Fitness to practise in the workplace: medical revalidation
Fitness to practise in the workplace: medical revalidation
Abstract and Keywords
The chapter provides a historical policy account of the introduction of medical revalidation in the UK and outlines the limiting structural and cultural factors at play and how these might well hinder its ability to identify poorly performing doctors.
Revalidation will be based on a local evaluation of doctors’ practice through appraisal, and its purpose is to affirm good practice. By doing so, it will assure patients and the public, employers, other healthcare providers, and other health professionals that licensed doctors are practising to the appropriate professional standards. It will also complement other systems that exist within organisations and at other levels for monitoring standards of care and recognising and responding to concerns about doctors’ practice.
Chapter One highlighted that two ideas have long defined the contractual nature of the relationship between the medical profession and the public under the legislative terms of the principle of self-regulation. First is the idea that, as they do an occupation which possesses specialist expertise and a strong ethical ‘service orientation’, (p.24) doctors can be left alone to manage their affairs, including the training, monitoring and disciplining of group members. Second is the related idea that, once qualified, a doctor can be left alone to practise until they retire. It also outlined how the shift towards risk-based regulation has led to these two interrelated ideas being challenged, with contemporary reforms to the GMC introducing greater transparency and accountability in the regulation of doctors and how their fitness to practise is ensured. Chapter Two focuses on one of these reforms – medical revalidation. It traces its historical development and implementation as well as critically examining recent research into its application. In doing so, the chapter highlights areas for critical consideration in relation to future policy and practice.
Challenging medicine: the rise of hospital management and the patient revolt
It is often argued that, although it was initially proposed in the 1970s, revalidation began in 2000, when the GMC published a consultation document: Revalidating Doctors: Ensuring Standards, Securing the Future (GMC 2000). This document came into being as a result of high-profile medical error and malpractice cases, such as the case of Harold Shipman, who murdered over two hundred of his patients. Yet it is important to note, if only for the sake of holistic clarity, that there was increasing state intervention in the field of medical regulation from the early 1970s onwards, particularly in relation to the operation of the NHS. As well as that, this was in no small part as a result of rapid advances in medical knowledge and technology and a concurrent need, first, to ensure that doctors kept up to date with these developments, and second, to minimise costs and increase service effectiveness.
On creation of the NHS in 1948, the state and the medical profession entered into an agreement that was mutually beneficial – the state obtained a suitability qualified expert workforce and the profession was granted a monopoly over the provision of medical services. The problem was that the concordat between medicine and the state was a product of its time. During the ‘consensus politics’ era after the (p.25) Second World War, the prevailing wisdom was that ‘experts know best’. However, by the 1970s, times had changed and the public was gradually becoming less and less willing to accept the authority of experts without question. Furthermore, when the NHS had been founded there was broad cross-party agreement that the welfare state was necessary and that steady economic growth would ensure the progressive decline of poverty and the improvement of public health. But by the late 1960s to early 1970s, growing public expenditure was a very real issue, with both main political parties instigating reviews of public services, particularly in relation to unemployment benefit, social welfare provision and the funding of the NHS.
Certainly, the 1979 Conservative administration, led by Mrs Margaret Thatcher, wished to reduce public expenditure. Thatcherism held a firm ideological commitment to ‘rolling back the state’ and introducing free market forces in both the public and private spheres. The 1979 Conservative administration’s neo-liberal commitment to the discipline of the market and the power of consumer choice meant it perceived all forms of professional self-regulation (and medical autonomy in the NHS in particular) as being opposed to choice and competition. This led to a situation where, although the state was publicly supporting a doctor’s right to clinical freedom, it was also calling for NHS reforms to contain costs and improve efficiency. It is against this background that in 1983 the NHS Management Inquiry gave its recommendations (Chamberlain 2012). Roy Griffiths, who was the Managing Director of Sainsbury’s supermarket chain, chaired this inquiry. The Griffiths Report, as it subsequently became known, led to the replacement of the traditional medically controlled hospital administrator with general managers (later known as ‘chief executives’) tasked with ensuring the efficient use of resources. Further NHS reforms initiated by Conservative administrations throughout the 1980s and early 1990s – such as Working for Patients (DOH 1989) and The Patient’s Charter (DOH 1991) – would lead to subsequent challenges to ‘doctor power’ under the guise of improving efficiency and empowering patients.
(p.26) By the beginning of the 1990s, NHS management had established control over hospital information systems and clinical budgets, which in themselves meant that managers possessed more control over doctors’ clinical activities than any ‘outsider’ ever had. The state’s reforms further expanded management’s influence, to include the allocation of merit awards, the appointment of hospital consultants and annual reviews of their job descriptions. Flynn noted that there had been a ‘tendency during the last decade … towards an erosion of professional dominance in the face of increased … managerial power’ (Flynn 1992: 50).
Increasing public concern with the principle of medical self-regulation was an interwoven theme of NHS reform and the growth of the viewpoint of patient as consumer. Certainly, public suspicion of collegiate control of doctors’ discipline came to the foreground in the early 1980s as the GMC’s commitment to protecting patients’ interests was increasingly questioned in the media. In 1983, Professor Ian Kennedy gave his Reith Lectures called ‘The Unmasking of Medicine’ (Kennedy 1983). Professor Kennedy criticised the GMC’s lack of openness and public accountability. He argued that its disciplinary procedures were not transparent and protected doctors instead of patients. He also called for measures to be introduced that would ensure the continued competence of doctors. Meanwhile, television programmes such as Dispatches, That’s Life, World in Action and File on Four, repeatedly highlighted cases of medical malpractice and blamed the GMC for failing to ensure that the doctors they investigated were trustworthy and competent (Chamberlain 2012).
The central issue of continuing medical education
By the early 1990s, NHS reforms and the patient revolt had led to the recognition that it simply could no longer be assumed that doctors would remain competent throughout their career without periodically updating their knowledge and skills. There can also be no doubt that the rapidly changing and expanding nature of medical knowledge meant that the elite institutions of the medical profession involved in medical education, such as the Royal Colleges and the GMC, came to (p.27) recognise by the end of the 1980s that they had to look at this issue, with a view to enhancing both its provision and governance.
