in September 2008
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It’s going to happen. It is going to directly affect you. Medical Revalidation - the Next Steps, published in July 2008 documents the whole change which is the biggest reform in medical regulation for over a hundred years.
The CMO and his group state that revalidation should not be burdensome for the medical profession but attempt to harness the tools and information clinicians use and collect in everyday working life. The Next Steps include a phased roll-out of the various elements of revalidation without a ‘big bang’ introduction. The timescales are however, much more meaningful and the Department of Health is setting aside significant funds for implementation.
The document highlights how the process will be local, with quality assurance by your Trust and the College. The GMC role will be final sign off, issuing Licences to Practice and for a very small minority of doctors, being involved when they are in difficulty i.e. Fitness to Practice. The major change from revalidation as described in early 2001, is that most of the scrutiny of this will be carried out locally near to your workplace. It also describes Responsible Officers (usually your Trust Medical Director) who will sign off a declaration recommending to the GMC that you are suitable for revalidation.
The changes that will be necessary in appraisal are highlighted and ways in which local clinical governance arrangements (relicensing) and scrutiny by College and Specialty Society (recertification) will be rolled out over the next two to three years, are outlined. While much of this applies principally to England, it is inconceivable that a similar approach will not be used throughout the four Nations.
Remember, the vast majority of geriatricians are easily expected to meet the criteria laid down; indeed physicians as a group are less commonly represented in the group of doctors who get into difficulty.
What is revalidation going to be?
Revalidation is a combination of two processes that lead to one result - revalidation or not.
Relicensing is about the maintenance of registration. It will be required to be recognised as a doctor with its associated privileges such as prescribing. It is the process for maintaining ‘primary’ registration every 5 years on the General Medical Register. It will apply to all doctors across the UK, once they have completed undergraduate training and will go on into retirement if doctors wish to remain on the register. It is a generic process based on Good Medical Practice and will be assessed by your local Trust with quality assurance by the GMC.
Recertification is the process that allows a doctor the ability to work as a specialist. This confirms that the doctor has been trained in a particular field and has been ‘positively affirmed’ by the appropriate Specialty and College.
The process of renewing the registration of doctors in the UK will now occur from 2010 – we will all be given Licences to Practice in 2009.. What is certain is that only by acting now can we be sure that, as individuals, we will successfully be revalidated in the future.
What should individual doctors do?
Reviewing your current activity may identify areas of strengths but also weakness that have to be addressed in this and in successive years.
Relicensing
We all undergo appraisal and this will be critical for relicensing. The documentation should include evidence to confirm that we are performing at a satisfactory level in all domains within the GMC Good Medical Practice. Recent work by the GMC outlines how the various components of appraisal will map onto this framework and the sort of evidence likely to be required.
Essentials to this process will be evidence of team work and “getting on” with one’s colleagues using ‘multi-source feedback’ (MSF) or 360 degree feedback and evidence of what patients think of us from patient satisfaction surveys. These will be specialty based and there are already many such tools used to assess physicians e.g. RCP(L) Appraisal Booklet series 2007. Both multi-source feedback and patient satisfaction surveys are likely to be processes that occur twice in any five year revalidation cycle for most of us. The GMC has validated such surveys/tools but it is likely that no one single method will be utilised – use what is available locally.
Recertification
Recertification is the five yearly process for maintaining ‘specialist’ registration. This will build on the relicensing evidence and will be more specific and individualised. This is because recertification identifies that this doctor is fit to practise medicine to a safe and high standard. For geriatricians this will be about showing that they are up to date, knowledgeable and safe to care for older patients with their attendant specialist problems. This process will require the BGS and thereby, the Royal Colleges of Physicians, to ‘positively affirm’ that an individual meets the standards expected of a geriatrician. This is a new role for all Colleges and one that will require a more structured approach by the BGS.
Recertification of work as an acute or general physician will also need to occur and it seems inevitable over time that doctors in specialist fields such as stroke will need separate recertification for this too.
