Revalidation of Doctors - Health Committee Contents


4  Current issues

Doctors whose performance gives cause for concern

27.  The attention of the Committee has been drawn to the limited consideration which was given in the consultation process to the question of how Responsible Officers or the GMC itself should respond in cases where they are concerned about the performance of an individual doctor.

28.  Dr Keighley of the BMA said that:

One of the big gaps that we have is that there is no clarity about remediation and the costs of remediation for those doctors found lacking. There is the worry about taking time and effort away from organisations to do this when there are priorities to spend it on patient care.[18]

The BMA argued that remediation should be "fully funded to ensure equality amongst branches of practice".[19] We were also told that there was a

clear association between impaired fitness to practise and undeclared, unrecognised concealed, undiagnosed and untreated mental illness and/or addictive disorder. Those clinical conditions account for the vast majority of the 400 (approximately) cases arising from the medical workforce within the London Strategic Health Authority Area during [a two year period]... Once identified there is a good chance of successful treatment and consequently a real prospect for restoration of full capacity to practise.[20]

29.  The Department told us:

The Department of Health established a Steering Group in 2010 to review the present arrangements for the remediation of doctors whose clinical performance is causing concerns ... The Group found many examples of very good practice, but also found that there was a need for greater consistency in the way remediation was managed and a need for more clarity about which organisations provide support to medical managers. Whilst the group concluded that as far as possible employers and contractors with doctors should manage the situation locally, there would continue to need to be access to external expertise. A report setting out the group's proposals and options for the way forward is in the final stages of drafting and will be published in due course when Ministers have considered its implications and recommendations.[21]

30.  The Committee finds it unsatisfactory that so little attention has been given to the issue of how to deal with doctors whose practice gives cause for concern. We regard this as an important weakness in the current proposals which the GMC needs to address if the introduction of revalidation is to help sustain public confidence in the medical profession.

31.  The Committee is concerned that instinctive use of the word "remediation" in cases where a doctor's performance gives cause for concern may have the effect of pre-judging the appropriate response to a particular set of circumstances. While it is important to ensure the rights and legitimate interests of individual doctors are safeguarded, the primary purpose of revalidation is to protect the interests of patients.

32.  The Committee therefore recommends that the GMC publishes clear guidance to Responsible Officers about how they should deal with the cases of doctors whose performance gives rise to concern.

Appraisal

33.  At the heart of the proposals for revalidation is appraisal. As Professor Malcolm Lewis of the Council of the GMC told us:

... it means that you are working within a system that allows you to be appraised on an annual basis. At that appraisal, you have an element of continued professional development which you bring to your appraisal and next year you establish whether you have achieved that or not and, if not, why not and what else might you have done. So that's about professional development in the context of your work.

Also, some patient and colleague feedback questionnaires which we are advocating should be at least once every five years within this system, which allows patients to feed into the process—that there is locally-held information about you, your clinical activity, any complaints and any significant event analysis, and that those are appropriately addressed within the organisation.[22]

34.  The catch, so far as successful introduction of revalidation is concerned, is that appraisal, although it has been a requirement for some time, is neither uniformly effective nor indeed universally available. Niall Dickson, Chief Executive of the GMC, told us:

... at the moment, across the UK, some parts are quite well developed in terms of the appraisals that they do, but in some places it is pretty patchy and some doctors are not getting appraisals at all. The variation can be as somebody described it to me in respect of a GP in one part of the country—I won't say where: the appraisal consisted of a discussion about their walking holiday. There is that on one level. So we want some degree of consistency, as you would, frankly, in any walk of life—this is not different, in that sense. We want a solid appraisal system which actually does tell you that the doctor is competent and fit to practise.[23]

35.  Professor Sir Neil Douglas, Chairman of the Academy of Medical Royal Colleges, agreed with this assessment:

It is in places in existence on an annual basis and effective. It is, I am afraid, still slightly patchy and that is one of our concerns. I think the first step towards getting a revalidation process in place has to be the introduction of effective appraisal for all doctors in all localities in all specialties in the UK in all four countries. If that can be achieved in a short time scale, then that will be a major step forward.[24]

Professor Peter Furness, who leads on revalidation for the Academy, added that:

... the variation around the country in the implementation of appraisal also highlights our concern that the emphasis on local decision making in something like this has the potential for variation in how appraisal is administered and how standards are set around the country, because there has been a great deal of talk of setting standards but ... there will inevitably be a large degree of judgment. If there isn't a great deal of national co-ordination, I fear that we will have variation in the standards just as we have had variation in the speed of implementation.[25]

36.  Dr Brian Keighley of the British Medical Association suggested that problems with appraisal were more of an issue for the secondary sector—"It is my view that appraisal and, flowing from that, revalidation is perhaps better established in primary care"[26]—but agreed with others that implementation was patchy:

It is well established in parts of the country, as you were hearing, and yet there are trusts and hospitals where it has hardly taken place. There is also a large lacuna with the locum and sessional doctors, and some PCTs have been better at producing the infrastructure than others. I think before we move to what has been called 'strengthened medical appraisal' we need to get everybody participating at the initial level.

