Where next with revalidation?
BMJ 2005; 330 doi: https://doi.org/10.1136/bmj.330.7506.1458 (Published 23 June 2005) Cite this as: BMJ 2005;330:1458
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I have been following the case of Nurse Grigg Booth (Daily Telegraph
30 Aug 2005) who was indicted for the murder of three patients but has
recently died herself. I ask myself, will there be the same demands for a
huge, bloated and expensive bureaucracy to monitor ‘revalidation’ in
nurses, as occurred after the death of Harold Shipman ?
Will we see Dr Fiona Godlee selflessly fling herself behind half-
rehearsed measures to monitor nurses in case there should be many more
Angels of Death lurking on the wards stalking the young and old, without
thought of her own personal preferment in Honours lists if it becomes
government policy ? She could entitle her editorials “Revalidation of
Nurses: GMC shows the way.” I could write the script if she wants.
Everyone who has witnessed a nurse’s compulsion to fill out nursing
process forms, will have a heart that sinks to hear of further paperwork
measures that get in the way of nurses and their patients.
Everyone loves a good nurse and we could completely confuse the
situation as they have in revalidation – having a good nurse and not
having someone like Grigg or Beverly Allitt. What is the answer ? I know !
Let’s start off by calling every nurse bad and insisting that they show us
they are good ! We could have patients filling out the nursing process
forms and countersigning whether or not the auxiliaries have carried out
any health care procedure. This would be patient appraisal. We could make
nurse revalidation worse – or better – by insisting on time-consuming
collection of data which can be shown to have no bearing on skills or
competences of personnel. There are around 700 000 registered nurses with
the NMC, and even if the classification is in error at a rate 1%, a
ludicrously optimistic estimate, then only 7000 nurses are mistakenly
called bad when they are good, just to reassure the public.
However, if there is no call for further intrusive and useless
monitoring, then we can conclude that the impetus for revalidation in
medicine is not patient-centred but politician-centred. This love of
controlling anyone in health care delivery, would certainly explain
demands that revalidation in medicine go forward despite lack of evidence
the measures will achieve their goals and in spite of quite a lot of
evidence that the measures will not.
Oliver R Dearlove FRCA
Conflict of interests ORD has been nominated as a candidate
contesting the GMC by election.
Competing interests:
as script
Competing interests: No competing interests
REVALIDATION AND THE EDUCATIONAL POTENTIAL OF PEER REVIEW
In his editorial “Where next with Revalidation?” Norcini highlights
the role that education “must offer” in addition to performance review1.
One crucial element as part of both the appraisal and revalidation
processes which has consistently avoided clarification by the GMC and Dame
Janet is the method whereby evidence being included in a doctor’s
portfolio is quality assured to ensure a consistent standard is being
achieved appropriate for both formative i.e. educational assessment and
summative i.e. good enough assessment.
Since 1996 throughout the United Kingdom all GP registrars have had
to submit a video, a written piece of practical work, usually an audit, a
completed trainer’s report and an MCQ of factual knowledge2. Experience
through peer review of this process over the past nearly 10 years has
shown the variation in the quality and therefore competence of those
submitting a video or an audit despite being in a training environment3.
Using the same trained peer review assessors, additional data from
the west of Scotland have shown even wider variation among GP principals
(in both training and non training practices) and SHOs vocationally
training for general practice4.
It would not be impossible to extend this national quality assurance
infrastructure already in place to include each bit of evidence required
for revalidation thus assuring both the public and the profession that
doctors are being assessed equally and fairly. The system could be
applied in both general practice and hospital and although on the surface
may appear bureaucratic and costly, it would begin to address the many
educational needs which have already become apparent in the early stages
of the appraisal process as judged by the material being submitted as part
of a personal development plan. To critics of this system, what is the
alternative? If self-regulation is to mean anything, we must take charge
of our own education as a means to both professional self-development and
revalidation.
