Guide to the Credit-based system for CPD


Introduction

The RCGP Credit Based System for Continuing Professional Development (CPD) is a mechanism for GPs to record their CPD based on the time spent on the activity and the impact it has on the doctor, their patients and the service.

At its simplest each recorded hour spent on a CPD activity, which can include planning and reflection, counts as a credit however additional credits can be earned by demonstrating the impact of the learning.

Credits are self assessed and verified at appraisal and account should be taken of the need for GPs to use their CPD to ensure that they are up to date in all areas of their work.

The system will help GPs meet their revalidation needs by providing a mechanism for collecting and demonstrating their CPD Credits.


Background information
The Academy of Medical Royal Colleges (AoMRC) has a consensus view that CPD activity for the purposes of revalidation should be recorded in a credits-based system. Furthermore AoMRC expects 250 credits to be accumulated in a five-year revalidation cycle and normally 50 credits a year.

The RCGP has recognised that a wholly time-based credit system will not recognise the true value of CPD. A system based on the impact of a developmental activity and to a lesser extent the challenge involved in completing the activity was piloted between September 2008 and May 2009. Lessons learned as a result of that pilot informed the development of this system, which is based partially on time spent on the learning but with the opportunity to gain further credits by demonstrating the outcome (Impact) of development.

Impact in this context refers to:

• Impact on patients (e.g. a change in practice, implementing a new clinical guideline, initiating a new drug for the first time)
• Impact on the individual (personal development e.g. development of a new skill or further development of existing skills)
• Impact on service (e.g. developing and implementing a new service, becoming a training practice, teaching others.)
• Impact on others (teaching, training, NHS locally or nationally)

This approach to Continuing Professional Development is also endorsed in the Report of the Chief Medical Officer for England's Working Group, Medical revalidation - principles and next steps as follows:

“6.3 It will be desirable to increase the linkage between CPD and appraisal. Appraisal focuses on meeting agreed educational objectives. Monitored systems which define College or Faculty approved educational activities may assist the meeting of those objectives. Presently most College or Faculty schemes are based on acquiring credits. The advantage of this system is that the time devoted to CPD can be measured and recorded. The disadvantage is that it is insensitive to the quality and relevance of the various CPD activities. The more that credits can encompass the value of the learning and not simply the time spent engaged in CPD, the more it will be valued by doctors and the better a measure it will be of their CPD activities.

6.4 Effective CPD schemes are flexible and largely based on self-evaluation. This lets doctors develop what they do in the context of their individual professional practice while providing evidence for external scrutiny. There is no single correct way of doing CPD. The methods chosen will depend on spheres of practice, learning styles and personal preference.

6.5 The principles underpinning CPD schemes therefore need to be as simple as possible while providing a good foundation on which to build an appropriate portfolio unique to the individual doctor.”

The important points within these three sections are:

• Increasing the linkage between CPD and appraisal
• Credits being based on the value of the learning
• Flexibility of CPD schemes
• Developing doctors in the context of their professional practice
• Evidence for external scrutiny
• Multiple methods appropriate
• Building a portfolio

GPs undertaking the normal route to revalidation will be expected to accumulate 50 credits each year. Appraisers should validate credits aiming for a broad range of CPD appropriate for the work that the GP undertakes. GPs who are outside the normal route to revalidation should refer to The Guide to the Revalidation of General Practitioners: http://www.rcgp.org.uk/revalidation.aspx

Accumulating credits

A CPD Credit is defined as being based on an hour of learning activity (including planning and reflection) recorded in such a way that it demonstrates the learning achieved relevant to the working situation of the GP.

In its simplest form one hour of activity equates to one credit. Credits are self assessed and although a certificate of completion or attendance may be used as evidence of activity it is the demonstration of learning achieved and relevance to the work that the GP undertakes that defines the credit. In short the RCGP does not advocate the collection of certificates, rather a collection of self assessed acquired knowledge relevant to the individual’s working situation.

The acquisition of knowledge in itself does not necessarily lead directly to patient benefit; under this system demonstrating impact is rewarded by a multiplication factor of 2 applied to time spent.

