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Features: Revalidation - a framework to fit all

27 July 2009

Pilots are being carried out to test different components in different practice settings. The aim – an efficient, effective revalidation framework.

Doctors across the UK have been taking part in a range of pilots to look at how local systems of appraisal and clinical governance can support revalidation. Much of this early piloting work has involved healthcare organisations working together to look at how processes at a local level can generate the  required information to support appraisal and revalidation.

Real life

Gavin Larner, Director of Professional Standards at the Department of Health (England), told GMCtoday:  ‘The Department, and our delivery partners, do not want to rush into a system without first testing how it works and what its “real life” impact is.

'Our idea is to test the processes linked to appraisal and revalidation with phased pilots that will allow us to work with the profession, employers and commissioners to evaluate and build, over time, a system that minimises bureaucracy and supports doctors in developing their professional skills throughout their career.'

The pilots, covering both primary and secondary care, locums, and the independent sector, have been split into three main categories: readiness reviews; testing the Good Medical Practice framework; and research on multi-source feedback.

While the UKRPB is providing strategic oversight of the implementation of revalidation across the UK, the NHS Revalidation Support Team, which is a Department of Health-funded body, is supporting the NHS in England to prepare practically for the future revalidation of its doctors.

The RST is in the process of developing an improved system of appraisal and is involved in a number of the ongoing pilots. The team’s National Director, Maurice Conlon, who also spends two days a week in clinical practice, wants a system which is practical and manageable in the context of a busy clinical day.

‘I am involved,’ he explains, ‘because I am driven by a desire to play a part in a radical new process which benefits all in the system.’

Speaking on behalf of his RST team he says: ‘Revalidation should be a win-win-win process: doctors will  win because they are receiving support throughout their careers; the service will win because it is populated by well-motivated doctors of increasing skill; patients will win because the considerable trust they already place in their doctors will no longer be blind.’

The GMP framework

One of the GMC’s early and most important roles in helping to progress revalidation was to develop a framework for appraisal and assessment based on Good Medical Practice and this has been a key focus of some of the pilots.

Wales GP, Dr Malcolm Lewis, who chairs the GMC’s Continued Practice Board and is a member of the UKRPB explains: ‘The annual appraisal is the main way that doctors will demonstrate that they are meeting the standards required for revalidation. The GMP framework sets out the generic standard of practice which all doctors will need to meet.

'The Medical Royal Colleges are translating these into specialty specific standards, and describing the sort of information that doctors working in the different specialties will need to provide for their revalidation. This framework is now being incorporated into local systems of appraisal, initially through a series of pilots in a variety of sectors and settings.’

The development of the new framework was a key recommendation of the UK Government’s 2007 White Paper, Trust, Assurance and Safety – The Regulation of Health Professionals in the 21st Century. The White Paper charged the GMC with developing a framework for appraisal linked to our generic professional standards for doctors set out in our core guidance Good Medical Practice.

Four domains

The GMC team, led by Assistant Director of Standards and Ethics, Jane O'Brien, looked at Good Medical Practice, which sets out the principles and values on which good practice is founded. Following extensive consultation, the team translated the guidance into a framework built around four domains: Knowledge, Skills and Performance; Safety and Quality; Communication, Partnership and Teamwork; and Maintaining Trust.

The structure of the GMP framework, once it has been embedded into the appraisal process, should enable all licensed doctors to demonstrate how they are meeting the relevant GMP standards. Jane explains: 'We divided the standards into those which applied to all doctors, for example, participating in professional and educational development.’

Piloting the framework

The Royal College of Physicians’ revalidation lead, Dr Ian Starke, has been leading a pilot in Merseyside looking specifically at how the GMP framework can be applied practically for all specialties within a secondary care context.

Clearly grateful to all the Merseyside doctors who have taken part, he says: ‘We’ve been asking doctors to look at what they’ve been doing previously for appraisal, and to consider whether the sort of information they were used to collecting would be sufficient. If it wasn’t, then what other information could they most conveniently obtain from their day-to-day work which they could bring to appraisal to show that they were meeting the requirements of the GMC framework?’

Dr Starke explains: ‘We’ve had a number of induction meetings with clinical directors, medical directors and doctors involved in appraisals, to explain the revalidation process and the pilot and to answer their questions. We’ll be running further support meetings later on in the year and will be obtaining detailed feedback via a series of questionnaires and focus groups.’

One of the challenges Dr Starke’s team has faced has been keeping together all of the different stakeholders who have slightly different priorities.

He explains: ‘We’ve done that through establishing a steering group with representation from all the key stakeholders for the project and that seems to be working well. There are some differences in emphasis but I think we should be able to meet all those expectations, providing information not only for the colleges and for the GMC but also for the NHS Revalidation Support Team and for the secondary care trusts in Merseyside.’

Dr Starke reports that the doctors involved in the pilot were ‘very enthusiastic’. ‘We have successfully broadened the pilot out to cover a wide range of specialties, including physicians, surgeons, psychiatrists and paediatricians.’

Another pilot in Tayside, supported by RCGP Scotland and NHS Education for Scotland, is using patient and colleague opinion surveys, self-evaluated open-book knowledge tests and ‘QOF Plus’ data to test the GMP framework in action. The  pilot is being managed by Dr David Bruce, Associate Postgraduate Dean, University of Dundee who says: 'The aim of the study is to design and test assessment tools blueprinted against the four domains of the GMP framework, for use in future systems of general practitioner appraisal.’

A further pilot in NHS Highland is proposing to examine the available sources of information to support appraisal, mapped against the GMP framework, across a broad range of specialties in both primary and secondary care, and across all grades.

Gathering evidence

In Northern Ireland, a pilot project is focusing on secondary care. Project lead, Jane Lindsay, from the Department of Health, Social Services and Public Safety, explains that amongst the key objectives of the pilot they will be looking to identify any additional evidence that may be required by doctors to demonstrate they meet the GMP standards, as well as whether any improvements need to be made to the appraisal process in secondary care.

They will also be looking at the time needed to collate the supporting information and any additional resources which may be required. Jane Lindsay says: ‘The project will survey around 100 doctors working in the five Health and Social Care Trusts and will cover a wide range of specialties. Alongside this group, a smaller group of clinical academics will examine how the supporting information can be collated for academics.’

Early indications

The different pilots will report back to the UKRPB over the next year. The development of processes to  support revalidation will be informed by the experience of doctors who are participating in these pilots. From the Mersey Deanery pilot, Dr Starke explains: ‘We will be recording the time taken for the new appraisal process and will be asking people how they found the framework, how easy it was to use, and how easily they were able to provide the supporting information that was needed.’