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COGPED

Committee of GP Education Directors GP Induction and Refresher / Returner Schemes

June 2011

Overview This paper describes the current COGPED position on GP Induction and Refresher / Returner Schemes (I+R Schemes) across the UK. These Deanery-led schemes provide the opportunity for qualified GPs to return to general practice after time away e.g. following a career break or time spent working outside of UK general practice. The paper also describes the COGPED position on supporting the engagement of GPs from the European Union and international medical graduates with a Certificate Confirming Eligibility for GP Registration (CEGPR) to UK general practice. In some Deaneries the I+R Scheme is also a means by which GPs with identified fitness to practise concerns requiring retraining can be remediated back into practice.

Background Employers and Primary Care Trusts have a duty of care to the public to ensure that doctors working in their service are fit to do so. This includes: Being satisfied that the doctor has a working knowledge of the NHS An appreciation of how to manage UK patients' expectations across the broad curriculum of UK general practice. In addition, in the case of doctors where English is not their first language, to ensure they have a level of linguistic competency compatible with safe practice. COGPED is committed to ensuring patient safety and providing high quality of care from all doctors working in general practice. COGPED is also committed to enabling GPs who have completed training to contribute to the GP workforce as fully as possible throughout their working lives. Individual GPs have a duty to ensure that they are not working beyond their competence and that their skills are kept up-to-date. There is no requirement in legislation for a GP to undergo a period of induction or refresher / returner training. A doctor wishing to work as a GP in the UK only requires to be on the GMC's GP register and the Performers List of the Primary Care Organisation (PCO) in the area that they wish to work. Further information on the requirements for joining a PCT Performer List can be found at http://www.legislation.gov.uk/uksi/2004/585/contents/made However, the Department of Health, COGPED and RCGP all both recommend a period of induction and adaptation for all EU and international medical graduate doctors new to the NHS.

COGPED quality assurance criteria for GP Induction and Refresher / Returner Schemes Any scheme designed to induct or return GPs to the UK workforce must be based on best practice with regards to ensuring patient safety and in accordance with the 9 GMC domains that underpin the quality of speciality training: 1. Patient safety 2. Quality assurance, review and evaluation 3. Equality, diversity and opportunity 4. Recruitment, selection and appointment 5. Delivery of the curriculum including assessment 6. Support and development of trainees, trainers and local faculty 7. Management of education and training 8. Educational resources and capacity 9. Outcomes A period of supervision in a Deanery-approved training practice is beneficial to GPs from both groups to give them a safe and secure start to working in / returning to primary care in the UK. Across the UK the Deaneries currently offer a range of I+R Schemes to meet local workforce needs based on: An assessment of the GP's learning needs on entry to the scheme. Up to 6 months whole time equivalent supervised clinical practice in a GP training practice with a GP trainer. Maintaining an appropriate level of Workplace Based Assessments and a learning log. A further review at the end of the placement to assess on-going learning needs. There is variation in the length of time a GP has to be out of practice before they qualify for their local scheme; normally it is 2 years out of active UK general practice.

Funding In England (see appendix 1) until 2006 the GP Returner Scheme had ring-fenced funding from the Department of Health managed through the English Deaneries. In 2004 it was agreed that EU GPs could also access this funding for a period of supervised induction into the NHS and general practice. Since 2006 various models of funding for induction and retraining / returner programmes have evolved based on using accrued underspends to support the non-salary costs including trainers grants. Salary costs for GPs on the scheme are subject to local negotiation and arrangements. NHS Education for Scotland (NES) currently funds a GP Returner Scheme including salary from non-ring-fenced monies. (See appendix 2)

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In Wales (see appendix 3), the deanery provides an educational grant to support the doctor on the scheme In Northern Ireland there has been ad hoc support to GPs returning to practice from accrued underspends. Currently there are no funds available to support this work. (See appendix 4)

Disclaimer COGPED cannot be responsible for contractual arrangements including remuneration for GPs engaged on an Induction and Refresher / Returner Scheme.