For instance:

• An individual attends a meeting (1 hour) on heart failure, acquires the knowledge that certain beta-blockers are beneficial in this condition and then records this within their appraisal documentation.
• Credits claimed 1 - this demonstrates the acquisition of knowledge and as yet there is no demonstration of personal, practice or patient benefit

• A different individual attends the same meeting. They record the same acquisition of knowledge however they include two patient case studies demonstrating the introduction of beta-blockers in heart failure.
• Credits claimed 1 x 2 (Impact) = 2

• A third individual attends the same meeting. The acquisition of knowledge is recorded however in their appraisal folder, an audit is planned after consideration of current practice (1 hour), they demonstrate audit of their patients with heart failure, changes are made appropriately following discussion with colleagues (1 hour) and a 2nd audit cycle demonstrates an improvement in care.
• Credits claimed 1 (initial meeting (1 hour)) + 2 (planning (1 hour) and discussion associated with audit (1 hour)) X 2 (Impact) = 6
 

In all of the above examples the GP would be expected to include evidence in their appraisal folder of:

• a record of the developmental activity
• learning points acquired
• relevance to their working situation

In addition, to claim the impact factor (credit X 2) the GP would be expected to include a demonstration of application of new learning

• Case study
• Simple data collection
• Audit
• Reflective piece demonstrating change in a practice

Appropriate claims

What can be claimed:
Time spent on developmental activities may include preparation, activity and reflection. Credits should only be awarded when a demonstration of the learning achieved is relevant to the practice of the GP.

What should not be claimed:
The credit-based system is designed to move beyond a simple hours = credits scenario. By requiring the individual to record learning relevant to the GP’s practice, simple certification of time spent is not adequate to claim credit. Examples of inadequate credit claim would be:

• I read the BMJ every week for one hour- claim 52 credits
• Audit data collection six hours - claim six credits

The above example of reading the BMJ may be eligible for credit claims however in the format presented it gives little indication of relevance to the GP’s practices, and such untargeted reading should not normally exceed 10 credits. Performing data collection for the purposes of audit should not be claimed.


Audit
Audit now occurs in every General Practice in the UK as part of the QOF target system. It is inappropriate to claim credits for the process of data collection or QOF achievements. The process of improving or maintaining QOF points is of course a quality exercise in itself that has impact and would be eligible. Audit outside QOF would also qualify for credits, it must be remembered however that it is the development that leads to the credit not the process of audit.

As audit is designed to improve systems and outcomes of care it is likely that all developmental activity associated with audit will be eligible for the impact multiplication factor

Examples of credit claims:

1. Audit of antibiotic prescribing in sore throat

I enclose an audit examining my personal use of antibiotics in uncomplicated sore throat presentation. This was prompted by my reading an article in EKU 3 (Essential Knowledge Update) entitled “prescribing antibiotics for self-limiting respiratory tract infections”. This highlighted the CENTOR criteria which may be applied to the presenting symptoms of a sore throat helping to exclude beta-haemolytic strep. I looked at a three-month period between January and March last year and then prospectively examined my prescribing between the same months this year applying the criteria to aid diagnosis.

I have demonstrated a 25% reduction in the prescribing of antibiotics without any major ill effects. This activity seems to improve my practice and I intend to continue to apply the criteria in future.

The initial EKU learning module took about an hour, preparation and planning a further hour, discussion of changes to be made with my partners a further hour and writing up and reflection on the audits another hour. Total = 4 hours.

• Credit claim - 4 credits for activity x 2 (Impact) = 8 credits

2. Audit of diabetic care

I recently joined an inner-city practice with a high prevalence of diabetic patients and low QOF achievement in diabetes. The initial data collection was based on QOF achievements from last year. The practice nurse and I attended a two-day update on diabetes. We used this as a springboard to rewrite the practice diabetic protocol and to start a call and recall system. In the first nine months we have seen an average 1% drop in the HBA 1C across the whole practice population of people with diabetes.

The prescribing of ace inhibitors in microalbuminurea has improved as has the prescribing of statins. There is still some work to do notably around diabetic foot care and retinopathy screening. I intend to re-audit next year. The audit is included along with my reflections and suggestions for further change.

