Professor Catto's editorial in APT on the regulation of healthcare professionals in the UK (Reference CattoCatto, 2008) sets out the government's proposals included in the White Paper Trust, Assurance and Safety – The Regulation of Health Professionals in the 21st Century (Secretary of State for Health, 2007a ). This document is likely to have significant consequences for future medical practice and it is therefore important that doctors are aware of what has been proposed and how it is likely to be implemented. It is also important to remember that the White Paper sets out a framework for the regulation of all healthcare professionals, not only the medical profession. It is possible, however, that medical regulation will be introduced first.
The background to the White Paper is that a series of critical reports about now notorious doctors raised, in the government's mind at least, the question as to whether the existing medical regulation was adequate (Secretary of State for Health, 2007b ). The document presents a considered view of the concerns, noting that,
‘Whilst patients and the public rightly hold the substantial majority of health professionals in high esteem, the need for reform to sustain confidence in the regulation of health professionals has been underlined by the findings of a number of high profile inquiries into doctors who have harmed their patients, most notably the Shipman, Kerr-Haslam, Ayling and Neale inquiries.’
Dame Janet Smith's fifth report on the Shipman Inquiry (Reference SmithSmith, 2004) was critical of the General Medical Council's (GMC's) proposals for revalidation, particularly the emphasis placed on the appraisal system, which she recommended be ‘toughened up’. She rightly asked the question, ‘What assurance is formative appraisal to patients?’
The White Paper, although recommending significant changes to regulation, is a balanced document. The key principles set out in the foreword by the then Secretary of State are as follows:
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• first, the overriding interest should be the safety and quality of the care that patients receive from health professionals
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• second, professional regulation needs to sustain the confidence of both the public and the professions through demonstrable impartiality
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• third, professional regulation should be as much about sustaining, improving and assuring the professional standards of the overwhelming majority of health professionals as it is about identifying and addressing poor practice or bad behaviour
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• fourth, professional regulation should not create unnecessary burdens, but be proportionate to the risk it addresses and the benefits it brings
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• finally, we need a system that ensures the strength and integrity of health professionals in the UK, but is sufficiently flexible to work effectively for the different health needs and healthcare approaches within and outwith the NHS in England, Scotland, Wales and Northern Ireland.
In the introduction, the Chief Medical Officer emphasises the concept of risk-based regulation and notes the core principles of proportionality, accountability, consistency, transparency and targeting required to bring a common-sense approach to regulation, recognising that time spent demonstrating continuing competence is time lost to patient care.
These principles should reassure doctors that revalidation is not intended to be an overly bureaucratic exercise but should be part of a process that looks to raise medical standards.
What might revalidation look like for psychiatrists? All psychiatrists will need a licence to practise. Those on the specialist register will also need to be recertified. The recertification process for psychiatry is being led by the Royal College of Psychiatrists, in conjunction with the Academy of Medical Royal Colleges, to ensure a uniformity of standards across the profession. Revalidation should be considered as one process which will have two outcomes – a licence for all doctors, with additional recertification for those on the specialist register.
The GMC intends to be ready to issue licences by the end of 2008. The necessary requirements for a licence will be as in Catto's editorial. Recertification will be based on additional requirements over and above the core relicensing requirements.
At the heart of revalidation will be a strengthened appraisal system. It will continue to have a formative component but will in addition have an important summative element, which will ensure that the necessary criteria for revalidation have been met.
Key components of appraisal over a 5-year cycle will include:
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• multisource feedback
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• evaluation against the standards of the GMC's Good Medical Practice (for all doctors) and the College's Good Psychiatric Practice (for psychiatrists on the specialist register)
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• participation in continuing professional development (CPD; also known as continuing medical education, CME)
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• participation in clinical audit
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• proof of satisfactory clinical skills.
Work to be done to establish the new appraisal process includes:
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• clarification of the formative and summative aspects of the appraisal process
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• ensuring that the appraisers are appropriately trained and accredited
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• determining at what level the ‘bar’ should be set and what action needs to be taken if this is not reached; such action might include:
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• educational support
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• work with National Clinical Assessment Service
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• a College-invited review mechanism
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• determining an external audit and quality assurance process.
