2012 accountability hearing with the General Medical Council - Health Committee Contents


2  Revalidation of doctors and remediation of practice

Scrutiny of revalidation

15. From 3 December 2012 the doctors registered with the GMC and licensed to practise medicine in the UK will be under new requirements to provide evidence of their ongoing fitness to practise.[14] This revalidation of doctors is a process designed to provide further assurance to the public that the doctors the GMC has licensed to practise medicine in the UK are up to date in their medical understanding and fit to practise medicine.

16. The GMC had 245,903 doctors on its register in 2011, of which 90,639 (37%) had their place of primary medical qualification outside the UK (see Table 1). 232,769 doctors were licensed by the GMC to practise medicine in the UK.[15] It is in the interests of good medical practice that all licensed doctors are subject to regular reviews of their practice.

Table 1: place of primary medical qualification of doctors on the UK medical register, 2011
Place of primary medical qualification Registered doctors, 2011
UK155 264
IMG*66 608
EEA or Switzerland 24 031
Total245 903

Source: The state of medical education and practice in the UK 2011, General Medical Council 2012, pp 18-19

*IMG—International Medical Graduates: doctors who are either (a) nationals of a country outside the UK, the EEA or Switzerland who graduated from a medical school outside the UK or (b) UK nationals who have graduated from a medical school outside the UK, the EEA or Switzerland.

17. This Committee has over the course of this Parliament taken a close and continuing interest in the proposals for revalidation of doctors registered to practise medicine in the UK. We first examined the issue in October 2010, questioning the General Medical Council on its response to its consultation Revalidation: the way ahead which ran from March to June 2010. In our report on Revalidation of Doctors, published in March 2011, we indicated that there were a number of aspects of the revalidation process which required continuing scrutiny as part of the annual accountability exercise with the GMC, namely:

  • What happens in cases where the performance of an individual doctor gives rise to concern
  • The operation of the appraisal system, and its consistent implementation across the country
  • The administrative burden that appraisal and revalidation place on doctors
  • The way in which patients and colleagues are involved in revalidation
  • Where Responsible Officers who are currently based in PCTs will be sited
  • The adequacy of the powers available to the GMC to ensure that doctors for whom English is a second language are able to communicate effectively with their patients.

Progress on revalidation

18. The Committee indicated in July 2011 that the GMC had a considerable amount of work to do before the implementation of revalidation as proposed in late 2012. In response the GMC stated that revalidation remained its 'number one priority': "we are determined and on track to introduce a system by late 2012 (subject to the Secretary of State's approval)".[16] The Department of Health in England (DH(E)) told us of 'steady progress towards readiness for implementation [of medical revalidation] in England',[17] and the GMC itself stated that it was confident that revalidation could start in early December 2012, should the Secretary of State agree to the commencement of the relevant legislation.[18] Since we held our hearing with the GMC on 4 September the Council has reported to the Secretary of State that the revalidation system is ready to be implemented. The Secretary of State announced on 19 October that revalidation would start in December 2012, and the Privy Council has now enacted the regulations governing the licensing and revalidation of doctors proposed by the GMC.

19. The GMC told us that following the expected date of commencement it would inform every doctor on the register of their expected date of revalidation by the end of 2012. The GMC expects 20% of licensed doctors to be revalidated between April 2013 and the end of March 2014, with the 'vast majority' undergoing revalidation by the end of March 2016.[19]

20. We welcome the fact that the system of medical revalidation is at last ready to be implemented. The purpose of the system should be to give the public greater assurance that the medical professionals treating them are being consistently and regularly appraised for their competence and fitness to practice. Although commencement of revalidation is a welcome first step towards providing this assurance, it is essential to recognise that its benefits will only be realised if the system is effectively managed and rigorously monitored.

Implementation of revalidation

21. In its 2011 report on revalidation the Committee identified two principal areas of concern in respect of the organisational readiness for revalidation:

  • the operation of the appraisal system, and its consistent implementation across the country; and
  • where Responsible Officers currently based in primary care trusts will be sited in future.

