This is the text of our letter to the GMC in response to their consultation document on Revalidation:

Dear [GMC],

Reference: The Consultation Document; Revalidating Doctors:
Ensuring Standards, Securing the Future

Thank you for inviting the NASGP to participate in the GPs Consultation Group and revalidation consultation process. We are pleased that the GMC has recognised the need for all stakeholders to have a voice in the process and have therefore consulted widely within our own membership and beyond, in the wider non-principal community by a variety of means (including our web site).
Accordingly, this response is a composite of those views, though I have encouraged individuals with a strong opinion to also respond directly.

I shall endeavour to link our response where possible to either the document paragraph or specific question concerned. However, there have been some more general comments and I will include these at the end.

Question 1.
Box 1; Benefits of Revalidation - bullet point 4:
Do we know that this process will increase the public's confidence in their doctors? They may seem a trite comment, but as this is the nub of the revalidation issue, the GMC and the profession must be sure it will.
What are the plans regarding public consultation (as opposed to patient organisations) on this point?

• Will this consultation be undertaken prior to revalidation being set in motion?
  Otherwise, the huge costs in time, money and effort associated with revalidation will be wasted.
  Box 2; Principles of Revalidation - bullet point 6:
  The exact nature of 'Proportionate' needs to be clarified. The presumption being that the revalidation process must not be overly prescriptive;
• Majority of doctors are 'good' & 'safe'.
• Revalidation must be robust enough to identify those doctors who are putting patients at risk, yet must avoid being so onerous as to drive the safe majority of doctors out of medicine altogether.
  Box 3; Attributes of Revalidation - last bullet point:
  No doubt in common with the rest of the medical profession, the question of revalidation being 'Properly resourced' raised many concerns amongst our members.
  Throughout the process to date, the professional organisations (including your own) have made it clear that unless revalidation attracts sufficient resources in time, man-power and training, let alone financial costs, the process will be a non-starter. On each occasion that this issue has been raised, the response has been to acknowledge this, but no concrete proposals have been forthcoming.
  The time has now come for such proposals to be generated and some cost projections must be done (as I gather the RCGP revalidation group have considered, at least with regards to the training/appraiser aspect).
  An additional 'attribute' would also benefit this box, that of the confidentiality of the revalidation process for doctors and patients. Granted, this issue is mentioned elsewhere in the document, but it is of such a fundamental nature, underpinning the whole process, that it deserves early mention.

Stage 2 - Five-year assessment;

• Why do the contents of the folder itself have to be physically examined at this stage?
  If it has been subjected to 5 annual appraisals, then satisfactory completion of these alone, supported by certification to confirm this, should be enough rather than the revalidation group having to double check what the appraiser has already done.

Question 2
Contents of the revalidation folder
A number of our members are concerned regarding how these proposals will relate specifically to locums. Locums are not employed and are at present usually neither expected nor encouraged to take part in 'quality assurance' methods of the practice/organisation they are working within. Indeed in some instances they are actively discouraged from doing so. True, the setting up of supplementary lists by Health Authorities envisioned in the recent consultation document by the Department of Health will help tie locums into the whole quality agenda (something which the NASGP welcomes), but locums work in a very non-standard way.
The NASGP Personal Learning Portfolio, "Striving for Quality" is an effort on our part, to engender the practice of recording evidence of reflective practice by UK non-principals. Yet without access to local tutoring and mentoring schemes, this evidence will by necessity be non-standardised.

• It is vital that acceptable evidence for the folder is flexible enough to allow inclusion of this non-standardised material from locums (and others).
• How does the GMC propose to assess such non-standardised material?
  This is of particular importance when one considers the resource issue alluded to earlier; many non-principals, especially locums, continue to be 'outside' present systems of CPD provision. As such, they are already disadvantaged compared to their principal (and even employed non-principal) colleagues.
• At the very least, the GMC should be supportive of efforts to make such resourcing universal.
  We understand that the actual criteria against which the contents of the folder will be assessed is being developed by Collegiate bodies for each discipline.
• It is essential that the GMC ensure that any system of criteria adopted is rigorous and universal, such that no group of doctors be advantaged or disadvantaged.
  When assessment against these criteria shows this non-standardised evidence to be 'substandard' (i.e. the evidence provided does not meet the criteria, rather than the practise not doing so), will proof of development be required over time, rather than the doctor's performance being considered unacceptable?
  

