Articles and Case Studies

UK Revalidation – A Valid Model for Australia?

04 Oct 2015

Surgeon in conversation


Heralded as “the biggest change in medical regulation in more than 150 years”,1 is UK revalidation a suitable model for Australia?

Following the announcement in March 20152 that the Australian Health Practitioner Regulation Agency (AHPRA) has commissioned international research from CAMERA (a leading healthcare regulation research organisation in the UK) to develop revalidation in Australia – the question is no longer “if”, but “when”. With similar debates occurring in Australia, as previously seen in the UK prior to the implementation of revalidation in 2012, we look at the situation two years on and ask whether lessons can be learned from the UK’s experience.

Implementation in the UK

After decades of debate and a series of medical scandals in the 1990s, the UK’s medical regulator, General Medical Council (GMC), introduced revalidation in December 2012.3 All registered medical practitioners with a licence to practise in the UK now have a statutory duty to demonstrate that they are up-to-date and fit to practise through a process of enhanced appraisal. With over 235,000 licensed doctors in the UK at the time of implementation, the national program was designed to be introduced over a number of years, ending in December 2016. Following initial revalidation, licensed doctors must revalidate every five years by demonstrating they continue to meet specified regulatory standards.  

How do they do that?

The process focuses upon the annual appraisal and places reflective evidence at its core. In doing so, doctors are now required to produce a portfolio of six types of supporting evidence for discussion at their appraisal during each revalidation cycle. These are:

  1. continuing professional development (CPD)
  2. quality improvement activity
  3. significant events
  4. feedback from colleagues
  5. feedback from patients
  6. review of complaints and compliments.

The process is supported and managed by a national network of Responsible Officers (ROs) who are charged with making revalidation recommendations on behalf of each licensed doctor. Consequently, the GMC, NHS England, the Royal Colleges, the British Medical Association and other ancillary organisations have published reams of guidance to support doctors through the process. This massive undertaking has come at great expense – in England alone, the costs are estimated to reach £97 million a year until 2023.4 Ultimately the scheme is predicted to generate net savings of between £50 million and £100 million a year from 2017 onwards as a result of improved quality of care, procedural efficiencies and reduced litigation costs.  

Is it on track?

By January 2015, 45% of UK doctors subject to revalidation had reached their scheduled revalidation date, with over 98% either approved or deferred pending submission of additional evidence.Thereafter, the majority of the remaining doctors are due to be processed by the end of 2016. But with the publication of the first reports into the impact of revalidation and scathing commentaries in the UK’s medical media, the Australian authorities may be wondering whether UK’s model is one to emulate.

As part of its ongoing commitment to monitor the implementation of revalidation, the GMC has published quarterly progress reports which have identified some revealing statistical trends. Firstly, there have been an unprecedented number of doctors relinquishing their licence to practise – some 18,655 since December 2012, as compared to only 2,230 in 2011.6 Although the majority of these doctors cited “retirement” or “moving overseas” as their reason for relinquishing their licence, the temporal link with revalidation cannot be dismissed.

Separately, the data shows a higher proportion of foreign qualified and ethnic minority doctors deferring their revalidation due to insufficient supportive evidence. This revalidation bias echoes concerns from those involved about the disproportionate burden placed on some sectors of the profession. The figures also show an age bias, with a substantially higher deferral rate for women in their 30s and doctors over 65 years of age. While this higher rate for young female doctors may be a result of career breaks, the figures for the over-65s accord with wider concerns that revalidation favours the IT literate and junior doctors who are schooled in the requirements of modern regulation, as opposed to the more experienced practitioners. 

Perhaps most interestingly, the GMC revealed that less than 1% of all UK doctors have been identified as requiring remediation,7 leading to criticism by patient groups that the process is bureaucratic, ineffective and lacks credibility.8 While these concerns have been dismissed by the GMC, they find some resonance in the impact reports published in 2014. The largest of these was from CAMERA,9 the same group commissioned by AHPRA, which identified uncertainty as to whether revalidation would achieve its aims. It noted a lack of clarity surrounding the conflict between patient assurance and quality improvement, and recommended reconsideration of the peripheral role played by patients, a key driver.

Further questions have been raised as to whether revalidation is the correct tool to improve the quality of health care. Research suggests that revalidation may be profoundly altering the dynamic of the appraisal process, prioritising performance assessment over personal development. This perceived loss of traditional mentoring has led to a concern that doctors may be less willing to raise problems and will submit self‑serving and potentially unrepresentative evidence to satisfy the new regulatory focus. Furthermore, with a fundamental reliance on the quality of individual appraisers, local inconsistency risks undermine the national process. With one survey10 reporting that only 43% of appraisers agreed that revalidation had improved the appraisal process, there is clearly much more work to be done to convince the profession and garner the support necessary to make revalidation a driving force behind quality improvement.

Recent research has inevitably focused upon deficiencies in the process, but it is undoubtedly the case that revalidation has significantly improved rates of engagement in appraisal. These have risen from 63% in March 2011 to 76% by March 2013.11 Whatever its deficiencies, revalidation has introduced a more systematic and quantitative approach to appraisal with a renewed focus on its importance. The GMC acknowledges that refinement of the UK system is required and fundamental questions about the impact of remediation remain. Only time will tell whether it is a model for Australia. 

Adam Weston
Solicitor, BLM*

*BLM is UK and Ireland’s leading risk and insurance law business.

References

1. General Medical Council. Revalidation Will Improve Patient Safety, GMC Tells MPs. Press Release, 28 October 2010.

2. AHPRA. Board Commissions Research on Revalidation. Media Statement, 24 March 2015.

3. General Medical Council. An Introduction to Revalidation.

4. Department of Health. Medical Revalidation: Costs and Benefits, Analysis of the Costs and Benefits of Medical Revalidation in England – November 2012. 2012.

5. General Medical Council. Revalidation Implementation Advisory Board. GMC Progress Report, 4 March 2015.

6. Ibid.

7. Matthews-King, A. Revalidation Identifies Fewer Than 1% of GPs Needing Remediation. PULSE 5 May 2015.

8. Donnelly, L. Alarm Over Doctors Check With 99.3% Pass Rate. Daily Telegraph 16 May 2015.

9. Archer J, de Bere SR, Nunn S, Anderson A. Revalidation in Practice: Shaping the Future Development of Revalidation. Plymouth, UK: Collaboration for the Advancement of Medical Research and Assessment, 2014.

10. NHS Revalidation Support Team. The Early Benefits and Impact of Medical Revalidation: Report on Research Findings in Year One. London: NHS, 2014.

11. Ibid.

 

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