Revalidation of Doctors - Health Committee Contents

Written evidence from the Royal College of Surgeons of England (REV 12)


  • The College supports the introduction of a revalidation system.
  • The leadership of and ultimate responsibility for revalidation must lie with the GMC.
  • The GMC needs to set out clearly the remaining tasks and who has delegated responsibility for them.
  • The independence and impartiality of responsible officers is not assured and more needs to be done to monitor them.
  • The move to implement revalidation as organisations become ready does not represent a risk based approach. The GMC needs to proactively support lagging organisations.
  • Following a risk based approach, further work is needed to ensure that systems are in place to revalidate appropriately locum doctors and doctors working solely in the independent sector.
  • The importance of specialty difference must not be lost in the rush to produce a simple system.
  • A consistent approach to appraisal must be championed by the GMC.
  • Whole practice appraisal must be supported by responsible officers and all health organisations.
  • Revalidation is an opportunity to improve existing systems and processes to collect and analyse information about the outcomes of health care.
  • Medical Royal Colleges should have a clear role in the quality assurance of revalidation.
  • The role of PCTs and SHAs within the regulations needs to be reconsidered in light of changes to these organisations which the Government has announced.


1.  The Royal College of Surgeons of England supports the introduction of a revalidation system Our hope is that revalidation will:

(a)  Provide a way for doctors to prove that they meet high standards of practice.

(b)  Protect patients through early identification of problems and strong clinical governance.

(c)  Reassure patients that their doctor is fit to practice.

2.  The College has supported the work done over the last 11 years to introduce a revalidation system. The various set backs have been frustrating but it is clear that even the anticipation of revalidation has improved the clinical governance landscape. Nevertheless there is still much more work to be done.


3.  The Royal College of Surgeons of England is clear that revalidation must be led by the profession and to that end the General Medical Council (GMC) must have overall responsibility. To date the College has encouraged the GMC to take a leadership role. However, we have been somewhat disappointed by the GMC's apparent failure to clearly set out how it expects the revalidation project to proceed. In particular it has not been clear what the GMC expects other bodies to do including the role of the Colleges. It is our opinion that this has led to delays and duplication and is the reason why the system has been criticised as being overly complex. It appears that this is now being remedied.

4.  We recognise that the four UK departments of health are concerned about the impact of revalidation on their health services and have therefore taken a proactive role in preparing for revalidation. Revalidation should be a UK-wide regulation system so that any patient in the UK can expect that their doctors are being revalidated to the same standards in a consistent way. It is not clear to what extent the GMC has oversight of these implementation activities. The GMC needs to retain the right to approve or veto systems in order to ensure that consistency and fairness is maintained.

5.  Looking forward, the GMC urgently needs to set out in very clear terms, what tasks are left to complete, who will be responsible for completing them and who will sign them off. It is only then that broader stakeholders such as Medical Royal Colleges, specialty associations and patient groups can identify how and when they can provide input to the development of standards, rules and systems. This will also minimise any future duplication.

6.  It is clear from the GMC's report on their consultation that a pragmatic approach is being taken to the implementation of revalidation focusing on information already widely available. This is sensible but the risk is that the most relevant types of supporting information for specialists may be ignored. Revalidation should be subject to continuous renewal which should make revalidation even more straightforward. Over time it will be possible for the profession to develop better forms of supporting information to replace those currently available. The support of the GMC and departments of health will be critical.

7.  The College, even as an identified partner, is still unclear what revalidation in its entirety will look like. Doctors have even less idea about what will happen and what they need to do to prepare. They are receiving conflicting messages from a variety of sources further adding to the confusion. The GMC needs to act authoritatively setting clear timescales for implementation and needs to make communication with doctors a priority.


8.  The College remains concerned about the responsible officer role. We are supportive of revalidation having a local dimension because it allows local circumstances to be taken into account and will strengthen clinical governance. However, placing processes at a local level opens up the potential for the revalidation process to become conflated with employment issues. Revalidation is about demonstrating performance against professional standards and while this overlaps with what an employer requires from its employees, other dimensions such as revenue raising are simply irrelevant.

9.  As it currently stands the College does not believe that effective safeguards have been introduced to ensure that the revalidation process will not be the subject of interference from employer led processes. We acknowledge that it may be impractical to change course before implementation but the GMC should make it a priority to assess, within the first two years of revalidation if the potential conflict is proving a reality. If this is the case then the GMC should consider whether an independent network of locally based responsible officers might prove a better alternative.