This move by the GMC towards looking at doctors’ continued competence to practise was progressive. Nevertheless, throughout the 1980s and into the early 1990s it remained an essentially reactive institution, providing little effective leadership to the profession at large. Indeed, it left this up to the British Medical Association (BMA) – the main medical union in the UK – and the Royal Colleges, as it historically had done. It was heavily dependent on building consensus within the profession when deciding policy. It was representing doctors, not regulating them as it should have been, and consequently was perceived by many critical commentators to be failing as a regulatory body in its statutory duty to protect the general public (Gladstone 2000). This situation led the state to feel increasingly justified in developing strategies to monitor (and challenge and change) doctors’ clinical activities. For example, by the end of the 1980s, the state was arguing that it was time ‘to develop a comprehensive set of measures of the outcome of much of the work of … doctors’ (DOH 1989: 2). It had decided ‘to consider how the quality of medical care can best be improved by means of medical audit, and on the development of indicators of clinical outcome’ (DOH 1989: 2).
First developed in the US to track quality through analysing treatment outcomes, and endorsed by the BMA as a strategy to protect professional autonomy, medical audit seemed to be the perfect tool the state needed to place doctors under greater surveillance and control. The problem was, as a study published at the time indicated, ‘rank and file’ doctors may ‘regard overall financial limitations as being legitimate restrictions on their autonomy … [but do] … not see a legitimate role for peer review or quality assurance’ (Harrison and Schultz 1989: 203). The Royal Colleges were ever aware of the turning political tide and had joined the BMA in viewing medical audit and peer review as a legitimate way of improving doctor performance, while at the same time retaining medical autonomy. By the early 1990s, they were actively involved in promoting medical audit to the ‘rank and file’ of the profession (Hopkins 1990). The state needed such allies to make its (p.28) reforms work and consequently had to accede to the view of medical audit possessed by the Royals Colleges and BMA. Namely, if medical audit was going to be used more frequently and formally, then it should follow what Pollitt (1993) called ‘the medical model’. This meant that its operation remained firmly in the hands of doctors themselves, who would periodically advise management on outcomes as they saw fit.
However, this was not the end of the matter. By the end of the 1980s, technological developments like the computer had become more firmly linked to existing statistical and epidemiological techniques. This had led to a rapid increase in the ability to manage and analyse clinical outcomes and to establish ‘low risk’ guidelines and protocols for doctors to follow (Wennberg 1988). As the 1990s progressed, the state would move towards introducing multidisciplinary clinical audit and proactively sought to develop risk management strategies across professional groups (NHS Executive 1994). While the use of medical audit and clinical audit was on the rise, evidence-based medicine was also developing to address regional variations in key performance outcome areas, such as mortality rates following surgery and length of stay in hospital following admission (Berg 1997). Some were worried that this would lead to the establishment of ‘cook book medicine’. Evidence-based medicine not only promised to help the state to place medical work under greater surveillance, but it also promised to help patients make more informed choices with regard to treatment.
Finally, a mixture of political will and modern technology was supporting changes in the nature of the doctor–patient power relationship. As Wennberg noted at the time:
[It] is now possible to speak of a new set of disciplines which together constitute the evaluative clinical sciences. They offer the promise of a scientific programme that can greatly improve clinical decision-making by decreasing uncertainty about the probabilities and the value to patients of the outcomes of care. They also offer new ways of communicating information to physicians and patients that can greatly increase understanding (p.29) about the consequences of medical choices and thus help patients make decisions they truly want.
(Wennberg 1988: 34)
Introducing doctor appraisal
To summarise, by the mid-to-late 1990s, peer and managerial surveillance of individual doctor’s clinical activities had become the norm under the banner of promoting cost-efficiency, reducing risk and ensuring patient involvement in medical decision-making. The rapid development in clinical guidelines and protocols to govern the performance of doctors and other healthcare staff was seen by many interested observers to be a consequence of the rise of the idea of patient as consumer. For example, Allsop and Mulcahy (1996) held the increasingly common view among commentators that there was an expanding web of formal rules (guidelines and protocols) as well as informal rules (norms of behaviour held by an individual healthcare actor’s social networks) – operating both internally and externally to the medical profession itself – which were increasingly governing the day-to-day activities of individual doctors. This state of affairs, they felt, was a result of new relationships being forged between what they held to be the four main stakeholders involved in healthcare – government, citizens, managers and professionals.
The introduction of annual appraisal was held by many to be symbolic of this new state of affairs. The publication of The NHS Plan in 2000 highlighted that the purpose of annual appraisal was to support doctors to maintain ‘medical excellence’ (DOH 2000). The BMA negotiated with the state an agreement whereby annual appraisal (which was finally introduced nationally in 2003) would be a formative developmental educational exercise, undertaken with another doctor, and ordered in line with the principles of good clinical governance and the GMC’s Good Medical Practice (GMC 2013a). In other words, although in principle and in practice open to managerial input and review, annual appraisal would essentially be doctor controlled. Furthermore, it would not lead to extreme punitive action against the doctor in question, such as removal from the medical register. Every (p.30) year a doctor would maintain a portfolio of evidence of their activities and achievements. This would contain, for example, an overview of teaching and clinical duties, prescribing lists, clinical guidelines used and results of trust clinical governance reviews (including, for instance, a doctor’s surgical success:failure ratio), certificates of attendance to Royal College continuing professional development (CPD) courses and specialty conferences, feedback from colleagues, as well as patient feedback or complaints. A Royal College trained colleague would review this portfolio evidence, to identify developmental needs for the next year.
Medicine’s new professionalism and the beginnings of medical revalidation
Annual appraisal was built on the recognition that throughout the 1990s, the Royal Colleges had gradually introduced more and more formal arrangements for ensuring a doctor’s CPD (Chamberlain 2012). They worked with the BMA, NHS management and the state to establish mechanisms whereby sanctions were introduced for doctors who failed to gain CPD ‘points’ for completing college courses, such as exclusion from merit awards and the supervision of junior doctor training posts. However, these lacked the key sanction possessed solely by the GMC: removal from the medical register for non-completion of CPD. In summary, while medicine’s elites recognised that something needed to be done to ensure that doctors remained up to date and fit to practise in their chosen specialty, a tendency towards mutual protectionism could be said to still be in operation.
