|©Parliamentary copyright||Prepared 9th November 2010|
Revalidation of Doctors
House of COMMONS
TAKEN BEFORE the
Thursday 4 November 2010
Professor Sir Neil Douglas, Professor Peter Furness and Ms Kate Tansley
Dr Brian Keighley
USE OF THE TRANSCRIPT
Mr Stephen Dorrell (Chair)
Dr Sarah Wollaston
Witnesses: Professor Sir Neil Douglas, Chairman, Professor Peter Furness, Vice-Chairman and Revalidation Lead, and Ms Kate Tansley, Revalidation Project Manager, Academy of Medical Royal Colleges, gave evidence.
Q62 Chair : Sir Neil, thank you for coming to join us this morning to give evidence on what we regard as an important but brief inquiry into progress on revalidation and how we can take this forward. Could I ask you very briefly to introduce your colleagues?
Professor Sir Neil Douglas: Yes. I am Neil Douglas. I am Chair of the Academy of Medical Royal Colleges. Peter Furness is a ViceChair of the Academy and also our lead on revalidation. Kate Tansley is our officer who leads on revalidation.
Q63 Chair : Thank you very much. I would like to begin, if I may, by asking questions about the basis on which the revalidation process is being developed-being developed, I have to say I think we feel, over quite a leisurely time scale since 2000. You might like to comment on that. But I would like to ask you a question in particular about the basis of appraisals. There are two related questions.
There seems to be very broad support that the process needs to be based on a current appraisal system, but question one is how content are you that appraisals are now deeply embedded into the culture of practice and carried out effectively right through the system? Secondly, how realistic is it, or is it correct, to base it on appraisals when appraisal should be concerned about the whole range of quality of practice, whereas revalidation is presumably primarily concerned with practice that is verging on illegal and therefore very much at the bottom end of the quality scale?
Professor Sir Neil Douglas: First, on the time scale, you are absolutely right that it has been leisurely. I was briefly on the GMC 10 years ago and revalidation was considered to be two years away at that stage, and it is now still two years away. I think one of the messages we want to give to you today is that we believe, this time, the time scale should be stuck to if we possibly can, even if it means that revalidation is introduced in a simple form initially and incrementally made slightly more complex, if necessary, thereafter. It need not necessarily start in the fully mature form.
Secondly, on appraisal, how content are we that it is fully fledged throughout the whole of the UK? It is in places in existence on an annual basis and effective. It is, I am afraid, still slightly patchy and that is one of our concerns. I think the first step towards getting a revalidation process in place has to be the introduction of effective appraisal for all doctors in all localities in all specialties in the UK in all four countries. If that can be achieved in a short time scale, then that will be a major step forward.
You ask about the conflict between appraisal, which has supportive elements, and revalidation, which has an element of summative assessment involved in it. Yes, there is a slight conflict there; however, the information being brought to the table in both settings is almost identical. It would be cumbersome and expensive in terms of time and therefore loss of clinical service to have two completely separate processes, I believe, to look at roughly the same sort of information.
We believe that it is a very, very small minority of UK doctors who will not reach the level required to be revalidated. To produce a cumbersome alternative system just for catching a few bad apples, which is not how we see revalidation principally focused, we think would be wrong.
Q64 Chair: Thank you very much. Taking the first of those two subjects and the variation around the quality of appraisal currently carried on, you have stressed the importance-and it must be right-that there has to be an urgent priority to secure a 100% effective appraisal round practising doctors. What are the steps that have to be taken? I guess the first question is why hasn’t that happened, given that it has been a commitment based on good practice for many years now, and what do we do that we haven’t done up until now to make certain that what has been recognised for years as good practice actually happens?
Professor Sir Neil Douglas: Part of the reason that it hasn’t happened is there has been no absolute necessity for it and just the introduction of revalidation, hopefully with a definite timeline for everybody to be enrolled in this, will ensure that that happens. Partly it has been because it has sometimes been inconvenient for individuals to find times to meet with appraisers and all these sort of very mundane aspects that can be used as excuses if there is no absolute necessity for having the process in place.
Peter, do you have anything you wish to add to that?
Professor Peter Furness: I think that is accurate. I think the variation around the country in the implementation of appraisal also highlights our concern that the emphasis on local decision making in something like this has the potential for variation in how appraisal is administered and how standards are set around the country, because there has been a great deal of talk of setting standards but, as I think we touched on in our written submission, there will inevitably be a large degree of judgment. If there isn’t a great deal of national co-ordination, I fear that we will have variation in the standards just as we have had variation in the speed of implementation.
Q65 Chair: One of the things the GMC offered us last week was some evidence on which parts of the country have particular lacunae in terms of effective appraisal. If you had any information on that subject, we would welcome it.
Professor Peter Furness: I don’t have any hard information on that, and I would suspect that the GMC’s information will be better than mine. I could only offer anecdote and I don’t think that would be fair.
Chair: You wouldn’t be the first.
Q66 Valerie Vaz: One point I would ask for is an example of how it could differ.
Professor Peter Furness: Some hospitals have not implemented appraisal at all. Others, like my own base in Leicester, have had fairly welldeveloped appraisal systems for some time. The Department of Health Revalidation Support Team has introduced pathfinder pilots around the country. Those units, I think it is now fair to say, are well ahead of the field in implementing a strengthened form of appraisal. But even there, with our contacts in each of the pilots, we can see there are some differences in the way it is being done in different sites.
Chair: Nadine Dorries would like to ask you some questions on the focus of revalidation.
Q67 Nadine Dorries: I wonder if you could give us an example of a good appraisal-where you think appraisals are happening that are good and how they happen. We have heard a number of stories about how appraisals take place, but can you give us an example of a good appraisal?
