Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Political will does not exist for radical reform
- Nigel Dudley (24 June 2005)
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endless reform
- benjamin dean (24 June 2005)
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what do other professions do?
- Gordon Pledger (24 June 2005)
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Revalidation
- Brian J. Penney (24 June 2005)
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Evaluating the evaluators
- Jayaprakash Gosalakkal (25 June 2005)
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second thoughts
- benjamin dean (26 June 2005)
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Appraisal will do the job, Revalidation won't
- Olusola O.A. Oni (27 June 2005)
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has public confidence in doctors been lost?
- Stephen F Hayes (28 June 2005)
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Re: has public confidence in doctors been lost?
- Stevie M Gamble (29 June 2005)
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Re: Re: has public confidence in doctors been lost?
- Stephen F Hayes (29 June 2005)
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Learning from other
- Debra Humphris (30 June 2005)
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Response to Kieran Walshe Article in BMJ of 25 June 2005
- Gillian Camm (1 July 2005)
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Robust revalidation needs to start with appropriate validation
- Alexander W Gray (5 July 2005)
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Nigel Dudley, Consultant in Elderly Medicine St James's University Hospital LEEDS LS9 7TF
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Walshe and Benson make many interesting observations about regulation of healthcare professionals and underline the importance of the primary mission to protect the public.[1] It is therefore surprising to see so little written in the article about the woefully inadequate arrangements for managers - deemed to be a group of professionals at the Bristol Inquiry - that still takes place behind closed doors rather than in the public domain. Just as a list of wayward doctors can be reeled off, it would be possible to reel off a list of managers who have not acted in a way compatible with "professional" codes;unlike doctors, rather than being held to account the managers are often simply and quietly moved on, sometimes into another healthcare post. The accusation levelled at doctors and other healthcare professionals by Walshe and Benson of blocking or watering down reforms is probably valid but it can be equally applied to managers as can the accusations of looking after self-interest rather than the interests of the public and the safety of the public. I would agree with Walshe and Benson that radical reform is needed for healthcare professionals, including managers. However, that is very unlikely to happen under the current government as despite the very strong case and call for proper manager regulation after the Bristol Inquiry the Department of Health chose not to introduce the recommended register and regulatory body for managers that would have been answerable to what is now the Council for Healthcare Regulatory Excellence. Instead minsters introduced another terminally useless Code of Conduct in October 2002 that fails to deter wayward managers and offers no protection to the public. Now that type of response to public concern generated by the Bristol Inquiry should not inspire public confidence and looks like protection of self interest and painful sloth; it is, however,something that makes the attempts at reform by the GMC over recent years look positively rampant by comparison. [1]Walshe K, Benson L. Time for radical reform. BMJ 2005;330:1504 - 1506 (The views expressed are my own and not those of my employing organisation.) Competing interests: Interest in patient safety and manager regulation. |
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benjamin dean, sho oxford
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Revalidation is essential, however in my opinion it is important that great care is taken in deciding how best to reform the system. It is very easy to chat about reform and say how much reform is needed, however it must be remembered that excessive regulation can be extremely damaging. Any proposed system for revalidation must consider the negatives as well as the positives of any new system, it is depressing how often any negatives are ignored. There are widespread staff shortages and massive financial problems in the NHS already, so any system must be efficient and not drain funds/resources excessively. Frankly a lot of what I have read on ravilidation in various publications has been nonsensical waffle, which is precisely what is not needed in todays NHS. Revalidation must be clear and concise in order to achieve its aims. Lessons can be learned from other topical mistakes, such as the incomprehensible draft EU constitution and the throttling over regulation of the FSA ( financial services authority ). After all if revalidation ends up becoming an incomprehensible over-regulated mess then the people it sets out to protect ( the patients )will be the ones to suffer Competing interests: None declared |
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Gordon Pledger, retired Director of Public Health Newcastle upon Tyne