Not all the critical voices belonged to individuals outside the profession. There had always been reformer voices within the profession demanding that the GMC become more proactive and take up the challenge of underperforming doctors and ensuring that practitioners remained fit to practise. Particularly among general practitioners, but also from powerful ‘in house’ commentators such as Richard Smith, who was editor of the prestigious publication the British Medical Journal (Smith 1992). Medical reformers felt that the (p.31) GMC was too far removed from the needs of the profession. They wanted it to provide definitive leadership to its ‘rank and file’ members, by forging a more open and accountable relationship with the public. One of these reformers, who was heavily influenced by the sociologist and GMC lay member Margaret Stacey as well as the eminent medical sociologist Margot Jeffreys, was a general practitioner called Dr Donald Irvine (now Sir Donald Irvine). When elected in 1995, he would be the first leader of the GMC to be a general practitioner since its foundation 137 years previously. Irvine noted:
In 1995, I stood for election as President of the GMC, on a programme of reform both of professionalism in medicine and the GMC itself. There were members within the GMC, both medical and lay, who believed that such reform of the GMC had to be carried out swiftly. Otherwise public confidence in the medical profession, and in particular in the system of professional self-regulation, for which the GMC was primarily responsible, could not be sustained.
(Irvine 2003: 11)
The foundation stone of Irvine’s new professionalism was the recognition that self-regulation was a privilege not an inherent right. Hence, the number of lay members of the GMC was increased. He also advocated the establishment of clear standards that could be operationalised into outcomes for assessment. Between 1992 and 1995, the GMC sought and took highly progressive steps to assume legislative powers to assess doctors’ performance through the Medical (Professional Performance) Act 1995. This led to the publication in 1995 of the first edition of Good Medical Practice (GMC 2013a), which listed the principal attributes of good medical practice under seven headings:
1. Good clinical care;
2. Maintaining good medical practice;
3. Relationships with patients;
4. Teaching and training, appraising and assessing;
Good Medical Practice has been subject to change over the years and the current version (GMC 2013a) divides these attributes into four competency domains:
• Domain 1: Knowledge, skills and performance;
• Domain 2: Safety and quality;
• Domain 3: Communication, partnership and teamwork;
• Domain 4: Maintaining trust.
A further publication, Duties of a Doctor (GMC 1995), placed respect for patients and the need to maintain clinical competence at the centre of medical professionalism. The publication of these two documents was the first sign that the growing culture of standard setting and performance appraisal in the NHS was reaching medicine’s own professional institutions. A key part of Irvine’s reforms included the revision of the GMC’s new performance procedures, which involved developing appraisal instruments. These operationalised Good Medical Practice into key competency domains, whereby assessors could mark a doctor’s ‘on-the-job’ performance. The scheme’s appraisal instruments were subsequently published in the academic journal Medical Education (Southgate 2001). The scheme was linked to the final part of Irvine’s reform agenda, which was to push for the introduction of the periodic recertification of a doctor’s ‘fitness to practise’ to stay on the medical register (known as ‘medical revalidation’). But then the events of the respective Shipman and Bristol Royal Infirmary cases (outlined in Chapter One) happened, and in the words of Richard Smith (1998), it became a situation where everything ‘changed, changed utterly’.
Bristol made the GMC realise its plans for medical revalidation needed to go ahead at pace. The consultation process started in 1998 with various stakeholders, such as the BMA and patient support groups, attending a GMC conference on the topic (Chamberlain 2012). The process was heated with debate raging over whether revalidation was needed, and if so, what form it should take. Members of the public wanted revalidation and voiced the need for it. Conversely, there were ‘rank and file’ members of the profession and members of its elite institutions, which under no circumstances wanted a periodic exam to form the basis for revalidation. The BMA’s Hospital Consultants and Specialists Committee (HCSC) argued against revalidation because of the time and expense it would involve. The Royal Colleges and GMC were for it. In 1999 it was decided that ‘to maintain their registration, all doctors must be able to demonstrate regularly that they continue to be fit to practise in their chosen specialty’ (GMC 1999: 1).
What had to be decided would be the form that revalidation would take. A further period of consultation was entered into to decide this. The GMC wanted regional centers to undertake revalidation locally. However, this idea was dismissed by the BMA as impractical. The GMC knew it had to move quickly. As part of its reforms of the NHS and because of the problems highlighted by Bristol the Department of Health had published Supporting Doctors, Protecting Patients (DOH 1999). This proposed that all doctors undergo an Annual Appraisal as part of their NHS contract. As already noted, the publication the next year of the NHS Plan formally introduced appraisal (DOH 2000).
Although not originally intended to link with revalidation it was generally agreed by 2001 that the successful completion of five Annual Appraisals, after external review by two medical and one lay GMC assessors, would in itself be enough for the purposes of revalidation (Gentleman 2001). Though it clearly had merits, this proposed method of revalidation was ‘lightweight’ compared to the original intention of establishing regional revalidation ‘centres’ to undertake pass/fail tests of doctor’s competence. Yet it never got off the ground due to the (p.34) case of serial killer, Harold Shipman, a general practitioner in Hyde, Greater Manchester.
Dr Shipman was a popular doctor, well respected by his patients. Between 1995 and 1998, he murdered 15 elderly patients with lethal doses of diamorphine. Subsequently, it was discovered that between 1974 and 1998 he had murdered 215 patients (all elderly) and doubts remained about a further 45 (Smith 2005). The police informed the GMC they were investigating Dr Shipman in 1998 and he was subsequently convicted of murder in 2000. It was only after his conviction that he was stuck off the medical register.
Similar to the Bristol case, the Shipman case caused a public outcry. It was discovered that Shipman had previously been before the GMC’s disciplinary committee in 1976 for dishonestly obtaining drugs and forging NHS prescriptions. He had been dealt with leniently and essentially ‘let off’ with a warning.
This signaled the start of another period of intense criticism for the GMC. The state ordered a public inquiry into the Shipman case, chaired by Dame Janet Smith. As the Secretary of State, Mr Milburn, made it clear at the time: ‘The GMC … must be truly accountable and it must be guided at all times by the welfare and safety of patients. We owe it to the relatives of Shipman’s victims to prevent a repetition of what happened in Hyde’ (quoted in Gladstone 2000: 10).
