Dr Andrew Hilson FRCP



Revalidation Specialty Representatives’ Group Meeting

Meeting held on 3 August 2011 from 14.00 to 17.00 at the Royal College of Physicians

|ATTENDEES | |APOLOGIES | |

|Sarah Campbell |Royal College of Physicians |Andrew Goddard |Royal College of Physicians |

|Helen Brownridge |Royal College of Physicians |John Quin |Association of British Clinical |

| | | |Diabetologists |

|Ian Starke |Royal College of Physicians |Jennifer Quirk |Association of British Neurologists |

|David Parry |Royal College of Physicians |Tim Peel |Association of Palliative Medicine |

|Elaine Tait (t/c) |Royal College of Physicians Edinburgh |Stephen Jones |British Association of Dermatology |

|Patrick Sharp |Association of British Clinical |Peter Belfield |British Geriatrics Society |

| |Diabetologists | | |

|Ian Judson |Association of Cancer Physicians |Paul Knight |British Geriatrics Society |

|Des Green |BNMS (Nuclear) |Lynne Turner-Stokes |British Society of Rehabilitation Medicine |

|Catriona Irvine |British Association Dermatology |Mike Homer-Ward |British Society of Rehabilitation Medicine |

|Deirdre Lucas |British Association of Audiovestibular |Graham Burns |British Thoracic Society |

| |Physicians | | |

|Ewa Raglan |British Association of Audiovestibular |Nick Clements |Faculty of Forensic and Legal Medicine |

| |Physicians | | |

|Mike Jones |Acute Medicine |Rod Jaques |Faculty of Sport and Exercise Medicine |

|Simon Ray |British Cardiovascular Society |Paul Harrison |Haematology |

|Chris Moore |British Society for Clinical |Eoin O'Sullivan |Medical Ophthalmological Society UK |

| |Neurophysiology | | |

|Adam Harris |British Society for Gastroenterology |Peter Drew |Renal Association/Nephrology |

|Mark FitzGerald |British Society for Sexual Health and HIV |Ian Rowe |British Society for Rheumatology |

|Stephen R Durham |BSACI (Allergy) |John Wass |Society for Endocrinology |

|Alan Fryer |Clinical Genetics |Linda Patterson |RCP |

|Mike Galloway |Haematology |Winnie Wade |RCP |

|Anthony Bradlow |British Society for Rheumatology |Neil Baldwin |British Association of Stroke Physicians |

|Derek Waller |British Pharmacological Society | | |

Welcome and Introductions

• IS welcomed Sarah Campbell, new Strategic Programme Manager for Revalidation at the RCP.

1. Revalidation for Physicians: key updates since the last meeting

• There is ongoing discussion on the focus for Quality Assurance, which may include the process for reaching the recommendation, and/or the recommendations themselves.

• Various Health Select Committee reports have been released relating to revalidation. The report last year raised the need to clarify a robust process for remediation. The recent report requested that the college requirements are made clear, and that the GMC need to demonstrate that everything is being put in place. It was supportive of the roles of colleges.

• There is debate over the word ‘remediation’ – this would apply to some but not everybody, and does not really cover what happens higher up the scale, when NCAS are involved.

Revalidation Guidance for Physicians – consultation

• The Academy has produced a core specialty supporting information framework, and each college has now populated a version with additional specialty guidance where necessary. The physician guidance document is now available in the public domain on the website for comment, deadline 22 August. RCPE is undertaking a similar exercise.

• It is important to focus on whether this document is adequate for all physicians. An e-mail with specific questions was circulated to this group.

• The final version will be piloted as part of the final phase pilots commencing in September.

• It was suggested that it would be beneficial to have steps demonstrating what physicians needed to do (key monthly activity) in the run up to revalidation.

• The roll out of revalidation will be based on organisational readiness assessments, and the percentage of doctors per trust is being discussed.

• The definitive version of this document will be on the website from 31st August. After this initial consultation, we will focus on additional physician specialty/sub specialty guidance, which may be included at the back of the document if necessary.

Action: group to feed back (sub) specialty guidance elements the week following the 22nd August, following feedback on generic physician content. IS/HB to send relevant instructions.

