Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Who wants revalidation?
- Brian J Penney (26 June 2005)
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Bringing Appraisal & Revalidation Closer Together
- N.Ken Menon (29 June 2005)
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Making revalidation credible
- David J Hatch (12 July 2005)
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Will these high flown principles be applied to themselves ?
- Oliver Dearlove (30 July 2005)
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Brian J Penney, Family Physician Ontario, Canada
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With respect to the author, the way the question is phrased in any poll of patients determines the answer. Yes, patients want to be assured that the physicians involved in their care are competent, well informed, up to date and have the patient's best interest at heart. That does not mean they are necessarily in favour of revalidation. If patients are asked, since most physicians including the chair of the GMC are not clear about the scope and details of the process, it is impossible for a patient to be competent to answer the question, "Are you in favour of revalidation of physicians?" Since assessing every physician as in revalidation could potentially cost many thousands of pounds per physician and millions for the whole profession, if the patient had to choose between relying on the doctor's integrity to remain competent or likely delaying their life protecting treatment even further because of finite resources, they might not choose revalidation as having a higher priority. Since professors of general practice and others will likely be paid for doing the assessment, is there a potential conflict of interest for these in being in favour of revalidation and who will assess them as being competent to assess, free of bias cultural, educational or ethnic ? Monitoring physician outcomes, hospital lengths of stay, complications, prescribing practices, wound infection rates, morbidity and mortality, patient satisfaction etc etc in real time is now totally within our grasp. This is a much more fertile ground in assessing physicians than revalidation and avoids the potential for bias in the evaluator. Competing interests: Physician subject to revalidation |
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N.Ken Menon, General Practitioner The Ongar Surgery, High Street, Ongar, Essex CM5 9AA
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Pringle’s definition of revalidation as a process that assesses competence in what one claims to do is arguably the best that one could currently ascribe to it. Appraisal remains an evaluation of various aspects of performance as a means to identify areas for improvement and/or change – a formative process. Common to both is performance assessment – in the former to identify weakness that could contribute to suboptimal performance and in the latter to seek out areas for learning and improvement. Herein lies the means of bringing the two processes closer together without adding substantially to costs or diluting the need for meaningful revalidation that could reassure the public, who are after all the consumers of healthcare! Appraisal has to become robust by: 1. Being grounded in the principles of Good Medical Practice (GMP). There needs to be a comprehensive statement on all aspects of GMP in the yearly appraisal documentation. 2. Being independent. This requires appraisal to be done by appraisers outside the sphere of one’s work i.e. for General Practitioners appraisers would be selected from outside one’s local PCT, not associated with the appraisee and preferably not known to the appraisee. This may sound controversial but most commercial organisations would not permit a choice of appraiser. 3. Providing evidence that educational needs identified in previous appraisal/s have been met. 4. Including audit which would demonstrate improvements in care or maintenance of a previously achieved satisfactory standard. As Pringle rightly points out, the respective Royal Colleges would provide criteria and standards of care that would be expected of its members. These would be incorporated into appraisal and also into revalidation. 5. Providing a record of continuing education to help maintain standards and to ensure that knowledge and therefore competence is current. 6. Input from clinical governance of measurable performance indicators of the appraisee in relation to local circumstances and performance of local peers, verifiable areas of concern since the last appraisal, details of complaints, disciplinary proceedings etc. Five or seven consecutive appraisals with the documentation stated above would be presented for revalidation and would meet the requirements set out by Pringle. This would now need to be assessed by a panel that includes meaningful lay representation as described by Walshe and Benson in this same issue of the BMJ. The assessment should proceed according to a defined plan to ensure uniformity and consistency. It, however, must be emphasised and recognised by all concerned that no system of revalidation would prevent errors or wrongful acts, although effective systems would serve to reduce these. Like any group of people doctors are a microcosm of the society from which they arise and which they set out to serve. Competing interests: None declared |
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David J Hatch, Professional Standards Advisor Royal College of Anaesthetists WC1B 4JY
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Editor -Pringle states that the standard of the General Medical Council’s fitness to practise procedures was described by the current president of the GMC, in the report of the Shipman Inquiry, as “remarkably low”.1 This is incorrect. It may be what Dame Janet Smith recorded in her report but, as the transcript of his evidence shows, it was not what the President of the GMC said to the Inquiry. It is unfortunate that Dame Janet chose not to draw on the written evidence I submitted to the Inquiry in July 2004, as the then Chairman of the GMC’s Committee on Professional Performance (CPP). No doubt she had her reasons. It is also unfortunate that Dame Janet appears to have been influenced by contributions to the inquiry’s seminars in which it was asserted, from a distance as it were, and without corroborative evidence, that standards within the performance procedures had fallen. For example, Irvine’s position appears to have been that standards had been appropriate when he chaired the CPP, from 1997 to 1999 but that they fell subsequently. The basis for Irvine’s assertions is not clear. Irvine was President from 1995 to 2002. I chaired the CPP from 1999 to 2004. I do not recall any conversation with Irvine in which he questioned or raised concerns about standards. I note