Revalidation (= Relicensing + Recertification)

Will it really start on 1/4/12? For more than the last 10 years revalidation has always been 2 years away. The current pilots have been extended to 2012 so it might start in 2012 but it is expected that different areas of the country will progress at different speeds depending on how well prepared they are to cope with it– there will be no big bang for all GPs!

Why are we doing this? The history is detailed below. There seems to some drifting in its perceived purpose and we are told ‘it’s not to detect the bad doctors, it’s a good thing and that everything will be better afterwards!’

How will it be resourced? RCGP have asked the Dept of Health and still waiting for a response. The current financial crisis may stall it further.

What will you need to do? It’s still uncertain. The GMC is responsible for revalidation but the RCGP is working in partnership. The RCGP’s Guide to the revalidation of GPs is an evolving document. Each new version sets out the plans for the process for revalidation of GPs. Some of the details about the process remain vague, particularly how the local responsible officer, RCGP external assessor and a lay assessor will assess your evidence for revalidation. The GMC should approve the proposals the RCGP submitted in 2010/11.

What if you are currently on the GP performers list but don’t actually work doing sessions in general practice? You will have to retire from the GP register and just work as a licensed doctor. If you want to work as a GP in the future you will have to undergo a re-entry process organized and funded by the deanery to get back on the performers lists and the GP register.

New versions of the RCGP guidance will be posted as they evolve at www.rcgp.org.uk/revalidation/revalidation_guide.aspx

• The revalidation cycle is over 5 years
• The standard portfolio described here assumes you are an NHS GP and it will be based on an enhanced NHS annual appraisal process organized by the RCGP under approval from the GMC, supported by PCTs. There is extra guidance for GPs who are not ‘standard’ NHS GPs
• You need to collect the evidence listed below in your revalidation portfolio (an eportfolio). You will be expected to report these according to a set standard in the eportfolio. The official revalidation eportfolio does not exist yet. In the meantime use the NHS on line appraisal toolkit and hope it will be compatible.
• Learning Credits. One hour usually equals one credit, but if it has impact on patient care then may claim 2 credits. You need to record your learning activities. The more you record the more credits you can accumulate. Your appraiser will confirm (or challenge) your self assessment of credits each year. You need 250 learning credits in the 5 year cycle. This may be changed to just counting hours (i.e. you will need to document 50 hours of education each year)
• Multisource feedbacks MSF of observable behaviour. This is usually best for relationships with patients and working with colleagues rather than clinical care or maintaining good medical practice. You need to complete 2 MSFs in the 5 year cycle. At present only the GMC’s MSF tool meets the RCGP requirements but its still a very blunt screening tool rather than a diagnostic tool. Usually you need about 8-12 peers, and 20-25 patients to complete feedback.
• Patient Surveys. You will need to complete 2 patient surveys (of your patients as they come through your door) in the 5 year cycle. The surveys must seek the views of patients who actually consult you. In due course the RCGP will recommend appropriate surveys.
• Significant Event audits SEA. A minimum of documented five in five years.
• Clinical Audits. You have to report 2 full audit cycles in significant clinical areas (ie one cycle is an initial audit, change implemented, reaudit). There will be more guidance on audits later.
• Probity and Health. You will have to verify a standard statement in the e-portfolio including having medical indemnity insurance, being registered in a practice where you don’t work, and appropriate immunization status
• Additional evidence will be needed for extended practice for activities like teaching, training, research, appraisals, OOH work, GPwSI,
• Personal development plan PDP. Your annual PDP follows on from your appraisal and the PDP goals must be SMART (ie Specific, Measurable, Achievable, Relevant, Time bounded). Success and any failures in your PDP will be important in the revalidation process.
• At your annual appraisal you will need to demonstrate that you have reflected and acted on the results of learning, MSF, surveys etc
• Any formal complaints (ie one that has activated the practice’s complaints procedures) must be reported
• If your appraiser is unhappy with the quality of your appraisal portfolio it will be referred to the RCGPs national adjudication panel where consistent national standards can be applied.
• If there is any unresolved cause for concern relating to poor performance your revalidation portfolio cannot be considered by the RCGP. The GMC will have direct responsibility for considering revalidation
• If you are a not a standard GP check the RCGP website for advice. The minimum standards for considering a revalidation portfolio will be that, there was active participation in approved appraisal with a PDP agreed, and review of previous PDPs in at least 3 of the 5 years revalidation cycle, 50 learning credits in at least 3 of the 5 years, working the equivalent of 1 day/week for at least 2 years in the 5 years.

The first GPs to be revalidated will submit evidence in 2012/13 and won’t have a 5 year revalidation portfolio. There will be transitional arrangements for submitting your collected evidence in the first four years.

What is the background to revalidation?

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/Public... set 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, 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.

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 examining 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

Why is the RCGP determining the process?

The GMC delegated the process of recertification the royal colleges. 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 do not need to be a member of the RCGP to participate in recertification.

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.

Will these proposals for revalidation assure quality? Do we need annual maintenance of GP competence?

The UK’s plan for revalidation has many problems to solve before we will have an effective system of quality assurance. We can expect the plans to change as the problems are recognized and 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. If the proposed revalidation process does not assure quality then this may 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 GP contract Quality outcome frameworks points scheme.

Cognitive expertise is the only component missing and eventually may be a feature in the recertification process. The only debate is what sort of examination will this be? Should we all get ready to take the knowledge test MRCGP examination every 5 years? 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