Revalidation, introduced by the General Medical Council (GMC) in December 2012, was described by the Chief Executive of the GMC, Niall Dickson, as “the most significant reform of medical regulation for over 150 years”. The GMC commissioned a report by Sir Keith Pearson, chairman of Health Education England, to review the impact of revalidation and meet with those involved at every level of the process. The results were published earlier this month: revalidation is working and is here to stay.
Revalidation – what is it and why was it introduced?
Revalidation is the process by which all licensed doctors are required to demonstrate on a regular basis that they are up to date, fit to practise and able to provide a good standard of care to patients.
Its introduction reflected a shift in the public view of the medical profession, moving from patients taking a passive “doctor knows best” stance to becoming increasingly aware and engaged in decisions about their care. This change was no doubt influenced by high profile public inquiries, not least Dame Janet Smith’s Fifth Shipman Report, published in 2004, following the inquiry into General Practitioner (GP) Harold Shipman. Although it is worth noting that the GMC first consulted on revalidation several years before this, in 2000.
Looking back, it seems surprising that, before revalidation was introduced, a doctor could go through their entire career without any check on their performance or competency. Whilst the implications for patient safety are perhaps obvious, the old system also did not provide adequate support for doctors. Before revalidation, there was a greater risk that any issues with a doctor’s performance could escalate into a full-blown inquiry or GMC hearing, rather than being picked up and addressed at an early stage, to the benefit of both the doctor and their patients.
What is currently required?
In order to practise medicine in the UK, a doctor must be both registered (demonstrating that they have the required qualifications and are of good standing) and licensed with the GMC.
Licensed doctors have to revalidate usually every five years through an annual appraisal based on the GMC’s core guidance, Good Medical Practice. While the GMC makes the ultimate decision as to whether a doctor should continue to be licensed, the process is owned and resourced at a local level. The annual appraisal involves a doctor meeting with an appraiser who conducts a whole practice appraisal. The doctor will bring supporting information such as feedback from patients and colleagues, a record of Continuing Professional Development and a record of quality improvement activities, such as clinical audits, to show that they are meeting the standards in Good Medical Practice. Doctors will need to reflect on and identify learning from this supporting information.
For the vast majority of doctors, a Responsible Officer (usually a senior doctor within a healthcare organisation) will report to the GMC every five years to either confirm that the doctor has been engaging in revalidation and that there are no outstanding concerns, recommend that the revalidation date is deferred or inform the GMC that the doctor is not participating in revalidation. The GMC will decide whether to revalidate the doctor, change the date for revalidation or withdraw the doctor’s licence.
As at the date of Sir Keith Pearson’s review, there had been 160,735 decisions taken to revalidate, 37,653 decisions to defer and 3,314 licences had been withdrawn from doctors who were not engaging with revalidation.
Positive outcomes from revalidation
Sir Keith Pearson outlines numerous positive outcomes from revalidation, even at this early stage, including:
More reflective practice amongst doctors
40% of the 26,171 doctors who responded to a revalidation survey said that they had made changes to their practice, behaviour or learning activities as a result of their most recent appraisal.
Significant increase in appraisal rates across the UK
While some doctors had regular appraisals before the introduction of revalidation, this was not always the case, and the approach was at times irregular and unstructured. The increase has been most marked in Wales where 82% of doctors had an appraisal in 2015/6, compared with only 53% in 2012/13.
Helping healthcare organisations to identify poor performance
Responsible Officers and appraisers reported that the appraisal process was helping them to identify doctors who may present fitness to practise concerns. Revalidation enables concerns to be identified and acted upon at an early stage, before leading to a complaint to the GMC.
…but there’s room for improvement
Sir Keith Pearson acknowledged that there is a feeling amongst some doctors that the process is burdensome and ineffective. 37% of respondents to the revalidation survey did not believe that revalidation will improve the standards of doctors’ practice. In particular, there was a concern about the amount of time doctors have to spend preparing for their annual appraisal and gathering supporting information.
