Revalidation – half-time score
By the end of March 2018, it is intended that all UK doctors with a licence to practise will have completed their first cycle of revalidation, with the great majority having done so by March 2016. The purpose of revalidation is for doctors to ‘demonstrate on a regular basis that they are up to date and fit to practise in their chosen field and able to provide a good level of care’,1 and all will be aware that the process involves an annual appraisal, a portfolio of evidence, and a recommendation to the General Medical Council (GMC) through a responsible officer every 5 years. Appropriately, the process of revalidation is being subjected to scrutiny, with an independent report commissioned by the GMC from the UMbRELLA organisation headed by Plymouth University, which has just produced an interim analysis2 (the full report is due in 2018), and an additional Department of Health-commissioned report on organisation and impact of revalidation.
UMbRELLA (UK Medical Revalidation Evaluation coLLAaboration, since you ask) invited over 156,000 licensed doctors (those in postgraduate training excluded) to participate, with a response rate of just over 16%. Although gender-wise and regionally the subgroup appears valid for the whole group of doctors approached, with the emotions and frustrations known to have been elicited by the process of revalidation, there are likely to have been some systematic biases in the report. One might speculate that both doctors with a well-developed bump of responsibility, and those notably aggrieved by being required to participate in the process, might be more likely to reply to the questionnaire than the large majority who ignored the invitation; but those biases might cancel out. Accepting the data as representative, the headlines included a rate of participation in appraisals of over 95% among consultants, with the overall proportion reduced by significantly lower rates among trust grade doctors, resident medical officers and hospital locums, and those in public health or non-clinical posts.
Disappointingly overall, since the GMC places the appraisal process as central to revalidation, the survey respondents seemed relatively unimpressed with appraisal as a tool for improvement – only a minority of 42% believed that appraisal improved clinical care, with presumably the same 42% stating their most recent appraisal had changed their clinical practice, learning behaviour or professional behaviour. The majority (57%) thought they emerged from the process unchanged in those respects – unsurprisingly, those who were older and more senior were the least likely to change (or acknowledge change).
The survey reports on many details of the appraisal process and the provision of supporting information thereto. Some details are a slightly amusing documentation of the obvious: pathologists have the lowest reported rate of patient feedback for example. But nonetheless there is useful information pointing to how the whole process of revalidation can and should be improved in the future. Probably the most striking issue is just how – as yet – variable the details of the appraisal process are between individuals.
One third of doctors choose their own appraisers – a fact that might surprise patients and the public. In respect to eliciting patient feedback – which was, in fact, rated the most personally helpful piece of data that doctors collected for submission in their portfolios overall – there was no uniformity about who asks for the feedback, whether the employer or the individual doctor, online or on paper, whether patients return the forms in person, and so on. In fact, one third of doctors distributed the patient questionnaires themselves. And in respect of the actual time commitment for the appraisal itself – collating the information, completing the appraisal paperwork before and after, and attending the meeting itself – this took a mean time of 27 hours for the 26,000 respondents. However, since median time was only just over half that figure, some people must have been very quick and others more ponderous.
Even if, as we mentioned, there was only minority support for the concept that appraisals improved clinical care, the appraisal process does appear to justify itself by the finding that at least 10% of the 4,000 doctors who acted as appraisers had formally raised (ie escalated) concerns about at least one of those they appraised, with an additional 20% finding concerns that they could deal with within the appraisal. While most of those concerns were under the rather hazy classification ‘lack of reflective practice’, a significant number reflected outdated clinical skills or knowledge.
The appraisals form the essential data base leading to revalidation, but the essential conduit to the GMC is through the responsible officers and their recommendations. Again, a striking finding is the lack of process uniformity among responsible officers. Some work simply from appraisal summaries, some discuss with others, some convene advisory groups, some delegate the process. And – an issue perhaps of courtesy – less than a third informed individual doctors of their recommendations concerning revalidation before they made the recommendation to the GMC.
So what’s the interim score? Appraisal comes out as well accepted, useful at best, even if more often judged as neutral. The process itself is highly variable, exemplified by self-selection of appraisers and varying mechanisms for obtaining patient feedback. Interestingly, there remains substantial scepticism that revalidation, over and above the appraisal process, will improve the standards of doctors’ practice – echoing the comment that every one of us will have heard ‘none of this would prevent another Harold Shipman’. This, however, ignores the effect that the introduction of formal revalidation has had in mandating and improving appraisal. While there are things to be done – for example process standardisation nationwide that could be initiated ahead of the final report emerging in 2018 – fair-minded observers will acknowledge that the profession is better equipped to look our patients in the eye as a result of the imposition of revalidation.
- © 2016 Royal College of Physicians
References
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- General Medical Council
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