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Revalidation should be based on objectively evaluated performance and outcomes

The word ‘revalidation’ did not get into the Oxford English Dictionary (OED) until 2004.

We are however well aware that the GMC was using it in the context of the revalidation of doctors long before that date.

Given a clue by Prof Sir Liam Donaldson, I contacted Sir Donald Irvine who said that he was the first to use it in a letter dated 30 June 1998 to the President of the Academy of Royal Medical Colleges.

He admitted that it was ‘entirely his sloppiness in assuming that the word existed’, believing it was no different from recertification. The sloppiness however ante dated Sir Donald’s letter. (BMJ 2013;347:f5316).

Part 111 A of the 1983 Medical Act, however had already laid down regulations for the ‘licence to practice and revalidation’.

Even our law makers seem to have been unaware of the etymology of revalidation. I subsequently requested the Oxford English Dictionary to add this to the etymology of the word.

Does this invalidate the legality of the concept?!

If you find it interesting, enjoy it since there is nothing amusing about the rest of the history of revalidation.

Recently doctors have been asked to participate in a survey undertaken by Dr Julian Archer Principal investigator for UMbRELLA (UK Medical Revalidation Evaluation coLLAboration). We are told that ‘this aims to assess the impact of revalidation and to offer evidence-based findings to shape its future development’.

It is my hope that the investigators would consider the fundamental concept that no structure is safe without a firm foundation. I hope the survey would bring to attention the weakness of the foundation for revalidation.

I am reminded of the reading in church last Sunday describing the house built on sand: ‘The rain came down, the streams rose, and the winds blew and beat against that house, and it fell with a great crash.’ A fate that perhaps awaits revalidation in its present format sooner or later.

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. It was therefore for the GMC to lay the foundation and erect the edifice.

The GMC Consultation Paper of June 2000 described the ‘Principles of Revalidation’. 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.

The GMC changed direction and, by 2003, decided that five successful appraisals would satisfy the requirements for revalidation.

Grave doubts as to the validity of this was raised from both within and without the GMC. The doubts within the GMC were clearly set out by Dame Janet Smith in the Shipman report.

She stated that the GMC ‘had started out with sound principles and high aspirations but that the GMC 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.

Criticisms were voiced from other sources. 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 consensus was that some sort of link with appraisal was inevitable, but there was concern that the ‘platform’ offered by appraisal was ‘patchy at best and very shaky at worst.’

SHM Productions Ltd was commissioned by the GMC to’ identify key issues and alternatives’ for revalidation. Proposed models of revalidation were classified as ’soft’, focussed on a doctor’s evolution and development, and ‘hard’ – based on assessment or testing.

While it outlined the reasoning in favour of the use of appraisals for revalidation, it also expressed grave concerns. The dichotomy of the formative nature of appraisals and the summative nature (pass/fail) was highlighted.

It is my opinion had measurement of outcome been an alternative proposal the course of revalidation might have taken a very different route.

Despite these criticisms the GMC buried its head in the sand, seemingly oblivious to the appraisal route to revalidation being grossly inadequate to assess FTP. SARD (Strengthened Appraisal and Revalidation Data base) was introduced in response to criticisms.

Another possible source of amusement: etymology of the word reveals that sard – now an apparently obsolete word – meant ‘to seduce’!

Criticisms have continued to be expressed. The results of a DNUK survey showed that 60% of GPs disagreed that the plans for revalidation would help to identify and deal with doctors who are not fit to practise (32% disagreed and a further 28% strongly disagreed), while only 16% agreed (15% agreed and a further 1% strongly agreed). The figures for the Hospital doctors were not too dissimilar.

Duty of quality laid down in the 1999 Health Act and in clinical governance requires: ‘NHS organisations to be accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish.”  This is therefore a statutory requirement.

Revalidation as currently undertaken through its failure to establish a doctors FTP may not fulfil the statutory requirement to create an environment in which excellence in clinical care will flourish.

What was the missed alternative. In my response to the consultation by the GMC I submitted that ‘Revalidation is best based on objectively evaluated measurable performance and outcomes: the measure of outcomes reflecting the ability of the individual’.

A worker’s competence and ability is best measured by the quality of their work. A demonstration of their fitness in their field. This should therefore be the means of establishing Fitness to Practice.

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