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Revalidation: a long time coming

The medical profession has been wrestling with the concept of revalidation for decades. Who and what has shaped the final version, due to begin this year?

As revalidation comes into force at the end of 2012, subject to an assessment of readiness, it will have been almost 40 years in the making.

The idea was first raised in the 1970s when the Merrison Committee, set up by the government to modernise medical regulation, suggested doctors might undertake some form of periodic 'relicensure'.

Then, as now, the position was that once a doctor had qualified, it was taken for granted that he or she remained competent and up to date unless fitness-to-practise proceedings decided otherwise.

But the committee decided recommendations about relicensing were beyond its remit and the issue remained dormant until a series of high-profile medical scandals rocked the profession in the 1990s and early 2000s.

GMC hearings into three doctors implicated in the high death rates at the Bristol Royal Infirmary paediatric cardiac unit, and the following independent public inquiry, put the issue firmly back in the spotlight - where it has remained ever since.

Impact of Shipman

Key players, including the BMA, may have agreed to support the essential principles behind revalidation early on, but pinning down exactly what doctors should do, how and how often has proved notoriously tricky to determine.

Revalidation was on the verge of being implemented in 2005 but was thrown off course by the public inquiry into the actions of the serial killer and GP Harold Shipman.

Shipman Inquiry chair Dame Janet Smith criticised the revalidation plans as inadequate for identifying bad or dangerous doctors, and the process was put on hold.

But revalidation was never intended to catch another Shipman, as BMA council GMC working party chair Brian Keighley points out,

He says: 'This was never the original intention of revalidation, which was to encourage gradually increasing quality in healthcare for patients through self-assessment, appraisal, continuing medical education and reflective practice.

'Over the past 10 years there has been confusion and tension between those who believe it is a screening tool for the incompetent, rather than a formative, educational process for the individual.'

Work in progress

A number of models for revalidation have been proposed over the years. Under an early version, doctors would have submitted evidence for examination by local revalidation groups, who would have used it to decide whether or not to recommend revalidation.

A subsequent design had three stages, which would have started with every doctor maintaining a revalidation folder containing information from several sources to show how well they were practising. This information would be reviewed through annual appraisals to identify and rectify any problems.

For stage two, a doctor's folders would be assessed independently every five years by a small revalidation group of doctors and lay people, judging the doctor against national standards. The group would make a revalidation recommendation to the GMC.

Stage three would see the GMC either revalidate the doctor or, if the group considered action necessary, decide whether to invoke fitness-to-practise procedures.

In 2003, the proposals were stripped back to automatic revalidation for doctors who had undergone five satisfactory consecutive annual appraisals — the model so criticised by the fifth Shipman Inquiry report.

BMA monitoring

The process due to be implemented later this year still has five annual appraisals at its heart but has been further strengthened with scrutiny by an RO (responsible officer) and the GMC.

It builds on the recommendations from former chief medical officer for England Professor Sir Liam Donaldson in his 2006 report Good Doctors, Safer Patients: Proposals to Strengthen the System to Assure and Improve the Performance of Doctors and to Protect the Safety of Patients.

Doctors leaders have monitored the various permutations closely, scrutinising the detail of multiple revalidation proposals to ensure the process allows doctors to show they are up-to-date and fit to practise, without being overly bureaucratic and time-consuming.

In 2010, for instance, the BMA told the GMC to take its plans back to the drawing board because they were too burdensome for individual doctors. As a result, the GMC simplified and streamlined its guidance on the type of supporting information that doctors would need to collect for their appraisals, while the government agreed to extend the revalidation pilots by a year.

The BMA has also argued successfully against doctors been required to take regular knowledge tests. These were proposed by Dame Janet in the fifth Shipman Inquiry report and were under active consideration by a number of medical royal colleges under their specialty-specific revalidation guidance.

Negotiated changes

The BMA maintained that the CPD (continuing professional development) requirements of the Colleges should be an indicator that a doctor's knowledge is sufficiently up to date and, while the Medical Royal Colleges are still finalising their guidance, recent GMC documents no longer refer to knowledge-based tests.

Other crucial improvements to the revalidation proposals, often influenced by BMA lobbying include:

  • A strengthening of the guidance relating to ROs, who will oversee revalidation at a local level, and possible conflicts of interest. Once mediation procedures have been exhausted, doctors now have the option to have their revalidation overseen by an alternative RO
  • An insistence that any multi-source feedback system use to assess doctors' practice should be validated properly. Research on the GMC's revalidation questionnaires was recently published by Peninsula medical school
  • An expansion of the role of the Revalidation Support Team to include examining the cost-effectiveness of the process.

Dr Keighley says: 'The BMA has worked constructively over the years with all interested parties. It has agreed to reasonable proposals for incremental and planned change to professional regulation, but has not hesitated to point out where there have been inconsistencies and flawed thinking.'

He says most of the association's anxieties have been heeded by the GMC but there has been less success with others involved in the 'revalidation food chain'.