Revalidation will be challenging in terms of gathering the appropriate evidence and ensuring that everyone who is involved in the process is prepared, says Dr Honor Merriman


Revalidation for all doctors was proposed in 2001, but a lengthy process of consultation has been needed between the General Medical Council (GMC), the Department of Health, the Royal Medical Colleges, and the Academy of Royal Medical Colleges. The run up to the start of revalidation has been so long that many GPs have reached a stage of ‘revalidation fatigue’ in which further guidance has been ignored as speculation only. To many GPs, appraisal has become a yearly chore with little in the way of challenge; this was borne out by the GP appraisal quality assurance process in Oxfordshire, where the only part of the process that was not graded as good or excellent by users was the challenge part of the appraisal discussion. However, this state of affairs is about to change rapidly.

Preparing for revalidation

The RCGP guide to the revalidation of general practitioners was published in April 2009 and is a key document for GPs wishing to know how to gather evidence for both their appraisal and revalidation.1 The guide states that the revalidation process will start from 1 April 2010, although it is likely that it will take longer than this for primary care trusts (PCTs) and health boards to be ready, with responsible officers in place. This means that GPs need to read the RCGP guide now and begin to prepare information for essential items that are new to them (e.g. feedback from a colleague or patient).

The experience of many GP appraisers is that most GPs do not send them all the requisite documentation in advance. A large proportion of GPs are not familiar with using the NHS appraisal toolkit to upload this information in electronic form.2 This is significant because the process of revalidation will require the responsible officer to be able to review this information electronically when deciding if the GP should (or should not) be recommended for revalidation. Although the RCGP guide states that it is possible to complete a paper portfolio, most PCTs will discourage this format due to the logistics of handing such large volumes of paper for hundreds of GPs.

Evidence required for revalidation

The RCGP guide divides the evidence required for revalidation into 13 areas, with the last one considering additional evidence for areas of extended practice, such as medical education or working as a GP with a Special Interest.1 The minimum amount of evidence required is shown in Table 1 and the RCGP guide provides further information on the evidence required each year.1 This is reassuringly similar to the Leicester Statement, the dataset already used by most GPs (see Table 2).3 The inclusion of audit and learning credits in the evidence portfolio will stimulate most GPs to find out what is needed and to make a start on an audit of their personal practice this year. Audits of what the whole practice does are useful as long as the role of the individual GP is clear. Revalidation is concerned with the individual GP while practice accreditation is a completely separate process. The RCGP guide gives examples of audits that GPs can carry out.

Information on alternative portfolios for GPs whose experience is not standard is provided in the RCGP guide. This is particularly helpful for GPs working as peripatetic locums and for those who have had career breaks.

Table 1: Evidence required for revalidation, year by year, during the introductory period1

Evidence Year 1 (2010/11) Year 2 (2011/12) Year 3 (2012/13) Year 4 (2013/14) Year 5 (2014/15)
Description of roles ? ? ? ? ?
Exceptional circumstances ? ? ? ? ?
Evidence of appraisal One Two Three Four Five
PDPs One Two Three Four Five
Review of PDP One Two Three Four
Learning credits 50 or CPD 50 100 150 200
MSF from colleagues Either one MSF or one patient survey One Two Three
Patient survey Either one MSF or one patient survey One Two Three
Review of complaints ? ? ? ? ?
Significant event review One Two Three Four Five
Conventional audits One One Two Two
Statement of probity and health ? ? ? ? ?
PDP=personal development plan; CPD=continuing professional development; MSF=multi-source feedback

Royal College of General Practitioners. RCGP guide to the revalidation of general practitioners. London: RCGP, 2009. Reproduced with kind permission

Table 2: Summary checklist of essential evidence for appraisal3

Document agreed at the National Conference on Appraisal held in Leicester in February 2007, co-hosted by NCGST and NAPCE
Item Requirement Present (tick)
Completion of new forms 1,2,3 Annual
Legible
Coherent
Provided in good time
 
Provision of ongoing PDP, with clear description in Form 3 of degree of attainment Annual  
Last year’s appraisal summary
(Form 4)
Annual  
Case review SRT 2 annually  
Data collection/audit with SRT 1 annually  
Significant event SRT 1 annually  
SRT on last year's learning Annual  
Patient survey SRT Within past 3 years  
Complaint SRT(s) or declaration of no complaints At least one annually  
Multi-source feedback SRT Within past 3 years  
Full declaration of all other professional roles Annual  
Other professional roles SRT Annual  
Probity SRT Annual  
Health SRT Annual  
NCGST=NHS Clinical Governance Support Team; NAPCE=National Association of Primary Care Educators; PDP=personal development plan; SRT=structured reflective template

NAPCE, NCGST Appraisal Support Group. Evidence for medical appraisal: essential/optional. Statement of the NAPCE/CGST Conference, February 2007. Reproduced with kind permission. Available at: www.appraisalsupport.nhs.uk

Challenges ahead

GPs who work regularly in one practice
Every GP needs to become accustomed to using the NHS toolkit and uploading all supporting data for revalidation to the toolkit. There is no certainty that this website will continue indefinitely, but it is secure and is currently being redesigned so that the evidence component (but not confidential details) may be viewed by the PCT’s responsible officer.