The other anxiety we have is perhaps lack of consistency across the country as to the types of appraisal that are being carried out. We hear anecdotally of some appraisals being a 'cosy chat' and others going on for two or three hours. I am now on my seventh annual appraisal and I think my interview lasts for about two and a half hours.[27]

37.  It is clearly unsatisfactory that there is such a degree of variation across the country in relation to appraisal, and unacceptable that some doctors are apparently not subject to appraisal at all. If an adequate appraisal system is not provided for all doctors, then revalidation, as currently envisaged, will not work. The GMC needs to satisfy itself that all organisations which employ doctors have satisfactory, robust and consistent systems of appraisal in place on a timescale that makes possible its objective of introducing revalidation in late 2012.

Requirements on doctors

38.  Another issue is the possible complexity of the process and the amount of information that doctors will be asked to provide. In its memorandum to the Committee, the GMC said that:

To meet its aims, revalidation must be relevant to doctors' day-to-day practice and build upon systems that already exist in the workplace to support high-quality care. It must not create unnecessary burdens which hamper doctors in fulfilling their main concern of caring for patients ... Revalidation will therefore be based upon a local evaluation of doctors' performance against national standards approved by the GMC. It will not involve a point-in-time test of knowledge and skills ... Doctors will need to maintain a folder or portfolio of information drawn from their practice to show how they are meeting the required standards. The information collected in their portfolio will provide the basis for discussion at their annual appraisal. For the purposes of revalidation it will be essential that the appraisal includes an effective evaluation of each doctor's performance against the relevant standards. Work is ongoing to embed the required standards into the appraisal process.[28]

39.  A number of concerns were raised with us. The BMA said that:

our confidence in the process was seriously undermined by the specialist standards frameworks that had been developed by the colleges. We felt that the college standards were not equitable, fair or proportionate to the extent that the process would have proved impractical, expensive, ultimately unworkable and would have diverted doctors away from direct care of patients. Many of the colleges had sought to provide a perfect revalidation system at the first attempt, instead of commencing revalidation with core standards and building on these during subsequent revalidation cycles—thereby, hopefully, enhancing quality over the coming years.[29]

The Academy of Medical Royal Colleges was critical of the need for doctors to demonstrate compliance with the GMC's twelve attributes of Good Medical Practice.[30] Professor Furness of the Academy, who has been appraised using this system under one of the revalidation pilots, told us "For each attribute we have a core question and then a set of supplementary questions. I think, if that is what the GMC expects, we are going to have a phenomenally laborious appraisal interview that focuses entirely on the summative, 'Are you fit to revalidate?' and we'll have no time left at the end to do the formative, 'How can we get better?', which is what, for most doctors, appraisals should be about".[31]

40.  Professor Furness was also able to comment on findings in some of the pilot projects about the length of time that doctors had taken to prepare themselves for their appraisal interviews:

In those pilots, my understanding is that, so far, with regard to the gathering together of evidence people are claiming a very wide range of how long it takes, from one hour up to a couple of weeks or so. I am not sure how they arrive at that figure. I personally went through that process and it took me an hour. With the appraisal interview, the length is varying from an hour to about three hours. Again, I am a bit surprised at the longer ones. One wonders what was having to be discussed. Of course there is a little while for recording things after that.[32]

41.  Others expressed concerns about the costs of the process. The Hospitals Consultants and Specialists Association told us that the costs of appraisal for the 37,000 consultants in England could be in the region of £74 million.[33] NHS Employers told us:

While we support a proportionate approach to revalidation based on existing processes, there will nevertheless be both immediate and ongoing costs to be met, including the training and re-training of appraisers, identified remediation costs where doctors in difficulty are identified across the five year cycle, and supporting quality multi-source feedback. Employers need to be able to plan for those costs now in order to meet the significant challenges they face over the coming years to deploy available resources to meet increasing demand. The current revalidation model assumes an employer-led, management-based process when the future may be less structured.[34]