During the Shipman Inquiry, the GMC made changes to its membership. A new GMC was launched in 2003, just after Irvine’s reign as president ended. The GMC’s executive membership was reduced, 40% of whom were lay members. In February 2003, Professor Sir Graeme Catto took over from Irvine as president of the GMC. Like Irvine before him, Catto continued to maintain its professionally led medical regulation, based on an open and accountable partnership with patients, which best protects the public interest (Catto 2006 2007). The GMC continued with its plans for revalidation during this time. Indeed Catto wrote to doctors in 2003 telling them to ‘get ready’ for revalidation (Chamberlain 2012). However, the GMC’s revalidation plans were to all intents and purposes deliberately slowed down until Dame Janet Smith published her full report in January 2005.
(p.35) In her report, Smith (2005) highlighted key lessons that needed to be taken on board by the NHS and the medical profession in relation to topics such as the checking of death certificates, scrutiny of single-handed GP practices and the monitoring of death rates and medical records. About the proposal that five Annual Appraisals would equal revalidation, Smith (2005: 1048) felt that this would not have identified Shipman and did ‘not offer the public protection from underperforming doctors’. She highlighted that the formative nature of Annual Appraisal meant that it was unsuitable for use as a summative pass/fail examination tool, as required by Revalidation. She felt that instead of taking a strong stance, as required of it as a regulatory body, the GMC had essentially caved in to pressure from within the profession to abandon its original idea of independent regional revalidation ‘centres’.
That is, the possibility of ‘summative pass/fail testing had been dropped in favour of a ‘light-touch’ approach to revalidation that essentially involved ‘rubber stamping’ existing Annual Appraisals. Indeed, Smith (2005: 1174) said that the GMC’s original ‘proposals were unpopular with a powerful section of the profession. So the GMC retreated from its earlier vision and devised a system that it calls revalidation but which does not involve any evaluation of a doctor’s fitness to practise’. Concerned about the GMC’s move away from adopting a more rigorous approach to revalidation, she actively criticised Catto’s comparison of it to an MOT on a BBC radio programme. She said:
He [Sir Catto] expressed pride in the fact that no other country in the world had a system of time-limited licence dependent upon doctors demonstrating they are up to date and fit to practise. To call revalidation an MOT for doctors is a catchword. It is easy for the listener to remember. I think that many people who heard that programme would have taken away the impression that revalidation is a test for doctors, just like the MOT. That is not a true impression.
(Smith 2005: 1086)
About the working culture of the GMC, Smith (2005) echoed the voices of many observers in feeling that although the GMC had changed it had not changed enough:
I would like to believe that the GMCs working culture would continue to change in the right direction by virtue of its own momentum. However, I do not feel confident it will do so. I am sure they are many people within the GMC, both members and staff, who want to see the regulation of the medical profession based upon the principles of ‘patient centred’ medicine and public protection. The problem seems to be that, when specific issues arise, opposing views are taken, and as in the past, the balance sometimes tips in the interests of doctors.
(Smith 2005: 1176)
Furthermore, Smith (2005) discussed how the elected nature of medical members on the GMC made the central issue of protecting the interests of the public difficult for members:
it seems … that one of the fundamental problems facing the GMC is the perception, shared by many doctors, that it is supposed to be ‘representing’ them. It is not, it is regulating them. … In fact the medical profession has a very effective representative body in the BMA, it does not need – and should not have – two.
Her recommendation was that the makeup of the GMC be changed so elected members were replaced with nominated members, selected by the Privy Council via the Public Appointees Committee after a period of ‘open competition’ on the basis of their ability to serve the public interest. Smith (2005: 1174) concluded that she was ‘driven to the conclusion that, for the majority of GMC members, the old culture of protecting the interests of doctors lingers on’.
What became clear after the publication of the Shipman Report was that the criticisms regarding the GMC’s working culture and proposals for revalidation meant the state had to step in and undertake a full review of medical regulation. The then Health Secretary, John Reid, commissioned the then Chief Medical Officer, Sir Liam Donaldson, to undertake the review. His subsequent report was published in July 2006 (Donaldson 2006) and informed the content of the Health and Social Care Act 2008. The Act introduced several key reforms in medical regulation. Non-medical lay members now have to make up half of the GMC membership. Furthermore an independent system overseen by the Public Appointments Commission was introduced to elect GMC members, while the grounds on which fitness to practise panels (FPPs) operate was also changed. As already noted in Chapter One, such cases whereby a practitioner’s fitness to practise is called into question have traditionally been judged on the criminal standard: beyond all reasonable doubt – a situation that frequently led commentators to argue that the GMC’s disciplinary procedures first and foremost protected doctors. But the 2008 Act required that such cases now be judged on the civil standard of proof: on the balance of probability. It was argued that this will enable underperforming doctors to be more easily stopped from practising medicine. To enhance impartiality and the independence of the case hearing process, the 2008 Act also required cases to be heard by an independent adjudicator, not by members of the GMC. This latter point was particularly contentious and what actually happened next will be discussed at length in Chapter Three, which explores FPP reforms in detail.
Chapter One noted how the 2008 Act is symbolic of the emergence of a risk-based approach to professional regulation in the UK, at the centre of which lies the recognition of the need to utilise risk templates and multiple data-points to identify, manage and minimise risk threats (Lloyd-Bostock and Hutter 2008). In the context of medical revalidation, the 2008 Act was built on the recognition of the need to use best-evidenced clinical governance frameworks and outcomes (p.38) to measure and judge medical performance, as well as of the need for greater managerial, patient and interprofessional involvement in revalidation. After a period of consultation with government, the NHS, the BMA, the Royal Colleges, and the general public, revalidation was implemented nationally by the GMC in a staged format between 2012 and 2016. In its post-Donaldson finalised guise, revalidation is essentially made up of two elements – relicensing and recertification – which incorporate NHS appraisal within them.
