Written evidence from the Hospital Consultants
and Specialists Association (REV 29)|
The Hospital Consultants and Specialists Association
(HCSA) is a Professional Association and non-political Trade Union
affiliated to the TUC.
It is the only Trade Union that exists solely to represent the
views and interests of senior hospital doctors.
However, in addition it takes seriously the wider
agenda of healthcare delivery in the UK. The membership is drawn
from a wide range of specialities in the NHS and individual members
are currently involved in many innovations and quality programmes
aimed at improving the functioning of the service.
The organisation has been following closely the discussions
concerning Revalidation and was pleased to be able to respond
to the recent GMC consultation document, "Revalidation:
The Way Ahead".
As professionals, clearly we take very seriously
the importance of continually improving patient safety, and will
continue to support all legitimate methods of achieving this.
- Despite a large amount of effort and resource
since 2005, no doctor has yet been revalidated.
- There is no consensus on how best to approach
- The proposed basis of revalidation is Strengthened
Medical Appraisal (SMA).
- To appraise 37,000 NHS Consultants (England)
in this way would be likely to cost the NHS approximately £74,000,000
- There is no evidence base for the value of SMA
in rooting out poorly performing doctors.
- Strengthening existing Clinical Governance systems
for specialities rather than individual doctors would be a better
and cheaper way of protecting patients.
1. Consultant appraisal was first introduced
in 2001. Although it has been subject to some criticism in that
it could be done in a superficial way,
nevertheless, the HCSA believes that it has significant value
when done properly and carefully. It is clearly beneficial for
senior staff to spend time, with an appraiser, reflecting on their
practice, reviewing outcomes and achievements, and setting professional
2. Since the publication of Dame Janet Smith's
Fifth Shipman Report
and the DoH response to this, the concept of revalidation of Consultants
has been proposed and discussed extensively. However, no real
consensus has been reached on how this should be done in a meaningful
3. The GMC undertook an extensive consultation
on Revalidation, and its response was published in October 2010.
The HCSA was one among many organisations which responded to this
4. Many of the same themes and concerns were
raised by all the bodies, and in this response the HCSA does not
see any value in merely reiterating them. We wish to concentrate
on one particular aspect which, in our view, has been addressed
only in very general terms.
5. At the heart of the proposal for revalidation
is the concept of Strengthened Medical Appraisal, SMA which would
include a requirement to provide positive proof against the four
domains and twelve attributes defined by the GMC. But all the
responses to the GMC consultation have indicated that, despite
its worthy intentions, the process is grossly over-complicated
and the Revalidation Pilot Toolkit a deeply "user un-friendly"
piece of software.
6. The HCSA fully agrees with these concerns,
and in addition have attempted to estimate the financial costs
7. An SMA will inevitably take considerably more
time than conventional appraisal, both for the appraiser and the
appraisee. It should be noted that appraisals are now being used
as part of the legal process, and some appraisers have already
been summoned by the courts and cross-examined over appraisals
which they have performed. This adds to the necessity for the
preparation of the appraiser to be as meticulous as that of the
appraisee, and it is deemed essential that appraisers are thoroughly
trained, and also have regular "time out" for supervision,
8. There are approximately 37,000 Consultants
in England. To appraise each of these would require approximately
5,000 Consultant appraisers, each performing an average of eight
appraisals per year.
9. Using rather crude figures the appraisee would
require a minimum of six programmed activities (PAs) to prepare,
undergo and complete the appraisal documentation, which approximates
to 222,000 PAs per year. This is probably a conservative figure
for some specialities. (A PA equates to four hours of Consultant
10. At a notional rate of about £175.00
per PA this equates to a total cost of £38,850.000 per annum.
11. 5,000 appraisers performing eight appraisals
per year, and utilising five PAs per appraisal equates to 200,000
PAs. Again at a notional rate of £175 per PA this equates
to £35,000,000. This figure does not take into account the
cost of training and training time required, and the time out
12. While the HCSA accepts that these figures
are rather crude, nevertheless, we feel that they give a reasonably
accurate reflection of the costs involved, and it totals a staggering
£73,850,000 per annum. It must be emphasised that
this is only for the Strengthened Appraisal of NHS Consultants
in England. It does not include General Practitioners.
13. These calculations do not take into account
Consultants being taken away from direct patient care, and the
associated but hidden costs of delayed patient management.
14. Despite the good intentions the fact remains
that SMA, as suggested, lacks any substantial evidence base that
it is any better at identifying poorly performing doctors than
the existing mechanisms based on the GMC "Good Medical Practice"
Guidelines and good Clinical Governance Systems.
15. Doctors are already the most regulated profession
in the UK (and possibly the world). Since the horrors of Shipman
et al the evidence is that strengthening of existing systems
of regulation has served to identify problem doctors at a much
earlier stage. Lack of care and harm to patients is now generally
related to systems failure rather than individual doctors (e.g.
Mid Staffordshire NHS Trust).
16. It is the view of the HCSA that, rather than
committing large resources to revalidation of individual doctors,
time and money would be better spent on reviewing the performance
of clinical specialities and Trusts. Such work is already being
led by the Care Quality Commission.
17. There is no "new money" to fund
SMA (or revalidation). The costs must be found from within existing
NHS budgets. Trusts are being asked to improve efficiency and
make huge savings. SMA is not consistent with these aims and without
evidence, does not represent good use of senior hospital doctors'
- It is the considered view of the HCSA that Strengthened
Medical Appraisal as the basis for Revalidation lacks a credible
evidence base and would prove hugely costly to implement.
- Conventional appraisal has some merit and should
be continued but it needs to be strengthened.
- A better approach would be to enhance overall
Clinical Governance procedures for clinical specialties rather
than focusing on individual doctors. This would be a better and
cheaper way of improving patient safety.
31 Hospital Consultants and Specialists Association:
Review of the readiness of appraisal and clinical governance to
support relicensure of doctors, KPMG, 2008
Shipman Inquiry, 5th Report Strengthening NHS Medical Appraisal
to Support Revalidation in England