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Gold, incentives and meh

Revalidation is not worth its cost

The £97 million bill would be better spent on patient care, writes Dr Peter Swinyard

Does revalidation offer value for money in times of severe financial stringency? The days of above-inflation increases in NHS resources are now long gone and the ever increasing costs of health care, forced up by an ageing demographic, increasing needs for dementia care (both real need and political imperative) and increasing costs of new treatments are conspiring to add pressure to budgets across the health service.

Pulse reported last week that the scheme will cost doctors over £450 in ‘opportunity costs’ per revalidation cycle and will only prevent 0.75% of cases of death, severe harm and moderate harm per year.

I am aware of the need not to be too cynical about improving standards in general practice. For instance, I find appraisal helpful – if only because some poor colleague of mine has to listen to me talking about myself for two hours – and I do find that doing them directs my learning to some extent. It’s a shame that 27% of doctors do not seem to participate in appraisal, either for lack of opportunity or other reason.

But does revalidation – as distinct from appraisal – add value? I know it is rather like questioning whether we should prescribe ß-blockers for patients with heart failure – but, as doctors, we should be questioning received wisdom.

We now hear that revalidation is going to have annual costs of £97 million. Reading the Department of Health paper on the subject, ‘Medical Revalidation – Costs and Benefits’ (yes, I have read the whole paper), the costings are based on conjecture as much as on evidence.

Zero benefits

Part of the analysis was something called a ‘BC2 survey’, in which doctors were asked to speculate as to whether revalidation might reduce rates of suspension, sickness absences among doctors, the number of avoidable deaths and incidents of severe harm to patients, and litigation claims.

But doctors’ responses to these questions made clear that some of the presumed benefits of revalidation would not bear out – for example, the estimated benefits of avoiding sickness absences in the BC2 survey quoted in the paper are 0%. Yes, zero.

We are told that revalidation will prevent 0.75% of cases of avoidable death, severe or moderate harm per year (again this is a speculative figure). As the National Patient Safety Agency figures quoted in the government paper say that 44,274 cases fell into this category in 2011/12, 0.75% of this would mean the prevention of 332 cases for that year. The DH confirmed that revalidation would prevent an estimated 97 cases of death or serious harm.

We can believe that if we will. The National Patient Safety Agency of course, no longer exists and its functions are now with the NHS Commissioning Board.

We are told that revalidation will prevent 3% of litigation costs – which is borne by the taxpayer for hospital-employed doctors, but by insurance or mutual societies for GPs. However, I do not anticipate a 3% reduction in my medicolegal fees next year.

We are told by politicians that revalidation will improve the public’s confidence in their doctors. But with respect, according to Poll Watch, David Cameron’s approval rating last week stood at minus 16 points and Nick Clegg’s at minus 55 while GPs consistently achieve top scores in measures such as Ipsos Mori’s veracity index. Who really needs the ratings boost?

The proposed benefits for revalidation – the Government is predicting a £50-£100m saving from 2017 onwards – are worryingly specious. They talk about an improvement in quality-adjusted life years (QALY) yet they wrap this up in such jargon that even the CEO of the Family Doctor Association, who studied health econometrics as part of her first degree at St Andrews, could not interpret this in real English. They offer a QALY gain of 0.001 years to 100 patients from 20% of 73% of appraised doctors. Eh?

Going into tabloid media mode for a while, there are other ways to describe the cost of revalidation in terms of clinical care. For example, this revalidation exercise is costing the equivalent of 12,933 total hip replacements in a year.

It costs £50,000 per QALY for the most expensive drug in renal cancer – spending revalidation cash here would allow an extra 1,940 years of good quality life for renal cancer patients each year. Not a bad result. NICE’s usual threshold for recommendation of a new treatment is £30,000 per QALY. These treatments relieve pain and suffering and improve the quality of life of our patients. Does revalidation do the same?

Dr Peter Swinyard is the chair of the Family Doctor Association and a GP in Swindon

Readers' comments (7)

  • The FDA seems to know the cost of everything and the value of nothing

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  • Mark Struthers

    "The DH confirmed that revalidation would prevent an estimated 97 cases of death or serious harm" ... is as about as fatuous as saying ...

    "It is estimated that about 400 lives could be saved in the UK every year as a result of vaccinating girls before they are infected with HPV."

    http://www.nhs.uk/conditions/hpv-vaccination/pages/introduction.aspx?WT.mc_id=090805

    Give me strength!

