Revalidation: a General Medical Council perspective
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* Peter Rubin

Most doctors in the UK are very good doctors who keep themselves up to date because they are highly motivated and committed to doing their best for their patients. In the past this was accepted on trust, but the world has changed. Revalidation is the process by which doctors in the future will confirm that they are up to date and fit to practise.

A *BMJ* editorial accurately foreshadowed a tumultuous decade for doctors: ‘All changed, changed utterly. British medicine will be transformed by the Bristol case’.1

Until the highly publicised events in children's heart surgery in Bristol, it had been assumed that doctors would maintain high standards in their profession by self-regulation. However, in Bristol some doctors had been harming patients by working outside their competence while others knew but had remained silent. Self-regulation had been found wanting and the General Medicine Council (GMC) proposed revalidation as a consequence. The idea that evolved within the GMC at that time envisaged a four-layer model of revalidation: the professionalism of the individual; constructive self-assessment within the clinical team; effective clinical governance and quality improvement within the organisation; and, at a national level, the regulator. These principles still stand today.

Revalidation has been a long time coming. The challenge has been to develop a system that is fit for purpose, while being usable by the 218,000 doctors with a licence to practise: revalidation has to work at the front line. The main pillars will be appraisal and multisource feedback (MSF).

Appraisal should be an opportunity to take stock; to reflect on what clinicians are doing to develop their knowledge and skills and what they need to do in the future; to discuss difficulties, personal or organisational, that may be preventing them from performing at their best; and importantly it should be an opportunity for the appraiser to say ‘well done’ to the large numbers of doctors who provide an excellent service, often in challenging circumstances. MSF, or 360-degree feedback, should involve colleagues – not only doctors – and patients and the outcomes should form the basis of a discussion at the appraisal. There may well be outlying views but if there is a trend going in one direction it can be a very useful pointer, either positively or negatively.

A crucial principle is that physicians will be revalidated to do what they do now, not what they once did. And they will be revalidated on what they do that impacts on patients, either directly, for the majority of doctors, or indirectly, for those with a licence who do not see patients. So, for example, a clinical academic doing one clinic a week in a very specialised branch of medicine with the rest of their time in research would be revalidated on whether they were up to date and fit to do that clinic. Their appraisal, as now, would be jointly administered by the NHS and the university, but their research is of no relevance to the process of revalidation, except in rare instances. Or if they are engaged solely in medical management and do no clinical practice, but take decisions which impact on patient care, they will be expected to show that they adhere to the principles of Good Medical Practice. The GMC is determined to ensure fairness and proportionality in the revalidation process and will be consulting further, in the light of the outcomes of recent pilots, from March 2010.

Determining the knowledge and skills appropriate to doctors who have progressively specialised as their careers have progressed will be challenging. The medical royal colleges are leading that work, with their proposals coming to the GMC for evaluation and ultimate approval. Appraisal will be delivered in and by the NHS and the system is being led by the UK health departments. The GMC is very clear that appraisal must be as free of bureaucracy as possible and are particularly keen to ensure that perfectly good existing systems are not swept aside. There has been much discussion about the costs of revalidation. Our view is that two issues are being conflated. Appraisal should exist in any organisation that is serious about quality improvement and excellence. A well conducted appraisal costs no more in time or money than a bad one and these costs should already be in the NHS system.

Recommendations as to revalidation will be made to the GMC by a responsible officer, usually the medical director. As the name implies, that person will be responsible for the accuracy of the recommendation, but will almost inevitably rely on many others to implement the process, particularly in large organisations. The GMC will have the final say on whether to revalidate a doctor – and, therefore, to challenge any recommendations that seem perverse or which are unsupported by evidence.

The GMC has never considered that the purpose of revalidation is primarily to identify ‘bad apples’. It is primarily to affirm good practice. Clearly, some doctors will be identified who need remediation – as happens now. It is very important that such doctors are identified early in the five-year cycle of revalidation and that remediation begins at that stage.

Revalidation is the biggest change in medical regulation for 150 years – and change brings uncertainty. The GMC recognises the need for timely and effective information and regularly updates the frequently asked questions section of their website: [www.gmc-uk.org/doctors/licensing/faq\_revalidation.asp](http://www.gmc-uk.org/doctors/licensing/faq_revalidation.asp). Change also brings challenges of implementation, so the GMC is piloting and consulting extensively to ensure that systems work. Revalidation will start in 2011, but not in all specialties or in all parts of the UK at the same time. We will start only where and when we are ready, with progressive phasing-in over the ensuing two to three years.

*   © 2010 Royal College of Physicians

## References

1.  Smith R.. All changed, changed utterly. BMJ 1998;316:1917–8doi:10.1136/bmj.316.7149.1917
    
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