Intended for healthcare professionals

Observations Body Politic

Revalidation seems to add little to the current appraisal process

BMJ 2012; 345 doi: (Published 02 November 2012) Cite this as: BMJ 2012;345:e7375
  1. Nigel Hawkes, freelance journalist, London
  1. nigel.hawkes1{at}

Ranks will close and feedback will be positive enough for all to win prizes

On the usually sound principle that there is nothing in British medicine that cannot be made worse by the involvement of the General Medical Council, I have long taken a beady eyed view of revalidation. Nobody can be against the general idea that doctors, like any other professionals, should be kept up to the mark, but it has always been questionable whether revalidation will do much to achieve it. There is a serious risk that revalidation will simply amount to a tsunami of paper in a system that already creaks under the weight of bumph on governance, quality assurance, and performance indicators.

The long gestation period and many false labour pains didn’t provide much cause for optimism, either. People started talking seriously about revalidation more than a decade ago, in the wake of the Bristol Royal Infirmary’s failures, and really good ideas don’t generally take that long to command approval. But, all credit to the GMC’s gritty determination to add another task to its bulging portfolio, it finally won through. The health secretary, Jeremy Hunt, gave his approval, and revalidation will begin on 3 December this year.

Nobody knows what it will cost, as the Department of Health’s impact assessment with the actual figures has not yet been published. The informed guesses are a figure of some tens of millions of pounds a year simply to run the system, plus the unknown costs of remediating doctors who fail. A report published in 2011 by the department’s steering group on remediation estimated that it costs £20 000 (€24 900; $32 300) for an initial investigation and £60 000 for a six month placement in another organisation for retraining. But the costs can be much higher.

The final bill depends on how many doctors are found to require remediation, and whether that number is greater than those who are already identified as inadequate by their employers. Many of us must have been struck by the recent claim by Sir Peter Rubin, chair of the GMC, that the first five year cycle of revalidation was likely to identify fewer than 125 general practitioners requiring remediation. “We’re talking about tiny numbers of doctors,” Rubin told Pulse. The existing system, run by the National Clinical Assessment Service, identifies nearly twice as many general practitioners as that (42 cases in 2011-12), after referrals from primary care trusts based on appraisals or complaints.

Of course, if fewer doctors require retraining under the new proposals than under the old, the NHS will save money. But the presumption of revalidation is that the existing system has failed to identify and retrain poor doctors. If it’s going to identify even fewer, why on earth do it? The president-elect of the Royal College of General Practitioners, Professor Mike Pringle, had a neat answer to this important question. “You might say if there is no increase, why are we doing it? Well, since it became obvious revalidation was serious, it has had a catalytic effect on standards,” he claimed.

Evidence, please.

Maybe Rubin and Pringle were just trying too hard to reassure doctors that they have little to fear. A survey by the NHS Revalidation Support Team found a larger number, around 1200 doctors in England, whose failings were of sufficient gravity to require remediation. So perhaps revalidation will catch more wrong ’uns than the existing system; perhaps it won’t.

It’s safe to assume that there are some doctors working in the NHS who are unfit to do so. Given the variation in every other aspect of NHS performance that can be measured, it would indeed be surprising if there were not a tail of doctors at the end of the distribution curve whose performance is unacceptable. The conundrum is how to identify these doctors without subjecting the rest to time consuming and needless procedures. Screening the whole population to identify a disease that affects less than 1% of them would strike most doctors as a poor use of resources, but that is more or less what revalidation proposes.

An equally serious objection is that revalidation is pretending to do what it cannot. Back in 2005, at an earlier stage in the long and stuttering process, Dame Janet Smith commented in her fifth report on Harold Shipman: “I have felt some concern that the public was being led to expect more from revalidation than it could reasonably be expected to provide, in terms of reassurance about the competence of an individual doctor.” While the public would expect doctors who have been revalidated to be good, she suggested, all revalidation will tell them is that they are not awful.

Revalidation has evolved since then, but her basic point remains valid. Any process that really tested doctors’ competence—such as the successful completion of a knowledge test, as Dame Janet suggested—would be disproportionately burdensome. But any process that was undemanding enough to be practicable would be a fraud on the public.

Most of the public, most of the time, think their doctors are wonderful. It’s a necessary psychological prop, since coming under the care of a doctor means the abandonment of personal autonomy. Most airline passengers think the same of the men in peaked caps sitting in the cockpit. So the feedback required under revalidation—doctors are recommended to find 34 consecutive patients willing to complete questionnaires attesting to their excellence—should be a doddle. Harold Shipman could have done it without breaking sweat.

As a single hander, he might have found it harder to find 15 colleagues willing to do the same; another GMC recommendation. But I dare say he would have managed. Who’s going to slag off a colleague and risk being counter-slagged? Doc does not eat doc. Far more likely, I’d say, that ranks will close and feedback will be positive enough for all to win prizes.

All in all, revalidation seems to add little to the appraisal process already in operation. But we’re all lumbered with it now.


Cite this as: BMJ 2012;345:e7375