• Credit claim - 10 credits for activity x 2 (Impact) = 20 credits

3. Data collection on prescribing of gliptins

I recently attended a diabetic updates focusing on newer agents. Amongst the learning points was this relatively new class of drug the gliptins. Although expensive they seem to be a third-line choice for appropriate patients and indeed may be a second line option for some. During the talk I immediately thought of two patients who could potentially benefit from the introduction of this agent. I intend to start prescribing these agents to my patients. The data collection included in my folder demonstrates the current situation and has highlighted 4 patients suitable for prescribing. Attached to the data collection are 2 case histories of the introduction of this drug and subsequent follow-up. It seems that initially good results are obtained. I suspect the numbers are too small to complete a full audit cycle for at least a further two years.

• Credit claim - 3 credits for activity x 2 (Impact demonstrated by Case histories) = 6 Credits

Distance Learning (including on-line)
Many on-line and distance learning packs have a number of “hours” attached. However, in order to claim credits, demonstration of learning achieved and relevance to general practice must be stated. Some online learning packages proffer certificates with a number of hours attached - often the time indicated has little or no bearing on actual time spent. GPs are encouraged to claim actual time spent rather than the estimate given on such certificates. Distance learning packages may also stimulate related reading or activity; these activities are probably best presented within the same credit claim.

Essential Knowledge Updates and Essential Knowledge Challenge
Essential Knowledge Updates (EKU) are structured learning activities produced by RCGP that help GPs to meet their CPD and Revalidation commitments by assimilating and applying new and changing knowledge in clinical practice.
• Two Updates are produced each year
• Each Update consists of a series of online learning modules on different topics. They are divided into major items and briefings. The major items examine the source document in detail, giving practical applications in practice, further reading and a self test quiz. The briefings simply report the outcome of the source document.
• The content summarises guidance in clinical areas of national significance where there is consensus about best clinical practice, as well as the latest information about changes to legislation or new ways of working
Each Update has an associated Essential Knowledge Challenge (EKC), an applied online self-assessment knowledge test, which will be issued 6 months after the Update. The topics chosen for the EKU have been screened for new and changing information that is relevant to general practice. It is likely therefore the majority of material will be appropriate for many GPs. The practical tips associated with the major items may be used to create impact thereby multiplying the credit claimed. It is likely that the completion of an entire EKU (and associated EKC) would generate between 10 to 15 credits. Impact on practice may be demonstrated increasing the credit value of this claim.


Examples of credit claims:

1. Chronic kidney disease

Read the EKU item on chronic kidney disease - very relevant to general practice -it helped me get straight in my mind the various stages of chronic kidney disease. I also discovered that statins are advised at a relatively early stage.

• Credit claim = 1

2. Prostate cancer

A 74-year-old patient presented to me with a PSA of 8. This blood test had been taken following a recent hospital admission for a hernia operation, the patient was asymptomatic. My normal practice in this situation would have been to perform a rectal examination and then refer to urology whatever the findings. The patient was not keen for onward referral and my examination revealed an enlarged but benign feeling prostate. I was unclear where to go from here.

I gave the patient some information from our computer’s information system and asked him to return in two weeks. I read the EKU on prostate cancer and from there followed through to the NICE guidance.

When the patient returned we were able to have a better informed discussion. He had accessed the patient information held within the NICE guidance and we were able to adopt a watchful waiting plan. He will return in three months time for a further PSA test. I now feel more confident to be able to apply what I have learnt to subsequent patients.

• Credit claim - two hours reading X 2 (Impact) = 4

3. Certificate in dermatology

This is a distance learning programme provided by our local university hospital. It consists of six modules dealing with common dermatoses. Each module involves reading and then responding to a written exercise which is marked. Passes need to be obtained in all six modules to gain a certificate. This has helped me develop a management strategy when dealing with rashes and I'm far more confident in dealing with simple eczema and psoriasis than I was. I enclose a certificate of completion, I further intend to utilise this knowledge within the practice and am working on an internal referral system. I intend to present this and an audit of care in next year's appraisal folder.

In this example it is tricky to decide whether or not impact has occurred. There is little evidence of a change in practice, however a university accredited certificate and an indication that this is going to change practice for the benefit of patients is explicit. There is however no evidence of application. It is likely that the impact will be seen next year where the credit may be claimed. This claim therefore will simply be on hours spent.

