CPD is an essential component of the revalidation process

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Revalidation has been in discussion and development for over 10 years, but the publication of Dame Janet Smith’s Fifth report, safeguarding patients: lessons from the past—proposals for the future¹ and the White paper Trust, assurance and safety—the regulation of health professionals in the 21st Century,² have resulted in the current policy that all doctors will be revalidated every 5 years.

Revalidation will be introduced in 2010,³ and will be based on two components:

• relicensing—for all doctors, the renewal of a doctor’s licence to practise and therefore their right to remain on the Medical Register
• recertification—for those doctors wishing to be retained on the general practitioner or specialist register.

The two components will be integrated so that there is one process with two outcomes linked together as revalidation. General practitioners will need to start collecting their evidence for revalidation from April 2009. The Royal College of General Practitioners (RCGP) has the responsibility of proposing the standards and methods used in the revalidation of doctors but these must meet the approval of the General Medical Council (GMC).⁴ In preparation for this, the RCGP has been working with key stakeholders, including the GMC, the General Practitioners Committee of the British Medical Association, the Academy of Medical Royal Colleges, and the Department of Health to develop tools to support revalidation.³

In autumn 2009, the GMC will introduce licences to practise. All doctors who are registered at the time that licensing is implemented will be offered a licence.³ This is the first step towards relicensing.

Revalidation

Revalidation will allow doctors to demonstrate on a periodic basis that they are keeping up to date and are fit to practise. This is different from the current system, which relies on complaints received by the doctor or practice.

Revalidation will encourage development and improvement in practice; therefore, it is important to ensure that the models being developed will allow GPs to demonstrate the competence and performance necessary for their day-to-day work, and that the process is flexible enough to be appropriate for all GPs whatever their working circumstances.³ It should, therefore, not disadvantage those doctors who are based in single-handed practice, work part-time, or have portfolio careers.

Continuing professional development

Participation in continuing professional development (CPD) by all GPs is essential in order to:

• ensure that they update and refresh their clinical knowledge and skills on a continual basis
• promote patient confidence that their own GP’s knowledge is up to date
• help improve patient safety
• ensure that the individual GP works within a system that encourages reflection on their own personal development needs, and also the requirements of their practice teams and the patient population.

The RCGP is developing a CPD scheme for all GPs, with patient care being central to the agenda. The scheme is based on the ten principles for CPD developed by the Academy of Medical Royal Colleges (AoMRC).⁵ The main principles of the RCGP CPD strategy are described in Good CPD for GPs,⁶ which outlines how CPD is central to the revalidation process—by being linked to the appraisal cycle through the personal development plan.

A brief outline of the RCGP CPD scheme is shown in Box 1. The scheme is based on a system of impact and challenge which defines a credit as follows: ‘A credit is a unit of professional development which is a product of the impact of a developmental activity and to a lesser extent the challenge involved in its completion.’⁷

Impact could affect:⁷

• the individual (personal development)
• patients (e.g. a change in practice, initiating a new drug—this has obvious overlaps with personal development)
• a service (e.g. becoming a training practice, teaching others, implementing a clinic system).

Challenge is considered as relating to:⁷

• context (e.g. more challenging to become a new training practice than a trainer in an established training practice)
• circumstances (e.g. a sessional GP undertaking audit is often faced with problems around the data and follow up)
• personal ability (e.g. personal disability, prior skills, prior experience)
• effort expended (e.g. attending an ophthalmology clinic for a whole day 40 miles away to gain experience).

