Revalidation and Individual Circumstances

Is there a requirement that the appraiser works in the same specialty as the appraisee?
No, there is no requirement that the appraiser works in the same specialty. An appraiser will be required to verify and validate the specialty supporting information presented by an appraisee during the appraisal discussion. Much of the discussion will be generic but another anaesthetist may have greater insight into the issues and skills expected. Where the appraiser is from a different specialty the College has developed guidance on the Supporting Information requirements for Revalidation.

Returning to work after a period of absence - what are the implications for Revalidation?

The return to work (RTW) process is your employer’s responsibility and should not just be driven by yourself. Your clinical director/lead (i.e. the employer) should be involved in drawing up an agreed plan for managing your return to clinical practice in a manner which meets patient safety concerns. This plan should identify how progression is to be demonstrated, how your learning needs are to be met, and a timeline with review meetings. You and your employer may wish to refer to the checklist of questions and guidance on Return to Practice developed by the Academy to help with the identification of issues and facilitate support planning – available here

The RCoA has also issued guidance on Returning to Work containing signposts to educational activities which are aimed at supporting anaesthetists, such as the AAGBI return to work days which are about refreshing knowledge, and simulation RTW sessions as delivered by the GAS (Giving Anaesthesia Safely) Again group, which are more around confidence and competence, reinforcing team skills and decision making.  

In relation to revalidation the dates of your 5-year revalidation cycle remains unaffected by the time you spent away from work. However, if your RTW falls around the time of your revalidation date the Responsible Officer may agree to defer the revalidation recommendation decision made to the GMC, giving you time to compile the required supporting information and participate in appraisal. If you are returning to work, an important item of supporting information for your appraisal and revalidation portfolio is evidence that you have successfully participated in a robust RTW programme supported by your employer. The College recommends that anaesthetists returning to work after a period of absence of more than three years should anticipate a significant supervised period with a robust assessment of progress. Particular attention should be paid to how patient safety concerns are met in a RTW programme. This is because revalidation is very much about demonstrating that you are fit to practise with no concerns about patient safety issues.

I am retired and no longer treat patients.  My practice is limited to writing medico-legal reports as an expert medical witness.  Do I need to revalidate, and if so, how can I do that?
The following answer has been provided by the Faculty of Forensic and Legal Medicine.

All doctors with a licence to practise medicine will have to revalidate.  There are a number of components to this question, and a number of different types of medico-legal reports which require different considerations.  If you retired from clinical practice some years ago, and if you only occasionally provide an expert opinion on the standard of care which would have been considered acceptable at the time when you were in active clinical practice, then it may be reasonable not to retain a licence to practise medicine just for that purpose.  However, if you make yourself available for such opinions, then there are two very important considerations to keep in mind:

  1. The first consideration is (a) to make it clear from the outset to the instructing solicitor or other person seeking your opinion, and (b) to prominently state in the substance of your report to the court or tribunal, that you no longer have a licence to practise medicine.
  2. The other consideration is to make sure that your medical defence organisation subscription or insurance premium is appropriate for the work you undertake, and that not having a licence to practise is clearly known, whether that indemnity is arranged directly by you, or through an instructing solicitor for example.

Medico-legal reports in contemporary cases on the standard of care provided by another doctor will almost certainly have a requirement from the court or tribunal for a licence to practise.  In the small number of cases which go to a court or tribunal hearing, the medical evidence may be challenged, and a medical expert witness without a licence to practise at the time the report was written could be placed at a disadvantage and criticised in public during cross-examination.

Many medico-legal reports are based on a clinical examination for current condition and prognosis, and there is an expectation that all doctors with direct clinical contact with patients will be licenced.  It is probable that courts and tribunals would be unhappy to rely on clinical evidence given by a doctor without a licence to practise medicine.  Furthermore, unless great care is taken, there is a risk that fully-informed patient consent to undergo the clinical examination could be challenged, even if you routinely mention to patients that you are “no longer licensed to prescribe”, and that in turn could raise a question of probity, and if such criticism is upheld, put your registration as a medical practitioner in jeopardy.

Turning to how you may revalidate, you need to establish a connection with a designated body, but that subject is dealt with elsewhere.  There is one aspect, unique to medico-legal report writing, that you need to be aware of.  Your medico-legal reports may attract legal privilege in addition to medical confidentiality, so you would have to be careful to get proper consent before you disclosed evidence of your work to your Responsible Officer or appraiser, or as part of a governance procedure.  Simple anonymisation may not be enough, and self-evidently that applies to high profile cases, but may also apply to less obvious cases.  It is important to get written consent for any kind of disclosure through the instructing solicitor or other person who sought your opinion.  You may also need to take expert advice on the need to get consent to disclosure from the other parties to the action as well.

I work and practise medicine wholly outside the UK.  How will I revalidate?
If you continue to hold a GMC licence whilst practising abroad you will need to revalidate through connection to a UK-designated body that will support you with your appraisal and revalidation.  Only UK organisations can be designated bodies, because the legal rules that determine this only cover the UK.  This might make revalidation challenging because if you do not have a relationship with a UK designated body you will not have access to systems such as regular appraisals based on Good Medical Practice to support you in revalidating, and a Responsible Officer to make a revalidation recommendation to the GMC.