• Credit claim - 4 hours per module for six modules = 24

Meetings
As with distance or on-line learning the knowledge gained at meetings should be made explicit, as should its relevance to general practice. Practice based colleagues are often the source of nuggets of information that change what the individual does. More formal meetings are excellent resources for up to date information and professional interaction although sometimes the impact on practice may vary from doctor to doctor in the same meeting.

Examples of credit claims:
1. Practice-based educational meeting on COPD

I am the practice lead for QOF on asthma and COPD. I have noticed that our use of tiotropium has been dropping over the last 12 months. I examined a number of patients’ records and it seems that the drug is being stopped because the patients do not perceive a benefit.

I presented a practice based educational meeting on spirometry results and the benefits that can be expected from the various inhalers utilised. During the meeting one of the partners said that they had been actively switching patients off tiotropium as they had not seen any benefit. We were able to discuss the use of spirometry in assessing benefit of treatment in COPD and we have now agreed an algorithm for treatment (or cessation thereof).

• Credit claim - 1 hour activity X 2 (Impact) = 2

2. Meeting at local postgraduate centre – Neuropathic pain

I attended this meeting as I find it difficult to treat patients with neuropathic pain. Talking to my colleagues before the meeting it appears that everybody else is in the same boat. The presentation defined neuropathic pain and explained the aetiology in as far as it is currently understood. Treatment modalities were discussed as well as local referral routes. I came away from the meeting with a slightly better understanding of neuropathic pain and a clear plan of treatments I can use in my own practice. However it was also clear that I'm not alone in finding this condition frustrating and difficult to treat.

• Credit claim - 1 hour activity = 1

3. GI meeting run by local consultants

This was a day-long meeting held at our local hospital which included a tour of the endoscopy facilities. I gained great benefit from the tour as the process of endoscopy and the facilities have changed markedly since I was a junior hospital doctor. There were also a series of lectures one of which consisted almost entirely of photographs obtained at endoscopy (very little value and very little relevance to general practice). There was an excellent session on IBS and a further small workshop on the genetics of bowel cancer and endoscopic surveillance. The main benefit however was in the management of dyspepsia in the under 45s. A local algorithm was handed out which I will share with my partners.

• Credit claim - 6 hours activity = 6 (this activity does not qualify for impact as there is no evidence of application of knowledge, if the treatment algorithm for dyspepsia was illustrated with a change in practice (e.g. Case histories) then impact may have been demonstrated)

Practical Skills
Practical skills are as important as knowledge in some areas of an individual’s practice. The demonstration of acquisition or mastery of a new skill can be used in the credit system. It is not just new skills that may be used in the system. For instance teaching others practical skills has some impact and certainly examining your own results either through audit or other markers is a legitimate exercise (% diagnosis of skin lesions subsequently proved correct on histology, or % complete excision of BCC).

Examples of credit claims:

1. Shave biopsy

I attended a practical skills update at the local postgraduate centre. There was a practical demonstration of a shave biopsy and an explanation why this was preferable to excision. I felt quite confident afterwards and I plan to use the technique when I can arrange some supervised practice.

• Credit claim - 2 hours activity = 2

2. Liquid-based cytology training

I attended the mandatory training for liquid-based cytology. The techniques of collecting a good sample were demonstrated and it differs quite considerably from the old-fashioned spatula and slide method. There was also some very useful information given about results and how to interpret them. I'm now using the technique.

• Credit claim two hours activity = 2. I have not claimed the extra impact as I have only used this technique a few times I will in a years time audit the adequacy rates of my cytology

3. Joint injection

About two years ago I attended a meeting discussing the use of Hyalgan in knee injection. I started using it on some patients with moderate arthritic problems and felt that the patients benefited. I look back on the seven patients that I have used this injection on (10 knees).

Two of the 10 have subsequently had knee replacement surgery; seven of the 10 have not consulted regarding knee pain since the injection. One of the 10 has ongoing problems that are managed with analgesia.

