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Biased surveys will wreck revalidation

Revalidation will never win any popularity contests with doctors, but the GMC's intention to use surveys of patients and colleagues to evaluate performance has always been particularly contentious.

GPs have been understandably anxious at the prospect of something as individual as their consultation style being exposed to such public scrutiny.

There has been concern, too, that surveys of colleagues could magnify partnership disputes into fitness to practise issues, and criticism of the potential costs of surveying huge numbers of patients and doctors.

But the chief reason the plan has been so controversial is that the GMC has been unable to produce evidence that surveys have been validated and shown to work. Now the research has been done, but its findings are hardly as the GMC will have wished.

The analysis of 50,000 questionnaires from patients and colleagues found evidence of ‘systematic bias'. GPs rated each other more harshly than hospital doctors did, and patients rated their GP more harshly if they were of Asian origin, had trained abroad or were a locum.

The significant number of locum GPs working in the NHS who are of Asian background or foreign-trained will have felt a certain chill reading these results.

The researchers who carried out the study insisted that overall, race was not an independent predictor of the nature of feedback. But still, this is the first time it's been suggested that a tool used to assess GPs' right to practise favours those with a certain skin colour, or at least that patients tend to favour the familiar over the alien.

Patient surveys were never going to be any use in assessing GPs' clinical skill – what is popular is not necessarily right – but the GMC had hoped they would tease out information about consultation style.

GMC chief executive Niall Dickson played down concerns, stressing surveys would be just one of a number of types of data collected about doctors, and would be discussion points in appraisal – not something you pass or fail.

He dismissed talk of a rethink, insisting ‘being aware of how patients and colleagues view your practice is important for every doctor'.

GPs won't be satisfied by that response. Revalidation is not simply appraisal with a few frills – its stated intention is to ‘assure the public, employers and other healthcare professionals that licensed doctors are up to date and fit to practise'.

If revalidation is to do its job, there will have to be passing and failing, whether Mr Dickson wants to admit it or not. And while he is right that GPs need to be self-aware about their practice, he is complacent in suggesting surveys can support that, when the evidence appears to the contrary.

The GMC must get to the bottom of these ‘systematic biases', and establish whether they are the result of prejudice, unfamiliarity, or genuine differences in consultation style among GPs of different backgrounds.

If so, that could shape future training strategies, but it would be the business of the RCGP, not the regulator. What the GMC cannot do is include surveys in revalidation without evidence they work and are fair. Surveys must be placed on ice until they can command the support and confidence of the medical profession – all of it.

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