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1 File: Revalidation 2 primary care FINAL.mp3 Duration: 0:24:15 Date: 24/12/2012 Typist: AC6 START AUDIO Male: You re listening to an audio module from BMJ Learning. Hello, I m Dr. Charles Hall, a clinical editor at BMJ learning. In this module we discuss what revalidation will mean for clinicians working in primary care. Who better to talk to us than Professor Nigel Sparrow, revalidation lead for the Royal College of General Practitioners, a practicing GP in Nottingham and a GP appraiser? Many thanks for joining us Nigel. Thank you Charles. Okay so moving straight in. So who has to do it and when? All doctors will have to be revalidated on a five year cycle. The Secretary of State announced revalidation earlier this year and it 1

2 started on the 3 rd of December. So initially all doctors who are responsible officers and medical leaders will be revalidated in what is called Year Zero, which starts now and extends until the end of March From the 1 st of April 2013, other doctors will be revalidated on a yearly basis - in the first three years. So 20% of doctors will be revalidated in the first year, 40% the second year and 40% the third year. So that by 2016 all doctors should have had their first cycle of revalidation. So how will it work? Revalidation will be based on appraisal. So all doctors have been used to getting annual appraisals each year, and from now on they will be appraisals which count for revalidation. Appraisals first of all are done by qualified appraisers who have a discussion with a doctor based on the headings of good medical practice. Appraisal from now will be based on all the work that you do as a doctor. Not just the clinical aspects; whatever you happen to do where you require your medical qualification. Those appraisals will then feed into your revalidation portfolio. The responsible officer will make a recommendation to the GMC as to whether the doctor should be revalidated. The GMC make the decision about revalidation. All doctors will have a responsible officer. A responsible officer is a doctor who usually is the medical director from what used to be the primary care trusts, and will now be based in the local area teams. There will be 27 local area teams in England and each responsible officer is assigned to a designated body. Those designated bodies 2

3 in England are local area teams and they recommend the revalidation decision to the GMC. Okay. What exactly will be required for GPs? GPs will have to demonstrate that they re up to date and fit to practice, the same as any other doctor. One of the tasks that we ve been doing is working with the Academy of Medical Royal Colleges and the BMA to ensure that GPs are treated fairly and equally and that all doctors provide the same sort of supporting information. So there are six types of supporting information: there s your continued professional development, there s evidence of providing some information about quality improvement activity, significant events, colleague feedback, patient feedback, and any review of complaints or compliments. So they are the six headings. First of all in a portfolio you describe what you do. So your personal details, the type of work that you do, some record of previous appraisals and personal development plans. Then you demonstrate how you re keeping up to date in the work that you do. So that will include again the scope of practice that you do, linked into the headings of good medical practice, and that should include your CPD where you demonstrate you re keeping up to date with a minimum of 50 credits per year, 250 over a five year revalidation cycle. Then there s the area of reviewing your practice, and that s where you bring in your quality improvement activity. That is clinical audit, significant event analyses and any other demonstration of the 3

4 quality of care that you provide. We ve agreed through the Academy of Medical Royal Colleges and with the GMC that one two cycle audit is required in a revalidation cycle, two significant events per year. Our significant events vary in the definition compared to what the General Medical Council use. Significant events which we ve been used to in general practice are case reviews which can include events that have gone well and events that we could do better. All significant events require you to demonstrate that you ve had some learning that s improved your practice. The GMC regards significant events are serious untoward incidents and that is quite a narrow definition. So two significant events in the general practice sense are those where you ve learnt something from a case and you can demonstrate that. Then finally there s the feedback on your practice which is the colleague and patient feedback. How will the process differ from what the current appraisal system consists of? Doctors that have had a good appraisal will find very little difference from now. The differences perhaps are that we ve been used to providing evidence of our CPD and often some patient feedback. Not all doctors have been providing colleague feedback in their appraisals, and that may be different. Although many doctors including myself have been used to getting some colleague feedback on a regular basis and that will make very little difference in terms of the way that the appraisals are conducted. 4