Relicensing seeks to make current NHS appraisal arrangements more rigorous, with greater direct testing of a doctor’s competence with regard to key day-to-day clinical tasks. To stay on the medical register, all doctors will now have to successfully pass the relicensing requirement that they have successfully completed five NHS annual performance appraisals. Specialist recertification will also occur every five years. It will involve a thorough ‘hands on’ assessment of a doctor, organised and quality assured by a doctor’s peers and associated professional associations. Although the resulting finalised process and language used to describe it differ somewhat from Donaldson’s, it is nevertheless the case that the 2008 Act signified on paper that there has been a shift towards a more robust and rigorous system than was envisaged by medical elites at the beginning of the new millennium.
Responsible officers: implementing revalidation at a local level
The Health and Social Care Act 2008 introduced what was called a ‘GMC affiliate’, who was later known as a ‘responsible officer’ (RO). This person operates at a local NHS level, to coordinate the revalidation of practitioners. The exact arrangements for this process were defined by the Medical Profession (Responsible Officers) Regulations 2010 and 2013, which also set out the requirements for professional oversight of the process. From April 2013 a new body, NHS England, was given responsibility for the RO role that previously was the responsibility of strategic health authorities and primary care trusts. As a result, ROs for doctors in England now have a prescribed connection to NHS England, while the remaining ROs are connected to either (p.39) Health Education England, NHS Education for Scotland, the Health Departments in England and Scotland or the Welsh Government (DOH 2014).
ROs work within what are referred to as ‘designated bodies’ (that is, employing organisations), which have overall responsibility for revalidation. An RO must, at the time of appointment, must have been fully registered with the GMC for the previous five years. Hence, given its recent implementation, they must have held a licence to practise from the time when medical revalidation was formally introduced in 2012. They must also complete a GMC and Royal College approved introductory training programme for ROs within 12 months of appointment. Medical practitioners in the UK only have one designated body and one RO, irrespective of how many organisations they are contractually employed to. The specific responsibilities of an RO are (BMA 2015):
• ensuring that effective systems to support revalidation are in place (including appraisal and clinical governance systems);
• evaluating the fitness to practise of all doctors with whom the designated body has a prescribed connection and making a recommendation to the GMC regarding revalidation;
• identifying and investigating concerns about doctors’ conduct or performance;
• ensuring that support and remediation are provided where a doctor’s practice falls below the required standard;
• overseeing doctors whose practice is supervised or limited under conditions imposed by the GMC.
ROs make recommendations to the GMC about a doctor’s fitness to practise. Their recommendation will be based on the outcome of annual appraisals over a five-year period, combined with information drawn from the organisational clinical governance systems (for example, surgical operation rates). To this end, practitioners are required to maintain a personal portfolio of their fitness to practise, which contains in it evidence that they have met the competency (p.40) domain requirements set out in The Good Medical Practice Framework for Appraisal and Revalidation (GMC 2014; see Appendix One). This lists required evidence within the four domains of Good Medical Practice (GMC 2013a):
1. Knowledge, skills and performance;
2. Safety and quality;
3. Communication, partnership and teamwork;
4. Maintaining trust.
In its ‘end-user’ document Revalidation: What You Need to Do (GMC 2013b), the GMC outlines how each practitioner must demonstrate that they have collected and reflected on the following:
• continuing professional development;
• quality improvement activity;
• significant events;
• feedback from colleagues;
• feedback from patients;
• review of complaints and compliments.
Based on the evidence presented, ROs can make one of the following three recommendations to the GMC concerning a doctor’s revalidation (BMA 2015):
• A positive recommendation: this means that the RO believes that the doctor is up to date, fit to practise and should be revalidated In order to have a positive recommendation, it is mandatory that the doctor has engaged with revalidation processes.
• Request a deferral: this could be because the RO needs more information to make a recommendation about the doctor. This might happen if the doctor has taken a break from their practice (for example, maternity or sick leave).
• Non-engagement: this is when the RO believes that a doctor has failed to participate in the local systems or processes (such (p.41) as appraisal) that support revalidation. The GMC defines non-engagement as: ‘A doctor is not engaging in revalidation where, in the absence of reasonable circumstances, they: i) do not participate in the local processes and systems that support revalidation on an ongoing basis and or ii) do not participate in the formal revalidation process.’ This recommendation is taken very seriously and can result in the removal of the licence to practise. Engagement in the process by the individual is absolutely crucial in order to avoid this recommendation.
Based on the recommendation it receives from the RO, the GMC will then make the final decision on whether the doctor can retain their licence to practise. It is undoubtedly the case that on paper, revalidation involves a thorough assessment of a doctor’s fitness to practise using a mixture of appraisals, patient feedback and CPD activities. It is not too difficult to conclude, therefore, that revalidation transforms the GMC from an incident-led, reactive regulatory institution to a proactive overseer of a rolling programme of performance review.
Non-medical input is essential to the revalidation process. Peer-based standard setting and performance assessment – via medical colleagues (in this case, the RO) and professional associations and regulatory bodies using established occupational indicators of good professional practice (in this case, the GMC) – is still acknowledged, by both medical and non-medical observers alike, as the essential mechanism by which an individual doctor’s clinical competence can be legitimately assessed and underperformance addressed (Irvine 2003).
As a result, revalidation can be said to have come about because contemporary challenges to professional autonomy have brought to the foreground the fact that the principle of medical self-regulation was first institutionalised in the form of the GMC by the Medical Act 1858, as it provided a workable solution to the complex problem of ‘how to [both] nurture and control occupations with complex, esoteric knowledge and skill … which provide us with critical personal services’ (Freidson 2001: 220). The changes to the GMC and medical regulation over the last four decades, traced in this and the previous (p.42) chapter, reinforce that there has been a move towards risk-based regulatory frameworks to better protect the public interest, while at the same time seeking a better balance between ‘nurture’ and ‘control’ (Chamberlain 2012).
However, revalidation is undoubtedly a highly contested product and process, the outcomes of which possess implications for the principle of medical autonomy and practitioners and their professional association’s traditional control over judgements pertaining to the quality of their practices. This may explain why practitioners and their professional associations resisted its implementation for so long. Initial pilot research into its implementation has revealed that doctors frequently subvert its aims and objectives, processes and outcomes, often claiming as they do so that revalidation seeks to codify and routinise medical decision-making and practitioner clinical performance, when the real world of medical practice is inherently situational, contingent and messy. The rest of this chapter examines this point, in order to more fully establish the impact of the implementation of revalidation on the ‘rank and file’ members of the medical profession.