22. All licensed doctors are to be assigned to a Responsible Officer (RO), also a registered and licensed medical practitioner, who is responsible for conducting the revalidation process. ROs are located in organisations - 'designated bodies' - such as NHS hospital trusts and (at present) primary care trusts, medical deaneries and private healthcare providers. The GMC told us that it had contacted over 600 ROs to date and was assisting them in scheduling initial revalidation dates and issuing guidance on helping them to make revalidation recommendations.[20]

23. The GMC further reported that 'the vast majority of designated bodies are ready or very close to being ready for revalidation', with over 90% of doctors in England connected to bodies 'ready or very close to being ready' for revalidation.[21] 'Sufficient numbers' of trained appraisers were either in place or will be in place to provide the capacity for revalidation in 2013.

24. The Department of Health in England (DH(E)) reported the following from the latest revalidation Organisational Readiness Self-Assessment (ORSA) exercise for the year to March 2012:

  • "Almost 100% of doctors have a responsible officer, 98% have a trained responsible officer
  • 73% of doctors had an annual appraisal that meets the basic requirements for revalidation
  • 85% of doctors are in designated bodies with a medical appraisal policy
  • 86% of doctors are in designated bodies with sufficient numbers of appraisers
  • 92% of doctors are in designated bodies which monitor the fitness to practise of doctors
  • 97% of doctors are in designated bodies which have a process for investigation of capability, conduct, health and fitness to practise concerns
  • 58% of doctors are in designated bodies with a policy for reskilling, rehabilitation and remediation."[22]

25. Una Lane, the GMC Director for Continued Practice and Revalidation, told us that the GMC considered the implementation of revalidation to be "a shared responsibility between the GMC and the four health departments and healthcare organisations across the UK". Ms Lane set out the principles which would underpin the timetable for revalidation of licensed doctors:

Patient safety is paramount. This is not about delaying taking action in relation to an individual doctor until such time as a revalidation recommendation is due, so that is an important principle. We think that in the first year every single healthcare organisation must be involved in making recommendations to us—not only organisations in the NHS but organisations right across the independent sector and locum organisations across the UK so that no particular group of doctors is left behind. We have also agreed with all of the organisations making recommendations to us that the doctors that are recommended in the first year must be representative of the population of doctors as a whole in each individual organisation. With that in mind, each of the four health departments [in the UK] has put together its implementation plans.[23]

In England, Ms Lane expected that the senior doctors in the Department of Health—the NHS Medical Director and the Chief Medical Officer—and responsible officers in strategic health authorities would undergo revalidation first of all, followed in the first quarter of 2013 by all other responsible officers across England.

26. While the GMC was clear that healthcare organisations across the public, independent and locum sectors should all be involved in revalidation in its first year, and that the candidates for revalidation in each organisation should be representative of the population of doctors in that organisation, Una Lane also indicated that revalidation was an activity which should be engaging all its registrants now, irrespective of when they were likely to receive their dates for revalidation recommendations:

It has always been important for us to get across to responsible officers and all organisations that revalidation is not a point-in-time assessment. The point of revalidation is that it should be a continuing evaluation of a doctor's practice close to where the doctor provides care in the workplace, in hospital or in primary care organisations or in GP practices. All doctors should now be doing what they need to do in order to be revalidated. They should be participating in appraisal, linking to an organisation that will support them with their revalidation, evaluating the information that is available to them in order to understand where they are and engaging actively in an appraisal process. Organisations should also be ensuring that they are identifying poor performance at an early point in the process and not simply waiting for the point where a revalidation recommendation is due to the GMC.[24]

She further confirmed that responsible officers who had identified concerns about a doctor's practice before the date for revalidation were expected to take action on such concerns immediately.[25]

27. We welcome the approach which the GMC is taking to ensure that all organisations responsible for doctors are engaged in the revalidation process from the outset, and that the doctors identified for revalidation are representative of the doctors across each organisation. We recommend that the practical implementation of this approach is monitored to ensure that candidates presented for revalidation are in fact properly representative.

