The consultation asks 20 questions covering:

1. How revalidation will work, including the roles of responsible officers (RO) and doctors in non-mainstream roles?

2. How it will affect doctors and employers in terms of assessment, education and training?

3. The inclusion of feedback from patients as part of doctors’ assessments.

4. How and when revalidation will be introduced?

Revalidation will be based on local systems of clinical governance and annual appraisal over a five year period. It will be based on a continuing evaluation of a doctor’s practice in the context of their everyday working environment.

For most doctors it will not mean having to do new things or change the way they work. It is not designed to create unnecessary burdens and the vast majority of doctors will have no difficulty in meeting the standards for revalidation, says the GMC.

Doctors will be required to provide information to support their revalidation such as audit data, outcome data and evidence of participation in CPD. The RO, who will most likely be the trust’s medical director, will then make a recommendation to the GMC as to whether the doctor should be revalidated and it will be for the GMC to make the final decision.

Where there are concerns about a doctor’s practice the RO will not be able to make a positive recommendation to the GMC. Where possible these concerns will be addressed through a process of remediation involving appraisal and clincial governance processes.

Also revalidation may be deferred if there are any gaps in the supporting information provided by the doctor.

GMC chair Prof Peter Rubin, says: “What is being proposed is no more than what should be happening in every doctor’s practice - it is based on local systems of annual appraisal over five years and affirms what has already been demonstrated through that appraisal process.”

Revalidation will be phased in over a period of five years following extensive piloting. It will be introduced only when individual trusts have a robust system of appraisal and clinical governance in place. The first ‘early adopter’ trusts are likely to go live with revalidation at some point during 2011.

The GMC says it is important that doctors respond to the consultation as further work is required to develop the detail of some of the proposals. “We want frontline doctors, patients and all those involved or affect to help shape the final product,” it says.

The consultation runs until 4 June 2010.

The questions the profession has for the GMC

The BMA has a range of concerns relating to revalidation:

1. Workload: reports from some of the pilots suggest that appraisals are taking too long. The proposed appraisal framework is too rigid and will be too time consuming unless greater flexibility is introduced.

2. Remediation: the Department of Health expects there will be a 75% increase in the number of cases involving remediation. But it is not yet clear who will carry out remediation, how it will be resourced and at what point GMC fitness to practise procedures will come into play.

3. Costs: the cost of setting up and then yearly funding of the new roles of ROs and GMC affiliates will be costly. GMC affiliates are a proposed new layer of regulation - they will be medical or lay individuals working at regional level who will help ROs and managers resolve concerns about doctors. The introduction of 1,000 ROs is estimated to be £6.7m in start up costs and £4.5m a year thereafter. The GMC affiliates model is estimated to cost between £4.1m-£7.4m to set up and then up to £4.5m a year to run. Who will pay for this? Is it affordable in the current climate?

4. Responsible officers: medical directors are likely to take on the role of ROs. But there could be conflicts of interest between the medical director’s role of supporting doctors and being accountable to the GMC and/or employer. Also, will medical directors be able to handle the additional workload?

5. IT system: will trust IT systems be able to cope with the need to generate accurate data in areas such as clinical audit, clinical monitoring and activity data, complaints and patients safety systems?

6. Equality: will the royal colleges be able to produce equivalent standards across each specialty and sector? Will locums and doctors from smaller specialties be able to produced sufficient evidence for revalidation?

Concerns raised by medical defence organisations:

1. New disciplinary sanction: the MDU and the MPS is concerned about a new disciplinary sanction against doctors called an “agreed statement of concern” (originally called a “recorded concern” when first mooted by the Chief Medical Officer in 2006). This will be a voluntarily accepted sanction offered by a RO. It will be used for concerns not serious enough to call into question a doctor’s fitness to practise but it will be made available to the public. This could impact on a doctor’s reputation and future career prospects.

