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versión impresa ISSN 1575-1813
Educ. méd. vol.9 no.4a dic. 2006
III SESION: CHALLENGES IN CONTINUING PROFESSIONAL DEVELOPMENT AND THE REGULATION OF THE PROFESSION
Dr. Ian Starke
Director of Continuing Professional Development Federation of Royal Colleges of Physicians, United Kingdom.
Organisation of CPD in the United Kingdom
The National Accreditation Authority for Continuing Professional Development (CPD) in the United Kingdom is the Academy of Medical Royal Colleges. The Academy is made up of some 15 Colleges and Faculties, each having a Director of CPD. The Directors of CPD form a group within the Academy, whose responsibility is to oversee the requirements, quality and consistency of CPD in the United Kingdom. The range of CPD schemes run by individual Royal Colleges differ in detail, but all Colleges work to the same "Ten Principles"of CPD and those Colleges that formally approve CPD events agree broadly similar quality criteria.
The Directors of CPD Group (DoCPD) includes representation from the UK Regulatory Body, the General Medical Council (GMC) and maintains awareness of CME/CPD regulations in Europe, governed by the European Accreditation Council for CME (EACCME). The three Royal Colleges of Physicians in the UK (The Federation) each have a Director of CPD who are members of a Federation CPD Policy Committee.
The definition of CPD used by the Academy of Medical Royal Colleges is:
A continuing process outside formal undergraduate and postgraduate training that allows individual doctors to maintain and improve standards of medical practice through the development of knowledge, skills, attitudes and behaviour. CPD should also support specific changes in practice.
History of CPD in the United Kingdom
In the UK, the term Continuing Medical Education (CME) is used to describe learning on clinical and other topics that directly relate to patient care. Continuing Professional Development (CPD) includes CME, but recognises that a doctor will become involved in many professional activities after completion of specialist training and that these activities require specific learning in order to ensure that the highest standards are met.
The Royal Colleges of Physicians first established CME in 1996 when a simple diary system was introduced, subject to a 5% annual random audit. There was no quality control of the CME events that could be recorded but they were categorised into different types - External, Internal and Personal. A total of 50 hours of activity was required each year.
In 2001 a new system was introduced which included an online database of approved events, a system of approving those events and an online diary kept by individual registrants. A paper based system ran in parallel which is due to discontinue from April 2007. We have recently introduced an on-line system for event approvals, and new quality criteria for the approval of distance learning materials
The current Federation CPD system
An educational event is submitted for CPD approval against agreed guidelines to an approver who is a Director of CPD or one of the Specialty CPD Representatives or Regional Advisers. If the event is approved it is entered onto the online database, but if not it is returned to the provider with a statement that it cannot be approved, or asking for further information or changes. Each participant registered with the system is able to access the online data base using a registration number and password and is able to enter CPD events in a personal learning diary. When the event has been attended credits can be obtained through a process of reflection made, again, within the online personal diary. Participants also give feedback about the quality of the event. This may be collated and reviewed by the approvers, or on occasion, fed back to the provider.
Currently CPD in the Federation of the Colleges of Physicians is divided into:
- Peers or providers ensure a regional, national or international context - verifiable - a minimum of 25 external credits are required per year of which it is strongly recommended that at least 5 should be non clinical ("professional") in nature.
- Routine local activity with colleagues - semi-verifiable but not usually verified at present
- Individual activity, such as reading and use of the internet, where the individual determines the benefits gained - unverifiable - not more than10 credits per year count towards required 50.
A number of other colleges and faculties in the United Kingdom use different categories of CPD. A minimum of 50 credits per annum is required by all Colleges.
The current approval criteria are:
- The target audience falls within the remit of the Federation (recognised medical specialties / generic and non-clinical aspects / UK providers or hosts)
- Any support, sponsorship or funding by commercial organisations has not influenced the structure or content of the educational programme
- Any commercial sponsorship or interests of the programme planner, presenters or facilitators must be declared on the application form
- The learning objectives are specifically defined, and are appropriate for the target audience
- The teaching methods used will achieve the stated learning objectives
- Evidence is provided that the programme planners and/or facilitators have the expertise to deliver the learning objectives using the methods chosen
- The evaluation record for previous events organised by the same provider is satisfactory, or reasons for previous unsatisfactory ratings have been addressed.
Medical Regulation in the UK and the General Medical Council
The General Medical Council (GMC) was established under the Medical Act of 1858. The purpose of the GMC is to protect, promote and maintain the health and safety of the public by ensuring proper standards in the practice of medicine. The General Medical Council has four main functions:
Keeping up to date registers of qualified doctors
Fostering good medical practice
Promoting high standards of medical education
Dealing firmly and fairly with doctors whose fitness to practice is in doubt
The Council of the GMC includes nineteen doctors elected by doctors, fourteen members of the public appointed by the NHS Appointments Commission and two academics appointed by the universities and medical Royal Colleges.
