The launch of the RCGP Rural Forum and reflections on revalidation

1. The launch of the RCGP Rural Forum and reflections on revalidation DDA conference 2009 Dr Malcolm Ward

2. RCGP Rural Practice Standing Group The Rural Practice Group was founded in 1993 to raise the profile of rural medicine in the United Kingdom through education, research and the dissemination of good practice in rural health care.

3. Key issues for ruralpatients • Access to services • Threats to local services posed by centralisation policies (Darzi report) • Poor public transport • Community hospitals • Minor injuries and pre-hospital care as essential (rather than optional) practice commitments. • Rural deprivation /mental health • Agricultural workers Health and Safety • Pharmaceutical services - GP dispensing

4. Concerns of rural doctors • Last of the true generalists?: Maintaining, updating skills • Political initiatives that favour large practices (money follows the patients) • Privatisation by stealth • NICE e.g. Minor surgery • Single handed GPs: OOH, recruitment, political attitudes • Revalidation • Practice boundaries? H.M. Mike O’Brien!

5. The quest for a non geographical rural faculty

6. Risks for College if RF was rejected • Disengagement of rural GPs • Membership losses • Call for: • Independent Rural College? • Intermediate Care College?

7. Rural Group survey April 2008 • 63% of respondents were from Scotland (total 144) • 83% were GP principals • 32.6% were not RCGP members • 57% had >4hrs of travel time to attend geographical faculty meetings • 77% said they had no college involvement • 72.6% were dispensing • 52.4% 10-50 miles to nearest DGH, 27.4% > 75miles • 72% thought the College has little or no understanding of rural issues • The majority were not happy with the current geographical faculty arrangements and preferred the formation of a UK rural faculty as opposed to devolved faculties or a separate rural college. • 63% of non members would become RCGP members if there was a rural faculty.

8. Key messages from Richard Hays • Key purpose to improve rural health rather than focus on just professional issues • Avoid ACRiMony: work within the College • Set out Forum objectives: training, education, support, advocacy for members • Broad coalition/inclusivity • Identify rural stakeholders and keep engaged with them

9. UK Council Feb 2009:The vote • The first vote concerned the establishment of a non-geographical rural faculty. The result of the vote was: • For: 17 • Against 33 • Abstentions 6 • The proposal to establish a ‘Faculty’ therefore fell. • The second question was the approval of the concept of establishing a grouping representing rural and remote GPs within the College, as set out in the paper, but without the term ‘Faculty’. This gained overwhelming support from Council, with the result: • For 44 • Against 0 • Abstentions 5

10. Forum = Faculty?

11. Overall aims of the Rural forum • To represent rural and remote general practitioners within the RCGP with the potential to promote rural issues within and outwith the College faculties and be the rural face of the College • To encourage engagement with the College of those fellows/members working in rural practice. • To facilitate communication between and networking of rural doctors across the UK. • To support the professional development of rural general practitioners, with particular reference to the required knowledge, skills and attitudes of a general practitioner to care for patients in a rural setting. • To promote rural practice and support associates in training with particular reference to the required knowledge, skills and attitudes. • To promote rural practice as a career path for associates in training and through the College strive to ensure availability of appropriate training. • To promote remote and rural issues at appropriate level, engaging with the profession, managers and informing political debate.

12. Rural Forum Steering Group • Chris Clark (Cornwall) • Aidan Egleston (DDA) • John Elder (Lins) • David Hogg (AiT) • Paul Kettle (Orkney) • Robert Lambourn (Northumberland) • Jane Randall-Smith (IRH) • Michael Smyth (N.I.) • Susan Taylor (RPAS) • Russell Walshaw(GPC) • John Wyn-Jones (IRH) • Malcolm Ward (chair)

13. Examples of what the Forum can do • Responding to national consultations • Informing and influencing national bodies • Rural proofing Revalidation • Practice support, sign posting re topical issues e.g.PCF development. • Promote and sign post rural health research • Develop a Rural E-network that will enable YOU to inform us of your concerns and needs.