Medical revalidation: a Foucauldian interpretation
The fact that revalidation is being introduced in a staged process between 2012 and 2016 means that currently there is minimal information regarding its practical impact on the day-to-day practices of doctors. What does exist will undoubtedly suffer from being somewhat episodic, as not all doctors will have undergone the process – and even those who have done so will only have completed a maximum of one revalidation round. Arguably it will be over a decade before its operation and impact can be fully evaluated. However, some initial investigatory research has been conducted and additionally there is pertinent relevant research relating to the implementation of portfolio-based forms of performance appraisal within the medical profession – annual appraisal.
Paper-based and electronic portfolios are now used throughout medical school and junior doctor training, in later specialist training, (p.43) as well as to support the implementation of annual appraisal and revalidation of doctors as part of their NHS contract (Snadden and Thomas 1998, Wilkinson et al 2002, Chamberlain 2012). Many things are called portfolios, including logbooks of activity, observational check lists, records of critical incidents and collections of personal reflective narratives (Redman 1995). In line with vocational and professional education in general, a portfolio is typically defined within medicine as a ‘dossier of evidence collected over time that demonstrate[s] a doctor’s education and practice achievements’ (Wilkinson et al 2002: 371). In the context of revalidation, the GMC (2012) currently lists six types of supporting information, which should be present within a doctor’s portfolio:
1. continuing professional development (CPD);
2. quality improvement activity;
3. significant events analysis;
4. feedback from colleagues;
5. feedback from patients;
6. complaints and compliments.
The introduction of portfolio-based performance appraisal within medicine presents a significant development in the governance of doctors and the regulation of medical expertise. Indeed, in Chapter One it was argued that it was synergistic with the development of a risk-based approach to professional regulation and forms of neoliberal governance more generally (Lloyd-Bostock and Hutter 2008). It certainly can be argued that the introduction of portfolio-based performance appraisal for doctors is just one more example of the internationally recognised trend that, like many other professionals, doctors are becoming subject to – a seemingly ever increasing number of formal calculative regimes, which seek to performance manage their work practices in order to better economise and risk manage occupational tasks (Coburn and Willis 2000, Checkland et al 2007, McDonald et al 2008).
(p.44) Power (2007) emphasises the enormous impact of the contemporary trend in all spheres of Western societies towards audit in all its guises – with its economic concern with transparent accountability and standardisation – particularly for judging the activities of experts in order to better minimise risk. This is bound up with the re-emergence of liberalism as an economic and political philosophy (Rose 2000). Against this background, Townley (1993a, 1993b), Newton and Findley (1996) and Chamberlain (2009) all suggest that performance appraisal (portfolio-based or otherwise) is a distinctive form of neoliberal governmentality. That is, it is a system of control which utilises surveillance and rationality to turn the object of its gaze into a calculable and administrable subject that is open to control and risk management (Foucault 1991).
This Foucauldian interpretation of appraisal holds that it acts as an ‘information panopticon’, which operates through the use of two key panoptic disciplinary mechanisms: normalisation and hierarchy (Zuboff 1988). Normalisation, or normalising judgements, involves comparing, differentiating and homogenising in relation to assumed norms or standards of what is proper, reasonable, desirable and efficient. Appraisal possesses normalising judgements due to its focus on establishing behavioural norms in the form of ‘on the job’ task standards from which to judge individual performance. Hierarchy involves a process of judging, ranking and rating an individual without in turn being judged. This reinforces that no matter how much its advocates hold that it is user-centred and developmental, performance appraisal is nevertheless a punitive disciplinary tool, concerned with identifying areas of underperformance and correcting them (Fletcher 1997).
Yet appraisal is not a straightforward punitive disciplinary tool, concerned with identifying and correcting poor performance ‘from the outside’. Indeed, the Foucauldian interpretation of appraisal holds that it may seek to promote and reward certain behaviours and rectify others, but it recognises that it nevertheless – more often than not – does so by operating using a more subtle and invasive form of soft power (Rose 2000). Certainly, within medicine appraisal seeks to work on the subjectivity of appraisees ‘at a distance’, through requiring that (p.45) they engage in self-surveillance of their clinical performance as if it were a normal and everyday practice as a result of the availability of best-evidenced clinical guidelines and protocols (Sheaff et al 2003). For example, for annual NHS appraisal, consultants and general practitioners must keep a portfolio of their CPD needs and fitness to practise, which contains personalised information relating to prescribing patterns, the outcomes of case note analysis, the results of clinical audit, as well as patient complaint case outcomes and surgical operation success rates. They must use this information to help identify and publicly record areas of developmental need in relation to best-practice performance frameworks, guidelines and protocols.
Furthermore, they must subsequently record activities and achievements that demonstrate they are proactively meeting their ‘self-identified’ learning goals, which will subsequently be subject to formal peer review, to prove that they are willing as a matter of good professionalism to admit to areas of poor performance and to learn from them (Irvine 2003). It will perhaps come as no great surprise, then, to learn that individuals who advocate portfolio-based performance appraisal within medicine argue that it simply formalises what should already be a normal and natural part of a doctor’s day-to-day self-monitoring of their clinical performance (see, for example, Snadden and Thomas 1998, Wilkinson et al 2002).
Appraising performance appraisal in medicine
It is certainly the case that research into the growing use of portfolio-based appraisal within medicine provides an invaluable opportunity to examine the positive impact of contemporary reforms in the performance management of medical work. For example, research by West et al (2002), Overeem (2007) Finlay and McLaren (2009) and Brennan et al (2014), among others, reinforces that although it is not possible to objectively establish a direct causal link between appraisal processes and outcomes with improvements (or otherwise) in patient care, there is nevertheless evidence to suggest that medical practitioners have been known to self-report satisfaction with appraisal processes, as (p.46) well as to claim that it helps them to make positive improvements in their professional practice and their self-management of the continuing fitness to practise.
