A guide to revalidation

Oct 23, 2019

Whether you view it as a genuine motivator to improve standards and refine practice or an unnecessary burden, for now at least, revalidation appears to be here to stay.

Finally implemented in 2012 after many years of being mooted, the system requires all licensed doctors and GPs to be revalidated by the General Medical Council every five years.

Relying heavily on evidence gathered during the annual appraisal process, revalidation involves amounting 360 feedback, continuous professional development, explanation of significant events and evidence of reflection.

What is revalidation?

Revalidation is an evaluation of a doctors’ fitness to practise and a legal requirement to maintain a licence to do so.

The General Medical Council says it revalidates doctors to keep standards of care high and demonstrate doctors are up-to-date and competent.

Every doctor must revalidate every five years and provide evidence that knowledge is current, they are fit to practice, there are no outstanding concerns about them or their work and they provide good standards of care.

Revalidation is awarded by the General Medical Council (GMC) and is based on submissions made to it.

How does GP revalidation work?

For the majority of doctors the decision is based on the recommendation of a ‘responsible officer,’ who is usually a senior doctor within the applicant’s organisation. The responsible officer relies on annual appraisals and any other relevant information to make the recommendation.

In cases where a ‘responsible officer’ is not available, another senior doctor, known as ‘suitable person,’ can make the recommendation. When neither a ‘responsible officer’ nor ‘suitable person’ is available, an annual return can be completed by the applicant and a written knowledge test may be required.

What are doctors’ responsibilities in relation to revalidation?

The General Medical Council’s Guidance for doctors: Requirements for revalidation and maintaining your licence outlines the responsibilities doctors have in relation to revalidation.

They include the necessity to fully engage with the process of annual appraisals and collect evidence on a day-to-day basis.

Also on the list are:

• Identify your designated body and responsible officer, or suitable person. Or inform GMC you don’t have one. There is a GMC tool to help you find out if you have a connection to a designated body or suitable person.
• Collect suitable supporting information
• Have an annual appraisal (or engage fully with your training programme if you are a
• doctor in training) which covers your whole scope of practice.
• Reflect on, and discuss with your appraiser, the supporting information you have
• Collected.
• Keeping your connection details up to date in your GMC Online account

A 2018 summary of changes by the Royal College of General Practitioners noted that locums must provide contact details of all the practices where they have worked as part of the process.

Necessary supporting information for revalidation

For revalidation to be successful six types of supporting information are required.

They relate to:

• Continuing professional development
• Quality improvement activities
• Significant events
• Feedback from patients or those to whom you provide medical services
• Feedback from colleagues
• Review of compliments and complaints

More information is available via the GMC’s ‘Guidance on supporting information for appraisal and revalidation’.

How long does preparation for revalidation take?

The amount of time necessary to commit to appraisals and evidence gathering for revalidation can be a controversial topic, with some GPs feeling the burden is too high.

Supporting information for appraisal and revalidation should be focused on quality rather than quantity of supporting information, according to the RCGP.

The guide ‘RCGP Mythbusters – Addressing common misunderstanding about appraisal and revalidation’ says: “We recommend that the final stage of organising the supporting information and completing your portfolio before your appraisal should take no more than half a day, around 3.5 to 4 hours. This is based on the original financial provision for annual appraisal, which was for one day of activity, half to prepare and half to have the appraisal discussion.”

It advises supporting information should be added to your portfolio on a day-to-day basis rather than retrospectively, which would prolong the process.

What recommendations can be made regarding revalidation?

When you have a responsible officer or suitable person to make a recommendation on your revalidation, as is usually the case, there are three options available to them.

They are:

• Recommendation to revalidate
• Recommendation to defer
• Recommendation of non-engagement.

Recommendation to defer revalidation

There are two instances when a recommendation to defer is appropriate, those being:

• Where, due to reasonable circumstances, it has not been possible for collection and reflection on all of the required supporting information. Reasonable circumstances include parental or carers leave, a sabbatical, a break from practice, or sickness absence.
• An ongoing HR or disciplinary process

A recommendation to defer revalidation does not imply any judgement about a doctor’s fitness to practise and is not publicly available or published.

Recommendation of non-engagement for revalidation

This is the recommendation when a responsible officer or suitable person feels there has been either a failure to meet requirements or to sufficiently engage with the revalidation process.

