Revalidation in the United Kingdom: general principles based on experience in general practice

Professional self regulation is at the heart of the organisation and philosophy of medical care in the United Kingdom. However, demands are growing for increasing transparency and accountability to patients in systems for ensuring doctors' standards. In response to this, the General Medical Council (GMC) has made a commitment to introduce periodic revalidation for all doctors on the medical register after 2002. Every five years all doctors will have to submit evidence that they are practising in accordance with clearly defined guidelines. There is debate about what methods of professional assessment are most closely linked with professional performance. In this article we describe an approach to establishing revalidation in the United Kingdom, highlighting areas of uncertainty and using examples of work in progress in general practice.

Methods

This article is based on our work in developing the performance procedures for general practitioners. The proposals are based on international guidelines for good practice in devising assessment programmes which emphasise the importance of using methods relevant to the purpose and content of the assessment.¹,²

Content of revalidation

Revalidation will be a proactive, inclusive programme, designed to demonstrate that the performance of doctors is acceptable. It will apply to all doctors on the register, be conducted locally by peers and lay people, be monitored nationally by the GMC, and must be implemented with a “light touch” if it is to succeed.

It is essential that an assessment programme assesses what it purports to assess.¹ Revalidation should therefore seek evidence of a safe standard of practice for all areas in which a doctor works, both clinical and managerial. This presents particular problems for specialist practice. There are professional debates about core competencies for specialists (for example, in diabetes or breast surgery) who are on call as generalists for patients being admitted to busy hospitals all over the United Kingdom.² They will need to be revalidated—albeit at the level of basic competency—for all these activities. If, as a response, these doctors were to work only in their specialty there would be a severe workforce crisis throughout the NHS. Such issues must be openly aired, with the public and the funders of health care, as revalidation is implemented.

Actual practice has two components. The first is generic to all doctors and is expressed in the GMC's guidance document Good Medical Practice.³ This document proposes a wide definition of competence, including relationships with patients, teamwork, participation in continuing professional development, and a commitment to maintaining performance alongside the traditional competencies in diagnosis, management, and practical skills that make up good clinical care.

In any discipline the generic attributes will be manifest within specific elements common to all of its practitioners. It is on this basis that several royal colleges have begun to elaborate Good Medical Practice for their members. The Royal College of General Practitioners' Good Medical Practice for General Practitioners⁴ contains a definition of the excellent and the unacceptable general practitioner in relation to all areas covered in Good Medical Practice (box).

Examples of criteria for the unacceptable general practitioner⁴

Clinical care

Does not listen to patients and frequently interrupts

Fails to elicit important parts of the history

Is unable to discuss sensitive and personal matters  with patients

Fails to use the medical records as a source of further  information about past events

Fails to examine patients when needed

Undertakes inappropriate, cursory, or inadequate  examinations

Does not explain clearly what he or she is going to do  or why

Does not possess or fails to use diagnostic and  treatment equipment

Undertakes irrelevant investigations

Shows no evidence of a coherent or rational approach  to diagnosis

Reaches illogical conclusions drawn from the  information available

Gives treatments that are not based on best practice or  evidence

Has limited competence, and is unaware of where  limits of competence lie

Keeping records and keeping colleagues informed

Keeps records which are incomplete, illegible, or  contain inaccurate data

Does not keep records confidential

Does not take account of colleagues' need for  information

Keeps records which are not in date order

Consistently consults without records

The second component of actual practice comprises the clinical problems which face the doctor. The generic attributes should be assessed in relation to common and important problems with which the doctor will be faced. This has implications for the type and range of evidence that must be supplied to support revalidation.

One possible model for revalidation is to focus assessment on a few key areas in Good Medical Practice that are relevant to a specialty with briefer coverage of the remaining standards in the guidance for registration. The box lists the areas which the Royal College of General Practitioners has suggested should be assessed in revalidation.

The importance of this approach is that revalidation maps back directly to the national guidance for all doctors on the GMC register. It illustrates that for revalidation to be implemented locally for all doctors, the detailed work of defining content must be done by peers.⁵ Participation and leadership from the royal colleges, specialist associations, and other professional groups will be essential.⁶ The input of lay people is also critical to ensure coverage of areas to do with communication and attitudes to patients.

Assessment methods

Assessment of performance in practice has high validity, but the reliability of the evidence depends on sampling doctors' work systematically and training peers and lay people as assessors. This must be balanced against the resources available to the profession and the effect on service delivery. The process of collecting evidence must easily be incorporated into doctors' daily work, and the evidence must be valid and reliable, stem from an approved source, withstand public scrutiny, inform and improve standards of health care, and be capable of supporting local assessment for revalidation.

Determining the content of doctors' practice

One of the primary tasks in establishing revalidation will be to develop a template for an “extended curriculum vitae” which will enable doctors to present themselves, their education and experience, and their clinical practice to the assessors. This document should have a common structure for the whole profession. It will enable the content for revalidation to be established and allow identification of the appropriate peer group to evaluate the evidence submitted by the doctor.