However, contrasting research does exist. With Redman et al (2000), Smith (2005), Checkland et al (2007) and Chamberlain (2009) have all noted that appraisal processes possess a tendency to operate superficially within medicine. They argue that doctors tend to engage in creative game playing towards appraisals procedural requirements and performance targets, and furthermore, when questioned on this, they tend to rhetorically deploy their specialist esoteric expertise to both normalise and justify their actions (Freidson 2001). Townley (1999) acknowledges that professionals tend to use the personal tacit foundations of their expertise, which is grounded in experiential learning from day-to-day practical professional experience of dealing with patients ‘on the shop floor’, to ‘trump’ the rationality of appraisal’s information panopticon, as it seeks to construct them as a knowable, calculable and administrable subject.
A key consequence of this is that professional practitioners are able to appear to have met the formal reporting requirements of transparent performance management and quality assurance processes, but have in fact continued to operate in much the same way they always have done. The added benefit is that their superficial, ritualised compliance with this new governing regime has created a more firmly bounded work space within which to operate without outside interference. For example, Chamberlain (2009) found that the practitioners he interviewed fell into one of three camps – ‘non-compliers’, ‘minimalists’ and ‘enthusiasts’:
• Non-compliers did not engage with the process. These individuals may be passionate about their medical specialty and the supervision of trainees, but they nevertheless said that they ignored the portfolio appraisal process evidence when assessing them. Instead, they used traditional teaching and assessment methods (for example ward rounds) and devised their own personalised tests, to assure (p.47) themselves of a practitioner’s competence. The portfolio paperwork was by and large ‘fudged’ afterwards.
• Similarly, minimalists would fudge the paperwork, but to lesser a degree, as they did utilise some elements of the portfolio appraisal process and evidence, when it came to assessing competence.
• Finally, the enthusiasts, as might be expected, are fully engaged with the appraisal process. However, most importantly, although they rhetorically enthused about the process and used portfolio documents to inform and guide them, like non-compliers and minimalists, enthusiasts reserved the right to exercise their discretion to assess others (in this case, medical students, junior doctors and more senior house officers) as and how they thought fit.
As a result of these findings, Chamberlain (2009) developed the concept of paperwork compliance to encapsulate the operation of portfolio-based performance appraisal within medicine. Paperwork compliance exists when the paperwork completion requirements of appraisal are fulfilled, with relevant sections of a portfolio completed and an appraisee ‘signed off’ by their appraiser as either having met minimum performance criteria or not. However, though the paperwork has been completed, the technical aspects of the appraisal procedures have not been adhered to by the appraiser; that is beyond a highly superficial tick-box, paper-filling level. Chamberlain (2010) notes that:
Stated in formal terms, paperwork compliance gives the impression that an appraisee has been appraised using collegially agreed minimum performance standards. These have been predefined with regards to occupational specific knowledge, skills and attitudinal competency domains. Yet, in reality these have played a superficial role in helping an appraiser form an opinion in regards to: a) Which tasks an appraisee should undertake and be assessed in to be defined as ‘competent’ at a level appropriate to their career level (that is, compare a final year medical student and a senior house officer); and b) The level of proficiency possessed by an appraisee about these tasks.
(Chamberlain 2010: 111)
The following comments from Dr Lime (Physician) encapsulate ‘paperwork compliance’ succinctly: “Its like this, you fill in the forms in a workmanlike ‘dot[t]ing the I’s and crossing the T’s’, fashion. But its all for the look of the thing. It doesn’t mean that you actually have done what you are meant to have done, or for that matter believe in what you have written past a very superficial level. You see, you tend to ‘bend’ the paperwork because you have checked out that everything is OK your own way. So you are just complying with the bureaucratic need to get the paperwork done, and that’s all really’.
(Chamberlain 2010: 111)
Revalidation: a ritual of employment?
A Foucauldian interpretation of appraisal holds that it acts as an information panopticon, constantly surveying, gathering up and processing appraisees as it seeks to make them ever more calculable and efficient. However, the concept of paperwork compliance draws attention to the fact, well recognised in the performance appraisal literature, that ‘if appraisals fail to meet their manifest purpose, they succeed rather as rituals of employment’ (Pym 1973: 233). In the sense that appraisal may appear to been carried out occurred on paper, but in reality it has been nothing but an elaborate tick-box exercise. Consequently, it seems to have failed to achieve its manifest panoptic purpose of ensuring worker productivity, organisational efficiency and institutional transparency and accountability.
Research conducted into their perceptions and experience of revalidation has certainly highlighted that many practitioners hold similar views of it as they do of portfolio-based forms of appraisal within medicine more generally. For example, research commissioned by the DOH’s own Revalidation Support Team identified a hierarchy (p.49) in engagement with appraisal and revalidation, with least support from ‘rank and file’ doctors, more support from trained appraisers and most support from ROs (NHS Revalidation Support Team 2014). A similar disconnection was seen in the perceived value of patient involvement in appraisal.
As revalidation focuses on doctors meeting minimal standards of practice and ongoing education, there is a real need to establish its impact on the culture and behaviours of doctors, including their willingness to identify and seek action on adverse aspects of their own and colleagues’ performance and conduct. In this regard, research has highlighted that 65% of appraisers said that they had been able to identify and agree specific circumstances in which doctors they appraised could deliver better care or treatment to patients, but that only 24% of doctors reported that they had changed aspects of their clinical practice or behaviour as a result of their last appraisal (Brennan et al 2014).
Additionally, independent research by the National Centre for Social Research (2014: 2) found that the majority of doctors thought revalidation would be of some value to the profession (59%); however, fewer doctors overall thought revalidation was of value to them personally (51%), or was of value for patient safety (51%). Similarly, independent research by the King’s Fund (2014: 1) found that: ‘doctors were receiving mixed messages about the purpose of revalidation. All could identify potential benefits, particularly the developmental opportunities. However, there was some cynicism about the overarching purpose of assuring the public of doctors’ fitness to practise.’
