Professor of Primary and Prehospital Health Care, School of Health and Social Care, University of Lincoln, Lincoln, UK
Revalidation of doctors, including general prac-titioners (GPs), is soon to be delivered after a gestation of over a decade.[1,2] The expressed aim of revalidation is to ensure that doctors are up-to-date and continue to maintain their fitness to practise. It is currently proposed that this will be achieved through annual appraisal and a five yearly review of appraisal portfolios and other routine clinical governance information. In general practice, appraisals will be carried out by a local appraiser and the revalidation review will be conducted by a senior clinician appointed as a local responsible officer. The responsible officer will review the appraisal portfolio of each doctor and will decide, based on information contained therein and local intel-ligence about complaints and concerns about per-formance, whether a doctor is to continue to practise.
Most GPs have welcomed appraisal because it has provided an opportunity to discuss their work as well as successes and challenges in confidence with a col-league. Appraisal has been professionally led, devel-oped locally under national guidance, supportive and largely formative and this has been largely in keeping with the wishes of GPs. Whether these positive attitudes will change because of delays in agreeing the process of revalidation and recent changes to appraisal remains to be seen. Appraisal now also includes an element of summative assessment of a number of mandatory cri-teria: appraisers check whether a specific number of educational credits (50 per year) have been achieved, a minimum number of significant event audits (two per year) conducted and a five yearly patient satisfaction survey, multisource feedback and clinical audit com-pleted.
GPs who have been interested in and championed quality improvement recently suggested, to experts writing the guidance for revalidation of GPs, that a quality improvement project could be accepted as an alternative to clinical audit as part of the evidence for revalidation. As a result, the Royal College of General Practitioners (RCGP) guide was amended to state that ‘GPs should be able, if they wish and they have the expertise, to include a quality improvement project as their audit’. The broad details are included in the guidance (see Box 1).
Although some GPs will have participated in a quality improvement collaborative, few will have had experience of conducting a quality improvement project themselves; most do not have knowledge of the tools and techniques involved and only a small min-ority have formally applied these methods to solving problems in their practice. Here is a real example of a quality improvement project that was conducted in my practice and which was submitted for appraisal (Box 2).
The Kings Fund in its recent report into ‘Improving the quality of care in general practice’ expressed a hope that the new primary care organisations would develop better systems to identify inappropriate vari-ation, discover gaps in care, and address these through wider use of quality improvement methods. Unfor-tunately, this is unlikely to occur unless knowledge and application of quality improvement methods increases, and leaders in the new organisations sup-port this development. These methods could prove valuable for improvement but also to evaluate inno-vations and changes in services.
Wider use of quality improvement projects for appraisal and revalidation as an alternative to clinical audit will require considerable investment in edu-cation and training of general practitioners in quality improvement methods during vocational training and afterwards as part of continuing professional devel-opment. Whether the promise of higher quality in the health system will be a consequence of the labour pains of revalidation remains to be seen.
Commissioned; not externally Peer Reviewed.
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