Appraisal will bring together information from several sources: multisource feedback, adherence to clinical standards, CPD, participating in clinical audit and the evaluation of clinical skills.
Multisource feedback
The GMC will produce a multisource feedback tool to be used for all doctors as part of the relicensing process. Discussions at the Academy of Medical Royal Colleges indicate that the GMC instrument will contain the minimum core questions, with each College being able to add further items according to its own requirements.
The Royal College of Psychiatrists already has a multisource feedback tool, the ACP 360 (www.rcpsych.ac.uk/crtu/centreforqualityimprovement/acp360.aspx). The current version will be amended in light of comments from members who have participated in the process so far and also to incorporate the GMC core questions. The new tool will also need to map onto the relevant domains of Good Psychiatric Practice (Royal College of Psychiatrists, 2008).
In the College, multisource feedback will probably be incorporated into the appraisal process. Both members and appraisers will need guidance on actions to be taken in response to significant negative comments on feedback forms.
Multisource feedback will be only one way of assessing a doctor's performance and it needs to be seen in that context. It is not a pass or fail process.
Clinical standards:
Good Psychiatric Practice
The setting of standards for specialist recertification is a crucial area for the College to lead on and ensure the validity and reliability of the recertification process. The College standards, as will be set out in a revised edition of Good Psychiatric Practice (Royal College of Psychiatrists, 2008), will form the basis of the standards expected of a specialist psychiatrist. They must be objective as far as possible and discriminatory – that is they must enable a distinction to be made between good, satisfactory and poor performance. This work will be coordinated through the College's Special Committee on Professional Governance and Ethics.
To achieve recertification, members will be expected to show that they have met and achieved the standards of Good Psychiatric Practice. This will be demonstrated through the appraisal process.
Continuing professional development
The College already has standards for CPD and a CPD accreditation service (www.rcpsych.ac.uk/training/cpd.aspx). The Academy of Medical Royal Colleges has set out ten principles for CPD, likely to be incorporated in a new edition of the current Good Psychiatric Practice: CPD (Royal College of Psychiatrists, 2001), which will be revised this year to meet the standards of recertification. This work will be coordinated through the College's CPD Committee.
Participating in clinical audit
The College needs to set standards for the appropriate mechanisms for evaluating clinical practice. There are several options, including:
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• the use of clinical outcome measures benchmarked against colleagues
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• evaluation of clinical practice in a peer review setting
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• participation in audits of national guidelines.
It is likely that this will be a new and ongoing role for the College, which will link with that of the National Clinical Audit Advisory Group established by the Chief Medical Officer.
Evaluation of clinical skills
Evaluation of clinical skills may include tests of knowledge, skills and performance. The College has developed workplace-based assessmentsFootnote † for trainees, which could be adapted for the purposes of recertification. This will increasingly be seen as acceptable by members as doctors graduate through the new run-through training grades, which will have included ongoing monitoring of clinical skills.
It is hoped that a two-stage process will be approved for the evaluation of clinical skills. All doctors would participate in stage one, with only those about whom concerns have been raised going on to more detailed assessment in stage two.
The Health and Social Care Bill (http://services.parliament.uk/bills/2007-08/healthandsocialcare.html) was introduced to Parliament on 15 November 2007. Part 2 of the Bill provides for the establishment of the role of responsible officer to oversee local elements of revalidation and the sharing of information on concerns about doctors.
It is recognised that consultants may undertake specialist roles such as teaching, research and management. Also, some consultants have particular specialist and supraspecialist skills. Appropriate recertification modules will be needed for such individuals.
Revalidation has the potential to help maintain high standards of practice using a process that has both the confidence of the public and the support of the profession. There is a danger that the process will become a bureaucratic exercise for which the benefits are not proportionate to time spent – each hour that doctors spend in revalidating one another will be an hour taken away from patient care. The revalidation process should allow those who are working to acceptable standards to be revalidated without undue difficulty or stress, while providing early warning for those whose practice may fall below acceptable standards.
The College will work closely with Members and Fellows, the GMC, the Academy of Medical Royal Colleges, service users and other stakeholders to ensure that the laudable aims of revalidation are met for psychiatry.
Declaration of interest
None.
eLetters
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