Anton Joseph

Imagine revalidation based on fitness to practice…

A recent survey revealed that revalidation is failing to identify poor-performing doctors. Pardon my audacity if I ask why has it taken so long for the truth to be exposed?

Revalidation was defined in the Medical Act 1983 as an ‘evaluation of a medical practitioners Fitness to Practice’, empowering the GMC to develop the necessary means to achieve this. This predates any attempts at how this might be achieved.

The GMC Consultation Paper of June 2000 described the ‘Principles of Revalidation’. Dame Janet Smith summarises these as: ‘It must be effective (i.e. it must sort out those who were fit to practise from those who were not), consistent and verifiable”. And by verifiable she states that the information used to decide FTP must be susceptible to audit.

Although information contained in the appraisal process would complement revalidation, the consultation document was emphatic that the ‘appraisal process was to be a formative process in that it was intended to support doctors in maintaining their professional performance’. Very different from the case now made for revalidation based on appraisals.

SHM Productions Ltd was commissioned by the GMC to report on the feasibility of revalidation and how revalidation may be carried out. Proposed models of revalidation were classified as ‘soft’, focussed on a doctor’s evolution and development, and ‘hard’ – based on assessment or testing. It is difficult to see how an organisation claiming expertise in ‘generating insights into methodologies’ failed to recognise outcomes and performance as a means of assessing FTP.

Early recognition of this might have changed the path followed by the GMC. In the early phases, the GMC and CMO Sir Liam Donaldson perhaps fancifully suggested that revalidation should be similar to the periodic assessment of airline pilots. But tests of knowledge and skills were ruled unacceptable to the profession. Several other models were suggested by SHM but Dame Janet Smith in her report commented that no attempts were made in applying these to establish FTP.

The GMC decided to develop appraisals as the route to revalidation and by 2003 had accepted that ‘five satisfactory appraisals equals revalidation’. Grave doubts were expressed from within the GMC in the use of appraisals not least that the benefits of revalidation as envisaged by the GMC in identifying poorly performing doctors was unlikely to materialise. Reaction within the profession itself was varied.

In his book The Doctors Tale, Sir Donald Irvine, who introduced the term revalidation, indicated that the BMA’s Central Consultants and specialists Committee (CCSC) was opposed to revalidation while the GPC was supportive of the proposals. However Prof Pringle, then chairman of the RCGP, expressed the view that it would ‘create an illusion’ of protection in the eyes of the public. The RCGP was also of the view that the appraisal for GPs had been designed purely for formative reasons and did not include any form of assessment.

Niall Dickson, the GMC’s chief executive, says in response to the survey that the annual check demonstrates that doctors are practising safely. Which sections of the appraisal justifies this conclusion? His claim that revalidation makes a ‘contribution to patient  safety’ is far from adequate from what revalidation was meant to deliver.

It should guarantee a far higher level of patient safety. If there are means outside revalidation that would contribute to patient safety should these not be integrated into revalidation. Dr Mark Porter’s comments on the survey that revalidation encourages lifelong learning and culture of positive cultural improvement. Does this guarantee ability and skill and patient safety?

It is clear that a majority of hospital doctors and an even larger percentage of GPs were of the opinion that revalidation would not identify doctors who are unfit to practise i.e. revalidation is not fit for purpose. A shocking revelation.

This comes as no surprise. Dame Janet Smith expressed this unequivocally in the Shipman report: the GMC started out with sound principles and high aspirations but the regulator realised that the task was more difficult and expensive, would create a considerable administrative burden and was unpopular with large sections of the profession. It changed direction.

It abandoned the principle of evaluating each individual doctor’s fitness to practice. It decided to base revalidation on the mere fact that they had taken part in an appraisal process. For GPs, at least, appraisal is a wholly formative process and, in my view quite incapable of providing a basis for an evaluation of fitness to practice.

In Dame Janet’s view the change of direction was substantial and it was made for reasons of expediency and not for reasons of principle. Strong words indeed. The relentless progress of the GMC despite this now culminating in the rejection by the profession is beyond belief. Yet the secretaries of State who received this report also proceeded to endorse the revalidation scheme proposed by the GMC.