The "Principal List" (Register) of the GMC contains the following information:
The doctors reference number, name, gender
Year and place of primary medical degree
Date of registration
Entry in general practice or specialist register
Any publicly available fitness to practice history since 20th October 2005
An amendment of the Medical Act, 1983, was passed in 2002 to allow revalidation to be one of the functions of the GMC.
"Good Medical Practice", Appraisal and Revalidation
In 1998 the GMC issued a document entitled "Good Medical Practice" which has become fundamental in the training of doctors in the UK as well as in the annual appraisal of trained doctors. "Good Medical Practice" has been regularly updated and includes the following seven domains of practice in which standards have to be maintained. These are:
- Good clinical care
- Maintaining good medical practice
- Relationships with patients
- Working with colleagues
- Teaching/training, appraisal/assessment
Participation in CPD is an essential requirement within Domain 2, Maintaining Good Medical Practice, but it is also relevant to the other domains.
In 2004 the GMC issued guidance on CPD which included the following recommendations:
- CPD should cover all areas of professional practice
- CPD should cover all aspects of "Good Medical Practice"
- should advise on content and evidence
- should confirm participation in CPD
- Appraisal should ensure relevance of CPD through a Personal Development Plan
- Doctors must record enough CPD to meet revalidation requirements
- There should be public and patient involvement in planning, standard setting and monitoring of CPD
CPD and regular annual appraisal are closely linked. The doctor will collect and reflect on information from daily activities and these will be discussed at the annual appraisal. From this, clinical and professional development needs will be identified and a Personal Development Plan (PDP) is developed. Participation in CPD is the means of delivering the PDP and will result in changes in clinical and professional practice or in maintenance of best practice where present. When the system was introduced it was intended that appraisal summaries would be submitted to the GMC for annual review by the Revalidation Group every five years.
Harold Shipman and Other Challenges
The revalidation process, as originally conceived, was put on hold following the discovery in 2003 of the activities of Dr Harold Shipman. Dr Shipman killed up to 250 patients between 1972 and 1998 by the use of large doses of narcotic analgesics. Dame Janet Smith QC conducted a full enquiry into these events which was reported between 2003 and 2006 . She concluded that the revalidation method currently in place was:
- Lacking in rigour
- Departed from the original concept
- Was not fit for purpose.
But there had been other examples of incompetent professional practice or criminal activity:
- Clifford Ayling
- 12 counts of indecent assault of female patients
- Richard Neale
- Serious professional misconduct, dishonesty and incompetent practice
- William Kerr and Michael Haslam
- Charges of indecent assault and rape
- Rodney Ledward
- Inappropriate tolerance of aberrant conduct and deviant practice
- Bristol Royal Infirmary
- Shortcomings in attitudes, decisions and judgements - a "club culture"
In 2005 Sir Liam Donaldson, Chief Medical Officer of the NHS, was commissioned to undertake a review in order to make recommendations as to how things should change. The terms of reference were to:
- Strengthen procedures for assuring the safety of patients in situations where a doctors performance or conduct pose a risk to patient safety or the effective running of services;
- Ensure the operation of an effective system of revalidation;
- Modify the role, structure and functions of the General Medical Council.
The Challenge of Determining the Quality and Effectiveness of CPD
During the eighteen months before Sir Liam Donaldsons report was published there was time to reflect on issues of quality and effectiveness in CPD. It is difficult to separate the two, as effectiveness is a key measure of quality.
The quality and effectiveness of CPD events may be evaluated at a number of levels. Firstly, the educational activity should be well designed in relation to the learning objectives identified and the nature of the target audience. Secondly, positive feedback from the educational activity indicates doctor satisfaction and it is logical (although not always certain) that greater satisfaction will be associated with a better outcome in terms of what is learned.
Change in knowledge can be assessed relatively easily by means of questionnaires or case studies, but may or may not lead to a change in behaviour. It is doctors behaviour that determines the quality of patient care, but the clinical outcome for patients is influenced by numerous factors outside the doctors control and outside the learning experience.
One might therefore consider a spectrum between quality and effectiveness. Quality can be high regardless of outcome, and is largely intrinsic to the activity itself. As we move to the right (or up the pyramid) the effectiveness of a high quality learning experience may be progressively disguised by other factors. At the same time the demonstration of change in knowledge, behaviour and outcome increasingly represent effectiveness, but cannot be measured by the design of the educational activity. Quality represents the degree to which the CPD activity is likely to produce a good outcome. Effectiveness is the degree to which a CPD activity can be shown to produce a good outcome. The highest level of quality is reached when the learning experience can be shown to be effective at a high level in all cases despite potentially confounding factors.
