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Measuring up: What next for competence assessment?

The Medical Council is continuing to focus on professional competence schemes as a means of maintaining doctors’ competence, as per provisions set out in the Medical Practitioners Act 2007. However, members of the medical profession and the Council have expressed concern that certain cohorts are slipping through the cracks.

There is broad agreement that responsibility for ongoing training and competency must be shared, and that the Council, training bodies, employers and practitioners all have important roles to play.

Mr Bill Prasifka, CEO of the Medical Council, says that now is a good time to review the schemes thus far, assess the impact they are having, and determine the best way forward.

The Council has been looking specifically into which cohorts of practitioners sign-up for the schemes and fulfil competence requirements, and which are failing to do so.

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 Medical Council CEO Mr Bill Prasifka

“One thing we have been focusing on is looking at basic enrolment levels and what they are,” Mr Prasifka told the Medical Independent (MI). “We’ve found out it’s a more complicated subject than meets the eye. Enrolment levels depend on at what point in the academic year you are measuring and who is enrolled.

‘We understand a lot of work has been done to get more practitioners enrolled’

“It seems that for some elements of the profession, there is a certain level of complacency that has come in. Some people are not enrolled, which is very serious, others are enrolled but they enrol later in the academic year. So we’re working with the postgraduate training bodies to tighten-up those procedures; to make sure people enrol and that they [do so] in time.”

He said enrolment is key to ensuring that doctors’ competency levels can be monitored.

“If people are not enrolled, we have no basis of monitoring them — and that’s very important, that there’s external oversight of all of this,” said Mr Prasifka.

“This is a requirement that we have under the Act and so we’ve been having a lot of engagement with the training bodies. We understand a lot of work has been done to get more practitioners enrolled. For many of the colleges, enrolment is at an all-time high level.

“We’re looking to take a definitive snapshot of enrolment levels in the spring — in May — and that, I think, will give us a very good benchmark. Now we’re working towards getting everyone enrolled who should be enrolled, but this will give us a very good snapshot of where we are in this element of the problem.”

Employers

Mr Prasifka said employers are working to ensure their staff are enrolled in the schemes.

“We’ve also worked with employers — we’ve worked with the HSE, with the Hospital Groups.” He said the HSE is going to tighten-up its procedures to seek information on what scheme doctors are enrolled in.

Mr Prasifka pointed out that, under legislation, the only power the Council has against a doctor who does not enrol in a professional competence scheme is to make a formal complaint and bring them before a fitness to practise inquiry — something that neither practitioners nor the Council want.

“The situation remains, though, what it has always been, which is that if someone is not enrolled, if someone has not done their credits over the year as they are required to do, the only formal power the Medical Council has is to make a complaint against that person and bring them to fitness to practise,” said Mr Prasifka. “We don’t have the power to deny them annual retention and that’s simply the fact.

“There’s no future in us bringing hundreds if not thousands of people to fitness to practise; that’s just a complete waste of resources. We will continue to bring some, as we have, but clearly the goal is to facilitate voluntary compliance.

“The option of using retention would require legislative amendment. As the Medical Council, we are dedicated to working within the current legislation and I’m satisfied that progress has been made, even in the past six months.

‘But the beauty of what the Medical Council is doing with regard to CPD is that it can be measured. That keeps regulators happy’

“So I know there is a lot of talk in the profession internationally about revalidation, about peer reviews or continuous assessment,” Mr Prasifka continued, “but this is the framework we have here — to do the 50 hours of CPD, and do one clinical or quality improvement [audit]. So what we’re doing is making sure that people are doing their credits, how those are being monitored, how those are being evaluated and to see how we can improve that.”

General Division

The Council has identified that while doctors on the Specialist Division of the Medical Register have very high rates of enrolment and compliance, those registered in the General Division seem to struggle more with enrolment, especially doctors working as locums and those on short-term contracts.

