Revalidation of Doctors - Health Committee Contents


Written evidence from Picker Institute Europe (REV 14)

Picker Institute Europe is a not-for-profit organisation that makes patients' views count in healthcare. We:

  • build and use evidence to champion the best possible patient-centred care;
  • work with patients, professionals and policy makers to strive continuously for the highest standards of patient experience.

ABOUT PICKER INSTITUTE EUROPE

1.  Picker Institute Europe developed the methodology of measuring patient experience in the UK. It has carried out numerous national patient surveys for the national survey programme and is now the single co-ordinating centre for these surveys under the Care Quality Commission. It also provides patient feedback to over 100 NHS trusts every year, using a variety of methods including "near real time" feedback.

2.  Picker Institute Europe has worked over several years on the development of medical revalidation. It was a member of the Chief Medical Officer's high level group, leading to the White Paper, "Trust, assurance and safety: the regulation of health professionals"; and of his working group on medical revalidation, which produced the 2008 report: "Medical revalidation - principles and next steps". This document affirmed that patient feedback would form part of the evidence base for appraisal and revalidation.

SUMMARY OF CURRENT CONCERNS

3.  Revalidation was developed in the interests of patients, but that focus keeps being obscured. The Select Committee on Health's Inquiry is a timely opportunity to help the medical profession regain that focus.

4.  In this submission, Picker Institute Europe wishes to highlight the following points, from the perspective of an organisation focusing on patient-centred healthcare - and the role, within it, of direct feedback from patients.

  • No further delays. The pace of implementation of revalidation has been too slow. Under current proposals, regions that have not prepared for revalidation may be allowed further, unacceptable delays. We propose that all regions should be ready to introduce revalidation by a deadline of 18 months after the early adopters begin.
  • Full integration and regular use of patient feedback. As agreed by the CMO'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.
  • Now is the key time to review and clarify the role of patient feedback. The medical profession remains unclear and unfocused with regard to the role and value of patient feedback within appraisal and revalidation. The current hiatus presents an important opportunity to re-open discussion, with the involvement of relevant patient-focused organisations. We would respectfully request the select committee to recommend this opportunity must not be missed.

INTRODUCTION

5.  Picker Institute Europe wishes to comment on two issues within the Inquiry: the way in which the GMC proposes to establish revalidation, and the responses to the consultation and the GMC and UK health departments' statement of intent issued on 18 October. We will cover these issues together.

6.  Our concern throughout is that revalidation should be implemented in the foreseeable future, with the experiences of doctors' patients fully and effectively integrated into their appraisal and revalidation, in such a way as to assist continual improvements in quality.

BACKGROUND

7.  Patients expect their doctors to be fit to practice, to be effectively regulated, and to be monitored for their competence. Most patients assume that regular monitoring does take place. Medical revalidation was developed in response to high level concern that adequate checks were not in place, and that this posed risks to patient safety and was not conducive to achieving high quality care.

8.  Revalidation, and associated appraisals, depend upon the regular gathering of good quality information about doctors' performance. At the launch of the White Paper, "Trust, assurance and safety", in 2007, the then minister for health and the Chief Medical Officer confirmed that this information would include direct feedback from the doctor's patients. Subsequently, in 2008 the CMO published "Medical revalidation - principles and next steps" which formally included patient feedback within the proposals for "multi-source feedback" which all doctors would need to collect.

9.  Methods of collecting patient feedback - measuring patient experience - have been available in England since at least 1998, when Picker Institute Europe conducted the first national patient survey (of primary care) for the Department of Health. Many of the "core questions" in the national patient surveys can be used, or adapted for use, in assessing the performance of individual health professionals. There are also many instruments developed by academic researchers, designed specifically to assess the quality of individual consultations with patients. For example, a recent review by Picker Institute Europe for the King's Fund identified 15 relevant questionnaires designed to study patient engagement in primary care alone.[4]

10.  Since at least 2008, various parties have been developing patient questionnaires for the purpose of revalidation. The General Medical Council has developed its own questionnaire; the Royal College of GPs has approved at least three other instruments.

11.  Hence there is no shortage of well developed, tested and validated questionnaires and indicators which can be used, or further adapted, to provide doctors with their patient feedback.