Professor Peter Furness: I think a good appraisal should start with proper preparation, accumulation of information and consideration of that by the appraiser and the appraisee before the interview starts. The way in which that information is gathered together is important and the information should come from the employer as well as from the employed doctor. I am thinking principally in secondary care; there are other issues in primary care. It should be fairly clear to both sides of the appraisal interview, if there are issues, where those are before the interview starts, and there may be a need for a bit of clarification and making sure that all the information is there before the interview starts.
When an interview starts, I think it should focus initially on a fairly rapid assessment of, "Are there any areas of practice that are real causes for concern?" That is the summative "Should you achieve revalidation?" question.
As soon as that is satisfied, which it should be for the vast majority of doctors, we should move on to discussing, in turn, the various aspects of practice. I should have said, of course, that the areas of practice of the doctor should have been set out and defined beforehand. We can then discuss the various aspects of practice and how they should be improved, what the targets should be, specific achievable changes and improvements in the coming year, how they might be achieved, how the institution and the doctor can work together to make those targets achievable and set that out so that that can be reviewed next year at the next appraisal interview-in a nutshell. That is for most doctors.
Of course, if there is a serious problem identified, then you have to get into a slightly different mode and start addressing what impact there might be for patient safety, how that is going to be sorted out, whether formal remediation is necessary, what steps might be necessary to ensure that patient safety is assured, and you are off down a slightly different channel, with a different emphasis at the very least.
Q68 Nadine Dorries: When you take specialities on top of that, and doctors who have particular specialisms, if you were to adapt that generic form of appraisal which you have just described to doctors who have specialist skills, wouldn’t you then be making the appraisal process expensive, complex and difficult, because you have just described what is already a quite comprehensive appraisal? Will that not do for all doctors? Will that generic form of appraisal system not suffice?
Professor Peter Furness: I don’t think so because what I have described is pretty generic and what I was meaning was that the information gathered together before the interview should relate to what the doctor does. You start with setting out clearly what the doctor’s practice is, bringing information along with regard to that, as we have set out in our written submission-evidence of the quality of practice, what people think of what you are doing and what you are doing to keep up to date. I should think that applies to any employee or any practitioner of any sort, not just medicine. We have had a great deal of head-scratching about the unusual forms of medical practice that some doctors undertake and I think that that approach would result in quite different sorts of information being brought to the appraisal interview, depending on the nature of practice, but the overall structure could remain as I describe without it being overly complicated. I am not sure how that would result.
What I have seen as a source of increased complication is the GMC’s prescription of these 12 attributes, some of which, for some doctors, are extremely difficult. Some of them are rather vague. For example, I am personally a histopathologist; I work in a laboratory and don’t see patients, so patient feedback is not part of the information that I would bring along to the revalidation interview. That is absolutely obvious if you look at a description of my area of practice. If you are, say, a medical coroner involved in medical legal work, then the same things apply. If you focus on evidence of the quality of what you do, what people think of it and so on, that will guide what is appropriate information to bring along and we would anticipate the Colleges providing additional guidance on what was appropriate so that we didn’t have an overly complicated approach.
Q69 Nadine Dorries: Can I get this clear because we have, obviously, a wide range of specialities? If you had a doctor who was particularly specialised and highly skilled in one particular area, would you think that the person who carries out the appraisal on that doctor has to be somebody who is equally skilled in the same area?
Professor Peter Furness: As we set out in our written submission, I think that one should seek for the appraiser to be as close as possible to the appraisee in the area for the reasons you have identified: the two would need to understand the area of practice they are talking about, specifically because we are not talking about measurements of quality. We are talking about judgments of quality, inevitably, especially when it is someone particularly specialised. I would not be in a good position myself to evaluate the quality of a neurosurgeon, for example.
It would be impracticable to say it should always be in the same specialty because some people are just so specialised that that is not practicable, but it should be, I think, someone who understands a related area. Of course, if you only have a small number of people in one form of practice in one unit, they might be a bit pally, they might be a bit too close to each other to be objective, and you have to bear that in mind and consider it.
There will be some circumstances where it is not possible to have appraiser and appraisee from the same specialty. I think if that is the case then the appraiser should try to appraise several individuals from that smaller specialty so that they can get a feel for the spread of what happens. It is a difficult balancing act with pressures on each side.
Nadine Dorries: It is, and what you have just described does sound quite complex and could be the reason why this process has been on the table for 10 years.
Q70 Valerie Vaz: Can I just ask how long it is currently taking for the doctor and the appraiser to go through this process-getting the portfolio together?
Professor Peter Furness: You will be receiving evidence from the Department of Health, I believe, and the Revalidation Support Team. I think the best information that I have on that currently is from the pathfinder pilots, which we have accepted-everyone has accepted-illustrate a need for simplifying the process. In those pilots, my understanding is that, so far, with regard to the gathering together of evidence people are claiming a very wide range of how long it takes, from one hour up to a couple of weeks or so. I am not sure how they arrive at that figure. I personally went through that process and it took me an hour.
With the appraisal interview, the length is varying from an hour to about three hours. Again, I am a bit surprised at the longer ones. One wonders what was having to be discussed. Of course there is a little while for recording things after that.
I think part of the problem there is that when we have looked at the number of pieces of information that people are bringing along to the appraisal interview, it has apparently varied from about three to over 100, and that is clearly something that needs to be clarified and sorted out, and the 100 perhaps explains the comment, "It takes me a week to get it together."
Q71 Chair: Can I just feed back to you what I am hearing from you and what we heard from the GMC last week? I will make the same point to you as I made to them. This all sounds very "early stage" for a process that we are asked to believe has been piloted as something that is less than two years away from implementation with clear ideas about how it will actually stand.
