Reinventing the wheel

Pulse reports on the concerns of one GP about revalidation. The concern is specifically addressing the new process for measuring how much continuous professional development (CPD) a GP does in a year. GPs will score their CPD activities on the basis of how ‘challenging’ they are and how much ‘impact’ they have. The magic (and completely arbitrary) total is 50 units per year. The RCGP’s document on revalidation is now available and gives all the lurid details.

Why are we going through this process? Prof Field suggests:

There are significant numbers of GPs who are not actively learning and acquiring new knowledge and skills – we need to encourage them to.

Significant numbers? Is passively learning new skills and knowledge acceptable? Of course, one could argue that if there is a single GP out there who is not updating their skills that is significant. It could be very significant if you are the patient on the receiving end. Presumably Prof Field wouldn’t make a statement inferring real concern about a large number of GPs without evidence. I haven’t personally seen the evidence that there is a ‘significant’ issue within the profession.

As an appraiser, I have also been involved with the piloting of the new scheme, and there are a number of aspects to it that I quite like. It is relatively easy to incorporate into an appraisal and it is not hugely intrusive. It seeks to add an extra dimension to the measurement of ongoing education. It rewards educational practice that is more challenging to achieve and that changes the way care is delivered to patients. All very laudable.

But there are questions. Lots of them. How well does the amount of CPD you undertake correlate with your clinical competence? It may demonstrate enthusiasm for the subject but in no way does it measure how well you treat the patients. Perhaps it will encourage GPs to develop their clinical services in line with new thinking. Is there any evidence that this was an area in which practices were failing to deliver? And how does that help with the revalidation of individuals? Does completing a single measly audit per year infer competence? Dr Spinks raises the issue of how consistently appraisers will score the activities. Inter-rater reliability I think they call that. That is why there is a pilot and the only issue I have with this is that it doesn’t feel much like a pilot. It feels like a done deal. It is ‘Evidence Area 6′ of the RCGP’s document. It has been decided this is what we are going to do and we all have to toe the line. Prof Field quoted in Pulse again:

He said it was vital for GPs to get the system right to avoid a less favourable alternative being imposed.

This feels like a veiled threat. But a threat of what? Let’s consider something – if I were a member of the public and I felt GPs should be regulated I would want to know, with a certain amount of confidence, that they are competent.  Not how keen they are on CPD (the credits), or how much their patients like them (patient satisfaction questionnaires), or even how much their colleagues like and respect them (multi-source feedback).  What we need is a reliable, valid, consistent measure of a GP’s competence. Is it just me but isn’t that the definition of an examination?

A huge amount of time and effort is going into reinventing the wheel.

Medical students still have examinations because it is the single best way to prove competence. We already have a set of examinations that test GP competence – nMRCGP. It involves an Applied Knowledge Test and then a Clinical Skills Assessment. These can test skills across a wide range of competencies. Communication skills, problem-solving abilities and even some factual knowledge can all be assessed. Trainees also do a Workplace Based Assessment which involves all the woollier things like multi-source feedback and patient satisfaction questionnaires. GPs can (and already do) incorporate these elements into their annual appraisal.

If we are serious about ensuring GPs are competent the way forward is an annual appraisal and a 5 yearly examination. Everything else will be open to accusations of poor validity and reliability. It would also be a completely inclusive package. There would be no issues with sessional GPs, locums and GPs with special interests having difficulties meeting practice-based criteria.

I suspect examinations remain utterly unpalatable to many GPs. Perhaps some GPs will head for the exits at any sign of a revalidation examination. Ultimately, the majority of GPs are conscientious and competent, so revalidation remains a bitter pill to swallow.