Reports > The Fifth Report > CHAPTER TWENTY SIX - Revalidation >
Whither Revalidation?
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26.188 |
It is not clear from the documents recently provided by the GMC whether its plans for revalidation are settled. It is fair to say that there has been a recognition that revalidation will evolve over time but it appears, from the 2004 draft Revalidation Guidance that the GMC does not expect to make any significant changes to its proposals in the near future. In my view, that is a pity, because the present proposals do not meet the requirements that were outlined so clearly in the Consultation Paper of 2000. Nor in my view will they satisfy the statutory definition of revalidation, which is an ‘evaluation of a medical practitioner’s fitness to practise’. |
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It appears that the GMC has set its face against undertaking an individual evaluation of every doctor. However, that is what the statute requires. In the early days, the GMC took the view that it could not delegate that function; it rejected the suggestion that the medical Royal Colleges might offer an alternative route to revalidation. It has now accepted that it can delegate everything other than the final decision to revalidate. The statute does not appear to forbid delegation. However, it does require an evaluation of an individual doctor’s fitness to practise. |
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26.190 |
Quite apart from the statute, the GMC has always promised the public an individual evaluation of fitness to practise. In my view, its present proposals do not fulfil that promise. I propose to set out my ideas for how both the statute and the promise could be satisfied - only in the context of general practice, because that is the limit of my remit. My proposals would satisfy the GMC’s wish to link revalidation closely with clinical governance. They would also, I believe, avoid doing serious damage to the formative nature of appraisal. |
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26.191 |
In my view, the main platform for revalidation should be the preparation by each doctor of a folder of evidence which demonstrates what the doctor has been doing in the last five years. Some of the contents of the folder would have to be specifically laid down and would be compulsory. They would include data derived from clinical governance. These would include, for example, prescribing data and records of complaints or concerns including any report from the Healthcare Commission or a GMC or NCAA assessment. I hope that, in the future, more information of that kind will be available to PCOs. Other compulsory items would originate within the doctor’s own practice. These should, in my view, be much along the lines proposed by the RCGP in its consultation paper. For example, there should be a record of the CPD activities the doctor has undertaken. A copy of appraisal Form 4, a patient satisfaction questionnaire, the results of a clinical audit and some significant event audits should all be included. In addition, there could be a video recording of the doctor in consultation with patients. I would also suggest that the folder should include a certificate to show the successful completion of a knowledge test. I shall say a little more about that below. Of course, it would be open to each doctor to include additional material besides the compulsory items. The doctor’s NHS contract of employment or contract for services would have to require the production of these compulsory items. |
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26.192 |
The preparation of the folder would take place over a five-year period. Its development could be discussed privately and in confidence during the annual appraisal, and advice could be given as to what more needed to be done. The appraiser would be entitled to see all the material, with the result that the appraisal would be of greater value; the doctor would not be able to conceal any problems. It would seem to me to be sensible if appraisers were to encourage doctors to produce one of the specific compulsory elements each year, for example a video recording or a patient satisfaction questionnaire, so that the appraisal could focus on a discussion of that topic. |
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26.193 |
At revalidation, the folder would be scrutinised - not by the GMC, but by a local group based within the PCO and probably chaired by the clinical governance lead. I do not claim this idea as mine; it is that suggested by the joint working group. I think it is a very good suggestion. The scrutinising group should, in my view, include a lay person from outside the PCO and a GP from another area, not personally known to the doctor under consideration. That GP should be accredited by the RCGP as an assessor to standards approved by the GMC. Scrutiny should not be undertaken by a single person; nor should a panel be drawn only from members or employees of the PCO. A positive addition could be that the doctor might be invited to attend the meeting. This would overcome one of the ‘weaknesses’of the GMC’s original plans identified by Mr Brearley. That group would make an individual evaluation of the doctor’s fitness to practise, based upon standards to be set by the RCGP and approved by the GMC. If the local group were satisfied, it would recommend revalidation to the GMC; if it were not, the GMC would take over and proceed to the second stage. |
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26.194 |