Can I just read what Professor Lewis said to us in evidence last week on this balance between the generic and the specialist? He said: "what we are discussing with the Academy at the moment, who are charged with this work, is that we should get to a starting point where we have the GMC standards for revalidation"-and that is the starting point. "Thereafter, if the specialties want to have a list of 100 things that doctors from that specialty can bring then that ought, initially, to be voluntary."
That doesn’t seem to be quite the culture that we are hearing from you for a process that we are asked to believe has been piloted.
Professor Peter Furness: Yes. I am afraid I disagree fairly profoundly with that statement. To start with, the use of the word "standards" is causing difficulties because the GMC uses the word "standards", and if you look at what they have set out, "attributes" is a better word. They have 12 attributes, which is a list of aspirational-"aspirational" is the wrong word. They have a list of general terms. It is really a checklist of things a doctor should cover. It doesn’t say anything about "how well".
Then when you start trying to drill down into what information should be brought along to support those standards, because of the variation in medical practice, we have largely got pieces of information rather than how good those pieces of information should demonstrate your practice to be. So the word "standards" has been used to gloss over a problem, and I think the standards will inevitably come down to a large element of judgment, and what we have been talking about so far is mostly what sort of information you will bring along to support those standards.
The GMC has recently passed back to us a couple of documents based on one that we put to them by way of making this process simpler and more efficient. They went up from three types of information to eight and set out what they thought doctors should provide and then, as you have said, tacked on at the end, "Other specialties can add what they want as well." We think that-
Q72 Chair: One hundred items-voluntary?
Professor Peter Furness: Entirely inappropriate, in my view. I think the core elements of evidence of your standards of practice will vary between specialties. What we want to do is discuss how those key elements like outcome data and proficiency testing, which happens in some specialties, should be judged in the context of the individual specialties. That is core stuff. That is not tacking it on the end, and it will vary between specialties. We think we can make that relatively simple for individual doctors. The GMC is pushing for this generic and, I think, slightly woolly approach, with the specialties tacked on the end. That worries me profoundly. I don’t think it will work.
The other document the GMC has given us in relation to this process is a list of questions relating to their 12 attributes. For each attribute we have a core question and then a set of supplementary questions. I think, if that is what the GMC expects, we are going to have a phenomenally laborious appraisal interview that focuses entirely on the summative, "Are you fit to revalidate?" and we’ll have no time left at the end to do the formative, "How can we get better?", which is what, for most doctors, appraisals should be about.
I have only had those papers a few days so this is an ongoing discussion, but it does worry me that if this is the direction in which the GMC are going it doesn’t look like simplification. It doesn’t look like streamlining to me.
Professor Sir Neil Douglas: One of the major problems, I think, is that for the majority of specialties you cannot press a button on your computer and get quality outcome data at all. You can for general practice, mainly, and you can for surgery, but for my practice I can get absolutely nothing other than the fact of how many patients I have seen, and even then some of them will not be my patients.
Q73 Chair: What is your practice?
Professor Sir Neil Douglas: I am a respiratory physician. The IT systems will improve with time and, therefore, yes, 100 is clearly a ludicrous number. But at the moment we have to give people the sort of areas they can come up with evidence from that shows they actually are safe because there isn’t a single button they can press to get something that says, "I am a good doctor."
Q74 Chair: Starting from where you are, which sounds like quite a long way apart from the GMC, how quickly are you going to get to a formula that can genuinely be piloted on the basis that "This is something that we are ironing out the detail on", before rolling it out nationally?
Professor Peter Furness: I think we are further apart from the GMC than I thought we were about a month ago because of these documents that have just appeared. In that time I have also personally gone through a strengthened appraisal because I am employed at one of the pilot sites. That has influenced my thinking as well, and I can see that there is no one in the GMC that I am meeting who is a doctor who has actually gone through the process.
I am hoping that we will get to agreement very quickly because it is perfectly clear that we all want the same thing. But at the moment my impression is that the 12 attributes that the GMC have set out were designed for assessing problem doctors, and they insist on those being up front almost as a sort of item of faith that cannot be challenged. I think if they can agree that those slip into the background and they should be brought out if a problem emerges-if we can agree that-we are very close to coming together. If they insist on those 12 attributes being ticked off mechanically at each appraisal interview, I think we are quite a way apart.
Q75 Nadine Dorries: Can you give us an example of what it is in the pilots that you have experienced that, after 10 years of this being on the table, has brought you in about the last month to change your mind or to have different thoughts? What was it in particular?
Professor Peter Furness: I went through the pilot as a doctor being appraised in Leicester and I gathered together all the supporting information as instructed, actually in paper form rather than scanning it in and uploading it to a computer, which is what some sites are expecting.
I then went into the software which is unique to Leicester-it is not being used by the other pilot sites-and mapped all the various bits of information that I had got against the 12 GMC attributes and was asked some, frankly, fairly banal questions about how I was justifying the attributes and so on, and realised that I was using the same piece of information multiple times. One piece of information would be relevant to about five or six of those 12 attributes, and I thought, "This is not efficient." I also looked at the information I had gathered together in a different way and thought, "Well it falls into these three categories. Why can’t we present it that way? It will cover the 12 attributes in the background."
Q76 Nadine Dorries: So it was just duplicated?
Professor Peter Furness: It was duplicated, yes.
Q77 Valerie Vaz: What are the three categories?
Professor Peter Furness: The evidence of the quality of what you do, which can cover various things, outcome data and whatever-audit; evidence of how people perceive what you do, which is multisource feedback, patient feedback, letters of complaint and that sort of thing; and evidence that you are keeping up to date, which is continued professional development, and all the Colleges have schemes to cover that.
Frankly, if there was a problem with performance, I think an appropriate spread for a specialty that covered those three areas would pick up something which a good appraiser could then focus on. If there’s a problem, it is entirely appropriate to bring out the GMC attributes and what the GMC says about that, focus on that and drill down and sort it out. But, otherwise, starting with the 12 attributes, it becomes the wrong way around.
