With so much at stake, revalidation has to be worth its cost
Julie Hoskin revisits the thinking behind the introduction of revalidation and examines both the progress made and the charge that it represents poor value for money
In December 2012 the General Medical Council (GMC) began the long-awaited process of the revalidation of every doctor in England, Wales and Northern Ireland whether working in hospitals or general practice.
The idea of revalidation has been around for a number of years, in fact since the 1970s, according to Tista Chakravarty-Gannon from the GMC. Progress has therefore been slow and, as with much to do with the NHS, has involved a flurry of activity followed by periods of inactivity. One such flurry included Harold Shipman. Shipman was the archetypal family doctor and yet he killed hundreds of his patients. This begs the question of whether a revalidation or appraisal process would have discovered his murderous tendencies. There was no evidence that he was incompetent, but then there was no evidence that anyone had tested his competency.
The examples of malpractice I have alluded to led to a restructuring of the doctors’ professional registration body, the introduction of clinical governance to all aspects of the NHS, changes to the law and the coronial set up in the UK. There were also a series of wide-ranging judicial reviews into what went wrong and how it could be prevented in the future.
Initially, the idea was for a system of appraisal for GPs, similar to that undergone by many in large employing bodies. However, GPs were reluctant to engage with this aspect of clinical governance, and the Primary Care Trusts set up in 1997 to enforce it were unable to manage the GPs, who do not form a single body of employees but rather a disparate group of individual businesses. Consequently, GPs could choose not to engage, could choose who appraised them and what they brought to the process. There was detailed guidance on what they should bring, what demonstrated competency and what didn’t, but the truth of the matter was that they could bring nothing and contribute nothing should they choose to.
The GMC hoped that the process of revalidation would help give patients confidence in the clinical competency of their doctor. They also hoped it would encourage a feeling of patient engagement and empowerment, as patient views about their doctor will be sought as part of the revalidation procedure. Patient views have previously been evaluated as part of the GP patient satisfaction surveys but questions were very general and abstract.
How it works
Revalidation is a much more formal and robust process. It is also compulsory, and by 2016 it is intended that every doctor practicing medicine in this country, whether in the state or private sector, will have been assessed as part of the revalidation process. And, if they are no longer suitable to care for patients, they will be removed from the register.
If a GP chooses not to engage, or if they fail to demonstrate satisfactorily that they are clinically competent and practising safely, then they can be struck off the register. The process will still involve interviews with an appraiser but, rather than it be a ‘cosy chat between professionals’ as the previous process was described by the Royal College of General Practitioners, all areas will have a responsible officer, who will be the final arbitrator and peer reviews and patient feedback will also be included. As it is also a more complicated procedure, where evidence must be forthcoming, the GMC and the British Medical Association have provided templates for doctors to work from and pages of frequently asked questions.
Value of the process
Despite suggestions that the process would lead to large numbers of GPs relinquishing their licence to practice and that the introduction costs would exceed £97 million, disengagement and relinquishment has been much lower than predicted with some 8,000 doctors appearing to prepare to surrender their licence to practice. Currently it is difficult to know how much of this represents a protest vote and how much is a natural phenomenon due to aging and retirement. Whilst start-up costs within the Trusts have been significant, costs to individual doctors working for Trusts have been very low. Costs have been higher for GPs as they don’t have an employing body to cover their personal costs.
That said, NHS England provides and pays for the costs of the Responsible Officers and the appraisers, so costs to GPs include their licence to practice £390 (with tax relief from HMRC), costs of education events, many of which are provided for free or are subsidised (as for example at the University where I work) and the cost of purchasing the feedback tools used for colleague and patient feedback. This tool is in some cases provided by the companies providing advice and guidance on how to keep an e-portfolio with reflective pieces based on the education events attended, but where it isn’t provided, companies provide both colleague and patient feedback for £85 plus VAT.
So, if the monetary costs to doctors are not demonstrably higher than the cost of appraisals, what of the costs in time and allocation of resources? Once again GPs are required to undergo an appraisal process as part of their contract with NHS England and the Department of Health, so the time costs may also be similar. What is harder to demonstrate is whether the intended deliverable outcomes have been achieved, for example, improved patient safety, reduced risk of harm to patients from incompetent practitioners or doctors who are too ill to discharge their duties. Patients would also be protected from discrimination, dishonesty or disrespect by their chosen doctor.
The jury is probably still out on deciding if the benefits outweigh the costs and it may take another year for that information to become available, but if engaging with revalidation prevents the Minister for health from taking another swing at doctors, if feedback from colleagues and patients pre-empts a visit to a coroner’s court and if the extra costs happens by complete chance to expose another putative Shipman, then it has to be worth it, doesn’t it?
Julie Hoskin is a senior lecturer at Sheffield Hallam University’s Centre for Postgraduate Medical and Dental Education, and is a nurse practitioner in the city.