Who wants revalidation? For a start patients do. They need to know that the doctor they consult is fit for what he or she claims to do. They want to know that their diabetologist is fit to be a diabetologist, their urologist fit to operate, their general practitioner fit for general practice. The idea that we get a lifetime licence to practise one year after medical school seems incredible to the public.
I, and many other doctors, want revalidation. I want to be able to show that I continue to be good enough to be a doctor and to know that my colleagues are all fit to practise. I want to see an end to the undermining of our profession through unacceptable standards eventually revealed through patient complaints.
A system of revalidation must identify poor performers and achieve two outcomes—protecting the public and supporting professionalism. If I am to put in the effort to be revalidated I want it to be time well spent. If we are to create a new bureaucracy then it has to be fit for purpose. I would rather we acknowledged that it couldn't be done—for political or financial rather than technical reasons—than we buy into a method of revalidation that will be exposed in time as a charade.
I believe that non-medical people must be intimately involved in the approval of every doctor
Is the General Medical Council's proposed system of revalidation good enough? I am an elected member of the GMC but my views are not shared by other members when I say “no.” I have no confidence that “five appraisals and a clinical governance sign off” will protect patients or support the profession of medicine.
My reasons are these. Firstly, appraisal has, as far as I can find out, never revealed that a doctor is underperforming. Clinical governance may be, in time, a better basis for revalidation, but at present it tells us more about teams and systems than individual doctors. There are no explicit standards in either appraisal or clinical governance, and both are applied variably from trust to trust. There is no lay involvement in either.
Further, if local systems do expose a problem, then the problem should be dealt with there and then. Having a five yearly revalidation will not expose any more problems than the continuous local systems will—so such a revalidation will be extra work and stress, with no gain for patients or doctors.
If my licence to practise is to be put at risk I want to know what standards I am expected to reach—and therefore against which I have failed—and that the assessment of those standards is objective. I want the system to be both effective and credible. Clearly the GMC's system does not meet those requirements.
How did such a “not fit for purpose” proposal get accepted? At first plans were developed for a perfectly adequate model. Then, between 2001 and 2003, the GMC developed a new model in which the NHS took on the role of revalidator. I believe that this was seen as a pragmatic way of keeping the profession on board while reducing the costs and complexity. It is a shame that it was not piloted. It is a shame that protecting patients was not considered the top priority.
What would I like to see? I want a system where evidence is assessed against defined standards within criteria derived from the GMC's Good Medical Practice. This is precisely the system that the Royal College of General Practitioners (RCGP) and the BMA's General Practitioners Committee consulted on in 2001, a proposal that won good professional support from general practitioners. The working group that drafted the consultation document, Revalidation for General Practitioners (London: RCGP, 2002), included senior staff from the GMC and lay people.
I want the evidence for revalidation to be assessed by peers and lay people using transparent methods that ensure a fair and appropriate assessment. In particular, if revalidation is to mean anything to the public I believe that non-medical people must be intimately involved in the approval of every doctor.
In recent months I have become concerned that the ultimate test of revalidation lies in the GMC's fitness to practise procedures, a standard described by the current president of the GMC, in the report of the Shipman inquiry, as “remarkably low.” As I said above, I believe that the licence to practise should be for what we claim to do. Since the colleges certify us as fit to enter our chosen disciplines, for consultants and general practitioners the colleges should be asked to certify every five years that, after assessment of a revalidation folder of evidence, the doctor remains in membership in good standing.
Is this proposal realistic? Most of the evidence will be collected for appraisal and through clinical governance (gathered for formative continuing purposes, used for summative five yearly assessment) but some extra work would be required. However, I would rather put in some effort to have a real renewal of my licence than be approved by a system that is inadequate for the task.