Mechanisms of revalidation

In last month's edition of the Journal, Glyn Elwyn gave an overview¹ of Mike Pringle's 2005 John Fry Fellowship Lecture.² Pringle outlines the history of the General Medical Council's (GMC) plans for revalidation, the GMC's current thinking around revalidation, associated concerns expressed in the fifth report of the Shipman Inquiry,³ his concerns about the current state of revalidation and, finally, some options on the way forward. Elwyn also provided an eloquent summary of his own interpretation of the persisting concerns around appraisal.

Pringle describes his disagreement with the GMC's position on revalidation and articulates thinking that is not all that dissimilar to the GMC's. Even more difficult to follow is the reconciliation between his definition of revalidation and his own options for delivery.

Although Pringle interprets the legislation (that refers to revalidation as ‘evaluation of a medical practitioner's fitness to practice’) as focusing solely on the absence of unfitness to practice, he quickly reverts to the GMC's early and continuing notion of the demonstration of positive attributes and not the identification of poor performance. One exception is ‘certification of meeting local standards for clinical governance and that there are no local concerns’, an aspect of raising and acting upon local concerns about a doctor's performance. The GMC includes this as the local clinical governance sign-off.

In recognising that appraisal was never intended to detect poor performance, we have evidence that some doctors' appraisals are deferred due to the detection of local concerns about performance.

Pringle's main suggestions for a mechanism of revalidation are about demonstration of positive attributes. His bullet points (see Box 1) are largely drawn from the Royal College of General Practitioners' Criteria, Standards and Evidence for Revalidation of General Practitioners.⁴ The public and the profession can be reassured that these are not new ideas. They are already imbedded in the culture that is building around clinical governance and appraisal. A quick examination of where we are highlights how the majority of these criteria are already included in the existing processes (Box 1).

Box 1. Main suggestions for a mechanism of revalidation.².

Suggestion	Current situation
A statement of what the doctor does	This is already present in the standard appraisal documentation for NHS and private sector doctors; locums and substantive post holders, in all four of the UK devolved administration
Evidence that the doctor is fit practise those activities, including:
• Certification of having effectively taken part in appraisal	Part of GMC's existing plan
• Certification of meeting local standards for clinical governance and that there are no local concerns	Part of GMC's existing plan
• The results from case-based and conventional audits	Easily and often already incorporated into advice on completing appraisal documentation
• The doctor's reflective continuing professional development within an annual personal development plan	Already an existing part of appraisal and its link to continuing professional development
• The views of patients and colleagues (360 degree assessment) including complaints and their outcome	Ongoing work by GMC and some medical Royal Colleges to develop questionnaires in this context
• Certification of technical skills required for the doctor's role (such as communication skills, medical records keeping and cardiopulmonary resuscitation)a	Can easily be incorporated into either appraisal or clinical governance where appropriate. There is a danger of creating a new industry around this particular point and further clarity is required as to validity and reliability of such certificates if they are to be considered.
• Self-certification of health and probity	Specific wording already provided by the GMC guidance on revalidation
• Other speciality specific evidence as required	This could be advised by the appropriate Royal Colleges

^aThis is the only aspect of Professor Pringle's suggestions that is not already covered by existing guidance.

At intervals Pringle appears very keen on the use of lay inspection of all doctors' folders. Despite recognising this as impractical, his final analysis requires all folders to be assessed by colleagues and lay individuals at least once. He implies that this is the only way of securing lay involvement in the revalidation of doctors. Leaving aside the issues of practicality and cost-effectiveness, I would suggest that other issues need to be considered.

Consideration of folders is best undertaken by those who know the doctor's practice locally, and have access to the necessary expertise and data to analyse and understand the results of audit and clinical governance data.

Lay involvement in groups is not the only way of securing patient involvement in revalidation. The GMC's guidance recommends the use of patient feedback questionnaires for all doctors. Lay involvement in quality assurance of both appraisal and clinical governance adds value.

Pringle believes that:

‘Clinical governance will, in time, become a very useful keystone in revalidation. But either alone or with annual appraisal, clinical governance is not, and will never be, a revalidation methodology that is fit for purpose.

My reasons are as follows. The application of clinical governance in the NHS is still variable and its presence outside the NHS is even more erratic …’²

Although I recognise that appraisal and clinical governance are inconsistent in their methodologies and delivery in different parts of the UK, much of this relates to organisational discrepancies. The fact that they are not yet fit for purpose is not a reason to discard these two complimentary and powerful tools as having the potential to be reliable mechanisms for delivering a positive demonstration of individual doctors' fitness to practise.

Pringle argues that we do not need revalidation if local processes become this effective, thus failing to recognise the positive impact that I believe the GMC's current model of revalidation will have on enhancing the quality and consistency of appraisal and clinical governance. Existing tools, thus enhanced and quality assured, can provide powerful statements about individual doctors and the environments within which the vast majority of doctors will be exercising their licences to practice.

Elwyn's article recognises that there is an ongoing debate about the constitution of revalidation.¹ Pringle's lecture and the fifth Shipman Inquiry report appear, to me, to do more to enhance the GMC's position than to detract from it.