Written evidence from Dr Anton E A Joseph
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
- 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
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.
MERGED: A LOGICAL
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
- 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
- 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
- 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.
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!!