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Practical steps for a calm revolution

Practical steps for a calm revolution
29 October 2010

It may have been put back, but revalidation will happen. Perhaps the most important take-home message from this article
is that there is nothing to fear and the process will be straightforward. The vast majority of GPs are, in any case, doing above and beyond what is required, and the process will be
a rewarding one and a positive affirmation of good practice.

It is intended that the appraisal process will remain formative and

It may have been put back, but revalidation will happen. Perhaps the most important take-home message from this article
is that there is nothing to fear and the process will be straightforward. The vast majority of GPs are, in any case, doing above and beyond what is required, and the process will be
a rewarding one and a positive affirmation of good practice.

It is intended that the appraisal process will remain formative and
developmental, and allow GPs the opportunity to identify any learning needs. Currently, the revalidation process is being piloted to ensure it is straightforward, fair and feasible.

Why has it been put back a year?
Revalidation was due to be launched in 2011, but will now happen in January 2013. There are many reasons for this. The British Medical Association (BMA) is asking lots of practical questions relating to funding. All the necessary Responsible Officers in primary care organisations have not yet been identified and trained. If remediation is required for any doctors who may not satisfy the process, the provision and funding for this needs to be determined.

Questions regularly asked
What is the basis of the revalidation process? It is based on the four domains of the General Medical Council’s (GMC) module
Good Medical Practice and the attributes within each domain:

• Domain 1 – Knowledge,
Skills and Performance.
• Domain 2 – Safety
and Quality.
• Domain 3
– Communication,
Partnership and
• Domain 4 –
Maintaining Trust.

Which ePortfolio should a GP use?
An ePortfolio mapping onto these domains will be available later this year from the Royal College of GPs (RCGP). Until this
is available, GPs are advised to continue to use the NHS
Appraisals Toolkit.
Will revalidation detect another Dr Shipman? Thiswas never the intention – revalidation is meant to be formative, developmental and affirm good practice.

What will revalidation look like?
Revalidation will be constituted by a “strengthened appraisal”; the evidence, or “supporting information” in 13 areas
to justify that a GP can be relicensed, which will
be kept in an ePortfolio.

Further information is in the RCGP Revalidation Guide
(see Resource), currently in its fourth version.
In your appraisal you should be asking, “What do I do well and what could I do better?” It also allows you to ask: “What am I doing as a GP? What knowledge and skills do I have to do it with? How do I know how well I am doing?”

It is therefore important to have feedback from patients and colleagues, as well as other substantiated evidence, to indicate that GPs provide a positive affirmation of fitness to practise and so provide care that is safe and of a high quality. The
necessary information should be a by-product of good systems in the workplace.

ePortfoilo evidence required for strengthened appraisal
For those GPs who currently use the NHS AppraisalsToolkit, the areas starred below indicate those for which GPs currently collect information for annual appraisal:

• Description of Roles (Forms 1-3 Appraisal).*
• Exceptional circumstances statement.*
• Participation in five annual appraisals.*
• Annual personal development plan (PDP) agreed with the appraiser – focus on SMART (Specific, Measurable, Achievable,
Realistic and Time-bound) objectives.*
• Review of previous year’s PDP.*
• Self-accreditation of continuing professional development (CPD): 50 “Learning Credits” if possible, demonstrating
impact on patient care/organisation and change.
• One Multisource Feedback Questionnaire in five years.*
• One Patient Satisfaction Questionnaire in five years.* (A final decision is to be made if this is to be two questionnaires.)
• Review of any formal complaints (prioritise where learning needs can lead to change).*
• Five significant event reviews in five years where learning and implementing improvements are demonstrated.*
• Two clinical audits in significant clinical areas in five years.*
• Statements of probity and health.*
• Additional evidence – statements in areas of extended clinical practice, eg, as a medical teacher or GP with a Special Interest

Hopefully this will reassure GPs that they are currently
doing most of what is required. (It makes it easier if all information is recorded daily or weekly in an ePortfolio.)

It is all too easy to leave things until two weeks before an appraisal, when chaos can ensue as one combs through a diary containing meetings that cannot be recalled easily. It may be helpful to identify someone in the practice to be the revalidation lead to help collect some of the information that is required and to co-ordinate the audits and feedback questionnaires from colleagues and patients.

So what’s new?
Let’s start with “Learning Credits” (CPD). This is not like the old “PGEA system” (postgraduate education allowance), where you collected Certificates of Attendance by attending educational meetings. Rather there is a need now to reflect on your learning in all the areas listed to see if this affirms good practice or if you need to make any changes to your practice.

In other words, what is the “impact” on a GP’s practice and what areas, if any, should a GP change as a result? Full details are available in the RCGP Revalidation Guide. Learning can be demonstrated in different formats, as follows:

• Presenting at a significant event audit meeting.
• Online learning, eg, BMJ Learning
• RCGP Essential Knowledge Updates (EKU).
• e-GP: the RCGP’s new e-learning resource.
• Protected Learning Time events.
• PUNs (patient’s unmet needs) and DENs (doctor’s educational needs).
• Attending clinical meetings.
• Reading journals.

