3 Revalidation
Identifying
failings in practice
18. In December 2012 the GMC introduced
revalidation for all licensed doctors. Revalidation "is the
process by which licensed doctors have to show regularly that
they are meeting our standards, including keeping their skills
and knowledge up to date."[20]
The GMC said in its annual report that this "marked the biggest
change in how doctors are regulated for more than 150 years."[21]
19. In their written evidence the GMC
offered an overview of the current status of revalidation. They
said that:
· We are on track to revalidate
the vast majority of licensed doctors in the UK for the first
time by March 2016.
· 86% of doctors in the UK
are now linked to organisations that can support them with revalidation.
And we have established a route to revalidation for doctors without
a designated body.
· 2,300 doctors who have not
yet responded to our requests to provide information for their
revalidation have received final notice letters advising them
that if they fail to respond we will have to take steps to remove
their licence to practise. Of these, 1,260 are registered as having
an overseas address.[22]
The GMC added that they "launched
a major project to monitor the implementation of revalidation
to assess and evaluate its impact on employers, doctors and patients."[23]
This work is being undertaken by the University of Plymouth and
will "take into account the perspectives of doctors, employers
and patients' groups."[24]
In their annual performance review of the professional regulators
the Profession Standards Authority said that by the end of 2015
"the GMC aims to have the first revalidation recommendation
submitted to the GMC by the responsible officer for the majority
of doctors."[25]
20. Discussing the impact of the introduction
of revalidation, Professor Sir Peter Rubin told the Committee
that the data does not yet exist to confirm that revalidation
has identified more failings in practice than old appraisal processes.
Sir Peter added, however, that in his personal opinion:
revalidation had a major impact
before it even started, because effective systems of appraisal
and so on were introduced in hospitals and identified people who
needed to be referred. I think the impact antedated the introduction
of revalidation by maybe three or four years.[26]
21. Una Lane, the GMC's Director of
Registration and Revalidation, explained further that the introduction
of revalidation had changed the way in which health providers
manage their clinical staff. Ms Lane said:
We see many more doctors who are
subject to appraisal than was the case a number of years ago.
We see many more organisations that now have policies in place
to identify poor performance at an earlier point in the process,
and indeed have processes in place to help the reskilling, rehabilitation
and remediation of doctors locally. There is some evidence thus
far that revalidation, in both its planning and introduction,
is making a change, but by this time next year, when we come back
before the Committee, hopefully we will have more robust, hard
evidence about what is happening on the ground.[27]
22. Revalidation
has only been in operation for a little over 12 months and as
yet the data does not exist to explain whether it is a fundamentally
better process to identify and address failings in professional
practice than the previous system which relied solely on employer
led appraisals. From the perspective of employers, this process
should be about more than simply helping their staff navigate
revalidation and should embrace ongoing appraisal and the management
of poor performance. Una Lane's comments in this regard are encouraging,
but at our next accountability hearing the Committee would like
to see a formal assessment of the evidence relating to revalidation
to ensure that it is making a significant contribution to the
improved practice of doctors.
Responsible Officers
The role of Responsible
Officers
23. Responsible Officers oversee the
process of revalidation at a local level and are based in designated
organisations which are typically local trusts or commissioning
organisations. The Department of Health has said that the responsible
officer within each designated organisation will:
· ensure that those doctors
who provide care continue to be safe;
· ensure doctors are properly
supported and managed in sustaining and, where necessary, raising
their professional standards;
· for the very small minority
of doctors who fall short of the high professional standards expected,
ensure that there are fair and effective local systems to identify
them and ensure appropriate remedial, performance or regulatory
action to safeguard patients; and
· increase public and professional
confidence in the regulation of doctors.[28]
24. At the Committee's 2012 hearing
with the GMC, Una Lane said that that it was not proposed that
the responsible officers who oversee the revalidation of GPs should
be based in Clinical Commissioning Groups (CCG) and, instead,
they would sit in NHS England's local area teams.[29]
Revalidation was launched on this basis, and whilst most doctors
are attached to a responsible officer within their employer organisation,
GP's responsible officers are based in one of the 27 NHS England
local area teams. The area teams grew out of the PCT clusters
which formed prior to abolition on 1 April 2013 after the Government
had proposed that all responsible officers should be aligned to
a fixed geographic area.[30]
25. Discussing the purpose and accountability
of responsible officers in 2012, Niall Dickson said "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."[31]
This indicated that the GMC regarded the role of the responsible
officer as being that of an individual who could be held to account
if the practice of a revalidated registrant was subsequently found
to be wanting. The tone of the discussion around responsible officers,
however, changed notably at our 2013 accountability hearing. Una
Lane said that:
The important thing about the role
of the responsible officer is that the regulations that brought
responsible officers into being place duties on organisations.
