By Ian Quinn
Pulse news editor By Ian Quinn spoke with the GMC's new chief executive Niall Dickson about the launch of its revalidation consultation, the appraisals process... and why the regulator is a 'source of good'.
IQ: So what is the key aim of the launch?
ND: Every one of your readers will know the idea of revalidation has been around for quite a while, but the launch of this consultation is the first opportunity to set out how it might work. We are beyond the argument about whether revalidation is a good idea or not as it has now been passed into law.
I think people are rightly saying; "Well ok I agree in principle but how are you going to do this so that it isn't costly in terms of my time or costly in terms of money?" The GMC has worked with many organisations, including the Royal Colleges and Specialist Societies, to develop an approach which should work and where there will be differences between different specialties.
IQ: Will the consultation feed into the pilots announced recently?
ND: Yes. They will be putting into practice what we have proposed and what emerges from the consultation. The pilots are also an opportunity to make clear what revalidation is and what it isn't. Perhaps the most important message to get across is that revalidation is a five year process, not a fifth year process. It is not about passing a test at a moment of time, it's about producing evidence over a period of five years which demonstrates fitness to practise. If there were problems they would be identified in year 1 or 2, and they should be dealt with then, not in year 5.
IQ: We reported a couple of weeks ago that there have been trials in Liverpool already and that there had been findings, not all good. What can you tell me about those findings?
ND: I can tell you that I heard some of those figures and I was a bit amazed by them but the short answer is we haven't got validated data based on that trial.
IQ: Yes, even so it was suggesting that there was a lot of very heavy bureaucracy involved. I guess it plays into the hands of all those who are critical …
ND: We have to answer that point and that's why the pathfinder pilots are so important in seeing how it works in practice. There is no point in us rolling out a system which is going to be disproportionate- it has to be proportionate. We believe that there is a real benefit to doctors, to patients and to employers of having a register of doctors which is a contemporary demonstration of competence of fitness to practise rather than a historical record.
This can benefit doctors in terms of being able to reflect on their practice and to discuss with somebody ways in which they can improve their practice. We think that's all worthwhile. It's not worthwhile if the doctor is spending a disproportionate amount of time doing this or it costs the system a disproportionate amount. But most people would say that a good clinical governance arrangement is what should be happening anyway, whether it's in general practice or in a hospital.
IQ: We have run stories about fears over cost. One of the GPC's big beefs is that it is very concerned that individual GPs could end up paying vast sums for remediation. Are those sort of issues addressed in the consultation?
ND: I don't think these issues are directly addressed in the consultation but I would doubt very much that GPs will end up paying vast sums for revalidation. The first thing to say is that general practitioners should be subject to and agree to regular appraisals which test their competence and their performance. If you agree that that is the case and that there should be good clinical governance arrangements in place, then there should also be in place systems for supporting doctors where there are issues with their competence and performance.
A lot of the issues raised will be probably quite minor - where through the gathering of the data it has come out that they aren't doing something quite right, for example prescribing. This should be dealt with and resolved locally, often by talking it through.
If there is something which becomes a bit more serious, it might well mean the doctor is supported for a while or given a bit of training around some aspect of their practice which isn't operating as well as it can. If it is even more serious than this, whereby the doctor is not performing effectively, then you should have systems of remediation both at local level and at a national level, for example referring a doctor to NCAS or, if you think their fitness to practise is impaired, then to the GMC.
The key point here is that this should all be going on anyway. Revalidation isn't introducing something new- what it will do is to ensure that these processes are taking place and to regulate them.
IQ: So there is not going to be new funding, new pots of money because they should be doing it anyway?
ND: That's right- they should be doing it anyway, and in some places they are doing it already.
IQ: Yes, do you know how it varies from different PCTs?
ND: As far as general practitioners are concerned it varies by PCT. Some PCTs are very good, as I understand it and have very good arrangements for appraisal, but the system is patchy.
IQ: You are laying the framework?
ND: Yes we are laying down a framework, and at local level it can be decided how to use this framework. There should be in place systems for supporting doctors. It's not meant to be a punitive process at all but it is an assuring process, so it's not simply saying let's just have a cozy chat every year and there are no consequences to it. It is about asking; ‘Are the doctors demonstrating that they are operating in the right area?', ‘Are they getting the right feedback from their colleagues, the right feedback from patients'? Of course not all patients will say their doctor is wonderful, but we can have proper tools for running those questionnaires and for understanding them. Lots of GPs are using things like the patient questionnaires already so none of this is by itself new.
IQ: The RCGP is worried that unless there is reassurance over the costs to the members, that they won't get fully behind it and then you will end up dragging people into the process reluctantly kicking and screaming rather than selling the benefits to them. I take your point that you are laying the framework but presumably someone has got to make the decision at the end of the day who's got to pay?
