For Professor Sir Denis Pereira Gray it was the top priority of his Chairmanship of Council in the late 1980s. For the 323 Fellows by Assessment it is a source of pride and achievement, as well as a stimulus to significant subsequent academic or career developments.1 For the Royal College of General Practitioners it was the flagship that led to other quality awards, such as the Quality Practice Award and Membership by Assessment of Performance and for the NHS it has been a foundation of the Quality and Outcomes Framework (QOF) system for assessing both the quality and the outcomes of care of every British general practice. Most of all, for patients it has had a significant impact on the quality of the care that they receive in general practice.
Fellowship by Assessment (FBA) had its origins in ‘What sort of doctor’, a College initiative in the early 1980s,2 which assessed the performance of established GPs in the setting of their own practices. Two working parties were formed and carried out more than 35 assessment visits to test the validity, acceptability, reliability, and value of the criteria. Despite recurring problems about whether it was the practice or the practitioner being judged, they concluded that ‘experienced GPs are able to reach agreement on matters of quality, criteria and levels of performance’. Twenty years later it is difficult to appreciate what a revolutionary concept this was.3
FBA then became the first scheme for the accreditation of practising clinicians in the UK, and the first College-run, on-site, practice-based assessment leading to a major professional award in the world.4 Professor Sir Denis Pereira Gray wrote the first key paper on the principles of FBA over Christmas 1987. He then took it through the processes of the College while the scheme was tested in his own Tamar faculty. By 1989 the first four prospective Fellows by Assessment applied, and passed all the 60 essential, published criteria of the award. One of those first four Fellows by Assessment, Mike Pringle, subsequently became the first Chair of the working group. The assessments were undertaken by three College Fellows (since this was a peer assessment) through a dual process of prior consideration of a portfolio of written evidence, and a day-long practice-based visit. This basic format has continued throughout the history of FBA.
From its inception, FBA aimed to assess performance (what the doctor does in daily practice) rather than what he or she was capable of doing in an examination setting. FBA required candidates to be assessed on many different aspects of patient care, ranging from numerous surveys of patient care to videos of actual consultations, at a time when both were unusual in general practice anywhere. The underlying principle was triangulation of different aspects of evidence to build up a detailed picture of the care patients were receiving. Experienced GPs could evaluate this from their individual and collective perspectives.
The criteria were reviewed annually and amended following widespread literature reviews and consultation. Changes to the criteria reflected, and eventually led, those in general practice and the NHS over the ensuing 16 years. Although ‘audits’ of management plans were required from the outset, these were, by today's terminology, single surveys. The concept of the complete audit cycle, along with specified standards and targets, was introduced in 1994 and then only required for half of the 10 main management plans. A specific system for ensuring demonstration of key consultation skills was introduced eventually in 1996 (as opposed to an implicit, ‘I know a good consultation when I see one’). In the following year the requirement for a patient satisfaction survey was established. A few other notable criteria changes reflected the changing face of general practice. The now archaic term ‘band 3 health promotion’ appeared in 1994 and disappeared 3 years later, along with the government of the day. Some other historical clues can be seen by the replacement of ‘reference books’ with ‘reference system’ in 1996 as the electronic age became firmly established; pre-conception care became a criterion the following year; and health and safety the year after that. In 1998 there developed an explicit requirement for candidates to declare upheld or pending formal complaints against them, something that affected about 10% of applicants (and a similar proportion of potential Fellows by Nomination). Excellence, not perfection, was the standard.
Peer review for the first 10 years was just that: review by existing Fellows of the RCGP in active, or recently retired from, general practice. As time went on, assessors were increasingly drawn from the pool of Fellows by Assessment. An interesting quotation from the working group minutes of April 1994 reads as follows:
‘During a discussion about the possibility of using non-medical assessors for FBA it was noted that Dr X believes that this would not be acceptable to the General Medical Council, and indeed some members of the group thought this would be unacceptable to the profession’.
Opinions about lay assessors by new Fellows by Assessment changed markedly between 1996 and 1998, and by 1999 a pilot of lay assessors was underway, partly influenced by the GMC who, in 1998, started using lay assessors in their investigations of poor performance. The initial six lay assessors were all from the RCGP Patients' Liaison Group. They had a weekend of training in the heart of the Peak District and brought an added enthusiasm and dimension to the subsequent progress of FBA. There was widespread endorsement of their abilities and the broader perspective that they brought to visits.5 They, like the candidates, believed that FBA was good for patient care.1
Administration of FBA was devolved to the Vale of Trent Faculty in 1993 and stayed there for 10 years. Initially this was supported by Janet Baily, assisted by Lynn Philips, and subsequently by Susie Johnson. Their dedication, patience, and enthusiasm are still appreciated by all involved in FBA over that decade. A working group based in the faculty, firstly chaired by Mike Pringle and later by Alison Kay (now Alison Miles), contributed a great deal to the development of FBA, especially refining and expanding criteria to reflect leading-edge practice. They reported to a national working group which met in London twice a year, who in turn submitted annual recommendations for revisions to the College Council. In latter years the administration was transferred via Mersey Faculty to the RCGP at Princes Gate, and John Holden was elected to the chair in 2002.
The views of Fellows by Assessment regarding their experiences and perceptions of the system have been sought each year by the working group. In 1998 the College published The First Hundred Fellows by Assessment, by Richard Moore,6 following an independent survey. The messages were consistent: FBA was hard work but worthwhile. It was good for patient care and led to improvement in standards of clinical care, team development, and organisation. Achievement improved confidence and subsequent career development, with the review by peers being particularly emphasised and valued. Many Fellows by Assessment became involved in College activities beyond being advisers and assessors for FBA and other quality initiatives.7
However, numbers of candidates remained relatively low compared with those nominated to Fellowship, and despite advisers and assessors devoting many hours of their own time at no cost, FBA has always required financial input from the College.
Council recommended in 1998 that there should ultimately be a single route to Fellowship, but it was 5 years before this goal started to be realised when the FBA chairman convened a meeting at Hassop Hall in Derbyshire. That group (Margaret Abbott, John Holden, Eileen Hutton, Clifford Kay, Alison Kay, Mike Pringle, and Alistair Wilkinson) discussed many ideas for the future of FBA. Within 3 months, Council had approved Mike Pringle's proposal that a unified pathway to Fellowship should be actively considered. On 1 April 2006, the new system was started, as nominations closed, with the remaining FBA candidates expected to be assessed over the ensuing few months.
FBA spanned the millennium and has its own place in history, reflecting and contributing to far more explicit standards of general practice. For those involved the rewards have been huge, especially given the chance to meet enthusiastic GPs and teams delivering, in the words of the College Charter, ‘the highest possible standards of general medical practice’ in a fascinating range of diverse settings throughout the British Isles. It serves to remind us how a vision can be brought to fruition by enthusiasts, the countless advisers, assessors, and members of FBA working groups. To all these people who have provided superlative standards of dedication, enthusiasm, and expertise, we owe our thanks.
- © British Journal of General Practice, 2007.