14. Primary Care Federations “GPs are good at adapting to change and seizing opportunities for improvement. We can achieve more through GP practices working together than by individual practices working in isolation.” RCGP chairman Professor Steve Field

15. Examples of areas where improvements to patient services and to GP’s lives might be gained via PCFs are: • Out of hours services where there are still problems • Holiday and sickness cover • Gaining GP quest cover enabling combined practice education/training events • Improving minor injury services • Improving and extending minor surgery provision • Improving access to investigations e.g. mobile MRI • Improving transport for test samples to improve result turnover. • Greater negotiating powers for improving premises to provide improved range of services.

16. Desk top analysers at a designated site • Improving access to Physiotherapy, chiropody services • Providing counselling services or extending existing service • Drug, alcohol support services • Outreach specialist consultant clinics, GP specialist clinics, nurse specialist clinics • Potential for improvements in practice management with shared expertise • Increased purchasing power for practice requisites • Increased potential in Practice Based Commissioning (where national governing bodies advocate PCB)

19. LCG Configuration

20. Why do we need revalidation?

21. ‘Organ scandal doctors 'presumed too much‘ - Bristol Royal Infirmary 1999 Thursday, 23 September, 1999, 16:06 GMT 17:06 UK Organ scandal doctors 'presumed too much' Some parents only found out after the inquiry was launched Doctors who took the hearts of children who had died during surgery "presumed too much", a leading doctor has said. Professor Robert Anderson of Great Ormond Street Hospital, London, was giving evidence to the public inquiry into child heart surgery at the Bristol Royal Infirmary. The inquiry is also investigating the routine retention of hearts and other organs for educational purposes.

22. Thursday, 8 February, 2001, 10:23 GMT Organ scandal: How can faith in the health service be restored? A police inquiry has been ordered after it was revealed that thousands of body parts were stripped from dead babies and stored at Alder Hey hospital in Liverpool. A report into the organ removal scandal has revealed that the bodies of dead children who underwent a post-mortem at the hospital were systematically stripped of all their organs. In a separate report, the chief medical officer revealed that that more than 100,000 organs are still being held by hospitals and medical schools across England. Many had been removed without the consent of relatives. The Health Secretary, Alan Milburn, described what happened at Alder Hey as unforgivable. He announced legislation to ensure this did not happen again.

23. Monday, 31 January, 2000, 16:39 GMT How many did Shipman kill? The conviction of Dr Harold Shipman on 15 counts of murder brings to a close the trial of one of Britain's biggest serial killers. But it does not represent the end of the story. It can now be reported that those behind the investigation believe Shipman committed many more murders, beyond those for which he has been found guilty. The police have investigated the deaths of 136 of his patients. Coroner John Pollard says: "It would not be unreasonable to say a figure of 150 would be a realistic, possible estimate." The Crown Prosecution Service says it is ready to prosecute in 23 of those cases, if the families of the deceased permit it.

25. Revalidation: Evidence areas • Statement of basic professional roles and other basic details. • Statement of exceptional circumstances e.g. career breaks, illness, maternity leave etc. • Evidence of active and effective participation in annual appraisals. • A personal development plan (PDP) from each appraisal. • A review of the PDP from each appraisal. • Learning credits in each year (50) of the revalidation period and revalidation (total 250 over 5 yrs). • Multi source feedback (MSF) from colleagues(x 2/5yrs_ normally in year 1 or 2 and in yr 4 or 5).

26. Evidence areas continued: 8. Feedback from patients ( 2 patient surveys/5 yrs) 9. Description of any cause for concern or formal complaint. 10.Significant event audits (minimum of 5 demonstrating reflection and change and discussion at appraisal). 11. Clinical Audits of the care delivered by the GP in at least two significant clinical areas of their practice, with standards, re-audit and evidence of both appropriate improvement, compliance with best practice guidelines and discussion in appraisal. 12. Statement of probity and health,and use of health care, including registration with a GP in another practice; evidence of appropriate insurance or indemnity cover 13. Additional evidence for areas of extended practice. Dispensing?