“Doctors on the General Division, and particularly doctors on short-term contracts who are doing locum work, are the ones who seem to be most likely to be not enrolled,” said Mr Prasifka. “It is very important for us to work with the postgraduate training bodies to begin to identify these doctors.

“All the doctors whom we have been able to identify as not being enrolled, who we believe should be enrolled, have all been written to individually and we’re further engaged with them.

“For some of these doctors, we found that they are complying and that our current information was simply not catching them under the current category, so we’ve improved our dataset on these doctors. There may be other doctors who are retired and didn’t tell us, or other doctors who are outside of the country and didn’t tell us.

“But in terms of those cohorts of doctors — the ones on the General Division, the ones in locum, short-term contracts which we deem to be much higher risk — we need to work with the training bodies to ensure that for those cohorts of doctors, that professional competence and CPD is accessible and relevant and it’s something which will meet the needs of doctors in those particular circumstances.”

Mr Prasifka emphasised that it is not just the responsibility of the Council and individual doctors to maintain and support compliance — employers also play an integral role.

“Employers would have a very significant responsibility,” Mr Prasifka said. “When any professional graduates with their degree, they’re not qualified to practice all elements. There’s a number of years before you develop the full range of skills.

“The professional competence scheme is a part of that, but it clearly is not all of that. Employers clearly have a responsibility in terms of supervising that, mentoring and also facilitating that the registrants are able to do the professional competencies.”

But there are varying reports from practitioners and employers regarding challenges to compliance.

“Sometimes we receive reports from practitioners who say they would like to do the CPD but their employer doesn’t give them any time,” said Mr Prasifka. “And then we talk to the HSE and they say they have schemes that are funded and that people are not taking them up. So we’re really trying to follow up all the loose ends and to have a better match between resources available and people actually taking them up.”

Dr Richard Brennan, a GP based in Co Kilkenny and a former member of the Council, agrees that doctors on the General Division can struggle to sign-up to the schemes. He argued that these doctors require additional support, especially from employers, but no-one appears to be taking responsibility.

“For those on short-term contracts or doing locum work, many are poorly supported by both their employing locum agency and the institution for whom they work,” Dr Brennan told MI.

“They are employed exclusively to provide service and their educational needs are often not assessed or met, due to the short-term, transient nature of their job. The short-term nature of the job often also precludes them from engaging with local educational activities, such as CME meetings.

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Dr Richard Brennan, GP

“As these doctors are not on training programmes, no-one is taking responsibility for their supervision and education, especially when working in service posts,” Dr Brennan continued.

“Some of these doctors are constantly changing discipline, going between hospital and community settings and even between different regulatory jurisdictions. The transient nature of their existence is not necessarily good for either the doctor or the patient.

“Locum doctors, especially, due to the transient nature of their work and workplace, require more supportive structures via their employers —  whether locum agencies, co-ops, the HSE  or individual GP practices. Alternatively, they need to be linked to educational activity ongoing in the area where they are working.”

Dr Brennan said doctors who go on maternity leave or who have to take a professional break due to ill health may also struggle to meet their CPD requirements.

“These doctors require support and assistance, not a punitive approach,” said Dr Brennan.

The GP said that while there was initial resistance to the CPD schemes when initially introduced through the Medical Practitioners Act 2007, the majority of doctors in practice are compliant with requirements.

Despite the eventual acceptance, though, doctors still view the system as unduly bureaucratic — so much so that some older GPs are choosing to retire, rather than stay in practice and learn a new auditing system.

“The current CPD scheme is a somewhat time-consuming and bureaucratic method of recording what the majority of general practitioners are, de facto, already doing,” said Dr Brennan.

“In general practice especially, time is a precious commodity and it is seen as another demand on our time. Its introduction unfortunately also coincided with other changes in general practice workload, increased demands and a general increase in paperwork.

“For many doctors, especially older doctors, learning the new skill of audit was a challenge, but increasingly now they recognise its use as an improvement tool in the practice.