Question 3
Inclusion of complaints in the folder
Some respondents have expressed concern regarding the inclusion of complaints that have proven unfounded and commented that this might be regarded as showing a lack of trust (on the patients' and revalidation group's part) in the complaints system reaching the correct conclusion.
The most concern was voiced over the inclusion of anonymous complaints, with the feeling that they should not be included.
We accept that a pattern of complaints, even if not upheld, may show a behavioral or performance pattern in the doctor concerned and there must be some mechanism by which this pattern can be brought to the attention of the revalidation process, without allowing room from malicious complaints.
However, if the purpose of including any complaint in the folder is to show how & what the doctor 'learnt' from the experience of having a complaint made against them and how they handled it, rather than simply as a 'black mark', then inclusion is justified.

• Complaints should be included for their formative value and not be purely punitive.

Question 4
Box 8; Appraisal and prompt action in unsafe cases
The proposed annual appraisal of all NHS doctors (set out in Supporting doctors, protecting patients and refered to in the NHS Plan), has caused concern amongst our members. Questions about the mechanics of such appraisals are best directed towards the CMO's department, however, exactly how these appraisals relate to the revalidation process is very much at issue here.
Bullet 1;

• Annual appraisals must be formative not punitive.
  Such appraisals should be part of a 'rolling' process - any areas of concern should be tackled as and when they arise, not left until the formal appraisal interview. In this way, there should be no surprises regarding the outcome of the interview; both appraiser and appraisee will be aware of 'problem areas' on an ongoing basis and be taking steps to address them.
  Bullet 3;
  
• Appraisal material should inform, but not dictate, the revalidation process.
  Bullet 5;
  Some of our members have expressed concerns regarding the necessity of working in practices where lack of resources may have an adverse effect on their own appraisal.
  
• Appraisal must take into account not only the presence of such resource issues, but also the fact that changing such issues may be outwith the individual doctor's control (e.g. in the case of a locum or employed non-principal).
  Bullet 7;
  
• Contents of the appraisal interview, and indeed the revalidation folder itself, must remain confidential.
  Some respondents have expressed concern that the folder may be called evidence in a complaints procedure. If this were to be the case, doctors may not be as free and forthcoming with information in the appraisal and for the folder as they should be. This would ultimately undermine the whole concept of revalidation being a protective mechanism for patients.

Question 5
Length of revalidation cycle
We agree that it is reasonable that this be set at five yearly intervals.

Question 6
Recording concerns on the revalidation certificate
There is concern over what such 'concerns' may be. If there is any doubt about a doctor's safety to practice then such a situation will not arise as the doctor will be referred for assessment under the fitness to practise procedures.

• What constitutes a 'concern in need of addressing' that does not impact on patient safety?
  
• Who will decide this and the course of action required?
  Some discussion has been ongoing regarding the setting of 'conditions' on a doctor's revalidation (akin to those used for GP trainer approval or training recognition of hospital SHO posts).
  The GMC document states, "The recommendation must be unambiguous: the doctor should either be recommended for revalidation or referred for review of fitness to practise …". It is difficult to see how this statement can allow for 'conditional' revalidation. Surely the place for setting such conditions when concerns arise, is the appraisal interview.
  
• Revalidation must be all or nothing: 'conditional' revalidation smacks of a two-tier system and will find it difficult to meet public expectations.

Question 7
Lay involvement in revalidation groups
Providing such involvement has been properly trained in appropriate techniques and is properly resourced, then there should be no restrictions placed on lay involvement (in that health service experience should not be mandatory).

Question 8
Participation in revalidation groups
It seems entirely reasonable for doctors familiar with the system that the individual works in to sit on the panel. Whether this goes as far as having a 'known' doctor, is questionable.

• If such a convened panel felt the presence of any particular doctor/individual might compromise its impartiality, could the panel itself co-opt additional members?
  
• Should the doctor under review feel that a panel might be biased, could he/she ask for a second panel be convened (instead of the first, rather than in addition to it - akin to the present choosing of jurors in English law)?
  Although we can see the attraction of having a doctor personally known on the panel - especially for peripatetic locums - we do not subscribe to the view that this be essential. What is essential is that at least one member of the panel is familiar with the working practices of the doctor under review.

