Quality Assurance of doctors post registration/licensure Moderator Niall Dickson GMC October 2010

1. Quality Assurance of doctors post registration/licensure Moderator Niall Dickson GMC October 2010

2. Quality Assurance Quality assurance programmes that require doctors to demonstrate they have maintained their competence and ability to practise

3. Quality Assurance How do we know doctors are any good after they qualify?

4. General Observations • A new and developing area • Some but not all MRA’s are developing systems • Language and terminology is difficult • We are all in different places • Represents a shift change in medical regulation • Broad support but acknowledgement that this or aspects of this could not be a priority for all • There are technical, legal and resource constraints

5. Aspects that were considered • Monitoring quality and safety • Maintenance of competence • Protocols and guidelines • Allocation of resources • Re-entry into practice • Record keeping and access • Physician workforce • Regulating the regulator

6. Question we did not fully answer Should be doing this? • Assumption that it was or could be proportionate • Medicine is risky and that quality assurance post licensure was a reasonable response • Recognised tension between professional ethic and regulatory imposition • In an ideal world doctors would do this for themselves • Self reflective practice was the goal • Some felt doctors were quite good at this while others believed they were not

7. Another question we did not fully answer Why are we doing this? • Look at the ceiling and you will fall through a hole in the floor – you need a floor! • Is this about catching poor performers? • Safety first – excellence later • So is it just about setting a minimum standard? • Or is it also about creating a climate of practice that constantly raises the bar for the individual and the system • We seek to create a climate of self reflective practice

8. Monitoring of quality and safety Issues and answers • A long way to go – this is complex and challenging • The moving target - doctor moves from rural surgery to primary care, from one jurisdiction to another • What are we measuring - what is good enough? How do you deal with borderline competence? • We are still largely reactive – how does MRA know when a doctor’s practice is sub-optimal?

9. Monitoring of quality and safety Issues and answers • Data quality poor or process not outcomes based • Data not collected for improvement but for cost control • There is a need to align incentives to drive quality and best practice e.g. high prescribing and use of tests does not = bad care • Need best practice guidelines to inform monitoring of practitioners

10. Monitoring of quality and safety Issues and answers • Mandatory CPD provides a way forward • But not necessarily a measure of competence - it is essential but not sufficient • System must measure competence and performance • Trust is vital - can we achieve professional ownership – developed for the profession by the profession?

11. Monitoring of quality and safety Good practice • Define maintenance of competence • Define scope of practice • QA needs to cover knowledge skills and attitudes • If you don't measure you don’t know • Need to demonstrate to doctors that it makes a difference

12. Monitoring of quality and safety Good practice • Public reports from MRAs – on CPD, on doctors who fall below standards, • Public disclosure of doctor’s credentials and scope of practice • Public representation on MRAs • Renewal of licence should be conditional and for a fixed time

13. Maintenance of Competence Good Practice • CPD should be mandatory • BUT more than that - demonstration of competence, however defined • MSF should be included • Some form of health assessment or declaration • Criminal behaviour check mandatory

14. Protocols and Guidelines Issues and answers • Still some resistance to use of guidelines • Seen by some as threat to professional autonomy • There is a desperate need to tackle variation in clinical quality • MRA can require compliance with guidelines • Need to build on quality movement – be part of it

15. Protocols and Guidelines Good Practice • Ideal – every encounter is monitored • But dependent on resources and environment • Novices may need different guidelines to experienced doctors • There should be buy in from the profession

16. Allocation of resources Issues and Answers • Is this a good use of resource? Can it be risk based? • Systems can be bureaucratic costly and overwhelming • Central control may help consistency but may not be do-able

17. Allocation of resources Good practice • Need to develop surveillance and risk indicators • Encourage individual professional responsibility • Clarify responsibilities relative to others • Rely on varied resources and varied solutions

18. Allocation of resources Issues and Answers • Need to be realistic in nations where resources are scarce • Is this a nice to have or a must do? • Will technology provide a way forward? • Finance will be problem even in developed countries

19. Record Keeping and Access Issues and answers • Fragmentation of MRAs can impede sharing within and between countries • Patient access is very limited • Challenge of privacy laws and data protection in different jurisdictions • Some differentiate between conduct, performance and health • We are in consumer age of choice but also need to define and recognise limits to information

20. Record Keeping and Access Good Practice • International database or searchable interface linked to national systems • Once information is in public domain information should remain there • Independent means of verifying where doctor has practiced • Agree extent how much information is accessible to the public

21. Regulating the regulator What is good for the goose is good for the gander • Our goals may be the same – massive differences in our systems – no national or international parameters • To whom should regulators be accountable? - the public, the state, the profession? • Opportunities to exchange information and identify areas of good practice • Would it be possible to set global standards to enable you to know what good regulation looks like? • Could we benchmark our activities against others?

22. Where now? • Broad agreement this is the way forward • Setting a minimum but fostering improvement • Pace of change will vary • Need better systems for sharing information and building evidence base • Must take others with us • This will redefine what we mean by proefssional regulation

23. Thank you www.gmc-uk.org