The criteria for applying
The GMC stages of application
The CESR evaluation by the College Equivalence Committee
The first application, review and appeal
Criteria for Application
A doctor can apply for a CESR in psychiatry if they can demonstrate to the GMC that they have six months of training in the specialty being applied for and/or a postgraduate qualification in the specialty attained anywhere in the world. Once successful in their application, the doctor is entered onto the Specialist Register for a psychiatry specialty, that is, given ‘specialist registration’ by the GMC. If they are overseas doctors who at the point of application do not have GMC registration at all, they are given both full GMC registration and specialist registration at the same time.
To practise medicine in the UK, all doctors need to hold registration with a licence to practise, undergo annual appraisal and participate in revalidation every five years. In addition, doctors also pay an annual fee. Doctors who are not practising medicine or who practise overseas can choose to hold registration without a licence to show they continue to be in good standing with the GMC. This shows that they continue to follow the principles and standards of good medical practice.
Why Apply for Specialist Registration?
The final aim of a CESR application is to attain specialist registration with the GMC and to be included on the Specialist Register. It is an acknowledgement of the applicant’s knowledge, skills and competences to practise as a consultant in the UK.
By definition:
The Specialist Register is a list of doctors who are eligible to take up appointment in any fixed term, honorary or substantive consultant post in the NHS excluding foundation trusts.
If a doctor is on the Specialist Register, it will say so as part of their status on the medical register. You will also be able to see:
the specialties (and sub-specialties) they are qualified in
the date they joined the Specialist Register for each specialty.
Doctors can practise in a specialty not shown on their Specialist Register entry. In most cases, they must be on the Specialist Register in at least one specialty to practise as a consultant in any of the UK health services.
For example, a doctor with specialist registration in general adult psychiatry might choose to work as a substantive consultant in forensic psychiatry; or a doctor with specialist registration in intellectual disability might choose to work in general adult psychiatry. There are several possible combinations. It depends on the confidence and personal career journey of the doctor and the job opportunities which arise. Nevertheless, ethically, a doctor should practise within the remit of their expertise and understand their own strengths and weaknesses in clinical competence to keep their patients safe.
Doctors can work as locum consultants without specialist registration. It depends on the organisation employing locum consultants as to whether they specify the need for specialist registration or not. Hence, an applicant needs to be clear in their mind about what specialist registration means for their career. What exactly can they do after specialist registration which they cannot already do in their clinical space?
Specialist registration opens the door to substantive consultant posts. Substantive consultant posts open further opportunities to become named clinical and educational supervisors of core trainees and higher psychiatry trainees in a rotation; medical managers; and senior educational leaders (training programme directors, heads of school in psychiatry, directors of medical education) in the local Trust, deaneries and the Royal College of Psychiatrists (RCPsych). A locum consultant can do the same clinical job, provide supervision to trainees and specialty and associate specialist (SAS) doctors (though without being acknowledged as the named supervisor), provide leadership in quality improvement projects and contribute to teaching and research. However, such opportunities are likely to be time-limited according to the contract held, and maintaining continuity and consistency is difficult. Consistent progress in educational and leadership positions is mostly available only to consultants in a substantive position.
An applicant needs to reflect carefully before embarking on the CESR journey. Many applicants are already locum consultants and clinical leaders. While being on the Specialist Register is a valuable acknowledgement, one would have to think about the further opportunities which will become available in a substantive post and if that is what they want for the future. Choosing to locum for the foreseeable future, taking advantage of the flexible working conditions and possible financial returns, might suit some doctors. One does not need to be on the Specialist Register to do that and doctors are entirely entitled to make their own choices. However, if doctors wish to progress as medical managers and educators, specialist registration is an important step in their career.
The CESR Journey: Application to Outcome
The CESR process is owned by the GMC. The Royal Colleges are advisors and work closely with the GMC (Figure 1) in assessing applicants’ evidence to evaluate whether it meets the standard for existing higher specialty curricula, that is, demonstrates the competences of a consultant practising in the UK.