Question 9
Arrangements for locums
Understandably, this question generated the most response from our members.
In addition to the points already mentioned above, please note the following:

• Requirement for a 'level playing field'
  All non-principals should have access to full educational, tutoring & mentoring resources. It is implicit in the document that the GMC recognises that revalidation of these doctors will require special arrangements. Such doctors should not find themselves in danger of losing their livelihood from a failure to access the means to prepare for revalidation. Equally important, the revalidation process should not be found to generate a disproportionate number of non-principal referrals to the fitness to practise procedures.
  The mention of the NASGP discussion document on "Virtual Practices" is welcomed -there has been considerable interest from many parties. Such groupings of locums would in effect place them within a 'managed' organisation and facilitate collection of the evidence required for revalidation. Such groups would also go some way to reduce the possibility of 'geographically mobile' locums from falling through the revalidation 'net' by job-hopping.
  However, the benefits of such a proposal would only be apparent if backed by local resources - particularly educational.
  Local revalidation groups should take advantage of the fact that locums often have a good overview of local practices.
  
• Non-principals should be eligible to sit on local revalidation groups and act as appraisers and tutors in the process.

Question 10
Privileges of registration
Doctors who do not need to take part in clinical practice etc. as part of their jobs must continue to keep up to date if they wish to retain the right to do so. However, what is vital is that patients are able to easily distinguish what a doctor's exact status regarding clinical practise is.

• There must be a clear distinction between doctors revalidated for clinical practise and those who are not.
  This is of importance to those of our members working in academic general practice, some of which feel that they should be allowed recourse to meet the requirements for full revalidation should they wish to (by maintaining clinical experience).

Question 11
Retired doctors and revalidation
There should be time limit imposed, so that anyone re-entering practise after the limit has expired must either submit to such an objective reassessment or practise in a supervised capacity for a prescribed period of time.

Question 12
Doctors working abroad
Equivalent experience should be recognised where documentary evidence can be produced. The difficulty would arise in situations where this is not forthcoming and the doctor has spent considerable lengths of time abroad.

Question 13
Distinguishing between revalidated and non-revalidated doctors on the register
Revalidation will re-affirm a doctor's fitness to practise - thereby maintaining registration. Failure to revalidate for whatever reason will lead into the fitness to practise assessment process, failure of which will remove that registration. As the register is designed to inform readers of doctors who are eligible to practise medicine in the UK, then presence on such a register following the institution of revalidation will surely only be possible for those doctors successfully passing revalidation. Otherwise patients will be confused.
However, distinction will again need to be made as to whether revalidation covers the clinical setting or not. Further categorisations of revalidation will only serve to confuse the issue more.

• Easy and clear clarification of the registration status of doctors is essential to maintain public confidence in the procedure.

Question 14
Rights and obligations of registration
As the revalidation process is confirming the doctor's fitness to practise, any doctor not being revalidated for whatever reason, therefore forfeits these rights and obligations. Doctors being revalidated in non-clinical capacities should only retain the rights and obligations commensurate with their actual revalidation status.
It is astounding that non-practising doctors should seek to continue to exercise clinical rights and privileges - such as the right to prescribe for their friends and family. This anathema is dangerous bad practise and revalidation will do well to bring about its demise.

Question 15
Doctors returning to practise after a break
Doctors taking time out (for whatever reason) will need to satisfy the GMC - via the local revalidation board - that their practise is safe. Setting a specific time period, after which the doctor must undergo some kind of re-training, may be inappropriate if said doctor has been participating in CPD throughout the 'break'.

• What constitutes a career break? Is it determined solely by time out of medicine, or out of the doctor's chosen discipline/specialty?
  At the very least, the returning doctor will need to be re-appraised to assess their need for remedial and/or supportive action.
  It seems logical to have a 'sliding scale' of possible routes back to practise for a doctor after a career break, ranging from a period of supervised practise through to one of formal re-training.

Question 16
Inclusion of revalidation date on the register
We too are concerned about the grey area of doctors who fail revalidation and are referred to the fitness to practise procedures being identifiable from a dated register entry.