28. Revalidation is a process which is designed to encourage continuing evaluation of a doctor's practice at the local level. We support the General Medical Council's message that all doctors should be considering now the steps which revalidation will require them to take in relation to their practice, irrespective of the date on which their revalidation recommendation falls due.

Revalidation and doctors

29. In our 2011 report on revalidation we identified two principal areas of concern in respect of doctors and revalidation:

  • what happens in cases where the performance of an individual doctor gives rise to concern; and
  • the administrative burden that appraisal and revalidation place on doctors.

30. The GMC told us that almost 7,000 doctors had helped with the revalidation model, through pilots and other means. Close working with the medical royal colleges and faculties, in part based on the example set by the Society for Cardiothoracic Surgery (as this Committee recommended in 2011) had led to the issue of specialty guidance for doctors providing supporting information for annual appraisals and eventual revalidation. As a result the process was said to be 'proportionate, effective and valuable for doctors'.[26] 73% of doctors in England had had an annual appraisal in the year to March 2012.

31. Una Lane indicated that concerns around the performance of doctors would be addressed initially at the local level, as at present, and ought to be addressed by the responsible officer.[27] In addition the GMC had put in place a group of 16 employer liaison advisers "right across the UK" who could support responsible officers in dealing with "emerging concerns" about doctors and providing advice as to when the GMC ought to engage with the matter and examine a doctor's registration.

32. Although the GMC was keen to stress that the thresholds for referrals of concern to the GMC should be applied by responsible officers in the same way as they had hitherto been applied by medical directors responsible for performance, Niall Dickson acknowledged that the revalidation process might well identify concerns about a practice which would not have been picked up previously: "we believe that we are putting in place something that really will help to drive up the quality of medical practice in this country".[28]

33. The introduction of employer liaison advisers to support responsible officers in assessing concerns around a doctor's practice is welcome. We expect this initiative to support earlier and more robust action in identifying such concerns and ensuring that they are appropriately dealt with.

REMEDIATION

34. In our 2011 report on revalidation we raised concerns about how Responsible Officers were expected to deal with the cases of doctors whose performance gave rise to concern.[29]

35. The purpose of revalidation is stated by DH(E) to 'provide a positive affirmation that licensed doctors are up to date and fit to practise'.[30] Nevertheless the Department acknowledges that the system will identify 'a small number of doctors who fall short of the high professional standards expected and whose practice gives cause for concern". DH(E) convened a remediation steering group chaired by Professor Hugo Mascie-Taylor which reported in December 2011 on the current processes for remediation of clinical competence. This report states that:

"The need for a good and consistent approach to remediation is independent of the new regulatory process of revalidation that will be introduced by the GMC for all licensed doctors. However, improved clinical governance and the more robust annual appraisal processes which will underpin revalidation may well mean that, at least in the short-term, more doctors are identified who have a clinical competence and capability issue, and are in need of remediation."[31]

36. The GMC's role in remediation is concerned with a doctor's fitness to practise. The Mascie-Taylor report states that "A doctor may be required by the GMC, through a fitness to practise process, to undertake a course of remediation as a condition of remaining on the register. The responsibility to ensure that the remediation happens rests with the doctor and they are re-assessed after any remediation as a pre-cursor to returning to full independent practice."

37. The British Medical Association, while expressing overall support for the aims and implementation of revalidation, has raised significant concerns over the potential financial burden on the colleagues of those doctors required to undertake remediation procedures resulting from the revalidation process.[32] It is argued that such colleagues will have to make arrangements for the work of the doctor under remediation to be covered, which will incur a financial burden which those doctors should not have to shoulder. Mascie-Taylor estimated the cost of locum cover for doctors unable to practise as a result of remediation to be as much as £200,000 per doctor per year. The BMA has pressed the Department of Health to develop a 'consistent, fair and equitable approach' to funding remediation activities.