This process is correct at the point of this book being authored. The journey might change in terms of timelines and how the GMC and the Royal College interact with each other. However, the basic process of the CESR application being put to GMC, the GMC seeking advice from the Royal College and GMC giving a final decision based on that advice are unlikely to change drastically.
First Steps in Uploading Evidence to GMC
The later chapters in this book will guide you through the content you need to collect to put on your GMC application for CESR. Once you have this evidence, the appropriate way to organise and present it is explained in an excellent document by GMC:
GMC. Online CESR/CEGPR Application – User Guide, appendix 8. www.gmc-uk.org/registration-and-licensing/join-the-register/registration-applications/specialty-specific-guidance-for-cesr-and-cegpr.
The GMC online account remains open for a year until an applicant is prompted to submit their evidence. Payment to the GMC is asked for at the final point of submission, not at the point of opening the GMC online account when an applicant starts uploading evidence.
The GMC online account for psychiatry is clearly divided into various sections of evidence which correspond to the domains of good practice. Evidence in one section might be relevant to various competences, but applicants are not expected to duplicate evidence.
Keeping Up to Date with the Curricula and Guidance
Owing to GMC altering their CESR transition policy, CESR applicants are able to apply for CESR under the previous curricula for a maximum of 12 months after the new curricula have been approved. Between January 2022 and January 2023, applicants will be able to apply under the psychiatric curricula of 2019 or under the newly approved psychiatric curricula.
After 31 January 2023, all applicants are expected to apply under the requirements of the new curricula. If applicants require specific support with translating their previous evidence under the new curricula, they are advised to contact the College for specific advice on their circumstances.
RCPsych. Transition Timetable for Curricula Implementation 2022–2024:
February 2022 Pilot (All New Starter CT1s and ST4s). www.rcpsych.ac.uk/training/curricula-and-guidance/curricula-implementation/curricula-2022-transition-timetable?searchTerms=CESR%2C%20curriculum.
The CESR clinics are a valuable resource in clarifying any points on personal circumstances.
RCPsych. Certificate of Eligibility for Specialist Registration (CESR). www.rcpsych.ac.uk/international/CESR?searchTerms=CESR%20clinic.
It is worth mentioning here that the content and standards of what is needed to be a consultant psychiatrist in the UK have not changed radically from the old curricula to the new. The organisation and principles are a lot neater and easier to follow, duplication has been removed and CESR applicants can navigate their way around the requirements and how to meet them a lot better. The curricula have gone from 19 intended learning outcomes (ILOs) to 9 higher learning outcomes (HLOs). The HLOs correspond to the newly ordered GMC ‘generic professional capabilities’ (GPCs). Each HLO contains several ‘key capabilities’ which describe the detail of what needs to be attained under each HLO. As a result, the curricula for all specialties (medical and surgical) across the UK have or are working towards a uniform structure. Each GPC has a corresponding HLO. Each HLO contains several key capabilities.
The Online CESR/CEGPR Application – User Guide is the ultimate reference for the logistic practicalities of uploading evidence for CESR. Some of the important points are highlighted in what follows.
Anonymising Evidence
It stands to obvious reason that confidential material must be redacted. Our advice is to do this electronically which is safer, neater and has less chance of missing names. Use the find–replace function on Microsoft Word for example. Patient and relatives’ names need redaction. GMC advises that gender and date of birth are retained (I feel more comfortable leaving only the year of birth and removing the day and month) to give assessors a sense of the demographic range of your submitted case histories. GMC also advises redacting colleague names where appropriate, for example in interview records, sensitive emails and workplace-based assessments carried out for junior colleagues.
GMC. How Do I Anonymise My Evidence? www.gmc-uk.org/registration-and-licensing/join-the-register/registration-applications/cesr-cegpr-application-process/anonymisation.