12.  Patients cannot be expected to report on the clinical competence of their doctors. However, they can report aspects of their own experience in consulting doctors, which are relevant indicators of the quality of the care being provided.

13.  For example, communication skills are key to correct diagnosis, understanding patients' symptoms, choosing the appropriate treatment option, and co-ordinating the patient's care with others.

14.  Patient experience questionnaires would typically include questions about these communication aspects. Those used in national surveys include:

  • Did the doctor listen carefully to what you had to say?
  • How much information about your condition or treatment was given to you?
  • When you had important questions to ask a doctor, did you get answers that you could understand?
  • Did the doctor treat you with respect and dignity?

15.  A key question used consistently in the national surveys is about the level of involvement the patient had in any decisions made:

  • Were you involved as much as you wanted to be in decisions about your care and treatment?

16.  These questions are based on what patients say is most important to them. They are directly relevant to the duties and required competencies of doctors: Good Medical Practice (2006) contains a duty for all doctors to work in partnership with their patients, including involving them in decisions. GMC guidance has further elaborated this duty, by advising doctors that consent to treatment must be sought in the context of shared decision making with the patient;[5] and by requiring all undergraduate doctors to demonstrate these competencies in order to qualify.[6]

17.  Patient experience is recognised as central to healthcare quality. The NHS Next Stage Review[7] defined quality as three components - safety, effectiveness and patient experience - and this formulation has been explicitly accepted by the coalition government.[8]

18.  This recognition is driven by increasing evidence that the success of healthcare depends significantly on the extent to which patients are engaged in it. Evidence from 280 high level and systematic research reviews, synthesised for the Department of Health by Picker Institute Europe, shows that engaged patients are, for example, more likely to choose appropriate treatment, less likely to choose highly interventionist options, more likely to adhere to chosen treatment (such as a course of medication), more confident to cope with their condition and its impact on their lives, and more likely to adopt preventive approaches such as attending appropriate screening.[9]

19.  Direct patient feedback, then, is both achievable and highly relevant to care quality and to the assessment of doctors' competence to carry out their duties.

THE APPROACH TO IMPLEMENTATION AND THE GMC'S RESPONSE TO ITS CONSULTATION

Doctors' uncertainty about patient feedback

20.  Over the last four years it has become clear that many doctors are uncertain and fearful about the collection and use of direct patient feedback. For example, only 67% of respondents to the GMC's 2010 consultation supported the involvement of patients in feeding back through questionnaires - even though Department of Health and GMC policy is unambiguous about this requirement.

21.  Likewise, in a recent survey of GPs by the King's Fund, 57% of respondents thought that patient surveys were the least effective approach to quality improvement.[10]

22.  This is in part understandable. Responses to the consultation also showed a clear preference for basing appraisal on information that is already routinely collected; but patient experience is not yet routinely measured at the level of individual doctors, and doctors are unfamiliar with its evidence base, methods and significance.

23.  However, it may also be in part due to medical prejudices. Research studies and programmes relating to patient-centred healthcare have concluded that many doctors are resistant to concepts and language of patient-centred healthcare.[11] Patient feedback is sometimes regarded as irrelevant, or wrongly perceived as being about patients "rating" their doctor. The communication, partnership and shared decision-making that are required by Good Medical Practice are often derided as "fluffy stuff", "touchy-feely", or things that nurses can do but doctors don't need to worry about.

24.  It is however important to note the increasing recognition and acceptance of patient feedback as a valid and important measure of the quality of care within national professional organisations and associations. The Society for Cardiothoracic Surgery for example, a pioneer of transparency in the publication of performance data, is currently developing its own patient experience measurement tools with a view to publishing patient experience data alongside data about the clinical outcomes achieved by individual clinicians.

Lack of clarity on the role and use of patient feedback

25.  For the above reasons, the role of direct patient feedback in appraisal and revalidation has often been misunderstood and downplayed in the development of plans for revalidation.

26.  In its consultation document, the GMC characterised patient and public involvement as a way of inspiring confidence in the way that revalidation will work. Picker Institute Europe emphatically disagreed, arguing that:

"The patient experience is a core dimension of "quality" in health and should be positioned as a core dimension of doctors' competence and performance. We do not see this reflected in the GMC's approach."

