Evaluating the regulatory impact of medical revalidation

In this months edition of the blog Mirza Lalani a Research Assistant for Improvement Science London discusses an evaluation of medical revalidation which they have been commissioned to conduct by the GMC.

After years of deliberation and procrastination mandatory medical revalidation finally became a reality in 2012.

So what exactly is medical revalidation? A paraphrased General Medical Council (GMC) definition refers to it as ‘demonstrating a doctor is up to date and fit to practice’ and ‘to provide extra confidence to patients that their doctor is regularly checked.’ Terms such as ‘patient safety’ and ‘care’ also feature in the GMC revalidation guidance.

Why are doctors being revalidated? Widely publicised tragic medical scandals, ensuing pressure from politicians and damning high profile reports on the state of medical regulation may provide the answer. It is also fair to ask why doctors should not be revalidated, exempt from regular monitoring or dare I say control? After all, the Royal College of General Practitioners recently described healthcare as a ‘safety critical industry’ not unlike aviation.  Or perhaps it is a reflection of the demands of modernity. Another element of a social contract in which accountability and transparency are reasonably expected of a profession that draws on the public purse and that has traditionally been regarded as privileged, autonomous and opaque.

Therefore, unsurprisingly, the notion of public trust underpins the basis for revalidation. Doctors recently topped the list of most trusted professions in the UK according to an IPSOS Mori survey. The narrative of a good and caring doctor is frequently told in homes and schools across the country. So will revalidation further harness public trust in doctors?

How does a doctor revalidate? Through 5 annual appraisals with a fellow doctor (the appraiser), at which they present a myriad of documentary evidence in the form of continuing professional development, feedback from colleagues and patients, clinical audits etc. Ultimately a Responsible Officer (RO) (also a doctor) makes a recommendation (based on the appraisal feedback) to the GMC (the regulator) as to whether the doctor should be revalidated. A simple paragraph to describe revalidation does it an unintended disservice. The appraisal process has been described by some as cumbersome and time-consuming, with an added frustration of having to work with archaic IT recording systems. Collectively these challenges may inadvertently increase pressure on an already teetering workforce.

An evaluation of the first cycle of medical revalidation in the UK has been commissioned by the GMC and aims to gather information about revalidation mechanisms at all levels of the process. To do this, we are using a mixed methods approach. We will use Cultural Historical Activity Theory (CHAT) to frame and systematically manage the extensive research study; conceptualising revalidation as an activity being undertaken within the wider complexity of healthcare delivery. CHAT will enable us to ask: how will revalidation’s regulatory objectives actually be achieved within healthcare delivery systems; how does revalidation, as a series of activity systems focusing on supporting information, appraisal and RO judgement making, impact on healthcare systems? Conversely how might healthcare systems impact on the implementation of revalidation?

The research will be delivered via seven work packages:

1. Literature reviews
2. Secondary analysis of existing GMC, Medical Appraisal and Revalidation System (MARS) and Scottish Online Appraisal Resource (SOAR) datasets for England, Wales and Scotland respectively
3. National and strategic surveys
4. Appraisal capture
5. Interviews with stakeholders (appraisees, appraisers, ROs and GMC Employer Liaison Advisors)
6. Documentary analysis
7. Root cause analysis of documentation when fitness to practice referral has happened

The overall evaluation is led by the Collaboration for the Advancement of Medical Education Research & Assessment (CAMERA) based at the Peninsula Schools of Medicine and Dentistry, Plymouth University. At UCL we will be working on work packages 1, 4 and 5. The appraisal capture (work package 4) will help us to understand what really happens in appraisal as opposed to what is purported to happen.

Subsequently, semi-structured interviews (work package 5) will be held with the same appraisees, each of their appraisers and a smaller sample of ROs and GMC Employer Liaison Advisors. These interviews will inform and add depth to our understanding of what is happening across the activity of revalidation. It is hoped the findings from the overall study will contribute significantly to shaping the future of medical revalidation.

 

For more information on the evaluation of the first cycle of medical revalidation in the UK visit http://www.umbrella-revalidation.org.uk and for more information about this work contact Mirza m.lalani@ucl.ac.uk.

 

This study is funded by the General Medical Council. The views expressed are those of the author and not necessarily those of the GMC.