It is essential to engage the event providers, the learners, and the accrediting bodies in the design of high quality CPD events. Each has their role to play. Effective CPD should be:
- Contextually relevant
- Based on an accurate needs assessment 
It is now generally accepted that CPD is effective, but much needs to be done to determine what kinds of CPD are effective. In addition it is self-evident that CPD is one of the main methods by which doctors remain up to date and fit to practice. It must therefore be:
- Able to meet needs in all domains of "GMP"
- Available to all practising doctors
- Accessible and timely to meet PDP needs
- Of high quality
- Of demonstrable effectiveness
- Seen as robust and effective by public and politicians
The challenge for CME/CPD is to demonstrate that these requirements can be met.
The Donaldson Challenge
In July 2006 Sir Liam Donaldsons report "Good Doctors, Safer Patients" was published . This proposed (among forty-four recommendations) a new division of revalidation into two separate processes of re-licensure and recertification. Re-licensure will relate to the retention of a doctors name on the GMC register, while recertification will relate to a renewal of a doctors speciality certificate. It is recognised that re-licensure is essentially a development of processes that are currently in place, but that recertification will require significant input from Royal Colleges and specialist societies.
In particular, it is recommended that:
- A clear unambiguous set of standards should be created for generic medical practice set jointly by the GMC and the Post Graduate Medication Education and Training Board in partnership with patient representatives and the public
- A clear and unambiguous set of standards should be set for each area of specialist medical practice by the Medical Royal Colleges and specialist associations, with the input of patient representatives, led by the Academy of Medical Royal Colleges
- The process of NHS appraisal should be standardised and regularly audited and should in the future make explicit judgments about performance against the generic standards
- Specialist certification should be renewed at regular intervals of no longer than 5 years.
Renewal should be based upon a comprehensive assessment against standards set by the relevant Medical Royal College.
- Renewal of certification should be contingent upon the submission of a positive statement of assurance by that College.
- Independent scrutiny will be applied to the processes of specialist recertification, in order to ensure value for money
Challenges for the Colleges
These new developments will essentially change the role of the Colleges from being primarily supportive to being, at least to some degree, inquisitorial. Effective regulatory structures will be required, such as 360º appraisal (multi-source feedback) and patient satisfaction, questionnaires. Individual commitment to CPD will need to be strengthened, and the effectiveness of CPD will need to be demonstrated. Work is underway to determine how this may best be achieved.
Regarding the appraisal system, the Report lists six key functions that might be expected in reviewing an individual doctors practice:
- Ensuring that practice is safe
- Ensuring that practice is of a good standard
- Taking opportunities to improve practice
- Reviewing performance in relation to service goals, objectives and targets
- Identifying and meeting professional development and training needs
- Checking that conduct is honest and ethical, and that the individual behaves with integrity.
The current appraisal system does not routinely address all of these issues, and many would argue that appraisal should be a formative exercise rather than a summative one. Thus issues of performance might more properly lie in the field of assessment. But for the appraisal process to achieve the other objectives it will have to identify clear professional development needs and be able to verify that these have been met using objective and valid methods.
Such methods might include:
- Knowledge tests
- 360 degree appraisal
- Patient surveys
- Observation of consultations
- Analysis of clinical audit data
- Regular checks on physical and psychological health.
It is possible to link many of these processes together to demonstrate the effectiveness of CPD. Participation in CPD to meet learning objectives can be shown to lead to a change in knowledge and behaviour and thus (by implication) to improved patient care. A change in knowledge and improved care may be evaluated by the methods listed. This information can be reviewed at annual appraisal and will again lead to the development of a personal development plan. As doctors show that the quality of their care is improving, or is maintained at a very high level, so the effectiveness of CPD will be demonstrated.
The current role of the Royal Colleges in CPD is to determine the nature and quality of the activity. The role of the individual learner is to record that activity, to reflect upon the learning that has taken place and to change behaviour/practice if necessary. Some Colleges then audit the individual doctors claimed CPD activity to provide verification but they do not monitor knowledge or behaviour. With the more robust revalidation (re-certification) procedures envisaged doctors will be expected to utilise new tools to demonstrate their fitness to practice. The Colleges will need to audit and verify doctors claims, but the imposition of sanctions on under-performing doctors should be left to the regulatory authority, the GMC.
1) The Ten Principles. A Framework for Continuing Professional Development - 2005. www.aomrc.org.uk/index.htm
2) Good Medical Practice, 3rd edition, 2001. General Medical Council. www.gmc-uk.org/guidance/good_medical_practice/index.asp
3) Guidance on Continuing Professional Development, April 2004. General Medical Council. www.gmc-uk.org/education/pro_development/pro_development_guidance.asp
4) Smith, J. The Shipman Inquiry. Chairman: Dame Janet Smith. First to sixth reports, The Stationery Office, London, 2003 - 2006. www.the-shipman-inquiry.org.uk
5) Robertson, Umbole, Cervero, Journal of Continuing Education in the Health Professions. 2003, 23; 146-156
6) Donaldson, L. Good Doctors, Safer Patients. Department of Health, 2006. www.dh.gov.uk/PublicationsAndStatistics/ Publications/PublicationsPolicyAndGuidance/fs/en