27.  In its response to the consultation (which quotes the above passage), the GMC makes the robust statement that "Patient and public involvement is expected, and will be included in revalidation". It recognises patient feedback as an important "developmental tool" for doctors. However, it also continues to position patient and public involvement as "critical to ensuring confidence in revalidation".

28.  The point remains that in the face of doctors' fears and uncertainty, the way the GMC positions patient and public involvement, and patient feedback, is critically important. It should give an unequivocal lead to the medical profession - in line with the duties it promotes in Good Medical Practice - that the patient experience, as reported by patients, is a core part of the quality of doctors' performance and requires regular monitoring and, where necessary, remedial attention.

29.  In response to concerns expressed by various respondents to its consultation - that patient feedback questionnaires may not be "robust" or reliable, or may be too onerous to administer - the GMC proposes further review work, to assure itself and others about the nature of the surveys.

30.  We consider this unnecessary - this is already a well researched area. Royal Medical Colleges have moved beyond this position, to examine and approve specific questionnaires. We would urge the GMC to involve recognised academics with expertise in patient experience measurement from an early stage, and to conclude the review as rapidly as possible.

31.  More generally, we remain concerned that, even at this late stage in the development of revalidation, the role and use of patient feedback remains at best unclear, and at worst, disputed and undermined. The current hiatus, while piloting is established and conducted, offers a very important additional opportunity to clarify these matters.

32.  We therefore respectfully request the select committee to recommend that the opportunity should now be taken to initiate a further debate and discussion aimed at clarifying the role of patient feedback within appraisal and revalidation. This should be a balanced debate, involving patient-focused organisations and the medical profession as widely as possible.

Frequency, consistency and significance of patient feedback

33.  Our concern remains that, in the planned approach, which is the responsibility not only of the GMC but also of other bodies including the Department of Health, patient feedback will be collected and used:

  • with less commitment and recognition than other types of information;
  • infrequently; and
  • inconsistently.

COMMITMENT AND RECOGNITION

34.  In its consultation document, the GMC described patient feedback as "useful supporting information", reinforcing the view of many doctors that such information is marginal. In its response to the consultation the GMC revises this to: "one of a range of types of supporting information that doctors will collect to demonstrate their practice at appraisal". This at least gives more of an appearance of equality with other data.

35.  We reiterate our contention that patient experience information is capable of being used to assess core elements of the quality of doctors' care-giving. These include mandatory aspects of the "patient partnership" duty in Good Medical Practice, such as:

  • listening to the patient;
  • explaining the patient's condition;
  • giving information about all treatment options, including that of doing nothing, and their associated risks;
  • answering questions in a way that the patient can understand;
  • supporting the patient to care for himself and to adopt appropriate behaviours;
  • involving the patient (to the extent that they wish) in discussions and decisions about their health and healthcare - (and achieving consent to any treatment in this context).

36.  We also reiterate that the evidence shows that where these competencies are absent from consultations, care and treatment will be less effective as well as being a poorer experience for the patient.

37.  It is incumbent on the GMC to defend and promote its standards, and to exercise leadership in this field.

38.  The risk here is that doctors, their supervisors and clinical peers, and responsible officers, may underestimate the significance of any patient feedback that is collected, and therefore may not act upon it. They may believe it relates only to "people skills", not to core best practice.

39.  This would be unfortunate, since, as the GMC notes, patient feedback is an important developmental tool for reflective practice. In Picker Institute Europe's experience, regular assessment of the patient experience, with attention to trends over time, is a particularly useful quality improvement tool when used by those who are committed to acting on its results. It is a sensitive measure of whether changes that are designed to improve quality are having an effect where it matters most - in their effect on patients.

FREQUENCY

40.  However, to be used effectively for quality improvement, patient feedback should be gathered frequently enough to be able to give a picture of performance over time, including the impact of any changes that doctors have made to their practice as a result of previous data.

41.  In this respect the current proposal - that patient feedback might be gathered only once every five years - is wholly inadequate and places a question mark over the utility of collecting it at all.

42.  There is a clear contradiction between the GMC's statement that patient feedback is "is one of a range of types of supporting information that doctors will collect to demonstrate their practice at appraisal" -- and its proposal that the feedback will not be gathered annually for appraisals.