Selecting Your Referees
You need to select at least four referees who are willing and able to provide a structured report about you to the GMC in a timely manner. Always select your referees at an early stage of planning your application. You should contact your potential referees, share your CV with them, explain the CESR process (if they are not familiar with it) and ask their permission before including their name as a referee in your application. The following resource can be helpful in having such a discussion:
GMC. I’ve Been Asked to Be a Referee. What Do I Need to Do? www.gmc-uk.org/registration-and-licensing/employers-medical-schools-and-colleges/information-for-referees-and-verifiers/i-have-been-asked-to-be-a-referee-what-do-i-need-to-do.
You may have more than four referees if you feel that would be helpful. The primary referee must be your current clinical director or equivalent even if you do not work with that person daily or know them personally. Of the remaining three, two should be doctors in the same specialty you are applying in or a closely related specialty.
GMC. Guidance on Choosing Referees. www.gmc-uk.org/registration-and-licensing/join-the-register/registration-applications/guidance-on-choosing-referees.
In some countries or organisations, the term ‘Clinical Director’ may not be used. In such situations, you should consider using your line manager or head of department as the primary referee. Each of your referees will be contacted by GMC via email – using their registered email if they are currently or were previously registered with GMC or if they have never been registered with GMC their work email address, which you will need to provide.
Referees will be asked to provide a structured report based on their direct observations of working with you (with some exceptions: a medical or clinical director may base their opinion on appraisal records and on colleagues’ and clinical supervisors’ feedback). Guidance is available for referees to complete the structured report.
GMC. Guidance on completing a structured report for a CESR or CEGPR application. www.gmc-uk.org/-/media/documents/sat–guidance-on-completing-a-structured-report-for-a-cesr-or-cegpr–dc5356_pdf-56569930.pdf.
Delays in submitting reference reports can mean delays in processing your application and consequently delayed outcomes.
CESR Verifier
This is an important part of your CESR application and, as per GMC, needs to be completed by ‘someone in a medical supervisory position’. You will have to identify a suitable person as verifier – one in each hospital or institution from where you are including evidence in your CESR portfolio. It is important to select your verifiers carefully; contact them beforehand, gain their consent and make sure they have adequate time to complete this very important document in your application. Supervisors who may agree to act as verifiers could be quite busy, and if they are unable to complete the document in time then your application will be delayed. It may be helpful to share the following information from GMC with your potential verifiers so they are better aware:
GMC. I’ve Been Asked to Verify Evidence. What Do I Need to Do? www.gmc-uk.org/registration-and-licensing/employers-medical-schools-and-colleges/information-for-referees-and-verifiers/i-have-been-asked-to-verify-evidence-what-do-i-need-to-do.
The current process replaces the need for every page of evidence to be signed, dated and stamped which was an earlier requirement in the days when evidence was submitted as hard copies. This process is in line with an online submission. The applicant identifies the persons who can vouch for the validity of documents submitted and GMC contacts them directly to do so once the application has been submitted.
Understanding How the GMC and RCPsych Work Together: The Specialist Registrations Team and the Equivalence Committee
The team within GMC which deals with all routes to the specialist and GP registers is the specialist applications team. The team within RCPsych which advises the specialist registrations team is the Equivalence Committee led by the associate dean for equivalence and overseen by the dean of RCPsych.
GMC. Applying for Specialist or GP Registration. www.gmc-uk.org/registration-and-licensing/join-the-register/applying-for-specialist-or-gp-registration.
RCPsych. The Equivalence Committee. www.rcpsych.ac.uk/international/CESR/the-equivalence-committee.
