Revalidation Policy for the South West
This document has been developed by the Health Education England (HEE) revalidation team in the South West and sets out the policy for the revalidation of doctors with a prescribed connection to HEE.
Where relevant, reference is made to policies held by Health Education England and COPMeD as well as the Gold Guide: A Reference Guide for Postgraduate Specialty Training in the UK, and GMC guidance.
This policy covers two groups of doctors:
1. Those doctors in a GMC approved training programme within either Severn or Peninsula Postgraduate Medical Education, for whom the Postgraduate Dean is their Responsible Officer (RO), which includes doctors who:
- are in foundation year two
- Core trainees (CT)
- Specialist Trainees (ST)
- General Practice Specialist Trainees (GPST)
- Trainees in combined Clinical and Academic training (ACF, CL)
2. Senior doctors (e.g. Associate Deans) employed or contracted by HEE for whom the Postgraduate Dean is their Responsible Officer.
Revalidation is the process by which licensed doctors are required to demonstrate on a regular basis that they are up to date and fit to practise. Revalidation aims to give extra confidence to patients that their doctor is being regularly checked by their employer and the General Medical Council (GMC).
Licensed doctors have to revalidate, usually every five years, by having regular appraisals with their employer that are based on the GMC’s Good Medical Practice. Trainee doctors also have an additional revalidation at the time of their CCT.
For doctors in training, revalidation will be based on participation in the Annual Review of Competence Progression (ARCP) process. For non-trainee doctors, revalidation will be based on participation in annual appraisals.
Responsible Officer (RO)
The Responsible Officer for HEE in the South West is the Postgraduate Dean. Supporting the Postgraduate Dean in their role is an Associate Postgraduate Dean, and two Revalidation Managers, referred to as the revalidation team throughout this document.
HEE has a national process of assigning an alternative responsible officer, should there be conflicts of interest or the appearance of bias. This will usually result in an RO from another local office in the same region being assigned to any individual where conflict of interest or appearance of bias is identified.
HEE’s Local Education and Training Boards (LETB) are the designated bodies for doctors in training in England. For the purposes of revalidation, the GMC lists our designated body as Health Education South West on the GMC Connect and GMC Online systems. The revalidation team, on behalf of the RO, ensures an accurate record of all doctors with a prescribed connection to the designated body is maintained.
ARCPs and Appraisals
Revalidation for trainees will be based on participation in the Annual Review of Competence Progression (ARCP) process. The ARCP has been enhanced to ensure that the requirements set out in the GMC’s Good Medical Practice Framework for appraisal and revalidation are met. To achieve this, the following have been incorporated:
- Form R (Part B) - Self-declaration for the Revalidation of Doctors in Training
- Educational Supervisor’s report – additional question added for revalidation
- Exception Reports – clinical governance information from LEPs/Employers
- ARCP Outcome Form - Revalidation section added
ARCPs should be carried out in accordance with the Gold Guide and local ARCP Policy.
HEE is the designated body for a small number of non-trainee doctors, usually in Associate Dean roles or similar, whose main NHS employer is HEE.
These senior doctors will have two appraisals each year; one performance appraisal with their line manager using HEE appraisal paperwork, and one whole scope appraisal using the Medical Appraisal Guide (MAG) model appraisal form. Where the line manager is also the RO, the MAG appraisal will be with a Postgraduate Dean from a neighbouring local office, as per HEE’s “Responsible Officer Medical Appraisal Policy”.
There are six types of supporting information that doctors will be expected to provide and discuss at their appraisal at least once in each five year cycle. They are:
- Continuing professional development (CPD)
- Quality improvement activity
- Significant events
- Feedback from colleagues
- Feedback from patients
- Review of complaints and compliments
Trainees’ Supporting Information
Doctors in training will be generating the supporting information required by the GMC in order to meet the requirements of their curriculum and training programme. They will also be in regular discussion about their progress and outstanding learning needs with their supervisors. These discussions should include summarising and reflecting on strengths and weaknesses, and significant achievements or difficulties, which will usually encompass information on significant events, and complaints and compliments.
If a training programme does not require trainees to routinely collect items of supporting information, they are not expected to go beyond the requirements of their training programme and collect this.
If a trainee has undertaken any other work outside of their training programme they will need to provide supporting information for this as well. As a minimum, a Wider Scope of Practice form should be completed for each instance of additional work.
