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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.