities, but in general terms will be accountable to the GMC for overseeing robust governance systems including strengthened medical appraisal, and making a recommendation to the GMC on whether or not individual doctors should be revalidated.

For revalidation to meet its objectives: appraisal must be effective and credible’ multisource feedback must provide constructive insights into all aspects of professional performance, and where there are problems there must be early intervention, and where possible remediation – problems cannot be left to fester until the end of the five year cycle, as by then patients will have been exposed to potential harm and the underlying problems will be more, not less difficult to resolve.

Further information on revalidation is available at http://www.gmcuk.org/about/reform/Revalidation.asp

Dr Keith Judkins - NHS Revalidation Support Team

The Revalidation Support Team (RST) is a Department of Health-funded body, which exists to support the implementation of Revalidation. Its main aims are to:

Dr Judkins described appraisal as a normative process combining both formative and summative elements, complying with clear and consistent quality standards and based on supporting information or evidence. Appraisal was not designed to detect problems – the hope would be that these would be spotted as they arose rather than waiting for the doctor’s appraisal. However, appraisal did act as a backstop for identifying performance issues.

To be effective appraisal must follow a common framework, with the necessary elements of assessment. Supporting information must be also be available.

Some doctors may have more than one appraisal, for example where a doctor has both private and NHS practises it may nit be practical for there to be one all practice appraisal. In these circumstances the appraisal should be linked with one feeding into the other so that together they form a complete of the doctor’s practice.

The appraisers themselves will require training and may in due course be subject to performance review and perhaps in time require accreditation in this aspect of their practice.

Dr Judkin’s key messages were that appraisal has to be a strong process supportive of doctors and to get it right would be path finding piloting would be undertaken. The end result must be rigorous and consistent.

Revalidation Support Team
http://www.revalidationsupport.nhs.uk/

Dr Judith Hulf – Academy of Royal Colleges

Dr Judith Hulf said that it was important to remember that:
The vast majority of doctors are practicing medicine to a high standard
The purpose of revalidation and medical regulation is not solely to identify doctors whose performance is not of a sufficiently high standard
Revalidation should be a process that will support continuous quality improvement in standards and practice for both doctors and patients alike

The recertification element of revalidation recognises the doctor’s ability to act as a ‘specialist’ or for those on the GP Register as a GP. The process also needs to support doctors who are not on Specialist/GP register and not in training. It is based on positive affirmation by appropriate College/Faculty to the GMC

The Colleges will set the standards for recertification and design methods of evaluation, and the GMC sign off the standards and methods of evaluation

There are three key areas in which the Colleges are going to contribute:

The appraisal process is an opportunity for doctors to demonstrate that they remain fit to practise – and that this is an opportunity that the profession should seize.

Like the GMC the Academy of Royal Colleges are determined to get this right and like the GMC will be embarking on a series of pilots – as yet there is no finished product at this stage.

Dr Ian Starke - Royal College of Physicians and Professor Anthony Narula - Royal College of Surgeons

The primary objective of specialist recertification should be to ensure continuing high standards of professional practice and the continuing improvement of those standards over time.

Using checklists as set out below, doctors will be able to organise their supporting information and so smooth the process.

view the checklist

Strengthened medical appraisal should culminate in a Personal Development Plan (PDP) against which progress can be assessed at the next appraisal

The next steps in this process are:

Mr Michael Wright Department of Health

Mr Wright began by saying that the vast majority of practicing doctors, and particularly those whose work affects the safety of patients, will relate to a responsible officer (and only one). For those doctors who do not relate to a responsible officer it is as yet unclear who will make a recommendation to the GMC on continuing fitness to practise and revalidation – the Department of Health will make a further announcement in due course.

The responsible officer (RO) is to be a licensed medical professional and it is the doctor’s personal responsibility to ensure that they know who their responsible officer is. Doctors cannot choose their RO. The DH have produced a flowchart to demonstrate how doctors should identify their RO. Prior to the conference many had assumed that the flow chart was hierarchal. However Mr Wright said that it is a system you can follow but if the preponderance of your practice is not in the NHS but in a private sector hospital the scheme allows you to identify an RO in the independent hospital, which caused considerable debate at the conference.

So it follows that if you are adept at working out where you conduct your practice you can manipulate a choice of RO even though the rules will say that you cannot.

ROs will be responsible for setting up local systems of clinical governance, in particular those relating to

Further information on responsible officers including draft guidance and regulations is available at;
http://www.dh.gov.uk/en/Consultations/Liveconsultations/DH_104587

Mr Stephen Collier – BMI Hospital Group and Mr Gareth Jones – Dr Foster

Stephen Collier described the Hellenic project (named after the centre in which it was developed). It has a great deal of potential benefit providing consultants with the ability to select certain data at the episode (rather than population) level; access patient-specific, procedure-specific, or consultant-specific reports; access common reporting indicators and common data definitions being developed with likely future options for comparisons with peers.

One question that always arises with data is who owns it? It “belongs” to the originator and must be held subject to: the provisions of the Data Protection Act 1998; the law on confidentiality; agreed releases (practising privileges) and disclosure in the public interest. In practice this means that MACs and the GMC will under certain circumstances have access to data.

Over the next five years Stephen Collier predicted that information, at the practitioner level will be available on demand, with comparative data being the norm. Clinical data will become part of management information, which itself carries a number of implications.

Gareth Jones described the advantages and disadvantages of using HES data and explored the potential for data collation into e-portfolios. In discussion there was general agreement that the right data sets must be collected and that data must be entered accurately if it were to be sufficiently robust to be fit for use.

Baroness Young of Scone - Care Quality Commission

The Care Quality Commission is the independent regulator of health and social care in England. Its aim is to make sure better care is provided for everyone, in hospital, in care homes, in their own homes, or elsewhere. CQC regulate health and adult social care services, provided by the NHS, local authorities, private companies and voluntary organisations, and protect the rights of people detained under the Mental Health Act.

Baroness Young stressed that she wants to avoid unnecessary duplication of effort, and over burdensome regulation.

In general the work of the CQC will not overlap with that of the GMC in relation to revalidation. However, there are some interfaces. In conducting its reviews of health providers the CQC will wish to see that all clinical governance activity is undertaken by individuals with the right skill and experience to do the job properly; that all healthcare professionals are registered with the appropriate regulator, and that suitable arrangements are in place to support this requirement.

The CQC will not regulate individual doctors or other health professionals but will work to develop revalidation and look to extend its use to other professional groups.

Interactive sessions Dr Gerard Panting and Mr Geoffrey Glazer – FIPO

Two interactive sessions with distinguished panels examined a series of potential practical problems and how they might be tackled once responsible officers are in place

Conclusion

This conference revealed the degree of concentrated effort made by so many individuals from a range of professional bodies and government departments to develop revalidation into a meaningful and constructive process. However, the conference also revealed how much of this work remains in progress; the question marks that remain over the role of the responsible officer, and how much more there is yet to do in terms of piloting and refinement before revalidation can be confidently implemented.

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