• Credit claim = 2 hours activity planning and preparing data collection X 2 (Impact) = 4

Practice Developments
Building a new surgery or buying an expensive piece of equipment often involves doctors in a managerial role. There may be the opportunity to gain some credits but only for development – for example managing the transition from old practice premises to new would present a challenge and patients presumably would benefit, however the credit claim would be related to the learning involved in management. Statements such as “I discovered new ways to motivate the team” or “this process, far from causing conflict, has engendered a team spirit” would demonstrate change.

Developing a new service (e.g. Insulin initiation) would certainly have impact and if this were measured by data collection or audit the impact could be shown to be significant.

Taking on a new role, with new responsibilities could involve development (e.g. leading on the staff appraisal system, becoming the finance partner), the doctor should reflect on the changes to estimate credits.

Examples of credit claims:

1. Practice finance partner

Our senior partner retired last year and he used to have responsibility for practice finance. On his retirement this responsibility fell to me. I have no real previous experience in this role. I initially sat for some time with my retiring partner learning the ropes. He had a mainly manual system with most transactions recorded in long hand. Our practice manager had suggested computerised accounts and indeed fortunately had an automated payroll. The first change I made was to purchase an accounting system and then my practice manager and I learned how to use it.

The first year although difficult has been a rewarding experience I now understand practice finance much better and the system is fully automated and this has led to a reduction in our accountants fee of over £2000.

• Credit claim - 5 hours activity x 2 (Impact) = 10 (this is probably a large underestimation of the time spent)

2. Patient participation group

I have established a patient participation group in the practice. We had tried this initiative a few years ago when it had failed. It seemed to be reasonable to try and reinstate this and so I first looked at why the previous group had failed and I suspect quite strongly it was because there was no medical input. I therefore decided that we would reinstate the group and that a doctor would attend each meeting. We have now had six monthly meetings and at least one of our partners has attended. We have used the opportunity to disseminate patient information about our services and at one of the meetings I gave a talk about preventative medicine and healthy lifestyle. There was an attendance of approximately 50 patients at this meeting.

Developments arising from this include changes to our appointment system, upgrading our waiting-room including the seating and the patients have started a collection for a second defibrillator for our branch surgery.

• Credits claimed - two hours x 2 (Impact) = 4

3. Warfarin services

I have become a doser in our anticoagulation servers. This involved me in completing the online learning module approved by our PCT and to complete an application form to be recognised. I am now dosing the patients on Tuesday and Thursday.

• Credits claimed - 3 hours for online learning x 2 (Impact) = 6

Puns and Dens (patient case reports and clinical experiences)

Patients are a rich source of learning opportunities; most will be familiar with Richard Eve’s model of Patients’ Unmet Needs (PUNS) and Doctors Educational Needs (DENS) (see BMJ learning module). PUNS and DENS rely on the doctor having a need. Patient reports and experiences can be used as a narrative to demonstrate good practice, highlight a good experience or use a bad experience to examine the need for change.

A quote from 1905 (Cabot RC, Locke EA Boston Med Surg J. 1905;153:461-5.) is as true today as it was then:

"Learning medicine is not fundamentally different from learning anything else. If one had 100 hours in which to learn to ride a horse or to speak in public, one might profitably spend perhaps an hour (in divided doses) in being told how to do it, four hours in watching a teacher do it, and the remaining 95 hours in practice, at first with close supervision, later under general oversight."

Recording what happens in a consultation (or case study) would be in the “general oversight” category, demonstrating that an individual was using best practice, dealing with problems appropriately, responding to emergencies, dealing with difficult patients, up to date with palliative care; using the BTS/SIGN guidance etc.

The unusual presentation, the rare condition, the referral on instinct that turns out to be significant, the wrong word that changed the consultation, the last extra of the day with rectal bleeding or similar scenarios provoke thought, reflection and action all of which may have impact on future behaviour.

This learning by experience or from an anecdote from others often goes unrecognised; the impact associated with this day to day learning can be converted into credits.

Examples of credit claims:

1. PUNS and DENS

I have included in my folder four examples of PUNS and DENS which highlight the learning needs that these consultations exposed and the steps I have taken to fill them. The learning undertaken in total took about four hours. I have not yet demonstrated any impact of the new knowledge however this may come at a later date.

