The president of the General Medical Council, Graeme Catto, is charged with introducing revalidation by 2005. Geoff Watts asks him how plans are progressing
It's almost exactly 12 months since Professor Graeme Catto, dean of medicine at Guy's, King's, and St Thomas's Hospitals Schools of Medicine and Dentistry in London, took on the presidency of the General Medical Council. He enters his second year at a time when the regulation of doctors in the UK is set to experience one of the biggest changes in well over a century: the introduction of revalidation.
To say that the advent of a renewable licence to practise has been greeted with dancing in the corridors of medicine would be inaccurate—unless such movements were of the kind prompted by reluctant treading on hot coals. It is 15 years since I last tried to report on “recertification,” as it was then known. The attempt came to nothing. Everyone was so apprehensive that no one wanted to comment on what was at that time merely an aspiration—or a threat.
Now, of course, the decision has been made and comment flows more freely—not least from the man who has to implement it. Predictably, and reasonably, Catto denies that recent events such as the inquiry into paediatric cardiac deaths in Bristol and the conviction of GP Harold Shipman for murdering patients have been the stimulus for reform. He does concede that these scandals added impetus to the process. But the changes, he says, have been discussed for years.
“My view is that revalidation is not just to catch miscreants who are far from the norm of medical practice. It has a much broader purpose. It's to promote public confidence in the profession. There's a need for the public to understand which doctors are up to date and fit for practice.”
One of the obvious fears is that revalidation will create a new bureaucracy—and to some extent it must. Catto is aware that public and profession alike may feel that time and resources would be better spent in other ways. He counters by pointing to the close links between revalidation and appraisal. The seven headings under which appraisal information is collected (including clinical care, medical practice, and relationships with patients) are also the criteria for revalidation. Moreover, appraisal is becoming routine in many occupations, and medicine cannot be an exception. “So long as revalidation links into the appraisal process and doesn't create an additional layer of bureaucracy then I don't think it's a sledgehammer to crack a nut.”
The GMC cannot, as it happens, insist that doctors use the NHS appraisal process to demonstrate their fitness to practise. It can only point out that this represents the most straightforward approach to making their case. If some eccentrics choose to present their evidence in the form of a petition signed by several thousand loyal patients, the GMC can accept or reject it as suitable evidence, but it cannot insist on the use of a more conventional method. Catto does not, however, expect many practitioners—not even the small number working entirely outside the health service—to be buying up clipboards and pens.
The first revalidations will not be until 2005, but appraisal is already under way. At this stage, according to Catto, evidence from around the country and from pilot studies shows that the system is robust. “But it's working well in some areas, not particularly well in others. It's patchy. We expect it to be better next year, and very much better the year after that. We have to give it time to bed down.” The speed with which this is achieved will, no doubt, reflect the quality of local management.
In keeping with the fashion of the times, the GMC nowadays garnishes its title with a brief suffix, a sort of short mission statement: “Protecting patients, guiding doctors.” So how do its plans for revalidation play with these two constituencies?
The director of the Patients Association, Mike Stone, is pleased. “We've campaigned for something like this for years. We have to welcome anything which gives patients greater confidence in their safety when they're seeing doctors.” He does, though, wonder if revalidation every five years is sufficiently frequent. The Consumers' Association too welcomes the advent of revalidation. Its main concern is that the new arrangements should prove adequate to keep a check on doctors who spend much of their time doing locum work.
The BMA's chairman, Ian Bogle, says that his early fear was that the GMC would create a bureaucracy that “might involve doctors in so much time trying to revalidate that it defeated the purpose of the exercise.” The close link with appraisal has greatly reassured him. His main residual anxiety is over the appraisal system itself. He echoes Catto's admission that it's so far proving patchy. “We've really got to get primary care trusts in particular up to speed.”
Might the looming prospect of revalidation push some older doctors into an earlier than intended retirement? “There is that risk,” says Bogle. “But the obligation to undergo appraisal is now in their contracts, so it won't be revalidation that pushes them out, it will be appraisal. I think the introduction of what some will see as yet another hurdle will cause some doctors to retire before they would have done. But as we're aiming for transparency in patient safety, this may be a price we'll have to pay.”
Does Catto too accept that some doctors may be tempted to retire early? “Yes, I think it is a possibility,” he admits. “But we must work with other colleagues to prevent it becoming a reality.”
Many doctors, he believes, feel they've been tarnished not just by recent medical scandals but also by an awareness that the outcomes of treating patients in the UK are not as good as in some other equivalent countries. On top of this, the revalidation procedure will inevitably cause each individual a certain amount of time and trouble. So what's in all this for the doctor? What thought would Catto offer to “Irritated of Harley Street” or “Exhausted of inner Grimethorpe” when confronting the new five year hurdle?
“That the profession can regain some of the self confidence, the self esteem it has lost.” The president rests his case.
Figure.
Graeme Catto: “So long as revalidation links into the appraisal process… I don't think it's a sledgehammer to crack a nut.”