• It was suggested that it needs to be made slightly clearer about the optional nature of the activities listed in review of practice; can more detail be given, e.g. an audit OR two of the other activities etc.

• Need to suggest RCP guidelines and tools, and physician specialties need to advise on appropriate audits.

The Medical Appraisal Guide consultation

• The Revalidation Support Team (RST) England has released for consultation the draft Medical Appraisal Guide and associated documentation that will be tested in the next phase of pilots.

Action: this group is highly encouraged to feedback as soon as possible in August, prior to the start of the piloting of MAG in September. Feedback can be provided through a link to survey monkey. Improvements need to be made via the consultation. Please visit the RST website.

• The RCP is going to respond with suggested improvements. One main issue is there is virtually no reference to the specialty guidance. We are working hard to ensure that there is joined up thinking represented by the GMC, the Academy and the RST. The MAG focuses on the elements of appraisal, not specifically supporting information – which is where the GMC and College guidance feed in.

Initial feedback/queries were captured as follows:

• There is still some confusion over what is specific to revalidation and what is clinical governance/performance management.

• It was asked whether the MAG would be mandatory for trusts, or just guidance. This raises important questions – an appraisee may be able to challenge a decision and say due process has not been followed.

• There is a user guide for the MAG which contains instructions/examples, to be included on the website. The detail needs to properly align, some of the wording is confusing.

• The MAG only applies to England. Process may differ across the UK which could be confusing.

• It was suggested that the MAG is fairly similar to what is already done – however appraisal processes currently vary greatly in trusts.

• Does the appraisee agree the appraiser statement before it goes to an RO? There needs to be clarification on the potential dissemination of the appraisers statement.

• There needs to be QA of the appraisal discussion and process, and clarity over what happens if the GMC want to review it.

• Need clarification on the interface between revalidation and clinical governance, and the disclosure of problems.

2. Revalidation framework for physicians

Sub specialty guidance

• Some work has been done on this previously, but feedback will be sought at the end of August for any further specialty elements that relate directly to the physician guidance document.

3. Specialty guidance and support for appraisal

College support for appraisers and ROs: role of the advisor

• Relating to the specialty guidance is specialty support from colleges for ROs and appraisers. It needs to be clear who an RO can go to for specialty advice (as well as a doctor/appraiser).

• Having a lot of advisors could lead to inconsistency in advice, which can create problems.

• From RCP perspective there are regional and specialty advisors, although not all colleges have these. IS explained that there needs to be consistency across colleges and faculties as far as possible. The project group responsible for developing the core guidance is now looking at potential processes.

Support from physician specialty associations

• There are different mechanisms for support in physician specialties currently, some have specialty advisors, others go through the college regional advisor as the first port of call, who then feeds back to the relevant organisation as necessary. Some manage queries through the JSCs and intercollegiate committees.

• One option is for an RO to go directly to the college, and the college can direct the query to the relevant advisor. This would mean ROs would not need to consider numerous contacts for each specialty. ROs will need advice when there is perception of a problem, at an early stage although specialty experts may be required at the later stages of remediation as well.

• Some physician specialties have regional advisors. JSCs have specialty and sub specialty expertise, including RSAs. For technical aspects, the specialty associations would need to advise.

• There needs to be robust information on the website e.g. what are good audits in that specialty.

• It is important to consider that in revalidation, if an organisation is providing advice at anything more than the guidelines, they may be at risk. College advice should relate to the guidance and process.

• It was suggested that advice on revalidation would need a revalidation officer, whereas sub specialty practice queries would need the specialty association. It was considered whether one option would be college trained revalidation officers in each specialty. The college could hold centrally the contact list, and direct the queries.

• Low level advice should be around the standards and supporting information. Early level advice may still be subject to review and used in evidence later on. Interpretation of standards may vary.

• It was highlighted that ROs may use their own experts (outside of the college), and may go to their RO with revalidation queries in the first instance. However the college needs a clear process of support.

• The college will need to consider workshops for training advisors, wherever they are based e.g. an association, JSC etc.

• RO training needs to incorporate the specialty frameworks.