Q78 Nadine Dorries: Do you know what the other pilot schemes are doing?
Professor Peter Furness: The other pilot schemes are all following the approach that the GMC set out to start with. They are using different software. All the other pilot schemes are using software developed by the Revalidation Support Team, which has been causing problems. But that is another story we mention in our written submission. So they are all following the framework of an appraisal interview that goes through the 12 attributes.
Q79 Nadine Dorries: Can I just ask how long it takes to get all the evidence together? As you are experienced in the pilot, how long did it actually take you to you get everything you needed together to begin answering the 12 questions?
Professor Peter Furness: That depends on how you count the timing. If you count the time taken-
Q80 Nadine Dorries: In hours and minutes?
Professor Peter Furness: No, no. If you count the time it takes to do all the activities, the continued professional development, the audit, the things that doctors ought to be doing anyway, you would very readily get to the week, two weeks or more that some people have quoted.
Q81 Nadine Dorries: Hang on a second. You are saying it would take a doctor two weeks to get the evidence together-two full weeks? Sir Neil is shaking his head next to you.
Professor Peter Furness: No, no. We would be doing that anyway. In my own case, knowing that this was coming, I had gathered together in a filing cabinet a bit of paper every time I got something that was relevant to appraisal. Pulling that dossier out, plugging it into the system and presenting it to my appraiser a couple of weeks before the meeting took me an hour.
Nadine Dorries: Okay.
Professor Sir Neil Douglas: But that depends how organised you are.
Q82 Chair: It raises an interesting question-which is possibly, but only possibly, outside the scope of the revalidation inquiry-which is whether in the modern world it is part of what it means to be a professional to keep the evidence of your own practice.
Professor Peter Furness: Indeed.
Q83 Nadine Dorries: But if you are a professional you should be doing what your specialty and your skill enables you to do, should you not, rather than concentrating on having to keep evidence of what you have been doing as you go along?
Q84 Chair: But how can you be confident of how good you are if you are not measuring yourself by the evidence of what you do?
Nadine Dorries: It is quality outcomes.
Q85 Valerie Vaz: There is the quality of the legal profession as well.
Professor Peter Furness: I think we have illustrated the difficulty of working out how much time is consumed by this process and, therefore, how much it costs.
Q86 Valerie Vaz: How does that apply to you-about the complaints procedure-if you don’t necessarily have patients, because you don’t, do you?
Professor Peter Furness: Yes. I didn’t have any complaints, which is not surprising. It’s possible. If I did have complaints it could well be from other doctors. I was amused to find it suggested that complaints were an expected item of a doctor’s portfolio, but that is another story.
Chair: A 360-degree appraisal of chairmen is going to get into trouble soon if we don’t move on.
Q87 Dr Wollaston: Could I come on to the issue of conflict of interest and the role of responsible officers? Essentially, if the medical director has responsibilities to deliver the targets of an employing organisation, does that not-I think you have pointed it out in your evidence to the Committee-immediately raise the possibility of a conflict of interest? I wonder if you could elaborate your views on that.
Professor Peter Furness: Yes, it does. From the very first day having medical directors as responsible officers was suggested I think that potential conflict of interest was identified. It’s balanced, as with so many of these things, by the observation that the medical director is probably, in most circumstances, in the best place to sort out problems that come from the process and to understand how the environment that the doctor is working in may interact with the problems that the doctor may be having. Were it not for that conflict of interest, the medical director would be the best person.
Given that balance, it is not surprising that we have had different opinions expressed, and, as I think I mentioned, some of the medical Royal Colleges have said it should not be the medical director; it should be someone completely independent. That view is, I believe it is fair to say, in the minority because others see the value of having the medical director as the responsible officer, but we are all concerned that because this conflict of interest exists there have to be open processes to ensure it doesn’t cause problems of the sort that we have identified and, if they are, that they are corrected very rapidly. It is one of the reasons for needing a good quality assurance process that looks at the outcomes, not just the process.
Q88 Dr Wollaston: Could you, for example, see in a place like Stafford that that could have been an issue? Where there are organisations aiming for targets, do you think that is an issue?
Professor Peter Furness: That is an excellent example.
Q89 Dr Wollaston: Can you think of any other places where that might have contributed to problems-specific examples?
Professor Peter Furness: It is difficult to think of examples. I suppose, whenever something goes wrong in a hospital, historically one could say, "Could revalidation have spotted that problem and sorted it out?" We have not actually had this process yet so the problems are, in a way, theoretical, but I think we all understand what they are.
Q90 Chair: Is it something that was covered in the pilots-the different ways? Were any of the pilots predicated on the assumption that the responsible officer was somebody other than the medical director?
Professor Peter Furness: I don’t think so. Again, you can get a more reliable answer from the Revalidation Support Team who are running the pilots. I think they are all medical directors. Do you know, Kate?
Ms Kate Tansley: I know that the West Midlands pilot is looking specifically around issues of responsible officers, so there might be some useful information coming out of that.
Q91 Dr Wollaston: Did they use people other than medical directors in that pilot site?
Ms Kate Tansley: Not that I know of. I know that there is one London PCT where this has come up, because the person who is the medical director currently is not a doctor and therefore would not be eligible to become a responsible officer. They are looking at that and how that could be resolved because they do feel that person, apparently, is an extremely useful person so they don’t want to lose them.
Q92 Chair: Do those Colleges that take the view there is a conflict here, and a serious issue, have a way of addressing the point that there are advantages in having a medical director? Do they have a way of bringing those advantages to the table without bringing in the personality of the medical director?
Professor Peter Furness: In my opinion, no. They may disagree.
