Revalidation: opportunity or challenge?

Comments: 14

On 3 December 2012 the UK was the first nation, and the General Medical Council (GMC) the first regulatory body, to implement large-scale changes to the regulation of its medical workforce. By April 2016 it is expected that the ‘vast majority’ of the UK’s 220,000 doctors would have undertaken revalidation – the process by which licensed doctors will demonstrate that they are up to date and fit to practise. Revalidation has been a popular topic in our leadership work with medical directors, GPs and consultants, having presented both opportunities and challenges. So what have we learnt so far?  

Revalidation is intended to assure patients, health care professionals and organisations that the medical workforce is formally regulated and that the quality of doctors’ practice is of a high standard. Under the process, doctors relate to a senior doctor or ‘responsible officer’ (RO) in their organisation who makes a recommendation to the General Medical Council about the doctor’s fitness to practise. For the majority of doctors, the evidence for this recommendation will be gathered over a period of five years (formally documented in appraisals) as well as from information drawn from the organisational clinical governance systems.

In light of the failings at Mid Staffordshire NHS Foundation Trust, good appraisal, supported by training and development, is important to ensure that doctors are delivering safe, high-quality care. Yet the revalidation appraisal process has received mixed reviews from both the doctors being appraised and their responsible officers.  One concern voiced by a number of medical directors we spoke to has been about the quality of appraiser development and the resultant variation in quality/impact of the appraisal. One medical director reflected that ‘despite providing them with training and ongoing support, a number (of appraisers) will take longer to grow into the role than others’. There also seemed to be inconsistency in ROs’ approach to the evidence they needed to acquire for the appraisal. Our conversations with those responsible for making revalidation happen suggest that organisational systems for conducting and documenting appraisals need strengthening and reinforcing through stronger clinical governance and feedback systems. This is also supported by recent work by Anna Dixon and Dan Wellings on public attitudes to revalidation.

However, for doctors who have always prepared carefully for appraisal – as one doctor commented, taking it ’reasonably seriously’ – revalidation appraisal has been ‘business as usual’. More challenging has been the response by some staff grade and associate specialist staff for whom one medical director remarked that ‘revalidation has been a huge wake-up call.’ 

Another potential challenge facing responsible officers has been technology. Many remember the failed NHS efforts to move to a single electronic patient record and have commented on the challenges of moving to e-portfolios and online appraisal toolkits (new electronic tools to support revalidation), which have been an area of triumph for some and trepidation for others. One medical director said this resulted in ’only 60 per cent of appraisals being completed with the completion date having to be moved back...’ in their practice.

Where a doctor’s practice gives cause for concern (either through conduct, performance or health), ROs enter into remediation. For example, in some surgical specialties remediation may take the form of retraining in one aspect of a procedure. For this process to work, ROs will need a particular skill-set, mind-set and a supporting structure. Many ROs have expressed the need for a more suitable, safer remediation process. As one medical director explained, the lack of a national remediation policy means that each organisation has been ‘pressed into producing their own local remediation policy’, leading in some cases to ‘concerns that what has been agreed locally in terms of financial support for doctors requiring some form of remediation could vary from organisation to organisation, leading to some doctors claiming inconsistencies in how they are being treated.’  The process could also reduce patients’ trust in doctors and in responsible officers – those who will be essentially overseeing and leading the system.

In theory, revalidation provides the leaders of our medical workforce with an opportunity for renewal – renewal of workforce values, competence and professionalism. If this vision is to be achieved, organisations and responsible officers need to be supported in making revalidation a priority and in uncovering the more nuanced set of skills needed to have difficult conversations with doctors, as well as the questions this throws up for how we develop our future medical leaders. We would like to promote a discussion about what will support leaders to succeed in this undertaking.  

Comments

#39931 sandra reeder
retired headteacher
Against All Odds

My book Against All Odds is an observation of relationships between doctors/patients over one year of my father`s hospitalisation. It should be read by all budding medical professionals; it is thought provoking, openand honest

#39950 Paul Ride
Resettlement Co-ordinator
Hestia (Back on Track)

Revalidation appears to be the constant re-evaluation of the able, whilst the unable are ignored and allowed to "stew in their own juices's" or luxuriate in the 'wealth' of their benefit status...

#39953 Kelechi Nnoaham
NHS Berkshire

This interesting blog sets out revalidation as an opportunity that has to be seized despite the challenges that come with it and I couldn't agree more as the promise of safety and quality improvement in clinical practice is too good to pass up. The challenges of variation in assessor quality and slow uptake of technology for delivering revalidation are not surprising and I don't think they will go away in a hurry. Having said that, I think the measured pace of the introduction of revalidation means that different parts of the system will benefit from sharing learning as part of the evolution of this revolutionary approach to medical regulation.

#39959 Gavin Lavery
Nhs consultant(ICU) & Regional Lead for Safety/Quality
Public Health Agency NI & Belfast HSC Trust

Long term preparation for revalidation is an opportunity for all to promote what good doctors already do - take an overall view of their practice and the service delivered to their patients. If the process of revalidation is sensitive enough to achieve that, it will have the support of most medics and the grudging respect of the sceptical.