Commenting on revalidation Hamish Meldrum, chairman of BMA council, says: “Despite some useful lessons being learned from the early analyses of the various pilot projects, there is still a long way to go before we have a realistic idea of what revalidation will really mean for doctors.

“The uncertainties over how revalidation will work in practice are a barrier to gaining the confidence of the profession - a confidence that is crucial for the success of any system.”

NHS ‘internal’ or ‘quasi’ market policies in England have aimed to promote competition among providers in the hope of replicating the benefits markets have been known to bring about in the private sector: decreases in cost, and increases in efficiency, quality, innovation, and provider responsiveness.

In 2002, the government introduced a new round of market-based reform within the NHS, which was initially focused on increasing choice for patients, decreasing waiting times, and improving quality of care.

Demand-side changes saw the creation of the primary care trust to perform a purchasing role similar to that of health authorities; and practice-based commissioning, a re-incarnation of GP fundholding but focused on community-based and specialty services rather than elective care. Patients were also given a choice of elective care provider (including non-NHS providers) at the time of referral.

Supply-side changes included the introduction of quasi-autonomous foundation trusts, and the encouragement of provider plurality. Market-based changes to the secondary care payment system took the form of payment by results (PBR).

The study, called The impact of the NHS market, involved a large-scale literature search on the effectiveness of these policies.

So how have the reforms worked? A summary

Patient choice studies show the percentage of patients who recall being offered a choice of hospital for their first outpatient appointment was 47% in March 2009, up from 46% in December 2008 and 30% in June 2006.

Eighty nine percent of patients offered a choice are able to go to the hospital they choose. Choice has contributed to decrease waiting times for elective surgery. There is disagreement among researchers on whether choice has had a positive or negative effect on equity. Fear of the impact of patient choice (rather than actual impacts of patient choice) has led some NHS providers to advertise services to both patients and GPs. In practice, the uptake of choice policy is not yet widely realised, and degree of implementation varies geographically.

The Choose and Book system may not be enabling as much choice as expected regarding appointment date and time and number of providers offered; GPs may use the system as an online tool to make referrals as usual. Patients and GPs desire more information on provider quality.

Neither strong theoretical nor empirical support exists on the benefits of secondary care provider competition; studies exist citing both improved and harmful outcomes.

Contestability, or the threat of competition, may be driving up efficiency but at the expense of inter-professional and inter-organisational collaboration. Competition is fostering development of more business-like cultures in NHS hospitals. Various impacts of competition policy have been seen on health economies, such as attraction of top quality nursing staff to private providers, confusion of PCTs and NHS providers over the nature of their relationships, and resentment among medical professionals toward local ISTCs regarding lack of patient treatment data.

ISTCs provide equal if not better outcomes than NHS providers, and receive higher levels of patient satisfaction; however, they treat a healthier case-mix of patients than NHS providers (as was intended by their contracts). ISTCs may have negative effects on NHS surgical training.

Increased autonomy over certain governance and finance decisions may not currently be a strong enough incentive to encourage further applications for foundation trust status. Many lay governors and directors of foundation trusts are finding their roles ambiguous and difficult to define. Many perceive that they have made little impact on the decisions of the trusts to date.

However, evidence does show gradual increased involvement of both governors and the public in their activities. Foundation trusts have generally performed well financially and have generated surpluses; and they have been high performers in routine NHS financial and quality measures when compared to NHS trusts.

Surpluses have, however, been modest in relation to total revenue; and many were among the highest performing NHS trusts even before status conversion. Little robust evidence exists to suggest foundation trusts are using their new status to innovate in a significant way.

Payment by Results has been fully embedded across the NHS since 2008. Unit costs fell quicker in hospitals once PbR was implemented, although administration costs increased. Hospital activity increased as PbR was implemented. No association has been found between PbR and quality of care. Where increases in efficiency were found post 2002 (for example, the increase in number of elective surgery patients treated as day cases, decrease in the length of inpatient stays, and reductions in avoidable admissions), authors note other policies and trends have also encouraged such results.

