| In the post Kennedy era, following the Bristol inquiry, it became
evident that Dame Janet Smith’s inquiry into the Shipman case would
produce far-reaching recommendations for all health professionals. The
fourth
Shipman Report is clear that the practice of health care and the use
of Controlled Drugs need to change radically. The fifth report criticised
the General Medical Council revalidation procedures and this resulted
in the Chief Medical Officer instituting a review of the effective revalidation
of doctors and the role of the GMC. This will have implications for other
health care professionals through the Foster Review.
The terms of reference of the Foster Review are to put in place comprehensive
and consistent measures to ensure all professionals treating patients
remain fit to practise. There is a need to strengthen fitness-to-practise
procedures, ensure effective continuing professional development, develop
appraisal and progress towards regular revalidation where appropriate,
ensure effective regulation of new roles where there is patient contact
and look at any changes needed to the role, structure, functions and
number of regulators.
The report of the Royal Pharmaceutical Society’s Shipman Working
Group stated, in its response to the fifth Shipman report, that “periodic
revalidation should be seen as a positive assessment as to whether the
practitioner is currently fit to practise, rather than a negative assessment
on the basis that nothing adverse is known about them”, ie, revalidation
goes further than CPD. Revalidation is important from both the public
interest and employers’ perspective. In most cases the “employer” for
pharmacists is the NHS, directly in the managed sector or as an independent
contractor to the NHS. However, pharmacists working elsewhere, such as
in the private sector and prison pharmacy, would also be included.
Lessons can be learnt from other industries that have developed various
models which give assurances to the public by raising continuing standards
and filtering out incompetence. For example the lessons from aviation
include the fact that revalidation is completely accepted within this
industry and this comes with an admission factor. Pilots are licensed
to fly (practise) every six months and there is an element of observation
in the revalidation process every 12 months. Revalidation is carried
out by people respected within the industry. There is a mandatory reporting
system that makes whistle-blowing easier (as a legal requirement). There
is, however, a cost in the loss of personnel. Teams are assessed by performance
on the job, which brings in the trust factor, and there are losses each
year due to health issues.
Further lessons can be learnt from the medical profession. It is assumed
that the public’s expectation is that registration is conditional
on revalidation throughout the doctor’s practising life and that
this includes assessment of practice, ie, what one actually does, rather
than just the knowledge and skills of what one could do.
So what are the medical profession’s revalidation proposals, why
are there problems and what are the alternative approaches that might
be considered? Furthermore, what are the potential implications for pharmacy?
Its proposed model for revalidation is a set of appraisal-based procedures,
operated locally and overseen by the GMC. The purpose is to secure the
evaluation of a medical practitioner’s fitness to practise as a
condition of continuing to hold a licence to practise. There is no assessment
involved; revalidation in medicine is about fitness to practise, not
unfitness to practise. It is intended to be a demonstration of fitness
to practise now, not just the assumption that possession of a primary
medical qualification leads to the award of a licence to practise.
Factors to be taken into account in revalidation include patient and
public involvement, clear standards, rigorous quality assurance and detailed
scrutiny when local systems are not fit for purpose or do not exist.
There appears to be an acknowledged problem around who accredits GPs
and local accreditation of GPs, which is not uniform. There needs to
be a clear purpose to revalidation: good revalidation should reward excellence
and not have the simple purpose of detecting the 5 per cent below grade.
What can pharmacy learn from this? There are many questions to be answered,
such as what CPD is and what it is not. What is revalidation and its
purpose in pharmacy? Why might revalidation be different for different
pharmacists?
First let us consider the role of appraisal as a measure of current competence
or performance. It will only be useful if it assesses whether performance
is satisfactory, identifies attitudes, values or behaviour problems and
highlights skills and knowledge that need to be enhanced. A more formal
performance assessment may be triggered around any concerns and this
may be a contractual requirement. It may go beyond solely addressing
individual development or working as part of a team and it may be appropriate
to introduce measures such as a validation process with periodic endorsement
by a supervisor or mentor. The purpose of revalidation is that renewing
registration assures fitness to practise, which for health professionals
must secure and maintain public trust and confidence in professionalism.
This can be done in a number of ways, such as a common set of minimum
standards, competency to do a particular job and being fit for
purpose.
There is a public expectation, endorsed by the fifth Shipman report,
that revalidation should be an effective indicator of a professional’s
competence. This means information supplied by the practitioner alone
without an assessment carried out by or on behalf of a regulator will
not suffice. Revalidation may or may not include information provided
by an accredited employer, such as an NHS appraisal, but the process
of revalidation should include, if necessary, remedial action and a managed
exit from the register. There should be a link to the regulator functions
with fitness-to-practise procedures. These should include rapidly addressing
serious concerns and recurrent themes of misconduct, including dishonesty
and abuse, to protect the public. There is, therefore, an element of
conduct, not necessarily deficiency of knowledge or performance. A major
change in culture is required right from the first admission to a school
of pharmacy that there is not a job for life by right. However, there
needs to be a balance between stifling innovation, which improves patient
care, and regulation.
It is clear that pharmacists in clinical practice will need to be assessed
to confirm fitness to practise on such competencies as communication
skills and application of medicines use reviews, although a different
format would be expected for an academic. The assessment may need to
include where relevant a practical assessment or in some cases, where
this is impractical, portfolio assessment. Consider what are the competencies
required normally for a pharmacist, informed by the core knowledge and
skills framework of the Society. How do competencies fit into revalidation?
Should health and suitability be considered? What else needs to be considered?
Are there any conditions that question suitability? Is the CPD record
adequate and does it take into account recent career changes and any
specialties within the sphere of practice? Can different jobs be easily
assessed? How will they be assessed and by whom? Which options for assessment
will be best and what are the practicalities? Critically, what are the
resource implications and who will pay?
These are just some of the issues to be considered and resolved as pharmacy
prepares itself for the future. If we want to be a step ahead, we must
first catch up with what is expected of us so far. CPD, and getting it
right is the first stage of preparation for the next step — revalidation.
There is at the moment an unknown timetable but the clock is ticking.
At a recent Chiltern regional meeting, following the presentation of
this information on revalidation, there was the first attempt to facilitate
a discussion on the subject with a group of pharmacists in an open meeting.
The following feedback was useful to the debate that the profession must
now undertake in order to gather the views and concerns of the membership:
· There was a concern about assessment against core competencies and
those attached to any specialism, for example hospital pharmacists who
work as community locums
· There is a need to consider how core competencies fit into the sector
the pharmacist is working in and how they can be revalidated
· There will be specialist areas where all core skills are not relevant
and there will also be core skills that will be needed by everyone
· Some areas of practice bring into question the need to be a practising
pharmacist if core competencies are not relevant; therefore, linked to
the questions on the fee declaration form there needs to be clarity about
where being a pharmacist does add value
· With regard to a portfolio pharmacist, the question was raised of annotation
of the register which at the moment only records the qualification not
the competency of, for example, a prescriber
· It became clear that on, admission to pharmacy university courses,
both undergraduate and postgraduate, potential students would need to
realise the commitment to life-long learning and the additional CPD requirement
in specialist areas with respect to future revalidation
The implications of revalidation, as the next step following continuing
professional development, are obvious and the Foster review ensures that
it will not go away. To develop an acceptable framework for revalidation
is a major piece of work for the Royal Pharmaceutical Society.
The members of the Society will want their say. |
The
Pharmaceutical Journal