Revalidation – where next for Sessional GPs?

The final report on “Revalidation processes for Sessional GPs – A feasibility study to pilot current proposals” is now available to read here. The study set out to explore the potential problems locum, salaried and remote GPs might have with the proposed supporting information required for appraisal as part of the revalidation process. GPs who experienced the most difficulty tended to be peripatetic locums and out of hours GPs with no permanent practice base.

The findings will come as no surprise to these GPs and will make worrying reading for those tasked with implementing a revalidation process that is fair to all doctors. Concerns raised in the report included:

• lack of support by practices and locum isolation.
• There were significant problems with the key revalidation requirements of Clinical Audit, Significant Event Audits.
• Patient Satisfaction Surveys and Multi-Source Feedback.

Possible solutions suggested included peer groups for reflective discussions, locum Chambers, greater support from Deaneries, LMCs, practices, OOH organisations and PCOs, alternatives to audit and other requirements, mentoring schemes, and locum prescribing numbers.

The RCGP has already gone some way to find alternative evidence that it would be acceptable for Sessional GPs to collate, and Version 4 of the Guide to Revalidation of GPs describes “equivalent portfolios” that GPs in Special Groups can present. However, substantial problems persist, and it remains to be seen how much support for locums will actually materialise. Past experience would suggest that there is a steep uphill path.
The BMA, in its evidence to the GMC consultation, had a number of criticisms of the current proposals, and opposition has come from several other quarters.

According to “Pulse” today, the “Department of Health is planning to substantially scale back revalidation in light of concerns over cost and anger among GP leaders about the level of bureaucracy to be heaped on practices”, and the article suggests areas where cuts may be made. With so many concerns about the cost, process, and fairness of the current proposals, it is surely time for the GMC to go back to the drawing board.

Working in isolation is not an option

I’m just on my way back from giving a talk on ‘Enhanced Appraisal’ for GP locums. When I arrived in the afternoon, I was leapt on by some a few delegates who’d been there for the morning and who reported the general angst about what PCTs should be doing about locums and appraisal.

I gave a half-hour presentation using Maslow’s Hierarchy of Needs as the model we need to be using when we think about planning resources that will actually support locums through revalidation. It’s all very well to look at the higher functions of quality and performance, but when the basic needs of education, work, security and ‘professional community’ are not being met then expecting locums to do audit, Multi Source Feedback etc are pointless.

The solution, as summarised by the conference’s chairman Dr Emyr Jones, was ‘if the problem is because GP locums have to work outside a managed environment, the solution is to create a managed environment for them to work within’. Fortunately examples do exist, and on these occasions I am able to give my own example of working in a Locum Support Team within Pallant Medical Chambers, where 45 locums work within separate local locum chambers. For those unable or unwilling to work in other similar locum teams, the opportunity to work as affiliates to a conventional practice also exist in the form of the affiliate Freelance GP Scheme.

What is clearly not an easy option – a point made very well by those from secondary care – is working in professional isolation. All doctors need to have a certain minimal level of integration with other professionals, and ‘soft’ features relating to communication, behaviour and clinical performance are increasingly being looked at as indicators for concern.

PCTs’ Pathetic Performance

Over the last ten years, PCTs have had the responsibility of providing a ‘managed environment’ for their sessional GPs. This includes the usual CRB checks, references and appraisal checks. Their remit also extends to providing education and professional support and just being a great umbrella organisation for sessional GPs. OK, you can pick yourself off the floor now and stop laughing. Where obviously there is the odd and, indeed, rare exception, we really hadn’t any idea that it was 

so bad. Up until the recent flu pandemic, there had been no real test to see just how truly awful PCTs were at disseminating the most simplest of information out to its sessional GPs. We knew that one PCT, maybe two, gave a tiny amount of funding to local locums and maybe even bothered to pass on the odd piece of useful information such as the occasional urgent prescribing alert. But when a national emergency occurred, such as invoking several years worth of crisis planning in the wake of a global outbreak of a highly infectious deadly virus, only 18% of locums’ (n=500) PCTs could actually ‘perform’ a simple email cascade. Instead, locums have been kept informed mostly by forwarded email from colleagues, the RCGP, parents, Google or the BBC.

Now that the Department of Health know of this shortfall, we’ll repeat the exercise again at a similarly opportune time later in the year. Far more deadly, however, than any flu pandemic, would be to hold one’s breath waiting for PCT management to pull their collective fingers out and actually rectify this situation.