that, in 2003, Irvine wrote ‘[the performance procedures] represented a major step forward in handling poor performance and have attracted serious international interest. Used within a legal framework and accepted by the profession and the public alike, they ultimately provided the foundation for revalidation’. In my view, nothing happened to change that. Pringle asserts that ‘the colleges certify us as fit to enter our chosen disciplines’. This is, of course, incorrect. In the case of general practitioners, certification comes from the Joint Committee on Postgraduate Training for General Practitioners’, on which I had the privilege of serving as the GMC’s observer from 1998 to 2000. The national standard for entry to general practice is summative assessment, as defined by the JCPTGP, not the MRCGP. Southgate, who played such a pivotal role in the development of the performance procedures, confirmed in her evidence to the Shipman Inquiry that the standard applied in the GP assessment within the performance procedures is the same or similar to that of summative assessment, set by the Joint Committee on Postgraduate Training in General Practice (JCPTGP). It is self evident that the GMC, through the CPP, could not have adopted a higher standard for the removal of GPs from practice than was being used by the JCPTGP to admit them to unsupervised practice. As I said to the Shipman Inquiry, I consider that the assessment instruments within the performance procedures, and standards, have been well researched and that they are at an appropriate level. I know of no evidence to the contrary. David J Hatch professor Royal College of Anaesthetists 48 Russell Square, London WC1B 4JY d.hatch@ich.ucl.ac.uk 1. Pringle M. Making revalidation credible. BMJ 2005;330:1515. (25 June.) Competing interests: Chairman, Committee on professional Performance, General Medical Council, 1999-2004 |
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Oliver Dearlove, Consultant Anaesthetist Royal Manchester Children's Hospital
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Suppose a practitioner appears before a GMC Fitness to Practise panel and says that systems have changed in his area of practice – a hospital – say , and he has no idea if the proposed system changes will do what they are designed to do, or are safe or practical or even fit for purpose. Furthermore the doctor (as we now call ourselves, I won’t tell you if he is a surgeon or not) says that some procedures are definitely making things worse – but there is no audit and no quality assurance, so in truth no-one has any idea at all who is benefiting from all the work. In fact there are well documented instances of harm but these have been ignored or covered up. However the doctor insists the show must go on! – and even worse shows no insight into the issues. Then will he be revalidated? Perhaps we would hope not, as his performance seems to be in the lowest 5% of doctors, on some scale, and we all know that Donald Irvine wishes to seek them out and call them bad doctors and stop them practising. Change the words from practice to regulation and this is obviously happening at the GMC. Last month Hospital Doctor carried a piece where the president of the GMC – who is going to be revalidated when it comes, on being a president not on being a doctor – told the BMA, the complaints procedure is not working as he would wish. He is the last person in the UK to realise this, by the way. Trusts who are not regulated by the GMC will not action complaints fast enough – no news there then. So open complaints at the GMC are now stretching to infinity – no news there then either. This is a direct consequence of devolving responsibility to a body [Trusts] over whom you exert no power. Since this is foreseeable, one may ask if they should have done it. There is no quality assurance of trust investigations and this has been an issue in previous GMC cases, for the simple reason that even if there is a system error, a Trust will minimise its liability by trying to blame a practitioner personally. Most recently this seems an obvious defect in the Van Velsen case where no defence was offered, so none of the evidence from Alder Hey was seriously challenged. A trust is unlikely to go through a mea-culpa exercise when it is giving evidence in an undefended petition against a practitioner who comments from another country he does not think the proceedings will be fair. And in case anyone hasn’t noticed, a case in which the cards are stacked against the defence in this way, is clearly contrary to the Human Rights Act. The root cause is the ‘dob-in-a-doc’ campaign of 1999 where the GMC specifically said that they would investigate all clinical complaints without exhausting local remedies. The result was a deluge of complaints of all kinds directly to London. This is not the first instance of the GMC promising more than it could deliver. Academics like Prof Pringle tell us in a recent personal view in the BMJ how people such as himself are queuing up to be revalidated when it finally arrives. The details are yet to be decided. Will it be on being a good academic – a notoriously subjective area? The reader will observe that all academics say they are good, so I hope more objective tests will be used. Or will it be on being a member of the GMC? I hope there will be Ramsay questionnaires handed out so we doctors can tell them what sort of job we think the GMC are doing regulating us. Prof Pringle is betting on a horse [revalidation] that may not even run – or it could turn out to have three legs. Who then will bear the blame ? The rest of us are hedging our bets and looking forward to retirement… Doctors are facing an uncertain future in revalidation and pensions and the best bet for the elderly is to retire and say ‘I told you so’. Even Sir Donald Irvine has done this – retire and said I told you so. First in a book, then in front of the Shipman Inquiry and lately in an article in the BMJ, so at last he is giving a lead where some of us can follow. The rest of us who like treating patients had better get involved in medical regulation before we are all rendered form filling civil servants – with of course extremely high paper productivities and an efficient appraisal system with delineated career path progression into and out of the various regulating bodies. Where, by the way, are the Lithuanian doctors who will run the hospitals while the rest of us are compiling our revised Ramsay questionnaires ready for revalidation? Oliver Dearlove FRCA Conflicts of interest. Dr Dearlove has been nominated to stand for the by-election for the GMC. As you would expect with the GMC, they have had some difficulty in deciding whether his nomination is valid or not and therefore whether they will allow him to stand. Competing interests: as script |
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