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Clinical Oncology 23 (2011) 657e658

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Clinical Oncology

journal homepage: www.elsevier .com/locate/c lon

Editorial

Revalidation and Lifelong Learning

A. Crellin

St James’s Institute of Oncology, St James’s University Hospital, Leeds, UK

Received 12 July 2011; accepted 14 July 2011

Following the public enquiry into excess mortality at theBristol Royal Infirmary in 2001 and the criminal acts ofHarold Shipman, there was strong pressure for an improvedsystem of regulation for doctors in the UK. The White PaperTrust, assurance and safety: the regulation of health profes-sionals [1] in 2007 suggested a formal process of revalida-tion to ensure that doctors were fit to practise and weresafe. With some of the more complex and costly schemesdiscarded after the House of Commons Select Committee onHealth 2011 [2], the proposal is now for enhanced annualappraisal. A sign off process on a 5 year cycle to the GeneralMedical Council for doctors, through a linked ‘ResponsibleOfficer’ will allow them to remain licensed.

It is difficult to criticise a process that ensures a doctor isfit to practice in line with the General Medical Council’sGood Medical Practice Framework for Appraisal and Reva-lidation, March 2011 [3]. This consists of four domains, eachwith three attributes covering the spectrum of medicalpractice, and provides a framework for the collection ofa portfolio of evidence over the revalidation cycle (Figure 1).It includes evidence of Continuing Professional Develop-ment (CPD) and 360� feedback from both colleagues andpatients and some suggested specialty elements. The idealis to identify any doctors that are falling below acceptablestandards at an early stage, allowing remedial adviceguidance, training and mentoring. It would be robustenough to provide assurance for the public while notcreating unnecessary and bureaucratic burden for doctors.However, employers must support meaningful and struc-tured appraisal, something that has been sadly variableacross the UK.

There is a need to ensure thatpre-Certificate of Completionof Training (CCT) training assessments fulfil revalidationfunctions, as the transition from, pre-CCT to post-CCT and

Author for correspondence: A. Crellin, St James’s Institute of Oncology,Level 4 Bexley Wing, St James’s University Hospital, Beckett Street, LeedsLS9 7TF, UK.

E-mail address: Adrian.crellin@me.com

0936-6555/$36.00 � 2011 The Royal College of Radiologists. Published by Elsevidoi:10.1016/j.clon.2011.07.010

a consultant post should be seen as a continuous pathway interms of governance.

There is no agreedNational Health Service (NHS) appraisaland revalidation IT system. The obvious deficiencies of therecent NHS Revalidation Pilot Toolkit, past failed NHScomputing initiatives and the current financial climate makethis unlikely before 2012. The Royal College of Radiologistshas supported the approach of a portfolio of relevantevidence as a basis, particularly given that individualemployers may insist on different administrative systems.

Clinical Oncology, as a specialty, has a particularly vari-able spectrum of clinical practice so anything valid must bebased around the components and treatment modalities ofindividual job plans. With a new focus in national guidance,such as Improving outcomes: a strategy for cancer 2011 [4],clinical outcomes will be valuable evidence of practicestandards and increasingly difficult to ignore (e.g. 30 daymortality figures for chemotherapy). However, teamworking and the multidisciplinary nature of oncology canmake the assessment of one individual clinician difficult. Itis important that different standards of performance are notapplied, for instance, to Medical and Clinical Oncologywhen in reality they may be sharing the same clinics andpatient workloads.

So what of lifelong learning and the concept of reflectivepractice? The concept is inherently ‘soft’ in that it isself-directed and leads to improvement based on personalexperience. CPD used to be attendance certificates witha currency of ‘time served’. More robust evidence oflearning is becoming routine e signing in to meetingsessions, passing a simple evaluation or making a reflectivenote. Clinical audit is a vital and much more robustcomponent of reflection, either validating or changingpractice. Individual case-based discussions and reflectionare proposed. This profile of evidence will require moreconsistent time applied to it rather than a last minute rushbefore the appraisal date. Some would say 1.5 supportingprofessional activity time in a job plan for personal revali-dation recommended by the Academy of Medical Colleges is

er Ltd. All rights reserved.

