Health Service Focus

Countdown to revalidation

We’re now just months away from getting underway with revalidation, with around 230,000 doctors due to go through the process in the next few years. At the NHS Confederation conference 2012, revalidation was discussed by Confed chair Sir Keith Pearson, who chairs the UK Revalidation Programme Board, alongside Niall Dickson, chief executive of the General Medical Council; Ann Lloyd CBE, a trustee of the Patients Association and former chief executive of NHS Wales; Professor David Haslam, national clinical adviser at the Care Quality Commission; and Dr Penny Dash, principal at McKinsey and vice-chair of The King’s Fund.

GMC chief executive Niall Dickson (pictured above) explains the need for revalidation with a biting analogy. If you were about to get on a plane, and heard that the captain is unable to fly, and a locum pilot is going to take control of the aircraft – the airline knows he got his pilot’s licence 20 years ago, but has never employed him before and doesn’t know his safety record or if he’s flown this type of plane before – would you fly?

He adds: “The interesting thing, of course, about this analogy is that there’s a crucial difference with doctors: the pilot is at least getting on the plane, so he’s taking some risk himself in this process!”

Dickson was one of five expert speakers on revalidation at an NHS Confederation conference session (pictured right), attended by NHE.

‘We’re ready enough’

Sir Keith Pearson, chair of both the NHS Confederation and the UK Revalidation Programme Board, spoke first. After outlining the need for revalidation, he said: “With many projects that many of us will have worked on over our careers, the danger is that you set yourself a landing place the size of a pinhead in order to achieve [a] state of readiness. That’s not the way it’s going to be: we’re going to have to reach a stage where we say ‘we’re ready enough’. And I think the UK Revalidation Programme Board has reached that position where we are ready to be recommending to the Secretary of State for Health that we think we’re ready enough to move forward.

“We’re ready enough to start a programme that will take about three years to implement, but it is important that we recognise that seeking perfection in the state of readiness is something that would elude any form of implementation.

“It is about three things: improving quality, achieving excellence and getting overall improvement. The programme is as much about reassurance for the patients and the public as it is about ensuring doctors are fit-topractise and up-to-speed.”

Current competence

Niall Dickson joked that revalidation has been “about 18 months away for the last 12 years”, but said it is now finally happening for real.

He said: “There’s quite a lot of evidence that the healthcare industry – not just in this country, but across the developed world – has been really rather slow to embrace safety.”

He said reports into the issue have noted a focus on volume and throughput at the expense of quality; a disconnect between medical staff and management; and a lack of clinical governance.

He quoted the Bristol inquiry, referring to a consensus that had survived into the 1990s, that “if enough well-qualified professionals could be educated and trained, they could then be relied upon to provide services of high quality throughout their working lives”.

Patient safety

He praised the work of the Scottish Patient Safety Programme and the National Quality Board, and the increasing understanding among NHS chief executives and directors that patient safety is “core to their business”, highlighted by the fact that 400% more of them attended the 2012 National Patient Safety Congress compared to the 2011 event. “The capacity of doctors to do both good and harm is greater than it ever was,” he said, and quoted Sir Cyril Chantler’s famous maxim to that effect.

He went on: “The medical register has changed by leaps and bounds over the last 150 years, and yet in some ways it’s fundamentally the same: this person passed an exam at a certain point in time, and became a doctor. We either do or do not know that something terrible has happened in the intervening period; then we say goodbye to them when they retire.

“So it is really a historic record of qualifications and actions taken: it’s not an indicator of current or contemporary competence. Every other safety industry checks its people, it’s an absolute basic. The nuclear and aviation industries may have had their problems, but the idea that you wouldn’t check absolutely critical safety people? They’d think you’d come from the wrong planet.

“Every other major business throughout the world uses performance management: it uses appraisal. They don’t do this because it’s something fluffy and odd and different: they do it because it makes business sense to do it.”

Constant feedback

He said revalidation isn’t about identifying “bad doctors” or the next Harold Shipman and isn’t a pass-or-fail test, but is about identifying potential problems early and also about the “middle of the curve” – improving mainstream practice and helping good doctors get better.