They place a range of statutory duties on organisations to evaluate
the fitness to practise of doctors; ensure that doctors have an
appraisal; and ensure that they have proper and robust clinical
governance systems in place. The role of the responsible officer
is effectively to be accountable for delivering the organisation's
duties in that respect.[32]
Ms Lane concluded that the "way
I tend to look at the role of the responsible officer is that
it is a function rather than an individual."[33]
26. The
Committee notes that the tone and emphasis around responsible
officers has altered as revalidation has been launched. The implication
of the GMC's most recent remarks appears to be that responsible
officers may not be held to account for a doctor's performance
on an individual basis in the same way as was originally envisaged.
The Committee is concerned about this development and recommends
that the GMC should clarify precisely the nature of the personal
responsibility of the responsible officer.
NUMBER OF RESPONSIBLE OFFICERS
27. The Government's proposals for responsible
officers stated that it would be for NHS England to determine
the number of responsible officers necessary to allow it to "adapt
to changing circumstances and to determine the most effective
and efficient way of providing this important function."[34]
In its performance review the PSA commented that work needs to
be undertaken to "develop sustainable, stable networks of
responsible officer following the recent restructuring of the
NHS in England."[35]
28. The Government's impact assessment
published in March 2012 noted that in the old NHS architecture
each PCT nominated a responsible officer, but once PCTs began
to cluster the number of responsible officers fell as constituent
PCTs within a cluster nominated the same person (usually the medical
director) as the responsible officer.[36]
The GMC made the same observation during last year's hearing[37]
and Niall Dickson told the committee that "in relation to
general practice, we would want the responsible officer and his
or her team to know who the doctors are"[38].
As of 31 October 2013, the GMC listed one responsible officer
for each of the 27 NHS England Local area teams.[39]
In May 2013 NHS England published information which said that
there would be 27 responsible officers for circa 45,000 GPs[40].
29. Explaining the principal that analysis
of responsible officers should be about the overall function as
opposed to each individual, Una Lane argued that extrapolating
basic ratios of responsible officers to registrants would not
help to understand the effectiveness of each responsible officer.
Ms Lane said:
It is not simply a numbers game;
it is much more about whether the area teams provide the right
and relevant resources to support responsible officers in delivering
the statutory duties that fall on these organisations. [...] it
is about resources provided to the individual rather than necessarily
simply about the numbers.[41]
30. Ms Lane conceded, however, that
the reorganisation of the NHS as a result of the reforms implemented
by the Health and Social Care Act 2012 may have had an impact
on the capacity of responsible officers to provide oversight.
Asked about feedback from registrants Ms Lane told the Committee
that:
looking particularly at NHS England,
there is no doubt that the restructuring presented some challenges.
When we began revalidation back in December 2012, we had strategic
health authorities and primary care trusts. Come 1 April, they
disappeared and we had a whole range of new organisations that
needed to take up the reins fairly swiftly. [...] Like everything
else, the views of doctors are mixed. Some have very positive
views about their experiences of appraisal and responsible officers
locally; others have a slightly more negative view. I do not think
there is a uniform or consistent view.[42]
31. The
GMC's commentary in relation to responsible officers suggests
that whilst the responsible officer may embody the statutory obligations
of an organisation, it is the organisation as a whole that must
make sure that the resources are in place to meet its obligations
in relation to revalidation.Therefore, any analysis of the success
of responsible officers in overseeing revalidation must go beyond
a basic assessment of the ratio of responsible officers to doctors
and examine the overall resources deployed by the designated body.
Nevertheless, the ability of each responsible officer to form
the necessary professional relationship with the doctors they
oversee will, in part, be determined by the total number of doctors
they are required to support. The Committee is concerned that
changes to the management structure of the NHS must not be allowed
to undermine the effectiveness of professional regulation.
