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1. Heading • Text 2nd Modular Credentialing event 12 May 2009, Forbes House

2. Stuart Macpherson

3. Welcome • Many definitions and many views on modular credentialing – both positive and negative • Debated the issues in 2007 at the jointly hosted event with GMC • Important for all stakeholders to be involved • Important to be a UK wide development, although A High Quality Workforce: NHS Next Stage Review (DH, 2008) was the recent key initiator in England

4. PMETB was asked by DH to lead on this work • Medical Royal Colleges, GMC, the four Departments of Health, COPMeD, employers, service and public will be among the stakeholders represented on a steering group • PMETB will lead the exploration in relation to the pre CCT work stream, including subspecialties • GMC will lead the exploration in relation to the post CCT work stream

5. Dr John Jenkins

6. Wikipedia Credentialing is... an objective evaluation of a subject's current licensure, training or experience, competence, and ability to provide particular services or perform particular procedures.

7. Health Education Credentialing Credentialing is an umbrella term referring to the various means employed to designate that individuals or organizations have met or exceeded established standards.

8. UCL MSc/Diploma/Certificate in Advanced Paediatrics The MSc award includes the research dissertation and corresponds to 180 credits. The Diploma corresponds to 120 credits and the Certificate to 60 credits. Module example (15 credits):Evidence-based Child Health: assessed by 3-hour unseen examination. Mandatory for Certificate, Diploma and MSc Module example (60 credits):Research project: assessed through dissertation of 8000-10000 words (including five credits from the viva voce exam at the end of the MSc course)

9. Commonwealth of Massachusetts Board of Registration in Medicine The Expert Panel on Credentialing was charged to create a standardized framework that healthcare facilities might utilize during initial credentialing and re-credentialing. This includes a broad array of methods, such as evaluation of patient outcomes through case reviews, analysis of data, review of accomplishments, complaints, certifications, and other competency assessments as recommended by specialty boards, professional societies, or regulatory agencies.

10. Credentialing for surgical practice Any basis for credentialing must be seen to be objective, reproducible, credible, validated and appropriate. In order to do this we must: Agree standards Decide on a framework for assessment Determine methodology Select appropriate methods for each individual Judge performance objectively Manage the strategy Evaluate the results

11. Credentialing for surgical practice Credentialing is primarily perceived as a protective mechanism against poor performance, but it should also be seen as encouraging development and building up an individual's portfolio.

12. Credentialing issues in emergency ultrasonography The use of ultrasonography, traditionally performed by radiologists, is becoming increasingly widespread in emergency medicine. This article discusses training and credentialing guidelines, paths to becoming credentialed in emergency sonography, and quality assurance issues.

13. Workshop March 2007 There are four key factors that have prompted the development of the concept of credentialing: • The general appetite for more information about the status and competence of doctors • The changing nature of healthcare delivery • The need to ensure that postgraduate medical training equips doctors to best care for patients now and in the future, and that this training can be shown to enable doctors to be fit for this purpose • The need to promote doctors’ continuing professional development.

14. 2007 report of the GMC Specialist Register Review Group Registering specialist credentials would enable recording of competences acquired throughout a doctor’s specialist career and not just at the award of a CCT. Specialist credentialing might be used to reflect the increasing modularisation of specialist training and the more flexible training opportunities that will be necessary because of the changing demographics of the medical profession. Credentialing would provide a way of giving formal recognition to the additional training undertaken and qualifications acquired by doctors. The recording of that additional training would make the expertise of specialists more easily recognised and the register more transparent.

15. 2007 report of the GMC Specialist Register Review Group Specialist credentials would enable the recognition of specialist competences in fields of practice for which it is not possible to obtain a CCT and where regulation has been identified as weak. Credentialing offers a more agile means of responding to developments in medicine than is possible through the recognition of CCT specialties. It should be possible in principle to extend the principle of credentialing to apply to general practitioners with special interests.

16. A High Quality Workforce July 2008 ‘In partnership with the medical profession, in particular the Royal Colleges and the professional regulators, we will develop plans to introduce modular credentialing for the medical workforce over the coming decade. This means the formal accreditation of capabilities at defined points within the medical career pathway that takes into account knowledge, capabilities, behaviour, attitudes and experience.’