Many hospitals have improved financial management and have a better understanding of patient costs since PbR implementation, yet a substantial agenda of cost improvement remains for the NHS. Mixed evidence exists on prevalence of hospitals ‘upcoding’ procedures in order to get paid more.

The fact that the PbR tariff for a procedure is set at average cost encourages hospitals to become ‘average’ rather than aiming to operate at the level of the most efficient hospitals. Being paid per case through PbR produces adverse incentives for hospitals to increase activity beyond affordable levels and possibly induce demand inappropriately.

Practice-based commissioning implementation is slowly advancing. It is being led by a few enthusiastic practices working with supportive PCTs. Variation exists in the quality of local relationships and levels of PCT support; with resources and experience often limited at both PBC and PCT level. Incentives and infrastructure used to support PBC are not sufficient to engage most GPs in commissioning. And many PBC consortia are more interested in self-provision than commissioning new services.

PCTs lack the necessary skills to purchase effectively; poor local management of resources was noted. PCTs do not always take full advantage of their potential power in the purchaser/provider relationship. Only weak incentives exist for PCT managers to break historical patterns of purchasing. The World Class Commissioning programme is too new for its impact to be determined.

In conclusion

Many researchers found difficulty in attributing improvements specifically to market-based reform. Improvements in NHS care, such as major reductions in waiting times, have more often been attributed to ‘targets and terror’ together with increased spending, than to competition. Lack of a stable policy environment de-motivates staff. As yet, there is a lack of patient and public understanding and support for market-based reform. And many desired outcomes have not yet been achieved, such as innovative models of patient care.

Although there are presently very few studies that evaluate the cumulative effects of market reform, there is an abundance of research on the effect of individual policies. While evidence on the impact on quality of care is mixed, research has found attributable impacts in the form of reduced waiting times, improved access for patients, and increased provider efficiency.

However, potential confounding factors (such as simultaneous increases in funding and pressure from enforced targets), along with weak monitoring strategies, make attribution to market policies alone questionable.

The market reforms of the past 20 years have had unmistakable effects on the culture of the NHS. In particular, the introduction of competition has developed a system-wide awareness of costs, efficiency and accountability. However, the reforms have not been proven to bring about the beneficial outcomes that classical economic theory predicts of markets, including provider responsiveness to patients and purchasers; large-scale cost reduction; and innovation in service provision.

Many researchers have attributed this to the failure to create a true, functioning market, as well as a lack of a stable policy environment to inspire staff commitment and enthusiasm. The available research indicates that the NHS may have found itself in a lose-lose situation - having taken on the extra costs of competition without experiencing the benefits.

He said the huge financial challenges ahead could only be met if more services were taken into GP settings in the coming years, which he said would come to be defined as ‘the decade of primary care’.

It follows controversy over plans to implement a massive shift of hospital workload to primary care polysystems, which prompted GP leaders to join nearly 200 health service workers at BMA headquarters last week to rally against NHS cuts.

But Mr Burnham insisted: “There is far more that can be done in the patient’s home and in general practice to cut unnecessary referrals to hospital. If we’re going into this coming period with no change to hospital services, that would take money out of primary care. My vision is the opposite.”

He also claimed the Conservative pledge to implement a suspension on hospital reconfiguration was not credible, saying: “A moratorium on hospital reconfiguration is not a sustainable position, and I think most GPs would probably acknowledge that.”

Read more at Pulse.

At about 4pm, before doing ‘a poets’, the team send down the most junior HO they can find to request a horrendogram on some poor sod who has been festering in the corner, unnoticed all week.

This particular Friday, some years ago, was no exception. The patient, admitted with a UTI, was now profoundly septic with a possible pyonephrosis and could I drain it please?

What they didn’t tell me is that she had a severe toxic confusional state and weighed well over 20st. To make it worse she was sent to the department at 5pm in a bed in which the hoist mechanism had failed, so it was virtually at ground level. The ultrasound images were comparable to driving a Morris Minor through a snow storm with no windscreen wipers.