32. As
part of their analysis of revalidation, the GMC should review
the way in which responsible officers relate to individual doctors
in order to ensure that responsible officers are able to discharge
their responsibilities effectively on behalf of patients. This
analysis should help to determine whether the number of responsible
officers available is sufficient to properly oversee the work
of doctors.
Remediation
33. One of the concerns expressed in
the Committee's report of the 2012 accountability hearing with
the GMC related to the remediation of doctors. In 2012 the Committee
reported that:
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.
Professor Sir Peter Rubin 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.
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.[43]
34. In oral evidence in 2012 Professor
Sir Peter Rubin did not express particular concern that 42% of
doctors were affiliated with designated bodies which had no formal
policy for reskilling, rehabilitation and remediation. He said:
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.
[ . . . ] 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.[44]
35. The Committee's 2012 report eventually
concluded that:
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.[45]
In response to the Committee, the GMC
said that providing resources for remediation is the responsibility
of the four UK health departments. They added that the introduction
of revalidation has resulted in more providers developing formal
remediation policies.[46]
36. At the Committee's 2013 accountability
hearing the GMC revealed that the launch of revalidation has prompted
a sharp rise in the number of organisations publishing formal
remediation policies. Una Lane said that:
The most recent survey completed
in England indicates that in the region of 85% of these organisations
now have those formal procedures and policies in place. Again,
we think that the introduction of revalidation has acted as something
of a catalyst and driver to ensure that organisations are doing
effectively what they should have been doing in any event.[47]
Ms Lane also observed that the presence
of responsible officers may have contributed to the increase in
formal policies:
From where we are sitting, the introduction
of the role of the responsible officer has made a significant
difference in addressing issues that should probably have been
addressed before now.[48]
37. The
Committee is pleased that significant progress has been made in
ensuring that employers develop formal plans to improve the skills
of the medical staff and address flaws in their practice. We believe
that the GMC should continue to monitor the commitment of employers
to effective remediation as well as examining why approximately
15% of employers have still not complied with the principles of
good practice. The Committee is concerned that 15% of employers
have not complied with this basic element of good practice.
Employer Liaison Advisers
38. As part of their response to the
concerns expressed about remediation in the Committee's last report
the GMC emphasised the importance of Employer Liaison Advisers
who support responsible officers. Employer Liaison Advisers are
based in the Employment Liaison Service and are employees of the
GMC. In oral evidence to the Committee in 2012, Una Lane said
that whilst low-level concerns should be dealt with locally by
responsible officers the GMC now has:
in place a group of employer liaison
advisers—16 in total—right across the UK. The purpose
of this role is to support responsible officers in dealing with
emerging concerns about doctors and in providing advice on when
the GMC absolutely needs to engage where the concerns are significant
and there is a role for the GMC in terms of taking action on the
doctor's registration.[49]
In oral evidence at our 2013 accountability
hearing Niall Dickson explained that "Their job is to advise
responsible officers on their—the responsible officers'—statutory
responsibility"[50].
Mr Dickson cautioned, however, that "There is no accountability
line between a responsible officer and employment liaison adviser".[51]
39. The PSA's performance review of
the GMC noted that the purpose of the Employment Liaison Advisers
is to build better relationships at local level with employers
who are also the designated bodies in which responsible officers
are based. The PSA said that that the presence of Employment Liaison
Advisers will:
maintain confidence in the GMC's
system of regulation by making it easier to share information
between the GMC and employers about the (continuing) fitness to
practise of doctors.[52]
In their annual performance review the
PSA commented in more detail on the work of the Employment Liaison
Advisers and said:
It was anticipated that one of the
benefits of the ELS (Employment Liaison Service) would be to increase
understanding among medical directors about when to make a referral.
While it is difficult to gauge precise figures, the GMC notes
that between April and December 2012 there were 138 employer referrals
where there had been explicit intervention by an Employment Liaison
Adviser.[53]
40. In
oral evidence the GMC made it clear that Employer Liaison Advisers
are not part of the formal accountability structure for responsible
officers. However, the Committee notes the significance the Professional
Standards Authority has attached to the role of Employer Liaison
Advisers in prompting medical directors to refer doctors about
whom they have concerns.