• Credits claimed - 4 hours = 4

2. Case study

I have included in my appraisal folder a case study of patients with heart failure. I have highlighted the therapeutic changes I have made and the investigations that confirm the diagnosis and monitor the patient's progress. I have maximised the patient’s therapy appropriately and have referenced this to a lead article in the BMJ. I have reflected that this is my standard therapeutic regimen for patients with heart failure. Writing this case study has stimulated my interest in the subject and I think I would like to do an audit on the topic next year (to be included in my PDP?)

• Credits claimed - 2 hours reading and reflection = 2

3. Emergency treatment

The mother of a patient aged five rang the surgery at 9 a.m. and asked for the child to be seen later. The receptionist taking the call recognised potentially serious symptoms and asked the patient to attend immediately. I was the on-call doctor and by 9.20 was able to assess the patient. Patient was demonstrating symptoms suggestive of meningitis. Another partner and our nurse attended, we were able to administer benzylpenicillin and phone an ambulance. The patient did indeed have meningococcal meningitis and recovered well.

This case history demonstrates that systems within the practice worked well, appropriate treatment was given and we highlighted this in a practice meeting. In my appraisal folder I have highlighted the changes we have instigated in training our receptionists in assessing patients.

• Credits claimed 1 hour (mainly reflecting on the incident and feeding back) x 2 (Impact) = 2

Reading
Reading can be arbitrarily divided into structured and unstructured, both have merit. An example of structured reading would be researching a condition – for example the use of the latest hypoglycaemic medication. Unstructured would be reading every issue of a journal. The individual is likely to gain some useful information however it is likely that a great deal of time would be expended in order to gain this information.

In both cases the reflection on the impact of this activity is the important thing when assessing the credits.

It is suggested that unstructured reading forms no more than 10 of the 50 credits in one year.

Examples of credit claims:

1. I read the BMJ each week and find that much of the information has little if any direct connotation to my work as a GP. I continue to do this mainly out of interest and occasionally assimilate knowledge that is useful in my role as a GP. I have highlighted in a separate credit claim an excellent review article that led me to change practice. On average reading the BMJ takes me an hour a week.

• Credits claimed = 10 (although 50+ hours were expended it is recommended that unstructured reading forms no more than 10 credits in any one year)

2. I have updated my knowledge in diabetes this year. I chose to do this by the researching and reading articles on the Internet. I include a list of the articles read and learning points from each. I estimate in total this took me six hours.

• Credits claimed - 6 (if the impact of the learning had been demonstrated then this could be multiplied by a factor of two, however despite demonstrating an improvement of knowledge there is no demonstration of utilisation of that knowledge)

3. A number of my patients are now using anti-TNF therapy. I had no knowledge of its mode of action, side effects and range of benefits. I read three different articles relating to their use in rheumatoid arthritis and psoriasis and I now have much better understanding and should be able to use this if patients need counselling prior or during treatment.

• Credits claimed - 2 hours reading = 2

Significant Events

Significant events as a learning tool have gained widespread acceptance. Adverse events or near misses can be used to address system or personal issues however positive significant events can be used to demonstrate impact and learning. An early diagnosis, dealing with an emergency, a medication review leading to significant improvements in a patient’s well being are all positive examples that can be shared with the team as learning points and can attract credits.

Example of credit claim:

1. The practice has a significant event system that I will share with my appraiser. We discuss significant events at our practice meetings and review the forms to ensure completion of changes necessary as a result. I have reflected on one significant event that directly involved me and I have contributed to many others throughout the year. In the significant event involving me I have demonstrated a change in practice and indeed a change in practice policy as a direct result.

• Credits claimed - 4 hours expended X2 (Impact) = 8


Structured Learning
(including certificates/diplomas etc)

Structured learning within the auspices of a higher education institution can also be used for credits. Impact should be demonstrable as presumably this will have been planned for a service or personal reason.

Example of credit claims:

1. I have completed the diploma in dermatology this year. In the practice we have an arrangement that is dermatology referrals are made internally to me first assessment and possible treatment. Our referral rate to dermatology has fallen by 30%.