When a recommendation of this type is received, the GMC will:

• Write to the doctor concerned to inform them
• Give the opportunity for representations to be made
• If representations are made, refer them back to the responsible officer or suitable person for consideration
• Consider deferring revalidation if efforts are made or representations show efforts to engage in the process

Outcomes and appeals in relation to GP revalidation

Where the GMC revalidates a licence there is no change to it and the rolling process continues with a new revalidation date set (usually five years in the future) and a need for ongoing annual appraisals and engagement with the process.

A decision to defer revalidation means you continue to hold a licence and can practise as normal and a new date for revalidation will be set.

If the GMC is considering withdrawing a licence it will notify of the reasons and allow 28 days for representations to be made. There is a right to appeal if a licence is withdrawn.

Concerns and questions around the revalidation process

Revalidation is a legal process and requirement for all doctors wishing to practise in the UK.

We offer specialist legal advice and representation, a telephone advisory service, training packages, workshops and courses for GPs.

Do contact us for further information.

The importance of safeguarding vulnerable adults

Oct 21, 2019

Failures in safeguarding vulnerable adults can and do result in tragedy and harm to individuals and professionals. It’s a tricky thing for GPs to get right – and vital to focus on.

The case of Joseph O’Hanlon, an alcoholic who was beaten to death in his home after concerns were raised about him being taken advantage of by drinking associates, was one which highlighted the issues around adult safeguarding. While steps taken by authorities in the case were said to have been reasonable and, in some examples, even excellent, the case led to calls for vulnerable adults to be treated in the same way as children at risk of harm. It was felt that had the case involved a vulnerable child ‘there would have been a much greater level of expectation in relation to the actions of professionals’.

A key tenet of safeguarding, both for adults and children, is that it is everyone’s responsibility. And all health care staff, from administrators and receptionists up to GP partners, have minimum standards of competency to meet.

Dr Joy Shacklock, the Royal College of GPs’ Clinical Champion for Good Practice and Safeguarding has said: “Safeguarding adults at risk of harm is a key duty for all who work in healthcare.”

Adult safeguarding: roles and competencies for health care staff

The publication of the Royal College of Nursing’s ‘Adult safeguarding: roles and competencies for health care staff’ in August 2018 was hailed as the first UK guidance to help healthcare staff better protect adults at risk of harm, abuse and neglect.

It was designed to be relevant to all healthcare and social care professionals and outlines to what degree staff at all levels must be proficient in the subject. In addition, it underlines the necessity for ongoing professional development and training within this area.

For ‘Level One’ staff, including receptionists and administrators, the document says there is a necessity to know the signs of possible neglect, harm or abuse and who to contact for advice over concerns. This includes the requirement to be willing to listen to concerns about risk, recognise how personal beliefs, experience and attitudes may influence safeguarding work and recognise how their own actions may impact on others.

‘Level Two’ staff, including GP practice managers, must have increased levels of competency including ensuring action is taken where necessary, including to organise advocacy for the individual where required. There is also a requirement to understand mental capacity legislation relevant to the country of practice, which varies between UK countries.

For staff considered ‘Level Three,’ including GPs, it outlines a comprehensive list of necessary competencies, knowledge and attitudes.

There is a further tier of competency for those in specialist roles including named GPs/doctors for organisations commissioning primary care.

The six principles of adult safeguarding

Six foundation principles of adult safeguarding, set out by the Department of Health, inform how professionals should engage with people at risk of abuse, harm or neglect.

The principles in themselves are open to a certain level of interpretation and highlight the potential for complexity in decision making and the balancing act involved in properly meeting safeguarding requirements.

The premise of the principles is around ensuring safeguarding is something that is done with patients and not to them.

The principles are:

• Empowerment There is a presumption of informed consent and for the patient to be involved in the safeguarding process, desired outcomes and any resulting action
• Prevention There is a duty to ensure help is given to allow patients to recognise what abuse is and pathways to support
• Proportionality A responsibility exists to provide the least intrusive response to the level of risk posed
• Protection This principle hinges around ensuring those who need support and representation to report abuse receive it.
• Partnership It’s necessary to ensure information is only shared to the degree that is helpful and necessary even where consent is obtained and that the patient has confidence in this.
• Accountability Patients need to know who is involved in the safeguarding process and in what ways they are involved.