“Perception of inflexibility by the Medical Council and the colleges initially did cause stress and anxiety among some groups, but I think — and hope — a more supportive culture is now in existence.

“Finally and anecdotally, the requirement for ongoing participation in CPD schemes is part of the decision-making process for some doctors in opting for early retirement, rather than having a wind-down or part-time approach that was more prevalent in the past. This is perhaps an unintended consequence, but important in the context of GP manpower shortages,” added Dr Brennan.

A number of doctors have come before the Medical Council’s fitness to practise inquiries in recent years who have been working either as locums or on short-term contracts and have trained abroad. These particular inquiries have highlighted the challenges that both hospitals and doctors face when working within the confines of these short-term scenarios, with practitioners who are new to the Irish system. They also suggest a lack of comprehensive induction in some hospitals, especially for those who have trained abroad.

“The fact that there is a particular cohort of such doctors suggests the need for further study of the problem and to identify where we can improve processes and support structures to assist these doctors to meet their CPD requirements,” said Dr Brennan.

He said areas that could be examined would include employment processes; the lack of comprehensive inductions; language and communication skills; and cultural and training differences. Educational support and clinical supervisors could also help support those cohorts of doctors encountering difficulties, so that they could remain competent and not end up before a fitness to practise inquiry.

The inappropriate placement of doctors to fill service gaps, better complaint management and reduced reliance of healthcare institutions on intermediate-grade doctors and locums to provide services would also be key areas to be examined, said the Co Kilkenny GP.

A number of these inquiries have also highlighted the desperation of many regional hospitals in their attempts to attract competent doctors and maintain EU quotas regarding staff members.

‘Optics’

Dr Stephen Murphy, a Dublin-based GP and member of the NAGP, said any doctor worth their salt will develop themselves professionally and that compulsory CPD is purely “optics”.

“In general terms, I think regulation is necessary to make sure the right people are qualified and the right people are doing the work they should be doing to an acceptable and a safe standard,” said Dr Murphy. “However, I am unconvinced that compulsory CPD is anything more than optics.

“The 50 hours of CPD that doctors currently have to undertake is not a particularly difficult target to meet for someone who is in actual practice. Does it [this system] make me a better doctor? I don’t believe it makes a whit of difference. I do my ongoing education — always out-of-hours and in my own time — because I’m interested, because I have a need to keep up-to-date and because I, fortunately, still have an enquiring mind. I don’t believe that this is significantly different from most, if not all, of my medical colleagues, whatever specialty they pursue.

“Does it make me a better doctor? Does it make anyone a better doctor? I very much doubt it,” Dr Murphy continued. “Does it protect patients in any way? Probably not. Take my particular specialty, which is general practice. People vote with their feet. If you’re a bad doctor, people will just walk away. 

“But the beauty of what the Medical Council is doing with regard to CPD is that it can be measured. That keeps regulators happy. That absolves managers from monitoring. That gives politicians another reason to obfuscate some of their responsibilities.”

But a more pressing issue, according to Dr Murphy, is that many of the doctors who are highly-skilled are leaving the country and hospitals are forced to fill in the gaps with less-talented staff.

“Something like the CPD, however, ignores the fact that the quality of doctor we have in this country now is falling fast,” said Dr Murphy, “and that’s because we’re losing our best and our brightest because we won’t employ them on terms that are available in most of the rest of the English-speaking world. 

“Additionally, we won’t pay them a competitive rate and we put extremely arduous conditions on their practice and so they leave. There is much hand-wringing in managerial and political circles but nobody’s prepared to call a spade a spade.

“We’ve also lowered the job qualification goalposts, whether at junior or senior levels, as it’s now just easier to get less-well trained and less-able doctors into our system,” Dr Murphy continued. “We’re bringing a different quality of doctor because many hospital jobs have ceased to be training posts and hospital management just want a doctor on a seat to see people in the outpatients. 

