Reaccreditation - Current State of Play

The issue of reaccreditation has assumed great prominence in recent years. The conviction of Dr Harold Shipman and the subsequent inquiry¹ and recommendations sparked major concerns about patient safety, the regulation of doctors and public confidence in the regulatory processes. A long period of consultation by government with representatives from various professional bodies and interested groups has followed.

This has had implications for doctors but also for governance more widely within the health service. It is important to consider the wider background to the changes in reaccreditation of doctors so that the current state of play can be better understood. It is appropriate to consider these implications and how to prepare for further anticipated changes.

Professor Scotland from the National Clinical Assessment Service (NCAS) summarises the 'governance challenge' posed by medical scandals such as that of Harold Shipman:²

• Was poor performance tolerated more than it should have been?
• Was the NHS able to learn from mistakes? It was apparent that there were common features in repeated service and individual failures and scandals.
• Were the systems for responding to these failures fit for purpose? These systems were considered outdated, unwieldy and bureaucratic. In addition they worked in an excessively legalistic, adversarial and court like manner.
• A culture of blame reflected or encouraged by the media response and reporting of incidents. In reality it can be difficult or impossible to distinguish individual failure and system failure from untoward incidents where no individual was at fault.

Professor Scotland summarises the wider response from government as:

• A statutory duty of quality placed on every health care organisation and underpinned by national quality standards (NICE/NSF) and support to local governance frameworks (Clinical Governance Support Teams or CGST).
• A national regulatory framework for private and public sector services (the Health Care Commission or HCC).
• National initiative to build systems for learning lessons on patients safety (the National Patient Safety Authority or NPSA).³
• National service supporting the resolution of concern at practitioner performance (NCAA/NCAS)

These processes are to form part of the means by which doctors are regulated.
The processes of reaccreditation (or recertification), revalidation and appraisal have been variously described:

• Reaccreditation is the process by which a doctor's continuing professional development, competence and fitness to practise is assessed, allowing revalidation of his or her registration status with the profession's regulatory body, which in the UK is the General Medical Council (GMC).⁴
• Revalidation is a set of procedures operated by the GMC⁴ to secure the evaluation of a medical practitioner's fitness to practise as a condition of continuing to hold a licence to practise. Revalidation's purpose is to 'create public confidence that all licensed doctors are up to date and fit to practise'. Its aims, in the GMC's view, are:⁴
  • To encourage all doctors to reflect meaningfully on their practice, using evidence gathered through audit and in other ways.
  • To update what being registered and being qualified means, by shifting the emphasis away from qualifications alone, to being up to date and fit to practise.
  • To replace the 'management by exception' approach that has been in place since 1858, by introducing regular confirmation that there are no significant concerns about a doctor's practice and that the doctor is up to date and fit to practise.
• Appraisals according to ACAS 'regularly record an assessment of an employee's performance, potential and development needs. The appraisal is an opportunity to take an overall view of work content, loads and volume, to look back on what has been achieved during the reporting period and agree objectives for the next.' Appraisal by one's peers and clinical mentors is currently part of educational supervision and employer career monitoring, but will in an amended form be part of a reaccreditation (or recertification) and revalidation process.

The Medical Act 1983

This recognised the need for revalidation and a clear public expectation that medical regulation should include measures to assure patients that consultants, and general practitioners, continue to perform effectively throughout their working lives. "We and patients are interested in performance, demonstrated day by day, not simply knowledge and skills displayed periodically under conditions removed from the doctor's place of work." GMC, 30 June 1998.

The Shipman Inquiry

The GMC's initial plans for the revalidation process were not introduced as anticipated in 2005, due to the reporting of The Shipman Inquiry. The report called into question the GMC's proposed mechanisms for ongoing revalidation of medical practitioners, reasoning that the arrangements as proposed would not have been sufficient to detect a problem in a case like Dr Shipman's.
Dame Janet Smith in the Fifth Report of the Shipman Inquiry further stated that:
'Local systems…if properly developed and well resourced, clinical governance could provide the most effective means of achieving two important aims. First, it could enable PCTs to detect poorly performing or dysfunctional GPs on their lists. It could also help practices to discover any problems or weaknesses among their own number. Second, it could have the beneficial effect of helping doctors who are performing satisfactorily to do even better. At the moment, I do not think it is achieving these ends.'

The subsequent White paper

On 21st February 2007 the Government published two documents:

• A White Paper, Trust, Assurance and Safety - the regulation of health professionals in the 21st century, and
• Safeguarding Patients - the Government's response to the recommendations of the Shipman Inquiry’s fifth report and to the recommendations of the Ayling, Neale and Kerr/Haslam Inquiries.

