A Pit Stop on the Road to Revalidation in the UK

Passport, visa and GMC documentation all in order? Now prepare yourself for revalidation…

Revalidation came into force at the end of 2012, and is the process by which virtually all licensed medical practitioners in the UK, including trainee doctors, must demonstrate to the GMC every five years that they are up to date and fit to practise. The cornerstone of revalidation is that doctors must undergo annual appraisal culminating in an enhanced appraisal undertaken by a Responsible Officer (normally the medical director of the doctor’s employing organisation known as a designated body) at the end of the five-year cycle. The Responsible Officer will make recommendations to the GMC as to whether (subject to there being no health or probity concerns) a doctor should be revalidated but the GMC will have the final say on whether to revalidate a doctor – and, therefore, whether to challenge any recommendations which seem perverse or are unsupported by evidence.¹

Historical backdrop

As far back as 1975, the Merrison Committee² suggested that there should be some form of “relicensure” for doctors. And there matters lay until a series of medical scandals³ brought the issue into the spotlight again and highlighted that self-regulation had been found wanting and the GMC proposed revalidation as a consequence.¹

Dialogue between the GMC and the medical profession about what would and would not constitute a fair and robust system for revalidation was slow and protracted. By 2005 the GMC were on the verge of introducing a scheme, until their plans were scuppered by Dame Janet Smith, Chair of the Shipman Inquiry, who expressed serious misgivings⁴ about what was being proposed. She highlighted in particular that the GMC may have oversold revalidation as providing reassurance to patients and the public that each doctor on the register was up to date and fit to practise when the model did not involve direct GMC assessment of a doctor’s practice. Further, a doctor may be deficient but not quite deficient enough for the GMC to invoke its fitness to practise procedures. Eight years later, revalidation is at last in place.

Professor Sir Peter Rubin, Chair of the GMC and the first doctor to revalidate in the UK, said that this is the biggest change in medical regulation since the GMC was established in 1858.

This may overstate the point a little, especially as the pace of change in medical regulation post-Shipman has been phenomenal; the current medical regulatory landscape is almost unrecognisable from what it was in 2005 or indeed at the time of the Merrison report when the Committee said that they could never imagine that the GMC could ever hope to dictate rules for doctors! There is no doubt, however, that the road to revalidation has been a somewhat rocky one.

Key principles and themes

The GMC provides a wealth of well written and easily-accessible guidance on its website⁵, which sets out the parameters within which a doctor’s fitness to practise and clinical knowledge will be assessed.

At the heart of revalidation is annual appraisal, and as ever with the GMC (and rightly so), reflection is the key. The purpose of revalidation from the GMC perspective is that it is not supposed to be a superficial tick-box exercise; rather it is intended to provide a meaningful opportunity for a doctor to reflect on their clinical practice and how they may develop and modify it as a result of that reflection.

The framework consists of four key domains against which fitness to practise will be assessed at the five-yearly enhanced appraisal:

1. knowledge, skills and performance
2. safety and quality
3. communication, partnership and team work
4. maintaining trust.

If you read nothing else, you should read Good Medical Practice⁶ and the linked Framework document before you leave the sunny shores of Australia, as they will tell you all you need to know about the clinical standards, conduct and ethical behaviour that the GMC expects from doctors practising in the UK.

Effectiveness

In today’s austere economic environment, the cost of revalidation, currently £2.75 million⁷, is probably the primary concern of critics who query if it will deliver value for money. The GMC say that they have never considered the purpose of revalidation to primarily identify “bad apple”’, but to affirm good practice.¹ In comparison to the cost, however, while the aim of ensuring continued high standards across the board for all doctors is of course a laudable one, the process itself may turn out to be somewhat of a blunt instrument. These and other issues such as increased bureaucratic burden on doctors, the ability to ensure fairness within a system which is inherently subjective in nature and, most importantly, the difficulty in identifying the real benefits which revalidation will bring in terms of increased patient safety will no doubt provide fertile ground for further commentary in the future.

All that said, in terms of patient protection, time may show there are potential gains to be had. Certainly revalidation will ensure that every doctor will have a meaningful appraisal on a regular basis, which will hopefully lead to more proactive, preventative regulation and better standards on the ground.

What it means for you

Remember, participation in revalidation is not optional; Good Medical Practice⁶ imposes a positive obligation to engage with the process and failure to do so could lead to the withdrawal of your licence to practise. Appraisal is not like cramming for your finals; you will need to maintain an evidence-based portfolio and gather information throughout the five-year cycle. Provided you plan, document and review then all should be well. Although potentially onerous, the new regime could be a positive and insightful experience for doctors and contribute to an improved patient experience and increased patient safety. For those who have no plans to visit the UK, this article may be dismissed as (thankfully) academic but beware where the GMC lead (at least in the UK), others will follow, meaning their revalidation model may well be replicated in other jurisdictions in the future, including Australia…

Andrew Truby is a solicitor at Berrymans Lace Mawer LLP, UK.

Read our short update on Revalidation in Australia in Defence Update Winter 2013.

1 Rubin P. Revalidation: A General Medical Council Perspective.Clinical Medicine 2010;10, (No.):112-113. Available at: rcpjournal.org/content/10/2/112.full.
2 Merrison Committee was formed by the government to look into the modernisation of the medical profession.
3 In particular, the Bristol Royal Infirmary Inquiry.
4 Final Report of the Shipman Inquiry – 27 January 2005. Available at: webarchive.nationalarchives.gov.uk/20050129173447/the-shipman-inquiry.org.uk/finalreport.asp.
5 GMC Good Medical Practice Framework 2013. Available at: gmc-uk.org/doctors/revalidation/revalidation_gmp_framework.asp.
6 GMC Good Medical Practice – March 2013 version. Available at: gmc-uk.org/guidance/good_medical_practice.asp.
7 GMC statement of financial activities for the year ended 31 December 2011.