Acute trusts will pay for remediation to keep senior clinicians working but that's not such an easy option for practices says Dr Brian Keighley, while Dr Mary McCarthy argues that if GPs pay for their professional exams why not remediation?
The answer to yes/no questions is rarely clear cut, but in this case I am firmly in the ‘yes' camp - mostly in the name of intra-professional equity.
In a market-driven NHS, the contractual status of GPs has become increasingly blurred by political dogma. One minute we are considered ‘private providers', no different from services offered by commercial companies driven exclusively by a profit motive for shareholders. The next we are ‘part of the NHS family', subject to every ministerial directive, conceived on a whim, and often with little contractual authority save from a blanket clause that obliges us to follow national and local ‘guidance'.
The other factor that seems to determine whether we are ‘independent' is where expenditure is involved – independence is soon forgotten when command and control are invoked.
Britain's doctors are now possibly within 18 months of the introduction of revalidation, yet the whole issue of the definition, resourcing and organisation of remediation has produced nothing but a deafening silence from the GMC, the Department of Health and primary care organisations.
There are grave anxieties that the public finance crisis will mean that where remediation is concerned GPs will be designated as ‘private providers' – with no resources for nearly 50% of NHS doctors.
But in secondary care matters are likely to be different. First, acute trusts are huge organisations and the cost of remediation for individual doctors within them will be a tiny proportion of annual spend.
Secondly, trusts will be in a position to make a commercial judgement on the benefits to them of securing the return of senior clinicians to productive work.
Consider a technically superb orthopaedic surgeon with a poor attitude to communication or relationships with clinical teams.
If he or she can be successfully remediated locally this is likely to be a far more economic proposition than seeking disciplinary procedures or even dismissal. Even in the larger GP partnerships, this is a very unlikely option in primary care.
So – to ensure equity in how revalidation is applied - there needs to be a lot of thought given to what happens to that few number of doctors who fail to respond to the messages produced by this new process and who get to the fifth year of the cycle without a positive recommendation to the GMC from a responsible officer. There must be no fundamental differences between them based on the sector they work in.
We must remember that revalidation is a professional issue, one that should be implemented without regard to the contract held with what is virtually a monopoly employer of UK doctors.
Unfortunately there is a small of cohort of doctors in all sectors of the NHS where remediation will always remain a remote possibility - for various reasons concerned with personality, health or perverse motives.
So I suggest every NHS doctor should have one concerted and dedicated attempt at remediation as a right. But failing to achieve satisfactory remediation at the end of that process moves us into new territory where answers are less clear.
The whole ethos of revalidation is based primarily upon professional development, reflective practice and, ultimately, better care of patients. Those same patients make a considerable investment into medical education as taxpayers.
The premature ending of a medical career costs the nation much in terms of that initial investment and it surely only makes sense that the public purse should seek to protect it when problems are uncovered.
Dr Brian Keighley is a GP in Balfron, East Stirlingshire and chairman of the BMA GMC Working Party
When anything new is proposed there's always the question: ‘and who is going to pay for all of this?'
And revalidation/remediation is a tricky subject anyway – when is it finally going to happen? –is it really going to start next year? And after years of discussion and debate – is it actually on the horizon?
I know I'm not the only one who thinks that this is not going to be as scary as others feel it will be – it can't be, can it? In practice the process cannot be so tough that half the countries GPs will fail. There is no raft of MRCGP trained doctors waiting out there ready to fill the vacant places. Up here in Shropshire it's hard enough to get a locum when you need one.
So – it is going to be reasonable and the majority of GPs will have no trouble with it – just as now, few doctors have any problems with appraisal.
But what about those GPs who do fail – and fail sufficiently badly that they need remediation. This is going to be expensive since it will involve the time and energies not only of the GP - who may not be able to work until it is complete - but the time and expertise of the panel of professionals who are going to organise the process.
We need to be sensible about this. As doctors we are responsible for keeping up to date and competent within our professional sphere. So if we fall down on these competencies we ought to play some part in remedying them. After all, we have paid to sit professional exams – and to pay again if we fail and need a second try.
So some of the cost should, in fairness, be shouldered by the GP who is being enabled to continue practising. Providing the revalidation process is robust and fair, then the doctor ought to be prepared to spend some money and time in repairing the parts of his or her professional life that need attention – as you would for a car that failed its MOT.
It may be that they will not have to pay the whole cost. In future one may possibly insure against failing revalidation in much the same way as you can insure against other events that may have a financial impact (the birth of twins, car accidents, even, with a pre-nup, a poor marriage).
Though I would imagine that the conditions imposed by the insurance company would probably make revalidation difficult to fail.
The BMA/GPC may well come up with ways of helping doctors who fail - providing support and advice in much the way they do now for doctors who have problems.
PCTs may develop retraining packages that could be shared with PCT neighbours and possibly part-funded. After all they do not want to lose doctors either and they may help financially with grants. Or LMCs may find a way of advancing a loan to a member.
It does depend a lot on what finally emerges as the robust revalidation process and whether it is seen as being fair and equitable. If GPs, as a body, judge it to be unworkable then the whole process will fail.
When I talk to colleagues about revalidation, most people are nervous about the whole process and have unjustified doubts about their ability to pass.
Senior ones have told me they would just retire if there was any problem, while younger ones talk of emigration. We need to avoid this scenario and have in place remediation plans that are achievable and affordable.
The RCGP needs to bear this in mind when finalising its plans. As someone said of criticism – it needs to be like rain –enough to water the roots of a plant but not so heavy that the whole garden is washed away.
Dr Mary McCarthy is a GP in Shrewsbury and chair of Shropshire LMC.GMC sign Yes No