Response of the BMA to the GMC’s consultation document, 'Translating "Good Medical Practice" into a framework for appraisal and assessment'


March 2008

Thank you for consulting the BMA on the General Medical Council's (GMC) consultation document on translating 'Good Medical Practice' into a framework for appraisal and assessment. Our response is split into three sections. Firstly, general comments on the proposals. Secondly, specific comments on aspects of the proposals. Thirdly, comments on the framework itself (these comments are included in the draft framework).

General comments
We have no objection in principle to the domains and attributes in the consultation, but the application of GMP to the appraisal process is problematic because differences in procedures require evidence to address the general standards and sheer bulk of evidence that might be produced. As such, the process as a whole could be time-consuming and burdensome for all those involved, particularly if the process is in addition to appraisal. If done correctly, effective appraisal for the vast majority of doctors should satisfy the process of revalidation.

We have some concerns that the new framework could eliminate the developmental element of appraisal and therefore the opportunity to reflect on serious untoward incidents (SUIs), critical incidents and good practice to develop a doctor as a professional and according to their working challenges and career aspirations.

The framework is very much within the performance management / clinical governance arena and we wonder how it sits in relation to the performance assessment tools established nationally through the GMC and NCAS and as well as local assessment procedures. We would oppose the introduction of knowledge tests as we feel that this is not the most appropriate way to assess the competence of experienced professionals. Any assessment of ability would be best based on a demonstration of everyday performance, for example by means of an annual simulated surgery with a debrief, or on the review of a professional development portfolio.

We also believe it is possible that an appraisal tool that has been tightened up on one hand may well become a less sensitive filter of inappropriate approaches to practice on the other. This is because prescriptive appraisal with specific requirements could be less challenging for practitioners who find it difficult to reflect on their practice and these are the very practitioners who we have learnt are the ones who are more difficult to remediate and integrate into the workforce as team members.

To conclude we think that this framework is inclusive across the profession but we would advise modelling it against current fitness to practise cases to test its sensitivity and emphasis in order for it to be beneficial to practitioners as well as to the patient safety agenda.

Specific comments on aspects of the proposals
Evidence
How will the evidence be collected without it becoming a huge burden and where will it take place? There will need to be clear and explicit guidance on what would constitute appropriate audit and benchmarking data (adjusted for casemix, resources etc) for the folder. It is not clear from the proposals if doctors are supposed to collect the data to do audit in their own time – something that could mean long hours of unpaid work.

The evidence brought forward for many standards are not clear, but it is likely in order to be certain to comply, doctors would have to produce large volumes of paper which the appraiser has to read and assess. This would overwhelm the appraiser and it is possible/probable that the actual problem would be lost in the process.

Multi-source feedback (MSF)
We have some concerns about the validity of MSF, which is not carried out widely in the NHS. It is a very time-consuming exercise which is likely to fall most heavily on more senior people and would adversely affect their ability to deliver clinical work. It may also be difficult to get a representative sample of patients.

However, feedback obtained from superiors, peers, juniors and patients has been demonstrated to be a good way to test interpersonal and communicative ability [1]

A good, validated tool for colleagues and patients would greatly aid the whole process. The tool for colleagues could be computerised but there might be some difficulty in MSF for patients being electronic, due to lack of direct computer access for many people.

Feedback system
We strongly support a properly resourced feedback system, which would address all the issues of quality management and revalidation. The BMA would be happy to work together with the GMC, Royal Colleges and Healthcare Commission where necessary, to put in place a useful feedback system that is fit for purpose.

Portfolio assessment
If there are to be any changes to a portfolio assessment for revalidation then they must be developed and validated by the profession.

‘Skills’ assessment
We would challenge the concept of skills assessment as a sound basis for revalidation and believe this to be an ambiguous assessment category. The lack of clarity could lead to examination and more processes.
Certificate of training
We agree with the certificate of training only if it is covered by continuing professional development (CPD).

The implementation process
Good tested examples of processes such as feedback exist, but professional validation and comprehensive testing of each process is needed before implementation. We have concerns with the GMC delivering this process in isolation.

1. Soh KBK (1998) Job analysis, appraisal and performance assessments of a surgeon – a multifaceted approach. Singapore Medical Journal, 39, pp. 180 – 185.

Draft framework for appraisal and assessment derived from 'Good Medical Practice'
Domain 1 – Knowledge skills and performance

Numbers following generic standards in this framework refer to paragraph numbers in 'Good Medical Practice'

Attributes Generic Standards

Generic Standards - Clinical

 Possible Sources of Evidence*
Maintain your professional performance
  • Maintain knowledge of the law and other regulation relevant to practice (13)
  • Keep knowledge and skills up to date  (12)
  • Follow appropriate national research governance guidelines (71c) - This could be read as applying to all clinical practice, but is aimed at research ; better wording would be “In research follow appropriate national governance guidelines”.

Develop and maintain the skills, attitudes and practice of a competent teacher (16)
  • Undertake regular and systematic audit of your practice and the practice of the team in which you work (14c, 41d)

Evidence from training or assessment of skills;
CPD
Audit
Tools for feedback about doctors’ practice

Apply knowledge and experience to practice
  • Manage colleagues effectively (42) - This applies to team leadership  and not wider practice. GMC point 42 simply refers to the sister document “Management for Doctors” . A less ambiguous bullet point would be “Apply principles found in GMC’s document “Management for Doctors”.

