Making revalidation work: what have we learnt so far?

Revalidation – the process by which licensed doctors demonstrate that they are up to date and fit to practise – was greeted with cynicism by some in the medical profession when it was introduced last year. But what have responsible officers – those who make recommendations to the General Medical Council (GMC) about doctors’ fitness to practice – thought about the process during its first six months? Our recent survey of responsible officers in London provided some interesting answers. 

Responding to questions on what would improve the experience of revalidation in future, the responsible officers we interviewed broadly agreed on four areas. 

First, they reflected that where a solid infrastructure had been established, and where boards had invested in the implementation of revalidation as more than a tick box exercise, it had been more seamlessly introduced. This also had a knock-on effect in helping to engage the doctors who were participating. However, there was widespread recognition in those surveyed that making the process easier for doctors to engage in was essential – a culture change is needed to move away from the view that  participating in revalidation is just uploading evidence of continued medical education and participating in reflective practice. 

Second, embedding a quality approach to appraisal was another area in which responsible officers felt the next revalidation round could be strengthened. This involves investment in training and developing doctors as appraisers, as well as enabling doctors to understand how to get the most out of reflective practice. ‘Winning hearts and minds, helping doctors to see that the process is fair, equitable and applied reasonably’ was the prescription written by one respondent. There was a strong belief that the introduction of revalidation is supporting the creation of a culture where doctors are investing in continued medical education and reflection, and that this would have a positive impact on patient care. One respondent said this would ‘move the average standard to the right so that in the whole medical body the performance thereof will improve over time.’ However, as heartening as this was to hear, there was another dominant view in the results that ‘culture change in the NHS changes with the speed of a very sluggish hyperthyroid snail’ which reinforces the need for maintaining the new practices that revalidation brings. 

One responsible officer candidly expressed that ‘it seems ridiculous that consultants can practice anything from 20, 30, 40 years without receiving formative feedback, unlike other specialist professionals in health and industry.’ But it would be too easy to cast doctors in a poor light in this regard, as one responsible officer reflected, ‘there is some work to be done in helping a cohort of doctors to see the value of constructive and formative feedback, to create a climate of maturity and trust so that the appraisal process, which incorporates peer and patient feedback, becomes a process that doctors value and therefore engage in.’ 

Third, in the light of recommendations from the Francis, Keogh and Berwick reports, respondents said that the element of revalidation that seeks to embed patient and peer feedback requires more work. While the majority of responsible officers surveyed commented on revalidation’s inability  to ‘catch the next Shipman’, the majority believed that giving patients voices, an enhanced role and presence alongside peer feedback would act as a deterrent to a minority of doctors who may have become complacent about their performance and professionalism. 

Fourth, many of the responsible officers we surveyed expressed a strong view that the GMC needed to follow up the process of revalidation by effectively managing the minority of doctors who fail to be recommended or for whom performance concerns continue to be raised.  

The test of revalidation will be seen by many as whether it can root out errant doctors and bring serious failings to light. If done well, the real benefits could go far beyond reducing risk and be far ranging in improving the quality and culture of care. 

This blog is also featured on the British Medical Journal website

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#40945 Mark Silva
Consultant Neurologist & Chief of Service Medicine
Gloucestershire Hospitals NHSFT

My concern was that the revalidation process would not be robust enough to identify poor practice. However, our initial data suggests that the revalidation process is producing valuable results. The 360 in particular has been far more revealing than I anticipated. The problem for our Responsible Officer is what to do with the data coming through? A difficult challenge, but at last we may be able to deal with the small percentace of doctors with bad/poor practice that drag the NHS down. Encouraging so far!

#40946 emma redfern
ED consultant, AMD patient safety
University Hospitals Bristol NHS Trust

'people' struggle with change. Doctor's historically haven had to prove they can do their job well. NHS struggles to deal with poorly performing Doctor's, as the system seems to protect them. Revaildation seems to be going well at UHB. We have appointed an Associate Medical Director for revalidation (Consultant from PICU). The IT system is easy to use. Previously comments in 360 were bland and meaningless, but teams have realised that we need to provide honest feedback in 360 in order to help people develop, and learn where their weaknesses may be, especially if the individual concerned has poor insight. I feel positive about revalidation and hope that this continues to play out


#40953 Constantinos Yiangou
Consultant Surgeon, AMD & Chief of Surgery and Cancer
Portsmouth Hospitals NHS Trust

The introduction of revalidation will undoubtedly improve quality of care and clinical outcomes. Early indications suggest that the appraisal process is becoming more robust, reflective practice is being encouraged and peer feedback has uncovered attitude and probity issues. As we head into the second year of revalidation the process will be strengthened by:
1. Improving appraiser training and ensuring choice of appraiser is appropriate in every case
2. Issuing more specific guidelines on how individuals should choose peers for the 360 degree appraisal
3. Giving responsible officers, especially those in large NHS institutions, optimal time and support to deliver
4. Identifying a GMC-led protocol to deal with the minority of cases where revalidation has been deferred and issuing guidance to the employing organisation on how these doctors should be managed until they are are ready for revalidation.

#40956 Vijaya Nath
Assistant Director
The King's Fund

Thank you Mark. Similar stories are emerging in other organisations . The identification of further support for the RO in concert with other organisation development is well worth reinforcing if we expect to see Revalidation achieve its intended impact.

#40957 Vijaya Nath
Assistant Director
The King's Fund

Emma, getting colleagues to appreciate and invest in mature & constructive feedback will enhance the quality of Appraisal and Revalidation . This has an impact on the quality of patient care (West et al research).Change is challenging , and as the first country in the world to provide their Medical Workforce with the means to reflect on their considerable practise, our global medical movement watches with interest . It is up to all of us to create a culture in which quality and evidence based decision making thrives . More work to be done to enable those being appraised/ revalidated to reflect on their experiences & much more to create ways of working In which we encourage clinicians to talk about areas of weakness & celebrating successes.

#40958 Vijaya Nath
Assistant Director
The King's Fund

Thank you, agree with all of the points reinforced in your reflections above. Our small study indicated that more needs to be done to finance and finesse arrangements around Remediation . If we are to create a learning culture Remediation needs to be resourced .

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