“So they’re getting a lower quality of doctors, who are interested in the post purely for the salary and have no interest in furthering their career because the posts that they are taking up have no training element. It’s a race to the academic bottom at this stage.

“In my own specialty, general practice, it has become almost impossible to get good-quality assistants and/or assistants with a view to partnership,” Dr Murphy added. “New principals are almost non-existent.

“This is nothing to do with CPD or training.  This is simply because Government policies over the last 10-to-15 years have made general practice financially unviable, with snowballing administration and an almost impossible situation regarding the availability of assistants and locums. And so the policy response is to add yet another layer of paperwork in the form of compulsory CPD.

Moving ‘upstream’ through Safe Start

Safe Start is a programme aimed at supporting doctors entering the Irish healthcare system for the first time, whether they trained in Ireland or abroad. It is being developed by the Medical Council.

It focuses on communication skills and developing an understanding of how the entire Irish system works.

The Council has undertaken a “scoping project” with University College Dublin to identify the issues that the programme needs to address.

“This is a type of programme that you see in other jurisdictions, particularly in the UK,” said Council CEO Mr Bill Prasifka. “But the important thing is that we come up with something. We obviously learn from the international experience but at the end of the day, we have to identify what are the most pressing needs here.”

The Council is to work with the training bodies to develop aspects of the programme, which will ultimately include online learning tools.

Portions of the programme are due to be rolled out later this year, according to Mr Prasifka.

“When people talk about those goals of regulation — obviously, we’re here to promote good standards, to facilitate better standards, better practice, and Safe Start is what they call ‘moving upstream’,” said Mr Prasifka.

“‘Downstream’ is the very end of the regulatory process, which would be a doctor before a fitness to practise [inquiry] — something has gone wrong and maybe there’s been some element of patient harm. The question is, what have you learned from that?

“The goal is not to bring more doctors to a fitness to practise [inquiry]. The goal is to improve standards and to learn from [experiences]. Safe Start fits into that and we’re trying to engage with doctors here at the very start of their career.”

Meanwhile, another event in the Council’s work programme will be the publication of a review of how the Council recognises specialties.

The review, which is being carried out by a UK-based consortium at Plymouth University Peninsula Schools of Medicine and Dentistry, is due for completion this June.

The Council is now reaching a point where some of the specialties that are looking to be recognised are having fewer and fewer practitioners, according to Mr Prasifka.

“Our current understanding of a specialty is not simply that it’s a discreet body of knowledge which has international standing — that’s just one element. But there also has to be a training programme, there has to be a professional competency scheme; the people who want to be recognised — do they have the capabilities of actually doing this, of actually implementing it?”

The Council has suspended recognition of new specialties until the review is complete.

Training bodies

Along with the Medical Council and employers, the training bodies have a huge role to play in ensuring competence. Doctors participating in training programmes are not required to be enrolled in the schemes because these count as their professional development.

The RCSI, for example, said it provides guidance, support and advice to surgeons through their professional competence scheme, as well as a range of educational activities.

“Under an arrangement with the Medical Council, RCSI also approves a wide variety of other courses for CPD purposes provided by specialty associations and other groups all over the country,” Prof Sean Tierney, Dean of Professional Development and Practice, RCSI, explained.

“This ensures that doctors have a wide range of activities to choose from to ensure they meet their professional competence needs and maintain their competence across all the domains set out by the Medical Council.”

Prof Tierney also argued that employers have a huge role to play in maintaining and supporting competency among practitioners  and stated that the HSE is currently playing its part in this area.

“Employers have an obligation to support doctors in meeting their CPD needs, including ensuring they can access leave and by providing financial support, as provided for in the doctors’ contract,” he said.

“In addition, the HSE funds the provision of a range of relevant CPD activities for doctors each year through the training bodies. Last year, with the support of the HSE, the RCSI ran 42 full-day and six half-day courses aimed particularly at doctors on the General Register in non-training NCHD posts.”

The HSE was contacted for comment on the issue of doctors’ competence, but had not responded by press time.

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