38. The Royal College of Radiologists, in its evidence to us, criticised the lack of effective systems for the remediation or retraining of doctors where appraisal or revalidation has identified a need for such support.[33] It considered the conclusions of the Mascie-Taylor report to be lacking any clear solution, and questioned the apparent failure of the GMC to actively address the lack of remediation processes.

39. We were concerned to learn from the Department that only 58% of doctors were affiliated with designated bodies which had introduced a policy for reskilling, rehabilitation and remediation, meaning that almost half of the GMC's registrants are practising in bodies where there is no such explicit policy in place.

40. Professor Sir Peter Rubin, Chair of Council at the GMC, suggested that the lack of a defined policy in so many designated bodies was not necessarily a cause for concern for doctors who took their professional responsibilities seriously:

[ . . . ] as a doctor, I and all doctors have a responsibility to keep ourselves up to date and fit to practise and not to get into that position [of requiring remediation of practice] in the first place. It is very important, as a doctor, that I say that.[34]

Where, for whatever reason, a doctor is found to need remediation, there have always been, over all my years in practice in the NHS, ways of achieving that. There is a difference [ . . . ] between organisations that have a written policy and those that do not yet have one. But we have no reason to think that revalidation should be further delayed while waiting for organisations to have their written policy. We need to get moving and others can then be encouraged to catch up.[35]

He was not overly concerned that 42% of doctors were affiliated with designated bodies which had no formal policy for reskilling, rehabilitation and remediation:

Remediation has been a feature of the NHS for all the years that I have been in practice. It is not new. What is new is that one of the successes of revalidation before it even begins is that it has stimulated organisations that do not have effective evaluation and appraisal systems to develop them. That will inevitably start to uncover doctors who are not practising to the high standards that we would all wish to see. So it is bringing a sharp focus on remediation, but it would be wrong to regard remediation or revalidation as inextricably linked because they are not. Remediation is a long-term issue that has been around for a long time. You are quite right that not all organisations have a policy, but I would be astonished if all organisations had not at some stage had to remediate doctors. It has often been done in a very ad hoc way in the past. Organisations are playing catch-up to formalise things that have been done very informally over the years. Our view is very clear. The public would not understand it if there were any further delays. We need to start revalidation and those organisations that do not have a formal policy of remediation will need to play catch-up quite quickly.[36]

[ . . . ] From all my years of practice I would be astonished if these organisations did not have—informal arrangements for remediation. They might not have a written policy, but they would have an informal one.[37]

41. Una Lane and Niall Dickson indicated the arrangements being made to institute formal reskilling, rehabilitation and remediation policies in all designated organisations:

The revalidation support team [ . . . ] funded by the Department of Health, is working with those organisations to make sure that they have action plans to put those policies in place and to formalise what they may very well currently be doing informally. The responsible officer regulations now place clear responsibilities and duties on organisations to have such policies in place for remediation, rehabilitation and retraining. All organisations must meet those statutory duties and the revalidation support team will be working with those organisations to make sure they put the processes in place very swiftly.[38]

Most of these things—not only the responsible officer regulations which Una has referred to, but the obligation to give doctors appraisals—have been in their contracts for many years. It is interesting that revalidation is acting as a catalyst to put in place basically what we would term clinical governance arrangements that should have been in place some time ago. It is very encouraging. In every inquiry where things have gone wrong you see weaknesses in this kind of clinical governance, and the fact is that the [revalidation] system is strengthening it.[39]

42. An important feature of the new system of revalidation is its focus on establishing and assuring consistency of standards of practice for all doctors licensed by the GMC. We consider it vital that this system is properly supported by clear policies in each designated organisation responsible for doctors which establish what steps are to be taken if a doctor's practice is found to be deficient as a result of the revalidation process, and how the doctor is to be reskilled or remediated if such courses of action are considered appropriate.