There is little doubt that both the GMC and the government succumbed to the influence and the pressure exerted by the BMA.

But the medical profession was in no mood to be disgraced all over again by doctors who are unfit to practice and are a threat to patients’ safety.

There could only be one way back from this debacle. Return to assessment of Fitness to Practice as was originally intended, and use verifiable evidence of fitness. The only reliable way that this could be achieved is for revalidation to be based on objectively evaluated measurable performance and outcomes: the measure of outcomes reflecting the ability of the individual.

The publication of the cardiac surgical mortality figures, those for other surgical specialties and those to be published shortly demonstrates the feasibility of this approach.

This is clearly not achievable  immediately but a start must be made now. Millions of tax payers money has been spent in a scheme now even rejected by the profession. What confidence can the public have?

It is time for the public to be aware, the profession to stand by their views and the politicians to demand the change. The GMC should accept their errors and deliver what the profession and the patients have a right to expect: Revalidation based on Fitness to Practice. Nothing less.

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5 Responses to “Imagine revalidation based on fitness to practice…”

  1. Paul McCoubrie says:

    Wise words, Joe!

    I could summarize the biggest problem with revalidation. It is based on an plainly wrong assumption. Appraisal is not assessment. Assessment can be used to inform appraisal. Appraisal ceases to be appraisal when used to inform assessment.

    Simples!

  2. Bob Bury says:

    But what’s not so simples, Paul, is obtaining agreement on what measures of outcome are valid, acceptable and realistic. What outcome measures would we use for us* radiologists, for example?

    * sorry, ‘you’!

  3. Joe says:

    Cardiac surgeons have identified outcomes. For us radiologists it is much simpler. Mammography already have their own extremely well,organised and controlled audits.
    It would be very straightforward for radiologists to have a conclusion for every report. These could be audited with patient outcome. All radiological procedures can be audited.
    There are valid acceptable and realistic outcomes to be audited. Failing to apply them is very different

  4. Bob Bury says:

    Agreed Joe, but can you begin to imagine the amount of time involved in chasing that information up? And how often is it possible to identify from the notes the accuracy of any particular report? Mammography is the easy one, because there is already an established audit trail, and a binary outcome measure (malignant/not malignant:right/wrong).

    You say that there are valid acceptable and realistic outcome measures which can be audited. I don’t believe that is true for most areas of practice, other than mammography.

    I wish I was wrong, but I suspect that any worthwhile revalidation procedure based on actual performance would be completely unmanageable.

  5. Joe says:

    Dear Bob, The precise conclusion the Alment committee reached in the mid seventies: ‘a system of licensing for all could not be based upon measurements satisfactory enough to justify it’, very short sighted in retrospect. Cardiac surgeons and others have established the feasibility (blog July 12, 2013).

    I circulated the current blog to a distinguished colleague, among others, well versed in the subject and I share with his approval what could be a very practical and sensible solution.

    What is lacking within appraisals is the ability to demonstrate Fitness to Practice. His solution was to request his team to list all major and minor the surgical procedures, immediate and long term complications and outcomes and total procedures. These parameters reflected the skills, ability and knowledge. This information was in addition to the requirements for appraisals. Audit need not be universal: could be of selected parameters. Shortcomings needed to be addressed.

    Audit is commonplace in all fields of medicine. For radiologists conclusion at the end of reports could be compared with final diagnosis. Radiological procedures could be audited for complication rates and success of outcomes. Patients’ outcomes monitoring is a sine qua non. Improvement cannot be achieved without effort or cheaply.

    Without having to dismantle the entire edifice, all that would be required is to add results of audits as a measure of Fitness to Practice. Appraisals would therefore combine the formative benefits of appraisals and FTP through audit.

    This could be the face saving solution. With doctors expressing doubt of the validity of appraisals sooner or later the politicians and the profession will demand changes and the GMC has to respond. Hope the profession will rally round a solution that establishes FTP, nothing short

    Not advanced appraisals but Assessment Appraisals could be the solution. Try and make it more attractive in name and effect.

    What we cannot afford is inaction.

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