Finding out more about what is available locally In order to find out more details including how to access you local scheme please refer to appendices 1-4 attached to this document or the GP Deanery website for where you wish to work. Further information can be found at: PCO GP Performer List Regulations http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyA ndGuidance/DH_4087622 Delivering Quality in Primary Care: Medical Performers Lists ­ Language knowledge http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitala sset/dh_111902.pdf http://www.rcgp.org.uk/policy/position_statements/admitting_gps_from_outside_uk. aspx See appendices 1-4 for details of Induction and Refresher Scheme arrangements in: England Scotland Wales Northern Ireland Appendix 1 Appendix 2 Appendix 3 Appendix 4 Page 5 Page 8 Page 10 Page 13

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Appendix 1 Induction and Refresher Scheme in England Time out of general practice If a doctor has been out of clinical general practice for less than two years they would not normally be eligible for the scheme, although in cases where the scheme is being used for remedial retraining there is no requirement for a minimum period away from practice. The scheme should be mandatory for those doctors who have been out of clinical general practice for five years. For doctors who have been out of clinical general practice between two and five years the recommendation to join the scheme may depend on some or all of the entry assessments. Any IMG or EU GP who has not worked in UK general practice requires an induction and adaptation course, whether they wish to work in a practice or in an out-of-hours organisation. A review of the Performers List Regulations undertaken during 2008 by the Department of Health (England) contains the following recommendation: `There should be a formal NHS induction process to help new performers settle into local health economies. This would be tailored to the needs of the individual but would typically cover both local and (for those who had not previously worked in primary care in the UK) national elements. There should be an emphasis, in appropriate cases, on developing English language and communication skills.' Entry assessments The entry assessments will enable deaneries to: Identify those GPs who would benefit from the scheme. Decide on the length of time required on the scheme, up to a maximum of six months full-time or equivalent part-time. Identify those GPs where six months full-time equivalent on the scheme would be insufficient for them to work as an independent practitioner in the UK. Screen out those GPs with retraining / induction needs but who do not currently have the necessary level of knowledge and skill for this to take place safely in a clinical setting. The entry assessments are: 1) Deanery Structured Application Form & CV 2) Interview conducted by the candidate's Deanery: fact finding, discussion for both parties and informal assessment of linguistic skills where appropriate. 3) The Knowledge Test is derived from questions used in recruitment for GP training. There are four sittings per year in agreed venues. These questions have been subject to appropriate standard setting by a modified Angoff with the relevant stakeholders. Consequently the pass mark that is set will be the responsibility of the deaneries rather than the NRO whose agreement is only to

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provide the questions. Applicants for the Induction and Refresher Scheme are limited to a maximum of two attempts. 4) Validated Simulated Surgery, including contextualised linguistic assessment if English is not the applicant's first language. Simulated surgeries are held quarterly at the RCGP CSA centre. An educational prescription is generated for each candidate based on their performance in the assessment. Applicants for the Induction and Refresher Scheme are: Limited to a maximum of two attempts at the simulated surgery to be taken after they have passed the knowledge test. Are required to commence a placement in practice within 12 months of passing the assessments. If more than 12 months elapses then they have to repeat and pass the entrance assessments to demonstrate that they have retained the necessary knowledge and skills for the scheme.

5) Two structured references ­ these may be character references if the GP hasn't worked in clinical practice for 3 years. 6) Occupational Health assessment 7) Enhanced CRB check as part of the PCT Performer List application. If applicants fail the first attempt of the Knowledge Test or Simulated Surgery they should be given guidance, including reading material, and advised to wait at least six months before repeating. Assessments during the placement Regular Workplace Based Assessments should be undertaken and recorded in the NHS Induction Logbook. These assessments should include assessments of clinical skills and communication skills, teamwork, etc. and will be based around consultation observation, case based discussions and observations of clinical procedures. Feedback from patients will also be collated. It is recommended that doctors maintain a reflective diary throughout their clinical placement to demonstrate progression in their knowledge, skills and professionalism. Exit assessments The exit assessments take into account that the GPs have already successfully completed the entry assessments. Whether a GP has successfully completed the scheme or not will be a decision for the individual Deanery based on performance in: 1) MRCGP AKT. 2) NHS Induction Logbook and appropriate level of WPBAs signed off by their trainer

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3) At the discretion of the GP's local Deanery an exit assessment in the validated Simulated Surgery. As per the entrance assessments the exit simulated surgeries will be held quarterly at the RCGP CSA centre and will create an educational prescription for the individual GP. In addition the GP is limited to a maximum of 2 attempts at the exit simulated surgery to be taken after the midpoint in the scheme placement.