17. Meetings involving Royal Colleges, regulators and Department of Health (DH) officials Recommendation 2 No changes to medical training should be introduced without consultation and engagement with stakeholders (including the public, trainees, employers and the professions), piloting and assessment of the impact of change. Recommendation 3 Any proposals for modular credentialing must be compatible with the recommendations made by Medical Education England on the future structure of training and agreed by the Devolved Administrations.

18. Discussion paper March 2009 “For the purposes of this paper a credential is regarded as being a marker of attainment of competences (which include knowledge and skills) in a defined area of practice at a level that would allow the holder of the credential to work unsupervised in that area of practice.”

19. Stages of the medical career Pre-certification:After completion of Foundation Programme and before CCT (whether in CCT programme or other posts): this covers the credentialing of individual modules which have been defined within a CCT training programme (hence modular credentialing). This includes recognised subspecialties. Post-certification:After achievement of standard for entry to the Specialist or GP Register, whether through CCT or otherwise: this would involve a narrower breadth and/or deeper level of competence than covered by the CCT, but would need to be different from the defined CCT sub-specialties. This would be inextricably linked to recertification and could also apply to GPs with special interest.

20. Stages of the medical career Non-certification: Recognition of competence attained in discrete areas of practice not covered by either CCTs or by PMETB recognised sub-specialty training.

21. Specialty doctors Credentialing would help to demonstrate and support the maintenance of standards of specialty doctors who had developed competence in discrete areas of specialty practice. There may be regulatory value in this in terms of public and employer reassurance. There may also be a related value in terms of giving better recognition to specialty doctors and their training needs.

22. Academy of Medical Royal CollegesMedical Workforce Project Service posts and Credentialing Some doctors may choose to step sideways from their training before achieving specialist registration and perform service roles. Their abilities will vary considerably and employers, colleagues, patients and the public need to be able to recognise their level of safe practice. Thus a mechanism to record the expertise doctors have achieved needs to be developed. The same might usefully apply to doctors who have performed additional training since completing their specialty training.

23. Potential workstreams Pre-certification credentialing falls naturally to PMETB. The review of CCT curricula and subspecialty curricula planned by PMETB for later this year and early 2010 could provide an opportunity for the medical Royal Colleges to identify discrete modules within their curricula, which might be credentialed in the future. This should involve the Training and Assessment Committees, together with the Board. Post-certification credentialing for specialists (including GPs) links with recertification and therefore falls naturally to the GMC. This would fall within the remit of the Continued Practice Board. “Non-certification” credentialing could best be considered together with post-certification credentialing.

24. Overarching principles Consistency of overall approach will be important in order to achieve a coherent outcome. Some overarching principles for all types of credentialing are needed. For example: Possession of a credential should signify attainment of a standard commensurate with working unsupervised in that area of practice A credential must be in a sufficiently broad area of practice that it would not restrict workforce flexibility or quickly become obsolete (therefore avoiding procedure-specific credentialing) A credential must not compete with a recognised sub-specialty field.

25. The strategic review The strategic review of the regulation of medical education and training being led by Lord Patel at the request of the GMC and PMETB will almost certainly have an interest in the regulatory implications of credentialing. Any work on credentialing will need to be tied into the review.

26. Purpose of this event To provide an opportunity for identification of different perspectives on this issue in order to inform the [Modular] Credentialing Steering Group’s discussions. The purpose of the CSG is to facilitate the coherent development of proposals for credentialing across all stages of doctors’ careers, and to provide information on work and progress to the Board, Council, Academy, four Departments of Health and other key interest groups.

27. GMC registers - an updateFinlay Scott

28. Adding Value to Registers

29. 'When I use a word,' Humpty Dumpty said, in a rather scornful tone,' it means just what I choose it to mean, neither more nor less.' 'The question is,' said Alice, 'whether you can make words mean so many different things.' • 'The question is,' said Humpty Dumpty, 'which is to be master - that's all.‘ • Lewis Carroll

30. Once upon a time … • Medical Act 1858: • ‘Whereas it is expedient that Persons requiring Medical Aid should be enabled to distinguish qualified from unqualified Practitioners:’ • ‘The Registrar of the General Council shall in every Year cause to be printed, published, and sold…a correct Register of the Names…Residences…and Medical Titles, Diplomas and Qualifications conferred…’