It is important to note that instances of end-user cynicism, disengagement and manipulation of portfolio-based performance appraisal processes within medicine – be it in relation to junior doctor appraisal, house officer appraisal, annual appraisal for consultants and GPs, or medical revalidation – could be red herrings when it comes to examining their impact on professional practice and organisational working culture. This is not least because these responses are likely to occur in any governmental system of professional performance (p.50) surveillance and quality assurance (Rose 2000). Certainly, the ‘frontstage’ and ‘backstage’ activity and game-playing associated with the concept of paperwork compliance is to be expected, given the esoteric practice-based nature of modern medical expertise and the resulting occupational culture, which reinforces the practical value of nurturing professional autonomy and discretion (Freidson 2001). Furthermore, it certainly is the case that, given time, procedural and outcome mechanisms can be put into place to capture and address end-user cynicism, disengagement and manipulation, with a view to enhancing quality assurance processes and mechanisms (Smither and London 2009). Could the focus on the initial individual response to revalidation to evaluate the success or otherwise of its implementation perhaps therefore be more than a little problematic, particularly given that we are still in the early stages of its operation?
Conclusion: appraising the system
Foucault (1991) himself argued convincingly that the performance appraisal systems and processes bound up with the emergence of modern neoliberal forms of governmentality can never fully capture the inherent contingency and messiness of individual human behaviour and everyday social interaction within complex social systems. It is not the accuracy of the systems in capturing the object of their surveillance, but rather their legitimacy as governing tools in the eyes of social and political elites and the masses, which Foucault noted enabled them to continue to operate as mechanisms for social organisation and control. After all, no form of regulation and governance is perfect, and furthermore, it is often regarded as being the fault of the individual and their attitudes and behaviour, rather than the imperfect system, when things go awry – particularly in Western societies, with their inherent focus on individual choice and liberty (Rose 2000).
Given this, what is arguably most important, at least in terms of the issue of ensuring that revalidation enhances the protection of the public from underperforming doctors, is not the presence of end-user cynicism, disengagement or manipulation in relation to revalidation (p.51) and its current gradual implementation nationwide in the UK; rather, it is the fact that currently there is little objective evidence that practitioner-based performance appraisal systems within healthcare – of which revalidation is an example – directly result in improvements in the quality of patient treatment and care (Mugweni et al 2011, Brennan 2014). Therefore, although a research and evaluation focus on individual and localised groups of practitioners is somewhat to be expected (and necessary), arguably the main critical-evaluative focus should remain on ‘the system’, particularly at this early developmental stage. After all, the organisational functioning and performance of the revalidation system as a quality assurance tool is, in these risk-aware times, one of medicine’s ‘“visible markers” of trust [which as] … tools of bureaucratic regulation fulfil [a] function as signifiers of quality’ (Kuhlmann 2006: 617).
Hence, it is perhaps not so important to ask: ‘What are doctors’ experiences and opinions of revalidation?’, but rather the following key questions:
• How many underperforming doctors is revalidation identifying?
• How does its processes and outcomes link to NHS systems of good clinical governance as well as professional mechanisms of practitioner mentoring, training and professional development?
• How does its processes and outcomes link to key regulatory processes such as the GMC’s FPP process?
Finding these answers will take substantial time and resource. Indeed, it is arguable that it will take at least a decade – two revalidation cycles – before we have the necessary initial longitudinal system process and outcome data, from which to form an accurate judgement on system success in protecting the public from harm.
Medical revalidation is undoubtedly a complex intervention that is taking place within an even more complex system of healthcare delivery. But at an organisational and institutional systemic level there are two aspects of revalidation that need to be examined:
(p.52) • At the local level, there is the provision of CPD opportunities, resources and training for appraisees as well as the selection, training and ongoing quality assurance of the RO, alongside the nature of the local clinical governance and professional practice quality assurance systems in place to respond to appraisal and revalidation outcomes.
• At the national training and regulatory level, the GMC and the professional associations – for example the Royal Colleges – are involved in implementing, supporting and overseeing revalidation processes and outcomes.
When revalidation was implemented nationally in 2012, there were 252,553 doctors on the medical register (GMC 2013c). Latest 2015 figures show that 103,070 doctors have been subject to revalidation: of these, 84,032 have been revalidated, 18,911 were deferred, and there were 127 non-engagements, while a further 1,081 have voluntarily relinquished their licence to practise (GMC 2015). Of the 127 approved non-engagement recommendations, the following outcomes apply: licence withdrawn 28; no longer licensed / registered 37; in the process of licence withdrawal (includes appeals within FPP process) 48; and continues to hold a licence 14.
In relation to deferrals, ROs can recommend a deferral for two reasons: insufficient evidence on which to base a recommendation; or an ongoing local process that needs to be concluded before a recommendation is made. The former can be for a range of reasons, for example a doctor is still completing training in order to enter the medical register, or is taking (or has recently taken) a career break, while the latter typically involves a doctor being subject to local disciplinary or national FPP processes. Indeed, key emergent statistical trends in relation to deferrals include that trainees are more likely to defer while they wait for their training period to finish and acquire their certification of completion of training and for there to be a substantially higher deferral rate of women in their thirties taking career breaks to raise families than for other age groups and genders. There is also some emerging anecdotal evidence that overseas and minority ethnic doctors are more likely to defer or voluntarily (p.53) relinquish their licences. Furthermore, a recent survey for the GMC, geared to gauging perceptions of fairness for minority ethnic doctors and non-UK graduates, found that only half of respondents thought that revalidation would have any value for patient safety (National Centre for Social Research 2014).
Currently, the GMC has appointed a UK-wide collaboration of researchers entitled UMbRELLA (Uk Medical Revalidation Evaluation coLLAboration), to carry out an independent long-term evaluation of revalidation. It will publish its final report in 2018 – two years after revalidation has been fully implemented nationally and six years after the first doctor was revalidated in 2012. As already noted, it is arguable that the developing dataset and trends therein need to be critically investigated in such a way that we obtain a fully ‘joined-up’ evaluation of the impact of revalidation. In this age of big data it is no longer acceptable for risk-based governance systems to operate in relative practical and statistical isolation. This is particularly the case when the goal is to identify and address poor medical practice within the NHS in order to minimise the potential for harm to the public and improve patient treatment and care. As well as that, it is widely perceived within the medical profession that Harold Shipman would have been revalidated with ease (Dalrymple 2011). If we are to judge the long-term impact of current reforms in the performance management and quality assurance of medical work, we need to make sure that we have the right analytical tools and data sources at our disposal. It remains to be seen whether current provision will prove to be adequate in this regard.
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