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We are rightly trying to improve the assessment of competencies and governance in the medical profession. I wonder if we are learning enough from the action that other professions take. For example there are well established procedures for assessing technical competencies of pilots. For the more general and difficult competencies perhaps we could learn from what tests are applied to other professions that have a major impact on peoples lives. For example who does what in relation to cabinet ministers, judges, company directors, military and police commanders, and senior civil servants? Competing interests: None declared |
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Brian J. Penney, Family Physician Ontario Canada
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The concept of revalidation if applied to physicians also needs to be applied to all others who provide any form of public service including so called "Health Care Policy experts". Who evaluates them and what qualifies them to expound on a need to revalidate physicians? If the same ethical, educational knowledge and moral standards that politicians would seek to impose on physicians were to be applied in equivalent form to themselves, we would have very few qualified to be elected. By the same principles, those practicing "Health Policy", law or pharmacy or midwifery or chiropractic or physiotherapy or dentistry etc also need to be evaluated by appropriate criteria. One of the other concerns I have revolves around who is to evaluate the evaluators and by what standard? What fair and objective test can be applied? The same test cannot be equally applied to the new graduate as the senior consultant. A test of competence may vary within the same specialty depending upon geography, ethnicity or age of the population. A physician competent in rural Devon may not be as competent in Bradford and vice versa. A GP practicing in a predominately retirement community may not have the same expertise in a new community with a large paediatric practice. Who will bear the cost of this constant revalidation of all professional? Aready over burdened physicians and professionals or the already over burdened public purse? My suggestion is that we cannot afford to target all doctors or indeed all professionals. What we can do is measure outcomes. Already we have access to the prescribing data of all physicians; already we have access to the numbers, types and some outcomes of surgical and medical procedures. By monitoring more outcome criteria, we can identify rapidly and accurately at lower cost those professionals in need of remedial training or education. Assessing every doctor to find the one rotten fish in the basket is pointless if all you have to is follow your nose to the source of the odour. Competing interests: Physician subject to revalidation |
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Jayaprakash Gosalakkal, Consultant in Paediatric neurology UHL Leicester UK
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This is indeed an area of major concern.The integerity of the process should be above board and should appear to be so.Do the evaluators have the necessary blend of knowledge,skills in the speciality and sense of fairness to do the job well?Sometimes in the current atmosphere what matters more is who is involved rather than the seriousness of the lapse.This issue is especially of importance to ethnic minority doctors who often find themselves at the recieving end of non standardized evaluations. One way to ensure that would be to appoint people as heads of deparments based on their educational,clinical and academic position rather than purely on their managerial skills.This is one difference I find from Americn programs where few will doubt the knowledge or standing of chairmen of a department.You may agree or disagree with them but in most cases you acknowledge their stature in the field.There must be some consideration to this aspect in the appointment of directors and evaluators if the process has to become above board.This system of evaluationg sometimes by who you know rather than what you know will struggle to gain the respect of the profession or the general public Competing interests: None declared |
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benjamin dean, sho oxford
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I have had second thoughts and would like to ask the question- is revalidation really needed at all? Maybe the 'claimed' need for revalidation is really just a political knee jerk reaction to keep the public happy, evidenced by the need to make it sound credible (1). The word reform means to 'make right what is wrong'. This is interesting given the way in which politicians use the word, or maybe they just have a twisted perspective on right and wrong. I think we need to accept that it is sometimes not possible in life to right all wrongs, and many attempts to do so merely create more wrongs, hence worsening the situation. Revalidation is likely to create many more problems than it solves. No system can be perfect but it can certainly be worsened by too much top down intervention. Would anyone seriously suggest that every single professional (lawyer/politicans) have his/her yearly exploits reviewed by his peers to check that he/she was not a closet serial killer? After all I have seen no evidence to suggest that murderers are more likely to be health care professionals than any other professional. Why are the medical profession being singled out here, instead of the managers and politicians who have so much impact upon patients treatment? How much will it cost to implement? that is assuming it is logistically