43. We note that a proportion of the designated organisations which did not have a stated policy for reskilling, rehabilitation and remediation in place in March 2012 may well have had some formal or informal procedure for the remediation of practice. We also accept the argument that the lack of formal procedures in a number of organisations is no reason to delay the implementation of revalidation yet further. The GMC must nevertheless realise the substantial risk to the integrity of the revalidation programme that a lack of clear and consistent remediation programmes poses. Although we recognise the danger of focussing on form rather than substance, we believe that it is an essential element of good practice for all organisations which employ doctors to have clear and effective procedures for reskilling, rehabilitation and remediation of medical staff when that is necessary. We expect the GMC to ensure that this condition is satisfied as part of its continuing programme for the development of revalidation and we shall seek assurances about the progress made in this area at our accountability session with the GMC next year.

Consistency in revalidation

44. We were concerned to examine the arrangements for appraisal and revalidation of doctors in 'hard to reach' areas of practice, such as locum GPs and other doctors working in non-mainstream areas.

45. Una Lane told us that "locum doctors should be able to revalidate in the same way as every other licensed doctor [ . . . ] the responsible officer regulations have what they call designated organisations—a whole range of organisations—and have given them statutory duties to support doctors. Over 50 locum agencies in England are designated bodies under the regulations and must support their doctors with appraisal and revalidation."[40] She stressed that the information which doctors needed to provide for their appraisals and revalidation would be consistent and focused on the GMC's manual Good Medical Practice, whatever the nature of their own practice: the Department of Health was undertaking a re-procurement exercise to insert into the contracts of all locum agencies who are preferred suppliers to the NHS the requirement that they have systems in place to support revalidation.[41]

The responsible officer regulations that were introduced at the start of last year absolutely changed the role of locum agencies. They are no longer simply providing a service to the NHS in whatever way they see fit. In future, they must correspond to the statutory duties placed upon them in the same way as every other organisation and must make sure that they meet the requirements set out in their contracts.[42]

46. Niall Dickson confirmed to us that it is the Department of Health, rather than the GMC, which is responsible for this reprocurement. He regarded this as a means of driving up the performance and accountability of locum agencies and their responsibility for the practice of the doctors they employ:

[ . . . ] This is a transformation in what locum agencies have been to what we want them to be. It is not only what we want them to be but what the service wants them to be and what the Government expect them to be, hence the reprocurement of approved locum agencies that the Department of Health is going through now. We will have to see how it works in practice.[43]

47. Niall Dickson emphasised that the responsible officers in locum agencies would all be GMC licensed doctors who would, as responsible officers, have to base their recommendations for revalidation of doctors on "proper evidence". Employers of locum agencies, in the NHS or elsewhere, would also be expected to provide feedback to agencies on their performance to enable them to build on their practice, though it is not clear how this will be achieved. Una Lane told us that "the process should look the same for all doctors. The kinds of supporting information that individual doctors might bring [to support their revalidation] will vary depending on the nature of their practice or the specialty in which they work."[44]

48. Professor Sir Peter Rubin thought that employers also had a responsibility to judge on the fitness of a doctor for the purpose required:

[ . . . ] It is probably appropriate to draw a distinction between fit to practise and fit for purpose. A doctor may well be fit to practise, having kept up with their continuing medical education, etc., but they may not be fit for purpose for a particular role at a particular time. It may be because they have not had any sleep for 24 hours or it may be because their experience in another EU country is not relevant to primary care in this country, which is a recurring issue. We are the gatekeeper with regard to being on the register, having a licence and being fit to practise in a chosen specialty or primary care, but employers have a big responsibility to say, "Does this individual doctor meet our purposes for this role at this time?"[45]

49. We suggested, and Niall Dickson confirmed, that there is an important role for the GMC to monitor and, where appropriate, raise concerns about the performance of locum agencies in the discharge of their statutory duties in connection with revalidation.

50. Revalidation must ensure a consistency of approach to standards of medical practice in all sectors. It is especially important for public confidence and standards of practice that all designated organisations apply the same high standards to the evidence to be presented to the GMC. This is especially necessary in those sectors particularly at risk from commercial pressures in the engagement and tasking of doctors, where there have been recurrent concerns over the competence of doctors recruited for short-term and peripatetic engagements.

