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John Fry Fellowship Lecture John Fry Fellowship Lecture Revalidation of Doctors: The Credibility Challenge Professor Mike Pringle Published by The Nuffield Trust 59 New Cavendish Street London W1G 7LP Telephone: 020 7631 8450 Fax: 020 7631 8451 Email: [email protected] Website: www.nuffield.org.uk ISBN: 1 905030 08 8 © The Nuffield Trust 2005 The John Fry Fellowship and Lecture The John Fry Fellowship was established by the late Dr John Fry, for many years a trustee of the Nuffield Trust. It provides an opportunity for the Fellow to write and lecture on a subject in the field of general practice and primary health care. This paper accompanies the lecture given by Professor Mike Pringle on 8th June 2005, at Cavendish Centre, London. John Fry Fellows: David Cameron Morrell John C Hasler Iona Heath Professor John Howie Professor Angela Coulter Professor Richard Saltman Professor Barbara Starfield Professor Mike Pringle The Nuffield Trust 59 New Cavendish Street London W1G 7LP 1 Revalidation of Doctors: The Credibility Challenge John Fry Fellowship Lecture Professor Mike Pringle, CBE, MD, FRCGP, FMedSci, is Head of School and Professor of General Practice at the University of Nottingham. 2 Revalidation of Doctors: The Credibility Challenge On the morning of the 15th launched. This was a profound event December 2004 two vital meetings in British medical history. were held in different parts of In the debate on the future of London. In its new premises on the revalidation the stakes are high. There Euston Road the General Medical are two powerful ideologies currently Council met in closed session to fighting for the soul of British discuss its response to the Fifth medicine. At issue is whether the new Report of the Shipman Inquiry1 led by Dame Janet Smith. Simultaneously,in culture of healthcare will be to refine the Department of Health in but essentially maintain our long Whitehall a summit was convened to tradition of medical paternalism; or discuss the department’s initial whether it will be to maximise patient response to the same report. care and choice, to protect patients That morning the General Medical from harm and to promote a patient- Council decided that the right policy centred, patient-led health care was to stick by its guns, including system3. reiterating its support for its model of In this paper I will look at the revalidation for doctors, only three background to the decisions on the months away from being introduced. 15th December 2004 and will try to Simultaneously, the Department of Health decided that revalidation could offer an analysis of the way forward not be allowed to proceed. Its formal for revalidation. I will be arguing announcement of the Chief Medical from the perspective of protecting Officer for England’s review was made and supporting patients. I will be two days later2. talking about all doctors, for an The effects of these concurrent effective system of quality assurance meetings cannot be under-estimated. has to apply across the profession, but Revalidation, that started with noble particularly referring to those doctors idealism in 1998, that had been in independent practice – consultants dramatically re-designed in 2001 – a and general practitioners. re-design found in Chapter 26 of the Before I start, however, I do need Fifth Shipman Report to be not fit for purpose – had been re-affirmed by to tell you a little about myself, and to the body that owned it, and had been offer a working definitions of the terminated, or at least deferred by term “revalidation” and “licence” that political power just before it was to be I will use in this paper. 3 Revalidation of Doctors: The Credibility Challenge My background College of General Practitioners I became that College’s representative Before I can ask you to accept my on the General Medical Council and analysis, you do need to know then, in 2003, I was elected to the something about my credentials. I am, reformed General Medical Council, first and foremost, a general continuing my involvement in practitioner. For over 25 years I have revalidation. delivered care to my patients in Collingham, a medium size rural practice in Nottinghamshire. I have What are revalidation and a also been an academic for over two licence to practise? decades and one of my themes has Before I get too embroiled in this been the promotion, the quality narrative I need a working definition assurance and the recognition of of “revalidation” and “licence to excellence of clinical care, in order to practise” since it has become obvious enhance patient outcomes. I was the to me that semantics underlie some first ever Fellow by Assessment of the apparent disagreements surrounding Royal College of General this debate. Practitioners, I coined the term Since the General Medical Council “significant event auditing” and coined the term “revalidation” it can introduced it to primary care: it is