This is the first and hopefully the only time that I have performed a nephrostomy on my knees, in bed with a patient who was completely doolally.

I prayed and plunged in the needle with little idea of where it was going, but when I removed the trochar was rewarded with a gush of laudable pus. 

I met her the following week to do the nephrostogram. She was now completely recovered, sane and proved to be a delightful erudite lady, a professor I think, and embarrassingly grateful for my ministrations.

Another Friday I remember also a lady of similar girth, referred from St. Elsewhere’s, presenting with severe dyspnoea related to a probable retro-sternal goitre. She was unable to lie flat; consequently a CT was not possible. I was asked to ultrasound her thyroid immediately prior to surgery, which would include a sternal split. The scan demonstrated an anechoic lesion just poking above the manubrium.

I popped in a needle, aspirated crystal clear fluid and after only 20ccs she exclaimed, “I can breathe!” In total I drained 130ccs of fluid from her simple thyroid cyst (quite rare in my experience) and returned her to the ward with a report stating triumphantly, “I have cured your patient.”

An hour later she appeared in the department on her way home. Like a Spanish galleon in full flow she bore down on me and pressing me to her ample bosom kissed me passionately on both cheeks, in full view of the waiting room. I was a bit concerned that she might give the same idea to the other patients! (Please don’t tell the GMC).

Despite the multitude of frustrations working in the NHS, the practice of our trade can still be deeply rewarding, even at 5.30pm on a Friday…

Well, blow that! It’s my turn soon and I want it clearly understood that I shall expect a great deal of fuss when I go.

I want to see strong men in tears, and women wailing, gnashing their teeth and (hopefully) rending their garments in good Biblical fashion. I want the biggest display of public grief since Princess Di bought it (but without the flowers - I don’t want all those flowers). A present would be nice, too. I shall place a list with Harvey Nicks.

It’s surprising how much more bearable work is, once you can see an end in sight, largely because you can ignore any ‘initiative’ (don’t you just hate initiatives?) with a timescale longer than six months, and smile serenely as threats are made to cap pensions, abolish merit awards (sorry, CEAs) or introduce uniforms for consultants.

OK, I made the last one up, but I’ve never had a problem with uniforms, largely due to the 16 years I spent in the RAF Medical Branch, and I’ve always thought it would be a good idea for doctors to wear them. At least patients would know who we were, and we could make sure that all those over-promoted ‘nurse consultants’ with stethoscopes ostentatiously draped around their necks could be clearly differentiated from proper consultants by the colour of their uniforms (they’d have muddy brown, we would have nice red ones, with gold piping and those big gold epaulettes like South American dictators, or commissionaires at the Odeon).

Still, it’s too late for me now. I’ll have to serve out my time tieless and ‘bare below the elbow’ (which, if you think about it, means that you should also be bare below the waist, unless you have unduly long arms; not something I’d like to inflict on patients or colleagues, come to that).

Incidentally, in an earlier blog I talked about Henrik Thomsen, the Danish radiologist who was being sued for libel by GE Healthcare. That case has been settled out of court, and I assume it will have been a condition that Henrik says nothing more about it in public. And that, of course, is the problem with the libel law as it currently stands - victims, or should I say defendants, can’t afford to take their case to the judges if their accuser offers an out of court settlement which is anything less than ruinous. I just hope that GE realised that they had slipped up by pressing the case, and accepted nominal damages.

Simon Singh, on the other hand, did have his day in court recently, and it seems to have gone well. However, it is not unknown for judges to sound sympathetic, and then deliver a contrary verdict, so we have to wait, hopefully not too long, for the outcome. 

Her latest craze is the Moshi Monsters website, which allows preteens to spend their evenings sending misspelt messages to friends they’ve just spent all day with, instead of getting on with their homework. Inevitably this leads to tears.

