Medical managers need to prepare themselves to meet the challenges of implementing revalidation. Dr David Scott, chair of the British Medical Association's medical managers sub-committee, and Dr Doug Russell, the committee's primary care representative, explain
The introduction of medical revalidation, and in particular the establishment of responsible officers, marks not only the most important change to the regulation of doctors in 150 years but also a significant shift in the focus of the work of medical managers, in primary and secondary care.
As representatives of medical managers, our biggest concern is the burden revalidation could place on our colleagues and whether they will receive the support necessary to undertake the tasks expected of them. Nonetheless, we would like to make it clear from the start that we believe the role of responsible officer is best placed with the medical director, both in primary and secondary care. There are several reasons for this.
Balance of duties
First, the responsible officer function must maintain a proper balance between the rigorous application of professional regulation and the pastoral and support work needed to assist doctors in difficulty. Only employers can provide the necessary resources for this pastoral work and only medical directors will have the clout to argue for it at the highest levels in trusts and primary care trusts. We also believe this balance is necessary to make the job an attractive one for doctors.
Second, medical directors already have oversight of the NHS's disciplinary and complaints procedures and the performers' list in primary care. Bringing these processes under the same person would minimise the risks of doctors facing double jeopardy, of conflicting advice and opinions, and of duplication of effort. The medical director can make a professional judgement about the appropriate procedures to follow.
The third reason is that appraisal and revalidation can only work with easy access to the necessary data. The will to collect such data and provide access to it will be enhanced if employers take some responsibility for this process through the person of the medical director.
Finally, only medical directors will have access to, or be able to argue for, the resources necessary to support this work. We do not envisage medical directors personally undertaking all the work relating to the responsible officer role and believe that a number of support staff, including clinical colleagues, will be required. Again, this will be much easier to obtain if trusts have a share in the responsibility for the function through the medical director.
We recognise that medical directors must have the trust of their board, while maintaining the confidence of their professional colleagues. The pastoral role of the medical director is very important and oversight of, and responsibility for, the triad of appraisal, continuing professional development, and addressing poor performance make the role of medical director/responsible officer role more rounded.
In essence, as the British Medical Association said in its submission to the responsible officer subgroup earlier this year, what should be expected of a responsible officer should not be significantly different from what is expected of a good, well-supported medical director.
We do, however, recognise that some doctors have concerns about such an important function lying with the medical director, arguing that there are possible conflicts of interest, and that employers could use the revalidation process to put undue pressure on individuals to conform. We acknowledge these concerns and accept that some form of appeal process could be required. We would note, however, that medical directors would be held professionally accountable for their actions as responsible officers.
Checks and balances
There are also two other important checks and balances that guard against a "maverick" medical director/responsible officer. First, the regional General Medical Council affiliate currently being piloted will link all the responsible officers in a health economy at strategic health authority level in England. This affiliate function will comprise medical and lay input.
Just as some doctors fear an overzealous responsible officer, patient groups have argued that a medical director-responsible officer may be too lenient on medical colleagues. The issue is about establishing a process that retains the trust of patients and the public while retaining the confidence of the profession.
Second, each responsible officer will also require their own responsible officer. A key part of their own revalidation should, therefore, be a demonstration of their competence and performance against a set of criteria related to the responsible officer function, among others.
More to do
We have outlined our ideal of how a responsible officer might function and be supported, but we acknowledge that many employers are not yet able to provide that support, especially in primary care. Many PCTs and ambulance trusts do not even have medical directors, which is why the BMA has argued that they should be added to types of trust statutorily required to have a medical director.
We are also aware that many existing medical directors do not have the support required to undertake this role, and the BMA is keen to work with the Department of Health and NHS Employers to remedy this. We believe that many of the key functions can be carried out by clinical colleagues, such as clinical governance and appraisal leads and, of course, the appraisers themselves. Nonetheless, medical directors must have the capacity to relate to and influence these other parts of the organisation.
The major area of concern for medical directors in primary care is the proposal that they would provide the responsible officer function for all doctors in their area not otherwise covered by a secondary care responsible officer. We remain unconvinced that it is practical or reasonable to expect a primary care medical director to sign off the revalidation of doctors not directly employed or contracted to their primary care organisation and with whom they have no professional relationship or clinical data. We have argued that the way forward may be to establish sectoral responsible officers at national or regional level. These non-NHS sectors should take responsibility for ensuring the doctors who work for them are fit to practice and not add to the burdens of the NHS.
In our view, the two key aspects of revalidation for managers and employers will be the need to collect the necessary data to support it and the establishment of the post of responsible officer to oversee regulation locally. To date, little has been done to ascertain the capacity of employers and medical managers locally to cope with the demands arising from revalidation. It has been of some concern to us that the extent to which NHS Employers has been asked to be involved in the discussions of the DH's Tackling Concerns Locally working group has been limited. We would therefore urge the involvement of NHS Employers, along with the BMA, as an important practical step in making revalidation work.
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