ND: The vast majority of GPs will not need the remediation you are talking about. A very small percentage will need remediation not because of revalidation like you say, but because there is a decent system of clinical governance. Remediation should be used where necessary not because of revalidation, but because we are trying to protect patients and provide a safe service.
IQ: What about responsible officers, because that is another one of the worries that have come up?
ND: I think there is a slight misconception about responsible officers. I think people have confused the roles of the appraiser and the responsible officer and think they are the same person whereas in reality they mostly won't be the same person.
The responsible officer will sit at PCT level and their job will be essentially just to approve all the appraisals that have been done within the area. Their role will also include insuring that the appraisal process is working effectively. The myth of an individual responsible officer picking on Dr X and deciding ‘I don't like the cut of your jib so I'm not going to pass you' is simply inaccurate.
A good system of appraisal at local level would have a facility where if a doctor had difficulty with a particular appraiser, then somebody else could have a look at that appraisal again.
IQ: It can work both ways I guess, so from being too chummy…
ND: Exactly. Too chummy would be the other way of doing an appraisal. A good system of appraisal would certainly have an ability to change appraiser where necessary.
IQ: How do you find the balance? Do you not have to be tough on GPs to please the Government?
ND: I'm generally not interested in pleasing the Government. That's not why we are here. We're not accountable to the Government, we are accountable to the parliament, and our job is to protect the public. That involves working with the profession, not against the profession and it is in the profession's interest to protect the public and to provide the highest quality medical care we have in this country. General practice is genuinely a jewel in the crown of healthcare in this country and it is one of our greatest assets.
Revalidation, if we can get it to work, will simply add to and enhance the reputation of primary care in this country being at the leading edge because we will be able to demonstrate that doctors in all different settings are operating safely and they are able to demonstrate results.
IQ: You mentioned that all this in an ideal world should be happening anyway and I guess that lots of members of the public would probably assume that this is already in place?
ND: I am sure they do think it happens anyway and I think they would be a bit shocked if they knew that doctors don't have to demonstrate regularly they are up-to-date and fit to practise. In most industries now, people's performances are regularly appraised.
What we have got to answer is how you implement revalidation in such a way that it doesn't take up too much time and too much money and be too much of a burden on GPs' practice. This is not about telling them how they should practice, it is simply about them demonstrating that they are competent and the vast majority of doctors will have no difficulty in doing that.
IQ: But you agree that there shouldn't be a punitive cost or either time or actual money costs?
ND: Absolutely. It has to be proportionate. It has to be the right amount of time and effort. In order to achieve this it will mean that the doctor will have to reflect on their practice and gather some information and data together. It will mean that they will have to ask some patients to complete a questionnaire. This takes a bit of time, but we have to get the proportion right so it feels right for the doctors and provides the assurance needed for the process.
IQ: With the economic background at the moment, obviously that's dominating the stories we are writing about, is there any danger that the appetite for it will wane...?
ND: I think there is a more general fear that is as we move into much tighter times that people stop focusing on quality and start simply focusing on costs. That would be a tragedy because we've managed to shift the focus within our healthcare system onto quality. Revalidation I think is part of having a healthcare system of quality and safe healthcare system. So yes, there is a danger that if people start focusing only on costs that they will lose the quality agenda and I think that would be in nobody's interest.
IQ: The GMC is trying to enforce tough regulations but at the same time is trying to move away perhaps from the image that it has had with some GPs and doctors and that was the only other thing I was going to ask you?
ND: I think the GMC has made very significant advances and it is a very different organisation from the one that was around 10 or 15 years ago. An example is in our fitness to practise work, where now in every case a doctor and a lay person look at the case and agree on how to proceed.
I hope in the longer term that it is not our fitness to practise stuff that we are known for. What should define this organisation is that we set the standards for the medical profession, and that we keep the register which gives assurance to patients, doctors and employers that the people on it are competent and fit to practise. This is an organisation that is regulating the education of doctors, and that will have an ongoing relationship with them from the day they walk into medical school to the day that they retire. We need to be an organisation that the profession is engaged with, so that they understand the standards that are expected and that they help to shape those standards along with the rest of society.
We want the profession to view the GMC as a source of good rather than being seen as an organisation which comes along and threatens your livelihood. Everybody in the profession who wants good practice will recognise that it is important we have a system for dealing with doctors whose practice is seriously and consistently impaired, because otherwise we would have no means of making sure that we are maintaining good practise and assuring the rest of the population. Our activity in this area is therefore very important, but what the GMC is really about is setting standards and ensuring good medical practice.Niall Dickson: GMC chief executive Niall Dickson: GMC chief executive