Revalidation cannot be left to GMC alone
Jeremy Hunt announced the final go-ahead for medical revalidation within days of his decision to ask the Independent Reconfiguration Panel to review children’s heart surgery.
It is more than a decade since the Bristol Royal Infirmary inquiry highlighted the variability of medical performance and fed the debate over the creation of specialist centres. The NHS has been wrestling with both issues ever since.
Despite some progress, service reconfiguration is still often a sticky mess of conflicting clinical “evidence”, thinly veiled political interference, poor consultation and local mischief-making. However, only the most optimistic can claim efforts to tackle the quality of doctors is in better shape.
It is important to state three things before explaining why this is the case. First, the quality of UK medical practice is usually good. Second, revalidation is an unarguable step forward and the General Medical Council should be congratulated for its tenacity. Third, revalidation should build on trusts’ established clinical governance systems and will hopefully evolve over time.
Mr Hunt has declared revalidation should ensure doctors are “up to speed with the latest treatments and technologies”. This is important not only for patients wanting to receive the best care, but also for a system facing unprecedented demands on its efficiency.
However, there remains considerable scepticism that revalidation will justify the time and effort required to make it a success.
The loudest mood music emanates from the framework which will “host” revalidation. The current clinical governance process is not considered a widespread success.
While there are examples of robust and transparent systems across the country, there are also too many cases of organisations going through the motions.
Too many doctors have not been convinced of the value of appraisals and, at best, treat them as an intellectual game. Too many medical directors lack the will or the support to challenge poor performance and behaviour. The introduction of revalidation will not solve the kind of deep-seated cultural problems present, for example, at Mid Staffordshire Foundation Trust six years ago.
Revalidation rightly stresses the importance of teamwork and patient involvement and seeks to gather feedback on this.
But as one commentator on hsj.co.uk remarked: “If one of my team said to a very junior staff member they were talking ‘crap’ and asked them ‘are you stupid?’ this would be frowned upon, but as it’s a consultant he is just ‘having a bad day’. Is revalidation going to address this? I doubt it very much.”
Another commentator - a medical director who champions revalidation - warned: “Sadly club culture and old boys’ networks are all [too] common in some trusts and revalidation may give the opportunity for some leaders to punish someone from the wrong club, colour or one who is outside the network.”
Then there is the question of how high the bar has been set. Revalidation, at present, appears to do little to test expertise in a doctor’s chosen specialism.
Finally, revalidation takes place every five years, a desperately long time to wait to deal with a poorly performing doctor.
But these problems are not insurmountable. Revalidation, and - crucially - the clinical governance process in which it sits, is a system and organisational issue, as well as one addressing the quality of individual clinicians.
It is something trust boards and those charged with improving the quality of primary care need to convince themselves is helping deliver a consistent improvement in medial performance.
Isolated as a straightforward matter of professional regulation, clinical governance and revalidation will slide into an increasingly irrelevant box-ticking exercise, resented for the time it takes from patient care. Strong and consistent engagement by boards can ensure it saves lives and enhances effectiveness.
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Readers' comments (10)
Anonymous | 26-Oct-2012 11:59 am
Concerns regarding a poorly performing doctor should be raised as they occur - this happens in other professions. What is worrying is the amount of doctors who do not understand what is expected of them for Revalidation. Doctors who have been scheduled to Revalidate in Year 1 are already panicking. On the whole, I think Revalidation is a good thing, not only for assruing patients and the public but also for the doctors own reflection of their practice. Five years may seem a long time but Governments stay in office for 4 years and look how well they are performing !
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Anonymous | 26-Oct-2012 1:13 pm
The time, effort and cost of revalidation will be stupendous. Much of the resources expended will, however, be hidden and not easily quantifiable. So there is no answer to the question: 'what will it really cost?' There is NO evidence that it is either required, nor that it will work. Everyone has just assumed it is a 'good thing' and that it will work. As Alastair writes, the standard of UK doctors is generally good. Where is the evidence that UK doctors are worse than anywhere else? So what is the 'problem' that revalidation is supposed to solve? It will NOT, of itself, catch another Harold Shipman. This is because so much has changed since Shipman was caught and since the Bristol enquiry. So what 'extras' will revalidation bring? Would suggest precious few. It would be better, cheaper and far easier to boost or reinforce what we have now, not reinvent the wheel. Revalidation will NOT stop another Mid Staffs or Maidstone: these were almost entirely failures of executive management chasing central targets or 'Foundation status'. In fact, revalidation is highly likely to muzzle exactly the independent Drs the system NEEDS to blow the whistle. In any system, it is important to have checks and balances that prevent a particular perverse incentive from running out of control. There is, at present, absolutely no balance whatsoever limiting the exponential expansion of the apparatus and bodies that could climb on the bandwagon of revalidation. No limit on what some vocal jobsworth could demand as part of the process. There are powerful forces at work to generate any number of non-jobs employing box-tickers, seen as 'essential', to administer the process. Look at what we have seen w.r.t. 'mandatory training'. A joke. Illogical, unnecessary CRB checks. The oppressive, hysterical 'Data Protection' rules. [Had to register as a data processor, which just meant paying £35 per annum to do what have always done anyway].
Here's the rub: it is government or 'the system' that wants to do this to doctors. Why should we have to pay for it? And we will, as the GMC will be forced to exponentially raise our subs. If society wants this [in my opinion insane mess], then let the taxpayer pick up the bill.
PS: British graduates are avoiding medicine like the plague. Within the last few weeks, know of 3 young 'best-of-the-best' surgical consultants who have left the UK for good. One to Canada, one to New Zealand, and one to the US. Carry on folks, carry on......