possible in the first place. The regulation of the medical profession, on the other hand, is another problem entirely that does need addressing. There are a number of alternatives to the current regulatory system which could be considered (2). The need for regulatory change does not need to go hand in hand with jumping on the revalidation bandwagon. There are already many ways in which the incompetent can be found out. Patients complain, patients take legal action, doctors have endless exams as it is, feedback is not in short supply and patient outcomes can be analyzed. Is revalidation the answer? I believe I am not speaking for just myself here; but revalidation is arguably an impracticable, unnecessary and ill conceived idea that will further restrict the medical profession's ability to do what they do best: practice medicine. To quote Tacitus: ' The more corrupt the state, the more it legislates'. 1. Making revalidation credible. Mike Pringle. BMJ 2005;330:1515 2. The Roadmap to Reform: Health. Dr Michael Goldsmith & Dr David Gladstone. (http://www.adamsmith.org/policy/publications/health-pub.htm) Competing interests: None declared |
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Olusola O.A. Oni, Consultant Orthopaedic Surgeon Koro Lodge, 16 Sutherington Way, Anstey LE7 7TH
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According to Pringle (BMJ 2005, 330:1515), appraisal is no good because it has not yet revealed one underperforming doctor, because it has no explicit standards and because there is no lay involvement. It is obvious that Pringle does not understand the concept of appraisal at all. What should happen in appraisal is this: data is collected about the doctor’s day-to-day practice over a period of say a year, then that data is analysed. That analysis is the only means of obtaining a true picture of what that doctor does and hence, his/her effectiveness. This precisely is what revalidation cannot do. Appraisal is about skill, revalidation is about knowledge and, we all know about the knowing-doing gap [1], don't we? The idea of appraisal is to make you better at your job. In addition to reinforcing, it also says, 'this is where you are at and, this is where you should be heading'. This is a better method of improving standards than is measurement against some phoney standards. The British public is more interested in improving standards than in detecting failures. The lack of understanding of appraisal arises because many doctors’ teachers including professors have no formal education/training in the teaching craft. They rely solely upon intuition. This is why postgraduate medicine is in such a mess in the UK. On appointment as Senior Lecturer at Leicester, I realised that intuition was not enough. I therefore went back to university and obtained a postgraduate degree in training and development. I was the only one humble enough to do so at the time. It would be interesting to know how many revalidation supporters have formal training as teachers. Walshe and Benson (BMJ 2005, 330: 1504-6) exhibit ignorance of educational theories in their simplistic reference to knowledge decay. Not all knowledge decays with time. Skill in particular does not necessarily decay with time. Riding a bicycle is a good example. Diagnostic, or as I call it pattern recognition, skills hardly decay with time. By contrast, theoretical knowledge decays. This is why most doctors would not be able to recall the Kreb’s cycle if asked. Fortunately, theoretical knowledge is not necessary for excellent performance. Hamilton Naki (eulogised in Obituaries BMJ 2005, 330: 1511) left school at 14 and yet he anaesthetised and performed operations to the highest standards. What Naki’s story tells us is that when one is taught well, one performs well. A poorly performing doctor is not likely to have been taught well. Therefore, it is in the teaching of young doctors that we should concentrate our efforts. But, how can we do that if the young doctors are on shift work? Extraordinarily, a third of doctors qualified in the UK a year ago are currently not in training! The medical profession is burning and all that doctors’ leaders can do is fiddle. 1. Pfeffer J, Sutton RI: The knowing-doing gap: how smart companies turn knowledge into action. Boston: Harvard Business School Press, 2000 Competing interests: None declared |
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Stephen F Hayes, freelance GP and GPSI Bitterne walk in centre, Southampton
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Walsh and Benson state that "The current reviews offer an opportunity for fundamental reform that can regain public confidence" and that "public and political faith in the professions and their regulators is lower than ever before." However, despite a small number of high profile (and very frequently cited) cases, the public continues to give doctors an approval rating of approximately 90% in the BMA's annual poll. Politicians, lawyers and journalists tend to receive trust ratings in the order of 20%. It is these latter groups whose voices are loudest in calling for ever increasing regulation of doctors. The public are wise enough to recognise that the appalling crimes of Shipman were a one off. This evil man would have sailed through any revalidation process and it is bogus to cite his uniquely evil deeds as an argument to pile yet more costly and time consuming processes on working doctors. His modus operandi is blown and cannot be repeated. Dame Janet's view that appraisal/revalidation was about 'stopping the next Shipman' is in my view a big mistake. The answer to optimising performance is regular compulsory CME and CPD supported by audit and mentoring, combined with an fair but robust independent inspectorate which can be alerted by safe whistleblowing. Rather than concentrating efforts and resources on 'stopping the bad doctors' we need to restructure so that every doctor is helped and guided to improve his or her performance. Appraisal, in which I am involved, is to my mind a useful developmental exercise but this has not been proven to improve performance.The costs locally have been something like £1,000 per GP (appraiser fee of £500, £400 for appraisee plus admin time). In my opinion this money could have been spent to better effect on providing and supporting education. Competing interests: working doctor, GP appraiser, I earn money by providing dermatology education to GPs |