Q93 Chair: Valerie, you are done. Are there any other points? Is there anything else that you would like to raise or draw our attention to in your written evidence, or indeed that has arisen in the conversation?
Professor Sir Neil Douglas: I’d like just to go back to the three points that Peter was making on item 11 of our written submission about simplifying the 12 attributes down to three. Two of the three are absolutely generic and the other one, which is on quality, is, by its very nature, specialtyspecific. Whilst I accept entirely we should be as generic as we possibly can, I do think to have a totally generic system that does not have the individual bringing along evidence about how good his practice in that specialism is would be a complete nonsense. So it needs to have a specialty component to it as well.
Going back to the question of whether the appraiser should be from within the same specialty, yes, I agree it should be, in broad terms, from within the same specialty. As many of you will know, there are, I think, 58 specialties recognised by the GMC. I think it has to be down to that level of granularity. For example, I’m a respiratory physician, as I have said, and there are at least eight, in practice, different things that respiratory physicians can do, so it should be down to the level of a respiratory physician to appraise me but not to somebody who works in sleep medicine, which is what I do most of my stuff in.
Q94 Chair: Thank you very much. That was an informative session. You have a challenge, I think, to get there by December 2012.
Professor Sir Neil Douglas: Indeed.
Professor Peter Furness: May I make one further point? It is not really set out in our written statement but touches on the discussion about the pilots. The time scale for the pilots is set. We are not yet quite clear what will happen in the additional period of time that the Secretary of State has indicated we have after those pilots finish.
We are a little worried about the evaluation of the pilots. One point that is perhaps not absolutely obvious is that those who participated in the pilots have been largely voluntary, which means that those doctors who know they have a problem, one might guess, aren’t volunteering. So there may be differences when revalidation goes live and it becomes mandatory for everyone in terms of the outcomes and the need for remediation. These are issues we are having discussions about. It just struck me that we had talked about the next steps and it was not made clear in our written submission.
Chair: That is a not unimportant point, I would have thought. Thank you very much.
Examination of Witness
Witness: Dr Brian Keighley, Working Party on Revalidation, British Medical Association, gave evidence.
Q95 Chair: Good morning, Dr Keighley. Thank you very much for joining us this morning. I think you heard the evidence being presented by the Royal Colleges. I would actually like to start off by asking how you reacted to the evidence that you have just heard.
Dr Brian Keighley: I think, in general terms, we would perhaps be a little more positive than the evidence I have just heard. We made a response to the GMC consultation, and I think the GMC have made significant steps to address some of those concerns. I do recognise that this new system is producing a lot of anxiety. I think that perhaps is more apparent in the secondary sector of care, in the area of specialist practice. It is my view that appraisal and, flowing from that, revalidation is perhaps better established in primary care, and I think you heard very positive evidence from Malcolm Lewis last week.
Q96 Chair: Indeed. We heard positive evidence from Malcolm Lewis. What I am also focused on is the fact that in the written evidence from the BMA you place considerable emphasis on the fact that effective revalidation will, in your words, "Depend on the successful implementation of strengthened appraisal, when for many doctors ordinary appraisal has never been successfully implemented." There were various other quotations I could take out of your written evidence which suggest that there is considerable unease within the BMA about where we are in the effective implementation of effectiveness of revalidation based on appraisal.
Dr Brian Keighley: I think our first anxiety is the fact that it is so patchy. It is well established in parts of the country, as you were hearing, and yet there are trusts and hospitals where it has hardly taken place. There is also a large lacuna with the locum and sessional doctors, and some PCTs have been better at producing the infrastructure than others. I think before we move to what has been called "strengthened medical appraisal" we need to get everybody participating at the initial level.
The other anxiety we have is perhaps lack of consistency across the country as to the types of appraisal that are being carried out. We hear anecdotally of some appraisals being a "cosy chat" and others going on for two or three hours. I am now on my seventh annual appraisal and I think my interview lasts for about two and a half hours.
I think also what is important is that some of the evidence you have heard is about finding bad doctors. I think the GMC are right to stress that the vast majority of doctors in this country are doing a good job. The purpose of revalidation to my mind is not the weeding out of bad doctors primarily. It came out of the Bristol heart scandal and was to encourage doctors to indulge in reflective practice.
That is what we are encouraged to do in my type of appraisal, and I think there has to be a degree of challenge. I want my appraiser to be friendly; I want her to understand my problems; I want to be able to share things with her. But, at the end of that appraisal, I want her to produce just that degree of challenge which makes me reflect upon my practice, about how I can improve, about areas of weakness. The important thing about revalidation, as opposed to appraisal, is that it is a fiveyear-not a fifthyear-process. It is not a binary decision.
As I approach my retirement, I find it more difficult to remember things and I think, if that is reflected back to me, in a year’s time I would show how I would rectify that potential area of weakness. I am in a practice where most of the other doctors are women, so most of the women selfselect those doctors and I become deskilled in areas of gynaecology and family planning. I reflect that to my appraiser and she says, "Well, what will you do about it?" I would put something into place, and a year later I will present to her what I have done to address an area of developing weakness.
When you get to the situation of poorer or weaker doctors, the great advantage of a fiveyear process is that you will pick up, hopefully in years one and two, an area of doubt, and produce some plan to address that area of practice and, hopefully, at the end of the day, we will have less doctors coming into the Fitness to Practise procedures of the GMC.
Q97 Dr Wollaston: I think that is a very important point. We would all accept that an appraisal should be a challenging process that is about personal development, but the public would like to be reassured that the process will also pick up at an early stage those doctors who are failing. Do you yourself feel it is possible to deliver both with revalidation?
Dr Brian Keighley: I think revalidation is part of an armamentarium of methods that failing doctors should be picked up on. What I think we have to remember, however, is that the GMC sitting in London or Manchester cannot do that, and it must rely on proper clinical governance. Part of the lack and part of the delay in the system, to my mind, is that clinical governance, which should be an intrinsic part of a National Health Service that spends so much of the nation’s resource, should be inbuilt, and it is very patchy.