Aspects of good medical practice for general practitioners that could form basis for revalidation

Professional values:Overall standards in Good Medical Practice

Professional relationships with patients—maintaining trust:Communication

Keeping up to date and maintaining your performance:ReflectionEducationChanges in practice when appropriate

If things go wrong:Complaints procedures and complaints

Good clinical care

Medical record keeping and informing colleagues

Access and availability

Working with colleagues and working in teams

Effective use of resources

Some doctors have unusual patterns of practice, and how evidence will be collected and evaluated in these circumstances remains unresolved. It is not an option to review only a section of an individual's practice; patients expect more.

Professional values

Professional values can be self reported, perhaps withinthe extended curriculum vitae, and countersigned by a colleague. But they may be best assessed through peer review. The system adopted by the American Board of Internal Medicine and the Royal Australian College of Physicians, in which doctors ask 15 colleagues to report on their performance,⁷,⁸ has proved reliable and might be useful in the United Kingdom, particularly as the data could be collected and analysed nationally. This would make it cost effective, remove it from local influences, and provide an opportunity for feedback to the doctor.

Professional relationships with patients

Maintaining trust within relationships with patients is part of professional performance and therefore part of revalidation. Communication skills must form part of the assessment of all doctors' fitness to practice. They might be assessed through a survey of patient views⁹,¹⁰or through another doctor assessing consultations.

In future data will be available from the annual national survey of user and patient experiences, which will be carried out as part of the national framework for assessing performance.¹¹ Coordination between government and the profession could avoid duplication and ensure the collection of relevant information. However, identifying the performance of individuals within the performance of large organisations will pose difficulties.

Keeping up to date and maintaining your performance¹²

With the move from continuing medical education to continuing professional development¹³ doctors will be expected to show how their educational needs are identified and then met. When appropriate, this should be mapped through into changes in services and patient care.

To assess their educational needs, doctors should reflect on their practice. They will also wish to take part in the audit of groups of patients and case reviews. These include confidential inquiries, case based discussions, significant event auditing, critical incident analysis, and monitoring of adverse events. All of these activities will be recorded in the extended curriculum vitae as evidence for revalidation, with further evidence available should the local peer group require it.

If things go wrong

Every doctor will be expected to show appropriate responses to comments or complaints from patients and to discuss patients that experience poor care outcomes openly with colleagues. Cooperation with effective complaints procedures will be expected, and each doctor could document this aspect of practice within the extended curriculum vitae.

Further areas of evidence

For most doctors working in the NHS, evidence about their performance will be collected as a result of the establishment of clinical governance. Much of the evidence will be about process, with some proxies for outcome.¹⁴ When outcomes are readily available, as in mortality after surgery, they will be used. But outcomes are unlikely to form the main evidence of performance until there is confidence that they truly reflect performance and are sensitive to context.¹⁵ This, of all the evidence to support revalidation, requires the most work and greatest cooperation between stakeholders.

Other routes to revalidation

Some doctors may wish to submit evidence of a higher standard of practice than that required for revalidation. Many general practitioners, for example, are planning totake part in peer review programmes such as fellowship by assessment (FBA) or membership by assessment of performance (MAP). These programmes are congruent with Good Medical Practice, and it seems sensible that such activities should be acceptable for revalidation of registration.

Making the assessment

The judgment on revalidation will be made by a trained and accredited panel which will include lay people as well as senior professionals. Trained lay assessors are vital for the credibility of revalidation and can assess all aspects of a doctor's performance except technical competency.

The revalidation judgments must be made and documented against predetermined standards. Doctors must clearly understand what is expected of them and have access to support and mentoring when preparing their evidence. When a doctor does not seem to meet the initial requirements further assessments should be made. Support and education should be provided to enable the standards to be met.

Exceptionally, a doctor may not respond to professional support or may be underperforming too severely. In these cases, the GMC will be informed. This referral may result in an assessment under one of the GMC's fitness to practice processes. Only the GMC can decide to remove a doctor's name from its registr.

Organisation of revalidation

We visualise several regional revalidation groups for each discipline, although smaller specialties may require only one. Such groups will need to be identified, trained, and monitored by national professional organisations, usually the royal colleges. In turn these national professional organisations will be recognised by the GMC. Each local revalidation group will represent the interests of the specialty concerned, the local professional organisations, the public, and doctors in health services management.

A doctor will apply to the local group for revalidation, offering the evidence agreed by that discipline. It is likely that the evidence will be assembled by each doctor over five years, and as the organisation of revalidation becomes clearer, mechanisms to support this process will develop. For most doctors the local group will recommend revalidation direct to the GMC. The work of the local group will be monitored and quality assured by the appropriate college.

This means that the evidence for revalidation must be in a standardised form so that a national standard can be guaranteed for the public. Although the GMC may receive only a single sheet of paper, the audit trail must lead back to individual components that support the statement. There will need to be equivalence across specialties, area, and settings, whether in the NHS or the private sector.

Figure.

Assessment of communication skills will be an integral part of revalidation

Editorial by Buckley