42.  The BMA said:

The lack of reference to the cost of revalidation and of remediation, severely undermine the case for successful implementation. There has also been little consideration of the indirect costs of the time that doctors will require to meet revalidation requirements instead of treating patients. In the current financial climate, with cuts to NHS funding already underway, it remains unclear how this process will be funded and by whom. What is clear is that the process must be fully resourced as the profession would fundamentally oppose any costs falling on individual doctors or, indeed, significant, additional costs falling on trusts and other organisations.[35]

43.  In response, Niall Dickson of the GMC argued that many of the costs that people expressed concerns about were not new costs:

There is no doubt that there has been some confusion about the cost of revalidation. ...Those things should be happening now. They should be happening across the system. The system has been funded to do those things. There are some additional costs...around revalidation but, in our view, they are not hugely significant. The big costs are having a proper system of clinical governance and a proper system of appraisal. Those are things that the National Health Service has said they should be doing and should have been doing for some years.[36]

44.  It is clearly undesirable that doctors should be required to provide an immense amount of documentation for their appraisals. We agree that much of what is required should already be in place, and that if institutions have effective systems for clinical governance then information that is required for that use will also be available for appraisal.

45.  Professor Lewis described the IT system that is used for GPs in Wales, which combines these two functions:

We have used an online toolkit since 2003. It's the only way to have an appraisal in Wales... It is all web-based so the information is all stored on the website. There is also a revalidation dashboard light which goes from red to green as you complete various aspects of it. That allows the Responsible Officer to take a view of how people on the patch are progressing as individuals and collectively.

It links with clinical governance. There is a large protocol document around concerns and how they feed into and out of appraisal, so that link is made. The acceptance of the tool is almost universal. Obviously, with IT, there are a few people who will inevitably be laggards. We don't have 100% uptake because there are always some people who are off on sick or maternity leave or are out of quarter or for whatever reason, but it is over 90% at any point in time.[37]

He told us that they were now developing a similar system for secondary care, and also emphasised that it was invaluable for managing the appraisal process, as it was possible to see very easily who had and who had not been appraised.[38]

46.  It is clearly the case that the mechanics of the process should not be so complicated or onerous that they adversely affect the effectiveness of appraisal. We have heard some legitimate concerns that the requirements as described to us by the GMC might cause the process to be unnecessarily bureaucratic and time-consuming; on the other hand, Professor Furness told us that in his case preparation took just an hour. And while we are aware that IT systems are no panacea, the Welsh example as described to us indicates that it is possible to provide technical solutions to reduce burdens on the appraisees.

47.  The Committee supports the approach set out in the GMC's consultation review document aimed at making the process simpler and more flexible.[39] In particular we agree that the different components of revalidation should be integrated into a single process, and that the requirements of that process should be integrated into the appraisal and clinical governance systems operated by employers.

Patient and colleague involvement

48.  Although we welcome the desire of the GMC to keep the process as streamlined as possible for doctors it is vital to ensure that the process allows for the voices of patients and colleagues to be heard. The Picker Institute, an organisation which champions patients' views, said that:

As agreed by the [Chief Medical Officer's] working group, the purpose of revalidation is not just to identify unsafe doctors, but to create continuous improvements in quality. Direct patient feedback on doctors' performance can help assess core standards and is an essential tool for quality improvement. Patient feedback should be fully and properly integrated into medical appraisal at regular intervals, at least annually and achieving a representative sample of patients sufficiently large to ensure valid feedback.[40]

49.  Separately, Sir Donald Irvine, a former President of the GMC and now Chair of the board of Picker Institute Europe, told us:

I think that the GMC's current plans are insufficient. A single small survey of patient experience every five years will contribute little if anything to the picture of a doctor's performance capable of being assessed through evidence of experience.[41]

He also said that:

The GMC and the Royal Colleges need to tell the public and patients, in plain language, what standards of everyday practice they should use as the benchmarks against which to judge their own experiences with their own doctors. People do not have this information at present. It needs to be immediately accessible to every patient and every patient's carer in the land. It would help patients to make fully informed choices of doctor. It would strengthen the leverage patients could bring to bear in securing improvement. And it would help to underpin revalidation decisions.[42]

50.  The Patients' Association agreed that patients' views were vital and also argued that a survey every five years was not adequate:

We consider the inclusion of patient evaluation as part of the revalidation process to be vital to ensuring the process genuinely ensures the suitability of a doctor to hold a licence is accurately reflected by the recommendations made by the Responsible Officer.

