The chairman of BMA council has written to the Department of Health warning them that the timescale for introducing revalidation - proposed for November 2012 - is unrealistic. Here’s the letter:
I am writing to highlight a number of concerns that we have in relation to England’s readiness to implement revalidation.
Supporting information for appraisal and revalidation
First, we remain concerned about the state of many employers’ clinical governance systems. The Organisational Readiness Self-Assessment exercise shows that many of these are still not sufficiently developed to support revalidation. As you know, this lack of progress is a significant risk and the prospect of relying solely on individual doctors to produce supporting evidence for their appraisal is not acceptable to us. We currently expect that a significant number of deferrals will be required for this reason.
The preparedness of designated organisations to support the introduction of revalidation is also variable. Some PCTs, for example, are attempting to implement the evidence requirements for revalidation before its start date and are preparing for revalidation in an inconsistent fashion, often not based on the GMC guidance, and before consideration of the business case and the enabling of relevant legislation.
The majority of doctors, particularly those working in managed environments, already have a connection with the appropriate Responsible Officer. There are however a significant number who do not and, to this end, the GMC is due to write out to around 70,000 doctors on the register to help them to identify a prescribed connection to a designated body. Further uncertainty has been caused by the Health and Social Care Bill as it is unclear who will provide the Responsible Officer function for GPs once PCTs have been abolished, or who will provide the relevant outcomes data on their performance. It would be useful to know when the DH consultation on Responsible Officers is expected, as this has been delayed for some time now.
The conclusions of the largest revalidation pilots to date stated that locums had ‘particular difficulties obtaining supporting information, particularly information relating to the clinical governance of the practices or organisations within which they had worked.’ This remains the case, despite further piloting and general agreement that the proposed arrangements for locum doctors are inadequate.
For revalidation to work, all types of doctor need to be able to revalidate, irrespective of the nature of their practice or contractual status. As it stands, it remains unclear how locum doctors will be able to gather the supporting information they require in areas such as significant events, or obtain multi-source feedback from patients and colleagues. Whilst organisations, such as locum agencies, have a responsibility to develop their systems, only a very small minority have engaged with the ORSA exercise to date.
Multi-source feedback (MSF)
We had assumed that the proposals outlined in the GMC consultation from 2010, whereby the GMC would kite-mark questionnaires to ensure that they met the appropriate GMC standards, would be taken forward. Seventy nine percent of respondents to the consultation agreed that there should be a mechanism for accrediting questionnaires. It now seems that responsibility for ensuring that MSF questionnaires comply with the relevant GMC standards will rest with Responsible Officers.
We think that this is unfortunate, as the local interpretation of these requirements has already been shown to be inconsistent. For example, we are aware that the validity of some questionnaires has been challenged by those involved on the grounds that the development, implementation and/or administration of the questionnaires has not reflected the GMC guidance.
It seems likely that the increased scrutiny arising from the appointment of Responsible Officers will lead to an increase in the number of cases requiring investigation. Remediation will be important part of supporting doctors in this situation and has been the subject of various working groups. Notable amongst these has been the Mascie-Taylor report, which provided a detailed insight into existing practices and outlined six recommendations, including the need to strengthen local processes and increase the capacity of staff within organisations to deal with performance concerns.
Despite all this work and despite the establishment of yet another working group, it is still far from clear how remediation will work in practice and who will be responsible for its delivery and funding. As we have said in the past, we cannot support the introduction of revalidation unless appropriate funding arrangements are in place to ensure consistency and equity between all types of doctor.
Time and resourcing for revalidation
The findings from the pilots have shown that doctors will require more time and resources to complete revalidation, at a time when they are already under pressure to deliver a more efficient service. With this in mind, the AoMRC has recommended that the minimum number of SPAs allowed for hospital doctors’ revalidation should be 1.5 per week, not including annual study leave.
However, this is being undermined by many employers, NHS Trusts and/or Boards reducing this allowance to 1 SPA. Trusts have reduced study leave budgets in their drive to make savings and in Wales, there is even a blanket restriction on all study leave. It is also currently unclear whether GPs will be provided with the extra resources and therefore time that they will need to complete the process. We therefore are sceptical that the climate is right for revalidation to succeed, both in terms of providing assurance to patients but also in being sufficiently robust to identify developmental opportunities for doctors.
All of these issues are fundamental to the successful introduction of revalidation and the lack of progress on them leads us to question whether the current timetable can be met. The assessment of readiness must take these factors into account. We would like to consider these issues at our next quarterly meeting, with a view to resolving them in advance of the ARM in late June. I also intend to raise them at the next meeting of the UK Revalidation Programme Board.
Dr Hamish Meldrum
Chairman of Council