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GPs will work under profound unease until the outcome of the revalidation review is known ­ Ian Cameron reports

Few GPs were looking forward to revalidation. At best, most saw it as a necessary burden. Now, after the Government's announcement that it is to conduct a wholesale review of the process, every GP could be forgiven for dreading it.

It is inevitable that the review, founded as it is on the Shipman Inquiry's indictment of the GMC's existing plans, will recommend a far stricter process of revalidation.

What most concerns GPs is that a new system will be punitive and based on the premise that the majority of doctors underperform.

If Sir Liam Donaldson, the Chief Medical Officer and head of the review, sticks closely to the recommendations in the inquiry's fifth report, GPs are in no doubt this will be the outcome.

But GPs are also adamant that much of what Dame Janet Smith has proposed be included in revalidation, such as knowledge tests, folders of evidence and a tougher 'pass or fail' appraisal system, is unworkable.

The question is, who will Sir Liam listen to?

NHS Alliance chair Dr Mike Dixon says he expects revalidation to become a 'harder instrument' and that doctors will be more closely appraised as a result of the review. 'It would be quite reasonable for assessors to sit in on consultations and read some notes,' he says.

But he argues against making appraisal a pass-fail system.

Such a move would cost the Government millions to train doctors to carry out the appraisals and place extra workload pressures on the profession. Most importantly, it would also undermine the basis of appraisal as a supportive, educational tool.

GPC chair Dr Hamish Meldrum adds that making appraisal tougher, and retaining it as part of revalidation, would lead doctors to hide their problems.

He says: 'Morale will go down and people will stop facing up to their problems, especially if they expect a punitive reaction coming down on them like a ton of bricks the moment they make their problem known.'

Given that Dame Janet's principal complaint is that using the existing appraisal system as a basis for revalidation is utterly unsuitable as a way of protecting the public, some form of change is inevitable.

An alternative that will be considered by Sir Liam's review is that appraisal stays broadly the same, but a new system of standards and correlating evidence is agreed for revalidation. This is likely to see the various royal colleges agree the contents of revalidation folders for each craft to demonstrate doctors' competency.

The RCGP backs such a move. Chair Dr Mayur Lak-hani says the review should go back to the drawing board. 'The most radical thing would be appraisal delinked from revalidation as it has been hijacked by revalidation. We want to see that,' he says.

'What we would have is a revalidation folder, with clear standards, high evidence and a positive clinical governance sign-off, looked at by local panels every five years.'

Dr Lakhani adds that Dame Janet has already said the college's plans are workable. Others are not so sure.

Having to compile a revalidation folder, containing objective evidence of competency in up to 35 different clinical fields, will mean a lot more work for GPs.

Stephen Brearley, chair of the GMC's registration committee, says routine evaluation of such folders would rely too much on selective evidence provided by doctors.

He adds that knowledge tests, another of Dame Janet's proposals, would not accurately measure performance and would need too many doctors to be involved to carry them out. 'The more managerial time you spend on that sort of thing the less time doctors have to see patients.'

Mr Brearley adds that the GMC ruled out these options while developing revalidation for precisely these reasons.

Although the GMC clearly has a vested interest in supporting its original plans, there is no doubt a new system of revalidation that requires doctors to gather more evidence, and demands more doctors to scrutinise it, will mean doctors spend less time with patients.

The outcome of the review is not expected for at least six months, well into the safety of a third term, the Government hopes. Meanwhile, GPs will work under profound uncertainty and unease.

What Dame Janet wants

·Revalidation folders comprising evidence of what a doctor has been doing for last 5 years

Folders to include:

·Clinical governance data, including a record of complaints, prescribing data and any report by the NCAA or Healthcare Commission.

·Record of continuing professional development activity

·Patient satisfaction surveys

·Results of a clinical audit and significant event audit

·Videos of consultations

·Successful completion of knowledge courses

Plus

·Appraisal to be tougher, possibly a 'pass-fail' process

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