Revalidation of Doctors - Health Committee Contents

Written evidence from The Health Foundation (REV 21)


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.


2.1.  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?").


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.


4.1.  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?  Back

20   GMC response to revalidation consultation, October 2010, p9. GMC_Response_to_Revalidation_Consultation__October_2010__Full_report.pdf_35892368.pdf 

21   Royal College of Physicians (2005). Doctors in Society; Medical professionalism in a changing world. 

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. 

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