What constitutes abuse, neglect and harm?

In order to fulfil obligations, GPs and their teams must be alert to the full range of potential abuse, neglect and harm and not constrained in their view of what can qualify as a potential safeguarding issue.

This can include:

• Physical abuse including inappropriate restraint or physical sanctions
• Sexual abuse including all non consensual or coerced acts, sexual harassment and non-contact acts such as indecent exposure and online abuse
• Psychological and emotional abuse inclusive of threats of harm or abandonment, coercion, isolation and unjustified withdrawal of support
• Financial or material abuse including theft, fraud, exploitation or coercion. ‘Cuckooing’ should also be considered, which is where a person’s property is taken over and used for illegal activity, particularly drug dealing
• Neglect and acts of omission inclusive of failing to provide access to appropriate health and social care, necessities of life or the necessary support to access those
• Self neglect as well as basics such as personal hygiene, health and environment. This may include certain behaviours such as hoarding
• Domestic abuse, which may occur within relationships irrespective of gender and is inclusive of coercive and controlling behaviour, female genital mutilation and honour based violence
• Discriminatory abuse unequal treatment due to any protected characteristics
• Organisational abuse may relate to one-off or ongoing failures or practices
• Modern slavery where people are forced to endure a life of abuse, servtitude or inhumane treatment.

An overview: safeguarding vulnerable adults

Adult safeguarding is a complex area of practice with heavy moral, as well as legislative requirements. It is an area that is open to interpretation at many stages, involves a wide client group and can involve many service providers.

The Care Act 2014, does not use the term ‘vulnerable adult,’ instead referring to adults with a care or support need – a reminder that all adults may fall into the category at certain times. A carer may be in need of safeguarding as a result of the pressures upon them or behaviour of their charge. Similarly an individual may become ‘vulnerable’ temporarily due to a specific period of ill health or mental strain.

GP practices must do everything possible to ensure adults at risk are protected via proper and effective training, information and protocols for all staff.

As well as being aware of legislative requirements, GPs may also have additional contractual obligations with commissioners in relation to safeguarding vulnerable adults.

Safeguarding is naturally interlocked with confidentiality, data protection and mental capacity legislation. Certain disclosures are required at certain times according to relevant legislation.

A breach in relation to responsibilities to safeguard vulnerable adults is a legitimate concern and can cause conflict in terms of doctor-patient confidentiality, for example.

For advice on any situation regarding safeguarding vulnerable adults contact us.

Significant Event Analysis: A guide for GPs

Oct 18, 2019

At MDS, we’re used to helping GPs to handle complaints and queries when things don’t go to plan. As GPs ourselves, we understand the challenges this job can throw up and we vow to step in with support where and when we can.

Yet, we’re also keen to help GPs by refreshing their knowledge and providing useful tips on what to do if things go wrong.

In this latest post, we’re going to look at significant events and how to react to these. If you’re currently concerned about a significant event and in the midst of dealing with this then don’t hesitate to contact us, otherwise read on for a quick refresher.

Significant events

The General Medical Council offers a useful definition of a significant event to keep in mind as a GP.

It states: “A significant event (also known as an untoward or critical incident) is any unintended or unexpected event, which could or did lead to harm of one or more patients. This includes incidents which did not cause harm but could have done, or where the event should have been prevented.”

The following, therefore, are all examples of significant events:

• The unexpected death of a patient
• A diagnosis that was delayed or missed
• A medication error
• A problem arising from a failure of communication

It’s vital to react swiftly and effectively in order to learn the lessons of a significant event.

Why to react to significant events

Significant events call for a significant response. First and foremost, this is because it’s the right thing to do. As a GP, you want to do your level best to look after your patients – and that means learning lessons and adapting your practices whenever required.

On top of this, it’s also important to bear in mind that:

• The General Medical Council requires you to be open and honest if things go wrong and will expect to see evidence of your reaction if a formal inquiry is needed
• The NHS complaints procedure requires you to learn from incidents
• The Care Quality Commission requires you to assess and monitor the quality of your service provision

The requirements of all of these bodies involve reacting appropriately once a significant event occurs.