Respective GMC and RCPsych email addresses:
Equivalence@gmc-uk.org
Equivalence@rcpsych.ac.uk
Figure 1 at the beginning of this chapter demonstrates the stages of the application passing from the GMC to RCPsych and back. The applicant submits the application to the GMC and is allocated a named certification officer from the specialist registrations team who checks the application for the basic requirements and then looks at it in more detail for gaps in curricular competences and asks for more evidence if appropriate. Finally, the application passes to RCPsych who have 49 days to give an opinion and pass an evaluation signed by the associate dean of equivalence back to the GMC. The GMC completes a quality check within another 41 days (within which time they might get back to the RCPsych for further clarifications) before issuing a final decision to the applicant. These 90 days (49 plus 41) constitutes the ‘3-month legal deadline’ by which the GMC is expected to give the applicant a decision on their application. The process before this point is between the applicant and GMC, with opportunities for more evidence to be submitted and evidence to be reorganised and further triangulated. In Chapter 12, we will describe the various routes of review and appeal which can be sought if there is an unsuccessful CESR application.
It is worth talking a bit more about the Equivalence Committee at this point. It will give the applicant more context as to who will be looking into their evaluation in depth and how it will be assessed. Also, the Equivalence Committee is worth joining as a consultant psychiatrist once an applicant has attained specialist registration and worked as a consultant psychiatrist for at least one year. The application process includes submitting paperwork such as certificates of good standing for CPD, examples of report writing and a letter of support from the medical director. The new evaluators attend an induction training session.
The Equivalence Committee comprises consultant psychiatrists in the UK from around the country and working in various specialties so that there is a wide range of curricular expertise represented. The committee meets twice a year to discuss application statistics and changes to guidelines and training for potential CESR applicants as well as to exchange experiences on difficult evaluations. These contact days are also combined with refresher training which usually looks into interesting applications and difficult decisions. The committee is active, vibrant, vocal and constantly developing in expertise.
The other important person working with the Equivalence Committee is the RCPsych training and CESR coordinator. I have had the opportunity to work with a number of talented people in this post who are mentioned in relevant parts of the book. The training and CESR coordinator looks after the entire administrative procedure of both CESR and Certificate of Completion of Training (CCT) applications.
When a CESR in psychiatry application is passed over to the RCPsych after having gone through the first process with GMC, the training and CESR coordinator emails the Equivalence Committee members to take up the application for evaluation. Two evaluators are allocated to a single application/review. Of these two, at least one should be a consultant in the specialty being applied for. We would prefer both evaluators to be from the specialty, but if resources are stretched we might settle for one consultant evaluator being within the specialty and another outside of it.
The evaluators carry out independent assessments based on the submitted evidence, filling in a detailed template which gives very specific reasons for the conclusions reached. If competences are not met, the evaluators provide SMART (specific, measurable, achievable, realistic, time-limited) recommendations as well. The two independent evaluations are returned to the training and CESR coordinator who then merges them and creates a ‘variance report’ on the competences which the evaluators have not agreed on. The variance report is then shared with the evaluators who now communicate with each other to come to a consensus. If there still remain competences which are not agreed on, the associate dean for equivalence makes the final decision. A final report is then sent back to the GMC. Then follows the quality check by GMC in 41 days. The evaluators may be contacted for clarifications if required or these might be dealt with by the associate dean for equivalence and/or the training and CESR coordinator.
It is also worth noting that appeals are brought against the GMC. The evaluators are not individually drawn into complaints and appeals. The College will work closely with the GMC in advising and supporting decisions. For example, Equivalence Committee members are called upon to be GMC witnesses in case of a registration appeal. In these cases, they represent the GMC and RCPsych.
Conclusion
Compiling a CESR portfolio can appear quite daunting at the beginning; however, with proper planning and information the tasks can be well planned and divided into manageable chunks. Regular small updates to the portfolio with frequent checks on where more evidence is needed can be rewarding. Also, regularly checking the current guidance and curricula can be helpful. Organising the portfolio and creating an index with each document page numbered and linked to relevant competences to aid the assessors can help massively. Proper anonymisation is vital and so is selecting the right referees and CESR verifier. If in doubt, seek help from the GMC and the RCPsych Equivalence Committee. Overall, good planning can make your CESR journey a rewarding exercise with substantial chances of success.
