Revalidation: What Is It? New unified system of Reflective CPD & feedback to improve: Awareness of educational/professional needs Quality of care Confidence (patients, public, employers, colleagues) Addresses Current inconsistencies in re-mediation Incorporates relicenship & recertification for all UK-licensed doctors

Revalidation: Why & When? NHS Plan 2001 Annual appraisal GMS contractual obligation Scotland: compulsory since /- inclusion on Performer’s List Previously CPD + 360° feedback +/- supervision NES led with local GP appraisers 1-2h Formative session(i.e. Feedback not Pass/Fail) Now Strengthen existing system Annual peer-led appraisal Continuous process Actioned every 5-year cycle Current pilots Inc nPEP in Dundee Phased-in from April 2011

Key Documents “Trust, Assurance & Safety – The Regulation of Health Professionals in the 21st Century” Feb 2007 “Good Medical Practice for General Practitioners” 2008 “Medical revalidation – Principles & Next Steps” 2008 “GMC Licence to Practice” Nov 2009 “RCGP Guide to Revalidation” Jan 2010 “Revalidation: The Way Ahead. Consultation Document” March 2010

Good Medical Practice GMC’s standards of Professional Duty for all doctors 4 domains, 12 attributes Knowledge, Skills & Performance Maintain Professional Performance Apply Knowledge & Experience to Practice Clear, accurate, legible records Safety & Quality Systems to protect patients & improve care Respond to safety risks Protect others from risks of own health Maintaining Trust Respect for patients Treat others without discrimination Act with honesty & integrity Communication, Partnership, Teamwork Communicate effectively Works constructively / delegates Partnerships with patients

Annual Appraisal Over 5-year period with local appraiser Supporting Information: Colleague & Patient Feedback CPD records Clinical Audit Medical Royal College / Faculty: Define standards for appraisal & supporting information Providing speciality guidance & advice for appraisers, appraisees and Responsible Officers

Annual Appraisal Over 5-year period with local appraiser Supporting Information: Colleague & Patient Feedback CPD records Clinical Audit Medical Royal College / Faculty: Define standards for appraisal & supporting information Providing speciality guidance & advice for appraisers, appraisees and Responsible Officers Responsible Officer Receives feedback on appraisal New role [Health and Social Care Act 2008] Senior doctor within healthcare organisation e.g. medical director Supported by experienced GP adviser and trained lay person Review supporting information submitted for several thousand doctors Thus Appraiser has key-role in informing the Responsible Officer

Responsible Officer Makes revalidation recommendation to GMC GMC: Doctor Revalidated Annual Appraisal Over 5-year period with local appraiser Supporting Information: Colleague & Patient Feedback CPD records Clinical Audit Medical Royal College / Faculty: Define standards for appraisal & supporting information Providing speciality guidance & advice for appraisers, appraisees and Responsible Officers Responsible Officer Receives feedback on appraisal Quality Assurance Royal Colleges System regulators (e.g. The Care Quality Commission) GMC

GMC Revalidation: “Single-process” Relicensure: license to practise on medical register (i.e. NHS doctor, prescribe & death certification) in accordance with the GMC’s generic standards [GMC driven] Recertification (re-accreditation): certificate confirms doctors meet standards appropriate to be on GMC’s GP Register [RCGP driven] Support: As a backstop, to identify for further investigation/remediation, doctors whose practice is/may be impaired License to Practise Certificate to be on the GP register 5-Yearly Relicence 5-Yearly Recertification One-Process Revalidation

Supporting Evidence CPD credits Personal Development Plans Appraisal What do I need to do?

Portfolio: 13 evidence areas 1. Profession Role description of work 2. Special Circumstances e.g. maternity/sick/sabbatical, job change 3. Annual Appraisals Review signed-off 4. PDP PDP for each annual appraisal 5. PDP Reviews 6. Continuing Education ≥50 learning credits/year 7. Multi-Source Feedback 2 x MSF every 5 years 8. Patient Feedback 2 x PSQs every 5 years / 1 + video-analysis 9. Formal Complaint Review if any 10. Significant Event Audits 5 x SEA every 5 years 11. Clinical Audits 2 x full-cycle audits every 5 years 12. Probity/Health 13. +/- Extended Practice e.g. OOH, GPwSI, teaching/research

Revalidation ePortfolio “Supporting information” (evidence) used for annual appraisal RCGP College Revalidation ePortfolio Most GPs will include information from April 2009 Easy, intuitive data entry to allow easy review of progress Structured to encourage reflection Traffic-light-coded ‘dashboard’ summary Integrate other online-tools Essential Knowledge Update (EKU): scenario-based learning Essential Knowledge Challenge (EKC): multiple-choice, voluntary PEP, e-GP, RCGP trainee ePortfolio, NHS appraisal toolkit