The practice should arrange its own patient survey with separate results for each GP, and a colleague survey. There are commercial companies that will do this at a cost, but it is not difficult for a practice to perform a survey with in-house resources. The GMC will soon be publishing its validated surveys for both patients and colleagues, but there are several others that can be used in the meantime, allowing everyone in the practice to become used to the process. Any practice that runs their own colleague survey now, and provides evidence of learning from it, will not be penalised because they took action before the validated surveys are published. Examples can be found at www.oxfordprimarycarelearning.org.uk and from PCT and Deanery websites.

GPs in exceptional circumstances
The RCGP guide provides a framework for GPs who have been away from practice, to demonstrate competence through the use of knowledge tests and clinical skills assessments.1 Other tools, which are in development, will allow GPs to demonstrate how well they deliver services from the patient viewpoint, and how they interact with their colleagues. It is debatable whether these will be a better guide to how effectively a GP works from day to day than a knowledge test or simulated surgery. However, it is likely that this approach will be welcomed by many GPs who would prefer not to be sitting multiple choice questions to test their medical knowledge when, in practice, they consult internet resources if they are in doubt.

GPs working as peripatetic locums
GPs who work as a locum in a practice for several months will be able to gain data for all parts of the revalidation process. Locums who work in many different practices and for only a few days at each time will have more difficulty in collecting evidence. In Oxfordshire we have worked with a group of locum GPs to refine the tools needed to gain the necessary data, and these can be accessed at: www.oxfordprimarycarelearning.org.uk. There are several web-based resources that consider appraisal from the viewpoint of a sessional GP, including:

  • Tools for GP appraisal4
  • The National Association of Sessional GPs website5
  • NHS Education for Scotland website6
  • Cardiff University website (which includes ideas on sessional GPs audits and significant event reviews).7,8

Actions for sessional GPs are now the same as GPs working in practices regularly, although they may be harder to carry out. It is worth sessional GPs meeting with each other to obtain and provide help with continuing professional development (CPD) and reflective learning.

GP appraisers and tutors

The evolution of GP appraisal to ‘enhanced appraisal’ (i.e. appraisal fit for revalidation) is already a source of concern to many GP appraisers. Tutors and GP appraisal leads have a role in aiding this process by ensuring that appraisers are confident about the changes. Appraisers need to be able to guide the GPs they meet during the appraisal discussion this year to see what extra evidence needs to be gathered and how this may be done most appropriately.

Some appraisers have expressed concern about assessing learning credits. Pilot schemes so far have indicated that GPs tend to underestimate the number of credits their efforts would merit. Tutors will need to guide both GPs and their appraisers in showing how the new learning credits system will work. This system is in the pilot stage so everyone is still getting used to the new concept.

As with any process of change, some GP appraisers will not feel equal to all that is now needed. Despite every effort made by appraisal leads and tutors, some GP appraisers may now resign, and PCTs will need to consider how to recruit and train new replacements.

Summary

Revalidation brings challenge to GPs, appraisers, tutors, and PCTs. To help with implementation of the process, the following steps should be taken:

  • all GPs need to be able to provide the evidence to support appraisal and revalidation in advance and in an electronic format
  • tutors and appraisal leads need to distribute information to everyone via websites, emails, and meetings to provide guidance and advice on preparing information for revalidation
  • appraisal leads need to ensure that all GP appraisers are able to provide guidance for every GP they meet this year so that information on supporting revalidation can be provided in the future according
    to the individual working circumstances of the GP being appraised
  • PCTs need to appoint responsible officers and decide how their local clinical governance mechanism will work to support GP revalidation. A response to a consultation on responsible officers can be found on the Department of Health website9
  • PCTs may need to recruit and train GP appraisers able to provide enhanced appraisal.
  1. Royal College of General Practitioners. RCGP guide to the revalidation of general practitioners. London: RCGP, 2009. Available at: www.rcgp.org.uk/revalidation.aspx
  2. NHS Appraisal Toolkit: www.appraisals.nhs.uk (accessed 11 June 2009).
  3. NAPCE, NCGST Appraisal Support Group. Evidence for medical appraisal: essential/optional. Statement of the NAPCE/CGST Conference, February 2007. Available at: www.appraisalsupport.nhs.uk/news4.asp?item=08052007090123
  4. Wright P. Tools for GP appraisal. 2007. Available at: www.bma.org.uk/employmentandcontracts/doctors_performance/1_appraisal/appraisaltoolkit120508.jsp
  5. National Association of Sessional GPs website: www.nasgp.org.uk
  6. NHS Education for Scotland. Scottish online appraisal resource—Appraisal evidence for sessional GPs. Available at: www.scottishappraisal.scot.nhs.uk/appraisal-preparation/sessional-gps.htm
  7. Cardiff University website. All about audit: a practical guide to the audit process. gp.cardiff.ac.uk/all_about_audit.htm (accessed 1 July 2009)
  8. Cardiff University. Appraisal support pack: referrals, prescribing and out of hours. Available at: gp.cardiff.ac.uk/downloads.php?file_id=471
  9. Department of Health. The role of responsible officer—response to the consultation on Responsible Officers and their duties relating to the medical profession. London: DH, 2008. Available at: www.dh.gov.uk/en/Consultations/Responsestoconsultations/DH_098851.G