10.  The GMC has not fully expressed how it will interact with responsible officers. Responsible officers will be supervised to some extent by their own responsible officers; but these will be provided by the four departments of health rather than by the GMC. Therefore it is not clear how the GMC will monitor the work of responsible officers directly in order to ensure that local systems and the revalidation recommendations made by the responsible officers are in line with GMC expectations.


11.  The GMC is understandably keen to implement revalidation as soon as it can. To this end their approach is to begin revalidation in the healthcare environments when they are ready. By definition those organisations with the best systems where doctors are likely need the least monitoring by the GMC will be first. The organisations with the poorest systems will begin revalidation much later even though the doctors working in those systems may be currently less well monitored and as a consequence pose a greater risk. In order to mitigate the effects of poor systems leading to greater risk due to delay the GMC should proactively identify such organisations and work with them to improve their systems and implement revalidation as early as possible. An agreed "start by" date is essential so that organisations can be held to account.

12.  It is relatively easy to identify some of the key groups that pose a risk because they work outside of the "managed" healthcare environment. These groups are sometimes termed orphan groups. Several groups concern us, in particular: peripatetic locum doctors, doctors working wholly in the independent sector (particularly those in the cosmetic sector) and doctors coming to the UK from overseas for limited periods of time.

Locum doctors

13.  Peripatetic locum doctors provide a vital service to the UK healthcare system. They provide cover at times of pressure and the service relies on their flexibility. However it is clear that they are not adequately covered by trust clinical governance systems and that locum agencies provide variable monitoring based on reports received from trusts. It will be much more difficult for peripatetic locum doctors to gather information for revalidation and for this information to be verified. The College has recognised this problem and is working on gathering together standards for locum surgeons. The GMC needs to work with the Colleges and others to consider what advice can be given to locums, and their appraisers, about acceptable adaptations to the revalidation process.

14.  We are especially concerned about locum doctors who do not have NHS practice and are not registered with an approved locum agency through which to obtain their responsible officer and appraisal. These doctors are supposed to be served by their Primary Care Trust or Local Health Board. Apart from the fact that these organisations are not familiar with surgical practice, in England Primary Care Trusts will soon cease to exist. The GMC and government urgently need to address this.

Independent Sector

15.  The College has established a working party to draw together standards for cosmetic surgery, both for the individual and for surgical services. Revalidation will be included as a regulatory mechanism for upholding these standards. This work is due to conclude in Summer 2011.

16.  The broader issues related to doctors working wholly in the independent sector are yet to be fully addressed. We welcome the pilot work undertaken by Independent Healthcare Advisory Services (IHAS)[3] but we are concerned that the responsibilities of healthcare organisations are not fully understood and compliance will be low. It is important that advice be given to the independent sector to ensure that they make suitable provision for the introduction of revalidation, including supporting whole practice appraisal. Revalidation does present costs but it is not acceptable for organisations to put off enhancing clinical governance systems. The GMC and Care Quality Commission need to work together to address this.


17.  The GMC has stated that doctors coming to the UK will need to be licensed and are therefore subject to revalidation. However there is almost no detail on how this will work in practice. The issues are similar to those concerning peripatetic locum doctors where their work is not subject to a continuous regime of clinical governance. These doctors pose a particular risk that must be addressed as a priority.


18.  Following the publication of the white paper, Trust, assurance and safety, the Medical Royal Colleges were quite clear that revalidation would contain a significant specialty element and that their responsibility was to set relevant standards complementary to the generic Good Medical Practice standards. Quite quickly it became apparent that the separation of relicensure and recertification was cumbersome and confusing. Rightly it was abolished in favour of something more streamlined. We supported the reunification in the belief that all surgeons, not those just on the specialist register, would be covered by standards relevant to surgeons.

19.  However, we are increasingly worried that the push towards simplification marks a move away from specialty standards and towards a one-size-fits-all approach. This must be resisted. We support the efforts to ensure consistency of terminology and the identification of essential items of supporting information across medicine. However specialty specific difference must be accepted. For example we have determined that outcomes data form an integral part of a surgeon's revalidation portfolio but such data would not be so relevant for other specialties and it is right that they not be required to replicate this. We would not approve of a move to make outcomes data an optional form of supporting information for surgeons. Where available it must be presented.


