Revalidation needs proper testing before adoption throughout UK

BMJ 2008; 336 doi: (Published 24 April 2008) Cite this as: BMJ 2008;336:913
  1. Lisa Hitchen
  1. 1London

    Thorough trials of revalidation are needed to test the new system for assessing doctors’ fitness to practise before it is introduced everywhere, says the Department of Health.

    Bruce Keogh, the NHS medical director, said, “This needs to be piloted. A big bang approach is going to be an utter disaster.” He said that a “whole system trial” is needed that tests the system in a number of different specialties and settings.

    He was speaking at a conference of the British Association of Medical Managers and Healthcare Events on the topic in London last week.

    Una Lane, assistant director for revalidation at the General Medical Council, agreed that a phased approach was needed. A recent audit by the company KPMG showed that the current appraisal system was patchily implemented geographically and in primary care, she said. Staff grades and locums were also often not included in the appraisal. This indicated that many organisations were far from ready for the new system.

    “Relicensing should start where local appraisal and clinical governance systems are developed and fit for purpose,” she said. “We can’t allow doctors to find themselves in a position to relicense where they are in an organisation and process that simply is not strong enough to support that relicensing.”

    Revalidation consists of a two stage process. Relicensing covers generic medical practice, and recertification is for specialist practice, said Professor Keogh. And it should be experienced by doctors as a single process.

    Relicensing would use information from appraisal, feedback, and concerns about individuals, and licences would be issued by the GMC from 2009, after new legislation currently going through parliament allows this.

    Standards for recertification would be drawn up by the royal colleges and specialist associations, which would assess doctors in their specialty.

    However, much of the detail on how to implement the government’s white paper Trust, Assurance, and Safety is still to be worked out, he added, and he said that further details would come from next month’s report from the chief medical officer’s medical revalidation and education working group (BMJ 2007;334:389; doi: 10.1136/bmj.39135.460266.DB).

    Some components of revalidation would need to be handled carefully, said Professor Keogh. The 360° feedback tool, in which colleagues and patients can provide feedback as part of appraisal, was one area that would need to be pilot tested. “There is going to be a turf war about who controls it,” he predicted.

    Also, deciding who could act as “responsible officers,” whose role it is to liaise with the GMC to improve relationships between doctors on the ground and the council, would be a problem for locums, unemployed doctors, ships’ doctors, and others, he said, and a working group had been set up to consider them.

    A stricter appraisal process, moving from a formative to a summative approach, was the challenge for GPs, thought Professor Keogh. “It is not supported by all [primary care trusts] and currently it is formative and voluntary. There is some concern that GPs may walk away if appraisals become too judgmental.” However, once it was statutory, trusts would have no choice but to comply, he added.

    Robin Gleek, a GP and appraisal lead for Western Cheshire Primary Care Trust, explained to Professor Keogh that GPs’ appraisal was not voluntary. With the changes it was likely the appraisers, not GPs, would be the ones who would walk away, he said.

    “The GPs’ appraisal system has been set up very strongly to be a formative process with no scrutiny. Some appraisers feel that if this is going to change they won’t carry on being appraisers.”

    Leslie Boobis, medical director of City Hospital Sunderland NHS Foundation Trust, pointed out that government messages about resourcing of revalidation had been diluted.

    “Can we have a reassurance that this is going to be properly funded and not come out of local budgets?” he asked. Professor Keogh said that he would take this question back to the Department of Health.

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