Revalidation is the process by which the General Medical Council (GMC) will confirm the continuation of a doctor’s licence to practise in the UK. In this article we look at the purpose and the possible consequences of this new process.
The Secretary of State for Health has confirmed that the process of revalidating licensed doctors will start on 3 December 2012. Dean Royles, director of the NHS Employers organisation, has commented that “this is a positive step forward which will herald greater patient safety and public confidence in the profession”. Concerns have been raised, however, that by underlining the present absence of an effective system for vetting a doctor’s competence, combined with any disagreements surrounding implementation, public trust and confidence in the profession may in fact be reduced.
The central aim of revalidation is to ensure that doctors are fit to practise and that their training is up-to-date. Many members of the public would be shocked to find out that there are currently no mandatory checks on the performance of individual doctors once they have obtained their licence to practise. This is despite regular assessments and monitoring being the norm amongst other professionals, such as lawyers and chartered surveyors.
To many, it would seem ironic that a profession that deals with the life and death of individuals does not have equivalent safeguards. It will therefore be vital for the successful implementation of the revalidation process to ensure that patients’ expectations, in this respect, are managed. Concerns over what the process involves, patients’ involvement and wider implementation issues all need to be adequately addressed if the process is to achieve its desired outcome, namely that patients receive the highest standard of care.
An historic moment
Niall Dickson, Chief Executive of the GMC, has heralded the revalidation process as an “historic moment. It is the biggest change in medical regulation for 150 years.” At first glance, Dickson’s comments may seem hyperbolic, but perhaps less so when one considers that the need to introduce revalidation has been discussed for the last 20 years. Consideration of the need for such checks began in the mid-1990s when the scandals surrounding the Bristol heart babies and Harold Shipman led to a great deal of further discussion as to the need for revalidation, what it should do and what the checks would involve.
Revalidation: in practice
The revalidation process involves an annual appraisal for doctors with a “revalidation” every five years. This will involve feedback from around 35 patients and colleagues before the doctor can be recommended to the GMC as fit to continue practising. The process is set to be applied universally to doctors in all disciplines of the profession, from consultants to general practitioners, as well as to those working in the private sector. Each NHS organisation will have a responsible officer, such as a medical director, in charge of revalidation.
The primary purpose of the new process is to ensure that doctors stay up-to-date with skills and knowledge. Significantly, the process is not in place to criticise; it is there to aid professional development. With the emphasis of professional development in mind, there are no plans for repeated examinations or any formal assessments. The aim is continual re-education.
Despite this educational emphasis, revalidation also needs to work as a safeguard against malpractice, so any complaints and mistakes will be discussed at the appraisal meeting and form part of the decision as to whether to revalidate the doctor’s licence. Minor issues that do not constitute a serious risk to safety may lead to a revalidation being deferred for a short period, but major problems will result in the doctor not having his or her licence to practise revalidated.
Anna Dixon, director of policy at The King’s Fund, and Dan Wellings, Head of Public Health Research at Ipsos Mori, have raised concerns that the process will focus too heavily on individual performance – a doctor’s performance is actually often influenced by their team. Within practice it is often a chain of mistakes that leads to an undesirable outcome, so it is important that the revalidation process looks at the environment and team in which a doctor works and the managerial aspects of decisions made.
Ideally patients should play an active role in the process, as the public are best placed to comment on a doctor’s bedside manner and communication skills. At present, patients’ viewpoints are to play an active part in the appraisal system. Patients have, however, expressed concern that any comments they make should not be relayed back to the doctor in question as this may affect the relationship. This underlines the importance of the trust and confidence placed by the public on the doctor-patient relationship, and any changes made to the profession should not threaten this in any way.
Katherine Murphy, Chief Executive of the Patients Association, is of the view that if a serious clinical matter is raised in the revalidation process then patients have a right to know. She accepts that if the issues raised were of human resources or a managerial nature, then those issues should stay between the doctor and his or her employer. However, with regard to clinical matters, she is of the belief that patients should be in the position to see the best doctor, no matter what their condition, and they need good accurate information to do that. On the other hand, Niall Dickson has commented that no other profession publishes the results of appraisals; patients should, he says, be reassured by the fact that all doctors will undergo annual checks, in the first national revalidation system of its kind anywhere in the world.
Officials at the GMC and Department of Health have stated that the position will be that patients will not be made aware of such information. It remains to be seen whether this will always be the case. In the last few years there has been a significant move towards allowing patients to make more informed decisions. For example, the NHS choices website allows its users to rate practices in terms of their experience and details an overall patient score calculated from GP patient survey data.
The revalidation process is for all doctors who hold a UK licence to practise, so even those working wholly outside the UK would be subject to the new regulatory regime. Any UK-licensed doctor working abroad would need to register with a UK organisation.
Any foreign doctor would also need a UK licence to practise in this country and would be subject to the regulatory regime of revalidation. This is a welcome move after the case of the German doctor, Daniel Ubani who, on his first shift in the UK, dispensed a lethal overdose of morphine to pensioner David Gray.
Although the Daniel Ubani case highlights the need for scrupulous checks of overseas practitioners before they obtain their licence in the UK, it also emphasises the need to have constant checks on individual doctors’ performance, and for that information to be made readily available across the profession. As a result of this case, the Department of Health expressed the need for a single list of approved GPs to be held nationally, in contrast to the current system, under which each Primary Care Trust maintains its own list. The present system has allowed doctors to move to another county, even if a problem is identified which resulted in their being removed from the local list.
The need for revalidation is not open to challenge. Many would say it is long overdue. The real test lies in its implementation and efficacy. Sir Bruce Keogh, medical director of the NHS, has commented that “implementation will be quite difficult to begin with and I suspect it will be imperfect but it is better to start than to wait for perfection.”
The focus should be on improving patient care, and the revalidation process therefore needs to be flexible and not bureaucratic. If the revalidation process is effectively managed and becomes an integral part of the development of the profession, then it will serve its purpose.
For insurers, revalidation may be seen in both a positive and negative light. On the positive side, if the process leads to real improvement in patient care, this should translate into fewer complaints and claims. On the negative side, insurers may be called upon to assist practitioners to defend the possible revalidation of their licence to practise, particularly if that revalidation may add credence to clinical negligence claims.