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Q&A with RCGP chair: 'We're just not ready yet for revalidation'

Delays, confusion over costs and concerns that some parts of the country may face far tougher assessment than others… RCGP chair Professor Steve Field knows lots of work is needed to get revalidation right. Here, Pulse reporter By Gareth Iacobucci puts Professor Field on the spot – and asks whether the college can produce a system that keeps both the Government and GPs on board

By Gareth Iacobucci

Delays, confusion over costs and concerns that some parts of the country may face far tougher assessment than others… RCGP chair Professor Steve Field knows lots of work is needed to get revalidation right. Here, Pulse reporter By Gareth Iacobucci puts Professor Field on the spot – and asks whether the college can produce a system that keeps both the Government and GPs on board

Are GP appraisers sufficiently trained up to provide fair and consistent assessment for revalidation across the country?

We don't believe the appraisal system in England is good enough - we don't believe it is consistent. Appraisers need consistent training and support. As a college, we would want to influence appraisal to make sure it is fair and appropriate, but it's difficult at the moment to say what the CPD credit scheme will look like because it's being piloted. What I can say is that any CPD system needs to be understandable by everyone, both appraisers and GPs.

What will happen to GPs who don't have an appraisal this year? How will they be revalidated is they miss an appraisal?

GPs can't be revalidated unless they have five appraisals. Until you've got the appraisal system sorted and responsible officers in place, I don't think revalidation can go ahead. I think the process of revalidation will be delayed, probably until 2011. We know some GPs haven't had the opportunity to be appraised in the last couple of years. It's a decreasing minority, but we've got to get a system in place for everybody.

Will responsible officers be able to overrule appraisers in the assessment of GPs' learning credits?

The introduction of responsible officers is not the responsibility of the college. Again, we would want to influence their development but we haven't yet seen the official Department of Health paper which lays out proposals. We very much welcome the fact the programme board has decided to delay the implementation of responsible officers so they can be piloted. We believe the officers should be supported by a college-accredited person and lay person to ensure consistency – and that they can't on one hand just look at things in a cursory way or on the other be a hawk.

Do we have information about how many GPs have been obliged to undergo retraining as a result of appraisal to date?

I don't think appraisal has demonstrated consistently the number of doctors with whom there are concerns. In some areas people haven't been appraised or they've been very light touch. All we can do is work out the figures for referrals to the National Clinical Assessment Service, for those who need extra support. We know that number varies depending on PCT, with larger numbers in places like Tower Hamlets. The idea of revalidation is that those being referred to NCAS should be identified at a much earlier stage. The key is to try and help people learn rather than finding that small proportion who are bad. Appraisal, if done badly, can be destructive and can actually do harm.

If GPs are not recommended for revalidation, will there be a period of grace during which they can do their extra training?

There are two scenarios here. One is that people have been identified in successive appraisals as having difficulties, have not addressed their learning and there are concerns. If there's a series of serious patient complaints, where a GP ends up in front of the GMC, and that comes out in appraisal, and if lessons aren't being learnt, then during the five-year period they might be referred to NCAS.

There's a second group who might have problems in their last year of revalidation, or a problem arises in year three or four, and they haven't got time to demonstrate revalidation. Then it will then be up to the GMC to say, we can't re-license you for five years, but perhaps you would be re-licensed for one or two years depending on you doing X, Y and Z. We would expect a small proportion might not have enough evidence even after five years.

If a GP had to re-train over 18 months, how may hours a week would they have to dedicate to re-training?

My experience is that in some cases you have to give a targeted treatment, whether that's from a health or a performance point of view. At the extreme end, I've had to refer GPs to a interactive skills unit at the University of Birmingham to help them with their communication skills, actually teaching them how to consult and communicate. You can do that while they're working or if they're suspended.

How many significant events will GPs have to review to get revalidation -and what if they haven't done enough?

We're asking for five significant events, but we know that Dr Maurice Conlon (national director of the revalidation support team) is going to ask for 10. Let's say I've done four years of appraisals. If I haven't produced any audits then at the end of year four, I'd know that I would have to produce in the last year. But your appraiser would have asked you about that in years one, two, three, and four.

How would plans for a National Adjudication Panel to work in practice?

This is not an appeal system. It's to help decision making. It might be for doctors working across different PCTs, or who have been out for a year or two. There might be GPs who have difficulty producing the evidence they need for revalidation. The responsible officer and the PCT might ask for external advice and help. But the responsible officer needs to make the decision.

Most things should be sorted out locally. It might well be that responsible officer's are just not sure and not ready to say things to the GMC. That's why we're offering it to help doctors rather than anything else. But it won't be an appeal mechanism. The ultimate responsible body is the GMC, and they're the ones that will have that formal appeal mechanism.

Who should pay for extra support and re-training?

It's so unclear and we need some clarity from the NHS. There are all sorts of options. One of them is for GPs to have an insurance policy on it. The second is for PCTs to pay for the responsibility and the third for GPs to pay their own way. An alternative for salaried doctors is to increase their fees. It will also depend on what's needed and what the circumstances are. I remain concerned about locums and salaried doctors and how they will get support, CPD and appraisals. Who pays for what and when need to be worked out clearly across the whole of general practice. This is something the NHS and the BMA needs to sit down and talk through soon.

Will there be a limit to how many times an individual can retake one part of the revalidation programme?

It's not an exam, so there is no take or retake. Over a five-year period, doctors will need to demonstrate evidence of their competence, so they'll have to produce so many event audits for instance. If at the end of five years they haven't done that, they will have had enough warning over each appraisal over those five years that it won't be a surprise. It will then be up to the GMC to decide if there's not enough evidence.

What guarantees is the College seeking that tools for patient and colleague surveys will be validated?

The CMO has obviously being pushing for this an important aspect of revalidation. On the colleague survey, we know that there's only one available at that matches the GMC's Good Medical Practice and has actually been pilotted on live GPs. The only one we want to pilot is the one that fulfils those two criteria. The alternative was to get PCTs developing their own tools and a plethora of companies developing them to make money at the expense of GPs. I don't think we would have any confidence in that. It's got to be relatively simple, light touch and effective. From a patient point of view the verdict is out on that because we've not got the results of our evaluation. We don't yet have the confidence in any of the patient tools and we've asked a team of researchers to look at them.

Pofessor Steve Field: revalidation set to be delayed Steve Field: revalidation set to be delayed

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