The GMC’s much-vaunted revalidation proposals are on hold after heavy criticism by the Shipman Inquiry. Dr Gerard Panting explains what this may mean for GPs
The GMC’s plans to introduce periodic revalidation from April 2005 are on hold pending review after they came in for considerable criticism by the Shipman Inquiry.
The criticisms are contained in the Inquiry’s fifth – and penultimate – report. This runs to three volumes and includes 13 chapters concerning the GMC, including one devoted to revalidation.
The GMC can legitimately argue that much of the criticism relates to a different era, and since then the Council’s constitution, ethos, procedures and personnel have all changed. However, the same cannot be said for revalidation, seen by so many as the GMC’s flagship initiative.
The GMC’s proposals
The GMC’s concept of revalidation and how it would work in practice evolved over several years. Debate focused on alternative pathways, one for doctors working in ‘an approved GMC environment’, which would include virtually all NHS GPs and hospital doctors including locums, and another for those in private practice.
The proposals would require all doctors wishing to hold a licence to practise (in addition to being on the Medical Register) to demonstrate every 5 years that they remain capable of doing their job.Without a licence to practise, the privileges of registered medical practitioners would be restricted to the title ‘Dr’ and being answerable to the GMC.
For doctors working in a GMC approved environment, the submission for revalidation would have included a description of their practice, evidence that they have participated in appraisal mapped against the headings of Good Medical Practice,1 and a completed personal development plan. A statement declaring eligibility for local certification and evidence of health and probity would also have been required.
The information provided by the doctor would then be scrutinised and a recommendation made to the GMC. If for any reason this appeared insufficient, the doctor might be asked to provide additional information or evidence. Alternatively, peer or patient questionnaires or observations of practice might be undertaken before further scrutiny on behalf of the Council, and an ultimate decision on renewing the doctor’s licence to practise.
Relying on annual appraisal and other local mechanisms to determine whether or not a doctor is sufficiently competent has considerable attractions for the GMC. How else could they deal with the numbers involved? With approximately 200 000 doctors on the Medical Register, and a possible 150 000 wanting to be included in the revalidation programme it would involve revalidating 30 000 doctors each year, or approximately 125 per working day. This would be quite a task if the GMC itself were to be closely involved in assessing each doctor’s fitness to practise.
However, the GMC’s proposals failed to cut much ice with Shipman Inquiry chairman Dame Janet Smith.
Shipman Inquiry Fifth Report
In the Fifth Report of the Inquiry Dame Janet said:
Revalidation is of considerable interest to the Inquiry. I have explained in this report how systems by which the NHS monitored the practice of general practitioners (GPs) during the period of more than 20 years in which Shipman worked as a GP, failed to detect that he was obtaining large amounts of diamorphine illicitly and killing his patients.
The Inquiry Report quotes the GMC President Sir Graeme Catto as saying that the performance of at least 90% of doctors did not give rise to concerns. To Dame Janet this suggested that as many as 10% of doctors are, or could be, performing poorly. She explained:
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 … If a member of the public is told that revalidation will ensure that his/her doctor is ‘up to date and fit to practise’, s/he will I believe have the impression that s/he can expect the doctor to be practising at a level of competence above the basic level of acceptability … yet the position is that a doctor will be revalidated unless his/her conduct, performance or health is such that an FTP Panel decides that it must take action upon the doctor’s registration.
My second concern about the position of the public is that they are told that, in order to secure revalidation, the doctor must demonstrate to the GMC that s/he has been practising in accordance with the principles of Good Medical Practice. In fact, as I have explained, it is not at all clear that s/he will have to do any such thing.
My third concern is that the public have been given the impression that doctors undergoing revalidation have to pass some sort of objective test … Under the present proposals [they] will not.
Revalidation is described by Sir Graeme Catto as ‘a sort of MOT test for doctors’ in a BBC radio programme … To call revalidation an MOT for doctors is a catchword. It is easy for the listener to remember. I think that many people who heard that programme will have taken away the impression that revalidation is a test for doctors, just like the MOT.This is not a true impression.
An alternative approach to revalidation
Under the heading ‘Whither Revalidation?’ Dame Janet sets out her own view of how revalidation should work in practice.
The main platform for revalidation should be the preparation by each doctor of a folder of evidence which demonstrates what the doctor has been doing in the last five years. Some of the contents of the folder would have to be specifically laid down and would be compulsory.They would include data derived from clinical governance. These would include, for example, prescribing data and records of complaints or concerns including any report from the Healthcare Commission, or a GMC or NCAA assessment.
I hope that, in the future, more information of that kind will be available to PCOs. Other compulsory items will originate within the doctor’s own practice. These should, in my view, be much along the lines proposed by the RCGP in its consultation paper.
Dame Janet goes on to suggest:
…there should be a record of the CPD activities that the doctor has undertaken. A copy of the appraisal form 4, a patient satisfaction questionnaire, the results of a clinical audit and some significant event audits should also be included. In addition, there could be a video recording of the doctor in consultation with patients. I would also suggest that the folder should include a certificate to show the successful completion of a knowledge test.
Dame Janet’s proposals for a more rigorous revalidation process continue:
At revalidation the folder would be scrutinised not by the GMC, but by a local group based within the PCO and probably chaired by the clinical governance lead … The scrutinising group should, in my view, include a lay person from outside the PCO and a GP from another area … accredited by the RCGP as an assessor to standards approved by the GMC … A positive addition could be that the doctor might be invited to attend the meeting.
Review of proposals
A full response to the proposals contained in the Fifth Report is expected from the Government over the next few months. However, the Fifth Report has provoked an immediate response with the decision to review the GMC’s proposals in the light of Dame Janet’s criticisms. The review, to be conducted by the Chief Medical Officer Sir Liam Donaldson will include the role of NHS appraisal and the GMC’s arrangements for examining a doctor’s fitness to practise through revalidation. Consequently, the intended introduction of revalidation from April 2005 has been postponed.
Explaining the decision, Lord Warner, the Minister responsible, said it would be unfair to doctors and confusing to patients to start the new revalidation scheme on one basis and then make changes following consideration of Dame Janet’s report. With such uncertainty it would have been inappropriate to ask Parliament to consider legislation for changes proposed for April 2005.
The concept of revalidation appears to be here to stay but with a shift away from total reliance on formative appraisal towards a system that incorporates objective data, evidence of CPD and a more summative form of annual review. In short, the most likely solution is a more rigorous appraisal process, making it more evidence based and bringing it nearer to the concept of an MOT test for doctors.
- General Medical Council. Good Medical Practice. London: GMC, 2001.