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Stevie M Gamble, retired HMIT EC2Y 8BL
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Stephen F Hayes, freelance GP and GPSI, claims in his Rapid Response of 28th June that: ‘Dame Janet's view that appraisal/revalidation was about 'stopping the next Shipman' is in my view a big mistake.’ I am unable to find any reference anywhere to Dame Janet Smith ever having made the statement he attributes to her. The closest I can get is in her statement on publication of her Third Report on 14 July 2003: ‘However, the changes that I propose should not be seen in a negative light, merely as a way of stopping or catching ‘another Shipman’; they should be seen as a means of improving the quality and reliability of death certification.’ (1) The Third Report has, of course, nothing to do with appraisal/revalidation, and furthermore the judge was using the phrase in the negative, not the positive as alleged by Dr Hayes. This particular member of the general public would feel a great deal more confident if Dr Hayes showed some signs of having read the Reports he criticises. Stevie Gamble (1) http://www.the-shipman- inquiry.org.uk/mediainfo.asp?from=a&ID=75 Competing interests: None declared |
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Stephen F Hayes, FreelanceGP/GPSI Bitterne WIC, Southampton
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I assure Stevie Gamble that I have read the full report and noted many of Dame Janet's comments, and also her reforming zeal. Dame Janet clearly sees herself as a woman with a mission as can be seen on the link below http://www.gmcpressoffice.org.uk/apps/news/archive/detail.php?key=164 where she states that medical students should be subjected to (undefined) 'ethical testing' and 'weeded out' if they 'fail'. I find this quite disturbing from a libertarian point of view. Furthermore it reminds me of a rugby limerick which I would not wish to quote in full here even if allowed 'there was a young man at the Trinity ... Who...(did a number of very bad things).... ..... ...and took double honours in Divinity.' In other words, the ability to pass tests is not a reliable indicator of moral character. I am concerned that someone who apparently believes the opposite should exert a major influence on the future development of my profession, which continues to enjoy the trust of 90% of the public (by contrast with the legal profession and politicians). Nobody is arguing that doctors can be left alone to do as they please, but I continue to assert that if we are looking at how the continuing learning and professional development needs of doctors can be addressed for the maximum benefit of patients, Shipman, Ledward et al are the wrong starting point. Competing interests: previously stated |
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Debra Humphris, Professor of Health Care Development Health Care Innovation Unit, University of Southampton
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The issue about the memebership of regulatory bodies is well made, as long as this is on the basis of individuals who have the free time this will constrain the membership. More importantly we should also be learning from others, an interesting ommission is the work in New Zealand who now have in place the Health Practitioners Competence Assurance Act 2003 which embraces all the regulatory bodies. Competing interests: None declared |
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Gillian Camm, GMC Lay Member General Medical Council
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Walshe and Benson argue that there should be fundamental reform of professional regulation. They give the example of a number of headline cases including Ayling, Green, Ledward, Neale and van Velzen. Those cases are said to exemplify a ‘constant litany of apparent failure to deal with incompetence, serious dishonesty, sexual misconduct and unchecked wrongdoing’. But their article omits a crucial fact: the GMC found each of the doctors guilty of serious professional misconduct and that they were erased from the register (or, in the case of van Velzen, soon will be unless there is a successful appeal). It is difficult to see how those cases demonstrate a constant litany of apparent failure of professional regulation. Of course, it can be argued that it took far too long to uncover the wrongdoings and to secure effective action. The GMC would certainly agree with that; and, no doubt it is why the relevant inquiry reports identified the importance of local systems capable of detecting and acting quickly and effectively on actual and emerging impairment. As Jean Ritchie QC said in the report of her Inquiry into the case of Rodney Ledward: ‘The sooner concerns about a doctor's practice are noted and acted upon, the greater the chance that patient care will be safeguarded, and the greater the chance that deficiencies in the doctor's practice will be remedied before his or her career is damaged. It is in the interests of all those who provide or assist in the provision of care, all NHS managers and the NHS as a whole, that concerns are raised and dealt with promptly.’ There are estimated to be some 120,000 doctors in active clinical practice in the UK. The implication of the article is that the GMC, as regulator, should actively monitor doctors in order to provide the first line of defence against seriously impaired practice. This is simply unrealistic and wholly inappropriate. As Lord Warner, Minister of Health, said at CHRE’s conference on 8 March 2005,‘ The responsibilities of employers must be properly exploited before we load more onto regulators’. CHRE’s referrals of regulators’ decisions to the High Court are said in the article to be further evidence of apparent failures of professional regulation. Two cases are cited to make this point. But of the two cases, one (Ruscillo) was found to be unduly lenient and the other (Truscott) was not. The article fails to distinguish systemic failure from the kind of error that is inevitable in a large scale system in which human beings exercise judgment. Mistakes are made in all such processes – by juries, by fitness to practise panels, and even by judges. That is why there are appeal procedures; and it is why the GMC has three times pressed the government to secure its own right of appeal. Meanwhile, the GMC has consistently welcomed CHRE’s power of referral. CHRE’s power of referral, which is tantamount to an appeal, came into effect on 1 April 2003. In the ensuing two years, the GMC’s fitness to practise committees and panels have made around 440 reviewable decisions. CHRE have referred 12 of those decisions to the High Court. One referral was subsequently withdrawn by CHRE; seven were resolved with the cooperation of the GMC, and one is pending. Of the remaining three, where CHRE and the GMC disagreed, the Court ruled in CHRE’s favour on one occasion (Leeper); in the GMC’s favour on one occasion (Solanke); and on one occasion the Court found undue leniency but CHRE failed to secure their desired outcome, namely erasure, although, by agreement, there was useful strengthening of conditions on registration (Southall). Modified outcomes in 8 cases, around 2% of the total of some 440, do not paint a picture of systemic failure. The article claims that Dame Janet Smith pointed out, in the case of the GMC, that it is unacceptable for the regulators to be run by boards or councils dominated by the professionals themselves, elected by their peers, and with weak, internally appointed lay membership. I am afraid that this is simply wrong. The GMC’s lay members are not internally appointed. In common with other statutory healthcare bodies, including CHRE, lay members are appointed independently, against pre defined criteria through open, external, competition. The GMC plays no part in the process. It may be right that there should be open and constructive debate on the future of professional regulation. There may also be a case for fundamental reform. However, if there is such a case, it has not been made by Walshe and Benson. Competing interests: GMC Lay Member |
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Alexander W Gray, Medical Director Ideapharma Ltd, Innovation Centre, Cranfield Technology Park, Cranfield, MK43 0BT, UK
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Sir Walshe and Benson are indeed correct when they state that "the crucial question is not whether reform is long overdue but whether the political will exist to embark on such a wholesale reform of professional regulation". One issue however that seems to have been forgotten in this discussion is the role of medical schools and the training they offer. As a physician who left the profession, I was left with a strong sense that the quality and extent of medical education differs not only between medical schools, but also for individuals within medical schools, dependent on their exposure to the clinical environment in the "firm" system. Thus it is possible to exit medical school with widely varying knowledge and skills dependent on an experience of medicine that could be described as "personal" rather than comprehensive. The long nature of the course makes this scenario even more unacceptable: there should be time enough over a 5 to 6 year period. Although more modern course structures may help to alleviate this problem, there is little sense that "best practice" in medical education is implemented across the nation. It is difficult to believe that individual institutions are able to design and re-design their courses, using students as guinea pigs, without recourse to any central view of what constitutes the best approach. I am sure that collaboration between the medical schools of Great Britain is long overdue. It would seem appropriate that any fundamental re-evaluation of ongoing professional competency should also examine the nature of the hurdle that needs to be jumped to initially become a practitioner. I suspect that re- validation of recently qualified doctors would already recognise significant variability in the quality and quantity of knowledge and clinical experience: variability that that may have been, at least in part, corrected prior to, and not after, graduation. Competing interests: None declared |
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