Griffin, A; Crampton, PES; Mehdizadeh, L; Page, M; Knight, L; Rich, AE; Viney, RAE; (2018) Understanding stakeholder perspectives on the GMC’s quality assurance of medical education and training. Research Department of Medical Education, UCL Medical School: London, UK.

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Abstract

Background, aims, objectives The General Medical Council (GMC) hold a crucial role in quality assuring medical education and training in the UK and is currently reviewing its approach. This research provides an in-depth and systematic evaluation of how the GMC currently undertakes this role and considers future directions. The aim was to synthesise a wide range of perspectives from key stakeholders about the GMC’s quality assurance processes. Our objectives were to synthesise their perceptions of: 1) strengths and weaknesses of the GMC’s Quality Assurance Framework (QAF), 2) suggestions for improvement, 3) assuring quality of standards in equality and diversity, 4) proportionality in the current approach, 5) collaboration with others and 6) alignment with best practice. Methods A qualitative methodology employed interviews to explore a diverse range of stakeholders’ views about the impact and effectiveness of GMC’s QAF. We used realist evaluation to develop a deeper appreciation of how and why the components (standards, monitoring, visiting, etc.) of the GMC’s QAF are effective, or not. The research included: a rapid review of the quality assurance literature from 2012 onwards; interviews with stakeholders; and six case studies. Aligned to the recruitment strategy the sample was professionally diverse and represented a wide range of national and international stakeholders within and outside medicine. In total we conducted interviews with 36 individuals representing 34 organisations, producing a considerable quantity of original data: 35 hours, 27 minutes. The individuals interviewed were senior personnel such as directors, chief executives, managing directors, accreditation leads, and education/standards/quality assurance managers. Results Overall there was recognition that the GMC has robust practices in quality assuring medical education and training. The GMC’s QAF was commended by stakeholders for being comprehensive and for enabling a broad understanding of an organisation’s performance. Quality assurance partners (QAPs) were able to offer specific critical insights into how the GMC’s quality assurance (QA) processes actually impacted on their organisations. Whereas non-quality assurance partners (non-QAPs) reflected on the GMC’s QA processes by comparing them with that of their own organisations/profession, and trends in QA more broadly. The GMC’s approach to quality assuring medical education and training was largely considered proportionate to the risks involved, although QAPs were more likely to be critical of how effective and proportionate the QAF is compared to non-QAPs. The main weaknesses identified fell broadly into two themes, those related to the overlap between QA bodies and those related to a heavily data driven approach associated with the GMCs monitoring activities. In order to reduce overlap, there was a unanimous view that collaborating with other QA bodies made sense, but a number of significant practical challenges to doing so were identified. In terms of future developments, all stakeholders had limited insights in relation to quality assuring fairness, and often struggled to provide a coherent answer to how equality was integral to quality assurance. A balance favouring enhancement over accountability approaches was advocated and was felt to be in keeping with current global trends in assurance. There was limited evidence from the literature to advance understandings. It was believed that closer partnership working was important in delivering enhancement, and case study data demonstrated how partnerships can be enhanced through collaborative practices. Conclusions Effective working relationships foster trust and informal communication channels allow the early communication of emerging risks and support quality enhancement approaches. Enhancement-oriented approaches should also facilitate closer partnership working, as enhancement is typically seen as more positive than assessment-oriented assurance approaches. Openness between the provider and the GMC can help to bridge the gap from policy into practice. In acknowledging the GMC’s responsibility to ensure minimum standards are met, a hybrid model of cyclical plus risk-based visiting may help to build provider relationships and drive improvement while also ensuring minimum standards. The move towards a risk-based approach is in keeping with current trends in regulation globally, but accurately and reliably gauging risk is reported to be challenging. Risk is context-dependent and it may need to be defined differently across undergraduate and postgraduate medical organisations. Greater clarity on the relevance of data requests and providing timely constructive feedback on submissions should prevent stakeholders’ disengagement in monitoring and self-assessment practices. The implications of the findings on equality and diversity point towards making fairness more explicit within quality assurance activities and having action points that directly relate to equality. For the GMC to tackle issues such as differential attainment, widening participation, and equality within training environments it should be much clearer how the GMC will regulate these particular aspects in practice. In addressing regulatory overlap by exploring collective assurance, there is a need for a comprehensive review and further consultations in order to understand if the benefits would outweigh costs. There are many theoretical advantages, and stakeholders were overwhelmingly positive about streamlining these processes, but there are significant challenges in practice. A clear stance on organisational remit, and particularly boundaries, is anticipated to be a key mechanism in conducting effective joint quality assurance.

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