Final Report > Chapter 25: Competent Healthcare Professionals > The systems for assuring competence > Revalidation

Revalidation

57 Revalidation in general terms is a mechanism whereby healthcare professionals are required regularly (for example every three or five years) to demonstrate that they remain fit to practise. It involves the submission of evidence to external assessors of continuing competence. In the case of the system proposed for doctors, it is linked to registration in that, if they cannot demonstrate evidence of continuing competence, their registration, and thus their right to practise as doctors, may be called into question and, ultimately, may be withdrawn. A form of revalidation already exists for nurses and for many of the professions allied to medicine. In fact, the practice in the case of nursing is closer to re-registration and is not the same as the revalidation process proposed for doctors. Essentially, every three years, nurses have to submit evidence of the CPD that they have undertaken in order to maintain their registration. There do not appear to be arrangements whereby the individuals are visited in the workplace by a group of assessors. We take the view that external assessment is a very important feature of the process and that methods should be devised to implement it in the case of nurses and others. In the case of senior healthcare managers, no system of registration or formal recognition currently exists. It would need to be developed alongside the introduction of revalidation for other healthcare professionals. We acknowledge that proposals for a system of revalidation for doctors are at an advanced stage of development. Thus we make our comments about the need for the revalidation of healthcare professionals, aware that the potential value of this mechanism is already coming to be widely recognised, by the public, as well as within most of the professions.

58 The call for the revalidation of healthcare professionals marks a significant break with the past. Until very recently, at least in the case of medicine, it was regarded as a sufficient assurance of competence that young, newly qualified healthcare professionals had passed the relevant examinations, and had received guidance and support from more senior colleagues. Thereafter, throughout the whole of their working life, there were no mechanisms, whether within or outside the professions, whether from employers or bodies concerned with registration and discipline, to assess and check a professional's competence. Of course, most professionals developed and improved their competence through experience. And, many have seen it as part of their professional duty to undertake continuing professional development. This is still the case today. For some, however, competence did (and does) not grow with experience. Others did (and do) not pay much attention to continuing professional development. And others tried their best but their competence diminished with time. Remarkably, there was no system in place to spot waning competence, to support these professionals and to protect patients. Only when things went dramatically wrong was action taken, and then, too often, it was too late for the patient and the professional. Thankfully, this state of affairs has been recognised as unacceptable. Both government and the various professional bodies have begun to develop systems of retraining and revalidation, whereby any shortcomings in a professional's competence can be identified and addressed at a much earlier stage than would have been the case in the past. [23]

59 We believe that regular revalidation must be mandatory for all healthcare professionals, and that a requirement to undergo revalidation should be incorporated into the contract of employment between the professional and the relevant body within the NHS. Every effort must be made to develop and implement systems of revalidation as soon as possible. We recognise that some current proposals do not have the wholehearted support of some healthcare professionals. We do not see this as a reason for delay, far less for not proceeding. The public is entitled to this form of protection. Revalidation will assure the public that the doctor, nurse or other healthcare professional caring for them meets agreed levels of competence. Healthcare professionals will benefit also. Revalidation offers them the opportunity to address any shortcomings that they may have in an environment of learning and support, rather than in a context of sanction and blame. It also offers healthcare professionals some protection against unfounded criticism of their professional competence. We find very helpful the observations made by Professor Darzi (Professor of Surgery at Imperial College School of Medicine) and colleagues in relation to the skills of surgeons:

`A specific and sensitive test of operative competence could also detect important problems and might improve surgical outcome. Revealing underperformance early would allow for further training or career guidance towards other less practical specialties. The surgical profession needs a reliable and valid method of assessing the operative skill of its members. A driving test may not be a guarantee against accidents but it makes it less likely that you career off the road. Surgeons, the public, and politicians need reassurance.' [24]

60 We do not comment on detailed aspects of current proposals of the GMC. There are, however, two important issues to which we must draw attention. Revalidation, as one of its aims, offers protection to the public. For it to gain and retain public trust and confidence, it cannot be a mechanism which is entirely controlled by the professions themselves. We believe that there must be some external perspective in the periodic review of a healthcare professional, that is, a person or organisation external to the professional's own profession and external to the employer. We do not contemplate that this external involvement should take the form of a `patient's representative'. Indeed, we doubt the existence of such a generic entity. Rather, it should be someone with an understanding of the public interest. To the extent that the person's view may be informed by the views of patients, so much the better. We note that the GMC is conducting research into how they might capture the views and experiences of a range of patients for use in a doctor's revalidation. We commend this approach. It should, however, be in addition to, and not in place of, an external presence on the revalidating team.

61 Our second point relates to the wider context in which revalidation of healthcare professionals is conducted. Currently, each of the healthcare professions, to the extent that they are establishing a system of revalidation, are doing so on their own. Thus, for example, a system for doctors is being developed by the GMC; a system for nurses, developed by the UKCC, is already in place; and each of the professions allied to medicine have their own requirements for regular re-registration of their members. As we have said, no system currently exists for senior managers. No single body is responsible for ensuring that these various systems are sufficiently rigorous and robust to protect the public. There is no mechanism of review to consider whether the systems are consistent and aligned. There is no mechanism for ensuring that the systems for revalidation of healthcare professionals are integrated into other initiatives for protecting patients, such as the inspection by the Commission for Health Improvement (CHI) of NHS trusts, or the publication of national data on clinical outcomes. This is in the tradition of the ad hoc, fragmented approach which has characterised the management of the NHS for too long. It is not in the interests of patients. There must be an overarching mechanism to co-ordinate these many systems to ensure that they are properly aligned, and capable of protecting patients. This should be a further priority for the Council for the Regulation of Healthcare Professionals.

Footnotes

[23] The GMC's performance assessment procedures, introduced in 1995, represented a first tentative step albeit limited, in that it is a system which is reactive and insists upon performance being `seriously deficient'. See www.gmc-uk.org

[24] Darzi A, Smith S, Taffinder N. `Assessing operative skill'. Editorial: `BMJ' 3 April1999; 318:887-8. See also Smith SG et al. `Objective assessment of surgical dexterity using simulators'. `Hosp Med' 1999; 60(9):672-5