Work has started on the approach to recertification for physicians and Dr Ian Starke, a consultant geriatrician, is leading the revalidation work at the Royal College of Physicians London. Indeed, the RCP London is at the forefront of work by the Academy of Royal Colleges and produces excellent and regular up-dates on what is happening in revalidation.
Collection of evidence
Junior doctors increasingly use e-portfolios to document competence and achievements in training and eventually all consultants will use an RCP approved e-portfolio. If you are a trainee, ensure your paper based portfolio is complete and of course this is currently scrutinised on an annual basis at the Regional Training Committee.
Most consultants currently use paper based systems for recording appraisal information and this will be their source of information for the relicensing process. However around 5000 consultants in the UK already use the on-line NHS Appraisal tool kit and I would recommend you look at it as an easy to use electronic way of recording and storing information.
At a minimum you should register and use the RCP on-line system for recording and reflecting on CPD activity as the College will have to confirm, for both relicensing and recertification, that CPD has been performed and has been effective. Another essential requirement will be that each appraisal has a documented outcome of a completed summary (Form 4) and a personal development plan (PDP).
Remember that both relicensing and revalidation are retrospective! The evidence that will be necessary to achieve both, will be that gathered over the previous five years of practice. It is still not clear how or when “the clock” of revalidation will start and how the first doctors will be selected – it is, however, certain that not everyone will wait to be looked at in 2015 for the first time. The logistics suggest a fifth of doctors will be reviewed every year in a rolling cycle. This may mean that those of us, in the potential first wave of revalidation after 2010, will have to have evidence dating back to 2005 available. Initially, standards are likely to be less stringent but a lack of appraisal documents will be unacceptable.
More controversially, Medical Revalidation – the Next Steps, talks about a suggestion of appraisal being graded (range of excellent, satisfactory and in need of improvement) and pilots of the feasibility of this occurring in the next year or two. The linkage with clinical excellence awards will be inevitably re-examined.
As an individual, review the ‘core topics’ section in the BGS CPD cycle and ensure that all clinical skills elements that are relevant to you are covered as part of a rolling programme of revision. Review the clinical skills appropriate to your job plan and any specialist practice you provide, and see what educational events – RCP or BGS courses, local events or e-learning materials – may be necessary to top these up.
Ensure that the ‘responsible officer’ (medical director or designated deputy) within your Trust actually has copies of your appraisals, or that they have acknowledged that they have taken place. This is usually part of the process of applying for a clinical excellence award and is required for pay progression of the 2003 Consultant contract.
Diagrammatic scheme of how revalidation will work :
What are the implications for the BGS?
The BGS will have to work with the RCP to reconsider standards for recertification. Our key aim will be to keep these simple and build on things geriatricians do in everyday practice. This is a key area of work for the BGS Policy committee and help and additional input gratefully will be welcome. Members of the Policy Committee will be attending workshops on revalidation at RCP(L).
Early suggestions for Specialty Standards :
- CPD diary appropriate to specialty field and core topics in Geriatric Medicine covered.
- Tests of knowledge such as KBA
- Specialty specific audits e.g. use of comprehensive geriatric assessment. beefore care home placement
- Peer review of MDT working
- Specialty driven patient/carer satisfaction survey questionnaires
The other major impact of revalidation will be how the BGS and thereby the College input into the quality assurance of appraisal to ensure recommendation for recertification occur. This will occur at local level and at present the RCP Revalidation Team and College are considering how this can be best achieved. What will be needed is input from the RCP/BGS at your local Trust to enable a recommendation for revalidation to be made to the GMC. At a minimum we as a Society will have to revisit Regional infrastructure and support to enable this aspect of the process to occur as painlessly as possible.
In summary
We will all undergo relicensing and recertification (or retire) within the next seven years. We have to act now to make this a trouble-free and satisfactory process. Keep watching the BGS website and newsletter for updates on revalidation as they will be posted whenever significant changes occur.
Peter Belfield
Chairman, BGS Policy Committee
Useful links:
BGS Newsletter, Oct 2008
Issue 18 ISSN 1748-6343 18