51. It is crucial to the integrity of the system of revalidation that the responsible officer is in all cases a doctor registered with and licensed by the GMC. As Sir Peter set out, with commendable frankness:

The clue is in the name, "responsible". We want somebody that we can nail, quite frankly. We want somebody who is going to be on our register that we can hold accountable for doing it right.[46]

52. Our previous reports have underlined the importance we attach to the role of the GMC as the "owner" and "leader" of the revalidation process. As revalidation is implemented, we look to the GMC to maintain this leadership role. This will involve actively monitoring and upgrading the operation of the new system to ensure that it fulfils its objective of providing greater assurance to patients about the quality and professionalism of doctors who provide care.

Language competence of licensed doctors

53. In our 2011 report on the GMC, we indicated our dissatisfaction with the present legislative bar on the routine testing by the GMC of the language competence of doctors from the European Economic Area and Switzerland who wish to practise medicine in the UK. We took the view that the current legal framework was at odds with good clinical practice, a situation which was clearly unacceptable. Public confidence in the medical profession required the issue to be addressed authoritatively.[47]

54. Niall Dickson updated us on progress towards a language testing regime for EEA and Swiss doctors. This is progressing in three areas:

a)  The Government proposes to bring forward for enactment by the end of 2013 an order under section 60 of the Medical Act 1983 which removes the prohibition in UK law on testing EEA and Swiss doctors for language competence.

b)  Even if the Medical Act is amended, the GMC will still be subject to the requirements of the relevant European directive—Directive 2005/36/EC on the recognition of professional qualifications—which prohibits universal language testing. The GMC and several of its European counterparts are pressing for amendments to the directive to give competent authorities in member States more authority to undertake language testing.

c)  Regulations governing the duties of responsible officers are to be amended to require them to assure themselves of the language competence of a doctor, by testing if necessary. These amendments are expected to be made in the course of 2013.

55. In the report of our 2011 hearing with the GMC we accepted the proposed amendment to the regulations governing responsible officer duties as a strictly short-term measure pending amendment of the Directive.[48] We were disappointed to learn from Niall Dickson that the GMC aspires only to have the relevant changes to domestic legislation—the Medical Act 1983 and the Medical Profession (Responsible Officers) Regulations 2010—in force by the end of 2013.[49] We consider that the proposed legislative changes to require responsible officers to assure themselves of the language competence of the doctors for whom they are responsible should be made as soon as possible, pending satisfactory amendment of the European Professional Qualifications Directive. In any event, we expect that should any issue about a doctor's language skills be identified, the responsible officer should be alerted immediately and should take appropriate action at once. The GMC and the Government should both confirm that this is their intention.

56. It is welcome that the GMC and the Government propose to amend existing legislation in order to require responsible officers to assure themselves of the language competence of any doctor licensed to practise in the UK. Nevertheless, the European directive which has the effect of prohibiting universal language testing by the GMC remains in effect. Although the European Commission adopted a proposal for amendment of the Professional Qualifications Directive in December 2011[50], we see no clear timetable for the effective revision of this legislation, and while the Department has told us that its officials are working closely with the department for Business, Innovation and Skills (the lead Department), the GMC and UK negotiators with the EU,[51] we have seen no clear statement of the Government's negotiating objective.

57. In our 2011 report we accepted the de facto work-around of local testing of language competence by responsible officers as a strictly interim measure. We are disappointed that no substantive progress seems to have been made at European level in addressing the underlying issue of language testing of doctors with primary qualifications from elsewhere in the EEA and in Switzerland. We continue to look to the Government, the GMC and the relevant EU institutions to produce a long-term solution to this problem within a timescale which reflects the potential risks to patients across Europe which are inherent in the present unsatisfactory situation. We ask the Government to set out in its response to this report the steps it is taking to seek amendment of the relevant Directive and the expected timetable.