How to react to a significant event

 So, what should you do to ensure you can react properly to significant events? The answer lies in the system, process and people in your practice. Consider the following:

• Staff training is essential. A GP practice is only as strong as its people. Ensure everyone understands your process and that training and retraining forms part of your schedule.
• You need a simple system in place to make it as easy as possible to report and react to significant events. It’s important to revisit this system on a regular basis.
• Communication is a key part of this system. People need to know who to report issues to and work in an environment where they feel they can report these issues without fear.
• When an event occurs, a report should be made and tis must be completely factual.
• There should be someone overseeing the whole process. This could be the practice clinical governance lead.
• A detailed log of any action taken must be kept.

Significant event analysis: The proactive approach

Significant event analysis involves taking a proactive approach. It’s about using the information accrued during and after a significant event and using it to introduce new measures to try to prevent one from occurring in the first place. It should involve the wider team and be an open and honest assessment of the case in question. This isn’t about apportioning blame, rather it’s a case of answering four key questions:

1. What happened?
2. Why did it happen?
3. What has been learned?
4. What has been changed or actioned?

Stick closely to these questions – which are those highlighted by the National Reporting and Learning Service (NRLS) – and ensure you’ve answered them fully before the process is complete.

Nigel Sparrow, Senior National GP Advisor and Responsible Officer for the Care Quality Commission, explained: “SEA should act as a learning process for the whole practice. Individual SEAs can be shared between members of staff, including GPs, and should focus on disseminating learning within the practice.”

He notes that SEAs should:

• Identify key events in individual cases (positive or negative) and use them to learn lessons
• Help to embed a culture of openness and reflective learning
• Promote the team ethic needed after a potentially stressful incident
• Reflect on the good elements of practice as well as the things that went well
• Identify training and career development needs
• Share information between teams

He added that when it comes to CQC inspections: “We want to see evidence of learning from incidents and improving quality. On inspection we look for the impact and learning that has resulted from the SEA. We expect ‘good’ practices to ensure that the learning from SEAs involves the whole team and becomes embedded in everyday practice.”

Significant Event Analysis: Resources

The above should hopefully serve as an introduction or refresher into significant events. We appreciate that this is a topic which you might want to read about in greater depth – and you might well want some resources that can help to ensure you are reacting efficiently and effectively when the moment occurs.

Here we’ve picked out some useful resources to assist you with this:

• This PDF is a great example of an SEA form from NHS Scotland that can be used as a template for your own forms.
• NHS Scotland has also produced this guide, which walks you through the decision making process at each stage, broken down into three key phases.
• There are simple and easy to use forms available from the National Association of Sessional GPs, either as a download or as a Google Drive document.
• This is another great toolkit, from Medical Appraisal Scotland, that was designed for sessional GPs.
• The Royal College of GPs has even produced a toolkit that looks specifically at cancer SEAs – with resources and thematic case studies.

If you want to learn more about significant events and how to react appropriately when they occur, get in touch with our team.

The NHS complaints procedure

Oct 15, 2019

The vast majority of the enquiries we receive at the Medical Defense Society relate to NHS complaints – and this is a key area in which GPs need support.

While all GPs aim for the very highest standards of care it’s a fact of life that not everyone will always be wholly satisfied with their care. Whether fair or not, complaints can occur and you need to know how to appropriately react to them.

While we would always recommend that our members come to us for full support after a complaint, we’re also keen to ensure you have handy information at your fingertips too. With that in mind, here’s a handy refresher to get you up to speed.

GPs and the NHS complaints procedure: What you need to know

The NHS complaints procedure has two basic tiers – one that is more informal entitled ‘feedback’ and the other billed a complaint.

Depending on the severity of the issue at hand, encouraging and engaging with feedback at an early stage can prevent an unnecessary progression to the ‘complaint’ phase.

It makes sense to provide clear opportunities to offer feedback in order to deal early with dissatisfaction and allow action to ensure similar problems can be avoided. Obviously it is in the best interest of both patients and GPs for complaints to be dealt with expeditiously.

The Health Select Committee has stated: “In moving to a culture which welcomes complaints as a way of improving NHS services, the number of complaints about a provider, rather than being an indicator of failure, may highlight a service which has developed a positive culture of complaints handling and it will be important for system and professional regulators alike to be able to identify the difference.”

Complaints can be made directly to the provider or to the commissioning body.

Meeting standards in responding to a complaint

Unsurprisingly, GPs often have concerns around responding to a complaint in terms of accepting or implying liability. However it is important not to delay or avoid acknowledging and dealing with issues as this can inflame matters. A simple and sincere apology can, when appropriate, prevent a complaint escalating.