REFERENCES
1. Norcini JJ Where next with revalidation?
BMJ 2005;330:1458-9
2. National Health Service (Vocational Training for General Medical
Services) Regulation 9(2) Statutory Instrument 3150, 1997, London HMSO
3. Murray T S, Attwood M, Lough M, Kelly M, Kelly D
Summative Assessment of the competence of General Practice Registrars 1996
-2001. Reasons for and implications of failure
Education for Primary Care 2004;15:169-174
4. McKay J Bowie P Lough M
Variations in the ability of general practice to apply two methods of
clinical audit:: a 5-year study of assessment by peer review.
Journal of Evaluation in Clinical Practice (In Press)
Competing interests:
None declared
Competing interests: No competing interests
Hear Hear for Brian Penney. In my 20 years as a GP, in three
practices, and when it comes to patient care, almost all my colleagues
have been highly motivated, generally altruistic individuals with the
normal human failings. This current round of the debate on revalidation
reminds of the old joke: save police time, beat yourself up. Change this
to: save government time, confess that you are a useless doctor
(especially if you are old) and do something about it.
Competing interests:
None declared
Competing interests: No competing interests
I'm sorry if I've angered Dr Penney. All I would say in reply is
that professions exist and practice only insofar as the public wishes them
to do so. This actually gives the public responsibilities as well as
rights! Rightly or wrongly I believe that the public now want to see some
evidence that members of the medical profession remain up to date and fit
to practice. I entirely agree with Dr Penney that other professions can
expect to do the same. I can indeed imagine that 'My Lord Judge' should
be subject to annual scrutiny of his (or her) knowledge or performance. I
suspect that something, albeit covert, of the sort happens now and if the
public demand better scrutiny it will happen. My responsibility is
however for myself and I simply wish to have some professional control of
the way I manage this responsibility. I don't need a judge to tell me how
best to revalidate; I can work it out for myself and I don't regard John
Norcini as an enemy because he's not a Physician. I'm afraid the comments
about , 'abandonment of critical appraisal' and 'holier than thou' are
incomprehensible, and possibly just rude, so I'll ignore them.
Competing interests:
None declared
Competing interests: No competing interests
I assume the survivalists of the profession will get into
revalidation. Better to be reporting on people than being reported on.
On a serious note, the authorities need to look at practice in terms
of how much daily on going evidenced based peer review in going on in a
team.
In our medium sized practice (non training)we have Jounral articles
sent around the E mail every day for discussion. The excellent On Medica
site automatically send around scores of articles every month which are
disseminated for discussion. Any interesting articles result in an e mail
to our audit clerk to search on our patients to see how we are performing
with reference to the article. The results are sent around and practice
influenced as a result. The audits are collected up and presented at the
weekly pracice meeting for further action. Many clincial cases and much
experience is shared via e mail to ensure that one doctors experience is
disseminated. Using our computer record all clinicians can automatically
tract interesting and signficant cases if prompted to do so by the
clinician in charge. Significant and interesting hospital information is
sent round via e mail using cutting and pasting of letter sections. We
have an electronic signficant event system disseminated via e mail. Using
our computer database we could show that a certain percentage of cases of
one doctor are seen by another doctor within 3 months. In a similar
practice I worked in, I could show that 46 % of my patients were seen by a
colleague in 3 months.
The moral of all that is that we rarely have set meetings for
education and peer review because so much is going on all the time.
Although we do automatically save our e mailed Journal articles and
interesting cases (using the Outlook Rules) and associated discussions for
a face to face meeting once a month. Indeed with desktop internet access
and all the experience sharing of primary and secondary care patient
involvement that goes on, I find the idea of attending an evening didactic
lecture as quaint and socially attractive but not an efficient use of my
time for staying up to date. The authorities must recognise that this
patient based education and peer review is actually far more effective and
valid that a walletful of certificates of meetings attended. It means that
I can do a full 8 session patient contact week and still be home for tea
and family while in many ways being better informed and educated than
ever.
