Medical Revalidation: An International Perspective Dr Mike Bewick Dr Jenny Simpson NHS England Brighton 5 June 2014

Context By means of background for those new to the thinking on revalidation And to recap for those of you who have been following our progress 2NHS England | Presentation to Ahead of the Curve Conference, Brighton 4-5 June 2104

Timeline First thinking - mid 1990s, following scandal at Bristol Children’s Heart Unit First attempts through clinical governance, late 90’s Appraisal introduced as mandatory for consultants and GPs, late 90s Further issues with quality and safety, culminating in exposure of Dr Harold Shipman’s murder of 200 plus patients, which went unseen due to failure to link information sitting in different parts of the system 3

Timeline 2003/4 Dame Janet Smith’s Inquiry into Harold Shipman – found that GMC was unduly biased towards the interests of doctors – and at times ‘behaves more like a gentleman’s club than a regulator’ 2005 Sir Liam Donaldson, initiated CMO’s Review of Medical Regulation 2007 White Paper ‘Trust, Assurance and Safety’ published, recommending some form of regular check on every doctor’s continuing fitness to practise 4

Evolution of revalidation in the UK ‘Trust, Assurance and Safety’ led to Ministerially-led programme of work for implementation, comprising a number of work-streams developing the structures and processes for revalidation Legislation drawn up (on the basis of considerable research) to introduce a new statutory position – the Responsible Officer. The Medical Profession (Responsible Officer) Regulations 2010 outline the role and its function. Regulations are unique in the UK in that they specify not only a close collaboration between the regulator and all employing/contracting organisations, but also mandating specific organisational processes. They also mandate the algorithm by which doctors relate to their responsible officers, by a ‘prescribed connection’ 5

Evolution of revalidation in the UK First responsible officers were introduced January 2012, Responsible Officer Regulations enacted October 2012, first recommendations made December 3, 2012 (year 0 – the responsible officers, higher-level responsible officers and other medical leaders) Regulations amended February 2013, to take account of major re-structuring of the NHS, abolishing regional and local structures, introducing NHS England and a new regional and local structure 6NHS England | Presentation to Ahead of the Curve Conference, Brighton 4-5 June 2104

Medical Profession (Responsible Officer) Regulations, 2010 and 2013 A doctor has one responsible officer, defined by how they are employed or where their contract is held Every organisation providing healthcare and employing or contracting with doctors has must appoint a responsible officer. Only one responsible officer may be appointed, other than at NHS England (employing some 43,000 doctors), which is entitled to appoint as many responsible officers as necessary 7NHS England | Presentation to Ahead of the Curve Conference, Brighton 4-5 June 2104

Medical Profession (Responsible Officer) Regulations, 2010 and 2013 Every doctor in the UK must demonstrate their continuing fitness to practise, in the role that they are currently employed or contracted, to the General Medical Council, every 5 years Doctors present a specified set of information, including an annual appraisal (to an agreed format), feedback from patients and colleagues, in addition to governance data from other internal and external sources - for every role in which they are employed or contracted as a doctor Organisations mandated to support and resource revalidation 8

In practice…. In the UK we are now in year 2 of a 3 year implementation Thus far, some 40,300 doctors have had a recommendation made on their fitness to practice to the GMC (22% of total). 226 doctors have had their licences removed, of which 14 have lodged an appeal By March 31, all 165,000 doctors in England (plus smaller numbers in Scotland, Wales and N Ireland) will have a had a recommendation made 9NHS England | Presentation to Ahead of the Curve Conference, Brighton 4-5 June 2104

In practice…. From then on the system moves to a 5 yearly process, 20 % of all doctors going through the process each year Hierarchy of prescribed connections established All responsible officers (800) in England trained to agreed specification Agreed set format for appraisal (MAG form) and agreed national training specification for appraiser training National policies in place for responding to concerns for every type of employment/contracting relationship 10

Prescribed Connections for all doctors in England 11NHS England | Presentation to Ahead of the Curve Conference, Brighton 4-5 June Area Team ROs 42,000 GPs 330 Non- NHS ROs 11,000 Doctors 46,000 Trainees 290 Other NHS ROs 60,000 Doctors NHS England National Office Responsible Officer 1,000 Doctors Department of Health Responsible Officer 10 DH Doctors The prescribed connection for doctors within the blue area is to NHS England NHS Litigation Authority (NHS LA) RO NHS Trust Development Authority (NHS TDA) RO 4 x Regional Office ROs ROs of Government Departments, Other Non-Departmental Public Bodies & Executive Agencies other than the Special Health Authorities Health Education England (HEE) RO 13 Local Education and Training Boards (LETB) ROs The prescribed connection for doctors within the green area is to Department of Health 10 ROs

Running the programme National PMO, works with small teams in each of 4 regions, running support networks, monitoring systems and QA National programme funded from DH/ NHS England budget. Other organisations must fund their own processes Responsible officers are themselves doctors and also relate to a responsible officer. A pool of regional appraisers has been developed to appraise responsible officers Challenges remain in ensuring funding is protected from demands of the wider service 12

Current work and next steps Ensuring consistency of decision-making and thresholds for intervention – networks for responsible officers, appraisers and case investigators/case managers, national and regional events to calibrate approaches and standards Aligning policies across every sector Locum doctors Doctors with no obvious connection 13NHS England | Presentation to Ahead of the Curve Conference, Brighton 4-5 June 2104

Current work and next steps Quality assurance - monitoring and reporting, implementation of FQA Integration of revalidation with wider quality improvement processes, across entire service Policy and programme in place to integrate and standardise remediation, through national Professional Support Unit National clinical priorities to be integrated into medical appraisals 14NHS England | Presentation to Ahead of the Curve Conference, Brighton 4-5 June 2104

In Summary: National programme to implement medical revalidation, mandated by legislation Now in year 2, of 3 year implementation programme Programme on track with plan, with licenses being withdrawn from non-engaging doctors Long-term benefits of implementation being assessed by both GMC and DH 15NHS England | Presentation to Ahead of the Curve Conference, Brighton 4-5 June 2104

Discussion at RACMA’s recent webinar Is it worth the effort, expense and time? Is legislating revalidation more effective than a voluntary, self-regulated approach? Do you really think you can achieve the consistency you seek? Is revalidation going to be more effective than credentialing? 16NHS England | Presentation to Ahead of the Curve Conference, Brighton 4-5 June 2104

From what you have seen… How did the conversations at yesterday’s conference match with your expectations of a system, just over a year in to a 3 year national implementation of major change? How well did you think the responsible officers of England grasp the new role? What (if any) factors struck you as impressive? What struck you as worrying? 17NHS England | Presentation to Ahead of the Curve Conference, Brighton 4-5 June 2104

And for the future: What do you think we could improve on in terms of implementation or structure? Would this system work, do you think, for other clinical specialties – nursing – for example? Would this system work in other countries? Which parts of our experience are of generic use to other systems charged with improving quality and safety of patient care? 18NHS England | Presentation to Ahead of the Curve Conference, Brighton 4-5 June 2104