Does revalidation offer value for money in times of severe financial stringency? The days of above-inflation increases in NHS resources are now long gone and the ever increasing costs of health care, forced up by an ageing demographic, increasing needs for dementia care (both real need and political imperative) and increasing costs of new treatments are conspiring to add pressure to budgets across the health service.
Pulse reported last week that the scheme will cost doctors over £450 in ‘opportunity costs’ per revalidation cycle and will only prevent 0.75% of cases of death, severe harm and moderate harm per year.
I am aware of the need not to be too cynical about improving standards in general practice. For instance, I find appraisal helpful – if only because some poor colleague of mine has to listen to me talking about myself for two hours – and I do find that doing them directs my learning to some extent. It’s a shame that 27% of doctors do not seem to participate in appraisal, either for lack of opportunity or other reason.
But does revalidation – as distinct from appraisal – add value? I know it is rather like questioning whether we should prescribe ß-blockers for patients with heart failure – but, as doctors, we should be questioning received wisdom.
We now hear that revalidation is going to have annual costs of £97 million. Reading the Department of Health paper on the subject, ‘Medical Revalidation – Costs and Benefits’ (yes, I have read the whole paper), the costings are based on conjecture as much as on evidence.
Part of the analysis was something called a ‘BC2 survey’, in which doctors were asked to speculate as to whether revalidation might reduce rates of suspension, sickness absences among doctors, the number of avoidable deaths and incidents of severe harm to patients, and litigation claims.
But doctors’ responses to these questions made clear that some of the presumed benefits of revalidation would not bear out – for example, the estimated benefits of avoiding sickness absences in the BC2 survey quoted in the paper are 0%. Yes, zero.
We are told that revalidation will prevent 0.75% of cases of avoidable death, severe or moderate harm per year (again this is a speculative figure). As the National Patient Safety Agency figures quoted in the government paper say that 44,274 cases fell into this category in 2011/12, 0.75% of this would mean the prevention of 332 cases for that year. The DH confirmed that revalidation would prevent an estimated 97 cases of death or serious harm.
We can believe that if we will. The National Patient Safety Agency of course, no longer exists and its functions are now with the NHS Commissioning Board.
We are told that revalidation will prevent 3% of litigation costs – which is borne by the taxpayer for hospital-employed doctors, but by insurance or mutual societies for GPs. However, I do not anticipate a 3% reduction in my medicolegal fees next year.
We are told by politicians that revalidation will improve the public’s confidence in their doctors. But with respect, according to Poll Watch, David Cameron’s approval rating last week stood at minus 16 points and Nick Clegg’s at minus 55 while GPs consistently achieve top scores in measures such as Ipsos Mori’s veracity index. Who really needs the ratings boost?
The proposed benefits for revalidation – the Government is predicting a £50-£100m saving from 2017 onwards – are worryingly specious. They talk about an improvement in quality-adjusted life years (QALY) yet they wrap this up in such jargon that even the CEO of the Family Doctor Association, who studied health econometrics as part of her first degree at St Andrews, could not interpret this in real English. They offer a QALY gain of 0.001 years to 100 patients from 20% of 73% of appraised doctors. Eh?
Going into tabloid media mode for a while, there are other ways to describe the cost of revalidation in terms of clinical care. For example, this revalidation exercise is costing the equivalent of 12,933 total hip replacements in a year.
It costs £50,000 per QALY for the most expensive drug in renal cancer – spending revalidation cash here would allow an extra 1,940 years of good quality life for renal cancer patients each year. Not a bad result. NICE’s usual threshold for recommendation of a new treatment is £30,000 per QALY. These treatments relieve pain and suffering and improve the quality of life of our patients. Does revalidation do the same?
Dr Peter Swinyard is the chair of the Family Doctor Association and a GP in Swindon