Revalidation of Doctors - Health Committee Contents

Written evidence from Sir Donald Irvine CBE (REV 07)


I was the President of the GMC responsible for the introduction of revalidation policy in 1998, and earlier chairman of the GMC Standards Committee which initiated the development of the GMC's Good Medical Practice.

Today, in partial retirement, I chair the Board of Picker Institute Europe, a UK charity which assesses and publishes patients' experience of health care; I am a board member of Picker Institute Inc in the USA; I chair the Ethics Committee of Dr Foster Intelligence; I am a Vice-President of the Patients' Association and President of Age UK Northumberland; and I am an Honorary Professor in the Department of Medicine and Health in the University of Durham. I am also a patient myself.

This experience gives me a fair insight into patients' expectations of doctors and their performance.


  • The most critical question today is whether the GMC, medical profession and government have the will to make revalidation work effectively for patients, without further delay.
  • The GMC should tell the public, in plain language, what standards of everyday practice they should expect from their doctors.
  • Greater clarity is needed on the standards thresholds to be used for revalidation and in the underpinning fitness to practise procedures.
  • The place for an assessment of knowledge within the context of continuing professional development should be reconsidered.
  • The GMC should require published clinical outcomes data for revalidation in all specialties where this is feasible.
  • The GMC's plans for assessing patient experience are insufficient, and should be reconsidered from first principles.
  • Non mainstream doctors who cannot supply evidence of performance of sufficient quality for revalidation should take an examination.
  • The potentially important relationship between revalidation and commissioning should be explored and developed.
  • The GMC should be held to account by Parliament in future through public hearings held by the Health Select Committee.


In considering progress with revalidation, there is important historical context which is relevant and needs to be restated here so that we can be clear why we are where we are today. For the last half century and more the British medical profession has enjoyed a generally good reputation with the public. This reputation, based on the conscientious practice of a majority of doctors, has tended to obscure the fact that over a long period of time the profession, perversely, has been prepared to tolerate mediocre or very poor practice from a minority of its members. The reasons include self-interest expressed are through a misplaced sense of collegiality (i.e. we must all stick together), and the lingering survival of early 20th century ideas of professional autonomy which still lead some doctors to think that, once "qualified", they have virtually unfettered discretion as to the standards of practice they will choose to follow subsequently.

4.  Over the last 30 years or so successive governments have attempted to deal with this problem by making the profession more accountable for the performance of its doctors, mainly through contract of employment measures in the NHS. None have been successful - hence the continuing problem. Revalidation, actually an initiative by the GMC itself following the failures in paediatric cardiac surgery at Bristol Royal Infirmary, was designed to provide a nationwide solution through the use of the ultimate power of licensure on a continuing basis. Revalidation thus replaces reactive professional regulation with a proactive system in which doctors become personally responsible for demonstrating regularly that they continue to be fit to practise in their chosen field.

5.  Not surprisingly, the GMC has encountered a strong rearguard action from within the rank and file of the profession designed to try and make sure that the process of revalidation would be as benign, undemanding and unchallenging as possible. The challengers have demanded, for example, that appraisal should be essentially formative and developmental - a "cosy chat"- never robust and summative; direct, objective evidence of competence and performance should be avoided where possible; and the public should be excluded from individual revalidation decisions.

6.  The challenge nearly succeeded when, in 2001, the GMC, under strong pressure from the BMA and others, was persuaded to water down its originally reasonably robust proposals to an annual appraisal unsupported by direct evidence of performance. "Five satisfactory appraisals equals revalidation" is how the press described it. The government of the day, by its inaction, seemed to agree, and protests from some within the profession (myself included) fell on deaf ears. It was Dame Janet Smith, in her Shipman Inquiry, who brought matters to a head by showing that the GMC's latest proposal had been weakened to a point where it would not comply with the new legal requirement for revalidation, namely, that revalidation should be "an evaluation of a doctor's fitness to practise"(1). Dame Janet's analysis caused the government and the GMC to revert to the original evidence-based approach by means of another review completed by the Chief Medical Officer of England in 2005(2).

7.  The price of this period of appeasement has been a huge delay in implementing this potentially significant contribution to patient safety. Compounding this, organised medicine is still - with some notable exceptions - reluctant energetically to develop and use methods suitable for assessing established doctors' performance and the outcomes of medical care. Thus, the critical question today is whether the GMC, the medical profession and the government have the will, singly and together, to give the public and patients the assurance they expect of good practice from all doctors practising in the UK in future.


Against this background, I offer the following comments on the way the GMC proposes to establish revalidation. Since I support the direction of travel and the general approach they should be taken as suggestions for improvement to current methods.

