Whatever you want to call it – medical revalidation, health checks for docs, medical MOT, fitness to practice, competency assessment – the announcement that a new system of assessment will start this December means that successive governments, the BMA, GMC and royal colleges have ended a decade of all dancing around each other playing pass the parcel. All medical personnel registered in the UK will now be subject to 5-yearly evaluations for licenses to practice and annual assessments of competency.
Some are cheering; I’m not – at least not yet – because I have some questions about all of this.
Is this a big step forward in terms of ensuring safe and effective patient care? I live in hope, of course, but 25 years of working inside the NHS as a lay person at the governance coalface of boards and executive committees is enough to make me more than agnostic about whether this will achieve its objectives. Why? Put simply, it is because regulation in itself is not the right process to achieve this sort of quality assurance objective. To make matters worse, piling on a new, expensive, bureaucratic system just at a time when we are trying to bed down the most extensive (in England) reforms the NHS has ever seen is not good timing.
The UK’s 220,000 registered doctors will scarcely be finished with one round of “checks” before the next annual round starts. It is creating a compliance treadmill that may turn out to be loathed for the time it diverts from patient care. It is meant to start before the end of this year with medical leaders. This means the very GP leaders we need to be putting all their energies into the new CCG commissioning system which kicks off in April 2013 will now have to divert time and attention to jumping through Mr Hunt’s new hoop. David Nicholson warned only a few days ago that if we get the CCG implementation wrong, the whole thing will end in “misery and failure”. I do not want him to be proved right and this could increase the risks.
Mr Hunt’s announcement about revalidation for doctors comes only days after he announced at the Tory Conference that he wants the CQC to license individual managers and hold them to account for safe and effective care in the institutions they run. This helps turn the NHS into a regulatory monster. It won’t make things better and could make them worse. Piling everything on to individuals will still allow organisations to behave badly and dangerously. Perhaps we should license health ministers next?
Patients loved Dr Shipman, don’t forget
What is in this for patients and the public? Will it identify and prevent another Harold Shipman or Mid Staffs scandal. Dame Janet Smith who chaired the Shipman Enquiry said some pretty pungent things about why more regulation on its own was not the way to go. Many of Shipman’s patients – the ones he didn’t murder – loved him as a kind and caring doctor.
Before I get howled down, I know revalidation isn’t really about “catching the next Shipman” because there are other ways of catching them if you just learn how to read data properly, which was one of the big findings of the enquiry. The objective is much more about making sure that doctors are keeping up with developments in their profession and undertaking the appropriate training. That is a welcome objective of public policy, especially as it includes patient input. A lot of people have been fighting for a long time to get it in there. But it has to work.
Government says that the evidence “must include examples of quality improvement activity, any significant events, feedback from colleagues and patients and a review of any complaints and compliments from patients.” The words sound good, but from personal experience of our PCT trying to remove incompetent GPs over the years, I know their patients are often doggedly loyal and supportive if they see “their doctor” being criticised. Until we get to a position where patients see themselves as customers who know what a good service looks like and can rate it against the one they are receiving, just asking what patients think about a doctor – especially a GP – may not achieve anything and may actually block needed change.
I hope I am being too cynical. I would be delighted to be proved wrong about this. I welcome the intention, but I want us all to ask some searching questions and not be complacent.
Do we know what works?
More regulation must not duck the key question: how to hold the individual clinician to account for her/his practice in a way that makes a difference to quality and safety? It isn’t a magic bullet, but I am a fan of regular peer supervision to do this, undertaken by people who are competent to give an opinion on the overall performance in the work environment of someone else. This should be coupled with continuing professional development – “lifelong learning”.
I shared this view with Lynn Young and asked for her thoughts on the revalidation issue. I got a challenging response. She wanted to get back to first principles and asked some very searching questions:
- Do we need a framework for doctors to help ensure safety?
- Do we leave it to peer group pressure and employers?
- Do we leave it to personal responsibility and integrity?
Her answer was that it requires something that is more rigorous than their character and conscience. She said we needed “more brilliance” in the system, namely
- Brilliant selection
- Brilliant preparation
- Brilliant mentorship and support
- Brilliant transparency
- Brilliant teamwork
- Brilliant review of professionals performance
- Brilliant and rapid remediation
Amen to all of that, but what none of us knows is, would this be good enough? It would take time and remember Juvenal’s query “who will watch the watchers?” Quis custodiet ipsos custodes? No one doubts that all practitioners need to be certified as currently fit for purpose. The question is who should do it, what process is involved and how is the information it produces used by consumers and employers? I want the new system to be transparent about all of these questions.
It can’t all be piled on the individuals
Here’s what I think. For the bulk of doctors (and nurses, and therapists – all clinical roles) a big part of the answer is that their employers should do this and be held to account for doing it well through a licensing system on institutions which deliver healthcare. I don’t think it is a function for the GMC, as in the present proposals, or any of the other registration bodies for other professionals.
For clinical contractors, meaning the bulk of GPs – who are self employed don’t forget – there is no substitute for a peer review process. The people who know best about good and poor medical performance are the local GPs in the CCG. I believe that they should deal with assessment, remediation and rooting out failure as part of the CCG’s own reputation management and clinical governance processes. And they should be held to account by the Commissioning Board for doing this well.
No matter where it happens, the process has to have a strong and meaningful patient (customer) input. That’s the challenge we need to put to the new revalidation system. Let’s hope the evidence shows that it can deliver what we all hope for it.
The Moore Adamson Craig Partnership supports user and public participation, trains lay representatives and develops responsive health, care and education organisations. We are ready to work with and support all those who want to make sense and a success of the new structures of patient and public engagement within the new arrangements for health and social care commissioning and providing. Feel free to contact us to discuss the opportunities.