Written evidence from The Health Foundation
(REV 21)
1. ABOUT THE
HEALTH FOUNDATION
1.1. The Health Foundation is an independent
charity working to continuously improve the quality of healthcare
in the UK. We are here to inspire and create space for people
to make lasting improvements to health services.
1.2. We want the UK to have healthcare systems
of the highest possible quality - safe, effective, person-centred,
timely, efficient and equitable. We believe that in order to achieve
this, health services need to continually improve the way they
work.
1.3. The Health Foundation has submitted evidence
to previous Health Select Committee inquiries and would be glad
to field a subject matter expert to provide oral evidence if this
would be helpful.
2. EXECUTIVE
SUMMARY
2.1. The Health Foundation supports revalidation
of doctors on the assumption that it will improve the quality
and safety of patient care. It is important that the process is
robust but not onerous for participating doctors.
2.2. There is likely to be a link between revalidation
and improving the quality of patient care but this has yet to
be proven. Therefore the implementation and roll-out of revalidation
must be strongly influenced by the developing evidence base through
ongoing research, pilot evaluation and expert consultation.
2.3. Revalidation remains controversial amongst
many doctors, in part because there is a lack of clarity about
its purpose as well as concerns that the process as currently
designed is disproportionate. If revalidation is make a positive
contribution to the care that doctors give and patients receive,
and not become another exercise in box ticking, it is vital that
a clear consensus emerges on what it should achieve and how this
should be achieved.
2.4. The Health Foundation is broadly supportive
of the General Medical Council's (GMC) response to their 2010
consultation on revalidation, particularly in the GMC's commitment
to building the evidence base for revalidation and its implementation.
2.5. As currently designed, there is a risk that
revalidation does not meet the principles of modern effective
regulation, most notably because it is insufficiently risk-based
and overly centralised. The founding principle of revalidation
should be the locally-based annual appraisal. This must have a
summative component ("is this doctor safe?") and a formative
one ("is this doctor committed to continuous improvement
and how should he or she go about delivering this?").
3. WHAT WE
KNOW
Evidence on revalidation
3.1. Although revalidation is new to the UK,
the idea is not a new one. "Relicensure", a process
in the USA similar to the UK's revalidation, is well established.[14]
As are, to a lesser extent, similar processes in Australia and
New Zealand.[15]
3.2. The health services of these three countries
are however very different to that of the UK and there is an absence
of focused research that evaluates the introduction of, or impact
on professional development, quality improvement and patient safety
of revalidation and similar processes.
3.3. Revalidation in the UK has had a controversial
history since its conception.[16]
It has been conceptualised and designed in a very different environment
from the one in which it will be implemented. In particular the
fiscal crisis and the plans to design a more devolved and less
centralised health service will impact on how revalidation is
perceived and made operational.
3.4. The development of revalidation has been
a lengthy process of consultation and compromise, led in large
part by the Medical Royal Colleges. There are benefits to such
a speciality-led process but there are also risks. Enthusiasts
tend to design processes that are too resource intensive, too
complicated, untargeted and insufficiently proportionate.
3.5. The Chief Medical Officer's (CMO) 2008 report
asserted that revalidation has three main aims relating to relicensure,
recertification and further investigation or remediation.[17]
3.6. The CMO's report appears to include secondary
aims, which include generating "further focus and energy
to doctors' desire to keep up to date and improve their practice
through continuous professional development and reflective practice,
[which] is one of several mechanisms for improving the quality
and reducing the risks of patient care".[18]
The extent to which revalidation can achieve all of these aims
is unclear.
3.7. This weakness of evidence means that the
implementation and roll-out of revalidation must be strongly influenced
by the developing evidence base through ongoing research, pilot
evaluation and expert consultation.
Developing the evidence base
3.8. The Health Foundation is currently funding
independent primary research into revalidation.[19]
This research seeks to explore policy and decision makers' views
of the origins, definitions, and potential purpose of revalidation.
It will also address how revalidation relates to concerns about
assuring and promoting patient safety and quality of care. It
is led by Dr Julian Archer at Peninsula College of Medicine &
Dentistry, Universities of Exeter and Plymouth and will be published
in 2011.
3.9. Our research is only part of the story.
Public perceptions and clinical experience are also highly relevant
in this context. The Health Foundation plans to support a second
project that will assess the impact on clinicians and clinical
practice within the pilot sites, including exploration of the
extent to which revalidation might help to deliver a new model
of professionalism (see paragraphs 3.12 to 3.15 below).
