Revalidation = Relicensing + Recertification?

The GMC planned to introduce the revalidation of a doctor's licence to practice every five years in April 2005. Following criticisms of the quality of the GMC's revalidation scheme in Dame Janet Smith's 5th report on the Shipman case, the government decided to review the GMC's proposed new system of revalidation. The review included the role of NHS appraisal and covered the GMC's arrangements for examining a doctor's fitness to practise within the revalidation process.

The Chief Medical Officer's report 'Good doctors, safer patients’ (July 2006) suggested major changes in the governance of doctors in the future.

The subsequent White Paper, Trust, Assurance and Safety - The Regulation of Health Professionals in the 21st Century (February 2007), reaffirms the Government's commitment to the introduction of a system of revalidation.

The Report of the Chief Medical Officer for England’s Working Group Medical Revalidation – Principles and Next Steps (July 2008) http://www.dh.gov.uk/en/Publicati... sets out the principles and next steps for implementing revalidation agreed between the GMC, the Department of Health, and the Academy of Medical Royal Colleges, the three key bodies with responsibility for revalidation.

Revalidation has three elements:

• to confirm that licensed doctors practise in accordance with the GMC’s generic standards (relicensure);
• for doctors on the specialist register and GP register, to confirm that they meet the standards appropriate for their specialty (recertification); and
• to identify for further investigation, and remediation, poor practice where local systems are not robust enough to do this or do not exist.

It also sets out the five main areas of challenge for the implementation of revalidation:

• Logistical - revalidation is expected to cover around 150,000 doctors
• Methodological - designing and implementing effective systems
• Connections - integrating revalidation with other quality and safety systems
• Information - working towards increasingly meaningful information on which to assess practice
• Culture - to create a climate and set of attitudes whereby revalidation is primarily a dynamic to support doctors in improving the quality of their practice.

Relicensing will rely primarily on information derived from a revised and strengthened form of annual appraisal (n-appraisal), which will usually include, amongst other things, evidence from periodic multi-source feedback from patients, peers and colleagues. There will be a standardised module of appraisal, agreed by the GMC included in all appraisal systems, but other aspects of appraisal will be a matter for local employers.

At a local level, the ‘Responsible Officer’ in the PCT will ensure that appraisal is carried out to a good standard; work with doctors to support them in addressing any shortfalls; ensure any concerns or complaints have been addressed; and collate this information to support a recommendation on the revalidation of individual doctors to the GMC.

Revalidation will be introduced following a series of pilot exercises to develop the best models for its component elements, and proposals will be adapted in the light of learning from evaluation of those pilots. A joint GMC and Academy of Medical Royal Colleges group has been established to:

• support the development of revalidation processes; and
• consider the practical issues about how the whole process will knit together in a coherent, unbureaucratic and proportionate manner.

As a first step towards the introduction of revalidation, the GMC will issue licences to all doctors who require one during 2009. All doctors who hold a licence will be required to participate in revalidation. Doctors will need to renew their licence to practise every five years. Doctors on the GMC GP register will need to demonstrate that they continue to meet the standards that apply to their medical specialty to achieve recertification.

Relicensure will start in those areas where local systems of appraisal and clinical governance are well developed and fit for purpose. The new appraisal arrangements will roll out beginning in the second half of 2009 and be completed by the end of 2010.

Recertification standards and methods will be developed over a period of 12 to 18 months, but different specialties will be ready at different times and some will require more careful piloting. The early adopters of specialist recertification will participate in full revalidation piloting which combines relicensure and recertification in 2010.

Whilst these plans seem sensible the problems will be resourcing all the costs of revalidation, relicensing, and recertification, its speed of introduction and the validity of the testing used. Making the RCGP responsible for specialist recertification examinations might be a mistake, as the RCGP will have a conflict of interest coaching members for the exams and examing them. Although all the stakeholders are committed to revalidation it may have become too complicated to introduce universally and successfully in less than ten years.

Revalidation latest news from the GMC: http://www.gmc-uk.org

Recertification by the RCGP

Good medical practice for GPs a joint RCGP GPC document (July 2008) sets out the standard expected for recertification

http://www.rcgp.org.uk/PDF/GMP_web.pdf

You will not need to be a member of the RCGP to participate in recertification.

The RCGP is planning to run its managed CPD scheme to facilitate your recertification as a GP specialist.

A programme of work to help RCGP members prepare for revalidation is now underway. http://www.rcgp.org.uk/practising_as_a_gp/revalidation.aspx

It’s likely to include 4 modules

Essential General Practice. GPs will be notified of all the essential updates in the speciality every 6 months and use e learning modules to help them keep up to date

Managed CPD. GPs will have to complete 50 hours of approved CPD each year. Its likely to be 50 hours each year because 'thats what everyone else does'

Modern Professional Practice ie - some assessment of your performance

Professional standing - the basic GMC relicensing process

There seems to be a major conflict of interest in the notion that the RCGP should both set the standards for recertification of GPs and be the craft society that helps its members pass its recertification tests seems flawed, but likely to be changed as soon as everyone realises that this compromises the integrity of the recertification test.

What else could happen? The annual maintenance of GP competence

The UK’s plan for revalidation has many problems to solve before we have an effective system of quality assurance. We can expect the plans to change as the problems are tackled. How might these plans change? The appraisal and revalidation assessments follow the experience of other countries in increasing the regulation of a doctor's performance. What’s next? The US boards of medical specialities have years of experience recertifying doctors competence, and they are shifting from the episodic recertifying examination of doctors competence every 5 -10 years to a continuous maintenance of competence? (MOC) cycle that assures a doctors professional standing, lifelong learning and self-assessment, cognitive expertise and performance in practice throughout the term of the maintenance of competence. The specialist or craft societies (like the RCGP) are not involved in the recertification process and help members pass the exams. This is likely to be our future.

MOC has four components:

Professional standing is a check that doctors licence to practice is not compromised, and may need references from colleagues or evidence of institutional appointments.

Life long learning and self assessment. Most schemes require continuing medical education hours ranging from 10-50 hours each year. Self assessment is by examinations, tests and educational modules.

Performance in practice. This is a challenging assessment of doctors performance. Doctors are assessed for how closely their practice compares with accepted standards of care. This includes assessing confidential patient satisfaction measures, use of evidence based or best guidelines, review of operative records or logs of procedures, office record reviews or audits, practice performance improvement modules, specific board feedback, case based oral examinations, linkage to practice data or outcomes though guideline measures and national benchmarks. The goal is to use the tools and techniques that are credible, valid, reliable, practical and feasible and improve doctors performances.

Cognitive Expertise. This required passing an examination within the course of the MOC cycle.

Does all this sound familiar? Most of the MOC components have already arrived into UK general practice, and only await the full assembly by a competent authority.

Professional standing is tested by Criminal Record Bureau checks, and the NHS appraisal. Life long learning and self assessment is included in the annual appraisal process and resultant personal learning plans. Performance in practice is very similar to the new GP contract Quality outcome frameworks points scheme.

Cognitive expertise is the only component missing and sooner or later will be a feature in the appraisal or recertification process. The only debate is what sort of examination will this be? Should we all get ready to take the MRCGP examination again? Is this the future of GP education?

If you have any suggestions about how we can improve this section email them to contact@bristolgpsolutions.org.uk