Health Service Focus

The cost & benefits of revalidation

Claire Ruth reports on the upcoming implementation of revalidation and the important findings of the Department of Health study into the costs and benefits of the new system.

The confirmation that revalidation of all doctors in the UK is to begin in December, after more than 30 years of debate and negotiation on the topic, has been greeted with general, albeit cautious, support.

A Department of Health study published on November 6 has outlined the anticipated benefits of the system, and has strikingly claimed that the benefits considerably exceed the annual cost of implementing the new system – to the extent that revalidation will essentially pay for itself.

It also quotes research which, interestingly, finds “a strong relationship between good human resource management policies and health outcomes”.

Nonetheless, the £97m projected cost per year cannot be ignored, particularly from the perspective of the doctors themselves, who may perceive the expense as being more than financial, as impacts on time and patient care continue to concern members of organisations such as the British Medical Association (BMA). The BMA itself has continued to stress that there is more work to be done to get revalidation into “proper shape”.

But there is plenty of anecdotal surprise among patients and the general public – many of whom seemed to assume that such checks on doctors were already in place.

Following the multiple and successful testing and piloting schemes since 2010 that have been investigating the practical implementation of revalidation, the Government has decided that the benefits are worth it.

Privately, some GPs contacted by NHE have their doubts about how much use the new system will really be, and suggest it will end up as just more paperwork and time away from patients for good doctors without really improving the quality of poorer ones. Others, with no love for the GMC, worry about the big expansion in its power and responsibilities.

Others, un-used to such intrusion and the necessity to prove their competence, instead of it being assumed based on their professional experience and standing, could choose to retire – as the DH acknowledges. Its report says the new system means “some doctors may choose to leave the system rather than undergo appraisal and revalidation processes that would be new to them”. It goes on: “This may particularly be the case for older doctors, who would take with them many years of experience and expertise. This could have a disproportionate impact on sectors that are more likely to employ older doctors. However, a counterpoint to this is that those doctors who are more unwilling to engage in appraisal and revalidation activities, which entail reflection on their practice, are those for which the most significant concerns around performance and patient safety exist, so there may be an overall gain to the system.”

Certainly, the scrutiny doctors are sure to face, in particular from their peers and their patients, will be stressful, both in terms of the work involved and the seemingly personal examination of their capabilities.

But the DH and GMC have been keen to ensure such fears are misplaced, and that the revalidation process is genuinely more than a tick-box exercise. The principle purposes of the scheme are to ensure that doctors remain fit to practise whilst allowing all doctors to evaluate and improve their practice on a continuous basis, all while improving patients’ confidence and trust. The DH says doing this will reduce malpractice issues, litigation costs and boost public opinion of medical professionals.

All doctors will be subject to revalidation and all doctors will be given the chance to progress. The system involves Multi-Source Feedback (MSF), wherein colleague and patient views will be collected, hopefully encouraging patients to speak out while reinforcing an ethic of teamwork, allowing doctors to collectively work on improving aspects of their services and attitudes. Due to the fact that this will be the first time that doctors will be assessed after obtaining their licence to practise, and that the UK is the first country in the world to propose such an intensive system, this resolution is nothing short of radical.

However, many health officials and organisations see it as radical but necessary to guarantee the quality of health care, and say that the only obstacle to its implementation would be the cost.

Yet the Department of Health’s cost-benefit analysis suggests it will more than pay for itself by helping to avoid compensation expenditures, reducing suspensions of doctors and achieving a 3% decrease in litigation costs.

On the costs of revalidation, the DH cost-benefit analysis says: “The main costs incurred are due to appraisal, which has been a mandatory component of all NHS doctor contracts since 2001. Therefore, the minority of NHS doctors who have not been fulfilling their contractual commitments will incur the largest costs.

“The ORSA (Organisational Readiness Self- Assessment) data shows that appraisal rates are lowest in the independent sector, including locum agencies, meaning that the impact will be greatest for these organisations. However, the ORSA data also shows that most of these organisations are on track to deliver systems that are ready for revalidation by December 2012. Moreover, as the evidence base shows, when undertaken properly, appraisal is beneficial for doctors and leads to a positive net benefit in terms of patient safety and quality of care.”