Reports > The Fifth Report > CHAPTER TWENTY SIX - Revalidation >
Introduction
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26.1 |
As I explained in Chapter 15, once a doctor qualifies to have his/her name entered on the medical register, s/he is entitled to practise medicine and to remain on the register unless and until such time as his/her name is suspended or erased from it. For many years, doctors have been under a professional duty to maintain their professional competence. However, there has been no means of ensuring that they do so and no sanction for failing to do so, unless and until the doctor’s fitness to practise is called into question as a result of a complaint to the General Medical Council (GMC). In 1998, in the wake of at least two high profile cases in which doctors were seen to have been practising at unacceptably low standards over a period of time, there was a move within the GMC to introduce a requirement for some form of periodic assessment by which a doctor’s fitness to remain on the medical register could be reviewed. This concept was developed and the GMC now proposes to introduce, in 2005, a requirement that all doctors wishing to retain a licence to practise must, every five years, undergo a process by which their entitlement to practise is ‘revalidated’. It is said that the process of revalidation will require doctors to demonstrate on a regular basis that they are ‘up to date and fit to practise’. |
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26.2 |
Revalidation is of considerable interest to the Inquiry. I have explained in this Report how the systems by which the NHS monitored the practice of general practitioners (GPs) during the period of more than 20 years in which Shipman worked as a GP failed to detect that he was obtaining large amounts of diamorphine illicitly and killing his patients. The GMC, as regulator of the medical profession, did not at that time undertake any routine monitoring of doctors; its role in the monitoring process was confined to reacting to complaints. It received no complaints that could have led it to suspect that Shipman might be killing his patients. Since 1998, there have been many changes within the NHS. I have described some of them in Chapter 5. In 1999, the NHS introduced clinical governance, which I described in Chapter 12. When these changes have had time to settle down and to develop to their full potential, they should result in much-improved monitoring of doctors’ performance, with the twin benefits of detecting the development of substandard performance and the raising of standards generally. The GMC is now to introduce revalidation, which, as I have said, should involve a periodic demonstration of the individual’s fitness to practise. |
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26.3 |
In this Chapter, I propose to examine the GMC’s proposals for revalidation, the way in which revalidation will be linked to clinical governance and the potential that the two processes will have for the detection of poor or aberrant clinical performance. I am in no doubt that the problems caused by poorly performing doctors are significant. As Professor Dame Lesley Southgate, Professor of Primary Care and Medical Education, University College London, said at the Inquiry seminars: ‘There are poorly performing doctors out there who are harming patients’. Professor Sir Graeme Catto, President of the GMC, speaking of the purposes for which revalidation was to be introduced, said that the performance of at least 90% of doctors gave rise to no concerns; that suggests that there is or could be a problem of poor performance with as many as 10%. That estimate may be on the high side; others mentioned a figure of 5% or even 3% of doctors whose performance gives rise to problems. Whichever figure is the more accurate, the problem is not insignificant. As I explained in Chapter 12, the methods of identifying poor performance through local clinical governance procedures are limited. Revalidation could provide a significant additional means of achieving that end. |
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26.4 |
Plainly, any system of revalidation of registration must have wider aims than merely the detection of the activities of a mass murderer practising as a GP. However, as a broad brush test, it is pertinent to consider whether, if revalidation as currently proposed had been in force during the 1980s and 1990s, it would have brought Shipman's activities to light. My overall objective in the Inquiry is to make recommendations for change to bring about the provision of interlinking systems of monitoring and regulation which will detect not only doctors who deliberately harm their patients but also those who harm them for other reasons such as incompetence, ill health or an unwillingness to keep up to date. I have already made recommendations for the reform of death certification and coroners’ investigations. I have also made recommendations for the strengthening of the rules relating to the use of controlled drugs. I believe that those recommendations, if implemented, could help in the detection of dysfunctionality. Now, I wish to examine the part that could be played by revalidation. If revalidation were to consist of a periodic assessment of a doctor’s competence and fitness to practise, it could make a huge contribution to safeguarding the public against the incompetent and out of date doctor. Whether it would catch another Shipman may be a different matter. It might make a contribution, as one part of the interlinked systems. As well as considering its potential benefits, I wish to examine whether revalidation, as currently proposed, will in fact achieve the purpose for which it is intended. |
Evidence
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26.5 |
The GMC’s principal witness on the issues relating to revalidation was Mr Stephen Brearley, a consultant general and vascular surgeon, a GMC member and the Chairman of the Registration Committee. Sir Graeme, and Mr Finlay Scott, Chief Executive of the GMC, also gave evidence about revalidation. Sir Donald Irvine, immediate past President, spoke on the subject during his evidence and made contributions at the Inquiry seminars. Dr Malcolm Lewis, a GP and Chair, Welsh Branch of the GMC, represented the GMC at the seminars. Other important contributions to the debate about revalidation came from Dame Lesley, Dr John Grenville (a GP, who represented the British Medical Association (BMA) at the seminars), Dr William Reith (a GP, on behalf of the Royal College of General Practitioners (RCGP)) and Dr John Chisholm (a GP and Chairman of the General Practitioners Committee (GPC) of the BMA). |
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CHAPTER TWENTY SIX - Revalidation
