Sunday, 30 October 2011

25 Reasons to Abolish Revalidation for the Health Committee

25 Reasons to Abolish Revalidation for the Health Committee on Revalidation of Doctors (submitted)


Revalidation has its origins in the early days of New Labour. Its potential to raise standards is very limited. It will incur substantial direct and even more substantial indirect costs. It is deeply unpopular with doctors both in the NHS and independent sector. As it stands, it will NOT identify an incompetent GP; it is meaningless.

The RCGP has been tasked with leading on revalidation pilots, collecting evidence and are creating their brand of revalidation ‘e-portfolio’ for GPs to use (free for members but charged for non-members). ‘E-portfolio is a CPD monitoring system under which GPs with sufficient ‘points’ and clinical experience can ‘qualify for revalidation. This process will be supervised by a cadre of newly hired ‘revalidation officers’ .This system was an alternative to an exam-based assessment, the latter of which, ie an 'exam' was requested by Dame Janet Smith in the Shipman inquiry.

The SoS has stated he is awaiting results of the pilots before making any decision, and of course unless we know precisely how many of the 230,000 GMC-registered doctors are expected to fail, we cannot accurately work out a cost-benefit analysis. We await to read an official cost-benefit.

The current plans for revalidation give rise to a number of specific issues:

1. Who polices the guardians (ROs)? Who vets the 1000 responsible officers (ROs)? Is it enough to just make medical directors automatic ROs? Where is the due diligence? An RO has already been brought to the attention of MPs.

2. Would you see a medical doctor who graduated medical school by passing coursework or by passing an exam? We are asking to revalidate 230,000 medical doctors based on paper coursework! This is a fundamental flaw with revalidation asking for paper evidence of competency rather than testing medical knowledge, safety and application through an exam as in the US who test 661,000 physicians.

3. Coursework is not an evidence-based test of competency. This is why we submit our students to A-level exams, our medical students to medical school finals, our newly qualified GPs to an MRCGP exam to be licensed, our cars to a physical MOT test. This is an enormous paper-generating exercise and is not evidence-based to prove competencies as an exam has been proven to.

4. I became a GP because as a child my baby brother died due to a missed diagnosis by a single-handed NHS GP in Tower Hamlets in 1975. He was incompetent. I have been fighting to ensure patients are safe. I repeat the US has over 661,000 physicians and all sit a medical knowledge based specialty board exam every 10 years as medical diagnoses and treatments are constantly evolving. The UK is asking for revalidation without an exam? How can it prove a doctor is up to date without testing ability to make a correct diagnosis and offer the correct and most current treatment? Prior to the 1970s, there was no GP training, so many GPs out there have never undergone specific GP training. Post 1970s came vocational GP training and an exit exam administered by each Deanery called summative assessment (a multiple choice knowledge test to test current medical knowledge and a video of consultations to test bed-side manner). From 2007, it then became mandatory that all newly qualified GPs sit and pass the MRCGP exam which is also a multiple choice knowledge test (applied knowledge test) and a clinical skills assessment (which is a simulated surgery consultation exam). I suggest politicians shelve revalidation as it stands, as incompetent GPs will continue to fall through the net, as their medical knowledge and bedside manner are not tested. A GP's knowledge of intussusception will never be tested in revalidation, nor his knowledge of gynaecological emergencies for women, etc. Revalidation as it stands does not test medicine or consulting skills, it only tests ability to amass paperwork. Do it properly or do not do it at all.

5. October 3, 2011, Channel 4 Dispatches aired an investigation into incompetent GPs who were known to the GMC. Two were male international medical school graduates and one unknown to the GMC was European and a university lecturer. Academic GPs are highly intelligent and would pass any multiple choice exam assessment if this were used as the sole tool for revalidation. What was needed was a GP consulting skills test which is also not covered in the current proposals for revalidation. An experienced peripatetic locum GP, as demonstrated in Dispatches, could assess whether a single-handed GP is safe or not and reported the European GP as 'unsafe'. As a past Lambeth PCT Primary Care Access Support GP, I have worked a single session in over 30 local GP practices in South London and assessed who was competent and who was not by reading their consultation notes. The one practice that I found to be severely lacking was already known to the PCT and the 2 GPs had been removed from practice. Conversely, a single-handed Asian GP in South London was doing a stellar job, and I commended him to the PCT and he received more funding!

6. GMC has a lengthy investigation process. We may be subjecting this to between 5-14% of 230,000 doctors estimated to be referred up to the GMC by the responsible officers. Currently the average length of investigation is 18 months! In the US, if a doctor fails his recertification board exam, he re-sits in 6 months. The GMC may need reform, before we subject 10,600-29,680 (5-14%) additional doctors to the GMC for investigation. It is a career-breaker and NOT a career-enhancer.

7. 57% of 3,000 doctors in official revalidation pilots say revalidation will NOT improve patient care. This was published in Pulse on 15 July 2011 and read by their readership, 30,000 GPs nation-wide.

8. Legal implications: Cost implication from impending lawsuits due to failing revalidation (i.e. allegations of vexatious patient satisfaction surveys, vexatious colleagues in multisource feedbacks, unscrupulous medical directors as revalidation officers).