3.10. The evaluation of pilot processes across
the four countries of the UK needs to be thorough and feed formatively
into the implementation and roll-out of revalidation. Our understanding
is that independent evaluations are currently being commissioned
by the GMC, which is essential for this process of revalidation
to be successful.
3.11. The international evidence base is essential
for guiding the development of revalidation, and the Health Foundation
is pleased that the GMC plans to "conduct a large-scale literature
review looking at clinical governance and appraisal, clinical
audit, patient and public involvement in the delivery of healthcare
and the evaluation of health professionals' practice… [and]
learn from the experiences and research of international and industry
experts. The latter will be informed by an international symposium
to be held in early December 2010."[20]
Learning from this symposium, sponsored and co-designed by the
Health Foundation, must influence implementation.
The role of "New Professionalism"
3.12. The Health Foundation intends to launch
a programme working with healthcare professionals and professional
bodies to explore a new model of professionalism which we believe
is required to respond to the context and challenges of medical
professionalism in a changing health landscape and society
3.13. The need for a new model of professionalism
has been recognised in academic literature, in the work of leading
professional organisations and within policy circles. For example
the Royal College of Physicians has undertaken work that redefines
what it means to be a doctor in the 21st century[21]
and this and other work has been summarised by Stanton and Lemer.[22]
3.14. We believe that the new model of professionalism
has a number of components. It places a stronger emphasis on accountability,
recognises the benefits of creating a different dynamic between
patients and professionals, assumes a stronger sense of responsibility
for how the wider health system works and for all dimensions of
quality. It promotes a constant drive to improve what clinicians
do and accepts change as a virtue rather than a threat. It commits
to using a range of different approaches to develop and mobilise
knowledge about how to improve care and build the formal evidence
base underpinning improvement. Finally, it emphasises the importance
of clinicians working as part of multi-disciplinary teams and
across professional and organisational boundaries.
3.15. We are interested in understanding the
role that revalidation may play in encouraging doctors to think
differently about their role in the health system. Revalidation
presents a valuable opportunity to embed the beliefs and qualities
of the new model of professionalism in what it means to practice
medicine in a modern context and for the next generation of clinicians.
4. CONCLUSIONS
AND RECOMMENDATIONS
4.1. The process must be proportionate and
based on local appraisal. The process must be robust without
being onerous. It must be informed by principles of modern regulation.
4.2. Revalidation must be influenced by high
quality research and evaluation. It would be sensible to ensure
that learning from the pilot programmes and the Health Foundation
research is thoroughly considered during roll-out.
4.3. Revalidation should be a vehicle for engagement
in the principles of continuous improvement and professionalism,
not just clinical skills. Revalidation is an opportunity to ensure
that doctors are engaging with the evolution of their profession,
rather than keeping their narrow clinical skills updated. While
technical competence is of great importance it is not, in and
of itself, sufficient. Revalidation should support the development
of medical professionalism in a modern health system.
November 2010
14 Dale D. Recertification
in Internal Medicine - The American Experience. Ann Acad Med
Singapore 2007;36:894-7; Dauphinee D. Revalidation of doctors
in Canada. BMJ 1999;319(7218):1188-1190. Back
15
Newble D, Paget N, McLaren B. Revalidation in Australia and New
Zealand: approach of the Royal Australasian College of Physicians.
BMJ 1999;319:1185-8. Back
16
Salter B. Governing UK medical performance: A struggle for policy
dominance. Health Policy 2007;82(3):263-275; and Adam J.
Revalidation of doctors. Clinical Radiology 2008;63(8):853-855.
Back
17
Medical Revalidation - Principles and Next Steps: The Report of
the Chief Medical Officer for England's Working Group. London:
Department of Health, 2008. Back
18
Ibid. Back
19
What is revalidation? http://www.health.org.uk/areas-of-work/research/what-is-revalidation/
Back
20
GMC response to revalidation consultation, October 2010, p9.
http://www.gmc-uk.org/ GMC_Response_to_Revalidation_Consultation__October_2010__Full_report.pdf_35892368.pdf Back
21
Royal College of Physicians (2005). Doctors in Society; Medical
professionalism in a changing world.
http://www.rcplondon.ac.uk/pubs/books/docinsoc/ Back
22
Stanton E and Lemar C (2010) Engaging with clinical communities
(unpublished); also see Levenson R, Dewar S, Shepherd S (2008)
Understanding Doctors - Harnessing Professionalism, The Kings
Fund.
http://www.kingsfund.org.uk/publications/understanding_docs.html Back
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