• Credits claimed - 30 hours of activity x 2 (Impact)= 60

• In this example 60 credits are claimed, however it is important that in subsequent years, variety is demonstrated in subjects. It would be acceptable for one year to be devoted to one topic however the PDP should reflect a change in direction for the subsequent year.

Surveys (patient, 360°)

The impact of surveys will vary from individual to individual. There may be few learning points that can be gleaned from the exercise, or the feedback may include factors beyond the control of the individual. There may be instances however where changes are required and those changes when made have an impact on the way a GP works. The reflection on the results and subsequent changes are the areas to examine when judging the impact.

Examples of credit claims:

1. We completed a patient survey this year; the results were quite favourable although there was some feedback around ease of access to our appointments. We discussed this in a practice meeting and have made a few changes which I've highlighted in a separate document. These changes seem to have eased pressure at reception without increasing the doctors’ workload.

• Credits claimed - 1 hour meeting and discussion the changes x 2 (Impact) = 2

2. I completed a 360° feedback exercise. I was gratified that most of the feedback was very positive I did however receive some negative feedback regarding my record-keeping. I therefore examined the records from 20 consecutive consultations three months previously and found that although diagnosis and prescribing were recorded well the description of the patient's condition and plan of action were missing in over half of the consultations. I have therefore changed my practice and although it is early days examination of a further 20 sets of records showed an improvement to 95% in both aspects.

• Credits claimed - 1 hour in examining feedback, two hours in design and reflection including changes made in the patient audit = 3 x 2 (Impact) = 6

RCGP suggestions for doctors collecting credits

The RCGP recognises that individuals have different learning styles and learning needs. The following are suggestions on the balance between different types of activity and are not prescriptive. They are intended to encourage a wide range of activity; an individual may however choose not to partake in one or more of these activities. The methods mentioned are not exhaustive, it is intended that all activity that contributes to an individual's development may be credited.

It is vitally important that individuals realise the expectation is that 50 credits will be accumulated year-on-year leading to at least 250 credits in a five-year period. Credits are self-assessed which means that even if the appraiser does not verify the full 50 they may still stand up to external scrutiny. If there is a short fall in one year it is suggested that more credits are accumulated the following year.

Suggestion one

• Balance of activity attracting impact

• individuals should aim for impact activity

• demonstration of an evolving change is an important development

• evaluation of a completed developmental activity potentially carries the highest impact

• individuals should aim to claim a minimum of 30 credits which include impact (15 hours x2 for impact) out of their annual 50

Suggestion two

• Balance of type of activity credited

• personal unstructured reading (e.g. reading the BMJ each week) should form no more than 10 out of the 50 claimed credits

• targeted reading - that is acquiring knowledge in response to a stimulus is a very important part of developmental activity. However as acquiring knowledge does not attract an impact rating this should form no more than 10 out of the 50 claimed credits

• changes made as a result of targeted reading, or indeed from unstructured reading are important (and attract impact), no upper limit of credit claim out of the 50 would be suggested

• attendance at meetings is an important part of a general practitioner's life. It gives the opportunity to network and discuss things above and beyond the agenda of the meeting. Pure attendance and gaining knowledge however does not attract impact and as such a maximum of 20 out of the 50 credits should be claimed in this way

• changes made as a result of knowledge gained from attending meetings are important (and attract impact), no upper limit of credit claim out of the 50 would be suggested

• online learning is becoming a more important and easily accessible form of knowledge accumulation. GPs have different speeds of working through exactly the same online resource. These resources usually result in a certificate; some of the certificates mention hours or credits. The individual should remember that in the RCGP scheme credits are self-assessed and as such credits claimed should reflect actual activity rather than merely following what is said on the certificate. Online learning may be unstructured (the resource was available so I used it) or targeted (I identified a need and one way of completing this was using an online resource). It is suggested that unstructured online learning should form no more than the 10 out of the 50 claimed credits. Structured online learning without a demonstration of change in practice does not attract impact, this should form no more than 10 of the 50 claimed credits

• changes made as a result of online learning are important and no upper limit of credit claim out of the 50 would be suggested

• learning in the workplace, learning from experience, identifying learning needs through patient contact and identifying learning needs by self or peer evaluation of practice are likely to be activities that attract impact. No upper limit is suggested however the individual is reminded that the implementation of change is the important factor here


RCGP suggestions for appraisers regarding credits

The RCGP recognises that there are many issues surrounding verification of credit claims. The appraiser is rightly mindful of the supportive role of appraisal; they may also be concerned that credit verification could potentially introduce conflict into the appraisal. Appraisers are already making judgements; in order to feedback to the individual and indeed to help with the construction of the subsequent PDP the appraiser must assess learning.