20.  Strengthened medical appraisal is the core process for revalidation. Existing appraisal needs to be enhanced and extended to include an assessment element for revalidation. The College is concerned that the GMC appears to have left the four UK departments of health to undertake this task without guidance from the GMC about what it expects. In order to make sure that revalidation applies equally all over the UK appraisal must be designed with a consistent philosophy and with common elements. For example the Revalidation Support Team for England has developed an appraisal system that promotes a small number of items of supporting information being put forward for inspection by the appraiser. An alternative approach might be that the appraiser chooses items to review from a long list of available information. The College has concerns about the Revalidation Support Team's approach but it is not clear if our lobbying on this issue should be directed at the Department of Health or the GMC.

21.  The College has long advocated whole practice appraisal. Patients need to be assured that their surgeon's work is of a high quality in all areas of their practice across all sectors. This means that information for appraisal is drawn from all places of work providing an overall picture. We are pleased that the GMC makes note of this in its documents but we are concerned that there is less commitment to this on the ground. We were disappointed that the responsible officer regulations did not include a duty to provide information to facilitate whole practice appraisal. We believe that the GMC should issue guidance to responsible officers making it explicit that the GMC expects whole practice appraisal to take place.


22.  The College would like to inform the committee about the College's aspirations for the use of outcome data. Revalidation presents a unique opportunity to commit surgeons and their employers to enhancing participation in clinical audit and to bring surgeons closer to the routine data collected on their behalf in order to develop this into a more clinically meaningful resource. In the NHS in England Hospital Episode Statistics (HES) is the largest and most complete data set about healthcare. Initially developed for administrative purposes, it has become far more reliable over recent years due to the focus on payment for activity within the NHS. Revalidation presents the opportunity to further develop this data set to better understand NHS activity and the quality of care provided to patients. This is in line with the coalition government's agenda to widen access and openness about NHS data as outlined in the current consultation Liberating the NHS: an Information Revolution.

23.  Understanding health outcomes is never easy. There are always numerous factors to take into account and results are rarely clear cut. Nevertheless, the College has worked with the surgical specialty associations to identify for the first time particular sets of operative procedures that describe the practice of specialist surgeons, along with a simple range of outcome indicators that can be derived from HES. This will enable comparison and benchmarking between units and between individual surgeons and will provide an essential source of supporting information for revalidation. Much support from the Department of Health and the NHS Information Centre will be required to realise the potential of this work which , if implemented, will further the aims of the government in its information strategy.

24.  The College believes that, even in the short term, outcomes data can form a part of revalidation through a combination of national and local clinical audits, routinely collected data (HES) and self collected data (personal log books). However, for surgeons and the public to have confidence in these data, there must be a commitment from the government, the GMC and the profession to invest time and effort into improving the quality of information to support outcome measurement. We are clear that the drive to streamline the revalidation process must preserve specialty difference and the standards the profession has set.


25.  A transparent and robust quality assurance process is essential to ensuring the success of revalidation. The revalidation process itself is mostly devolved with very little GMC involvement. For that reason the quality assurance process must be thorough and involve routine checks as well as investigations triggered by anomalies. We understand why the GMC is keen to work with systems regulators in order to not duplicate and create a burden but the GMC must retain control of quality assurance overall.

26.  The quality assurance process should focus on two elements:

(a)  Revalidation systems in organisations

(b)  Individual revalidation recommendations and decisions

The GMC should take a risk based approach to this, targeting identified high risk institutions but retaining an appropriate degree of randomisation in its approach.

27.  The Medical Royal Colleges are guardians of the specialty standards and as a result must be party to the quality assurance system in order to retain the confidence of medical professionals that the standards are being upheld. The Royal College of Surgeons has engaged the GMC in discussions about how this might be undertaken but we are not confident that the role of Medical Royal Colleges is firmly embedded. Colleges can provide support in a number of ways such as reviewing information to trigger further investigation, providing service reviews with specialist input.

November 2010

3   Assuring the quality of medical appraisal for Revalidation, Strengthening Medical Appraisal: A Report of the study in the Independent Sector (England), Independent Healthcare Advisory Services, 2010. Back

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Prepared 8 February 2011