Placements Placements are subject to available funding and should normally be in a training practice with a named trainer. The minimum length of time on the scheme should be three months (or equivalent part-time) and the maximum six months (or equivalent parttime). Except for statutory reasons extensions beyond six months full-time (or equivalent part-time) should not normally be granted and this must be explicit at the start of the scheme. GPs should normally only be eligible once in their career for the I&R Scheme. GPs who are working part-time on the scheme may continue to work in another capacity, except NHS general practice, providing they are able to attend the required educational sessions and that the work does not conflict with their commitment to the I&R scheme. GPs with performance issues, and those where the DPGPE or their deputy feel they will struggle to pass the exit assessments in six months, should complete 12 months @ 50%, with the remaining time free for personal study. The full-time working week should be nine sessions (37.5 hours). A minimum of one educational session per week pro rata must be in the timetable and this should include a weekly tutorial or assessment by the trainer. Additional study leave should depend on the learning needs of the doctor in consultation with the Deanery. In larger deaneries there may be a weekly mandatory I&R half day release. The Deanery should recommend to the local PCT that the GP is conditionally put on the Performer List under the supervision of a named GP trainer for the duration of the scheme. On completion of the scheme the DPGPE or their deputy should write to the PCT saying whether or not the GP has "successfully completed the GP Induction and Refresher Scheme". It is then the PCT's decision whether to place the GP unconditionally on their Performer List.

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Appendix 2 NHS Education for Scotland Policy Statement on Returners to General Practice Definition For the purpose of this paper, a returner is defined as a doctor who has certification of completion of GP training by the competent authority and current GMC registration and in addition has not been working in clinical General Practice for the preceding two years or greater. For doctors who have been out of practice for five years or greater, a 6 month period of supervised practice (whole time equivalent) is recommended. A shorter period of supervised practice will be required for those out of practice between 2 and 5 years depending on candidate's exposure to work and CPD activities. All placements will take place in approved training practices. Background GPs require career breaks for a variety of reasons. Supporting re-entry of such doctors back into General Practice is a stated priority for the NHS. Funding for returner training is the responsibility of the SHA's in England and NES in Scotland, although such funding is contained within global budgets and no longer ring-fenced. Guidance for doctors considering returning to the GP workforce is available from the General Practitioners Committee of the BMA. There is however no requirement in legislation for a GP to undergo a period of returner training, and a doctor wishing to work as a GP in the UK only requires to be on the GMC's new GP register and the Performers List in the Health Board area that they wish to work. Doctors applying to join the Performers list are required to produce their certification from the competent authority, GMC registration and two clinical referees. There is no process at Health Board level to check for continuity of clinical experience by the applicant. Employers have a duty of care to the public to ensure that doctors working in their service are fit to do so, and individual GPs have a duty to ensure that they are not working beyond their competence and that their skills are kept up to date.

Entry to NES Returners Scheme and required assessments Entry to the Scheme is dependant on recommendation by the local Director of Postgraduate GP Education and availability of funding from the NES central GP budget. NES Returners requirements Entry assessments Interview with GP Director CV and references Health and criminal self disclosure forms Disclosure Scotland check Assessment during placements RCGP WPBA tools used as determined by trainer RCGP nPEP 7

Scottish National Peer Review of Video consultations Exit assessments Completed Educational Supervisors Report External assessments nPEP The Personal Education Planning tool (PEP) was launched by RCGP Scotland in 1992. It has evolved through paper-based and CDROM formats into a web-based facility that was rolled out across the UK in 2007. From its inception, PEP has been a formative self-assessment tool suited to all GPs. There is no pass nor fail outcome to the test, but comparison with peer performance is possible. It is perceived that, because of its nonsummative and educational approach, it is generally trusted by the GP community. PEP's primary objective is to identify the learning needs of individual GPs by the use of AKT (Applied knowledge test) ­ style items or questions. The items are a mix of SBAs (Single best answers) and EMIs (Extended matching items). The assessment covers all clinical aspects of the GP Curriculum, as well as management and ethical issues. PEP's secondary objective is to provide relevant evidence-based feedback and electronicallylinked reference material, immediately on completion of each item. Scottish National Peer Review of Video Consultations Developed in West of Scotland, the national peer review of video consultations provides formative feedback to GP returners on 4 clinical consultations. This has been established since 2002 for general practice CPD and is also used with candidates entering the Scottish Prospective Educational Supervisors Course (SPESC). Recent requirement for safe storage of digital data and correct handling of Patient Identifiable Information has resulted in changes to the process required to prepare and submit video consultations for peer review. It is recommended that GP returners use the process developed by the National Training Development Group Please note however that the requirements for GP returners are to submit 4 consultations only. For further information: http://www.nes.scot.nhs.uk/media/966337/nes%20policy%20statement%20on%20retur ners%20to%20general%20practice%20dec%2010.pdf

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Appendix 3

GP Induction and Refresher Programme in Wales

Introduction The Local Health Boards (LHBs) in Wales must be assured that all general practitioners given unconditional inclusion on the Medical Performers List (MPL) are safe to practise independently. Doctors on the GMC generalist register who have not worked in UK general practice within the last 2 years are therefore considered for inclusion on the MPL which is conditional on them undertaking an appropriate period of supervised induction. This applies to: UK qualified GPs who have not worked in UK general practice for 2 years or more Other EEA qualified GPs who have not worked in UK general practice for 2 years or more Non EEA qualified GPs who have been awarded Article 11 certification by GMC and have not worked in UK general practice in the preceding 2 years.