It is not rocket science, what we do, and actually costs nothing. In
my view it is a revolutionary way of staying up to date and well informed
in a way which directly influences practice. I can demonstrate that it is
happening and think that as evidence of being effective, up to date and
open to peer review and learning is worth far more than the cosy
confidential chat of reappraisal where mendacity is always tempting, or an
exam which can be studied for and will never represent patient focussed
learning.
Competing interests:
None declared
Competing interests: No competing interests
David Levines simplistic acceptance of the Norcini oracle and
abandonment of critical appraisal is breathtaking. Norcini is not a
physician but has made himself an "expert"
The obsession that some physicians have with being "holier than thou"
now is accompanied by the need to have been proven "Holier than thou" by
revalidation.
Physicians should have the same rights, restrictions and privileges
of other professions whose practice may affect the life or limb of
citizens.
I cannot imagine any Administrator, hospital manager or politician
being revalidated on an annual basis on his knowledge or indeed the
outcome of his cases. These professions are as culpable as any physician
if a patient is denied or delayed access to any life preserving treatment.
Why should physicians be unique? I am aware of studies indicating
potential for deterioration in physician performance. However, the same
potential exists in every profession. Can you imagine My Lord Judge being
subject to annual scrutiny of his knowledge or performance? Yet arguably,
he has more influence over the lives of people before him than most
physicians ever do.
We have done enough self flagellation following Bristol, Shipman,
Alder Hey & Ledward et al. It is time to re-examine the need for
revalidation and if for physicians then for all professionals.
Competing interests:
Physician subject to revalidation
Competing interests: No competing interests
As ever John Norcini's is the voice of reason and deep understanding
of this issue. No more time can be wasted on pointless debates about the
need for revalidation but all our efforts must go into making it useful,
effective and fair. The distribution of performance in a medical
population and the relevance of this to the two uses of revalidation are
keys to progress. The need to start soon, even in a small way, and learn
as we go, is the only way to maintain our professional self-respect and
the trust of the public as a whole. We don't need to waste our time
squabbling with other professions who like to be seen as wise after
events; they have to sort out their own problems.
Competing interests:
None declared
Competing interests: No competing interests
Nurses' Revalidation
Nurses revalidation
I see another nurse has been indicted for murder (1). But from no-
one, displaced civil servants, lay members, patient advocates, under-
employed regulatory apparatchiks looking for work, do I hear strident
proposals for Shipman-like checks on all 700 000 nurses. Think of all the
work for the regulators ! Why are they so silent?
The evidence is out there. There seems to be more than one Sr Shipman
( Grigg Allitt ) poisoning patients on the not so Q T. The revalidators’
day will come, so let us discuss what form it will take.
I can already see in my mind’s eye, the General Nursing Council
trumpeting half-assed proposals foisted on them by lay members and civil
servants and claiming they are leading the world. Moreover we will be told
that this enormously expensive regulations untried and untested, is the
envy of the world. Apparatchiks from the regulator will flock to Eastern
Europe. Where will the expenses paid gravy train stop? Perhaps at Sofia or
Belgrade to tell the stunned Slavs how to do nurses’ revalidation the
English way. A cloying self-congratulatory House journal will carry
photographs of clutches of them, from all parts of the globe, Zimbabwe
perhaps, all of them simpering into the camera.
On thing is clear through all this. Evidence under pinning nurses’
revalidation will have to be externally confirmed and not by nurses as
they cannot be trusted. So my question is this: will doctors, who everyone
knows are not to be trusted to validate their own evidence of good
practice be allowed to validate the evidence of the nurses ? Or will this
be a cue for more lay regulators ?
Millions of regulatory pounds could be diverted to lawyers’ pockets –
in fact anywhere except Health Care, to decide these and other important
regulatory issues.
The possibilities are endless and stretch out in the imagination but
always at the tax payers’ expense. Has anyone costed the likely impact of
revalidation ?
Oliver Dearlove FRCA
Conflicts – None
Reference
Daily Telegraph Male Nurse is Indicted for murder Thursday 13 October
2005
Competing interests:
None declared
Competing interests: No competing interests