The general practitioner (GP) and specialist registers list those doctors who are eligible to work as GPs or as substantive, fixed term or honorary consultants in the NHS. To join these registers, doctors have to demonstrate that they have the knowledge, skills and experience needed to practise medicine at this level. Many doctors do this through completing a formal training programme that we’ve approved and gaining a certificate of completion of training (CCT). Some doctors who have not gone through a GMC approved specialist or GP training programme may still have done equivalent training and experience. If so, they can apply to have their eligibility for GP or specialist registration with the GMC assessed through what are referred to as the ‘equivalence’ or CESR/CEGPR route to registration.
This consultation seeks views on proposed changes to the way doctors are assessed for GP or specialist registration through the equivalence route.
Comments on
General Medical Council Consultation on the routes to the general practitioner and specialist registers
The Royal College of Physicians of Edinburgh (the College) is pleased to respond to the GMC Consultation on the routes to the general practitioner and specialist registers.
Question 1: Do you agree that the current model for evaluating equivalence by assessing documents should be replaced by a model based on the four elements set out above?
Yes.
Further comments:
There may still be a place for some documentary evidence as it will be challenging to test all competencies and practical skills within the time available and the limitations of an examination. However the 4 element model has much merit.
The Colleges should continue to oversee the final recommendations to support consistency and bring an essential element of specialist objectivity to what otherwise will be a local procedure.
Question 2: Do you agree that the period of acclimatisation should be at least six months in the previous three years? If not, what would be an appropriate period?
Not completely as the College would prefer longer and have some concerns that this could be 2.5 years before the application date.
Further comments:
We recommend that at least 6 continuous months is undertaken in a relevant related specialty, e.g. 6 months in general practice split into 3 x 2 month locums would not prepare a doctor adequately for hospital practice and vice versa.
We strongly support the view expressed in the consultation that an application for evaluation should not take place until the acclimatisation period has been completed.
Question 3: Do you agree that applicants should be required to demonstrate their specialist knowledge by taking a formal test of knowledge in their specialty set by the relevant medical royal college or faculty?
Yes.
Further comments:
It is important that applicants achieve the same standards as their CCT colleagues. In medicine this would be supported by requiring applicants to take one of the 12 Specialty Certificate Examinations provided by the 3 Colleges of Physicians and their specialist society partners (acute medicine, dermatology, endocrinology and diabetes, gastroenterology, geriatric medicine, infectious Diseases, medical oncology, nephrology, neurology, palliative medicine, respiratory medicine, and rheumatology). Other medical specialties have alternative examinations or are exploring other methods of knowledge assessment as an examination is impractical due to the numbers and/or nature of the specialty.
This would be appropriate for all CCT specialties but difficult for doctors applying in non or partial CCT specialties, e.g. diabetes.
MRCP(UK) is regarded as an essential requirement for entry to medical specialty training but we consider that it would not be necessary to apply this requirement to CESR applicants, who may have been practising at “specialist” level for a number of years.
Question 4: Not all colleges and faculties have existing tests of knowledge in every specialty set at the appropriate level. With this in mind, would it be reasonable to use tests for those specialties they exist for, but to evaluate applicants’ knowledge in other ways where no appropriate test exists?
Yes.
Further comments:
See question 3 above. Several specialties will need to consider this challenge and the GMC should work with the Colleges and Faculties to establish clear criteria to ensure alternate methods of assessment are effective and consistent.
Question 5: Do you think that formal tests of knowledge should NOT be part of the CESR/CEGPR application requirements? If so what other valid and reliable means of assessing applicants’ knowledge should we use?
No.
Further comments:
It is essential that doctors and the public are confident of the true equivalence of CESR as a route to the specialist register. The JRCPTB has the experience and the knowledge of curricula and assessment methods to advise the GMC for the medical specialties.
Question 6: Do you agree that successful application for a CESR/CEGPR should require evaluation of performance in practice in the relevant specialty in the UK against prescribed competences at the level of the final year CCT?
Yes.
Further comments:
This is essential to provide a true measure of equivalence. The work base placed assessment developed for CCT candidates can be usefully employed for CESR candidates and are understood by educational supervisors. There is however an issue of local capacity to provide appropriate supervision as trainers are under extreme pressure.
Question 7: Do you agree that the performance in UK practice of CESR/CEGPR applicants should be evaluated by approved specialty (including GP) educational supervisors?
Yes.
Further comments:
See Questions 1 and 6 above. If CESR is to be accepted as an equivalent route, the standards and assessment methods should mirror those of CCT as closely as possible. This includes an element of external quality control provided by College/Faculty input. Trainers will need time and support to support their own skills to deliver local assessment – this has implications for consultant job plans.
Question 8: How do you think we should ensure assessments are objective and independent?
Further comments:
The system in place for CCT recommendations provides this essential element of objectivity through external representation on ARCPs and PYAs. Indeed the PYA process may provide an ideal model for the evaluation of the training/acclimatisation needs of CESR applicants before they start their period in the UK.
The SAC structure within JRCPTB provides a ready-made evaluation panel to make the final recommendation to the GMC and protects against inconsistency and/or local bias.
Question 9: For those specialties for which there wasn’t a formal test of specialist knowledge (see questions 3–5 above), could evidence of performance in UK practice at the same level as the final year of a training programme leading to a CCT provide enough assurance that applicants have the necessary breadth and depth of knowledge?
Yes.
Further comments:
Examinations provide a knowledge test only and most specialties will require some formal assessment of practical procedures and skills. Although the GMC indicate that there is no evidence that CESR candidates are more likely to be feature in fitness to practice cases, having assessment of key practical skills where such tests are readily available makes sense. These work place based assessments could in some measure substitute for a knowledge-based examination in some specialties.
Question 10: Do you agree that applications from figures of genuine international renown should continue to be evaluated on the basis of documentary evidence rather than through evaluating their performance in practice?
Yes
Further comments:
This would be sensible, but there should be clear and non-negotiable criteria developed to determine who qualifies under this route, including how they can demonstrate understanding of practice in the NHS/UK.
Question 11: Do you agree with the criteria at Appendix G for evaluating applications from doctors of international renown?
Yes.
Further comments:
Appendix 7 identifies the process but is unclear on how such applicants will satisfy the acclimatisation hurdle required of others – language proficiency may be insufficient however skilled a practitioner.
Question 12: Do you think that the proposed new model provides a robust, fair, proportionate and accessible means of evaluating whether doctors possess the knowledge, skills and attributes equivalent to those required for a CCT? If not, why not and what alternative would you propose?
Not entirely
Further comments:
The model has much merit but risks excessive reliance on the robustness of local assessment procedures and is open to inconsistent recommendations. CCT candidates are recommended for entry onto the specialist register by the Colleges who develop the standards and assessment methods. CESR applications should include this final objective check.
Question 13: Are there particular groups of doctors who could be adversely affected by the proposed model and, if so, how could we reduce or prevent the adverse effects?
Yes.
Further comments:
Those seeking specialist registration in a non-CCT or part CCT specialty may struggle to find suitable acclimatisation placements and/or supervisors and assessors and may require a more tailored assessment process.
Question 14: Our report contains 13 specific recommendations for changes to the current CESR/CEGPR process set out here and listed in full at the end of our report. Do you have any other comments on the conclusions of the review and the report recommendations?
None.
The College works through the Joint Royal College of Physicians Training Board (JRCPTB) and assesses CESR applicants through the SACs which are coordinated by JRCPTB. We commend their response to this consultation.
The College has an active Trainee and Members Committee, which is committed to retaining the highest standards of specialist training and have expressed their views in a separate response to this document and which is also commended.