Revalidation and Recertification – The Future
Although the government White Paper “Trust, Assurance, Safety” concerned the regulation of all healthcare professionals, there was a substantial element that concerned reform to the medical profession. One of the key changes expanded on earlier proposals contained in the Chief Medical Officer’s report concerning revalidation. A system of revalidation that would incorporate both relicensing and recertification for specialist areas is currently being developed by the Department of Health, GMC, Academy of Medical Royal Colleges and the respective Royal Colleges.
The GMC envisage that licences to practice will be introduced in October 2009 subject to renewal every five years. In order to obtain a licence, doctors will have to demonstrate they adhere to Good Medical Practice, maintain adequate professional indemnity or insurance and participate in revalidation. When the GMC implement the new system, doctors will be given the option of taking a licence to practice plus registration, registration only or apply for voluntary erasure.
The relicensing process will mean all licensed practitioners must demonstrate to the GMC that they satisfy the framework translated from Good Medical Practice. The four key areas are:
- Knowledge, skill and performance,
- Safety and quality,
- Communication, partnership and teamwork,
- Maintaining trust.
Doctors will also need to collect information about their practice which will include information about appraisal, CPD, audit and patient/colleague feedback. Confirmation will also need to be obtained from the Responsible Medical Officer (RMO) that any concerns regarding their practice have been resolved. The RMO will make a recommendation to the GMC, who will then determine whether the doctor’s licence should be renewed. This ensures that the GMC will retain control of the overall process. It will be interesting to see whether doctors identified as poor performers, will have their concerns resolved primarily at local level as suggested, or whether we will we see an increase in the numbers referred to Fitness to Practise Panels.
Currently the GMC are piloting the use of medical and lay affiliates that may provide assistance in the resolution of concerns. It is envisaged affiliates will help bridge the gap between national and local regulation. There has been some concern that this is an expansion of the scope of GMC regulation however this has been refuted by the GMC, stating it is merely to provide a link between central professional regulation and local workplace regulation. The main objective is to support local clinical governance with medical affiliates assisting in the development and delivery of remedial training to doctors with identified performance issues.
Is this concept anything new?
High profile scandals such as Shipman, Bristol and Alder Hey seriously affected public perception of the profession and the way it was regulated. The GMC came under unprecedented criticism and some may argue were lucky to survive after the Shipman Inquiry. In 1975 the Merrison Committee were the first to recognise that a medical degree, payment of the annual retention fee and a clean fitness to practise history provided no guarantee of competence. In 1998 after the Bristol heart scandal, the idea was resurrected by the then GMC President, Sir Donald Irvine. However it was the Shipman report and Dame Janet’s recommendations that prompted Sir Liam Donaldson into his broad review of medical regulation and subsequent recommendations. The GMC also appear to have made a concerted effort over the last 4 years to try and demonstrate to the public that they continue to safeguard their interests and accountability within the profession.
The BMA have observed that different specialism’s and areas of the profession have developed various assessment techniques, with GPs utilising peer reviewed video consultations, with those in a hospital setting being used to a more formal management appraisal. However since 2000, there has been a movement away from traditional didactic lectures towards problem based learning, which in some instances, is lead by students themselves. The theories of personal/professional development are taught at an early stage in medical schools together with the importance of continuing education; the concept of formative and summative assessment is something all trainees are familiar with. The proposed framework for revalidation of audit, evaluation of CPD and feedback from patients and colleagues appears to adopt some of the principles of triangulation. By combining different data sources, the argument is that the intrinsic biases that arise from single methods or theories can be overcome.
Relicensing and Recertification – an additional burden?
The process of recertification will only apply to those doctors who are on the GMC’s specialist register or GP register. This group will have to demonstrate that they continue to meet the standards that apply to their area of speciality. There has been some concern that this will lead to duplication and an additional bureaucratic burden for practitioners. The GMC have established a joint working group with the Academy of Medical Royal Colleges. The GMC have emphasised that “revalidation should be viewed as a single set of processes, with two potential outcomes – relicensing and, for those on the Specialist Register or GP Register, recertification.” It is evident that there needs to be consistency in both the approach and standards set by each Royal College, whilst also satisfying the GMC that this approach is sufficient to maintain the integrity of the medical register.
It is clear that the process will become unworkable if it becomes unduly burdensome for doctors, taking away time that would otherwise have been spent with patients. The system must also be fair and transparent, ensuring that an appraiser is not determining whether a doctor should or should not be revalidated. It should be a systematic review of a doctor’s portfolio leading to plans for future development and improvement. We have yet to see what support the Royal Colleges will provide in assisting doctors during the evidence gathering process.
The message from the profession is that revalidation must be a mechanism for quality improvement rather than a process for weeding out ‘bad apples’. Some critics have argued that as performance will be assessed during the relicensing process, there is little point continuing to a second stage. This assertion can not however be correct. Recertification ensures that specialists continue to meet the particular standards that apply to their area of practice, with licensing looking at the principles of Good Medical Practice and annual appraisal/feedback.
The principles of revalidation have been welcomed by NHS employers and patient groups. NHS employers have stated it is “absolutely correct that patients and the public should be assured that doctors, who have a central role in providing care, continue to perform to the appropriate quality standard and we believe revalidation should provide that assurance.” This is perhaps unsurprising as under the clinical governance framework, trust chief executives are responsible for the clinical performance of their employees. The term “clinical governance” is defined by the Department of Health as a “ system through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care, by creating an environment in which clinical excellence will flourish.”
The objective of these reforms is to define and maintain professional standards and demonstrate to the public that there are robust regulatory systems in place within the profession. It is clear that the system will depend on honesty and transparency. Doctors need to regard the process as a five year cycle, rather than a fifth year exercise. Reflective practice needs to be encouraged which hopefully in turn will lead to higher standards of patient care. The Department of Health has provided £1 million in funding for a Revaildation Team set up by Sir Liam Donaldson. It is envisaged that they will “provide professionally informed leadership, support and advice to the NHS, patients and doctors representatives” in the development and administration of the process.
Doctors must be supported in this process and given assistance if remediation is required. The main objective should be the improvement of clinical standards and the demonstration that the majority of medical practitioners continue to provide high quality health care. This may go some way to avoiding an escalation in the practice of defensive medicine. The vast majority of doctors have nothing to fear from the proposed changes and should look upon the process positively as a way to develop and audit their own professional standards.