Revalidation of Doctors - Health Committee Contents

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.[31] 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 this.
  • 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 per annum.
  • 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,[32] 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 objectives.

2.  Since the publication of Dame Janet Smith's Fifth Shipman Report[33] 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 way.

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 consultation.

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 involved.

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, as recommended.

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 time).

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 for supervision.

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' time.


  • 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.

November 2010

31   Hospital Consultants and Specialists Association: Back

32   Review of the readiness of appraisal and clinical governance to support relicensure of doctors, KPMG, 2008 

33   Shipman Inquiry, 5th Report Strengthening NHS Medical Appraisal to Support Revalidation in England 

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Prepared 8 February 2011