9. Economic cost implications: £156 million annual costs to pay for remediation of 9% of 212,000 doctors. Cost of remediating each surgeon is £40,000 and of each medical doctor/GP is £20,000 according to Dr Laurence Buckman, Chair of the BMA General Practitioners Committee. Why create a new expense when the UK is £4.8 trillion in debt????

10. Responsibility for implementation of remediation of 6,360 (3%) UK doctors? Who is going to be responsible for the implementation of remediation of doctors? Low estimate is 3% of 212,000 = 6,360 UK doctors? Has this been thought out thoroughly? 3% is cited by Professor Mike Pringle of the RCGP Revalidation Lead. He says primary care trusts are already aware of 2% of doctors who are underperforming on their lists and estimates a further 1% identified through revalidation.

11. Against EU law: It is against EU law for UK to introduce a new requirement to work as a doctor in the EU when this requirement does not exist in other EU countries. This may lead to further lawsuits as EU doctors are blocked from working in the UK, as they will need revalidation to get on the GMC register and practice in the UK. EU doctors already cover a number of out of hours shifts for GPs and patients.

12. Source within the GMC is against revalidation. ' Revalidation won't alter casualty rates of those being damaged by charlatans. It will only drive mad doctors underground.'

13. Current revalidation pilots bias against locums, part-time GPs with families, GPs who are carers or who have disabilities as they find it difficult to collate 4-10 pieces of evidence over 16 attributes to pass revalidation which explains why concerns were raised in the 10% who undertook the revalidation pilot. That’s 64-160 pieces of paper evidence! Labour legacy. Proves nothing but that you are good at collecting paperwork.

14. Millions of patients face being without a GP: If 5% of 55,000 GPs are referred to GMC, 5.5 million patients will have no GPs. An average GP covers his own list size of between 1,700 and 2000 patients. This does not include 5% of the 157,000 hospital doctors who will be suspended and therefore patient care in hospitals will fall behind due to lack of clinical manpower.

15. 95% of GPs are opposed: Doctors net uk poll showed 70% of GPs voted that revalidation is a waste of time and money and 95% of GPs voted in opposition.

16. 99% of national LMC GP representatives opposed at annual LMC conference in June 2010: I conducted a straw poll of national LMC reps which showed 99% against revalidation.

17. Revalidation discussed for 10 years on the RCGP Council: Doctors still not in agreement here.

18. Concern that without GMC reform, we will see an increase in doctor deaths during GMC investigation: Doctors Support Network 15-page report by Dr Liz Miller to the Health review group confirms 10 doctors commit suicide during GMC investigation each year. Will we see a further increase in doctor deaths due to the 3% increase in GMC referrals?!

19. Caught in GMC cycle of assessments, if referred. One GP partner with MRCGP was stuck in a 6-year GMC cycle  of assessments of GMC multiple choice exam x 2 and passed, simulated surgery exam x 2 and passed, after an alleged malicious ex-partner referral, despite past Prime Minister Gordon Brown’s recent intervention! She has given up the battle after 6 years and resigned her license. A salaried GP has asked for BMA backing to clear his name as he is caught up in 5 years of assessments, repeating a GMC multiple choice exam and simulated surgery exam even though he passed his MRCGP exam when he was allegedly referred 'maliciously.'

20. Over-regulation does NOT ensure quality. Of course doctors should be safe and are safe in countries like Canada (no revalidation, just CPD and declaration of no outstanding complaints), like Australia (no revalidation, just 130 points every 3 years (CPD)), like the US (board re-licensure every 10 years by exam) and we have had no revalidation for the past 150 years, and doctors are still ranked at the top of the BMA Mori public survey on public trust. Lawyers in this country just submit CPD points. Nurses just submit CPD points yet now nurses are being given prescribing rights as nurse prescribers and nurse emergency room consultants, so why are they exempt from revalidation as nurses? Bankers submit nothing and yet have caused more damage to society than one Shipman.

21. Undesired effects of revalidation: Competent experienced UK trained GPs are taking early retirement, emigrating to Australia, New Zealand and Canada. My local practice in South London has already lost 4 of its 8 GP partners, to early retirement this year alone. I repeat Australia, New Zealand and Canada just rely on CPD points and no revalidation.

22. We are changing the face of general practice, to salaried and locum doctors with a handful of wealthy managing director GPs. Fewer in medical school would like to be GPs now. And fewer are pursuing medicine at A levels (opting for law or banking). This will lead to the UK relying more on EU GPs to cover NHS services. It is imperative therefore that both language AND NHS medical knowledge be tested, ie by PLAB which is sat by all international medical graduates except for the EU. How may EU GPs be able to pass revalidation? We are facing widespread shortage of GPs to cover day and  night shifts!

Female GPs who work part-time due to child-care or secondary income may decide to stop working as revalidation is too onerous for the handful of sessions they cover and cope with child-care. Yet the public often prefer to see female GPs!