Revalidation and patients

58. In our 2011 report on revalidation we found it unsatisfactory that little attention had been given to the issue of how to deal in the revalidation process with doctors whose practice gives cause for concern, particularly since it appeared that remediation of practice was the instinctive response to any indication of inadequacy. We concluded then that "while it is important to ensure that the rights and legitimate interests of individual doctors are safeguarded, the primary purpose of revalidation is to protect the interests of patients".[52] In its response to that report, the GMC indicated that should any deficiencies be identified in the revalidation process which gave rise to concerns about a doctor's fitness to practise, they should be raised with the GMC immediately through its existing procedures.

59. We asked what rights patients had to be informed about the outcome of appraisal processes and revalidation processes. Una Lane told us that all the information held by the GMC on doctors' revalidation was "open and transparent":

Where we take action in relation to a doctor's registration through our fitness-to-practise procedure, all those decisions are published on our website and linked to the individual doctor's entry on our register online. Similarly, where we withdraw the doctor's licence through the revalidation process, that information will be publicly available. Where doctors decide to relinquish their licence, again that information is publicly available online via our website. As far as appraisal is concerned, local healthcare organisations run an appraisal process. For most of us who have an appraisal, the output looks like a professional development plan for the following 12 months.[53]

Professor Sir Peter Rubin added that

[ . . . ] the GMC is the most transparent medical regulator in the world. Where we find a doctor's practice is impaired, that information and the reasons why we came to that conclusion are in the public domain. You can go on to our website and see this information. [ . . . ] The information is there and is well known to be there.[54]

60. Revalidation will introduce a more comprehensive framework for doctor appraisal and assessment, and public knowledge and understanding of the process and the degree of assurance which revalidation is intended to give will doubtless increase as more systematic appraisals take place and responsible officers make their submissions to the GMC as to whether practitioners are fit to practice. The information provided to the public on the GMC website states:

Most doctors already have a regular appraisal, but the focus and content can vary from one place to the next. The introduction of revalidation will mean that every licensed doctor will have their practice regularly evaluated against the standards that we set them as their regulator. We believe this will give you greater confidence in the doctors who treat you.

As part of their regular appraisal, doctors will be expected to think about their practice and consider the areas in which they could improve their practice in the future. Over time we believe this focus on doctors' development will help to improve both the care that patients receive and the safety of that care.

We'll revalidate a doctor based on a recommendation that we receive from their 'responsible officer'. This person will usually be the doctor's medical director. They will make their recommendation based on a doctor's appraisals over a five year period. They will only make such a recommendation if there are no outstanding concerns about that doctor's practice.[55]

61. The GMC is clear on its policy on publishing information about cases under its fitness to practice procedure where the practice of doctors has been found to be impaired. Information to the public about the revalidation process is also important in demonstrating how the system is functioning and helping to sustain confidence in the medical profession: but national policy on publishing information for patients and the public about the revalidation process is less than clear.

62. Una Lane suggested that the outcome of an annual appraisal undertaken at local level would normally resemble a 'personal development plan'. It seems to us unlikely that such a plan would be published as a matter of routine, especially where it might be interpreted to give rise to concerns about a doctor's practice, and we do not advocate routine publication of such appraisals.

63. Nevertheless, circumstances are bound to arise where appraisals identify the need for improvement in a doctor's practice in order to meet the standard required for a positive revalidation recommendation. If a doctor is under an obligation from a responsible officer to take steps to improve standards of practice, the rights of that doctor's patients to be informed of the obligation must be considered in proportion to the potential risk. We continue to believe that the arrangements for informing patients of circumstances where a doctor has been required to undertake remediation measures are not sufficiently clear. In view of the imminent implementation of the revalidation process we recommend that the GMC take steps to clarify these procedures as a matter of urgency, and certainly before our accountability session next year.