Q98 Dr Wollaston: That brings me to the next point. In your response to the consultation, the BMA said that many doctors facing Fitness to Practise procedures are those doctors working in areas where there is little or no robust system to conduct revalidation. I was just wondering whether you could share with the Committee where you think that is happening. Which areas are you referring to?
Dr Brian Keighley: I am sorry, can you just repeat that?
Q99 Dr Wollaston: Yes. Are you able to say which parts of the country the BMA is referring to when, if you like, the implication is that the areas that need it most are the areas that don’t have it, where we are seeing most doctors who are facing Fitness to Practise procedures?
Dr Brian Keighley: I think perhaps we were more referring not to geographical areas but areas of practice and areas where there are not managed environments.
Dr Wollaston: Right.
Dr Brian Keighley: A lot of these doctors are in the private sector and do not have clinical governance structures, do not have managed structures and do not have peer review. Those are the areas where it is going to be hardest to establish this.
Q100 Dr Wollaston: I’m sorry, did you say areas of private practice?
Dr Brian Keighley: Areas of private practice, I think, because they are outside the management structure of the health service, and even people who work almost as a single practitioner in a very esoteric specialty will have overview from nurses with whom they work and other clinicians. So there are areas perhaps, especially in the city, where some doctors are working completely outside the health service in a niche area of practice and that is the area where perhaps there is most difficulty in providing the overview.
Dr Wollaston: Thank you.
Chair: Valerie, are you following up on this?
Valerie Vaz: No.
Chair: Okay. Can I go to Nadine and then to you?
Q101 Nadine Dorries: I have a question about something that you wrote in your response to the revalidation consultation. You said that the proposals "depend on the successful implementation of strengthened appraisal, when for many doctors ordinary appraisal has never been successfully implemented". Does the lack of successful implementation mean that an appraisal isn’t done, and what do you mean by that in effect? Can you just elaborate on those statements?
Dr Brian Keighley: In some trusts and in some areas of the country, NHS strictures that appraisal is part of the contractual arrangements of NHS doctors, for reasons of prioritisation, have just not taken place. Some people have done it with enthusiasm; in other areas it has slipped down their list of priorities. Sometimes, when it has been carried out it has been carried out half-heartedly and without much rigour, or the challenge that I was talking about before.
Q102 Nadine Dorries: Are you saying that these doctors-the GPs who have not had this process that you are talking about who fall into that category-will find it difficult to accept a strengthened appraisal because they have not even had a successful appraisal?
Dr Brian Keighley: I think it is easier to go on a graduated step, but this type of appraisal that we are talking about-I think the Chairman was talking about professionalism-should not be something that is unachievable or something that is particularly frightening. But it does worry us that where appraisal is working well in many parts of the country-we are now talking, or the Validation Support Team is talking, about strengthened medical appraisal-it is not being uniformly applied now. I think, as a matter of urgency, it does need to be generally applied and then I think the standards of appraisal and the challenge that’s given should incrementally increase.
Q103 Nadine Dorries: You have quoted some areas where it is working well. Can you give us an example of a good successful appraisal? Where do you know that a good successful appraisal process or model is being implemented and taking place? Can you quote one to us?
Dr Brian Keighley: Scottish Primary Care, Welsh Primary Care, many trusts.
Q104 Nadine Dorries: We heard evidence from Wales last week. You think that is a good pilot, one we could look at and you think it is working well.
Dr Brian Keighley: You don’t actually need pilots to see where appraisal is actually working well. The National Health Service Education Board for Scotland has trained appraisers. We have a model now to move it into secondary care appraisers. With the short lines of communication in Scotland and one national body who is underpinning the system, I think it is working well in primary care for the most part in Scotland and is certainly not as patchy as in England. It is much more patchy in secondary care in Scotland, and there are issues that our consultants have about changing the nature of the appraisal because we feel it is a terms and conditions item, but we have now entered into a dialogue with the SGHD and we are moving forward on that.
There is a desire in professional terms to make this work because it is, I think, important-more than weeding out bad doctors. The principal thing that the GMC are trying to deliver, and which we would support, is to give the public assurance that doctors are remaining up to date and that once they pass their primary medical degree at the age of 24 they actually do something more, and they are giving the public that assurance that they are up to date and that they are reflecting on their practice.
When you think back to Bristol, the heart surgeons in Bristol were all very well-meaning and highly skilled doctors, but they had not reflected on their morbidity and mortality rate. The main driving force for this is to make doctors pause and think, and to have an outside agent, which is an appraiser, that will help them do that and give the appropriate degree of challenge. It’s a very positive thing.
I think the thing that worries the BMA is some of the details. We would now like to see the GMC-I was myself a member of it for 14 years-take leadership of this and to take it forward and not to rely so much on partners and stakeholders.
Q105 Nadine Dorries: Just to conclude, you were in the audience and you heard the evidence that was given prior to you coming in. You heard a description of an appraisal, which was the gathering of the evidence and the preference that it goes down to three categories. Could you tell me, of that evidence you heard, how would that measure against your description of a strengthened appraisal? Would you describe that as a strengthened appraisal, a successful appraisal or a basic appraisal?
Dr Brian Keighley: I think a strengthened medical appraisal must be predicated on data. One of the biggest problems we have is the inability of the secondary sector of care easily to produce that data. They have incompatible IT systems, and you heard Neil Douglas talk about not being able to bring useful information in his highly skilled area of practice.
In general practice, I think perhaps it is a bit easier. We are used to appraisal because for 30 years I have been a training practice. So every three years I have to jump through several hoops and people look at my prescribing, my referral and how I relate to my patients, and I look after all the health and safety stuff that cascades upon us. We go through that on a regular basis.