Non-trainees’ Supporting Information
It is the doctor’s professional responsibility to produce a portfolio of supporting information. The supporting information should be presented and discussed at the doctor’s annual appraisal. The nature of the supporting information under each category will reflect the doctor’s particular specialist practice and other professional roles.
Clinical Governance Information
In order to make a recommendation to the GMC, the RO needs to take account of available clinical governance information that may be relevant to the evaluation of a doctor’s fitness to practise.
For doctors in training, the organisations in which they have undertaken clinical placements are required to submit an Exception report to the revalidation team whenever a trainee is involved in:
- Conduct (resulting in local HR investigation/action)
- Named in and significant involvement in SIRIs and Never Events
- Named involvement in reported incidents or patient safety incidents (at a level where a root-cause analysis was required, or disciplinary action required).
- Named / involved in formal patient complaints (regardless of severity of issue)
- GMC investigations or action
The trainee should also always be given a copy of any exception report they are named in for their portfolio.
For non-trainees, the RO may request information from other organisations in which a doctor works.
Out of Programme (OOP)
Trainees undertaking approved time out of training for experience (OOPE), research (OOPR), training (OOPT), or career break (OOPC) must remain connected to HEE, have an ARCP and retain their licence to practise and their training number. Please refer to the HEE guidance on OOP and Revalidation.
Period of Grace
Trainees in their period of grace should remain connected to HEE until they relinquish their training number.
Recommendations to the GMC
The RO can make one of three recommendations to the GMC for doctors who are under notice:
The RO makes timely recommendations to the GMC about the fitness to practise for all doctors with a prescribed connection to the designated body, in accordance with the schedule, the GMC Protocol for Making Revalidation Recommendations.
Day to day responsibility for submitting these recommendations is delegated to the revalidation team. All relevant information known to the designated body, from the whole of the scope of work and across the doctor's revalidation cycle, is considered in making a recommendation about a doctor's fitness to practise.
Deferrals for doctors in training are made in line with the COPMeD Trainee Revalidation Deferrals Policy.
Responding to Concerns
A key function of Revalidation and the remit of the RO is to ensure that concerns relating to a doctors fitness to practise are identified and appropriately managed.
The Fitness to Practice (FtP) Concerns process for trainees is managed by the relevant department depending on the training programme the trainee is in, in accordance with the South West Management of Fitness to Practise Concerns Guidance. The RO and the Revalidation team will provide oversight of the process and guidance on the management of specific cases as required.
Transfer of Information
The primary method for transferring information from RO to RO for doctors in training is via the ARCP Outcome Form. Should there be additional information of note to share with the future RO, a Medical Practice Information Transfer (MPIT) Form will be used with the ARCP Outcome Form included as an attachment.
The MPIT form will be used for transfer of information requests relating to non-trainee doctors.
The sharing of information collected to support the statutory role of the RO is normally exempt from the restrictions of the Data Protection Act 1998. Therefore, when sharing information relating to the doctor’s fitness to practise, the doctor’s consent is not normally required. When information is shared for these purposes only relevant factual information is shared. This is only shared with those who have a right to know, for example, the RO, the employer or the GMC. The information shared should not contain personally identifiable information relating to patients or other staff.
Information Governance and Data Protection
Management of revalidation information is supported by and applied within existing legislative frameworks. These include:
- The Medical Profession (Responsible Officers) Regulations 2010
- The Medical Profession (Responsible Officers) (Amendment) Regulations 2013
- The Data Protection Act 1998
- The Freedom of Information Act 2000
Most revalidation information for trainees is part of their training portfolios and ARCP paperwork. It is, in addition to the above, managed in accordance with local policies and the Gold Guide.
The RO and revalidation team are all required to regularly undertake information governance training.
Equality and Diversity
HEE is committed to integrating good practice concerning the equality and diversity agenda within all aspects of its working practice.
The RO and the revalidation team keep up to date with Equality and Diversity policies and practices by undertaking training every 3 years.
HEE quality assures the implementation of revalidation and responsible officers within the local teams. In turn HEE assure NHS England, as senior responsible owner for revalidation in England that revalidation is being implemented fairly and transparently across local teams.
The responsible officer Reports to the LETB on compliance with the RO regulations and any other statutory requirements in accordance with the HEE Quality Assurance Framework for Responsible Officers and Revalidation.