43.  We believe that patient feedback should be gathered at least annually, to be used in each appraisal. Annual collection of feedback is not onerous. "Medical Revalidation: principles and next steps" noted in 2008 that "Many trusts already ensure annual MSF [multi-source feedback] as part of local clinical governance processes." If so, then patient feedback should be part of that MSF. It should have parity with colleague feedback.

44.  If patient feedback is only collected one in five years, it will be impossible to interpret the findings from one revalidation period to the next. Changes to results will be impossible to assign to any of the many possible causal factors occurring in such a long period. A five-yearly set of either good or poor results could easily be attributed to "luck" with a particular cohort of respondents.

45.  Changes are somewhat easier to attribute in an annual cycle. However, we note that in acute hospital trusts, the gap of a year between results of the annual inpatient survey became a criticism used by hospitals who felt they were having to wait too long to measure the impact of improvement plans. As a result, increasing numbers of hospitals are now adopting more frequent patient experience measurement ("near real time" feedback, monthly or even fortnightly).

46.  We also ask the select committee to note the context in which revalidation will be introduced. The government is committed to much greater and wider use of patient experience measurement across the NHS, including near real time feedback. It seeks the rapid establishment of information systems that will allow patients to see service-level reporting of healthcare quality.[12]

47.  In short, the proposals for implementing revalidation are falling well behind the curve of the development of patient experience information, quality information, and information for choice in the English NHS. This is a potentially serious issue, which needs to be taken into consideration.

48.  We respectfully request the select committee to consider Picker Institute's alternative proposals, that:

  • patient feedback should be used at every annual appraisal, and therefore collected at least annually;
  • there should be formal consideration of establishing more frequent and continuous collection of patient feedback data, tailored to the doctor's service settings and patient characteristics where relevant, to enable both early alerts to weak performance on patient experience, and early assessment of the impact of any improvement actions;
  • where patient experience data give cause for concern, a remedial action plan for improving performance and monitoring patients' experiences of care should be agreed and implemented. Doctors should be required to submit real-time evidence of compliance with the plan to their appraiser and Responsible Officer until repeated patient experience surveys demonstrate satisfactory performance.

CONSISTENCY

49.  In its response to the consultation, the GMC makes clear that it does not intend to establish a "central" system for collecting patient feedback. It also notes that questionnaires which it makes available will need to be administered independently.

50.  These statements imply a devolved approach in which local workplaces, or even doctors themselves, will choose which instruments to use, how and when to administer them, what assistance and which third parties to contract.

51.  While we understand the good reasons for wishing to devolve quality management to a local level, where people "own" the results, Picker Institute Europe is also conscious of the real risks this poses to the consistency of patient experience measurement. Here we offer the benefit of lessons from co-ordinating (and participating as a survey provider in) the regulator's national patient surveys in both primary and secondary care.

52.  Staff and service settings vary considerably in their expertise, confidence, capacity and willingness to co-operate to administer patient feedback questionnaires consistently and in accordance with agreed methodologies and protocols.

53.  Inconsistencies are not acceptable to medical professionals. If, for example, one doctor receives poor feedback from his patients, but a nearby colleague or a similar specialist is perceived to have "skated by" using a different method, or the same method administered or reported in a different way, there will be complaints of unfairness that will undermine the validity of patient experience data.

54.  Similarly, if one region takes a "maximalist" approach to data collection, and another a "minimalist" approach (in terms, for example, of numbers of patients or numbers of questions/indicators), it will be unacceptable to those being appraised.

55.  Hence whatever system is established must be capable of delivering consistency - it is the same thing as credibility, especially in a profession which is so ruthlessly evidence-based.

56.  In the national survey programme, inconsistencies are ruled out as far as possible by using a combination of devolution and co-ordination:

  • A single standard questionnaire is used, providing "core" indicators that are comparable between the trusts and departments being surveyed - but trusts can, should they wish, use additional tested questions according to their own needs.
  • Each NHS trust administers its own survey. It may or may not choose to employ an independent contractor for this. However, a rigorous administration method is laid down, to which trusts and their contractors must adhere. Central co-ordinators provide regular advice and assistance to trusts, as well as quality assuring their implementation.
  • A minimum sample size is stipulated. Again, however, it is open to individual trust to seek a larger sample where they believe it is helpful and justifiable. Larger samples produce richer results.
  • There is a competitive market in survey contracting, but within a managed "framework", which means that survey providers must be approved for these purposes. This helps to ensure that all independent contractors work to similar standards and follow the approved methods.

