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.