The credit system is one of the requirements for revalidation for GPs and it is in the individual's interest that a fair and honest judgement is made on the credit claim. Validating exaggerated claims will not be in the doctor's interest as this may be examined when a revalidation decision is made. It is in the doctor's interest (if appropriate) to be aware that their credit total is lower than they have self-assessed. In the pilot of a credit-based system, the majority of GPs underestimated their credit claims. Many of the doctors were able to demonstrate well in excess of 50 credits. The appraiser’s role should be simply to verify that a minimum of 50 credits are demonstrated.

If a doctor has fallen short in a previous year and, by an increase in activity, demonstrates an excess, then in this situation verification of an excess of credits may be appropriate. The RCGP have produced a paper entitled “making judgements at appraisal” which may be helpful for appraisers unfamiliar in this role. The doctor being appraised will want to know that the material presented reaches 50 credits, and if it does not may require help and guidance from the appraiser or local tutor for the subsequent year’s activity- this can be negotiated and agreed through the Personal Development Plan.

Suggestion one

• Balance of activity attracting impact

• individuals should aim for impact activity

• demonstration of an evolving change is an important development

• evaluation of a completed developmental activity potentially carries the highest impact

• individuals should aim to claim a minimum of 30 out of the 50 credits which attract impact

This is only a suggestion, however it may be prudent to discuss methods of increasing impact with an individual who produces mainly material without impact. This concept does not differ greatly from current appraisal practice.

Suggestion two

• Balance of type of activity credited

• personal unstructured reading (e.g. reading the BMJ each week) should form no more than 10 out of the 50 claimed credits

• targeted reading - that is acquiring knowledge in response to a stimulus is a very important part of developmental activity. However as acquiring knowledge does not rate on the impact this should form no more than 10 out of the 50 claimed credits

• changes made as a result of targeted reading, or indeed from unstructured reading are important (and attract impact), no upper limit of credit claim out of the 50 would be suggested

• attendance at meetings is an important part of a general practitioner's life. It gives the opportunity to network and discuss things above and beyond the agenda of the meeting. Pure attendance and gaining knowledge however does not attract impact and as such a maximum of 20 out of the 50 credits should be claimed in this way

• changes made as a result of knowledge gained from attending meetings are important (and attract impact), no upper limit of credit claim out of the 50 would be suggested

• online learning is becoming a more important and easily accessible form of knowledge accumulation. GPs have different speeds of working through exactly the same online resource. These resources usually result in a certificate; some of the certificates mention hours or credits. The individual should remember that in the RCGP scheme credits are self-assessed and as such credits claimed should reflect actual activity rather than merely following what is said on the certificate. Online learning may be unstructured (the resource was available so I used it) or targeted (I identified a need and one way of completing this was using an online resource). It is suggested that unstructured online learning should form no more than the 10 out of the 50 claimed credits. Structured online learning without a demonstration of change in practice does not attract impact, this should form no more than 10 of the 50 claimed credits

• changes made as a result of online learning are important and no upper limit of credit claim out of the 50 would be suggested

• learning in the workplace, learning from experience, identifying learning needs through patient contact and identifying learning needs by self or peer evaluation of practice are likely to be activities that attract impact. No upper limit is suggested however the individual is reminded that the implementation of change is the important factor here

The appraiser should be mindful that these are suggestions, however activities that do demonstrate change for example audits, significant events etc are requirements for revalidation for GPs. A range of activities may be suggested at the appraisal discussion and changes to the type of activity may be negotiated through the Personal Development Plan.

With acknowledgement to Dr Chris Price, Professor Nigel Sparrow, Sam McNabb and Caroline Turnbull 28 8 09

This page was last updated on: 07 October 2009