Revalidation of Doctors - Health Committee Contents


Written evidence from Dr Anton E A Joseph (REV 03)

REVALIDATION AND CLINICAL GOVERNANCE

The now celebrated definition of Clinical Governance, introduced by Sir Liam Donaldson is given below.

"National Health Service organisations are 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"

The introduction and practice of clinical governance was not straightforward and was not well understood in the early days. Dame Janet Smith in her Shipman Inquiry Report was perhaps the most important individual to express her concerns. She stated, "I personally did not find that definition easy to understand and it did not seem surprising, that in the early days at least, there was a great deal of confusion and uncertainty in the medical profession about the concept of clinical governance and about what it would mean in practice." Perhaps she gave in, to a degree of intellectual snobbery!

The GMC in its consultation document place a high level of clinical governance in the revalidation process. It should however be noted that the above definition is for an organisation and revalidation is needless to emphasise is for the individual. There has been little acknowledgment of this in their post consultation document, in spite of the arguments given here below.

1.  Revalidation should be kept simple. While it is appreciated that the GMC consultation should cover all aspects of revalidation, an enormous amount of time and money has been spent in what might have been approached in a simpler and more logical manner. Obviously my submissions to the consultation process has not been taken into account.

2.  I therefore kindly request the select committee to give consideration to the following basis for revalidation. This is based on aspects of clinical governance and defined for the individual as:

3.  A framework in which an individual is held responsible to comply rigorously with the guidelines for good medical practice, assessed for the provision of high quality healthcare and the maintenance of the means by which it can be delivered.

This identifies what is expected of each individual and is precise in its requirement.

4.  There are three components incorporated in this definition:

  • Held responsible for good medical practice - Requirement to abide by the guidelines laid down by the GMC, the Royal Colleges, DoH and other relevant organisations.
  • Assessed for the provision of high quality healthcare - through the pathways set out for the revalidation process: appraisals and, above all, through audit. The GMC independently recognised "that all doctors must be able to demonstrate that they can continue to be fit to practise in their chosen field". Faced with mounting criticisms the GMC moved away from the initially chosen routes to demonstrate Fitness to Practice. However there has been significant criticism about appraisal being the preferred route chosen by the GMC, not least by Dame Janet Smith. Perhaps the best means of assessing delivery of service would be through the well established and widely practised audit system: a measure of performance through outcomes. This could resonate with the original purpose of the GMC, namely Fitness To Practice.
  • Maintenance of the means by which it can be delivered - Continuing Personal Development, adherence to evidence based practice. Achieving aims and objectives clearly set in advance.

It is my view that the fulfilment of these three components would comply with the requirements of clinical governance and would provide the key components for revalidation. It will establish the individual's fitness to practice: the whole purpose for revalidation

5.  Appraisals clearly will be the mainstay to help career development. Several components of the appraisal system will contribute to the above three categories.

An appraisal system operating on a one to one basis will be subject to criticism. It will be subject to abuse. It is an invitation to abuse. The majority of doctors will abide by the requirements and follow a legitimate path. It is almost certain that a small number will abuse the system. Dame Janet Smith was highly critical of the appraisal system. A fancy name does not reduce the possibility of fraud. The enhanced appraisal if practised is better than the previous version. A mountain has laboured and brought forth a mouse as far as credibility of the scheme goes. It is a matter of time before malpractices get exposed and would not be long for another Dame roundly criticise the GMC for persisting with it. It would be an indictment of the profession not the GMC.

6.  This presentation dares challenges the respected and admired concept of Clinical governance as defined at present which was formulated for the institutions. Revalidation is for the individual and therefore an appropriate definition as above should be invoked.

The GMC is proceeding relentlessly believing revalidation can rely on clinical governance which few people are in a position to define as applicable to an individual. The delay to implementation of revalidation may have given us some breathing space.

7.  Alternatively a description of Clinical Governance incorporating governance for the individual and for the institutions should be formulated combining the two.

8.  In the pre clinical governance era the individual took all the responsibility and the blame. Sir Liam's concept of CG is a great advance in shifting significant responsibility on the institutions. However the pendulum has now swung too far with the individual out of the picture at a time the government is pushing decentralisation.

Delivery of health care can only be achieved through harmonising the corporate responsibility and the individual responsibility.

REVALIDATION AND CLINICAL EXCELLENCE AWARDS SCHEMES SHOULD BE MERGED: A LOGICAL AND ECONOMIC MOVE

As is being rolled out the Clinical Excellence Awards (CEA) Scheme and the Revalidation scheme for the hospital consultants will run in parallel. This is totally wasteful in time and money. It was the intention of the previous government that two thirds of all consultants would have received awards at the time of retirement. The following description applies to hospital consultants but can be extended to all doctors and general practitioners.

  • CEA's are rewards for doctors making contributions over and above their contractual requirements. The ACCEA requires doctors to provide evidence for revalidation for consideration for awards.
  • It should never happen that a doctor could possibly receive a CEA and at the same time does not satisfy the requirements for revalidation. If it does there is something grossly wrong with the process.
  • It is therefore reasonable to conclude that all doctors who receive awards would and should fulfil the requirements for revalidation.
  • Is it necessary for two separate committees to decide this independently.
  • Should a consultant who was found worthy of an award be required to prove being worthy of being revalidated. It would be a farcical set up if the consultant fails to be revalidated.
  • The vastly experienced awards committees that function in each trust could be expected to recommend the suitability of the individual for revalidation to the Responsible Officer: a technical requirement due to an ill thought out law on Responsible Officers. Revalidation cannot at present be undertaken by a committee. It is the responsibility of the RO to make the recommendation to the GMC, but surely the RO can take advice.
  • The decision to revalidate or not supported by a committee will have a greater credibility than if it is to be based on the evidence gathered by the RO alone. Perhaps the law needs to be amended.
  • The awards committees function in each Trust. Above all they serve on the committees for no remuneration.

It is not possible in this brief submission to expand the details. The DoH should be required to give consideration to similar schemes that utilise currently operating schemes. The schemes could be synchronised for consultants applying for award to be considered for revalidation in the first instance or simultaneously.

RESPONSIBLE OFFICERS

Highly inappropriate powers have been provided to the ROs' in the revalidation process. The number of challenges by consultants is bound to rise if it is an individual's decision. So called safeguards will not prevent a significant increase in the number of Wendy Savages'. Any recompense is always too late for the individual. An individual performing this function is highly unacceptable to many. It is most popular among medical directors who will automatically assume the role. One must pause to ask why!!

October 2010


 
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