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Former RCGP chair suggests CSA exam should be scrapped

Exclusive Former RCGP chair Professor Clare Gerada has questioned the necessity of the controversial clinical skills assessment (CSA) aspect of the MRCGP exam as its pass rates are so high.

Speaking to Pulse, Professor Gerada sugggested that while the CSA exam had been found to be ‘very good’ and ‘robust’ by a judicial review in 2014, it could be time to look at scrapping it altogether.

Professor Gerada pointed out that there was a very high pass rate of 97%, and said the entrance exam for GP training was robust enough to weed out candidates not suitable to be GPs.

The CSA, which replicates a GP consultation with actors playing patients, has been controversial since its inception in 2007, but hit the headlines again in a 2013-14 row over whether it was fair to non-white medical graduates.

At the time, Professor Gerada robustly defended the CSA exam, but has told Pulse she thinks the time has come to reconsider its place as a test of consultation skills. She also raised the high cost to candidates, who are charged £1,642 per sitting.

She said: ‘Entrance exams are predicated on whether you can pass the CSA. The challenge is to start to think about why we need this exam and if we need it at all.

‘You still need to have a robust workplace-based assessment of clinical skills and communication – although that could be difficult if supervisors already know their students. You still need to ask if we just have this exam to satisfy the patients.’

But her successor as RCGP chair, Dr Maureen Baker, said it was the college’s responsibility to ‘maintain standards of patient care’ and that the RCGP ‘firmly believes’ the CSA is the best way of ensuring this.

She said: 'The Clinical Skills Assessment is a world-renowned, comprehensive and robust exam that along with the Applied Knowledge Test and Workplace Based Assessment gives us – and our patients – confidence that our trainees are ready to practise independently, having clearly demonstrated the appropriate skills and clinical knowledge.

’Being a GP is about more than knowledge – it’s about having excellent communication skills and being able to make a diagnosis at initial presentation – and that is what the CSA has been designed to assess.’

Defending the cost of taking the CSA, she said that ‘in common with most professional exams’ there are ’significant running costs involved in making the CSA such an effective, valid, and rigorous exam’, including backfilling for examiners.

She added: ’The college will continue to review and develop all aspects of the MRCGP, particularly in reference to the GP training curriculum and the changing landscape of our profession, but we firmly believe that the CSA is the best way of demonstrating that new GPs are able to practise independently and safely, and provide excellent patient care.’

In 2013, a row erupted after Pulse revealed that international doctors group the British Association of Physicians of Indian Origin (BAPIO) was taking legal action against the RCGP over poor pass rates among non-white medical students sitting the CSA.

A paper published in the BMJ at the time found that non-white medical candidates were 3.5 times as likely to fail the CSA exam as their white colleagues.

But the judicial review ruled that the MRCGP was lawful and ordered BAPIO to pay £50,000 of the costs incurred by the GMC and the RCGP.

A skills assessment courting controversy

On the surface non-controversial, the CSA is an exam that replicates a GP surgery, with actors playing patients.

Introduced in 2007 as part of the revamped MRCGP exam, it tests how GP trainees perform in these circumstances. At the time, it was met with criticism from the start because of dropping pass rates.

Following a judicial review into the differing pass rates for white and non-white candidates, the RCGP said it would take further action to support trainees who fail the MRCGP exam.

Recently, the college was also put under pressure to prove it had made no money from the exam, after claiming it was ’cost neutral’.

Figures released to Pulse at the time showed that during 2010 to 2014 the college made a very small surplus of £527,000 from the MRCGP exam, but this was wiped out by a £1.3m loss in 2014/15 which was down to a drop in candidates.

Readers' comments (43)

  • Is the RCGP a fit organisation to be setting any examinations ?

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  • I wouldn't let the RCGP set a jelly let alone an examination.

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  • The exam is not reflective of the real life scenario. Strange, I do not remember seeing one ethnic minority patient when sitting the csa, and the "impossible" patient was not realistic either - just like the astronomical fees they charge for sitting this joke of an exam. It's a money making scheme for swanky offices in the middle of london

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  • What a disgraceful character is gerada , I am surprised she is not robustly challenged on this ;that she is thinking about scrapping something that she introduced only 5 years ago and defended robustly and shamelessly during 2014.
    98% pass rate over all , are you drunk we have been talking about this for years now , this is the pass rate for white local graduates. not even BME local graduates .
    On top of that RCGP has spent money on unaccountable stuff , money from trainees .
    Now she comes and sprinkle her wisdom that this exam should be scrapped. I would say make it tough for every one , so that there is 50 % pass rate and I will see how many local graduate join your general practice.

    CSA is not clinical exam , its ethnolinguistic exam favouring a group. nothing to do with medicine.

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  • Hang on, ex-chair? So, did have power to change or scrap the CSA at some point but chose not to. No wonder members are leaving in droves.

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  • For what its worth
    The CSA was not introduced under my Chairman ship
    I am only challenging the need for the exam given the high pass rate and the predictive value of the exam to enter VT. I think its a very good exam and robust and fair

    I am always struck how personal the comments get on this forum - yet the writers hides behind anonymity. At least I challenge and fight and discuss in the open and take the consequences. If we all started to do that we might get somewhere!

    All best

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  • The justification for all this assessment was to protect the public in the wake of Shipman ,the Bristol fiasco and a number of other disasters .Have those calling for the CSA forgotten all that?

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  • Dear Clare,
    I dont blame anyone who stays anonymous, Do you know how many whistle-blower is still at the same job after they criticized their organization?!
    just for the record CSA was not introduced whilst you were RCGP chair, but it was changed dramatically when you were there and you observed the significant increase of fail rate of ethnic minorities trainees, Dear Clare you were there, you could have done something which would make remembered forever, you didn't do any changes, you were the best person to stop such biased practice and stupid expensive exam fees, I was one of the doctors who was hit badly with this practice. all the hard work was gone for nothing in return, Do I need this exam now , I wouldn't even be proud of having it after having MRCP/MRCS, passing real exams like MRCS and MRCP led me to get back my confidence in the British education system and also the confidence to say that I was just stupid to believe all the lies of general practice myth of better working life and future.
    I am not surprised you think that this exam is unnecessary, I welcome you to the reality behind this stupid exam, even we are looking at it from different angles.

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  • The RCGP is a cult; there is only one true way and the unbelievers are wicked; all who question the wisdom of the wise shall be cast out into darkness.

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  • Don't be manipulated into responding by name if you prefer anonymity.

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