#39961 Christine McGowan
Leadership and OD Consultant
HSC Leadership Centre

The blog higlights the important issues relating to the training of appraisers and availability/usage of electronic systems to support appraisals. We should also pay attention to the support available following training. There are some good examples emerging of Lead Appraiser/Appraiser support teams. These experienced doctors quality assure the appraisal processes and act as sounding boards for appraiser colleagues who are unsure about the quality of supporting information or who need to talk through issues that arise in the course of appraisals. This type of support is invaluable, particularly in these early stages of the revalidation process and should be encouraged and resourced.

#39963 Joe McManners
GP, CCG Locality Clinical Director
Oxfordshire CCG

I agree that revalidation presents an opportunity for the medical profession to embed a change of culture, perhaps towards one of continuous development and improvement. As a GP, I'd welcome that as there can be a feeling of being 'left to get on with it' after qualification.
However, I fear that the present scheme as is risks failing to do this. We should be looking at where the current appraisal system was weak. In my experience colleagues saw it as a 'tick box exercise' to get through and it was terribly subjective and fairly vague. It also took a lot of time to prepare for, most of which time was not for any direct patient or professional benefit. We should be developing our revalidation process on a more standard basis which doesn't require huge amounts of time to prepare. The information and data can then be used to plan development over the year. The key is consistency between appraisers and process, followed by easy to access development work (whether it is coaching, courses etc). I don't think we can be a long way from this, but currently too many good, keen doctors are approaching this process with a weary sigh as a bureaucratic hoop to jump through.

#39968 Vijaya Nath
Assistant Director
The King's Fund

Thank you. Agree about the importance of consistency and quality of appraiser with regards skills, knowledge and capability this is important and an area which is being invested in. As with all large scale changes this investment needs to be maintained.

#39969 Vijaya Nath
Assistant Director
The King's Fund

Gavin , more needs to be done to see this as a long term commitment to re- inforcing what you rightly highlight as good practice.Would be good to continue engaging with what Revalidation brings for colleagues in Northern Ireland .

#39970 Vijaya Nath
Assistant Director
The King's Fund

Thank you Christine,are the lead appraiser/appraiser initiatives you refer to specific to NI health system? would be an area which many appraisers have identified as being helpful to their on going development.Will explore further.

#39971 Vijaya Nath
Assistant Director
The King's Fund

This is an insightful and honest view which shows a commitment to making Appraisal from good to great . With more input and feedback from Drs like yourself the gap you describe will close over time.

#39978 Julian Brookes
Deputy Director, Policy and Business Projects
NHs South of England

It’s easy to forget the origins of revalidation - Shipman, the Bristol Children's Heart scandal. It has been years in the development and has passed the scrutiny of two governments. It is based on the bitter lesson that quality cannot be assumed - in any ones practice, doctor, nurse, manager. Indeed I would be surprised that on the back of Francis II, revalidation is only the beginning.

It is important to not forget the origins as it is too easy to get caught up in the systems and their current fragility. Yes, systems need to be made more robust; yes, training needs to be improved for all participants; the Responsible Officer, the assessor and those to be assessed, but the goal of continually assessing the quality and competency of doctors should not be forgotten.

It’s funny, I was discussing this with a good friend who works in a completely different sector. He was appalled that this measures were not already part and parcel of the daily work of professionals.

Of course for many this is business as usual, they have already an effective and supportive appraisal system and the revalidation will come out of their existing assessments as a matter of course. I chaired one of the national pilots in revalidation a year or so ago. It was clear then that the biggest task was to standardise the assessment process so that all could produce the evidence required. Some doctors received excellent appraisals, some did not. Also attitudes differed between the younger doctor and the older and between Primary and Secondary Care.

All this factors will need to be resolved, but they are process issues. The fundamental driver, higher quality patient care through continuous appraisal, leading to revalidated doctors needs to be clear and not lost in the fog of developing systems and processes.

#39979 Suparna Das
Consultant anaesthetist
South London Healthcare NHS Trust

Good blog and some thoughtful comments above. Agree that those doctors who have always been organised and well-prepared for their appraisal will find the revalidation process fairly straightforward. The Royal College of Anaesthetists has developed a CPD matrix and e-portfolio system that is functional - I find it useful for storing everything in one place and mapping my CPD to the matrix. There are also apps that can summarise my logbook data as reports. The key challenge that support specialties like anaesthetics, radiology and pathology will face is collecting patient feedback.

As already mentioned, we know that revalidation was introduced in the wake of Shipman. Although the revalidation process, when mature, is in itself a worthwhile exercise, it is unlikely to stop another Shipman. His patients loved him and thought of him as a kind and caring doctor but nobody had a handle on the controlled drugs that he was using on his patients.

#39980 Vijaya Nath
Assistant Director
The King's Fund

Agree the vision behind Revalidation needs to be greater than the logistics it takes to manage the process well and to a high standard. Having the difficult conversation, with regards Quality and the resultant outcomes for patients is an area in which appraisers and those being appraised/ revalidated require support . This will not happen without a commitment and the requisite time and all of this requires funding.The second Francis report will ,as you rightly say , focus us all once more on what matters most in delivering high quality patient care . Another reason to remind all responsible (including boards in primary & secondary care) of the need to assign Revalidation to their highly important box!

#39981 Vijaya Nath
Assistant Director
The King's Fund

The challenges for colleagues working in anaesthetics, pathology and radiology around completing MSF ( multi source feedback) including patients continues and is a point well restating. This is also an issue for locum Drs in secondary care and locum GPs . As has been highlighted without these professionals we would be unable to staff our establishments. Making Appraisal/ Revalidation meaningful is crucial if all involved are to participate .

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