There should be mention made of a 360 degree analysis in this section.
  • Adequately assess the patient’s conditions (2a)
  • Provide or arrange advice, investigations or treatment where necessary (2b)
  • Prescribe drugs or treatment, including repeat prescriptions, safely and appropriately (3b)
  • Provide effective treatments based on the best available evidence (3c)
  • Take steps to alleviate pain and distress whether or not a cure may be possible (3d)
  • Consult colleagues, or refer patients to colleagues, when this is in the patient’s best interests (2c, 3a, 3i, 54,55). Support patients in caring for themselves (21e)

Evidence from training or assessment of skills
CPD
Audit
Tools for feedback about doctors’ practice
Keep clear, accurate and legible records
  • Make records at the same time as the events you are recording or as soon as possible afterwards (3g)
  • Record clinical findings, decisions, information given to patients, drugs prescribed or other information or treatment (3f)
 Anonymised records


* This column shows possible sources of evidence; it is not comprehensive, nor are any of the sources of evidence mandatory. For doctors who are Medical Directors with no direct responsibility for patients but are responsible for the provision of information and services to them, this footnote needs to be spelled out more prominently.

Domain 2 – Safety and quality

Attributes Generic Standards

Generic Standards - Clinical

 Possible Sources of Evidence*

Put into effect systems to protect patients and improve care

  • Recognise and work within the limits of your competence (3a)
  • Take part in quality assurance and quality improvement systems (14d)
  • Respond constructively to the outcome of audit, appraisals and performance reviews (14e)
  • Provide only honest, justifiable and accurate comments when giving references for, or writing appraisals or other reports about colleagues. (18,19 )
  • Make sure that all staff, for whom you are responsible, including locums and students, are properly supervised. (17) – this needs clarification to make sure that systems are in place to ensure that all staff, for whom you are responsible etc. This is a more appropriate expectation when you have a responsibility for staff who are out posted to a distant office or the community.
  • Ensure systems are in place for colleagues to raise concerns about risks to patients (45)

     

  • Provide information for confidential inquiries and adverse event reporting (14g)
  • Report suspected adverse drug reactions (14h)
  • Co-operate with legitimate requests for information from organisations monitoring public health (14i)
  • Ensure arrangements are made for the continuing care of the patient where necessary (40, 48)

Information collected for folder

 

Tools for feedback about doctors’ practice

CPD – reflective practice
Respond to risks to safety

Take action where there is evidence that a colleague’s conduct, performance or health may be putting patients at risk. (43,44) - it would be preferable to use the word people instead of patients.

 
  • Report risks in the health care environment to their employing or contracting bodies. (6)
  • Safeguard and protect the health and well-being of vulnerable people, including children and the elderly and those with learning disabilities. (26,28)

 

Information collected for folder
Protect patients from any risk posed by your health

  • Make arrangements for accessing independent medical advice when necessary. (77)

  • Be immunised against common serious communicable diseases where vaccines are available (78)

Statement about registration with GP, appropriate immunisation etc – verifiable if need arises

Tools for feedback about doctors’ practice



Domain 3 - Communication, partnership and teamwork

Attributes Generic Standards

Generic Standards - Clinical

 Possible Sources of Evidence*

Communicate effectively
  • Ensure any published information about your services is factual and verifiable (60, 61)
  • Communicate effectively with colleagues within and outside the team (41b)

     

  • Listen to patients (22 a 27a)
  • Give patients the information they need in order to make decisions about their care in a way they can understand. (22b, 27)
  • Respond to patients’ questions (22c, 27 b)
  • Keep patients informed about the progress of their care (22c)
  • Explain to patients when something has gone wrong (30)
  • Treat those close to the patient politely and offer support in caring for the patient.  (29)
  • Pass on information to colleagues involved in, or taking over, your patients’ care (40, 51-53)

Practice leaflets etc

Tools for feedback about doctors’ practice

Work constructively with colleagues and delegate effectively
  • Treat colleagues fairly and with respect (46)
  • Support colleagues who have problems with performance, conduct or health (41d)

 

 

  • Ensure colleagues to whom you delegate care have appropriate qualifications, experience, knowledge and skills  (54,55)

 

Information for folder
Establish and maintain partnerships with patients

It is still possible to have a vicarious responsibility to establish and maintain partnerships with patients even though you are not providing direct care eg through Heart Support Groups and a Patient Liaison Group.

  • Encourage patients to take an interest in their health and take action to improve and maintain it (4, 21f)
  • Be satisfied that you have consent or other valid authority before you undertake any examination or investigation, provide treatment or involve patients in teaching or research. (36)

Information for folder

Tools for feedback about doctors’ practice


Domain 4 - Maintaining trust

Attributes Generic Standards

Generic Standards - Clinical

 Possible Sources of Evidence*

Show respect for patients

Show respect to members of groups for which you are not providing direct care (as above).

     
  • Be polite, considerate and honest and respect patients’ dignity and privacy  (21a, b, d)
  • Treat each patient fairly and as an individual (38-39, 21 c)
  • Implement and comply with systems to protect patient confidentiality. (37)

 

Tools for feedback about doctors’ practice

Policy/evidence of ending relationships with patients

Treat patients and colleagues fairly and without discrimination
  • Be honest and objective when appraising or assessing colleagues and when writing references (18-19)

 

 
  • Provide care on the basis of the patient’s needs and the likely effect of treatment (7-10)
  • Respond promptly and fully to complaints. (31)

 

 

ITools for feedback about doctors’ practice
CPD, e.g. completion of equalities training

Folder, evidence from complaints
Act with honesty and integrity

  • Be honest in any formal statement or report, whether written or oral, making clear the limits of you knowledge or competence. (63-65, 67-68)
  • Be honest in undertaking research and reporting research results (71 b)
  • Ensure you have adequate indemnity or insurance cover for your practice (34)
  • Inform patients about any fees and charges (72a)

 

Tools for feedback about doctors’ practice

© British Medical Association 2008

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