Seventh-year itch

So here we are, into our seventh year since the much-trumpeted launch of … revalidation. Am I the only one left thinking it has been a terrible mistake?

Sadly, the GMC’s data only extends as far as 2016 but still it holds some interest. For example, in the 4 years from 2012, the year revalidation started, the number of doctors registered without a licence to practise almost tripled to over 43 000.¹

On the other hand, during the 11 years centred on 2012, although the number of GMC fitness-to-practise investigations rocketed to 2953 in 2013, the number of doctors who had sanctions imposed rose much more modestly, peaking at 517 in 2011, the year before revalidation was introduced.¹

Sir Keith Pearson, Head of Health Education England, invited to conduct a review by the GMC in 2017, included among his recommendations the advice that the ‘GMC should work with others to identify quantifiable, long-term impact measures for revalidation’.² Boring this might sound, except spot the revelation that no one yet knows how to measure its effects. Which in turn means that nobody yet knows if it helps anything.

Of course, the prime justification was always to protect the public from dodgy medics in the wake of Harold Shipman. Sir Keith’s review reports the opinions of Responsible Officers who, like zoo keepers’ views on animal welfare, you would expect to contain bias, and yet less than half of those surveyed thought there had been a positive effect on clinical practice.^2,3

This doubt is echoed in the Umbrella report from last year, also funded by the GMC.⁴ It states: ‘Many in the profession believe that the main aim of revalidation is to identify “bad doctors”, and that doctors’ participation in appraisal will not achieve this aim.’ It adds, ‘There is no statistical evidence, as yet, that referrals from employers have dropped as a result of the earlier identification and local remedy of concerns.’

Talking of appraisal, revalidation rests its foundations on the floating timbers of that annual process. It is an exercise now conducted expressly with an allocated appraiser to prevent collusion. This, too, like the whole process itself, has a big flip side. Is a stranger likely to achieve better insights?

I am by no means the first to raise doubts: in 2016, reviewing appraisal, Nikhil Khisty commented: ‘appraisal may not serve the multiple purposes of detecting unsafe practice, quality assuring good practice, ensuring compliance with contractual duties, improving practice, and facilitating continuing professional development’.⁵

In fact this observation was drawn from the Chief Medical Officer’s annual report from 2006 in which, despite also noting there was no convincing model for it, revalidation was endorsed.⁶ There was certainly plenty of support at the time, driven itself by the fallout from the Shipman Inquiry.⁷

The cash cost of the whole exercise was estimated by the Department of Health in 2012 at about £97 million annually.⁸ Other costs have not even been estimated, including lost productivity relating to those preparing for and being appraised. Nor the lost contribution from all those doctors who chose not to remain licensed. Nor even the patient costs, reckoned in terms of waiting times or what truly matters: morbidity and mortality.

So, now, does anyone really believe this is the sunlit uplands of medical quality assurance? Even though someone without even a medical degree can still fool the system?⁹

Or am I alone in my doubts?