If a GP wishes to keep
Certificates of Attendance,
I would suggest that these
should be about reflection
and not just attendance.
So the following should
appear on the reverse of the
• Learning outcomes –
ie, what you learnt.
• Reflections, impact and
possible changes.
• Self-assessment in a number
of learning credits (in units
of half an hour).

The number of learning credits is self-assessed, but will need to be justified to the appraiser. Some GPs have heard that they can multiply some learning credits by a factor of two – this is correct but the GP has to demonstrate, for example through an audit, how the implementation of learning has made a change to practice and therefore involves further work and learning. I would stress that this is not an easy option, and the extra credits will need to be justified to the appraiser. One credit equates with one hour of learning.

Multi-source feedback (MSF) questionnaires
MSF, or what is sometimes referred to as 360-degree appraisal, is an opportunity for at least four clinical and four non-clinical colleagues whom the GP chooses to give feedback using a validated questionnaire. The results should be analysed externally and then the GP is provided with feedback that they should reflect on, making appropriate changes.

MSF will provide evidence about records, teamwork, communication and your professionalism. Current proposals are that the MSF should be conducted twice in five years, with the second time being used to look for changes in areas of concern if appropriate. However, the requirement may be reduced to just one MSF in the five years.

The Patient Satisfaction Questionnaire (PSQ) is similar and GPs are already familiar with this, having undertaken these for the Quality and Outcomes Framework (QOF). The PSQ will again use a validated GMC questionnaire on 25 consecutive patients, twice in a five-year period. The results should be analysed externally, the results again reflected upon and changes made if required.

Extended roles and exceptional circumstances
If a GP undertakes a role, such as a GPSI, clinician, GP trainer,
teacher, researcher etc, it is important to gain a statement from the person overseeing that role to say the GP has been satisfactory. This is an area that employers and educational authorities are becoming aware about, but it may be worth writing to them in advance, just in case they are not. It is easier still if the GP already has an appraisal with this employer.

Exceptional circumstances are where a GP has a time out of practice, eg, as a result of prolonged sick leave or a lengthy sabbatical, and this will involve a discussion with the responsible officer at the primary care organisation to ascertain what the GP may be required to do to be revalidated.

Sessional doctors
Sessional GPs have to collect the same amount of information. If a GP is working as a locum they should be proactive in organising their PSQ by gaining permission from the practice to do it, rather than just arriving with the questionnaires on the day. Audits will be personal to the doctor, rather than the practice team.

The RCGP Revalidation Guide provides a list of helpful topics, such as the “prescribing of antibiotics” that can be undertaken and relevant to one’s day-to-day practice. The key to collecting the information required for revalidation is to be organised in advance by becoming familiar in recording any information electronically (or getting someone to do this if it has been done by hand).

Will the role of the appraiser change?
This is a worry for many appraisers, but the answer is: “Not really”. As with appraisal currently, an appraiser’s role is to be a constructively supportive clinical reviewer of the GP, not to sit in judgement as part of strengthened appraisal.

An appraiser can therefore provide guidance, reassurance and advice. They can still be supportive and formative, and let a GP know whether they are on track with populating the GMC domains with data by collecting the necessary amount of information required. Also, an appraiser can help discuss whether a GP has reflected appropriately and made changes to their practice, if required, and also help with creating better PDPs.

One occasionally still sees GPs who record the following for their CPD: “Reading the BMJ and GP magazines”. It needs to be more than this; CPD should be carefully structured around the likely learning areas in their practice for the next 12 months, as identified by the GP and their appraiser.

The appraiser should be facilitative, keeping their colleagues “onboard” with the process. Some appraisers worry as to whether it will be their fault if a revalidation portfolio is poor. As long as they have recorded their concerns on Form 4, with the suggested actions, then there should be no issues. Also, most appraisers are appointed by their primary care trust (PCT) and so have indemnity with their contract (not that it will be needed!).

Role of the Responsible Officer
The Responsible Officer will be a medically qualified doctor, employed by the PCT, who will look at three aspects of a GP’s learning:

• Whether they are suitably equipped to do the job.
• How the GP is keeping up-to-date.
• Demonstrating peer review.

If the Responsible Officer has concerns, they will be able to refer to both a trained layperson and an RCGP adviser before giving a recommendation to the GMC. The key question for a Responsible Officer is whether a GP is “fit for purpose” and is developing and improving professionally, thus assuring the quality of care that patients receive. The GMC will then be able to sign off a GP for revalidation and so relicensing.

Revalidation Guide – RCGP

Dr Rodger Charlton MD FRCGP
GP Principal and GP Appraiser Hampton-in-Arden, Solihull
Associate Clinical Professor Warwick Medical School
Project Lead RCGP Revalidation Pilots in England and Wales

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