The White Paper Trust, Assurance and Safety – The Regulation of Health Professionals in the 21st Century (February 2007) set out the following recommendations:

• Medical Revalidation will have two components: relicensure and specialist recertification. All doctors wishing to practise in the UK will require a licence.
• The Department will consult with the General Medical Council (GMC), the profession, the medical royal colleges, patient groups, National Clinical Assessment Service (NCAS) and the Devolved Administrations, and develop proposals to commission and pilot appropriate national tools for multi-source (360-degree) feedback to support this process.
• The Department will discuss with stakeholders the most effective means for the introduction of an appraisal process with summative components. The quality of the process will be regularly assured by the GMC.⁴ The appraisal arrangements will need to take account of the large number of doctors who work outside the NHS as well as in NHS Trusts, Foundation Trusts and Primary Care.
• There are some non-medical professional staff, such as clinical scientists, who undertake higher specialist training and practise for most of their careers at a specialists autonomous level. The Department will work with the Devolved Administrations to establish a short term working party to consider how regulation and revalidation should reflect this.
• The Government agrees with the proposal for a three-board model covering undergraduate education, postgraduate education and continuing professional development.

The Medical Revalidation Working Group

The Chief Medical Officer, Sir Liam Donaldson, was asked to lead a consultation exercise involving the GMC, the profession and other interested parties.
As part of the implementation planning, the Department of Health (DH) held a stakeholder conference in London on 5th June 2007 to discuss the membership, terms of reference and work programmes of the various working groups. A national working group was established to pursue these recommendations. The Medical Revalidation Working Group is tasked with the development of a strengthened appraisal system for doctors and a new relicensing system for doctors.

Terms of Reference for the Working Group

'To consider the proposals in Trust, Assurance and Safety on revalidation and to make recommendations on the timely, effective and affordable introduction of a revalidation system - comprising re-licensure and re-certification of doctors. Further, to consider the impact of the introduction of such a system on medical education, training and continuing professional development.'
Particular considerations are:

• The role of appraisal in supporting revalidation.
• The appropriate balance between summative and formative components in appraisal.
• The scope, structure, standards and process for re-certification of specialists, GPs.
• The introduction of a multi-source feedback (MSF) element to appraisal.
• The role of GMC affiliates in appraisal and revalidation (liaising closely with the working group developing the role of affiliates).⁴
• Scope, structure and process for re-licensing all doctors.
• The relationship between appraisal and assessment for doctors in training.
• Links between re-certification of specialists and any appropriate measures for career grade doctors.
• Necessary measures for doctors who are not in substantive NHS posts or whose practice extends to more than one setting.
• Arrangements for doctors who are retired from practice.
• The timetable for the introduction of new processes.
• Embedding the principles of Good Medical Practice within curricula.
• Developing and enhancing the concept of professionalism.
• The assessment of educational progress as evidence for revalidation.
• The effect on medical education at all its stages of the introduction of revalidation.

Aims and timing for the Working Group

Revalidation:
The key task of this group is to develop, oversee and evaluate pilot projects (from across the specialities) that support a revalidation programme (jointly with the non-medical revalidation working group). This task is set to be completed by the end of 2008.
The aims are to :

• Establish standards to support summative appraisal.
• Set standards for specialist and GP recertification (to be developed by Royal Colleges).
• Establish methods of testing against the agreed standards for specialities.
• Develop a system of multi-source feedback (360-degree appraisal).
• Advise on a management information system that supports the process of re-licensure and recertification
• Ensure that an effective appraisal and revalidation system for all doctors is practical and affordable for the NHS and others.
• Establish a remediation strategy for those not meeting the relevant standards.
• To provide advice and support to GMC during the implementation phase of the new arrangements for relicensure and recertification (by October 2009)

• To provide options and advice on the establishment of a three board education model for undergraduate, postgraduate and CPD between GMC and PMETB.

'The White Paper sets out the key principles for a lasting settlement for professional regulation, but putting those principles into practice effectively will require the advice and participation of a wide range of stakeholders to ensure effective delivery.' The Working Group will continue to meet on a regular basis throughout 2008/09. Further information on the progress of the working groups will be published on the DH website.

There are some clues in the White paper:

• 'Appraisal In the absence of standards or standardisation of approach, the pattern of appraisal around the country is reported as variable. …Such practice, apart from having no value, undermines a process intended to benefit the quality of care.' Sir Liam Donaldson Good doctors, safer patients Chapter 5.
• 'Patients in the United Kingdom rightly have great confidence in their health professionals …The danger is that …we risk highlighting too much the poor practice or unacceptable behaviour of a very small number ……professionalism is an unquantifiable asset …which rules, regulations and systems must support not inhibit.' Secretary of State for Health, Foreword, White Paper.
• 'The core principles of proportionality, accountability, consistency, transparency and targeting are bringing a more common-sense approach to regulation.' Sir Liam Donaldson in the Introduction to White Paper, paragraph 23.

GMC role⁴

The GMC will issue licences to practise as soon as practicable. Before this can be done the GMC will have to:

• Collect personal data, including 'diversity data', for all doctors who want a licence.
• Use practice and other data to inform a risk based approach.
• Possibly accelerate initial revalidation for high risk groups and repeat the process at shorter intervals.

Medical revalidation

Medical revalidation will have two core components:

• Relicensure
• Specialist recertification:

• All doctors will have a licence to practise
• The licence to practise will have to be renewed every five years
• It aims to bring objective assurance of continuing fitness to practise
• The appraisal process will include summative elements which confirm that a doctor has objectively met the standards expected
• The relicensing process will generally be based on agreed generic standards of practice set by the GMC
• The license will be renewed on the basis that:
  • The doctor has engaged in an annual appraisal.⁵
  • The doctor has participated in an independent 360-degree feedback.
  • Any issues arising have been resolved.

