Revalidation for trainees and the annual review of competency progression (ARCP)

The background to revalidation for trainees

Revalidation for doctors in the UK formally began in December 2012 and is the 5-year successful renewal of a doctor's licence to practice.¹ Two fundamental arguments underpin revalidation: to give patients greater confidence in the profession and to support the individual in maintaining and improving their practice.

The General Medical Council (GMC) decided early on that all doctors in training would need to revalidate in the same way if they wished to maintain their licence to practice. The GMC also determined that the postgraduate dean in the deanery (or local education and training boards [LETB]), who managed the training programme, would become the responsible officer. The deanery (and subsequently the LETB) is the ‘designated body’ that, for a doctor in training, has the formal prescribed connection to ensure that the doctor is properly supervised and managed in maintaining their professional standards. Thus, it is the postgraduate dean, as the responsible officer, who will make revalidation recommendations to the GMC.

Therefore, a doctor in training will be formally revalidated every 5 years, starting from when they obtain their licence to practice at the end of their foundation year (FY) one (FY1). The postgraduate dean also has to make a revalidation declaration at the point at which the doctor obtains their certificate for completion of training (CCT). Thus, a doctor training as a general practitioner, having done a year of FY2 training and then 3 years of specialty training, will have a revalidation decision made at the point of their CCT. However, doctors in most other specialties, certainly all those training to be physicians, will need to have at least one revalidation decision, if not two, made during their training as well as at the point of CCT.

The challenge for postgraduate deans is that they are not the employer of the trainee, yet the revalidation decision must be based on the whole of the scope of practice of the doctor. This means that issues, such as significant incidents or complaints that might have been seen previously to be purely the responsibility of the employer, must now be fully disclosed to the postgraduate dean as the responsible officer. Thus, any matter that the medical director of the employing trust would know about must also be known to the postgraduate dean. The situation becomes more complex when doctors move in and out of training posts and career grade posts, when the responsible officer for the trainee will change each time and the information flows must also follow the doctor to enable proper revalidation decisions.

The annual review of competency progression

All doctors in training, including foundation year doctors from 2013, have an annual review of their competency progression, when they present a portfolio of information about their practice and the competencies that they have achieved against the curriculum they are currently studying. This already involves a review of most aspects of a doctor's practice and training, and portfolios are increasingly detailed and comprehensive. Therefore, the GMC decided that the annual review of competency progression (ARCP) should be used as the vehicle for progress towards revalidation in the same way that the annual appraisal is used for career-grade doctors, including consultants. No extra assessments or appraisals are needed for doctors in training over and above the processes that are already in place. However, the ARCP panel requires access to more information than is currently guaranteed. This was to assure themselves that there were no serious incidents, significant events, conduct problems or serious complaints that might in any way raise concern about the trainee's fitness to practice. The standard self-declarations that other staff, such as consultants, already do around health conduct and criminal convictions also need to be put in place to make revalidation a seamless process for all doctors.

During 2011–2012, there was an English national revalidation pilot that determined that three further sources of information needed to be available to the ARCP panel.² These were an enhanced trainee declaration (form R), an updated educational supervisor's declaration and, finally, an exit report from each employer over the year before that ARCP. For the trainee, the enhanced form R (the self-declaration) ensures that: all work and placements including locums are declared; any investigated significant event has been dealt with and reflected upon within the trainee's portfolio; any complaints have been logged, resolved and again reflected on within their portfolio; there is a record of compliments; and there are self-declarations on probity and health.

However, the report of the educational supervisor remains the key document at an ARCP discussion. The global assessment of a trainee's observed performance is crucial evidence for further progression. The educational supervisor is now asked to sign off if they are aware of any serious incidents or complaints and, if so, whether they been resolved satisfactorily (Table 1). The educational supervisor does not need to make extra enquiries where they are aware of events because they are simply dealt with as part of routine appraisal discussions and logged within the trainee's portfolio. If there were any issues where it was unclear whether they had been properly resolved, then enquiries should be made of the medical director or other responsible officer in the employing organisation.

The third source of information is an employer's exit report. The deanery will send every employer, usually twice a year, a list of all the trainees that they have employed and their responsible officer will sign off to say that there are no significant concerns. If there are any fitness-to-practice concerns or unresolved problems, then an exception report is made for the deanery, a copy of which must be given to the trainee.

Thus, the ARCP panel will now have greater self-declared information from the trainee, security of sign-off by the educational supervisor as well as confirmation from the trust that there are no concerns. There is one supplementary question on the ARCP form (Table 2) that relates to revalidation. It is important to recognise that this is quite separate from the educational decision-making, which has remained unchanged with the standard ARCP outcomes (Table 3). The revalidation questions and comments are simply to track any ongoing concern that might eventually affect revalidation or need for a fitness-to-practice discussion with the GMC. It is not in any sense a formal revalidation decision. Any decisions about revalidation can only be made by the postgraduate dean, but it does give an audit trail and will be particularly used for the transfer of information between responsible officers. Indeed, it is not possible to recommend that the doctor should not be revalidated. The only recommendations allowed by the GMC are as follows: a positive recommendation; a deferral for more information; or notification to the GMC of non-engagement.

Therefore, trainees will only not be revalidated if they fail to engage at all with the ARCP process or if are referred to the GMC for fitness-to-practice procedures in exactly the same way as they are now.

The ARCP and revalidation concerns in practice

For most trainers, the work and outcomes of the ARCP panel³ will be little changed because there will be no concerns regarding revalidation and the discussion remains around educational progress. However, for a few trainers, fitness-to-practice concerns might be raised in the documentation and, simultaneously, there may or may not be educational concerns. It is possible to have no concerns educationally (an ARCP1) but still have ongoing potential revalidation concerns. Equally, it is possible to be released from the programme (with an ARCP4) but with no revalidation concerns. Several of these, as worked examples, are highlighted in Table 4. Thus, in example 1, a core medical trainee who has failed to pass their exams despite full support and extra remedial time will be released from the programme (ARCP4), but there is nothing to suggest there is an ongoing fitness-to-practice concern. All these examples are for illustrative purposes; thus, even in example 1, if the reason that the trainee failed their exams was because they were drinking excess alcohol then there could be cause for concern as well as a GMC referral.

Summary

Revalidation has now started for all doctors, including trainees. Postgraduate deans have to make the first recommendations for trainees starting in April 2013.

The GMC has decided that the ARCP should be used as a vehicle for making judgements on the revalidation progress as well as educational judgements for those doctors in training. Several process changes have to be made to ensure that the panel has information about all aspects of a doctor's practice. Certainly, for most trainees, the ARCP process should be completely straightforward.

Competing interests

David Black devised and ran the English pilot of revalidation for the Revalidation Support Team.