• Why is a revalidation date needed on the public register?
  If the revalidation process is working effectively and identifying poorly performing doctors, then those on the revalidated register will be known to be fit to practise. A date of revalidation is unnecessary - it will simply cause problems for doctors in the grey area; the public will assume their fitness has been found wanting. In reality, this is not actually the case - their fitness is only in question. Should they pass the procedures they will be revalidated and their reputation may well have been suspected unfairly. As with the jury system, the doctor should be innocent until proven guilty. Contrary to the belief that patients might be put at risk whilst this limbo is in place, the system for fast-tracking the suspension of a doctor considered dangerous is already in place and will be actioned speedily to protect patients.
  Your documents states, "the public is entitled to know." We agree entirely that the public need to know that a doctor is considered unfit to practise. However, why should the doctor not yet found unfit have their reputation prejudiced (and livelihood jeopardised)?
  To play Devil's advocate, if revalidation dates are recorded in the register, what is to stop patients exploiting the situation of a doctor whose date is approaching? Not to mention the possibility of malicious complaints being made in an attempt to tip the balance.
  
• A simple 'revalidated' status is all that is required on the public register.
  Of course, local revalidation groups and the GMC administrative departments will be well aware of when a doctor's revalidation date is due.

Question 17
Disclosure of past GMC findings
It seems only right and proper that findings of a serious nature regarding a doctor's fitness to practise be known to local revalidation groups when considering if a doctor should be revalidated. How long these findings should remain in the revalidation folder itself is debatable and ultimately should depend on the nature of the findings.
It is sad that recent criminal cases have thrown doubt on the ability of the medical profession to keep its house in order - especially regarding serious offences. However, again as with the judicial system, a convicted person who has paid their debt to society and is no longer considered a risk, should not be discriminated against. So should it be with GMC findings.

• 'Current' restrictions or adverse findings should be held in the revalidation folder.
  
• Past findings which do not throw doubt on the doctor's present 'risk' status (from a fitness to practise point of view) should be taken out of the folder once the revalidation cycle they occur in has been successfully passed.
  
• The GMC will continue to hold all past findings information and could make it available to local revalidation groups on request.
  It is our understanding that the (already referred to) proposed 'supplementary lists' of GPs held by Health Authorities will address this issue and as there should be close liaison between Health Authorities and local revalidation groups, the issue of missing findings should not arise.

Question 18
Awarding of costs
As with any new system of regulation, there will inevitably be doctors who chose not to participate. As the revalidation process is designed to ensure doctors are fit to practise, such individuals must either be assessed in some way, prior to a decision being made about their erasure from the register.
It is vital that whatever system is developed to deal with this situation, it is seen to be fair but not an 'easy option'.
The committee proposed by the GMC must make clear to doctors refusing to participate in revalidation what alternate evidence might be submitted that may satisfy revalidation requirements. However, in the case of doctors found unfit by virtue of their decision not to participate, some deterrent should be imposed. In this situation, awarding costs against the doctor is such a deterrent - and an appropriate one.
The reverse scenario - of a 'refusnik' doctor being ultimately found fit and revalidated - is much less clear. Surely awarding such doctors costs could be seen as a reward for their refusal to participate.
General Points
This consultation document is to be commended. It tackles some big issues head on and attempts to address a situation that has been long considered unanswerable; How does one measure the unmeasurable? Although this document itself does not have all the answers, it is useful as a starting point.
Resources
The most pressing 'unanswered' question is the one of resources. To label this as a need for more money is to over simplify things. These resources include (at the very least);

• Time: personal; to collect the evidence for and collate the revalidation folder.
  educational; tutoring, mentoring and performing appraisals and revalidation
• People: appraisers, tutors, mentors, local revalidation group members
• Training: of appraisers, tutors, mentors, local revalidation group members
  Failing the revalidation process triggers the further resource issue of re-training.
  It is vital that someone starts to address these resource issues and draw up realistic costings - now.
  Mentoring
  As mentioned throughout this response, educational needs are paramount for revalidation, especially if it is to remain a largely formative, educational, supportive process that "celebrates excellence" in the medical profession. Several of our members feel that for revalidation to succeed and be effective, a comprehensive mentoring system must be set up and be universally available to all doctors - in our case GPs.
  

Once again, thank you for inviting the NASGP to participate in the consultation process. I have personally found it a stimulating, informative debate. I hope our response helps in the development of a realistic, universal and fair process of revalidation.

Regards,

Tina Ambury

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