57.  We do not argue that this system must be exactly replicated for medical appraisal and revalidation, but we would point out the benefits of co-ordination to all parties.

58.  Everyone in the system knows with confidence that they are measuring the same things, in the same way.

59.  Everyone in the system knows with confidence that they are not being disadvantaged by any variance in the number or character of the questions, or by undue variations in sample size.

60.  Everyone in the system knows where to go for advice - and that the advice they receive is the same as would be provided to everyone else.

61.  The results are comparable between all trusts (nationally); between trusts within a region; and between trusts of similar type, or size. Importantly, where a consistent method is used for repeat surveys, results are comparable over time, and can show whether performance is improving or deteriorating on any specific indicator.

62.  Local workplace organisation and administration of patient experience measurement carries a substantial risk of poor process, poor data quality and considerable expense.

63.  Poor process can include the introduction of bias. This is likely if staff directly involved in patient care administer the questionnaires; or if patients complete them while still within a care setting on which they still feel dependent.

64.  Poor process can also include undue variation in sample size, or in demographic sampling, leaving uncertainty about the representativeness of the data.

65.  With regard to confidentiality, local devolution also carries a serious risk that individual patients will be identifiable.

66.  We would therefore respectfully request the committee to consider recommending that the General Medical Council should review the potential benefits of a managed, co-ordinated and quality assured system for organising and administering patient feedback collection.

TIMESCALE FOR IMPLEMENTING REVALIDATION

67.  Medical revalidation, and the associated improvement in medical appraisal, have already been in development for nearly a decade. This is too long. No further undue delays should be tolerated. Patients expect - and have a right to expect - that the quality of their doctors is regularly assessed and assured. This is about the safety, effectiveness and appropriateness of the healthcare that citizens receive.

68.  The GMC's consultation proposed a phased approach to implementation that would potentially give organisations that are not ready an additional five years after 2011. The majority of those responding to the consultation apparently agreed.[13]

69.  This potential extension is perverse because it apparently licences organisations with clinical governance systems that are not fit for purpose to continue in that state. It is unacceptable because patients and the public expect the NHS to have these systems in place now.

70.  Picker Institute Europe believes, and asks the committee to consider, that:

  • the introduction of revalidation should drive improvement, not encourage complacency;
  • a firm target date should be set for revalidation to go live, with the expectation that all areas and healthcare organisations will implement revalidation from that date;
  • those areas or organisations that appear not to be ready should receive targeted assistance to achieve the implementation date.

71.  Roughly 18 months remain for piloting. While the early adopters are engaged in piloting (or learning from it), weaker organisations should be putting their systems in order. Therefore:

  • organisations should be required to be ready to introduce revalidation within 18 months of early adoption;
  • organisations should be required to introduce revalidation within 24 months of early adoption.

November 2010


4   Examples include the Consultation satisfaction questionnaire (Poulton 1996); Consultation and relational empathy measure (Mercer 2004; Mercer 2005); OPTION scale for measuring patient involvement (Elwyn et al 2003); QUOTE instrument (Sixma et al 1998, 2000). See "The quality of patient engagement and involvement in primary care", Parsons S et al, Kings Fund, London 2010. Back

5   Consent: patients and doctors making decisions together, GMC, London 2008. Back

6   Tomorrow's Doctors, GMC, London 2009. Back

7   High Quality Care for All, Department of Health, London 2010. Back

8   Equity and excellence: liberating the NHS, Department of Health, London 2010. Back

9   This evidence is published at www.investinengagement.info. Back

10   Capturing opinions from the front line, King's Fund, London, 2010. Back

11   See, for example, Seeing the person in the Patient, Goodrich J and Cornwell J, King's Fund, London 2008. Back

12   Equity and excellence: Liberating the NHS, Department of Health, London 2010; and An Information Revolution: a consultation on proposals, Department of Health, London 2010. Back

13   We note, however, that while it remains committed to a phased approach, no time period is specified in the GMC's own response to the consultation. Back


 
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