A minimum threshold of patient evaluation should be set taking into account average patient contact, likely response rates and the available time for collection. We believe a timescale of 5 years is unambitious. We would prefer a shorter time scale for the entire process but recognise the need to balance the burden on clinician time when developing this process. If revalidation is to be conducted on a 5 yearly basis the collection of patient experience data should be spread across this period with a mechanism for bringing forward revalidation should concerns arise.[43]

51.  The need for patients' views to be an integral part of the revalidation process is clear. We agree with the Patients' Association that for there to be patient feedback only once during the five year cycle is unambitious. If part of the justification for the revalidation is the desire to maintain and improve public confidence in doctors then a greater degree of public involvement would be helpful.

52.  The Committee also welcomes the commitment of the GMC to ensure that the revalidation process includes provision for hearing colleagues' views. The Committee believes that although the relationship between professional colleagues should be supportive, the first responsibility of all professionals is to improve the standard of care provided to patients. It is often the case that it is working colleagues who have the clearest view of the strengths and weaknesses of individual doctors; the Committee therefore believes it is important that the revalidation process includes the opportunity (with appropriate safeguards) for input by the professional colleagues of all doctors.

53.  In its response to the consultation the GMC commits itself to further development of its proposals for colleague and patient feedback. We welcome this commitment; we hope the GMC will undertake a review of best practice in gathering the views of patients and colleagues and develop its proposals in the light of that review.

Responsible officers

54.  One of the main concerns expressed during the consultation was on the role of the Responsible Officer (that is, the person making the recommendation on revalidation). Some thought that if, as proposed, the medical director of an organisation is the person designated, there might be some conflicts of interest. As the Academy of Medical Royal Colleges said in its memorandum:

The Medical Director has responsibilities to deliver the targets of the employing organisation. In some circumstances these could differ from, or even conflict with, the ideals of good practice. For example, a doctor whose standards are questionable might be essential to delivering a service and difficult to replace; would the Medical Director then be as stringent as with a doctor who delivers adequate care, but too slowly to meet Trust targets?[44]

55.  Professor Furness, for the Academy, said that this potential conflict of interest was

balanced, as with so many of these things, by the observation that the medical director is probably, in most circumstances, in the best place to sort out problems that come from the process and to understand how the environment that the doctor is working in may interact with the problems that the doctor may be having. Were it not for that conflict of interest, the medical director would be the best person ... we are all concerned that because this conflict of interest exists there have to be open processes to ensure it doesn't cause problems of the sort that we have identified and, if they are, that they are corrected very rapidly. It is one of the reasons for needing a good quality assurance process that looks at the outcomes, not just the process.[45]

56.  We believe the risk of conflicts of interest arising from the dual role of medical directors as Responsible Officers within the revalidation system, and members of the employers' senior management team, is real.

57.  We also believe, however, that this is the inevitable consequence of using appraisal as the basis of revalidation. Appraisal is part of robust clinical governance and is a key requirement of good management; it is therefore, inevitably, part of the responsibility of the medical director of the employer.

58.  In the light of this unavoidable risk of conflicts of interest arising we recommend that the GMC publish clear guidance to Responsible Officers about how such conflicts should be handled. We also recommend that the GMC consider further what safeguards may be desirable to protect the interests of individual doctors in circumstances where they believe a conflict of interest may have influenced the decision of a Responsible Officer.

59.  The Health and Social Care Bill[46] proposes important changes to the management of the NHS. Following these changes it will be necessary to ensure that Responsible Officers are still appropriately placed. In respect of Responsible Officers now based in PCTs, Niall Dickson told us:

Obviously, their role is going to disappear as Primary Care Trusts disappear and we have certainly asked the Government, "What is the new structure going to be?", because we will require and the legislation will require that there should be Responsible Officers. Every doctor has to have a Responsible Officer. That will be in the law. So we need a new system.[47]

He suggested that Responsible Officers might be "embedded in [commissioning] consortia".[48]

60.  The GMC needs to satisfy itself within a timescale that will allow introduction of revalidation by 2012 that there is clarity about where Responsible Officers currently based in PCTs will be situated in future.

Doctors with non-standard careers

61.  Some concern was expressed to the Committee about how doctors whose careers do not lie wholly within a single practice context will fit into the revalidation system. The BMA said in its memorandum:

The consultation did not adequately address how locums, doctors with portfolio careers, retired doctors, those in non-mainstream roles, those in non-clinical roles (such as medical managers) and those who do not work in managed organisations as employees, such as private practitioners, would be able to complete this process ... The parties involved in revalidation need to consider the difficulty that such doctors may have in securing an annual appraisal and address this issue accordingly. The current options appear limited and potentially very expensive for some doctors. This suggests that there will not be equality of opportunity for all entitled doctors to revalidate.[49]