31. And then … • ‘The purpose of medical registration is to enable the public to recognise the competent practitioner. It follows that an indispensable feature of any system of registration is that it shall mark the attainment of a certain educational standard… Such a registration system works because patients, when provided with the means of making the choice, will naturally resort to the qualified in preference to the unqualified.’ • Report of the Committee of Inquiry into the Regulation of the Medical Profession 1975 (Merrison Report)

32. Today • Medical Register no longer printed • List of registered medical practitioners - a single electronic database on the GMC website: • ~230,000 registered doctors • ~60,000 doctors on the specialist register • ~60,000 doctors on the GP register

33. Appetite for information • In 2008: • LRMP accessed over 3.5 million times • 275,000 registration status by automated faxback • 50,000 calls to GMC Contact Centre about registration • NHS Occupational Health Smart Card. • Employers seeking better information from the registers about doctors’ sub-specialty practice.

34. But … • Still a historical record. • Still limited information: name, primary qualification, registration date, whether on the GP register or specialist register, and specialty if on specialist register. • Information sometimes misleading - 15% of doctors on the specialist register working partly or wholly in a field which is different from that recorded

35. Ambition • ‘The registers should carry a wider range of information if that is of benefit for patients, the public and the NHS and other health providers’ (GMC Council December 2005) • ‘…the register will be further developed to become the single authoritative source of information on doctors…’ (Trust, Assurance and Safety – The Regulation of Health Professionals in the 21st Century)

36. Shape of things to come? • ‘[DH] should work with the GMC to create robust databases that hold information on the registered/ certificated status of all doctors practising in the UK. This will provide an inventory of the contemporary skill base and number of trained specialists/ subspecialists in the workforce as well as those training for such positions to inform workforce planning.’ • Tooke Inquiry into Modernising Medical Careers, 2008. Recommendation 13

37. Opportunities • Revalidation rooted in evidence from practice. • LRMP will display more up to date information • LRMP to describe revalidated field of practice? • To include additional information on ~20,000 specialty doctors? • To include trainees’ progress toward CCT? • More effective regulation of areas such as cosmetic surgery?

38. There is no use trying, said Alice; one can’t believe impossible things. I dare say you haven’t had much practice, said the Queen. When I was your age, I always did it for half an hour a day. Why, sometimes I’ve believed as many as six impossible things before breakfast. • Lewis Carroll

39. Review of curricula and assessment systemsPatricia Le Rolland

40. Present situation • 57 specialties and 33 subspecialties • The term subspecialty has a specific meaning and only PMETB can award certificates in subspecialties • A published list of those recognised in the UK is available on PMETB website • The terms special interest, modules, credentials etc to describe particular ‘element/s’ of specialty curricula presently have no standing in regulatory terms and is not recognised as a subspecialty. They can of course have meaning for the specific Medical Royal College.

41. Order 2003 no 1250 • The Board shall.. establish standards and requirements relating to pmet necessary for the award of a CCT… (Part 3, Article 4 (1)) • “13 (5) In order to satisfy the Board that he has a particular expertise in a field such that he is entitled to have that expertise indicated in the register under paragraph (4)(b), the person must satisfy the Board that he has satisfactorily completed – • a) Sub-specialty training in the United Kingdom that is approved by the Board; or • b) any other sub-specialty training outside the United Kingdom that the Board is satisfied is equivalent to sub-specialty training approved by the Board.”

42. Review – 2009 to 2010 • Three stage approval process agreed in 2006 between AoMRC and PMETB • Letter to all Presidents in April 2009 confirming the requirements for the review • To assess whether the remaining standards for assessment are met for each specialty and subspecialty • To include all minor and major changes for 2009 – no annual college summary required in 2009 -2010; no separate major change process this year • Dates set and published in the Operational Guide

43. Review – 2009 to 2010 • “It is important that the Colleges and Faculties take the opportunity to develop the clarity and transparency of how the assessment systems blueprinted against the curriculum contribute to progression. In particular that there should be clear progression points within the curricula, with explanation of the assessment requirements that will enable progression at each ARCP, as well as the completion of the CCT.”