claim, as it does, that it means exactly now embedded in the new General what the General Medical Council Medical Services contract’s quality wants it to mean. It says that “the and outcomes framework. I was co- purpose of revalidation is to ensure chair of the Diabetes National Service that patients have the confidence that Framework, which set out a patient licensed doctors are up to date and fit centric vision for diabetes care4. to practise”6, a positive endorsement In 1998, the year that revalidation of their performance. It goes on to say was first proposed by the General that revalidation identified for further Medical Council, I was elected to be review those whose fitness to practice chair of the Council of the Royal may be in doubt. College of General Practitioners, a It is not, they say, about post that was, over the next three identifying poor performance. Yet that years, to give me increasing insight is exactly what the legislation into policy development around introducing revalidation (which refers revalidation5. Soon after completion to revalidation as an “evaluation of a of my term as chairman of the Royal medical practitioner’s fitness to 4 Revalidation of Doctors: The Credibility Challenge 7 practise” ), Dame Janet Smith and the CONTINUOUS PROCESS Internal: Shipman Inquiry, and the public at Professionalism 8 Peer Pressure large think it is about. Patient Expectations External: My view is as follows. We are Clinical Governance Audit/Quality Assurance embarking on a process that has two Annual Appraisal components – continuous monitoring Performance Management Complaints and episodic re-certification. Either of Litigation those processes can lead to concerns and these will result in either assessment or, if thought sufficiently EPISODIC SUBMISSION FURTHER severe, referral to the Fitness to OF EVIDENCE ASSESSMENT Practise Procedures of the GMC. The vast majority of doctors are up to date and fit to practice. The FITNESS TO continuous processes will raise no PRACTISE CONTINUING LICENCE PROCEDURES concerns; they will satisfy revalidation’s first stage (the episodic Figure 1: The full system of continuous and episodic quality submission of evidence) and their assurance licensure will be continued (the left the Fitness to Practise Procedures of hand side in Figure 1). the GMC. Since the processes are an However, let us imagine a doctor integrated system of proactive who is slipping into under- scrutiny I refer to everything beneath performance. Perhaps the doctor has the dotted line in Figure 1 as developed a tremor that interferes “revalidation”.Thus for me with surgery, an alcohol problem or a revalidation both identifies those who depressive illness. Or the doctor hasn’t are up to date and fit to practise, and kept his clinical knowledge base up to those who are not – and deals with date. Or poor communication skills them appropriately. are being compounded by increasing The outcome of revalidation is a lack of insight. continuing licence to practise. Most In a perfect world such doctors would regard that as a licence to would always be detected and dealt undertake the work that they purport with by the continuous process; in the to undertake. So a licence to do renal real world many will not be. The transplants for a renal surgeon; a episodic submission of evidence will licence to undertake general practice be identified some for further for a general practitioner; a licence do assessment which may even lead to dermatology for a consultant 5 Revalidation of Doctors: The Credibility Challenge dermatologist; and a licence to offer policy document of the year before supervised care for a junior doctor. (The New NHS: Modern and The essential outcome of revalidation, Dependable14) with A First-Class however defined, is that the public Service: Quality in the NHS15 in which and the profession can have it set out a new commitment to confidence in the licensure of doctors. ensuring all patients had better and This is the credibility challenge safer care; and the concept of regular referred to in the title – the public will re-certification of a doctor’s expect revalidation to protect them competency – now called revalidation from poor and under-performing – was seriously resurrected16. doctors. If it will do so, then let us say The 1998 revolution did not arise so. If it will not, then I would argue out of a void. While I regret that there that we are wasting our time. is insufficient time to explore the foundations of revalidation in full here, I believe that a summary will The background to help to develop my argument. revalidation In 1975, the Merrison Committee9 The promotion and assessment recommended periodic tests of of quality in individual doctors competency for doctors. The Alment Committee then examined the First I will look at the attempts to concept in more detail and in 1976 promote and assess quality in declared it impractical.
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