5 We want to make sure that appraisal maintains that supportive and developmental aspect. We don t want it just to turn into a tick box exercise to say whether somebody is fit to be licensed. It s about continued professional development. It s that opportunity which a doctor has on a yearly basis to discuss their professional development with a colleague. We don t want to lose that formative and developmental aspect of appraisal. So in terms of the actual appraisal, what else has changed? There s been quite a change in the way that appraisal will be conducted in terms of the forms people fill in in their pre-appraisal forms. We used to fill in form three covering the seven headings of good medical practice. That has now changed to the four GMC domains, and those four GMC domains are knowledge, skills and performance, safety and quality, communication, partnership and teamwork, and maintaining trust. So in the knowledge skills and performance, that s the section where you complete your reflections on your CPD and how you re keeping up to date. Safety and quality is something about your health declaration, any complaints reviews, audit significant event analysis. Communication, partnership and teamwork includes things like your reflection on your consultations, colleague feedback, patient feedback. The maintaining trust section is about probity, showing respect for patients and treating patients and colleagues fairly and without any discrimination. So again you can quote your patient feedback, colleague feedback, some equality and diversity training and a probity declaration. 5

6 Do clinical commissioning groups have a role to play here? The NHS is being restructured, so we used to have PCTs. They formed clusters and now from April we will have clinical commissioning groups and the National Commissioning Board. The clinical commissioning group will commission services for general practice. It won t have a role in appraisal and revalidation. That role will be taken on my the local area teams which in effect were the PCT clusters, and the medical directors of those clusters have now generally moved into the local area teams. They will be responsible for GP performance, maintaining the performers list and conducting and quality assuring appraisal. So please could you tell us about colleague feedback; is there a standardised colleague feedback tool? The GMC have set standards for what a colleague feedback should look like and there are various tools that are out there now. In the college, the RCGP have accredited five tools for multisource feedback. All doctors will have to nominate colleagues to have to give feedback on their performance and when you do that feedback, it s important to cover all the types of work that you do. So when I did mine fairly recently I included not only people I work with in the practice, but trainees who I supervise and any students 6

7 I ve been involved with. Colleagues that I refer to in the hospital, so some consultants that I referred to, and then there s people I work with in other areas, for example within the RCGP. You d need to nominate about 20 colleagues to get a valid feedback, and each of the tools require a different number of colleagues to make it valid, based on the type of tool that they re using. When you ve done your questionnaires, they have to be analysed by an independent party. Now, the GMC questionnaire for example is incorporated into the [College E 0:10:11] portfolio and you can nominate your colleagues through that process and your colleagues feedback on that online. The e-portfolio will do the analysis for you at no cost and then you get a report based on your MSF and comparing that with a peer average and obviously the comments that go with that as well. That allows you to reflect on the results and bring that feedback to your appraisal for a discussion. Moving on to patient surveys; how will these be used? It s very similar to the validation of multisource feedback forms. Patient surveys, there s many of them about. We ve been used to doing patient surveys in our practices for many years now. The patient surveys that have been approved for revalidation relate to the individual doctor and again the GMC have set down some standards as to what a patient survey should look like. The RCGP have validated five questionnaires which can be used for patients in general practice. That includes the GMC questionnaire, there s others such as [CFEP, SHEFPAT 0:11:29] and 360 which is 7

