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Validating trust in general practice

Validating trust in general practice
29 October 2010

Most doctors are good doctors. They take their responsibilities seriously. They are well trained, self-motivated, highly intelligent and they have a strong professional ethos.

Most doctors are good doctors. They take their responsibilities seriously. They are well trained, self-motivated, highly intelligent and they have a strong professional ethos.

Most doctors are good doctors. They take their responsibilities seriously. They are well trained, self-motivated, highly intelligent and they have a strong professional ethos.

Most doctors are good doctors. They take their responsibilities seriously. They are well trained, self-motivated, highly intelligent and they have a strong professional ethos.

This is reflected in how they are viewed by their patients. The medical profession is regarded like no other in this country. Surveys carried out by Ipsos MORI for the Royal College of Physicians consistently show that doctors are the most trusted of all professions. In their most recent poll, 92% of adults told Ipsos MORI that they would “generally trust doctors to tell the truth”. (1) There is also strong evidence to show the value of GPs and effective primary care in improving levels of health. (2)

It may seem perverse then that the General Medical Council (GMC), which is responsible for medical regulation, should regard it as necessary that all doctors with a licence demonstrate on a regular basis that they are competent and fit to practise. The process, known as revalidation, does however have sound logic behind it.

Perhaps the most obvious justification for requiring doctors to show they are up to scratch is that this is what patients expect. None of us would wish our family to be treated by a doctor who was anything other than competent. As the new health secretary put it: “Revalidation is something that the public expect their doctors to undertake and, if implemented sensitively and effectively, is something that will support all doctors in their innate professional desire to improve their practice still further.” (3)

In reality, most patients probably believe that happens already. Many would be surprised to learn that some doctors in the UK may not have had any kind of appraisal of their performance since they qualified.

The GMC’s register currently provides vital information about the doctor’s qualifications and any fitness-to-practise history. But it is primarily a historical record of educational attainment, not a contemporary record of their competence and fitness to practise. The individual who comes to service your gas boiler is subject to regular checks on their knowledge and skills, yet your doctor, who more than any professional is life-and death critical, can plough on with no such safeguards.

And while patients do trust their doctors, it is no longer as unquestioning as it once was. They are more likely to want to be involved in decision-making about their care, they are more aware of variations in standards and treatments, and they are less likely to accept that the doctor must be right.

Yet the trust they have in their doctor is an essential part of the healing process, and further assurance about the doctor’s competence should help to strengthen that confidence and the bond on which they rely. In a poll the GMC conducted in April, patients said they would welcome further assurance about their doctor’s competence.(4)

Revalidation should also bring benefits for doctors by giving them more opportunity to focus on their professional development, to reflect on their practice and identify areas for improvement. The other major change in the landscape has been the potency of medical practice. The power of doctors to do good has never been greater. But the corollary is that their capacity to do harm by omission or commission is also greater.

As the eminent paediatrician Sir Cyril Chantler pointed out: “Medicine used to be simple, ineffective and relatively safe. It is now complex, effective and potentially dangerous.” When a GP working 30 years ago missed a diagnosis of cancer, the repercussions were often not as great as they are today, because failing to act may have made very little difference to the outcome. Today, that omission could be critical.

A fair assessment
Given all this, a system of regular checks to ensure every doctor is keeping up-to-date, is competent and fit to practise seems like a proportionate response. It will create a system that supports doctors in continuing to develop their skills. What we are proposing is not something entirely new or different. As part of their national contracts, GPs and other doctors are supposed to be offered and take part in annual appraisals. They should work under good clinical governance arrangements that enable them to gather information about their performance and that of their teams.

The revalidation process will simply build on these arrangements. The annual appraisal will be the main way in which doctors will demonstrate that they are up-to-date and fit to practise and, for most of them, that will be nothing new. However, the quality of appraisal is inconsistent and this needs to change.

We also want to ensure that appraisal includes an evaluation of the doctor’s performance against the professional standards set by the GMC.

As part of this assessment, at least once every five years we believe it is important for patients and colleagues to be asked to give feedback on the doctor’s practice. Patient feedback is common now at practice level, but is less common for individual doctors.

Some doctors may be anxious about this but experience suggests that asking the views of patients and colleagues can be extremely positive. In Alberta, Canada, where all doctors are required to do this, 72% reported that they had changed their practice for the better as a result of patient and colleague feedback.(5)

Revalidation will not change the world and it is not designed to do so. Nor will it necessarily prevent another Dr Shipman. Mass murderers have a habit of finding their way around systems. But it should provide that extra assurance for patients, employers and doctors themselves, and encourage self-reflective practice.

Next steps
There is more testing to be done – we want to introduce a system that is relatively simple and straightforward and which recognises the current limits on what information is available for doctors to assess their performance.

We recognise that one of the challenges for practice managers will be to help generate the supporting information that is needed by doctors for their appraisals. We are working with the Academy of Medical Royal Colleges to make sure that the impact upon both doctors and practice managers is neither burdensome nor bureaucratic.

We will be producing a timetable for introducing revalidation over the next few years. The government has just taken the first step by approving the regulations that will lead to the appointment of Responsible Officers (ROs). These are the individuals who will oversee the revalidation process locally – soon every licensed doctor, whether in the NHS or private practice, will have an RO. The RO will usually be a senior, licensed doctor in the healthcare organisation where the doctor works.

For GPs, the RO is likely to be from the primary care organisation with which they are connected – clearly in England with new arrangements coming in, the detail will have to be worked out.

Based on the series of appraisals, the RO will be expected to make a recommendation to the GMC to renew the doctor’s licence, normally every five years. But this is not really a point-in-time decision – if there were any problems with an individual doctor they should have been picked up at a much earlier stage. In the vast majority of cases the recommendation will be a formality, based on what has gone on before.

This model for revalidation will be the same for all doctors, including salaried and part time GPs, as revalidation is based on what doctors do in their day-to-day practice.

However, we recognise that no two doctors’ practice is the same and that it is important to ensure that the system is flexible enough to meet the needs of doctors in a wide variety of circumstances, including salaried and part time GPs and GPs who take a career break.

We have just completed a major consultation on all this and it is clear that there is overwhelming support for the principle that doctors should renew their licences on the basis of evidence of their competence and fitness to practise. There is strong support too for a simpler model, which we are proposing. There was also a view that we could go further and in particular make sure that the supporting information was easy to access and that the appraisal itself should be as straightforward as possible. We are going to act on all of this.

Reinforcing trust
Revalidation is all about promoting high standards and encouraging and supporting self-reflective practice. For patients, it should offer further reassurance and reinforce the trust they have in the profession. For employers, which includes many doctors themselves, there is the prospect of further reassurance and the knowledge that they are providing the support and monitoring that key groups of professionals require. And for doctors themselves, it should ensure they are given the time and opportunity to reflect and develop their practice.

In one sense, all this builds on what is already happening. In another, it is a major advance and an ambitious one. We are confident revalidation can work well though, and we will all probably reflect in a few years’ time on what all the fuss was about.

1. Ipsos Mori Veracity Index 2009. Available from: http://www.ipsos-mori.
com/researchpublications/researcharchive/poll. aspx?oItemId=2478 2. B Starfield. Refocusing the system. New England Journal of Medicine 2008;359:2087-91.
3. Letter from Rt Hon Andrew Lansley, Secretary of State for Health, to the Chair of the GMC, Professor Sir Peter Rubin.
4. news/6853.asp 5. Violato C, Lockyer J, Fidler H. Multisource feedback: a method of assessing surgical practice. BMJ 2003;326:546.

Niall Dickson
Chief Executive
General Medical Council

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