A thematic review of general practice complaint handling across England said: “GPs can fear liability, litigation and a damaged reputation, which can act as a disincentive to being open and honest, despite a duty to do the right thing.”

Saying sorry need not be an admission of liability and doctors have responsibilities to be open and honest under the duty of candour.

Staff within your practice must be well trained and briefed on how to deal with feedback and complaints and a sensible procedure put in place.

Appropriate advice should be taken in terms of training, procedure development and, where necessary, at the point of a complaint being received.

Requirements must be met in relation to acknowledgement of a complaint, proper investigation, feedback and resolution. In addition, patients must not be treated differently despite their complaint. Your procedure should ensure this point is demonstrable.

A complainant is also entitled to expect appropriate action to be taken in response to the issue they raise.

When and how can a complaint be made

An NHS complaint can be made long after the incident or issue in question as, while there is a time limit, it is broad.

The rules state a complaint should be made: “Within 12 months of the incident, or within 12 months of the matter coming to your attention.”

Even that time limit can be extended.

It is admissible for the complaint to be made by any person appointed by the patient, providing they have their permission that could be a family member, carer, friend or even a local MP. Confidentiality rules still apply.

Advice and liaison services can assist in ensuring complaints are brought in a timely way and may support resolution. Displaying details of local Healthwatch and similar services allows patients to access good quality advice on raising their compliant and providing the necessary information for you to deal with it well.

Escalation of a complaint

If a complaint is not dealt with to the satisfaction of the person who raised it, it may be escalated to the Parliamentary and Health Service Ombudsman.

The ombudsman can make a variety of recommendations but does not have the power to impose those.

It can ask for:

• Action to be taken to put things right
• A decision to be reconsidered if it is lear mistakes were made, the matter was not dealt with fairly or procedure was not followed
• The improvement of services to avoid the same things happening again

The Parliamentary and Health Service Ombudsman should not usually look at a complaint where there is or has been the option for resolution via a legal mode, such as court or tribunal. Discretion can be shown.

How well do GPs do when it comes to handling complaints?

The ‘thematic review of general practice complaint handling across England’ found that whilst 55% of general practices did a good job of complaint handling, 45% were falling short.

The review said: “Most people have far more contact with their GP practice than with any other NHS service, and they are often an individual’s link in to other NHS services. That’s why getting complaint handling right in general practice is so important – it has the potential to make a difference to everybody who uses the NHS.”

The review stated that in 2014-15, the Parliamentary and Health Service Ombudsman completed received 5,086 complaint enquiries about general practice. Of those 696 (14%) were investigated and 32% upheld. This was at the lower end of the uphold rate, with 44% of cases about acute trusts and 33% of mental health, social care and learning disability trusts upheld.

It said GP practices tend to receive 8.5 complaints annually. GPs face the additional challenges of not usually having a specialist team to deal with complaints and the likelihood of a close relationship between the person being complained about and the internal investigator.

Top tips for GP complaint handling

A joint publication from the Care Quality Commission, NHS England, Healthwatch and the Parliamentary and Health Service Ombudsman offers 10 tips to help GPs improve complaint handling in their practices.

It says: “Complaints and concerns are a valuable source of feedback that can help your practice improve its service. Handling them well not only shows patients that you are listening and that their concerns matter, but it can also help to improve your reputation.”

The ten pointers on complaint handling best practice are:

1. Show how you have responded to complaints and feedback with a ‘you said, we did’ resource such as a noticeboard
2. Invest in training to share experiences of complaint handling and resolution
3. Work with the Patient Participation Group, for example to:
   • Ensure your complaints policy is clear, easy to understand and fit for purpose
   • Actively collect feedback from patients
   • Help review comments and feedback
4. Be open and responsive
5. Clearly explain decisions about care and treatment, following NICE guidelines.
6. A genuine apology may prevent an issue developing into a formal complaint
7. Acknowledge the value of advocacy services and Healthwatch groups and signpost to them
8. Use NHS England’s Assurance of Good Complaint Handling for Primary Care Toolkit
9. Ensure a joint approach where the complaint is about another provider too
10. Only remove a patient from your list due to and at the time of an incident, not as a result of a complaint