64. We raised with the GMC the adequacy of the requirement under revalidation for doctors to gather formal patient feedback once every five years. Una Lane saw this requirement as part of a process to ensure that all doctors sought patient feedback on their practice as a matter of course: "we know that it does happen in many GP practices currently, and in fact in many good hospitals, but it absolutely does not happen universally and it is not something that every licensed doctor is currently engaged in. We think it is [ . . . ] a big step forward and that revalidation will drive doctors to ensure that they seek such feedback from patients."[56] She nevertheless did not want to introduce a system that was overly burdensome.

65. The GMC says that patients will play 'an important role' in revalidation, and that each doctor will have been expected to have collected 'formal patient feedback' at least once in every five-year revalidation cycle.[57] Patient and colleague feedback questionnaires have been prepared by the GMC for employers and doctors to use: the GMC says they have been subject to in-depth research and testing with numerous doctors, patients and medical colleagues.[58]

66. The GMC reports strong support from patient groups for revalidation, and cites a 'patient Statement of Support' for revalidation which states that "patients and the public need to be sure that the doctor they consult or the doctor who is treating them is up to date and fit to practise". The King's Fund, reporting to us the findings of a study of public opinion on attitudes to revalidation which it had undertaken with MORI, indicated that the proposed inclusion of patient feedback within revalidation had met with "particular approval".[59]

67. There is clearly a balance to be struck in ensuring that doctors seek patient feedback on their practice at regular intervals: the feedback must be sought regularly enough to be worthwhile and to ensure that patients have a genuine opportunity to give their views, but the procedure should not be burdensome. We consider that the minimum frequency of feedback stipulated by revalidation — once only in the five-year revalidation cycle — risks sending the wrong message to patients about the importance of their feedback to the process. We consider that the requirement to seek feedback from patients at least once every five years does not sufficiently reflect the aspiration of the GMC, which we share, to ensure that every doctor seeks periodic feedback from patients. The GMC should consider setting a more challenging target which will provide greater assurance to patients that their views are regularly sought and reflected upon by their doctors.


14   Under the General Medical Council (Licence to Practise and Revalidation) Regulations Order of Council 2012 (SI 2012/2685) Back

15   The state of medical education and practice in the UK 2011, General Medical Council 2012, p. 16 Back

16   HC (2010-12) 1699, para 4 Back

17   Ev 21, para 2 Back

18   Ev 33, para 8 Back

19   Ev 33, para 12 Back

20   Ev 34, para 15 Back

21   Ev 34, para 14 Back

22   Ev 21, para 9 Back

23   Q4 Back

24   Q5 Back

25   Q6 Back

26   Ev 33, paras 9-10 Back

27   Q36 Back

28   Q39 Back

29   Health Committee, Fourth Report of Session 2010-11, Revalidation of Doctors, HC 557, para 32. Back

30   Ev 21, para 5 Back

31   Report of the Steering Group on Remediation, Department of Health, December 2011, p 9 Back

32   Ev 38 Back

33   Ev 30-31 Back

34   Q47 Back

35   Ibid.  Back

36   Q19 Back

37   Q20 Back

38   Q22 (Una Lane) Back

39   Ibid. (Niall Dickson) Back

40   Q23 Back

41   Q24 Back

42   Q25 Back

43   Q28 Back

44   Q42 Back

45   Q43 Back

46   Q14 Back

47   Health Committee, Annual accountability hearing with the General Medical Council, Eighth Report of Session 2010-12, paras 19-23 Back

48   Ibid. Back

49   Q49 Back

50   COM(2011) 883 final, Proposal for a Directive of the European Parliament and of the Council amending Directive 2005/36/EC on the recognition of professional qualifications and Regulation on administrative cooperation through the Internal Market Information System Back

51   Ev 22 Back

52   Fourth Report of the Health Committee, Session 2010-11, Revalidation of Doctors, HC 557, para 31 Back

53   Q60 Back

54   Q62 Back

55   http://www.gmc-uk.org/doctors/revalidation/12398.asp , last accessed on 28 November 2012 Back

56   Q63 Back

57   Ev 34, para 18 Back

58   Ev 34, para 19 Back

59   Ev 24 Back


 
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Prepared 3 December 2012