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Anonymous | 26-Oct-2012 1:35 pm
Sorry, should have said that the BRIGHTEST British graduates are avoiding medicine like the plague. They do the numbers, look at the demands of things like revalidation, then go off into something else. We are self-selecting obsequious, obedient, marginally intelligent enough, worker drones to become the doctors of the future. Bland, politically correct and clinically useless. Is that what we want?
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Anonymous | 26-Oct-2012 2:50 pm
So just because UK doctors are no worse than anywhere else we should roll over and forget lots of things that every other professional have to attain to attain national standards of good clinical practice and safe patient care...... oh I forgot they have super powers and their halo never slip.
Further 3 bright young people going elsewhere isn't a crisis - it is the changing face generally of the workforce across the whole of professional groups.
Finally what I find remarkable in 2012 is that Doctors know the problems with their peers but the culture continues whilst the patients and the rest of the MDT have too tiptoe around them. And yes I have taken a medic down the route of raising concern only to find I was moved as a Senior practitioner, so personally I think revalidation has to be done.
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Anonymous | 26-Oct-2012 3:34 pm
1:13 - forget what has changed. Shipman was well liked by peers and patients (and we all know that iIt always helps to be liked when there's any form of assessment). Only got caught because he got greedy...
1:35 - that situation isn't going to get any easier with tuition fees and, in the case of GP, the virtual death of the partnership.
2:50 - you can take things even further than raising concerns to even then discover that nothing gets done. Except for you being hounded out.
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Anonymous | 26-Oct-2012 4:29 pm
"and forget lots of things that every other professional have to attain to attain national standards of good clinical practice and safe patient care" Please explain what other professional group has to 'attain national standards of good clinical practice and safe patient care' and has to REVALIDATE to 'prove' this? No?
I thought not. Why don't we revalidate everyone? Nurses, physios, OTs - the lot. Why just Drs? Answer: because we can. In my opinion, your comments have more to do with professional jealousy than anything else. I have come across plenty of precocious, incompetent 'Senior practitioners' [sic] and they are just as impossible to remove or complain about. You are not special and quite frankly come across with a massive chip on the shoulder.
Yes, I only gave the example of 3 bright youngsters leaving. You make a big mistake to say this is irrelevant and assume there aren't hundreds or thousands more. Despair. The NHS is going to go right down the tubes more because of attitudes like yours than the manifest, criminal political mismanagement of recent times.
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Andrew Craig | 26-Oct-2012 8:40 pm
Revalidation can’t all be piled on the individuals and the registration bodies are not the right ones to lead it. For the bulk of doctors (and nurses, and therapists – all clinical roles) a big part of the answer is that their employers should do this and be held to account for doing it well through a licensing system on institutions and all other organisations which deliver healthcare. For clinical contractors, meaning the bulk of GPs – who are self employed don’t forget – there is no substitute for a peer review process. The people who know best about good and poor medical performance are the local GPs in the CCG. I believe that they should deal with assessment, remediation and rooting out failure as part of the CCG’s own reputation management and clinical governance processes. And they should be held to account by the Commissioning Board for doing this well. No matter where it happens, the process has to have a strong and meaningful patient (customer) input. That’s the challenge we need to put to the new revalidation system. Let’s hope the evidence shows that it can deliver what we all hope for it.
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Jerry Luke | 27-Oct-2012 12:53 pm
Andrew Craig writes clearly and convincingly for a strong form of assessment. That is exactly what Revalidation will not provide.
Appraisal is all about knowing the latest guidelines and avoiding too many complaints. Five complete appraisals equals guaranteed revalidation.
There is not a single element of assessment of ability in it. Yes there is an occaisonal feedback form for colleagues and patients but that will just ask if you are a nice guy/girl, not whether those who know would let you treat their family.
I think it highly unlikely that CCGs have anywhere near enough maturity or resource to look to performance management of clinicians in the near future.
I don't know the right answer to rooting out poorly performing Doctors, but I do know that revalidation in its current form is certainly not the answer.
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Anonymous | 28-Oct-2012 4:28 pm
I was interested to see the problems of Maidstone laid at the door of the Exec team for chasing targets/Ft status. Of course they, including the Medical Director have to take ultimate responsibility , but the levels of CDiff and MRSA , which was one of the key issues here must be the responsibility of clinical teams to identify and action and it has been a mystery to me that the consultants in this Trust seemed to be able to completly abdicate their responsibilities for good patient care. Admittedly what really is going on in the Trust is different to what we see in the public domain and I trruly hope that there was more humility and soul searching than appeared to be the case. If appraisals include a rigorous review of outcomes including infection rates we will make progress, if they continue to contain the smoke screeens that I know many currently do then forget it.
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Anonymous | 29-Oct-2012 2:38 pm
Anonymous 4:28PM. You are right, but how long have you been in the NHS, and at what level? Anyone in the NHS in acute Trusts for any length of time will realise that clinical teams often have very little say on where priorities may lie. As a former clinical director, I vividly remember asking Estates to come and look at the orthopaedic ward [I.e. where joint replacements were nursed] where there were stains running down the walls, [just below the handwash dispensers] ceiling tiles groaning with black, hanging dust, disintegrating curtains and the chairs at the nurses' station were so threadbare the foam rubber was billowing out. 2 suits arrived and told me they would be happy to quote for refurbishment, but where was I going to find the money out of 'the orthopaedic budget'? Quaint. As if I controlled the budget! Needless to say, by the time I resigned and left the Trust 2 years later, nothing had been done.
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