I do not think that these arrangements would impose an undue burden on PCTs. On average, they have about 100 GPs each. That would mean evaluating about 20 GPs per year and some locums; I am not sure how many of those there would be. I would have thought that that would be manageable. However, there are several ways in which the numbers might be reduced by permitting alternative routes to revalidation. For example, the Membership by assessment of performance of the RCGP requires a high standard of performance. Any doctor who achieves that in the five-year period should, in my view, be automatically revalidated. If the RCGP were to devise a ‘refresher assessment’ (which could no doubt be approved by the GMC as a proxy for revalidation), I would expect that some doctors would take that route. I think, also, that GPs who are approved trainers could properly be automatically revalidated. Trainers have to be reassessed to a high standard of performance every three years. They could not possibly go through that process successfully if they were not fit for revalidation. Another possibility would be to exempt a GP from revalidation during the first five years after passing the summative assessment. That too would reduce the number of doctors that had to be scrutinised by the group. If it were thought that this proposal would still impose too much of a burden, I suggest that consideration should be given to stretching the revalidation period from five years to seven. Another alternative would be to keep the five-year period for GPs over the age of 50 and allow a longer period between revalidations for doctors under that age. In short, I think it is vital that there should be an individual evaluation of each doctor and I think that the burden that this would impose on individual PCOs could be made tolerable. I advance no proposals about the revalidation of doctors in the hospital service or the private sector. |
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So far as the second stage is concerned, the GMC must ensure that this is transparent and rigorous. It should ensure that there is adequate lay involvement. Above all, it must not permit a doctor who has failed to be revalidated at the first stage to be revalidated ‘by default’ at the second stage. At present, the uncertain nature of the steps to be taken makes that a real possibility. The GMC must ensure also that the standards by which second stage decisions are to be taken are clear and understood by all, including doctors and the public. |
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26.196 |
I have already expressed my concern about the low standards of the old performance procedures, which would, but for the advent of the new FTP procedures, have generally underpinned revalidation. The GMC has not said that the standards of deficient performance that will justify action on registration under the new procedures will be any higher than those in operation before. These standards are too low and do not provide adequate protection for patients. In my view, they must be raised if revalidation is ever to have credibility. |
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26.197 |
I said that I wished to mention the use of knowledge tests. The evidence received by the Inquiry is to the effect that no doctor can function well unless his/her knowledge base is adequate and kept up to date, but the fact that the knowledge base is satisfactory is not, in itself, a guarantee that the doctor is practising well. This second factor is often used as a reason for not including any form of knowledge test in the revalidation process. In my view, that is not a satisfactory reason for excluding a knowledge test although it is a good reason for not basing revalidation solely upon such a test. I think that the real reason why so many people seem to veer away from the idea of knowledge tests is that they believe that doctors will not accept them. I cannot believe that there could be any rational opposition to what I am proposing. Nowadays, knowledge tests can be taken on-line and in private. The doctor can find out in the privacy of his/her own study whether his/her knowledge base is satisfactory. If it is, that will provide the doctor with a degree of comfort and might also draw attention to any areas in which a gap has been revealed. I am sure that most doctors who do not do well would wish to remedy the situation. Such a doctor can take another test - and yet another if necessary - until s/he reaches a satisfactory standard. If a doctor cannot bring his/her knowledge base up to standard within five years, surely s/he should not be practising. In my view, there should be a mandatory requirement to produce a certificate of satisfactory completion of a knowledge test taken at some time within the five-year period. |
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Clearly, the changes that I have proposed are not entirely a matter for the GMC. They call for the close involvement of the DoH. They would require consultation and I dare say that they would give rise to some consternation in the profession. I do not think that they need to. I believe that the profession has accepted that the public is entitled to the reassurance that doctors are up to date and fit to practise and I believe all those who are intellectually honest, which I believe to be the great majority, will recognise that, if that assurance is to be given, it must have a more solid base than that which is currently contemplated. |
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An Important Concern
