Revalidation of Doctors - Health Committee Contents

Written evidence from Dr Foster Intelligence (REV 35)


Dr Foster Intelligence is joint-venture company half-owned by the Department of Health. Dr Foster provides clinical benchmarking services to hospitals and commissioners. It also publishes information about outcomes achieved by different healthcare providers in the UK. Dr Foster is committed to achieving a more patient-centred and transparent health service and consequently operates to a high level of transparency and accountability itself. Oversight of the company is provided by an independent ethics committee.


2.1  Dr Foster Intelligence supports the introduction of revalidation and believes that it is an important step in ensuring high quality healthcare.

2.2  We understand the reasons for delay in the introduction of revalidation and agree that the system must be proportionate, cost effective and supported by clinicians if it is to work. That said, we are concerned at the length of time it is taking to implement a system of revalidation.

2.3  We have recommendations in relations to revalidation in two areas:

2.3.1  We believe if it is to be cost effective, revalidation must be looked at in the broader context of initiatives to improve the quality of health services through monitoring of standards. If done in a way that complements these broader initiatives it will prove cost effective. Quality improvement initiatives are often specific to the devolved administrations within the United Kingdom. However, there is sufficient commonality of approach to be able to take useful steps to ensure that revalidation is developed in line the broader objectives of quality improvement and regulation.

2.3.2.  We believe that a large part of the cost of revalidation is collection of data in the areas of patient feedback and clinical outcomes. However we believe that by using existing data resources more effectively the costs can be managed.


3.1  There are a number of policies and initiatives currently to monitor and improve quality in the NHS. These include:

3.1.1  The outcomes framework and transparency (England only)
This outcomes framework a proposed set of outcome metrics and supporting measures defined by the National Institute of Clinical Excellence that will be used to judge the overall quality of the NHS. Another proposed policy aligned with this, is a plan to encourage greater transparency around outcomes. This is intended to ensure accountability not just to national government but also to local populations and individual patients.

3.1.2  Regulation (CQC in England, the Healthcare Inspectorate in Wales etc.)
The healthcare regulators monitor a wide range of data and have responsibility for ensuring quality of healthcare providers.

3.1.3  National clinical audit (can be UK wide but participation is voluntary)
These are a range of specialty specific audits (data collections, databases and benchmark reports) designed to track measures of quality for secondary care specialists and allow comparison of outcomes between clinicians.

3.2  There are some clear principles that underpinning all of these initiatives as well as revalidation. These principles are:

  • Clinicians should be auditing and comparing measures of clinical efficacy and safety including both outcome and process measures.
  • Clinicians should have access to data about what patient think about the services they provide and understand where there expectations are not being met.
  • Data should be shared with colleagues and clinicians should receive feedback from colleagues about their practice.
  • Appropriate comparative measures of performance derived from these data should be published. There remains different views as to the appropriate level of transparency in health systems but where transparency is regarded as important, revalidation can play an important role in supporting it.


1.  Where clinical audit already exists and specialty associations have recommended outcomes for monitoring, it should be mandatory to review this evidence as part of NHS appraisal. This could be introduced now.

2.  Where there are no relevant national audit standards and outcome measures, such standards should be developed. The use of local audit - as for example, proposed for GP revalidation - is of limited benefit. We would like to see a timetable for establishing national standards for audit that include an element of outcome measures for all doctors.


In the areas of clinical outcomes and patient safety the key data resources are:

  • Primary care clinical data.
  • Routinely collected hospital data (HES, PEDW, HIS, ISD).
  • National clinical audit data.

4.1  There are a number of ways in which these data are not well suited to revalidation. The key issue are:

4.1.1.  Primary care clinical data

There are no requirements on GPs to systematically record any data on their clinical systems. These systems exist for the benefit of the GP to support the administration of their practice and the management of patients. However, these data provide the most extensive source of information with which to understand the clinical quality of practice.

A requirement on GPs to meet minimum data recording standards is also increasingly recognised as vital to underpin the broader management and quality monitoring of the health system. Revalidation provides an important mechanism through which it will be possible to develop consistent and accurate records of primary care.

4.1.2  Routinely collected hospital data

Routinely collected hospital data is being proposed as a source of data for revalidation by some specialty associations. A number have put forward clinical indicators that can be derived from these data. However there are a number of aspects of the data that mean it is not as effective as it might be in supporting either revalidation or, more broadly, monitoring of quality. In particular:

  • There is no accurate record of the doctor or anaesthetist performing any procedure.
  • There is no "present on admission" flag to distinguish the diagnoses with which the patient presented at hospital from those which may have resulted from treatment.
  • There are inadequate rules around the coding of complications such as Deep Vein Thrombosis.

Modest investment in the development of routine data sources could greatly reduce the costs of ensuring doctors have the data they need to support revalidation.

A related issue with routine data is lack of clinician involvement in the recording of these data which can result in inaccuracy and mistrust of the data. Secondary care providers need to take steps to ensure clinicians take an active role in ensuring information is recorded correctly.

4.1.3.  National Clinical Audit

The key problem with National Clinical Audit data is the cost of completing the data, the consequent lack of completeness of many records and the lack of independent checks to identify where data is incomplete.

Stronger requirements on clinicians to participate in audit would help. We would also like to see routine comparisons between the hospital's routine records and the clinical audit record to ensure completeness and accuracy.


1.  Minimum standards for data recording on clinical systems are established for GPs

2.  A review of routine hospital data is implemented and the data set is adapted to enable it to best support revalidation.

3.  National Clinical Audits are required to regularly compare themselves with official records of activity to identify where data is not being recorded

November 2010

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Prepared 8 February 2011