Our deputy head has spoken severely on the subject of cyber bullying on Facebook where apparently “4 letter” words were being used by some of Year 6.

My daughter has a firm idea of what constitutes bullying (“someone saying something nasty about you”) but unfortunately it’s not always so simple. It’s got to the point where you can’t actually raise your voice above a soothing whisper without being accused of harassment. Like any word which you repeat often enough, the word bullying has become practically meaningless.

That’s not to say ‘real’ bullying doesn’t go on. The only surprising thing about the bullying in Downing Street debacle is that anyone was surprised by it.

Fans of In the Loop like me, have known for ages that bullying is endemic in politics. Perhaps it’s something about the sort of people who get on in Whitehall - kindness and politeness probably don’t get you very far.

Just imagine the atmosphere when the minister realises their pet policy has failed or the media questions their ‘non-dom’ status - our dreaded senior managers’ meetings must seem like a WI coffee morning by comparison.

The problem is that, just as in a school staff room, a toxic atmosphere at the top filters all the way down - the hyper-aggressive attitude to targets is transferred from Whitehall to SHAs, to hospital executives, to middle management, and finally to us at the coal face.

But let’s be careful what we mean by bullying. Recently a consultant surgeon wrote a letter to BMA News because his clinical director kept sending him emails telling him to roll his sleeves up on the ward round, in compliance with trust policy. These repeated demands constituted, in his view, bullying and harassment.

I disagree. Bullying is not being told to do something which your trust has accepted as policy, but which you, personally, happen to disagree with. Nor is it, for instance, being asked to stay late to finish a list (as overtime) provided saying “no” isn’t penalised, even if it makes you feel uncomfortable.

The toxic atmosphere of hospital management does, however, lead to a certain scenario: that of middle managers being expected to meet impossible targets and being criticised for their inevitable failure; these middle managers then repeatedly ask frontline staff to do extra work and become extremely stressed and angry when those staff refuse; and, frontline staff become stressed about constantly being asked to do extra work and either don’t perform well, or go off sick.

I’m sure many of us recognise this. How much of this constitutes real bullying I’m not sure, but it certainly creates massive amounts of unhappiness.

My daughter’s bullying episode was easily solved - a quick call to her friend’s mother, a couple of nice messages posted (“boys aren’t worth falling out over”) and an early night with her favourite reading material (the Argos catalogue) and everything was forgotten.

Now I just need as clean a solution for work…

New regulations mean that consultants need to undergo a Criminal Records Bureau (CRB) check every time they work at a new hospital and are not allowed to start work until the process is completed and hard copy received by post by the employing trust.

The overzealous interpretation of the requirements by trusts, and long delays in the system, mean that NHS surgeons cannot move between many hospitals quickly enough to deal with rare cases or cover absences.

The Royal College of Surgeons (RCS) is calling for immediate roll out of passport-style arrangements that allow NHS staff who have already received an enhanced CRB check for one trust to be recognised across the health service.

The vetting and barring scheme (VBS), implemented in October 2009, sets new high standards for checking all those working with children. However, the system to deal with this additional demand does not come into full force for four years. Trusts are being overly cautious and demanding that NHS surgeons who have already received enhanced CRB checks go through the time-consuming process each and every time.

The RCS says the Department of Health is yet to offer a quick solution. As a result, highly specialised surgeons are restricted to working at one site with no flexibility to move at short notice to cover and assist colleagues with rare or emergency operations. And children must either wait or travel for treatment. 

The college says the VBS has created a range of problems, including trusts being unable to fill locum positions or having to wait up to three months for surgeons to begin work, and trainee surgeons being unable to work or receive training, particularly across central London hospitals. 

Mr John Black, president of the RCS, said: “The college has flagged up this situation with government on three separate occasions in a three month period, and we were reassured that a solution would be reached within a week.  That surgeons are still faced with this situation is simply unbelievable.”

Some trainee surgeons have had more than ten separate CRB checks in just two years.