Box 1: Outline of the RCGP CPD scheme7

The system is process and outcome based It will provide a flexible framework for the quality assurance of CPD for participating GPs It will encourage reflective learning It will fulfil the standards and requirements of CPD required by revalidation Credits will be measured by impact and challenge of learning, rather than simple participation Credits will be self-assessed and verified at appraisal A minimum of 50 credits will be required per year A broad range of general practice should be covered in 250 credits over 5 years Quality assurance of the CPD portfolio will be linked to appraisal and recertification Evidence of CPD will be captured in a portfolio of learning. This should: describe the GP’s personal development plan describe the learning undertaken, with reflection on how working practise and/or behaviour has changed include evidence of how the GP has kept up to date with new and changing information and the effect on practise

CPD=continuing professional development

Credit allocation

The RCGP document entitled Credit based system for continuing professional development provides guidance on how to allocate a number of credits.⁷ The value of credits is dependent on the level of impact and challenge as shown in Table 1, and examples of how credits can be earned are given in Box 2. If the impact and challenge is greater, the number of credits awarded should increase. Reflection on the learning is the basis of this system. This focus on outcomes—not the activities that produce the outcomes—is also highlighted in the Chief Medical Officer for England’s Working Group, Medical revalidation: principles and next steps.³

Most of the other medical Royal Colleges are using a time-based credit system to measure CPD, with a minimum of 50 credits in a year and 250 CPD credits in a 5-year cycle supporting a positive revalidation decision. The RCGP scheme agrees with these values but credits are expected to reflect a variety of learning styles and a broad range of general practice education, with at least 50 learning credits being achieved, and confirmed by the appraiser each year. It will be the responsibility of the individual GP to ensure that they undertake a range of CPD that reflects the local and national needs of their patients, and their own learning needs. This will be confirmed as part of the appraisal cycle by the appraiser.⁷

Table 1: Royal College of General Practitioners credit allocation system7
Impact Challenge	Low	Minor	Moderate	Moderate	Moderate
Low	1–2	2–4	3–5	4–8	5–10+
Minor	1–3	2–4	3–7	5–10	6–12+
Moderate	2–4	3–6	4–8	6–12	8–15+
Significant	3–5	4–7	5–11	7–15+	10–20+
High	4–6	5–10	6–14+	10–20+	20+
Sparrow N, Price C. Credit based system for continuing professional development. London: RCGP, 2008. Reproduced with kind permission.

Box 2: Examples of how credits may be earned

The GP: presents a significant event to a significant event audit meeting, reflects on the discussion, and writes up the outcome—2 credits reads five articles in Guidelines in Practice, assesses learning using the CPD knowledge tracker (www.eguidelines.co.uk/eguidelinesmain/cpd/index.php), and keeps a reflective note of how this will influence practice and patient care—5 credits ensures that all the Essential Knowledge Updates have been completed and the Essential Knowledge Challenges have been passed throughout the year—20 credits records PUNS and DENS, and meets the identified needs—10 credits (these are not ‘standard’ credits but illustrative for a particular doctor. The GP needs to reflect on the impact and challenge and justify the credits claimed. For example, if several PUNS and DENS have been achieved, the GP could claim 15 credits) attends eight half-day PLT local education events—10 credits attends one PLT on chronic kidney disease and undertakes an audit, introduces a new protocol into the practice, and re-audits to show improvement—15 credits attends a PLT, reviews the practice policy on safeguarding children, and checks the notes of three recent cases—10 credits

CPD=continuing professional development; PUNs=patient unmet needs; DENs=doctor’s educational needs; PLT=protected learning time

 

Assessment of credits

Detailed advice on how credits are self-assessed by the GP and how an appraiser should validate those credits will be published by the RCGP in July 2009. By reading through the evidence and discussion at appraisal, the appraiser should verify that the credits claimed by the doctor being appraised are a reasonable estimate of the impact and challenge.⁷ The appraiser will have the opportunity to discuss in greater detail any aspects of the credits claimed that need clarification. Further discussion should take place if the appraiser believes that:

• overall, the doctor has claimed too many credits
• overall, the doctor has claimed too few credits
• the numbers of credits claimed for individual items bear little relation to the impact and challenge model.

Conclusion

The impact and challenge model of credits is currently being piloted in 10 regions within the UK. The pilot is due to conclude in May 2009. Over 400 GPs (sessional and partner) have registered to take part in the pilot and this number is likely to be much higher as the appraisal year draws to a close.