You should consider the following:

  • Retain your GMC registration but relinquish your GMC licence to practice which indicates you are in good standing with the GMC but means you will not be required to participate in the UK revalidation process.  Please remember the GMC licence gives doctors legal rights and privileges in the UK only that are not applicable in any other country.  Relinquishing your licence can be done online via your GMC account and the steps are found here.
  • If in the future you do plan to work in the UK you will need to apply to the GMC for your licence to be restored.  You will need to make an application no more than three months before you want your licence back and provide proof of ID and other supporting documentation from your employer and the medical regulator of the country you worked in.  Full guidance is provided by the GMC.

For further information see the following GMC guidance document – Revalidation FAQs for Overseas Regulators and Overseas Organisations.

 Is there a minimum amount of anaesthetic sessions I should undertake in order to retain clinical skills and remain competent?
There are some doctors whose scope of practice is largely away from the anaesthetic environment. It is conceivable that doctors who spend only one day per week or less giving anaesthetics could lose the ability to maintain their clinical skills. However this is a complex multifactorial situation, and will be heavily influenced by such factors as their other clinical activities, the case-mix that they undertake and their overall career progression. It is not possible to generalise, since there is so much individual variation from doctor to doctor.

Appraisers are faced with a difficult decision in these cases, particularly if the appraiser comes from another specialty and is unable to determine whether or not the doctor has maintained the key skills necessary to fulfil his or her clinical commitments.

We therefore recommend that if a doctor spends only one full day per week or less in clinical anaesthesia, and their appraiser is not an anaesthetist, the views of the Clinical Director in Anaesthesia, or an appropriate Deputy, are sought and that their views are considered at the appraisal.

 What advice can you provide on the allowance for supporting professional activities (SPAs) in a career grade anaesthetist’s job plan?
The issue of adequate SPA time is a difficult one and needs to take into consideration all your commitments, including whether you have any teaching, service development, management and other non-clinical duties.

The Academy document on consultant job planning and supporting professional activities proposes that the minimum number of SPAs allowed for a consultant to keep up to date should be 1.5 per week not including annual study leave. This is something the RCoA concurs with for all career grade doctors including those working as locums.

In addition to the 1.5 SPA, adequate time should also be made available if the doctor has any other SPA work, e.g. teaching, research, service development, clinical governance, etc. Depending on the extent of this work an additional 1.0 SPA (in total 2.5 SPAs) seems reasonable. Consideration of an adequate number of SPAs is therefore not just about meeting the formal process of revalidation but also about contributing to service development, management, training, quality improvement and patient safety initiatives in the department. Should you be involved in these initiatives it should be an area when discussing your SPA time with your Clinical Director or Lead. In the case of locums their contribution to non-clinical work might well be limited because of their job plans. Their jobs might well be tailored in that way. However this is not universally the case, and some locums are very active in clinical service development, teaching, etc. If this is the case for you, adequate documentation of time spent on specific duties should be kept to inform on the job planning discussion with your clinical lead. 

We must point out neither the RCoA or Academy are regulatory bodies. The advice we offer is an opinion based on good professional practice but is not a contractual right or enforceable. It would be disappointing though if our advice was willingly disregarded by employers and we believe that doctors should demand a clear explanation of why such advice is considered not appropriate. The necessity of SPA time for a range of activities is furthered explored in a RCoA Bulletin article on SPAs published in July 2012. The article is focussed towards the standard consultant role but the main principles holds true for all career grade doctors including those in locum posts.

Does the RCoA consider that the CCT in anaesthesia and specialist register status indicate that a consultant anaesthetist has undertaken appropriate Advanced Life Support (ALS) training, or does this have to be supplemented by a commercial (UK Resuscitation Council) ALS course?
The College requirements are deliberately flexible in this area, as anaesthetists may be able to demonstrate their continuing skills in their daily practice, and many are involved in teaching resuscitation skills to others. In our Guidelines for the Provision of Anaesthetic Services document we recommend that all clinicians dealing with patients should be 'appropriately trained' in resuscitation skills. Anaesthetists should be 'appropriately trained and assessed' in advanced life support. The reference level is that of the ALS courses or equivalent. The 'equivalence' aspect is one for local agreement; there are simply too many organisations providing these courses to be prescriptive.

That said, some Trusts simply accept the CCT qualification, ongoing clinical experience and the maintenance of CPD with in-house assessment in this area – others may demand specific certification confirming the doctor attended their requisite course recently.

The ALS Certificate (being the example given here) is one specific qualification, with other alternatives available, and completion of specific qualifications is not mandatory for a successful revalidation outcome. Revalidation requires the doctor to keep their knowledge and skills up to date through CPD, and being up to date and passing a formal assessment are different matters. Certainly having an ALS Certificate (or equivalent) would help to demonstrate this, although the precise content of the doctor's CPD and how this should be demonstrated will be discussed with their appraiser during the formulation of their personal development plan, which will vary considerably between doctors depending on the scope of their practice.