Sir Keith concludes that: “…the vast majority of doctors fully accept the principles of accountability and assurance that are central to revalidation. But many do have reasonable concerns about the efficacy of the process. At a time of significant workload pressures in the health service, some doctors mention revalidation as one of the reasons why they are considering early retirement. Organisations need to be alert to the concerns of doctors who wish to continue their career but require additional support and encouragement to undertake annual appraisal and to prepare for revalidation.”
Key recommendations from the review
The review does not recommend a major overhaul of the system and comments favourably on how the system is better fulfilling the expectations of the public, but concludes that some aspects of revalidation can be improved: “…the principles of revalidation are sound but more can be done locally to support doctors to meet requirements while maintaining a focus on personal development and improvement”.
The report contains 10 key recommendations:
1. “Healthcare organisations, with advice from the GMC and national partners, should work with local patient groups to publicise and promote their processes for ensuring that doctors are up to date and fit to practise, including the requirement for periodic relicensing.”
Sir Keith is of the view that all healthcare organisations should set out more clearly and publicly their local assurance arrangements, including appraisal and revalidation, and local patient representatives should be invited to review those arrangements from time to time.
2. “The GMC should consider setting an earlier revalidation date for newly-licensed doctors so that they receive their first revalidation within two years of commencing practice in the UK.”
3. “The GMC should work with stakeholders to identify a range of measures by which to track the impact of revalidation on patient care and safety over time.”
4. “The GMC and others should begin using the term ‘relicensing’ in place of ‘revalidation’, in order to increase understanding of the significance of the process for both patients and doctors.”
Sir Keith received feedback that the term ‘medical revalidation’ was not understood by patients who did not realise that this related to whether a doctor should be allowed to continue to practise. A change in phraseology would assist in increasing understanding and awareness.
5. “The GMC should work with others to identify ways to improve patient input to the revalidation process. In particular it should develop a broader definition of feedback which harnesses technology and makes the process more ‘real time’ and accessible to patients.”
Currently, doctors must distribute questionnaires to their patients at least once in every five year revalidation cycle and must demonstrate to their appraiser that they have reflected on the results. Sir Keith identified several problems with this and concluded that a more sophisticated approach should be developed as the questionnaires may not provide sufficient quality and breadth of information to enable a doctor to reflect properly on their interaction with patients.
6. “ROs should report regularly to their board on the learning coming from revalidation and how local processes are developing. Boards should challenge their ROs as to how they are learning from best practice and how revalidation is helping to improve safety and quality.”
7. “The GMC should work with others to update its governance handbook for revalidation and set out expectations for board-level engagement in revalidation and provide tools to support improvement.”
8. “The GMC should continue its work with partners to update guidance on the supporting information required for appraisal for revalidation to make clear what is mandatory (and why), what is sufficient, and where flexibility exists. They should also ensure consistency and compatibility across different sources of guidance.”
9. “ROs should make sure that the revalidation process for individual doctors is not used to achieve local objectives that are not part of the requirements specified by the GMC.”
10. “Boards of healthcare organisations should make sure that effective processes are in place for quality assurance of local appraisal and revalidation decisions, including provision for doctors to provide feedback and to challenge decisions they feel are unfair.”
As a nation, we are rightly proud of the high standards that exist amongst members of the medical profession; for many, revalidation is simply a necessary step in demonstrating competence and continued fitness to practise.
When issues do arise in a doctor’s practice or performance however, the revalidation process should help to ensure their early identification and resolution, without the need for recourse to a formal regulatory fitness to practise process.
The revalidation process is still really in its infancy. As with any major change to the way that professionals are expected to work, opinion will naturally be divided and of course, there is always room for improvement. However, overall the findings of the review are likely to be seen as encouraging; revalidation is making a positive impact on ensuring continued competence. 23% of the appraisers who responded to the revalidation survey had identified a concern about one of their appraisees which was not escalated as it could be dealt with at the appraisal. Indeed, Sir Keith commented that: “Revalidation provides a mechanism for identifying and acting upon concerns before they reach a level that needs GMC attention”. While he did not seek to quantify this in terms of a specific reduction in GMC complaints, it does seem that this is the likely and welcome result of early and local resolution of any concerns. What also seems clear is that while adjustments will be needed, revalidation is here to stay.