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  • Mark Struthers

    “The GMC's "verdict followed 217 days of deliberation, making it the longest disciplinary case in the GMC's 152-year history."

    http://ind.pn/U8VPl6

    Professor Walker-Smith "paid tribute to his supporters who included the parents of many children with autism and bowel disease seen by him at the Royal Free Hospital in north London up to his retirement in 2001. His supporters say one of the consequences of the GMC's actions is that families are facing serious difficulties in finding NHS treatment for autistic children with bowel disease.

    The money spent on prosecuting the Royal Free Three would have been better spent on patient care. Would Dr Peter Swinyard care to comment?

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  • Revalidation is about as much use as a bucket of cold sputum.

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  • Edoardo Cervoni

    I can just subscribe all the above and repeat what I already stated on the matter.
    This is that revalidation may well be, above all, an alluring trap for clients/patients looking for that reassurance so much needed by the public opinion/clients/patients to mitigate the greatest hindsight bias linked the Harold Shipman case.
    The worse the consequences, the greater the bias: the already large Harold Shipman case bias was reinforced by a few other highly publicized press news, such as the Dr Ubani case.
    It was thought to introduce revalidation perhaps to rebuild the public trust in doctors rather than because it was truly felt that our profession really needed revalidation.
    I suspect, in that political climate, it was much easier jumping on the "revalidation bus", rather than objecting to it on the basis of its questionable benefits.
    Another reason why jumping on the "revalidation bus" was and still is appealing is that revalidation is a business. A very large, new, profitable business.
    The costs of this new business will be passed to the clients. I am not sure if this is clear enough.
    It is my humble opinion that we are not too far away from the negative consequences of the rising malpractice litigation.
    Litigations have changed the way doctors work no much because of new evidence and/or better clinical evidence based practice, but because of by ordering more tests and referring to specialists, or applying treatments even when they are unlikely to help, inevitably would reduce the risk of being sued.
    This attitude may protect physicians, but it is less likely to help patients.
    Revalidation may pose far greater risks to our profession than civil litigations are.
    Keeping in mind the "law of small numbers", it may be easily anticipated that some group of physicians are at higher risk of being tagged as "in need of revalidation", or "poorly performing".
    Those groups will be the small groups. Solo-physicians, now a minority, or foreign medical graduates, or even ethnical groups, to make a few examples. This is and will be because small samples yeld extreme results more often than large samples do.
    Of course, following the same reasoning, it shall appear that one or more of those groups may do extremely well, but this will not be attracting any attention from the "Revalidation Team".
    The halo effect of the Ubani case cannot be neglected either. Likewise, there will be an halo effect attached to received complaints.
    For instance, I exclude that I have been right on all the clinical decisions, no matter how much effort I did put in them and how highly I think of them. In fact, I am sure that we do make "errors" on a daily basis and I am confident that in 20 years time, my today's best practice could be exposed to severe criticism due to new knowledge.
    Perhaps, I have been just "lucky".
    Does time we spend practicing and number of patients we do see counts and if so, what could be the practical implications?
    To be able to answer this question we need to answer the following questions: "Do I think that a GP working 9 sessions per week would be likely to make the same number of "errors" - I am not considering purposely the rate errors/patients- of a GP working 5 sessions per week?".
    Medical Professional Indemnity firms know the answer to this question and the reader may verify what this is asking for the formula being used to calculate the insurance premium .
    You may therefore easily guess the answer to the second of my questions.
    The point I am making is that Revalidation is a costly exercise not able to bring," per se", any improvement to our professionalism. If anything, it will give us negative feedback and outcomes.
    I would very much welcome the same amount of money invested in Revalidation going toward to CME instead.
    I would like to see money to be directed toward to helping colleagues in professional difficulties as the profession itself may benefit from it.
    Revalidation is very much the fruit of negativity rather than of an attempt to respond to our educational and professional development needs.
    My constructive string feeling is that, far more than revalidation, transparency, improved interactions between doctors (and patients), shared and informed decisions, are what our profession needs.
    I am most confident than most doctors enjoy CME. Investing in CME is key.

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  • Disagree - many doctors require urgent validation (not revalidation) - as ESSENTIAL - not due to NHS changes but to ensure correct, professional and appropriate delivery of patient care. My GP is excellent but a locum who only works one session per week and inconvenient timings mean access is difficult during working hours - even then he is mostly booked. Both partners and others at the practice only treat financial incentives or by ensuring the cheapest treatment pathway is undertaken with no consideration of patient wellbeing or quality of care. Moreover, they lack the basic knowledge required in treating most conditions. Some time ago one of the partners discharged me without measuring basic BP when it was 190/120. It was only the practice receptionist who instantly recognised how unwell I was, took BP and called an ambulance. Revalidation is a must.

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  • Most other professions nowadays require continuous retraining and periodic MOTs, to make sure thay are still up to speed. Why not medics, above all other professionals?

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