Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
"Day-Dreaming"
- Joseph . C . Obi (5 June 2005)
-
GMC response
- Krishna Rao Korlipara, London NW1 3JN (7 June 2005)
-
No revalidation without a ballot of all doctors
- Olusola O.A. Oni (7 June 2005)
-
Appraisal and Revalidation can come together!
- Nimal K Menon (9 June 2005)
-
Criteria evidence and standards
- David A Bruce, Ross Reid (17 June 2005)
|
|
|||
|
Joseph . C . Obi, Provost and Emeritus Chair of Nutritional Immunomodulation RCAM (Royal College of Alternative Medicine) www.RoyalCAM.org
Send response to journal:
|
What If . . . The General Medical Council (GMC) concentrated purely on just the Registration and Licensing of Medical Doctors in the United Kingdom ? What If . . . The National Clinical Assessment Authority (NCAA) handled all Revalidation and (associated) Clinical Performance (or Conduct) Concerns relating to all UK-Registered Clinicians ? What If . . . An Independent Clinical Tribunal (ICT) permanently took over the full ajudication of all appropriate Fitness To Practise (FTP) Proceedings concerning all Statutory UK Healthcare Professionals, not just those registered with the GMC ? Competing interests: Professor Joseph Chikelue Obi FRCAM (Dublin) FRIPH (UK) FACAM (USA) also supervises an Interdisciplinary Revalidation Initiative (IRI) for Seasoned Practitioners in Complementary and Alternative Medicine. |
|||
|
|
|||
|
Krishna Rao Korlipara, Elected Member General Medical Council 350 Euston Road, London NW1 3JN
Send response to journal:
|
Lakhani’s article on revalidation (5 June 2005) attacks the GMC’s model of revalidation. He states that ‘The GMC model is predicated on doctors working in a managed environment’. That is simply wrong. What the GMC has said is that, if doctors are working in an approved working environment, then the GMC will be prepared to rely on local, quality assured, processes rather than duplicate them. This is the approach supported by the Government. It is also wholly consistent with the Hampton Report published by the Treasury - ‘If regulators operate effectively, and use the best evidence to programme their work, administrative burdens … can be reduced while maintaining or even improving regulatory outcomes’. An approved working environment for this purpose is one which has an effective system of clinical governance; has an effective appraisal system, based on the headings of Good Medical Practice; and is independently regulated or quality assured. But there is no assumption that all doctors, or even all NHS doctors, are working in environments which satisfy those criteria. Where the criteria are not satisfied, evaluation of the doctor’s fitness to practise will involve a greater level of scrutiny. Lakhani also states that ‘Revalidation should protect the public from poorly performing doctors’; and ‘Revalidation is an essential tool to protect patients from the minority of poorly performing doctors’. However, by Lakhani’s own argument, revalidation is an episodic process. In common with Dame Janet Smith, whom he quotes, Lakhani believes that the revalidation cycle for some doctors could be extended to as much as seven years. The public is surely entitled to more consistent and frequent protection than this against poorly performing doctors. It makes no sense to position the GMC as the first line of defence against impaired practice. We do not employ, or contract with, the more than 120,000 doctors delivering UK healthcare. Local systems are the key to detecting and addressing impairment. That is the consistent message from a string a high profile cases. It is precisely because of such cases that the GMC and the Government have stressed the importance of local systems. Lakhani attempts to deal with the episodic problem by describing processes that will operate more frequently than five or seven years. In his model those processes are separate from appraisal and clinical governance because both ‘are insufficient by themselves’. It is not clear why clinical governance should be insufficient. On the contrary, it is difficult to see how clinical governance can succeed in ‘safeguarding high standards of care’ if it does not include means of identifying and dealing quickly and effectively with poorly performing doctors. As Dame Janet Smith said in the Fifth Report of the Shipman Inquiry: ‘… if properly developed and well resourced, clinical governance could provide the most effective means of achieving two important aims. First, it could enable PCTs to detect poorly performing or dysfunctional GPs on their lists. It could also help practices to discover any problems or weaknesses among their own number. Second, it could have the beneficial effect of helping doctors who are performing satisfactorily to do even better. At the moment, I do not think it is achieving these ends …’ Therein lies the key. Those who, in common with Dame Janet, have argued that clinical governance today is not capable of delivering adequate patient protection criticise the GMC for not filling the alleged vacuum. However, that looks at the problem through the wrong end of the telescope. If local systems are not yet fully effective, the answer is to make them so, because otherwise our successors will continue to lament the damage to patients caused by repeated failures, at the point of delivery of healthcare, to detect and act upon serious impairment. That is the core message of the Ayling, Ledward, Neale and other inquiries. As the Report of the Public Inquiry into children’s heart surgery at the Bristol Royal Infirmary said: ‘It must be the employer first and foremost who should be able to deal with poor performance and misconduct.’ Lakhani proposes a three point framework: • The GMC should set the overall standards and framework for revalidation including quality assurance. • The royal colleges should establish detailed criteria, standards and evidence for their specialities. • The NHS should work with professional organisations to develop clinical governance and appraisal into more effective processes. This looks remarkably like the GMC’s framework. It is why, for example, the GMC has commissioned the Academy of Medical Royal Colleges to undertake a review to ensure that appropriate standards are in place for each speciality. The review will consider whether there should be an agreed format and approach to the guidance issued by the Royal Colleges, which doctors will use in compiling their folders of evidence for appraisal, revalidation and other purposes. A further aspect to the project will involve considering the potential for identifying key indicators of actual serious impairment for each speciality, so that prompt action can be taken locally to prevent harm to patients. Of course, the GMC has made mistakes along the way; and we must continue to listen carefully and address legitimate concerns. In particular, we must provide more detail on patient and public involvement, on clear standards, and on rigorous quality assurance. The aim of revalidation is to increase public confidence. That is why we warmly welcomed Sir Liam Donaldson’s review. The GMC’s model for revalidation is fundamentally sound and, if further changes are required, we will embrace them. Competing interests: None declared |
|||
|
|
|||
|
Olusola O.A. Oni, Consultant Orthopaedic Surgeon 16 Sutherington Way, Anstey LE7 7TH
Send response to journal:
|
Lakhani’s (BMJ 2005; 330: 1326-8) is the fourth in a series of articles purporting to discuss the regulation of the medical profession. Like the ones before it, this article treats revalidation as if it is the same thing as regulation. The medical elites are panicked because revalidation has been seen for what it is, a phoney. It deserves to be rejected by the profession, if for no other reason than the fact that it is based upon dubious statistics. Dame Janet could hardly have come to any other conclusion when the medical elites kept telling her how rotten we are. The only statistics that matters is what our customers tell us. They tell us in poll after poll that they are satisfied with what we are doing1. The onus is on supporters of revalidation to demonstrate exactly how it would protect the public from poorly performing doctors. These schemes have been operating in the US and Australasia yet there is no evidence that these countries have been rid of poorly performing doctors or, for that matter, that their doctors are better than ours. It is not enough to say that revalidation can be made to work here. What we want is concrete evidence that it ‘does what it says on the tin’. Unless its supporters can demonstrate that revalidation will remove every single poorly performing doctor from practice in the UK, we must reject it. The medical elites think they can move the goalposts any time they feel like it. Revalidation is the latest manifestation of this. Ordinary doctors played no part in it. True there was consultation but it was only in so far as to obtain acquiescence. All that was conceded was for doctors to peruse the details of a policy which the GMC already had unilaterally and unconditionally imposed. Do we really have to accept it? The answer is no. If we as a profession refuse revalidation, it cannot be imposed. Before 1975, registration for doctors was for life following the payment of a single fee. To improve its finances, the GMC unilaterally and unconditionally replaced it with an annual retention fee. Doctors threatened not to pay. It was obvious that if they carried out the threat, they would all be erased from the register. There would thus be no registered doctors and the NHS would not be able to function. The government realising this intervened and came up with a compromise. In return for the annual retention fee, ordinary doctors for the first time would be elected onto the GMC and also form the majority on the council. Revalidation, which treats the medical profession as if it were an extension of the NHS, has been placed on hold following Dame Janet’s intervention. We must ensure that it is not resurrected. The only concession that any profession is obliged to make to society is the entry qualification to that profession. We have done that with our undergraduate and specialist certifications. Any other restrictions on trade need to be negotiated. No one has negotiated revalidation with us. BMA and college agreement is not proof of the profession’s agreement. The BMA and the colleges should now tell the CMO and the government that there would be ‘no revalidation without a ballot of doctors’. If they do not do so we should withhold our membership fees and bankrupt these organisations. It is no longer acceptable for those purporting to represent us to subordinate our interests to those of others. 1. www.mori.com/polls/2001/bma2001.shtml Competing interests: None declared |
|||
|
|
|||
|