8 available on our revalidation guide and there are links to those questionnaires to choose which ones you want to do. These have to be conducted within your practice so that on consecutive patients you arrange to have survey forms distributed by your reception staff as patients come in. You need about questionnaires to be completed, dependent on the type of questionnaire that you re doing. This has to be carried out independently of the doctor, so the receptionist will hand it out, will collect the forms from the patient when they leave and that data will be inputted by somebody other than the doctor so that the analysis can be done. Again, similar to the multisource feedback, the RCGP e-portfolio contains the GMC questionnaire and a nominated person in the practice can enter that questionnaire details onto the e-portfolio. The portfolio will analyse those results, compare you to the peer average and give you feedback on the comments that are there, again for you to reflect upon and bring that reflection to your appraisal discussion. So on the subject of reflection, in terms of learning and revalidation, how can doctors do this particularly with increasing pressures on doctors time? We all keep up to date, we have been doing CPD for many years and it s part of our normal practice. For the purposes of revalidation, we ve adopted the credit system. All colleges have done so and every college has gone down the system of 50 credits per year, 250 over a revalidation cycle, and one credit equals one hour of learning 8

9 accompanied by a reflective note about that learning, so you can demonstrate what you ve learnt. It s not about simply participation in learning and producing certificates, you ve got to show that you ve actually learnt something from your CPD. The unique feature about the credit system in general practice is that we recognise implementation of learning in practice as worthy of credits. That s different to the other colleges and we piloted this system some years ago and found very favourable results, that GPs like to do that and it shows the value of learning. So if you ve taken part in a CPD event and you ve got your reflections there and then you take that learning and demonstrate that you ve used it in practice, you can double the credits. Let s talk a bit about locums and sessional GPs; what are the issues here in terms of revalidation? We ve worked very hard to make sure that revalidation is no easier or more difficult for doctors working in different circumstances. Locums and sessional GPs have been considered very carefully in all the work that we ve been doing on revalidation. We ve piloted models of revalidation with sessional GPs, out of hours GPs and doctors working for example in secure environments. Each recording CPD, for example, is just as easy to do whether you re a locum working in lots of different practices to somebody working in one single practice. The challenges happen with doing clinical audits, significant event analyses and getting some patient and colleague feedback. 9

10 Now if we think of that as a locum can do, it s important that locums and sessional doctors aren t isolated, that they link in with peer groups. So we want to avoid professional isolation. The same applies for doctors who are in single handed practice. It is important that doctors work with colleagues and teams. So in a peer group you can do discussions about significant event analysis. You can carry out audit of your own clinical care, whether you re working in one practice or working in multiple practices. Carrying out patient feedback requires the cooperation of the practice where you re working in. It s a responsibility of that practice who are employing locums to ensure that they can collect adequate patient feedback and that the practice is prepared to help that doctor conduct a multisource feedback as well, of colleagues. We all have colleagues so it shouldn t be that difficult to collect colleagues, not just in the practices that you re working in but also people who you work with in different circumstances. So again, doctors who you refer to in hospital and colleagues working in other situations where you have contact with them and they can see what sort of care you re providing. Those doctors that see patients will have to do a minimum of 200 clinical sessions in a five year revalidation cycle. So that equates to about one session a week. So that applies to those doctors who perhaps are in an academic role and in management roles, but are actually seeing patients as well. So remember that you are revalidated for the work that you do if you want to be revalidated as a clinical general practitioner, then you have to do a minimum of 200 clinical sessions. If you don t see patients at all, then you will be revalidated for being a medical manager for example or being an academic GP but without seeing patients. You will still remain on 10

11 the GP register but you won t be revalidated for seeing patients on a clinical basis. Are there any particular things that a practice has to consider when they employ locums or part time doctors? Yes, practices need to recognise their responsibilities as employers for both salaried doctors and locums, recognising that those doctors have to fulfil the requirements for revalidation. They need to make sure that they are open for allowing the doctor to carry out patient surveys and multisource feedback, and perhaps that they can come into meetings to discuss significant events and audits if necessary. Is it possible to defer or delay revalidation? What about those people having a career break, for example if they re on maternity leave, doing a Masters or a PhD or travelling or working abroad? How will revalidation affect them? Responsible officers will be allocating dates for doctors to have their revalidation. This should be a negotiation, because if a doctor is going through particular circumstances whereby they re not doing clinical practice at that time, whether it s a career break or on maternity leave, then they need to have that discussion with the responsible officer so it s fixed at a time that s appropriate for them, within the timescales that are allowed. You re allowed to have up to two years away from clinical practice without interfering with the revalidation cycle. 11

