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The implementation of revalidation is still shrouded in uncertainty with less than a year to go before the scheme is supposed to be launched across the UK.
While the detail of the core elements for GPs has largely been decided, there are still major issues showing little sign of being resolved.
Left to right: Dr Joshi, Professor Pringle and Dr Marshall at the revalidation
roundtable (Photograph: Jason Heath Lancy)
And predictions for the number of GPs being revalidated in 2011 have been drastically scaled back from 12,000 to a maximum of 2,000, since October last year.
The RCGP's revalidation lead, Professor Mike Pringle, told a recent roundtable debate at the college's London headquarters that although the overall picture was 'reasonably positive', there were clouds that had to be acknowledged - including the funding of the scheme, the poor state of clinical governance systems in many localities, and the identification and support of struggling doctors.
'The incoming government is going to be looking at the cost of everything, including whether we have got the cost base right for revalidation.'
He said the cost of 'remediation', or retraining of doctors who are identified as performing poorly, should already have been in the system as part of clinical governance.
But RCGP chairman Professor Steve Field (pictured below) said many areas of the country were not properly covered by clinical governance procedures.
Professor Field wants GPs coming together to work in federations (Photograph: Jason Heath Lancy)
'Despite having a decade to implement robust clinical governance systems, the NHS has failed to do so. If the NHS had delivered on clinical governance, it would be far easier for us to take forward a professionally led revalidation system.'
Professor Field said that remediation was a 'separate and different' issue to revalidation but the GPC has made the delivery of a support system for GPs a deal breaker - an element which could be endangered by the NHS funding crisis.
Concerns over costs
GPC negotiator and chairman of GPC Scotland Dr Dean Marshall said: 'We have always had concerns about the cost. We have certain issues that are must-dos. One of those is that it must be funded properly and of course this should have been sorted out a long time ago.
'Unfortunately events have overtaken us and we are now in a very difficult financial situation that will make it even more difficult to get proper funding.'
Professor Pringle said that assuming all of the elements were in place, the roll-out of revalidation would start in April 2011, with the first doctors being revalidated in the summer of that year.
These would be the doctors currently participating in pilots around the UK, including the 2,000 or so doctors from all parts of the profession in the 10 pathfinder sites in England.
'The GPs involved will know who they are and will go from being pathfinders to early adopters. So the first year, which I am fairly confident about unless something quite dramatic happens, will be a limited roll-out of those who have already had a dry run. For most doctors it starts for real in 2012.'
Professor Pringle said the GMC and NHS would decide the detail of the roll-out, including which localities and medical specialties would go first.
'The college would like the GMC to look at a PCT and check whether they have a responsible officer in place, whether they have clinical governance sorted out, and whether strengthened appraisal is in place throughout their patch.
'We would then like to see a discussion between the LMC and PCT about how everybody is ordered to go through revalidation and how they go. I think people should have a choice and I think we can do that in a very mature way if we are asked to do it.'
Dr Marshall said the BMA view was that revalidation was a 'whole profession' issue and that 'everyone should go together'.
Professor Pringle said: 'That would be our position too. We certainly do not want GPs being revalidated and then waiting for the rest of the profession to catch up. But there will be areas where clinical governance is not sorted out and they will clearly not be ready to go.
'So we will have a multi-speed economy but we do not want any particular professional group to feel they are being put in the firing line.'
GPs need new support system for revalidation
GPs need to be protected and supported to prevent revalidation from damaging their health, according the chairman-elect of the RCGP.
Dr Clare Gerada (pictured below), who takes over as chair of college council in November, said her role in running the Practitioner Health Programme in London had made her aware of the potential problems ahead.
Dr Gerada: revalidation should be linked to a national practitioner health
programme (Photograph: Jason Heath Lancy)
'Revalidation is fantastic but it has to be offset by a system of national support for doctors. PCTs have now stopped funding doctors going to neighbouring PCTs when they fall ill, which deters people from seeking help.'
Dr Gerada said her programme was handling 350 cases, with five to six new referrals each week, but would have to stop taking referrals from August because of funding cuts.
'I think revalidation is going to frighten those people who are already struggling for whatever reason,' she said.
'I would like to see an insistence that revalidation is linked to a national practitioner health programme across the whole of the UK, with confidentiality and a return-to-work system.'
Dr Gerada said there was a strong financial case for investing in support for sick doctors. 'We see £200 million spent on regulating doctors in some form or other, medical defence fees are increasing by up to 12.5 per cent this year, and there has been a staggering increase in fitness to practise cases.
Service could save £100m
'A national service would save £100 million by getting sick doctors back in to service, and saving on locum costs - let alone the cost of litigation.'
She also raised the issue of doctors having to disclose sensitive health information to PCTs as part of the appraisal process.
'We are the only group in society having to do this at appraisal. If the doctor gives details, these have to go to the PCT and that doctor is seen as a risk.'
Chairman of GPC Scotland Dr Dean Marshall said that north of the border a doctor's health information was only passed on with their agreement: 'Your situation sounds worrying and would not be acceptable to the vast majority of doctors and needs to be taken up.
'We have to win the confidence of the profession but when the building blocks are being removed that's going to influence their confidence. The government cannot have it both ways. We have to have a support system in place.'
Dr Gerada said there was also a problem with doctors' privacy coming under attack: 'I have had lots of phone calls from doctors asking if they have to tell the GMC that they have taken an overdose in the past.
'Why would you need to do that if you did it as an 18-year-old? These are where the fears are coming - at really low levels of health issues, let alone the higher level problems.'
RCGP revalidation lead Professor Pringle said the problem was not necessarily linked to revalidation, in that the GMC was taking a far greater interest in the working and personal lives of doctors.
'Of course there are doctors out there who are concerned about revalidation. But I have spoken to 1,200 in the past month and they are becoming more positive. They are understanding it and saying it's not that bad, so bring it on.'
Profession must change its attitude to locums
General practice will need to undergo a major culture change in order to give every GP the same chance of passing revalidation.
RCGP revalidation lead Professor Pringle said he believed practices had a duty to look after the CPD and revalidation needs of their locum GPs.
'When a practice contracts over a period of time with a locum, or series of locums, they have a responsibility to help these doctors collect evidence, review cases, and report any complaints back to that doctor so they have an opportunity to respond.
'They need to be aware of their responsibility for the CPD of these doctors as part of the contract of employment.'
Professor Pringle said locums would also have to look at their own ways of working in order to avoid becoming 'vulnerable'.
'They need to recognise that in a modern healthcare system, operating in complete isolation is no longer going to be feasible. Locums are going to need support networks.'
Professor Pringle said it was a political issue that needed to be addressed, but chairman of GPC Scotland Dr Marshall insisted it was a professional issue.
'This is a major issue but it's not political. I would much rather see this as a professional issue and we should all be helping our colleagues get through revalidation.'
He added: 'Whoever is an employer has a responsibility to ensure that every doctor has the opportunity to revalidate. It's about being a member of a profession.'
RCGP vice-chairman Dr Has Joshi said that culture changes were also required to properly help doctors who were found to be failing under revalidation.
'Revalidation should be about improving the profession, not about weeding out bad doctors. The culture is very important when it comes to remediation - at the moment we do not have remediation in practices.
'Nobody wants to take these doctors on because what are you going to tell your patients? That part of the culture needs to be changed.'
RCGP chairman Professor Steve Field said many of the issues around professional development and remediation could be dealt with through GPs coming together to work in federations.
'When practices start to come together more in larger groups and federations, while still maintaining the identity of the practice and the practitioner, the evidence is that when the doctors lead these organisations they look at what each other is doing and deal with any performance issues before any retraining is needed.'