The Early Years

Learning Credits All colleges agree - record continuing education in the form of learning credits At least 50/year = 250 over a full 5-year revalidation cycle RCGP: 1 credit = 1 hr education (learning, planning, reflecting) Self-assessed then reviewed at appraisal IMPACT FACTOR Each hour of education that can been shown to lead to improvement in care or practice will qualify for 2 credits Impact on Patients e.g. Implement new guideline / initiate new drug Individual e.g. new / further developing skill Service e.g. new service / becoming training practice Others e.g. Teaching, training, NHS services

HF Meeting (1h) Dr A: Logs learning (knowledge & relevance) Dr B: As Dr A 2 case studies of appropriate B-blockers use in HF Dr C: As Dr A + plans an audit (1h) + discusses findings (1h) Change implemented & 2 nd cycle demonstrates change 1 credit 6 credits 2 credits 1 credit Impact Factor x 2

Personal Development Plan RCGP Guide to the Revalidation of GPs. Jan version 3.0

Special Consideration Maternity leave Work Abroad Sessional GPs GPs in remote or small practices GPs in Forces / Prison Service GPs in training Non-clinical (medical managers) ? re-entry portfolio

Career Breaks RCGP Video May 2010 Ordinary Portfolio requirements (within 5 year period) Appraisal ≥3 years Kept up-to-date (CPD) ≥ 3 years Clinical Activity ≥ 200 half-day clinical sessions Otherwise Responsible Officer may d/w RCGP / GMC Out-of-practice at time licence up for revalidation... License may not be continued Can re-apply when ready to go back If “sustained” period of time will need “re-orientation” Assessment Re-entry course

Drawbacks “Unfair” Punitive process for wholly independent practice Older GPs & electronic record and reflective practice Locums (paper record prescribing, referrals, feedback) “Bureaucracy” More political form-filling Wasted time away from clinical care Costs (implementing, carrying out, remediation) Uncertainty DoH terminating contracts of underperforming practices

BJGP (July 2009:476) Most doctors see revalidation as a focus for CPD to bring regulation and education together Some GPs the process seems like a bureaucratic nightmare and an inefficient way to weed out villains of the profession Need to move away from this idea if revalidation is to reach its potential (improve care, reassure public/profession, support) Society wants doctors to be more accountable Collecting evidence of what we do is significant part of profession Needs to be properly resourced to avoid “squeezing it in” around “proper work”

Public Interest Increasing climate of general loss of public trust & increased awareness of medical error Bristol enquiry, Shipman, etc GMC figures April ,300 patients 14 % not confident in last Dr seen 71% felt revalidation would boost confidence Inc 2/3 those quite/very confident

“Information for Patients” Tell doctors when care is good Thank you letters, compliments Say when care is not as good as expected Talk, letter, formal Report when things go wrong Give views when asked

Appraisal Performance “Central document underpinning revalidation & supporting GPs through it” Performance GMP Objectives = Appraisal Standards 3 phases: Preparation of evidence Submission & Assessment Relicense/Remediate

The Excellent, Good & Unacceptable Dr Clinical Care Record keeping Access, Availability, OOH Resources Access to Medical Care Emergency Treatment Keeping Up To Date Training & Assessing Dr-Pt Relationship Team-work Probity Health Standards

F “A doctor’s certificate and registration cannot be restricted or removed, except through due process, under the GMC’s fitness to practise rules and where there is evidence of impaired practice”

Remediation Small minority Early identification of concerns Follow up local support /action RCGP National Adjudication Panel after 2 unsatisfactory appraisals Next stop GMC (can appeal) May defer decision to allow Dr to fill gaps in supporting info Outcome based on local, National Clinical Assessment Service or GMC process Re-entry portfolio Resourcing is key concern

Other Countries Formal revalidation Germany Netherlands ‘Herregistratie’ (recertification) 2001 OOH mandatory, thus older GPs felt discriminated against Initially required GPs complete whole 3 y of GP- training again year programme started 4 days/week supervised work + 1 day education

Summary Aims to continually improve: Professional accountability Standards of Care Faith in doctors Taking into account Standards Clinical guidelines Good Medical Practice Accumulate evidence: Annual appraisals Audits / SEA / Complaints Record learning hours Feedback Patients & Colleagues Responsible officer review Every 5 years