62.  The Medical Defence Union told us that:

There are a significant number of doctors who are not in managed environments and who are not currently undertaking regular appraisal or collecting supporting information such as evidence of CPD. It is important, in the interests of fairness to all, that the GMC outlines the minimum requirements that doctors will have to fulfil as early as possible so that any doctors who are not currently in a position to provide such information can put systems in place to allow them to do so. Doctors must have an equal opportunity to collect sufficient evidence before they are required to revalidate.[50]

63.  The GMC told us that some concerns were raised during the consultation:

Doctors in clinical practice generally were quite supportive of the proposals. The concerns, I think, were from groups of doctors who do different kinds of things—doctors who don't necessarily see patients every day, doctors who are in medical management, Medical Directors in post and doctors who are clinical academics. I think what they were looking for was some further and more detailed information as to how this process would apply to them.[51]

64.  The Government has addressed this issue in the Medical Practitioners (Responsible Officers) Regulations 2010, which provide that the Responsible Officer for the body for whom the doctor carries out most of his clinical practice is responsible for that doctor's revalidation.[52] The Responsible Officer also has a duty to take account of the work the doctor has undertaken for any other body.[53]

65.  The Committee welcomes the clarification provided in the Medical Practitioners (Responsible Officers) Regulations 2010. It believes this clarification will resolve many uncertainties, but it looks to the GMC to provide a further detailed response to the other concerns raised on this subject in its consultation.

Doctors from elsewhere in the European Union

66.  There has been at least one recent high profile fitness to practise case in which the doctor was from elsewhere in the EU and working as a locum. We asked Niall Dickson of the GMC how doctors from the EU would be incorporated into the process. He told us:

The Government have been ... very helpful. I believe they have recognised that this is a two-stage problem. There is a problem with UK legislation at the moment to the effect that it stops the GMC from doing any form of language testing, but there are also problems with the way the EU Directive is drawn up and the fact that, as a regulator, you have to establish doubt about the doctor's ability to speak English before you can test, which is a sort of Catch 22. We are exploring ways in which we might be able to get round that.

Secondly, the Government is committed to working on the current review of the EU Directive and we have also been having talks with other regulators and with the Commission directly. Again, this is a slow process. So there is work being done on all that and we hope that we will be able to make some significant progress in the medium term on language and, certainly in the longer term, on language and competency. But I am not underestimating the obstacles involved in either of those things.[54]

67.  He added that employers also had a role to play here:

I accept that there is a hole in our regulatory system because of the nature of the current EU law, but employers still have a responsibility to ensure that any doctor they employ or contract with is both fit to practise and fit for purpose, and because there is this gap in our system it puts a particular onus on employers who are taking on doctors from the European Union to make sure that those doctors that they employ and contract with are fit for purpose—the job that they are actually being given—as well as fit to practise.[55]

68.  We regard the ability of a doctor to communicate effectively with his or her patient as fundamental to good medicine. As the body responsible for revalidation, and with a commitment to introducing it by late 2012, we expect the GMC to satisfy itself that it has the necessary powers to fulfil this role; if it is not satisfied (whether as a result of EU legislation or for any other reason) we expect it to say so publicly and report to Parliament what changes are necessary to allow it to fulfil its function effectively.


18   Q 119 Back

19   Ev 38 Back

20   Ev w26 [Dr Douglas G Fowlie] Back

21   Ev 31-32 Back

22   Q 6 Back

23   Q 7 Back

24   Q 63 Back

25   Q 64 Back

26   Q 95 Back

27   Q 96 Back

28   Ev 35 Back

29   Ev 39  Back

30   Ev 43 Back

31   Q 72 Back

32   Q 70 Back

33   Ev w56 Back

34   Ev w45 Back

35   Ev 39 Back

36   Q 47 Back

37   Q 54 Back

38   ibid Back

39   Revalidation, The way ahead, Response to our revalidation consultation, GMC, 18 October 2010, para 211: that work should be done to streamline the Royal Colleges' and Faculties' specialty and general practice frameworks, making clear what is expected and what is optional; to refine the GMC's framework based on Good Medical Practice to make it more flexible; and to ensure that all components of revalidation are integrated into a single process. Back

40   Ev w20 [witness's emphasis] Back

41   Ev w6 Back

42   Ev w4 Back

43   Ev w47 Back

44   Ev 45 Back

45   Q 87 Back

46   Health and Social Care Bill [Bill 132 (2010-11)] Back

47   Q 34 Back

48   Q 35 Back

49   Ev 40 Back

50   Ev w59 Back

51   Q 29 Back

52   Medical Practitioners (Responsible Officers) Regulations 2010, Regulation 10 Back

53   ibid, Regulation 11 Back

54   Q 22 Back

55   Q 23 Back


 
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