Ms Su-Anna Boddy, Consultant Paediatric Urologist, said: “We are meant to be training expert paediatric surgeons of the future, yet training opportunities are being wasted due to the unnecessary bureaucracy of re-checking doctors who have already passed rigorous CRB checks. 

“It is imperative that we are able to utilise the best training opportunities, in the right hospitals, at the right time, and it is totally inappropriate that children be transferred to another hospital so that trainees can learn.”

A DoH spokesperson responded: “The current advice from NHS Employers is clear that a person can start work before a CRB check has been received where there is an urgent need to employ someone quickly and an appropriate risk based assessment has been carried out.

“We are committed to working with the Royal College of Surgeons, the Care Quality Commission and other interested parties in drawing up revised guidance and bringing it to the attention of NHS HR directors.”

Motions on any topic will be considered, but this year there will be a focus on those under the headings of revalidation, SPAs, service reconfiguration, EWTD, and health policies. There will also be workshops on SPAs, CEA applications and working with the press and politicians.

All NHS MSCs and private hospital equivalents can send a representative, so if you do want the BMA to ‘do something’, please ensure your professional community is well represented. Apply by 1 April to the above website. The BMA will reimburse reasonable expenses. Non BMA members are welcome.

Additionally, it is essential that the BMA has its members’ details properly recorded, and that email addresses are registered. Members are asked to go to the BMA website and check under ‘My BMA Details’. Please ensure that if you do private practice, this fact is properly registered. Only by this means will the BMA be able to fairly determine and allocate resources towards lobbying and developing policies for issues in the independent sector.

Mayra Cabrera died following her son’s birth in 2004 after Bupivacaine was mistakenly connected to her arm at Swindon’s Great Western Hospital.

Lyn Hill-Tout, chief executive of Great Western Hospitals NHS, entered a guilty plea before Swindon magistrates.

The case was committed to Swindon Crown Court to be heard at a later date.

The court was told how a nurse at the Great Western Hospital had made a fatal error on 11 May 2004.

Mrs Cabrera, who had worked as a theatre nurse at GWH, had gone through a relatively straightforward birth but required saline to help bring her blood pressure back up.

But a nurse attached the wrong bag of solution to a drip attached to her right arm. Within minutes, Mrs Cabrera began to feel unwell - and then started to fit. She died soon after.

Read more at BBC Health.

Many trusts are exploring how they can deal with more patients into primary care inorder to avoid financial crisis.

In London, one of the key assertions of the strategic planning guidance issued to PCTs in the capital last year is for “60% of A&E activity to shift to polysystems”. Up to 12 A&E departments across the capital face possible downgrading to urgent care centres, with more patients being directed towards polyclinics.

However, a Department of Health-commissioned report released today shows that no more than 30% of patients attending A&E departments could be classified as needing only primary care. It may be a little as 10%.

These proportions are much lower than the levels assumed by managers and health chiefs. It followed Lord Darzi’s suggestion, in 2007, that 50% of less serious A&E cases could be dealt with by polyclinics.

The report, by the Primary Care Foundation, investigates the use of GPs and primary care professionals in A&E. It finds that the increasing number of GPs and primary care nurses working in A&E can improve the quality of patient care. However, it found little evidence for claims that this approach drives down costs or avoids inappropriate hospital admissions.

Dr David Carson, joint director of the Primary Care Foundation, said: “Patients know who their GP is and where the nearest emergency department is. So, it’s vital to get the service right.”

Dr John Lister, information director of campaign group London Health Emergency, said: “This new report shoots plans for A&E closures and hospital rationalisation in London, and in many other cities, out of the trees.

“It is clear that diverting the least serious A&E cases away from hospital A&E departments would affect less than half the number of cases that managers had assumed - and that little or no money would be saved.

“This document means that every plan to scale back A&E services to “Urgent Care Centres” or polyclinic level needs to be torn up and revised. NHS London needs to go back to the drawing board.”

Read the full report.