Medical revalidation of doctors became a statutory obligation in 2012, but its origins stretch back to 2000. In that period, the NHS has undergone many changes and been scrutinised by several reviews.
‘Revalidation has evolved within this shifting context,’ explains Vijaya Nath, Assistant Director of Leadership Development at The King’s Fund. ‘While the original lever might have been the Shipman Inquiry, many developments since then, such as the failures of care at Mid Staffordshire NHS Foundation Trust and the subsequent Francis report and Keogh review, have all had an impact on what revalidation looks like today.’
The NHS Revalidation Support Team commissioned The King’s Fund to carry out a qualitative assessment of the impact to date of revalidation on the behaviour of doctors and the culture of organisations within seven case study sites across England. The results show that, while compliance with processes is well established, there remains much to do to ensure revalidation is part of a sustained commitment to quality improvement.
‘Our study revealed both triumphs and challenges,’ explains Vijaya. ‘One benefit of revalidation has been an improved participation in appraisal. As part of revalidation, every doctor must have a recorded appraisal conversation at least once a year and what revalidation has brought attention to is the quality of that appraisal discussion. It’s highlighted the importance of reflective practice and of building evidence of participating and valuing patient experience and peer feedback.’
Revalidation has created the role of responsible officers: each employing organisation has to appoint a responsible officer, who has a statutory responsibility to ensure they have robust systems of appraisal and clinical governance in place to support the process of revalidation. ‘I think the creation of the responsible officer role has been a success of revalidation,’ says Vijaya. ‘This is because resource has been put behind the initiative and the responsible officer has to be a doctor, either practising or retired, so it involves the profession in their own regulation.’
The study highlights concerns around the time required to undertake revalidation, as Vijaya explains: ‘As with many quality improvement initiatives, there seems to be very little time given to make this happen. So where it’s happening, doctors are often doing it in their own time. What you risk then is “compliance to minimum”.’
Related to this is the need to recognise that this is a huge change that goes well beyond process implementation; it’s about culture and leadership too. When you consider that the United Kingdom is the first country in the world to introduce the mandatory revalidation of its medical workforce, it underlines the scale of the challenge. ‘This is a change that spans more than two decades and two parliaments,’ notes Vijaya. ‘In many ways revalidation is still in its infancy. To get the greatest gains from any cultural change takes time and the commitment of leaders within organisations employing doctors.’
Moving to commitment
How can we move beyond process compliance to using revalidation as a fundamental part of the toolkit to drive quality improvement?
‘The first thing is to ask doctors for feedback,’ says Vijaya. ‘Employing organisations should be open to receiving feedback on what went well during the first cycle of revalidation and what could be done to make it better, and should act on that. There needs to be a conversation with doctors around how they can demonstrate that they are participating in quality improvements when they are under enormous time pressure.’
Beyond this, Vijaya considers leadership to be vital: ‘A change of this nature requires leadership skills atevery stage, to help people through the process. ’Investment in appropriate development for doctors and everyone involved in delivering care will enable revalidation to move from a tick-box exercise to part of longer-term quality improvement and better patient outcomes.
The question that remains is ‘can this happen?’
Vijaya is positive that it can. ‘We need to remember that it’s a long game, in terms of developing both the processes and the cultures which underpin revalidation. One point to consider is that revalidation may seem difficult now – as change often can – but for those training to be doctors now, using reflective practice, gathering evidence and focusing on quality are already second nature.’
‘It’s one of a number of measures which will underpin the development of cultures that are focused on quality and which organisations should employ to make sure that they are creating open and learning cultures, where patient feedback continuously drives quality. Everyone involved in a patient’s journey – including doctors – needs to be part of that conversation.’
This article was taken from the Summer 2014 edition of Insight: the latest health care insights from The King's Fund.