27. How will CPD learning credits be awarded?

28. Range of credit scoring activities • Background reading eg BMJ, BJGP • Targeted reading, eg case prompted internet searches/reading, or to plug recognised knowledge gaps • Attendance of conferences, educational meetings • Training courses: new skills, improving skills eg to become GP trainer • On line learning: RCGP/BMA e-learning modules • Clinical audit • Learning from significant events/improved clinical practice • Research • Practice/service innovations that improve patient care etc,

29. Demonstration of Impact to attract Additional Credits (x2) Additional credits to be awarded where acquired knowledge is put into practice and where through audit improvements to patient care can be demonstrated.

30. Example of enhanced crediting • An individual attends a meeting (1 hour) on heart failure, acquires the knowledge that certain beta-blockers are beneficial in this condition and then records this within their appraisal documentation. Credits claimed 1 - this demonstrates the acquisition of knowledge and as yet there is no demonstration of personal, practice or patient benefit. • Another individual attends the same meeting. The acquisition of knowledge is recorded however in their appraisal folder, an audit is planned after consideration of current practice (1 hour), they demonstrate audit of their patients with heart failure, changes are made appropriately following discussion with colleagues (1 hour) and a 2nd audit cycle demonstrates an improvement in care. Credits claimed 1 (initial meeting (1 hour)) + 2 (planning (1 hour) and discussion associated with audit (1 hour)) X 2 (Impact) = 6

31. Specific expressed concerns for small or remote practices: • Multi source feedback (MSF) • Clinical audits • Significant Event Auditing (SEA) • Learning Credits.

32. MSF • The limited pool of colleagues means that comments would be more easily attributed. • If not a full sample of colleagues, would that reduce the validity (e.g.spouses) and/or increase the risks of breaches of confidentiality? • Concerns that an MSF might be used to “settle scores”? RCGP challenge to the Forum to provide a solution

33. Clinical audits • Problem of getting sufficient numbers to be of statistical significance where small list size. Proposed solution: to give guidance as for sessional doctors to allow appropriate flexibility in audit topic choice to minimise this effect.

34. Significant Event Audit • Single-handed doctors: the absence of a peer on whom to reflect clinical views. • Option to join a “quality assurance group” or “educational federation” to share SEAs.

35. Learning Credits • Difficulty in access to Protected Learning Time. • Difficulty to access appraisers who understand rural practice (with its specialist skills). •  Difficulties in attending distant courses, educational meetings. Solution? On-line learning, RCGP/BMA e-modules Create appropriate rural practice e-modules, e.g. Dispensing? Intermediate care?

36. Phased introductory requirements

37. Assessment of the evidence • Initial sifting by the PCO Responsible Officer and staff. • Grading: 1. appears satisfactory; 2.needs discussion; or 3. substantial issues are raised. • The “Local Group/trio” looks at samples from 1 &2 and all in 3. Local Group consists of Responsible Officer, an RCGP external assessor and a lay assessor. • The Local Group notifies GMC names of those recommended for revalidation. • The Local Group refers unsatisfactory portfolios for moderation by the RCGP, GMC.

39. The rural blog

40. Rural blog: Use or lose • Independent of RCGP RF but associated • Rural GP resource and central portal to other resources • Looking for contributors, news copy • Need feedback, innovative ideas • 12 month pilot

41. Membership The Rural Forum is open to all RCGP Members, Fellows, and Associates in Training who declare an interest in rural general practice and signal their wish to join.

42. Sign up today! • The scale of the membership at the end of the 2 year pilot could be the deciding factor when the College evaluates the RF achievements and determines whether it has a future within the College. • Please fill in an application form NOW. There is nothing to lose!

43. Ask your partners to sign up on line • If you already have an RCGP online services login Go to the online services members area [https://integra.rcgp.org.uk/membersarea/login/login.asp?type=EXTRANET] and login. • If you do not yet have a members area password you can request one by emailing helpdesk@rcgp.org.uk or telephone us on 020 7344 3182.

44. You need the Rural Forum and the Rural Forum needs you!