Revalidation review urges GMC to cut burden on doctors

Appraisal and revalidation impose too great a burden on doctors, with many asked to complete activities 'above and beyond' GMC requirements, a review commissioned by the regulator has warned.

Charlie Massey: GMC chief executive
Charlie Massey: GMC chief executive

Many doctors say local healthcare organisations force them to provide information or complete tasks that exceed specifications in GMC guidance, a report on the review concludes.

It warns that a lack of clarity around the process for locums is 'unacceptable', argues that local organisations need to do more to help doctors collect information easily to support appraisal and that they should do more to ensure appraisal is fair, efficient and effective.

Patient feedback should play a greater role in informing appraisal, and responsible officers (ROs) should 'avoid placing revalidation requirements on doctors that go beyond what is specified as necessary by the GMC', the review found.

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It also raises concerns that GPs in particular face duplication of work because information they must collect for appraisal and revalidation is required in a different form by the CQC.

But despite concerns, the review led by Sir Keith Pearson to mark the end of the first three-year cycle of revalidation found that the process 'has already delivered significant benefits'. The introduction of revalidation had tackled the long-standing issue that unless a serious concern was raised about a doctor, they could 'practise from registration to retirement without any check on their performance or competency', the report said.

Patients expect that doctors are subject to ongoing review, and want assurances that this is taking place in their local area, Sir Keith wrote. The introduction of the process in late 2012 had helped to ensure that annual appraisal now takes place for most doctors and strengthened clinical governance, the review found.

It cited evidence that 90% of doctors have undergone appraisal and that 95% of these had done so in the past year - a sharp rise from the situation six years ago. 'Despite appraisal being a contractual requirement in the NHS for many years, annual appraisal rates in England in 2010 were just 36% for SAS doctors, 64% for consultants and 73% for GPs,' the report says.

'Throughout the course of my review I have repeatedly heard that revalidation has been the catalyst for increases in appraisal rates across all settings,' Sir Keith wrote. He cited evidence from the BMA that structured annual appraisal 'prevents a doctor's skills becoming so out of date that they become subject to formal competency procedures without being given the opportunity to put things right'.

Fitness to practise

Up to 40% of doctors say revalidation has had a positive impact on their clinical practice, and the review highlighted evidence from appraisers that suggests it has helped to identify poor performance.

One in 10 appraisers in a survey cited in the review had formally escalated a concern about at least one appraisee's fitness to practice, and nearly a quarter had identified a concern and dealt with it during appraisal.

Sir Keith's review says that he believes that 'revalidation underpins and evidences the professional standing of a doctor'.

But he said he was concerned that 'some doctors report very negative experiences' and say revalidation has undermined the quality of appraisal, and reported that some doctors had been asked to carry out a specific number of clinical audits, or asked to collect more patient or colleague feedback than was required by GMC guidance.

Sir Keith wrote: 'I hear and share doctors' concerns about the cost and administrative demands of the appraisal and revalidation process. I am asking healthcare organisations, the GMC and system regulators to look at practical ways they can reduce the time and effort needed to prepare for appraisal.

GPonline reported last year on research showing that revalidation had pushed some older GPs to retire early. Sir Keith highlighted this as a particular concern, but warned that although this reflected concerns about the burden and efficacy of the process to some extent, some negative comments about revalidation 'betray a lack of understanding of the purpose of the process'.

Revalidation impact

Responding to the report, GMC chief executive Charlie Massey said: 'It is reassuring to hear that revalidation is settling in and beginning to impact on clinical practice, behaviour and patient safety.'

He acknowledged increasing pressure on doctors and the need to make revalidation 'as efficient as possible, while maximising its impact'.

Evidence that doctors were being asked to carry out work beyond GMC requirements was concerning, he said, and the GMC would work with employers and royal colleges to clarify what doctors should be asked to do as part of the process.

BMA chair Dr Mark Porter said: 'The vast majority of doctors are good doctors - they have the skills, experience and expertise to deliver first-class care.

'While many of the recommendations will be broadly welcomed by doctors, it not yet clear how this how these will be turned into a reality. The BMA will continue to press the GMC and other bodies about the actions needed to relieve the unnecessary burden that revalidation can sometimes place on doctors, in order to ensure the process delivers for patients, doctors and the NHS.'

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