9.  A benchmark for patients

Good Medical Practice is excellent and should be used as the foundation for revalidation. However, it is written primarily for doctors. 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.

10.  Clarity on the bar for standards

The GMC needs to tell the profession and the public what threshold of practice it intends to use for revalidation. Is it to be optimal practice, which is the best that can be achieved under normal practising conditions? That seems to be what patients instinctively expect. Or is it to be something less than that, a minimum standard, and if so how minimal is the minimum? The question applies to decisions made in the course of the revalidation procedures themselves, but equally to the GMC's fitness to practise procedures. These latter procedures are the backstop for revalidation; they will be the means by which the GMC finally decides, in cases of doubt, whether a doctor can continue to have an unrestricted license to practise.

11.  The question was explored in 2004 by Dame Janet Smith, at the time of her Shipman Inquiry (3).The nub of the argument, set out in paras 26.98, 26.180 and 26.181 of her report, is that the "remarkably low" standard above which doctors will be revalidated does not square with the claim that revalidation gives an assurance that the doctor is "up to date and fit to practise. Today it would appear that some GMC panels are still giving doctors the benefit of the doubt, signing off some doctors as fit to practise when colleagues who have referred them, or who have done preliminary investigations, or who have attempted remediation, still have serious concerns.

12.  This matter must be clarified urgently and resolved, once and for all, for if the foundation for continuing licensure is shown to be unsound the whole revalidation exercise becomes pointless in terms of protecting patients. If nothing else, The Health Select Committee could assist all concerned by helping the GMC and the profession to get to an answer which is right for patients as soon as possible. It all boils down to how determined the GMC, the medical profession and the government - all three - are prepared to be in making sure that the public are properly protected from the insufficiently competent doctor.

13.  The assessment of knowledge

In the development of revalidation few things have been more contentious than the question of whether doctors' knowledge should be tested. For patients, the matter seems straightforward - in the 2005 government survey on revalidation the public put being up to date at the top of their priority list, with outcomes second (4). It would be difficult for doctors to be able to claim to be up to date without being able to show that they know what they are supposed to know and therefore that they know what they are doing. It is a self-evident truth that modern medicine is heavily dependent on knowledge coupled with higher order problem solving skills. The medical profession in the USA has acknowledged this by making a knowledge test the only mandatory part of their national Maintenance of Certification (ie revalidation) procedures (eg 5, 6). And it is almost certain to apply when relicensure becomes operational.

14.  However, in the UK the profession is divided. On the one hand the BMA has said that as a matter of "principle" knowledge testing should form no part of revalidation (7). This sits rather oddly given that the profession is proud of the excellent assessment instruments which it uses rigorously and systematically in the training which leads to basic qualification in medicine and subsequently in the preparations for specialist or general practice. On the other hand there is the approach being taken by the Society of Cardiothoracic Surgeons of Great Britain and Ireland (8). Even though they are the only specialty to record and publish their powerful clinical outcomes on a continuous basis, they have in addition decided strongly to recommend to their members that they should complete an on-line SESATS formative assessment of knowledge and problem solving skills every five years, as part of their continuous professional development. Indeed they plan to offer this assessment without charge as part of their service to members.

15.  My own view is that our cardiac surgeons (and the Americans) are right on the need to assess and demonstrate essential knowledge as one element of the evidence for revalidation. This is especially true in those subjects where it will be very difficult to develop valid measure of outcome - general practice, and geriatric and psychiatric medicine are examples - and where checking knowledge and skills would be an economical and effective alternative. I hope that the Select Committee will commend the stance of the UK cardiac surgeons, and ask the GMC to explain why other parts of the profession should not do something similar. I am sure the public would appreciate the degree of added objectivity and rigour such an approach would bring, at minimal cost to the doctor and no cost to the taxpayer.

16.  Clinical outcomes

Well developed clinical outcomes are an excellent indicator of clinical performance and, wherever possible, must become the central part of the evidence for revalidation. I have referred earlier to the data produced by the UK cardiac surgeons to illustrate the point. Their evidence of clinical success, reported day by day by individual surgeons, is very impressive. It contributes to quality in its own right and will be their basic evidence for revalidation. I am struck by the impact that their imperative for quality data has had on forcing improvement in the quality of clinical governance and patient care. Their motivator was Bristol. Now, revalidation must become the motivator needed to generalize from their experience across the broader spectrum of medicine. We have no other instrument with comparable reach and the potential power to change practising culture. Therefore, I would urge the GMC to be ambitious and far-sighted, to raise its game, to require outcome data for revalidation from other specialties - especially others in surgery - to drive quality in the NHS. The time is propitious because of the declared commitment of The Coalition government to give priority to clinical outcomes. This is the way of the future.