• Will apply only to doctors who are on the specialist or general practice registers.
• Will demonstrate that they continue to meet the particular standards that apply to their medical speciality, including general practice.
• Will be a positive affirmation of the doctor's entitlement to practise.
• Occur at regular intervals of no more than five years.
• Where possible, it will coincide with relicensure.
• The process will be carried out by the relevant medical Royal College.⁶
• Based upon a comprehensive assessment against the standards drawn up by the college.
• Will be contingent upon a positive statement of assurance by that college to the GMC.⁴
• The evidence will vary between specialities.

Key issues

• The overwhelming majority of doctors will meet and exceed the standards required.
• Where doctors fail to satisfy the requirements of either element they should spend a period in supervised practice in order that a tailored plan of remediation and rehabilitation may be put in place.
• In the majority of cases, remediation is expected to result in revalidation and return to practice.
• Regulation will be risk based. If regulators operate effectively this will target resources where they are most needed.
• Risk assessment is an essential means of directing regulatory resources where they can have the maximum impact on outcomes.
• Regulators should use the resources released through risk-based assessment to provide improved advice, because better advice leads to better regulatory outcome.
• The revised system of NHS appraisal is an important part of the process. Key factors are likely to be:
  • The development of generic and specialist standards.
  • Translation of 'Good Medical Practice'⁷ into a framework for appraisal and objective assessment with a summative element rather than the current formative nature of appraisal.
  • The introduction of multi-source feedback (or 360 degree appraisal).
  • Development of roles to oversee and coordinate the process (role of responsible officer and a GMC affiliate) centrally and locally.
  • The relicensing process is expected to follow agreed generic standards of practice set by the GMC, a revised system of NHS appraisal and any concerns known to the medical director (or responsible officer).
  • The responsible officer will submit a formal list of recommendations to the GMC affiliate.
  • License renewal will then be on the basis that the doctor has engaged in an annual appraisal (incorporating participation in independent 360-degree feedback) and that any issues have been resolved.
  • Development of approaches to assessment for recertification in the time frames outlined.

National Clinical Assessment Authority and National Clinical Assessment Service²

It is worth also considering National Clinical Assessment Authority (NCAA) and how it will work alongside professional regulatory processes. The NCAA supports a service to health authorities, primary care trusts and hospital and community trusts who are faced with concerns over the performance of an individual doctor or dentist. This relatively new organisation will work alongside but independently of the professional regulatory process described.

The National Clinical Assessment Service (NCAS) promotes patient safety by providing confidential advice and support to the NHS in situations where the performance of doctors and dentists is giving cause for concern. Employing organisations, managers or practitioners themselves can contact NCAS for advice to help the practitioner to deliver a safe and useful service to patients. The NCAS Handbook explains the services in detail.

The NCAS describes a performance triangle of health, clinical capability and behaviour in the work context. Problems in any of these areas may give rise to concerns that have evaded the process of professional regulation.

It seems likely that in the near future a clearly-defined structured set of procedures will be introduced involving local NHS appraisal mechanisms and a new local and national system of monitoring and reporting. It is likely to involve examining supportive evidence, collected by medical practitioners, of their continuing professional and personal development, reflective practice and any issues such as health that may impact on their fitness to practise. To this end, it would be prudent for all doctors to collate and organise information that would support them in this process. The emphasis, on the basis of the tone of previous GMC opinion on the subject, should be on work-based information. Useful details to begin collecting might include:

• All information assembled for each and every appraisal^8,9,10,5,11
• Nature of work and working patterns
• Evidence of reflective practice (for example audit projects, research, risk-management initiatives, incident reporting and action to correct errors)¹²
• Peer and mentor support and supervision (including the NHS appraisal process)
• Clinical governance experience^11,13,14
• Educational details (including meetings, on-line learning, journal time, reading around cases/current medical issues, use of Webmentor)^15,16,17,14
• Membership of and involvement with medical societies
• Proof of having examined and complied with professional development advice from specialty college¹⁸
• Information concerning any personal health issues that may affect fitness to practise
• Maintain personal development plan (PDP)^19,20
• Collect some information on a practice basis (to share between clinicians and save time)

It is worth considering that appraisal in future is likely to incorporate:

• 360 degree appraisal. This implies feedback from everyone who works with you including staff, colleagues and patients.
• More summative information. This means incorporating 'measurable' or 'measured' elements.²¹ In theory any data currently being measured which can be ascribed to your own professional activity could be looked at more closely. It seems logical that with a risk based approach those who stand out from the crowd will attract closer scrutiny!

Appraisal in general practice appears often to have developed as a personal and quite 'closed' process. Opportunities to develop and improve practice performance may be overlooked. It is perhaps worth trying to derive benefit to the practice by:

• Sharing some of the information collected where practicable
• Sharing where possible appraisal outcomes, personal development plans and other aspects of individual appraisal which may benefit or affect practice development, practice management or partnership planning.