Fig 1. GMC Good Medical Practice Framework for Appraisal and Revalidation.

A. Crellin / Clinical Oncology 23 (2011) 657e658658

generous. Employers should support this as otherwise theburden of risk begins to fall back firmly on them. The RoyalCollege of Radiologists has a range of suggested tools formany of these elements available online [5].

Formal documentation of competency, skills or compul-sory training certificates is not unreasonable when newequipment, treatment planning systems, chemotherapyprescribing or other IT are introduced. The Ionising Radiation(Medical Exposures) Regulations (IRMER) require a traininglog for these in radiotherapy. Maintaining good clinicalpractice accreditation for clinical trials practice is essential.Objective criteria and regular competency assessmentswould provide a more robust revalidation programmecomparedwith the largely reflective process proposed by theGeneral Medical Council. It would, however, impose a muchmore complex and costly system for the NHS, and for thatreason seems unlikely to be widespread.

One of the most valid and useful potential elements forlearning by reflection in clinical practice is 360� feedback.Several simple tools evaluating relationships withcolleagues of varying complexity have been used for someyears as a component in appraisal in many hospitals.Experience has shown a valuable insight into personalbehaviours. A range of colleagues is encouraged acrossdisciplines; radiographers, physicists, outpatient and wardnurses, clinical nurse specialists, managers and secretaries.This can justify ‘performance management’ or interventionin the case of serious problems. The introduction of 360�

feedback from patients is fraught with problems, however.Faulty methodology seems to abound here. Problems canarise in asking the patient to give the completed form backto the doctor, confusion between a tool designed to assessa hospital episode and one designed to assess satisfactionwith a consultation with a particular doctor, consultationsinvolving several doctors in a multidisciplinary setting or intraining junior staff. In oncology it might be consideredinappropriate to ask for a feedback form to be completedafter just having been given bad news. The General MedicalCouncil and Royal College of Physicians tools are generic

and some questions inappropriate for oncology practice. Amodified and validated oncology-specific tool is beingexplored through the Joint Collegiate Council for Oncologyto ensure that Clinical and Medical Oncologists are assessedwith the same appropriate tool.

Revalidation needs to be matched by a robust NHSmanagement process that can identify and will actuallydeal with the ‘bad’ doctors, be it dangerous practice orunacceptable behaviours. On the other hand, ina specialty with a documented burnout risk [6] it wouldbe good to know that struggling or failing doctors,through illness or personal circumstance, are dealt withsympathetically.

The proposals are designed to reassure the public thatthe doctors looking after them are safe, competent and upto date, a laudable aim. They are also designed to ensurethere will never be another ‘Shipman’, but then again onreflection.....

References

[1] White Paper. Trust, assurance and safety: the regulation of healthprofessionals. London: Department of Health, 2007. Available at:http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_065946.

[2] Health Committee, Fourth Report. Revalidation of Doctors,2011. Available at: http://www.publications.parliament.uk/pa/cm201011/cmselect/cmhealth/557/55702.htm.

[3] GMP framework for appraisal and revalidation. GeneralMedical Council, 2011. Available at: http://www.gmc-uk.org/doctors/revalidation/revalidation_gmp_framework.asp

[4] Department of Health. Improving outcomes: a strategy forcancer. London: Department of Health, 2011. Available at:http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_123371

[5] Royal College of Radiologists. Revalidation. Available at:http://www.rcr.ac.uk/content.aspx?PageID¼1929

[6] Ramirez AJ, Graham J, Richards MA, Cull A, Gregory WM.Burnout and psychiatric disorder among cancer clinicians. BrJ Cancer 1995;71:1263e1269.