Who wants to undertake a career-breaker every 5 years with revalidation? Every 5 years??? This is why bright students are shying away from medicine now and those that are already in medicine are emigrating or retiring early. Lawyers and bankers do not undergo revalidation, and certainly not a career breaker every 5 years of their professional career.

With GP partners selling off their practices to larger companies who own between 15 and 50 NHS practices; these practices are not being manned by GP partners but filled with salaried GPs and nurse practitioners. One company offered a newly qualified GP only £37.50 an hour which is less than a plumber’s wage and offered only 2 weeks paid sick leave which is half that recommended by the British Medical Association standard contract.

23. Dr Harold Shipman was a white UK-trained GP and would have easily passed revalidation in its current form. Revalidation does NOT pick up a dangerous or incompetent doctor. Shipman had good patient satisfaction surveys. The process for multisource feedback requires a doctor to submit e-mail addresses of colleagues to a private company who then e-mails these contacts with a colleague feedback form for the fee of £100. Do you think Shipman would have supplied e-mails of doctors or nurses who suspected him? Shipman was highly intelligent, organised and thorough. He would have sailed through submission of paperwork evidence (audits, patient surveys, MSF, etc.). I repeat revalidation does NOT spot a dangerous doctor.

My local deputy medical director even announced at a local GP locum meeting that she herself did not think appraisal or revalidation would pick up a dangerous doctor and even my own GP appraiser questions the purpose of revalidation and what it is set out to do.

24. BMJ published findings of the Peninsula Study on patient surveys for revalidation on 28 October 2011 are subject to systematic bias against locums and doctors not from European or S Asian countries. A private company charging £100 x 230,000 doctors for surveys will make a turnover of £23 million every 5 years. Why are we relying on subjective tools to assess competency? Would you trust an airline pilot who says he has 30 positive passenger feedbacks or would you rather he passed a test, testing his ability to pilot a Boeing 747 at 10 yearly intervals to ensure he is not suffering from chronic fatigue or loss of intellectual responsiveness?

25. Abolish revalidation (high cost vs. little/no benefit to society). It is about collaboration and cooperation between the government and the medical profession. If revalidation persists, despite high levels of disagreement and costs, with little benefits to patients, this only fuels the current uproar over the Health Bill, 40-page CQC practice registration, £20k a year pension cuts in the GP Contract, and further divides the medical profession and government; the perception will be that government has little value for doctors’ opinions and their outstanding service to the public.

Possible solutions to reduce incompetent GPs.

1. To reduce incompetent GPs, we could ask medico-legal indemnity organisations to start increasing annual premiums on a sliding scale of complaints (claims). This is used in the States to weed out incompetent doctors as the annual renewal premiums become too prohibitive to continue working if a doctor is found to be repeatedly under investigation. MDOs’ know who the incompetent doctors are just as lawyers know who the guilty criminals are. Revalidation does not assess/test medical knowledge, caring, or consulting competence. All it asks is for patients to do a survey, your choice of 3 colleagues to rate you, a practice audit, review a handful of cases and significant event discussions, CPD points with reflection, etc. Where does it test your medical knowledge? Your bedside manner with the patient in front of you? This is why the MRCGP GP licensing exam tests both medical knowledge with AKT and bedside consulting manner with CSA. However 57,000 GPs will not submit to this every 5 years as it is too soon, perhaps every 10 years as a 'summative assessment test' but only if a detailed syllabus is provided as in the States so that exams in the UK are fair and without duress. This is why some doctors are against an exam to test their competence; they need to be reassured it is a fair test and update material is supplied with which to revise so that they may learn and keep up-to-date. Revalidation done properly is a 10-yearly medical knowledge exam. Our medical profession has been without revalidation for 150 years. Australia and Canada have a shortage of GPs so do not ask for revalidation but only CPD point systems.

2. Many PCTs, LMCs, locums, patients, MDOs already know who the bad GPs are. GP consortium now have the power to remove bad GPs/ practices from their consortia. Consortia are led by a panel of GPs who may then auto-regulate their profession with the NHS commissioning board supervising.

About Dr Una Coales

I have 19 years medical experience as a medical doctor (surgeon and GP in both the US and UK), 9 of which spent in GP training and as a practicing NHS GP. I studied and trained in America (Johns Hopkins University, Oregon Health Sciences University School of Medicine, St Lukes-Roosevelt surgical residency training programme) and the UK and have sat both country's medical licensing exams (NY state licensing exam, UK PLAB and the UK MRCGP GP licensing exam). However as a GP educator and author of 14 medical exam revision books, I have acquired extensive insight into assessing GP competencies in over 4,000 established and training GPs to have an opinion as to whether revalidation is fit for purpose; it is not.

I lost a baby brother, and my adult sister almost died too on the NHS due to actions of incompetent 'bad' NHS GPs. I am not satisfied that revalidation as it stands would have identified these 2 'unsafe' GPs, one male international graduate GP and one male UK-trained GP. If it did, I would be its biggest advocate; it does not, which is why I fight revalidation, as I object to the public being hood-winked. Do it properly or do not do it at all. I have lost my good family NHS GP of 18 years, as he has taken early retirement this year due to the threat of revalidation on the horizon for next year. This is the biggest shame of all.