He said: “You can’t ‘fail’ revalidation.

“Especially once the first cycle is over, the idea that for some coincidence at the point of the fifth year of that revalidation, something’s going to suddenly go wrong, is rather bizarre: if something’s identified, it should be identified during the ongoing process that is revalidation, not the point when the Responsible Officer (RO) is making a recommendation.”

Dickson said the feedback and evidence doctors must bring to their annual appraisal are not onerous: evidence they are engaging in CPD and quality improvement activity; a discussion about significant events in the past year; and colleague and patient feedback.

He said the feedback element will “develop over time”, acknowledging that patient groups especially wanted it to go further. “It’s all about making sure licensed doctors are working within governed environments. There should be some assurance, not about their 20-year-old licence, but their current competence to do the job,” he added.

Revalidation timeline

Connections have already been made between more than 120,000 doctors and their designated body, 724 of which have been identified around the UK, with about 630 ROs in post.

Dickson sketched the timeline: the ROs and medical leaders revalidated first, by March 2013; 20% of all doctors revalidated by March 2014; the “vast majority” by March 2016; and everything being done by March 2018.

He said: “We will lead the world on this. There isn’t another nation that I know of anywhere in the world that is building as robust or as comprehensive a system as this. We are being watched by others.

“It is a top-down process, it’s come out of legislation, but it will ultimately only work if it lights a fire of enthusiasm. If it becomes burdensome and tick-box, if people don’t see the value in it, of course it won’t work.”

Trust and communication

Ann Lloyd, a new trustee of the Patients Association and former chief executive of NHS Wales, said the basic desire of patients is simple: good quality care from a health professional they trust.

She said it would come as “a bit of a shock” to most patients to find out their doctor is not already ‘revalidated’.

She said: “It is vitally important that the trust and confidence that patients have, in the main, in their health professional is protected and enhanced. Revalidation is part of the growing conjoining of the experience of patients and practitioners in delivering a much better service for them.

“The Patients Association has been working with the GMC on how to engage patients more effectively, to enable them to really contribute to revalidation. It’s great that patients are being involved, through their feedback, in the revalidation process right from the outset.”

Too often, Lloyd said, patients and their families are reluctant to complain or give feedback about health services because of the risk of some imagined retribution, especially if they are in hospital for a long time.

She said: “It’s very galling, when you think you’re running a good organisation that communicates well and is doing absolutely everything it can to improve care, to get that sort of feedback.”

“We almost despair”, she said, when patients keep quiet ‘in case something happens’.

Quality

Professor David Haslam told the audience that revalidation must be part of a wider shift to a culture prioritising quality across healthcare and in which both clinicians and patients felt happy and keen to give feedback and raise concerns.

He said: “I can’t believe there’s anyone in the health service who goes through a year without seeing anything that should be flagged up as a concern.

“Everyone should be flagging these things up: it shouldn’t be a mark of failure, but a mark of caring.”

Whistleblowing is all well and good, he said – but by then it is too late. If someone feels they have to blow the whistle on poor practice, it shows that the system has already failed.

He wants “systematic feedback across all healthcare interactions” to become the norm, contrasting the situation in the NHS with a recent holiday, where on his return he found an email asking him for feedback – but there is nothing similar for someone who’s had a transplant.

He said: “For the first time, there will be an ongoing focus on whether doctors are up to the mark; and with this comes a real culture shift. Quality won’t be assumed: it will have to be demonstrated.”

The wider context

The final speaker, Dr Penny Dash, spoke of the changing context for healthcare – away from the primary challenge being acute need, and towards older populations with long-term needs.

She noted some of the quality challenges that remain, from excess deaths of healthy newborn babies outside of working hours, to poor care for people with diabetes.

She said that other organisations’ approaches to quality could be useful in determining what doctors can be assessed against. She was keen that revalidation should become embedded in the thinking of NHS boards, and not seen as a separate process of consequence only to doctors and the GMC.

The ‘Reaping the strategic rewards of revalidation’ event was chaired by Sir Keith Pearson and held jointly by NHS Employers, the GMC and the NHS Revalidation Support Team.

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