Q106 Nadine Dorries: What we have talked about is a model, and it is required that it has an application to fit both the primary and the secondary sector. Could that be where the rub is-that it is difficult to get a model? In the secondary sector you have doctors or housemen moving from department to department, from patient to patient, from ward to ward, and it would be difficult, even with the best IT system in the world, to constantly track where those housemen and those doctors were moving and the patients that they were working on and dealing with. Should there be a model which is one for the primary sector and one for the secondary sector? Is it because we are trying to find one overarching model that we have been stalled, and it has not been applied and we are still where we are today?
Dr Brian Keighley: I think the reason for the delay is that the revalidation agenda has been hijacked by events, steered by events, in a political sense. We were ready in the GMC when I was a member to launch revalidation five years ago, and it was at a very much lower tariff than was proposed by various suggestions from the Department of Health and the CMO at the time. That is where affiliates came from and it now seems to have gone away. That is where the split between relicensing and recertification came from. Fortunately, I think we are now rewinding to something which is much more reasonable-
Q107 Nadine Dorries: -which would fit both sectors.
Dr Brian Keighley: In both sectors. Because what we are looking at, I think, are core values. If you revalidate a neurosurgeon, there aren’t many people who will get into the depths of what he does, but he will know whether he is keeping up to date. He will know how he relates to patients; he will know if he throws scalpels at his nurses in the middle of the operating theatre. Those are core values. I think that is what revalidation is about. It is not a detailed forensic examination of everybody’s individual practice. It is about core values-about being a doctor. Part of being a doctor is keeping up to date and relating well to your patients, your management, your staff and everything else.
Q108 Dr Wollaston: Can I ask about the evidence that we heard from Dr Furness? He talked about three areas, broadly: evidence of the quality of what you do, evidence of how others perceive what you do and evidence that you are keeping up to date. Would you agree with his assessment that that should be the key to revalidation?
Dr Brian Keighley: I think the Colleges are trying to simplify things, which in some ways is ironic because they were asked a few years ago to complicate things. I think Good Medical Practice is a very powerful document, not in what it says but what it doesn’t say. It is not that thick-it is that thick and it gives you principles. I think it is important that that seminal document is interpreted for different specialties. I was part of helping to write the first edition of Good Medical Practice for General Practitioners, and other specialties did the same. I think, broadly, your appraisal should be mapped not religiously, but to the broad principles laid out in the interpretation of Good Medical Practice for your specialty.
Q109 Valerie Vaz: I want to turn our attention-briefly, because of the time-to the pilot schemes, and the question comes out of what you have been saying. Do you know exactly what they have been demonstrating and what we can all learn from them and, given the previous comment, that only the good ones are volunteering for them?
Dr Brian Keighley: I think the pilots are important. Unfortunately, some of the pilots that are going on at the moment are predicated on what the GMC asked for, which was much more complicated. I think it is important that there is enough time, even if it is going to lead to slightly more delay, to evaluate the pilots and to act upon the lessons that we learn. The pilots, I understand-I don’t have detailed information but I can get that from the office-are somewhat running into the sand. They are delayed. There are people dropping out. There is a great deal of frustration with the revalidation toolkit and the software, which I think is a shame because there are other systems that work well, and the pilots are not about testing the toolkit; they are about testing the principles. There are important lessons being learnt from the pilots but they will need to be retested and recalibrated with the GMC’s newer, simpler approach.
Q110 Valerie Vaz: Do you know who is actually on these pilot schemes?
Dr Brian Keighley: I know they are around the country, that some are primary care, some are secondary care, some are mixed and some are looking at different aspects. The information that’s coming out is mixed. It is usefully pointing out some of the problems in terms of overcomplication. Certainly, it is pointing out some of the difficulty that some doctors are having in producing the data to support the process. In that context, isn’t it surprising? With the NHS and clinical governance, one would have thought the systems would be there for those reasons alone and they are not. I think that is one of the difficulties.
Q111 Valerie Vaz: What are they actually testing? You are saying that the mechanical aspect of it isn’t working so some people are getting frustrated with it. But what about the medical side? What are they actually testing? Do you know?
Dr Brian Keighley: I think they are testing the standards, they are testing the process, they are testing the relationships and they are testing the ability to produce the data, and, yes, a change in regulation this large really should be going through a pilot. As I say, I don’t have exact details, but we can certainly give you reports on that and will be very happy to send that in to you.
Q112 Chair: One of the very strong themes that comes out of this evidence is, frankly, a disagreement between different stakeholders about the balance between generic and specialist knowledge. Several times in the course both of the evidence you have given this morning and the written evidence, it seems to me that, from your standpoint, the Royal Colleges are to some extent the villains of the piece here with their emphasis on the need to focus on what doctors actually do in their daytoday practice and the evidence of the specialist service they deliver. Am I getting something wrong here?
Dr Brian Keighley: I think the Royal Colleges were asked to produce some work, which they did, and, unfortunately, I think that it was overcomplicated. I think we have to remember that revalidation is about all doctors and the Royal Colleges, certainly my own, are about excellence.
I think it is also important to remember that if you take a cohort of good doctors, 50% of them will be below average. It is a question of pitching the standards that you are looking at at the correct level, and I think for revalidation, which is looking after all doctors, that should be pitched at competence and not necessarily at excellence. Maybe that is some of the difficulty.
I am not sure how important the Colleges are to give that kind of advice now that the processes are merged, because our experience in fitness to practise or the GMC’s experience in fitness to practise cases is not really about how someone ties off an artery in the middle of an operation. It is more about not listening to the patient, not keeping up to date or letting your personal opinions impinge on consultations. It is much more fundamental than that. The Colleges have an important calibration role as long as they understand that what they promote is excellence, and what we need is competence.