Nimal K Menon, General Practitioner The Ongar Surgery, High Street, Ongar, Essex CM5 9AA, UK
Send response to journal:
|
Lakhani has raised some important issues and drawn appraisal and revalidation closer to each other while showing that they are different processes serving different purposes – developmental and educational in the former, definitive in the latter. It is important to appreciate that revalidation is final – one is either fit to practice or not, without any grey area in between. Additionally, fitness to practice would be viewed in its totality with fitness across the whole range of competencies claimed. The need for robust appraisal systems and local certification for revalidation implies, quite rightly in my view, the need for performance assessment. Performance assessment relating to both of these aspects would involve the properties set out by Lakhani i.e. quality of care, quality of the doctor-patient relationship and/ or interaction and compliance with the principles of Good Medical Practice. As regards appraisal the need for a minimum data set is now due. This would include audit with some degree of the candidate’s ownership in the process, medicines management, deaths in the Practice etc. Input from clinical governance would aid the process of appraisal and facilitate eventual revalidation as this information would now be included in the folder for revalidation, especially if records of consecutive years of appraisal are presented for revalidation. It would, however, still not be possible to make a positive statement as suggested by Lakhani. To indicate that “I know that there are none” would never be possible because, even after triangulation, a judgement can only be made on the available evidence i.e. “I know of none” on the basis of the information available. I do not believe that the independent contractor status is incompatible with effective clinical governance. On the contrary, there needs to be a willingness to implement and monitor the provision of best practice. This is no different from that which would apply to employees who are not in such a relationship with their employers. Although poor performance in a knowledge test is the only currently available predictor of suboptimal performance in practice, such a test bears little relationship to continued satisfactory performance. Importantly, a knowledge test for revalidation may, in the final analysis, test at the lowest common standard Unfortunately, at the outset, appraisal and revalidation were linked. This has inevitably caused confusion for the GMC and for doctors. While politicians saw and continue to see appraisal and revalidation as means of assuring the public, especially with identifying and dealing with doctors whose performance is suboptimal – a summative process, doctors see appraisal as a formative process The dichotomy between these two needs - political and professional - has always been present and has hitherto not been appropriately addressed. Additionally, appraisal is a means of separating performance which is due to the doctor from that which is influenced and determined by the organization that the doctor works for. The Bristol Inquiry highlighted deficiencies in the systems of the NHS that contributed to problems in the hospital. Appraisal can now highlight constraints to practice due to organisational problems and failures. While five pieces of chalk still do not make one ball of cheese without accentuating the former or dimeaning the latter, it is possible to bring appraisal and revalidation closer and satisfy the needs of both. Competing interests: None declared |
|||
|
|
|||
|
David A Bruce, Director of Postgraduate GP Education Tayside Centre for General Practice, Ross Reid
Send response to journal:
|
In Lakhani’s article from General Practice proposing a way forward for revalidation of doctors, 10 guiding principles are outlined(1). While we have no argument with any of these principles, we are however surprised that a call for detailed criteria, standards and pre-defined evidence to be developed is made without mention of published work in this area(2). The Tayside revalidation pilot was a large scale study involving 66 GPs (principals and non-principals) who worked over a period of 2 years to both define the content of GPs revalidation folders and make an external assessment of these folders against pre-determined standards. The evidence from this study subsequently informed the development of the RCGP Scotland’s Revalidation Folder and material from the original research was incorporated in the RCGP Scotland Revalidation Toolkit which received mention in the 5th Shipman Report(3). As a study on the scale of the Tayside revalidation pilot is unlikely to be repeated it is important that evidence from this work on criteria, evidence and standards is built upon and it is our view that the failure to recognise the work that has taken place in General Practice is a serious omission to this article. Reference List (1) Lakhani M. GMC and the future of revalidation: A way forward. BMJ 2005; 330:1326-1328. (2) Bruce DA, Phillips K, Reid R, Snadden D, Harden RM. Revalidation for general practitioners: randomised comparison of two revalidation models. BMJ 2004; 328:687-691. (3) Dame Janet Smith DBE. The Shipman Enquiry; Fifth Report: Safeguarding Patients: Lessopns from the Past - Proposals for the Future. 2005. Crown Copyright 2004. Competing interests: Lead clinician Tayside Revalidation Project |
|||