Why make locums responsible for governance in revalidation?
GP locums are not responsible for, let alone easily involved in, governance at the practices they serve, Dr Fieldhouse argues, and revalidation should protect patients rather than embroiling doctors who have opted not to work as principals into complex governance issues outside their control.
When we get our cars serviced, we expect the mechanics to be up to date with their knowledge of new models, brakes and engines; to know that they're maintaining their quality through monitoring previous servicing of other cars; finding out when they've made a mistake and making sure they learn from that mistake; listening to what their colleagues say about them – and their customers; and finding out when someone's made a complaint about their vehicle servicing. In all, that's six areas that any customer deserves to know about a service they're paying for. And in the context of your car, you want to know that the dealership is making sure that their mechanics are all participating in this six-point process. Not only that, but warranties, insurance, MOTs etc all rely on certain minimum standards being met. If they weren't, the country's road network would be a mess, with deaths, accidents – chaos. As GPs, we'd be the first to queue up to complain about it.
So if we ever wonder what revalidation is for, ever question its point or purpose, or just see it as one big ruse by the government to really piss doctors off, we need to just sit back and ask ourselves what our average patient would expect in terms of the assessment of quality of the GP they're being treated by in the same way we'd expect our cars to be serviced. What happens in the automobile sector, or indeed any other sector (apart from banking…) is probably an awful lot more draconian than what's currently being proposed for us GPs.
In the context of what you demand as a driver, and what a patient would require of a doctor, its hard to argue against our patients need to know that the organisation within which their carers work would reliably and effectively make sure that all parts of that organisation work as they should to ensure minimum levels of quality. When you drive out of the garage forecourt and your wheel falls off, you would insist that the garage makes sure that the mechanic learns from their mistake – indeed if you knew that mechanics were never told of their mistakes, you'd be a fool to take your car there again. Organisational governance is the less attractive sister of clinical governance, and even clinical governance pales compared to good old clinical professional development. All organisations need governance, but if you work in one that has poor governance you're as likely to know as if you worked in one with good governance. You know the Rumsfeld quote – we don't know what we don't know. But what we do know is that that isn't good enough for our patients.
Every organisation should have governance structures, and producing this evidence for all its employees should be a no-brainer and is all part of running any business, from a corner shop, to GP practices, garages, factories etc. And unfortunately, self-employed locum GPs can't be excluded from organisational governance. If working for a locum agency, or working with other locums in a chambers, it will be incumbent upon that agency or your chambers to provide you with evidence of how it involves you within its organisational structure. For example, if a practice has ever complained about you, does that agency or chambers have a robust system to ensure you are informed of that feedback? If you're an independent locum, like any other GP, you have to be in a position to say that systems and processes are in place for you to be told of a complaint, or a compliment or a significant event, as and when they occur.
If you do fall into this latter category – and many locums will – your options are limited. Apart from the obvious of joining an employment agency or joining up with other local locums into a formal chambers, ensuring that those necessary systems are in place is going to be arduous and technically for an independent locum to do.
The very least an individual locum can do is to ask every practice to sign a declaration - why not put it at the end of your invoice? – stating that they will inform you within a set time of any feedback, incidents, changes to your management, mistakes or compliments that they receive about you.
But the idea that part of a locum's appraisal will be based on the clinical governance of an organisation over whom they have no say or control seems obtuse.
One responsible officer, Dr Swanson at NHS Western Chesire and NHS Warrington, has already written: ‘The responsible officer's recommendation for revalidation of GPs will take into account the clinical governance systems within each practice as well as the GP's participation in appraisal.'
GP locums are not responsible for, let alone easily involved in, governance at the practices they serve. Revalidation should protect patients and improve the quality of care, rather than embroiling doctors who have opted not to work as principals into complex governance issues outside their control.
To say, ‘well, I've not heard of any significant events involving me, so I assume everything's been OK' would not be good enough for your mechanic and it certainly is not good enough for a doctor. But to ensure that GPs continue to keep patients safe and raise care standards, everyone needs to be included in the conversation.
Dr Richard Fieldhouse is a GP in Chichester and chief executive of the National Association of Sessional GPs.