Q113 Chair: We could do with a bit of excellence too presumably, but I understand. There is clearly a dilemma that we started off talking about with the Royal Colleges-whether, in their language, this is summative or formative. I have to say I was quite attracted by their presentation, which said, "Let’s first establish whether there is a fitness to practise issue and, if there isn’t, move on to a quality agenda." What is wrong with that approach?
Dr Brian Keighley: I would have reversed that. I think revalidation is about reflective practice and about public assurance. Clinical governance and other methods should be picking up people who are poor doctors. Revalidation, to my way of thinking, is a backstop. Harold Shipman has been mentioned. It was in the Royal College submission that Harold Shipman would probably have passed revalidation, which is worrying.
What we want revalidation to do-I remember Liam Donaldson saying it-is to move the mean of the bell curve two clicks to the right so that everybody improves, dragging the tail with it. That is done by encouraging all doctors, not just the enthusiasts, to advance and to keep up to date.
Q114 Chair: That is actually in conflict with what you were arguing, isn’t it? Moving the bell curve two notches to the right you can achieve by moving everybody. Actually, if revalidation is purely around minimum fitness to practise, it isn’t about moving the bell curve two notches to the right. It is about eliminating to zero the people at the bottom end notches of practice. They are two different things.
Dr Brian Keighley: I think if you move the bell curve there is still a trailing edge and that is where your problems will be. Revalidation will help to identify those people, but in a professional context that is not what it is about. Revalidation is giving assurance that you are keeping up to date. It is giving people opportunities to reflect on their practice, to indulge in improvement, peer review-a very positive process. At the end of the day, if the responsible officer is not able to make a recommendation, it is not his binary decision. It then goes to the GMC for consideration, if there is a case to answer, so it’s not the RO’s decision to end a career.
Q115 Dr Wollaston: I think the public would be rather distressed to hear that revalidation wouldn’t pick up the Dr Shipmans of this world and also that it wouldn’t, possibly, pick up those doctors that the public are currently very concerned about, such as Dr Ubani, that are coming in working as locums. Do you not see any possibility for revalidation having a role in actually doing what the public expect it to do?
Dr Brian Keighley: I don’t want to be too negative about that aspect; I think it is a byproduct. But would the public not be much more concerned if the Bristol heart surgeons or some other situation was not being reflected upon?
Q116 Dr Wollaston: Absolutely, but I think the public would expect it to deliver both.
Dr Brian Keighley: Consider them both, but I think the Bristol situation was a systems thing.
Q117 Chair: What I think Sir Ian Kennedy found was not that it was systems: it was a lack of willingness to use information that was available to the entire clinical community.
Dr Brian Keighley: Yes. They weren’t reflecting.
Chair: Yes. "Funking" might be the word.
Q118 Valerie Vaz: You had some concerns about the costs of revalidation and where that would fall. Could you just expand on that?
Dr Brian Keighley: I have said in print that the last thing we want at any point in time is half the nation’s doctors going up the M6 to test the other half-that is the extreme. But we are living in straitened circumstances, and we have anxieties that the opportunity costs of all this could at the end of the day detract from patient care and the time that doctors have to spend on it. It should be as simple and as straightforward as possible. It would be ironic if we allowed a system to develop and then found that there weren’t the resources to support it. Yes, we have concerns about the costs.
Q119 Valerie Vaz: Where would you see the costs falling?
Dr Brian Keighley: There are financial costs. One of the big gaps that we have is that there is no clarity about remediation and the costs of remediation for those doctors found lacking. There is the worry about taking time and effort away from organisations to do this when there are priorities to spend it on patient care.
We also have the added anxiety in England-I wish you well-of throwing the health service up in the air and seeing where it lands. Where are you going to put the responsible officers in PCOs that are not going to exist and strategic health authorities that are not going to exist? There are grave anxieties about the costs of that.
Q120 Chair: You are tempting us down long avenues that are slightly outside the scope of the revalidation inquiry-relevant too, though.
Is there any element you would like to cover that we haven’t covered in the session this morning?
Dr Brian Keighley: I think just to say that the BMA represents doctors’ interests, but we also are there to represent patients’ interests and the best interests of the health service. We think that the GMC’s latest response is far more practical than previously.
Time scales are important and I think there needs to be a co-operative spirit to take things forward, but the GMC has to learn from its experience. It can be a dogmatic organisation and I think it has to work with the doctors that we represent because revalidation and regulation, at the end of the day, can only be done with consent. They are nearer to it than they were but there are still big issues that we will have to work out working together.
Q121 Chair: Do you think that it is realistic to resolve these areas of current debate within a time scale that allows revalidation to become effective before the end of 2012?
Dr Brian Keighley: I think 2012 is a target and I hope it is a realistic target. The Revalidation Delivery Boards-I am on the one in Scotland; Hamish Meldrum is on the UK one-are the ones that will sign off and it is very important that they don’t sign off the process and make it go live, until everything is in place and is reasonable. I think there is a chance we will do it by 2012, but if it wanders, hopefully it won’t wander too far from that.
Q122 Chair: Is there not a need for there to be a set of milestones? It’s no good waiting till we are halfway through 2012 and then concluding, "Oh, we’re not going to make it by December," is it?
Dr Brian Keighley: I think Niall Dickson covered this last week. He said that, yes, they will make a big effort to get everything in by 2012 and then there will be a second date by which they will sweep up everyone. We believe that there is an irony in putting the easy things first-because that is where we suspect there are least problems-and leaving the hardest bits till last. If it is going to come in for the vast number of doctors where there are least problems, then there must be a hard and fast rule that everyone is swept into the system and the hard cases are involved very soon thereafter.
Chair: Thank you very much. Thank you for coming.
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