The Deanery holds a limited amount of funding to provide induction placements. Eligible GPs are able to compete for this funding. This guidance sets out eligibility criteria, the application process and further details of induction placements.

Eligibility UK and EEA GPs are eligible to apply for induction training and undertake the needs assessment process if they: have had a career break from General Practice in the UK for 2 or more years. have full registration with the GMC. hold a JCPTGP / PMETB (GMC) Certificate or have an acquired right to work as a GP in the UK. have undertaken undergraduate medical training in English have the following scores in the academic International English Language Testing System (IELTS) ­ Overall 7, Speaking 7, Listening 7, Reading 7, Writing 7 (or equivalent). Articulate a commitment to work in Wales within general practice.

Practice Preview Sessions If after completing the application the inductee is deemed eligible to proceed to the next stage, prior to attending the Assessment Centre, they will be required to complete a Practice Preview Session. 9

The preview is designed to be a supportive and informative process and is not used to make selection decisions about inductees, but rather to give them the opportunity to see first hand what they can expect from their workplace and to reflect on potential learning needs with a trainer. What will the preview consist of? The preview will consist of two days based within a training practice and although the schedule for the two days may vary from practice to practice. The core components will consist of the opportunity to: 1. Observe consultations 2. Learn more about the way information technology is used to support consultations. 3. Discuss the current GP contract and its influence on the GP's role 4. Sit in on practice meetings 5. Meet and spend time with administrative staff and the practice manager The Assessment Centre Providing the inductee is deemed eligible to apply for induction or refresher training and they have completed a Practice Preview session, the application will be held on file and they will be invited to the next assessment centre. The assessments include: a machine marked test of relevant clinical knowledge and problem solving ability. a simulated patient consultation a written exercise an interview with the GP Lead for the Induction & Returner Programme a computer exercise to assess IT competency

The simulated consultation and the written exercise will be marked by trained assessors who will not have any prior information about applicants. After the assessment centre the Deanery will provide the inductee with a report which sets out their performance in each of the assessments. They will be advised to attach this report to the application form when applying for conditional inclusion onto the Medical Performers List. This information will also be forwarded to the appropriate LHB. The decision regarding their conditional inclusion on the Medical Performers List rests with the Local Health Board but will be informed by our appraisal of their performance. If following the Assessment Centre the inductee reaches an acceptable standard, they will be placed in an induction and refresher placement. If there is no appropriate placement available they will be placed onto a waiting list for up to 12 months. If the inductee does not reach an acceptable standard at the Assessment Centre to be considered for funding, they cannot re-apply until a year has elapsed from the date of the previous Assessment Centre.

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The Placement If an inductee is provided with induction and refresher funding, the Deanery will endeavour to find them a placement within one of the approved Further Training Practices in Wales. The trainers within this network of practices have experience of providing training to both UK GPs returning to practice and EEA GPs receiving induction into the NHS. Placements will normally be for a period of 6 months full time or 12 months part time and will commence following negotiations with a Further Training Practice. The trainer will use a variety of educational techniques during the placement such as hot review, video consultations, 360 degree multisource feedback etc. An inductee would not be expected to attend the GP Registrars half day release course. All inductee's will be asked to sit the Applied Knowledge Test (AKT) run by the Royal College of GPs as an end point assessment. They will also need to submit videos containing 6 consecutive consultations which will be assessed by 2 Trainers from the Further Training network. 6 consultations halfway through the placement and 6 consultations at the end of the placement. The trainer will be required to submit regular reports on their progress to the Deanery at 2 weeks and every 6 weeks thereafter. These reports will also be made available to the LHB. When an inductee is in practice they will not be expected to undertake an appraisal during their placement as they will receive regular support and assessment from their trainer. When they have finished their placement they will need to undertake an appraisal 12 months after completion of their induction and refresher training. The Appraisal Unit will clarify the timeframe for completion of this appraisal. Further information on the appraisal process can be sort by contacting the Appraisal Unit, either by e-mail [email protected] or by telephone on 02920 687509.

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Appendix 4 GP Returner Scheme in Northern Ireland

NIMDTA IS CURRENTLY REVIEWING ARRANGEMENTS FOR A RETURNER SCHEME

For further information please contact Mrs Caroline Diver on [email protected]

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