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BMA statement of principles on revalidation

July 2008

On 22 July, the Chief Medical Officer re-announced plans to introduce a process of 5-yearly revalidation for doctors in medical practice. Here we set out a set of principles on which we would like to see revalidation policy developed in the months ahead.

This is the first of a series of updates from the BMA on the introduction of medical revalidation.

Current proposals
Under the 2007 White Paper, 'Trust, Assurance and Safety',and the CMOs July 2008 report 'Medical Revalidation – principles and Next Steps', revalidation will be required for doctors to demonstrate their continuing fitness to practise. The process will consist of two elements: relicensure and recertification. In this document, the word “revalidation” should be taken as an umbrella term covering both these processes.
The CMO’s latest most recent report can be found on the Department of Health website.

Relicensure
All doctors wishing to practise in the UK will require a licence to practise, which will be issued by the General Medical Council (GMC) and will need to be renewed every five years. The process of relicensure will enable a doctor to renew their license and will be based on:

• Standards of practice set by the GMC and based on its ‘Good Medical Practice’ guidance
• A revised system of NHS annual appraisal (for doctors working in the NHS)
• Any concerns known to the doctor’s medical director or responsible officer (where these exist)

To take forward this work, the GMC issued a consultation on translating Good Medical Practice into a framework for assessment and appraisal. Based on that, it seems likely that generic principles for revalidation will be introduced by the GMC. These principles can be broken down into four domains, each point of which refers to a referenced paragraph of its guide:

• knowledge, skills and performance
• safety and quality
• communication, partnership and team work
• maintaining trust

The Academy of Medical Royal Colleges (AMRC) is using this document as a template and developing it to be applicable for each speciality for all doctors, other than those in the training grades, who will be covered by existing processes.

The White Paper suggests that annual appraisal will involve an independent 360-degree feedback (also known as multi-source feedback) exercise as well as an assessment of whether performance has met specific standards (summative assessment) and a look forward at any changes that might be needed (formative assessment).

There are various timetables for relicensure currently being proposed by the GMC, AMRC revalidation group and CMO (England) but none of these are yet set in stone. It is likely that the bureaucratic exercise of determining which doctors currently on the register want a licence to practise will begin around now (July 2008).

Recertification
All doctors on the specialist and GP registers will need to demonstrate that they meet the standards that apply to their medical speciality, and this will be achieved by a process of recertification. These standards will be set by the medical Royal Colleges and their specialist societies and approved by the GMC. Recertification will be carried out at regular intervals of no more than five years and, where possible, will coincide with relicensure.

Proposals for recertification state that evidence for the process will be drawn from a range of sources and activities, interpreted flexibly depending on the precise duties expected of a particular doctor, which could include:

• Employer/PCO appraisal
• Contribution to education (undergraduate, postgraduate, CPD) research and development
• Clinical audit
• Patients’ feedback
• Continuing professional development (CPD)
• Observations of practice
• Simulator tests
• Knowledge tests

The timetable for recertification is rather less clear. There is some talk of 2010, but even this is viewed as difficult to achieve, as in many areas and specialties the structures are not yet in place to collect the necessary information. The GMC and Academy of Medical Royal Colleges (AMRC) currently favour a gradual roll-out of revalidation, starting with areas/specialties where the necessary structures are in place. The BMA has taken an opposite view, considering it unfair to implement all aspects of revalidation and any accompanying sanctions for some groups of doctors before others and favouring a random, or alphabetical, gradual roll-out.

The BMA’s Central Consultants and Specialists Committee has produced guidance on how job planning and appraisal can be used to satisfy revalidation. It can be found on the BMA’s website.

Principles
The BMA believes that revalidation must be based on the following set of principles;
1. The processes of revalidation must be workable in practice, relate to the doctor’s actual field of practice (as opposed to the formal training route the doctor took), and must not be an inappropriate burden on doctors or employers, in terms of effort, time and expense.

2. Whatever sector they work in, all doctors must be provided with adequate opportunities to successfully and easily demonstrate their suitability for relicensure and recertification.

3. Both relicensure and recertification should be based on the same or a very similar set of information about a doctor’s work and be undertaken as a single event.

4. As much of this information as possible should come from existing audit, data-gathering and performance management processes.

5. Appraisal and other forms of review (such as job planning for hospital career grades in the NHS) should already be gathering and providing this information from a variety of sources. Where they are not doing so, or not doing so adequately, those processes and the information systems supporting them, must be improved before revalidation can be implemented.

6. Appraisal should be maintained as a formative process, providing positive information for revalidation, such as participation in CPD. It should be conducted as a developmental, rather than a punitive process.

7. Compulsory periodic examination, through knowledge-based or simulator tests, applied to all doctors in a given field, is not an acceptable method of providing information for revalidation.

8. Multi-source feedback from patients and colleagues may be an appropriate method of providing information for revalidation but is likely to be resource and time intensive.

9. The appropriate use of significant event audit, complaints etc, is an acceptable method of providing information for revalidation.

10. Clinical outcomes information used for revalidation must be attributable to the individual, rather than to a team or department.

11. Where doctors fail to satisfy requirements for revalidation, they should be offered a tailored, funded plan of remediation and rehabilitation.

12. Implementation of revalidation must be fair and appropriate, following proper evaluation and piloting. It should ideally be implemented for all groups of doctors at once, or introduced randomly. It should not be implemented first for doctors in certain specialties or localities where systems are already in place. Any specific sanctions linked to revalidation must only be activated when all doctors are covered by revalidation processes.

13. Employers and PCOs must make adequate time and facilities available for doctors to prepare for and undergo revalidation.

14. Defence Medical Services doctors, retired doctors, private doctors and doctors working solely in industry, the private sector, academia, education and research councils cannot rely on a revised system of NHS appraisal in order to be revalidated in their fields of practice. Employers, working in partnership with their doctors in these sectors will also need to make provision for improved appraisal where it is not yet fit for the purpose of providing sufficient information for revalidation.

15. Specific arrangements will have to be made for those, such as medical managers, working in the NHS but undertaking few or no clinical activities.