17.  Patient experience

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.

18.  I agree with comment being submitted by the Picker Institute Europe that this strand of evidence needs to be rethought from first principles. With the deferred date for implementation introduced by the government there is an opportunity to do just that. This is a fast developing aspect of healthcare where new instruments and technologies have the potential to bring more sophistication to assessment than is envisaged in the GMC's current plans.

19.  Non mainstream doctors

I fully appreciate the difficulty some doctors in this category will have in being able to produce evidence of performance of an acceptable quality. Since, inevitable, relatively little is known about the capability of many of these doctors, I believe they should be revalidated early in the introductory cycle. Think of the locum Dr Ubani - I suggest that his basic clinical deficiencies would have been detected, and loss of life prevented, if he had been properly assessed for revalidation before being allowed to practise here. So I think the GMC should grasp the nettle, and ask these doctors to complete a five yearly assessment. This was first mooted as an obvious solution some years ago now. Many of them might be quite relieved to have uncertainty removed. The start-up assessment instrument could be PLAB, which is up and running, and successful.

20.  Commissioning

If commissioning is to be successful, commissioners will want to seek evidence that the medical practitioners from whom they will purchase care will, amongst other things, be capable of providing personal medical care of a good standard. Successful revalidation should be the indicator of that standard. By the same token, patients will want to know that general practitioners commissioning care on their behalf are themselves in good clinical standing, and therefore to be trusted by them with commissioning decisions. In this context, everything points to the importance of establishing revalidation from the outset as a reliable indicator of clinical quality and modern professionalism, and therefore as an important component of commissioning.

21.  The GMC's accountability to Parliament

Lastly, I mention accountability because I believe that the current method of holding the GMC to account by Parliament is insufficient, and should therefore be reconsidered.

22.  The GMC, as the medical licensing authority, carries the ultimate responsibility for the effectiveness of the professional regulatory system. Parliament gave it the power to license doctors, to hold the specialist and general practice registers, and to have overall supervision of all stages of medical education. Only the GMC can say who shall practise medicine in the UK and who shall not. Ultimately only the GMC can say what "goodness" and "poorness" mean, in terms of doctors' competence and performance. Therefore, the public is utterly dependant on the integrity of licensure and specialist certification.

23.  To ensure its continuing effectiveness, the GMC needs to be held to account for its management of medical regulation and medical education. It needs the discipline and indeed the support that can flow from public accountability, a fact the GMC itself recognized and sought when in 2006 it responded to the CMO's report on revalidation. Subsequently, the government strengthened the reporting requirements from the GMC to the Privy Council and specified that copies of these reports should be laid before each House of Parliament.

24.  This mechanism is insufficient and lacking in transparency. For these reasons I wish to revive a proposal I first put forward in 2001(9). Parliament should establish a Select Committee mechanism for conducting a regular review of the GMC, rather like US Congressional Hearings, designed to hold it to account for the integrity and good performance of all regulatory functions for which it is ultimately responsible. The Committee, armed with thorough analysis of its performance prepared a by an independent organisation like the National Audit Office, would question the chairman and chief executive of the GMC, in front of the television cameras, about the Council's stewardship of medical regulation and medical education. Ideally, there would be a transparent mechanism for letting the public ask questions also. Dame Janet Smith's methods of assessing the GMC's performance in the Shipman Inquiry give an excellent insight into how such reviews could be made to work well. They would give the public the chance to judge for itself whether the medical profession continues to meet expectations.


1.  The Shipman Inquiry. Safeguarding patients: lessons from the past, proposals for the future.London: Stationery Office, 2004, see pages 1023-1176.

2.  Donaldson L. Good doctors: safer patients. A report by the Chief Medical Officer for England. London: Department of Health, 2006.

3.  The Shipman Inquiry, see pages 1057, 1083-85.

4.  Mori Social Research Institute on behalf of the Department of Health. Attitudes to medical regulation and the revalidation of doctors. Research amongst doctors and the general public. London: Department of Health, 2005.

5.  Choudhry NK, Fletcher RH, Soumerai SB.Systematic review: the relationship between clinical experience and quality of care. Ann Intern Med.2005; 142:260-273.

6.  Holmboe ES, Lipner R, Greiner A. Assessing quality of care: knowledge matters.JAMA 2008; 299:338-340.

7.  British Medical Association. Statement of principles on revalidation 2010. Access at:

8.  The Society for Cardiothoracic Surgery in Great Britain and Ireland. Modern medical professionalism 2010. In preparation.

9.  Irvine DH. The doctor's tale: professionalism and public trust. Oxford: Radcliffe Medical Press, 2003.

October 2010

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