Incorporating patient feedback
41. In its report of the 2012 accountability
hearing the Committee expressed concern that within the revalidation
process doctors were expected to seek patient feedback only once
every five years. The committee concluded that:
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.[54]
In their formal response to the committee
the GMC said:
The introduction of revalidation
means that, for the first time, all licensed doctors must seek
feedback from patients. We regard this as a significant first
step. In designing the process, we have sought to balance the
aspirations of patients and others with the concerns from doctors
and employers about the cost in time and resources of conducting
formal objective reviews. However, we do recognise the need to
keep this aspect of revalidation under review. This will form
part of the evaluation and we will examine not only the frequency,
but also the methods of obtaining feedback.[55]
The GMC's written evidence submitted
in advance of the 2013 accountability hearing provided further
commentary and stated that:
Patient feedback is one of six types
of supporting information that a doctor must collect for revalidation
at least once in every revalidation cycle, usually every five
years. Doctors need to review this feedback with their appraiser,
reflect and act on what it says about their practice and performance.
[...]
[...] we are conscious however that
more can be done to ensure patient views are regularly sought
and reflected upon and we will keep this aspect of revalidation
under review. As part of our evaluation of revalidation we will
examine the frequency and the methods doctors use to obtain patient
feedback. We will also continue to work with patient organisations
to raise awareness of revalidation and the role patients can play
in providing feedback.[56]
42. The regularity at which patient
feedback should be sought is not the only consideration in assessing
how feedback should be incorporated into revalidation. Una Lane
told the Committee that providers have become much better at seeking
structured feedback from patients, but she added:
Our view is that it is not simply
a matter of moving from once every five years to twice every five
years, and that will be fine and everybody will be happy. We need
to get much more sophisticated about how we engage with patients
on this particular issue.[57]
43. The Committee agrees
with the GMC that the successful incorporation of patient feedback
into the process of revalidation depends on more than just the
regularity by which feedback is required. The quality and applicability
of feedback is crucial as the information has to be able to inform
and improve a doctor's practice. The challenge for the GMC is
to begin to develop more sophisticated mechanisms for incorporating
the views of patients into revalidation. At our next accountability
hearing with the GMC we shall seek specific evidence about the
regularity and effectiveness with which patient feedback is incorporated
into the revalidation process.
20 GMC, Annual Report 2012, p 10 Back
21
Ibid Back
22
GMC (GMC 02) paras 6-8 Back
23
Ibid Back
24
Ibid Back
25
PSA, Performance Review, para 12.16 Back
26
Q32(Sir Peter Rubin) Back
27
Q32 (Una Lane) Back
28
Department of Health, The Role of the Responsible Officer - Closing
the Gap in Medical Regulation - Responsible Officer Guidance,
July 2010, para 1.5 Back
29
HC 566, Ev 7, Q32 Back
30
Department of Health,Responsible officers in the new health architecture:
A Public Consultation on the Amendments to the Medical Profession
(Responsible Officers) 2010 Regulations, April 2012, para 2.16 Back
31
HC 566, Ev 7, Q14 Back
32
Q34 Back
33
Q35 Back
34
Department of Health, Responsible officers in the new health architecture,
para 2.13 Back
35
HC 566, Ev 10, Q 49 Back
36
Department of Health, Responsible Officers in the new health architecture,
March 2012, para 41 Back
37
Ibid, Q35 Back
38
Ibid, Q34 Back
39
http://www.gmc-uk.org/DB_list_with_RO_details___DC3503.pdf_52637845.pdf Back
40
NHS England, Prescribed Connections to NHS England, May 2013,
Annex A Back
41
Q35 Back
42
Q36 Back
43
HC 566 para 39-40 Back
44
HC 566, para 43 Back
45
Ibid Back
46
Health Committee, 2012 accountability hearing with the General
Medical Council: General Medical Council Response to the Committee's
Fourth Report of Session 2012-13, HC 1110, p 6 Back
47
Q38 Back
48
Q38 Back
49
HC 566, Ev 7, Q 36 Back
50
Q39 Back
51
Q39 Back
52
PSA, Performance Review, para 12.18 Back
53
Ibid, para 12.32 Back
54
HC 566, para 67 Back
55
HC 1110, p 5 Back
56
GMC (GMC 02) para 14 Back
57
Q41 Back
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