• The advisor training would have to be considered in light of individuals job plans, time out of NHS etc.

4. Remediation

Mechanisms for specialty support and remediation

• The RCP is considering specialty support mechanisms to enable or provide remediation where it seems a doctor is slipping below the line. This will in the main be where enhanced PDP may be required which will identify actions for the year, and may include e.g. targeted learning/access to re-training.

• There are different stages of remediation – please refer to diagram in slides.

• Appraisers need to be aware of the specialty take on supporting information.

• NCAS have experience of managing problems toward the higher stages but there is a gap at the lower level end, and processes need to be clear. NCAS support a staged process.

• MF explained that this needs to be highlighted, because it will alter current mistaken attitudes that revalidation is a case of pass or fail with no intermediate stage.

• It was suggested that there may be a conflict if the college supports remediation at a low level but in later stages becomes part of the judging process.

• The assessment of someone successfully implementing remediation is difficult. There is a dichotomy of appraisal and assessment. Also currently, suspension can happen at an early stage, much before referral to the GMC. IS confirmed that clinical governance processes will always be there to act in the interest of patient safety and can bypass perceived stages.

Action: amend to say directed activity, not directed remediation activity.

• The RO is responsible for putting remediation in place, and can seek help from external agencies. There are already mechanisms in place to deal with SUI, complaints etc. MDs currently make a judgement on whether to call in external assessors.

• The RCP can confirm that an individual has undergone an activity successfully, but not make a statement as to whether that individual has been successful or that there will be a resulting improvement back at the trust. The RO would have to assess whether the problem has been resolved. The college can state whether standards have been met at the end of the training programme.

• Concern was expressed on the legal responsibility of specialty associations stating a doctor has successfully been retrained, leaving them liable to be sued.

• There is concern that ROs who aren’t certain about these issues may delay revalidation. There is no structure to where an RO goes to with queries. It needs to be clear where the legal liabilities lie. Colleges/ specialties would purely be providing the means by which a doctor can be remediated, and provide adequate support for ROs

• Colleges/specialties will have a role in the diagnosis and design of the training.

Action: IS to raise these points with GMC and RST.

5. Quality Assurance

• The RCP is currently considering the needs for QA of appraisal. The GMC/RST have confirmed they don’t want to QA appraisal, and ROs can’t QA their own appraisal processes. There may be a role for the Academy/colleges.

• There was reluctance from the group for colleges to take this on

• Guidance is needed on what a good appraisal looks like and some of this is covered by the MAG. There needs to be guidance on the quality of appraisal.

• The GMC has said that colleges may need to be involved in QA of the decision making process, and of outputs. The Academy is pushing for involvement of QA of outputs, with annonymised documentation, and certification of ROs.

• The GMC has also mentioned looking at a certain percentage audit of all organisations, and those giving cause for concern if highlighted. They also state ‘soft intelligence’ will have part to play.

• The RCP can look at how QA of appraisal may happen. It doesn’t need to be undertaken by a doctor, it can be done by a manager.

• MD/RO conflict of interest remains a concern. It was highlighted the ROs will be subject to scrutiny from their RO, and will have to produce evidence for appraisal.

Action: the RCP will continue to press the GMC for the process to be agreed.

MSF

• The RCP is looking to potentially undertake piece of work looking at the process for how MSF is fed back in appraisal, including whether the feedback should be held at an appraisal meeting, or in a separate meeting, and the action plan taken to the appraisal; also who does the feedback.

6. Any Other Business

• It was asked whether preparation for revalidation would be included in SPAs. The view of the DH is that there will be no extra time/resources required. Experience from the pilots show that preparation time for doctors currently ranges up to 15hours. Data is being collected to make recommendations. Trusts are allocating time for appraisers but not appraisees.

• It is also the obligation of the employer to make the necessary information available.

IS asked what would be useful to have on the RCP website. The following suggestions were raised:

• A countdown to revalidation – stating if it is unknown yet

• When will trusts know?

• Preparation for revalidation

• Draft templates and when they will be available

Action: IS/SC/HB to look at providing forms on the website

Date of the next meeting: TBC

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