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.