12 If you re absent from clinical practice for more than two years, then you would need to go onto a form of return scheme to return into practice. But if you re away from practice for up to two years, then you should be able to maintain a revalidation portfolio and you are allowed to have up two years absence from practice. But you should be able to demonstrate during that time that you re keeping up to date with all aspects of the work that you do. So single handed GPs and those in isolated or rural areas, is there specific advice you have for them? Yes, we need to take a pragmatic approach to revalidation to make sure it works for wherever you happen to be. Doctors working in very isolated communities do have challenges in gaining multisource feedback from 20 colleagues for example. But we need to ensure that doctors link in to as many professional groups as they can to avoid the professional isolation, because that s good for GPs, it s good for patients. But we need to ensure that we aren t making it too difficult for doctors in very isolated communities. So if they can produce a portfolio of practice which demonstrates that they are keeping up to date, they are getting as much colleague and patient feedback as they can, then I think that should be appropriate for an appraisal. So is there anything specific to bear in mind for trainees? 12

13 Yes, trainees will have their postgraduate Dean as their responsible officer and when they complete their training and get their CCT, that is their first revalidation. Doctors that have longer than five years training will get revalidated within that training programme. Generally that doesn t apply in general practice because we only have a three year training programme at the moment; we might have four years soon. So when you get your CCT, that s your first revalidation and that will be done through the Deanery. So if a doctor has their revalidation and the responsible officer decides that they haven t been revalidated, what happens then? Yes the responsible officer makes a recommendation to the GMC. The responsible officer can do one of three things, he or she can say that There are no concerns; I can recommend that doctor for revalidation. It can be that there s a deferral recommended, because more information is required. The third option is the responsible officer can t recommend revalidation for that doctor. The GMC then put in their fitness to practice processes to assess that doctor according to the well tried and tested fitness for practice procedures that the GMC have. It is the GMC that decide whether that doctor can retain the license to practice, and that process has been in operation long before revalidation. So if a doctor fails revalidation by the GMC then they lose their license to practice and they will then need to have a remediation process. Appraisal and revalidation are linked but appraisal shouldn t be there to detect underperformance. It might in the 13

14 process highlight areas of development but revalidation itself is the moment in time when the GMC make that decision. But through the five year process, there shouldn t be any shocks in that system. It s a developmental process over five years and hopefully there won t be doctors that suddenly find at the end of five years that they re not being revalidated. Those warnings should have been highlighted much earlier on, and that s where the responsible officer comes in because they are there to maintain the performance of doctors in their local area. If problems are highlighted during the revalidation cycle, remediation needs to happen during that time, not wait for the GMC to say, There is a problem. Thanks very much, that s been very informative. What would you advise GPs to do now, once they get their date for revalidation? Okay the first thing that all doctors should have done already is to ensure that they ve got a responsible officer. If they haven t got a responsible officer allocated to them, they need to contact the GMC and ensure they have one. The next thing is to ensure that they re having annual appraisals, and that those appraisals are conducted according to the headings of good medical practice. It s useful to be able to collect your information in an electronic portfolio and the RGCP e-portfolio is becoming extremely popular. We ve got over 24,000 users now and that s a good way of logging your information. If you haven t done a patient or colleague feedback, start doing one now. If you haven t got a two cycle audit, start doing one now. 14

15 The important message about revalidation is that we want to make sure this is a positive process; something which is of benefit to the doctor to develop their professional work, to reflect on their professional development and improve clinical care. Many thanks to Professional Nigel Sparrow. For further reading and useful resources, follow the links on the next page. Male: Thank you for listening to this audio module from BMJ Learning. END AUDIO 15