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A faulty production line

'Good enough' must be the standard for revalidation

GPs must speak out against the GMC’s illogical demand that ‘below average’ doctors are not good enough, Dr Sarah Gray argues

GPs understand how and why the process of revalidation has come into being. Now that it has it is worth taking a step back and checking that it is fit for purpose. What are we trying to achieve? The laudable aim is to identify GPs whose health, performance or conduct represents a risk to public safety or to the profession itself.

I lead performance assessment teams for the GMC. Those of us involved in the fitness to practice procedures are aware that doctors who give cause for concern tend to do so consistently and have little insight into the consequences of their actions. It is these colleagues who the revalidation process is trying to identify, ideally before harm has been done.

But the most salient fact is that, the numbers involved are very small, and I would reassure the rest of the profession that there should be nothing to fear from revalidation.

Basic stats

Those with a basic understanding of statistics but few politicians will appreciate that ‘average’ is in the middle of the distribution curve and 50% of observations will fall beneath it. We should not therefore be promulgating the idea that we are looking to weed out ‘below average’ doctors as 50% of the profession would lose their jobs. Neither those concerned nor the country can afford this. Less than 100 doctors undergo performance assessment each year and this is the group we should focus on identifying.

This leads to the standard to be set. The GMC standard is ‘acceptable’, not first class. While we should be encouraged to be good, ‘above average’ should remain an aspiration, and the revalidation standard should be good enough.

Asking too much

Five satisfactory annual appraisals with production of a portfolio of evidence are required before a revalidation recommendation is made by the responsible officer. We have great concerns arising from reports that some appraisers and responsible officers are applying their own aspirational standards rather than that of being acceptable. This is putting unnecessary pressure on General Practice which is already stretched to breaking point. Those who are conscientious will be driven harder to jump through ever higher hoops and amass unnecessarily gold standard evidence. It could become the proverbial straw that breaks the camel’s back and lead to good doctors leaving the profession before they had intended to. As well as this being a personal tragedy, it would in turn have profound workforce implications.

Having set a standard it is important that this is applied consistently across the country. The hoops should be the same diameter, height and distance apart whether you work in Dartford or Darlington, Carlisle or Canterbury.

The Cornwall and Isles of Scilly motion at LMC conference noted these inconsistencies. We called for the GPC to lobby for a nationally-agreed standard of evidence for GP appraisal in England and an overarching national appraisal board to ensure evidence for appraisal is consistent and proportionate. The motion was passed, but in order to take this forward it will be important to stand together, look at the bigger picture and understand the concepts involved. There is an important role for national oversight and the grassroots clinician should feel supported, rather than intimidated, by this.

Dr Sarah Gray is a GP in Truro and a member of Cornwall and the Isles of Scilly LMC.

Readers' comments (7)

  • I am not a statistician. But if you got rid of 50% of below average GPs this year, next year you would get rid of of another 50% and so on. Obviously, Einstein does not work in the GMC.
    If 50% of GPs got 98% and 50% got 100 % in a revalidation test then 50% would get less than the mean of 99% and would have to leave. You have to have a pass mark. Averages won't do as there will be always 50 % below average in a large group. In a small group, every one could get 100% and be OK

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  • Zeno's paradox for doctors. Get rid of 50% each year but the GMC, I suppose knows you can never get rid of everyone much as they might try!! And these folks run our systems and are in charge. Dear, dear God !!!

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  • How can you be sure the GP population is in reality normally distributed? Your argument rests on this assumption.

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  • We have to assume normal distributions. What other distributions should we assume or expect ? Are we different from every one else ?

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  • Revalidation is a 5 year cycle , so the whole system workforce effect is a 10% loss per year- easily replaceable with an enlarged medical school entry.
    The steady state position of the effect would be a younger, less expensive workforce running harder to meet a rising standard, basically the same as the rest of us on the service delivery hamster wheel today, but at a lower cost to the exchequer.

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  • What the statisticians should in fact be doing is quantifying the harm revalidation does to patients through lost doctors hours. I think the opportunity cost of this crackers scheme has been grossly underestimated in facetious arguments over the process. Revalidation is in fact just a means of disenfranchising the medical profession by providing a another stick to beat us with. It has nothing to do with patient care and we should be looking to hold those who brought it in accountable to the damage they are doing to the profession.

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  • I have no problems with revalidation but had major issue with the tedious appraisal process. I was not too keen on filling in minute details like what made me choose a course and what have I got planned to learn the coming year! Come on! the guys who planned this really need to get a life.

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