GP and Professor of Health Development at Staffordshire University, Clinical Lead for Royal College of General Practitioners Essential General Practice Update Programme, Chair Clinical Governance Subgroup Department of Health Tackling Concerns Locally revalidation working group, CPD consultant, KSS Deanery, UK
Received date: 1 May 2008; Accepted date: 22 May 2008
There was a lot of discussion about strengthening professional regulation five or so years ago – but now it really does seem to be happening. So far so good. There seems to be a general confidence that revalid-ation will be about improving and maintaining indi-vidual practitioners’ performance rather than focusing on specific faults.[1–3] It will hopefully be about enhanc-ing the quality of care and safety of patients, rather than a bureaucratic exercise for health professionals that takes yet more time and energy away from patient care.
The primary purpose of professional regulation is to ensure patient safety. Box 1 describes the various purposes of revalidation for general practitioners (GPs). So the clinical governance framework in all healthcare settings must ensure that individual practitioners provide minimally acceptable standards of care in terms of the safety and quality of care.
Progress with pilots
The seven revalidation working groups are producing their initial reports, so that the Chief Medical Officer of England can agree the pilots of the new system. The other three countries of the UK are observing progress so that they can adopt or adapt the English system, all being well. The Medical Royal Colleges are all working hard to anticipate the systems and processes that will be required for recertification of their specialist mem-bers or, in the case of the Royal College of General Practitioners (RCGP), all GPs. Many of the deliber-ations about the way forward are drawn from the experiences of appraisal and tackling underperformance of doctors and dentists, but also from how the work of practitioners such as independent midwives is overseen.
The thinking seems to be to launch revalidation for doctors before that of other health professionals. The medical system will be more complicated than that for other professionals, with its twin components of re-certification by the Medical Royal College, and relicensing by the responsible officer of a trust/primary care organ-isation (PCO) affirming a doctor’s fitness to practise to the General Medical Council (GMC) regionally based affiliate.
We need pilots of how the responsible officer role will work out in trusts and PCOs, receiving informa-tion about individual practitioners’ performance and affirming that they are fit to practise. Figure 1 illus-trates how the responsible officer role might work for operating the relicensing process for doctors employed in their trust or on the performers’ list of the PCO.
It can be seen in Figure 1 that clinical governance is going to be central to professional regulation, that is, the framework through which healthcare organis-ations are accountable for continuously improving the quality of their services and safeguarding high standards of care. The investment in clinical govern-ance should engender provision of clinical services focused on:
• continuous quality improvement
• assurance of safety
• reduction of risk
• minimisation of costs (without detriment to the other objectives).
So this means systems will be created so that infor-mation about a practitioner’s performance will be generated through multisource feedback exercises with colleagues and patients: through comparing their per-formance with peers and adhering to best practice, via local audits or patient complaints. An appraiser will receive that information from the trust/PCO for the annual appraisal, as well as information prepared by the doctor or other health professional being appraised about the continuing professional development (CPD) they have undertaken, or other personally collected evidence of their performance, such as practice-based clinical audits.
There will need to be good leadership in the trust/ PCO to make the flow of information work and develop good communication systems between the various people in roles relevant to clinical governance and revalidation.
Clinical governance will grow in importance with the increasing emphasis on accrediting primary care providers and the services they deliver. The RCGP is piloting a scheme with 40 general medical practices, which should be ready as a voluntary accreditation scheme when revalidation is in full swing. The body replacing the Healthcare Commission, the Commission for Social Care, and the Mental Health Act Commis-sioner will also have a remit for inspecting the quality of primary care providers.
Appraisal will be key
The RCGP has successfully agreed a common policy on GP appraisal with leads from all four countries of the UK. At present the four countries differ substan-tially in the way they run GP appraisal, with Wales leading on integration of appraisal with clinical gov-ernance information systems. Appraisers will form a judgement about whether the quality and extent of CPD a doctor has undertaken in the previous year matches the learning plan previously agreed, whether any variation is justified, and if it is equivalent to at least 50 learning ‘credits’.
Quality assured CPD will be more common
The RCGP is setting up a managed CPD scheme for GPs. This will be a process- and outcome-based ‘credit’ system, which will serve as a framework for the quality assurance of CPD for GPs. GPs will be expected to complete a minimum of 50 credits from a learning-based credit system (with credits matching the impact of learning) each year, with a good balance of CPD reflecting the doctor’s range of practice within the 250 credits of a five-year cycle. The ‘credits’ will be based on the process and outcomes of learning rather than just being present when CPD is delivered – encouraging GPs in reflective learning. Many other Medical Royal Colleges already have such schemes. It is likely that other health professions will follow suit or adapt their CPD requirements to fit with requirements for revalidation.
The RCGP already has a system for quality assuring educational providers other than higher education institutions in Scotland, and plans to pilot a similar scheme in England soon.
Tackling concerns locally
We can expect that the extra focus on health profes-sionals’ performance through enhanced clinical govern-ance will reveal more concerns about an individual’s performance or fitness to practise. The revalidation working groups are considering what sort of informa-tion systems and governance arrangements we need in place to be able to record concerns about individual practitioners. There should be ways to collate any ‘soft’ or relatively minor concerns where there are no ap-parent risks to patient safety, so that someone in a position of responsibility becomes aware that a picture is building of substantial numbers of minor concerns, which by themselves would not trigger an enquiry or referral. There may be more significant concerns about performance generated too, which will require suf-ficient resources and expertise to be available for detection, diagnosis and assessment of an individual’s performance, and remediation, reskilling and rehabil-itation as appropriate. The tools used for diagnosis and assessment should also be viable for monitoring progress to obviate the need for re-assessment before a practitioner is allowed to practise in an unsupervised way again.
There are many challenges to resolve: the matter of who pays for this expensive resource – the practitioner themselves or the responsible trust/PCO – and how we support patients so that they feel able to make a complaint about a practitioner’s performance. Trusts/ PCOs need an educational and supportive ethos. It is important to create a culture in which healthcare professionals should feel able to self-report their learning needs, or their concerns about colleagues – knowing that these concerns will be dealt with fairly and with the aim, wherever possible, of remediation, reskilling or rehabilitation.
It is time to turn rhetoric into reality (oh dear, is using that sentence more of the same?). Any investigation into concerns about a practitioner’s performance will usually reveal weaknesses in the trust/PCO or practice systems. It’s rare for the individual to be underper-forming without there being other factors involved too – poor communication, a dysfunctional team, un-realistic targets, inadequate resources, etc. So if the systems and processes involved in operating revalidation at a local level are to be fit for purpose, then trusts/ PCOs/practices will have to establish a sound clinical governance structure, and provide sufficient resources to allow consistent best practice.
They will have to be prepared to learn lessons from all the information generated to monitor practitioners’ performance and investigate poor performance – to improve quality and safety of services in sustainable ways.