Most clinical academics, like me, work with patients in clinical settings as well as recruiting them to our research. I, however, have found myself becoming, at least in theory, one of my own research participants. I am not ill – other than the side effects of being a consultant paediatrician – but like all doctors in the UK, I am now required to revalidate with the General Medical Council (GMC) every five years.

Revalidation requires all doctors to collect evidence from their practice such as patient feedback, significant events and the evidence generated through clinical audit. This evidence is then collated and discussed annually at an appraisal. Arguably appraisal is a model for quality improvement – a protected safe space to identify areas where improvements can be made, with the doctor themselves as the focus – but in the case of mandatory revalidation, as is the case in the UK, it has also been linked to a regulatory objective: to assure patient safety by potentially identifying poor practice.

I have long been following the development of revalidation and similar ‘fitness to practise’ programmes around the world. I wanted to better understand the introduction of revalidation in the UK as an assessment method within a complex and dynamic system, and to explore its impact on doctors and the wider health care system. Thanks to funding from the Health Foundation my team has been able to carry out research into revalidation and its impact on health care. This week we published a second report of our findings.

We started by exploring how revalidation has developed as a policy. We found that policy leaders still held contrasting views on both the aims and the purposes of revalidation, even though it was already being piloted in England at the time. Some policy leaders described revalidation as a means of assuring patient safety, whereas others viewed it as a quality improvement intervention. Problematically, in terms of assessment methodologies, these are not mutually exclusive, but they are certainly not the same thing and need to be approached differently.

When revalidation was formally launched in December 2012, we started to look at revalidation from the perspective of those undergoing the process: doctors – as appraisees, appraisers and responsible officers – and the GMC. In order to really understand how revalidation was working in practice, we examined the heart of the process: appraisal. Although it was challenging to recruit participants, we recorded a selection of appraisals across Cornwall, Plymouth and Devon and followed this up with 1:1 interviews with appraisees and their appraisers.

Our study found a general consensus that revalidation is a well-intentioned and positive initiative that seems reasonable and logical. However, despite it appearing logical, our research highlighted that ‘bolting on’ aspects of the revalidation process to the existing appraisal process may lead to unintended consequences. And these are likely to have major ramifications on the outcomes of revalidation as a quality improvement intervention if they are not recognised and addressed.

Like the policy makers, doctors’ views on the purpose and processes of appraisal and revalidation differ. For example, we found that the emphasis on the pastoral element of appraisal varied across settings, with appraisers and appraisees in primary and community care stressing its importance far more than those in secondary care.

But, in spite of these differing opinions, the doctors we interviewed all valued their appraisal. They were, however, anxious that linking appraisal to revalidation would change the dynamic of appraisal conversations; moving away from the professional, quality improvement model to a tick-box, regulatory model. There was a fear that revalidation might actually take doctors away from thinking about their clinical practice and patients, and focus simply on overcoming bureaucratic hurdles.

How then could revalidation be structured to help drive quality improvement?

Well, the first real challenge for those shaping revalidation – who are still seen as distant somewhat irrelevant bodies to some professionals – is the need to identify the problem that they are trying to solve. Is it about poor performance? Or is it about the opportunity to drive up standards in all practitioners through quality improvement measures, developing evidence-based strategies that they hope will have the desired impact?

There is also clearly a need to carefully evaluate the impact of revalidation. That said, from the research that we’ve been involved in, I’m optimistic that revalidation can evolve into a positive quality improvement initiative in health care that ultimately benefits patients and the public.

It would be interesting to hear your thoughts on revalidation so please do add your own experiences of revalidation in the comments below.

Julian is Director of the Collaboration for the Advancement of Medical Education Research & Assessment (CAMERA) and clinical senior lecturer in medical education, Plymouth University Peninsula Schools of Medicine and Dentistry

Comments

Kit Byatt



My experience is that the appraiser, through his/her style & approach, is the key determinant of the process. This is, of course, shaped by the RO's guidance notes, but even so variance of approach from transactional (outcomes designed to produce certain actions) to transformational (outcomes designed to change the person) are wide.
I see this as a complex matrix: in addition to the above, there is also the 'minimum performance standard' checklist vs the 'developing the professional' QI process - if you prefer, lowest common denominator vs highest common factor.
This can have a massive effect on the dynamic of the appraisal - the former being more parent/child, whereas the latter, adult/adult in transactional analysis terms.
My suspicion, based on informal discussion with 1° & 2° care colleagues, is that the former type is more common in secondary care.
I also have experience of consultants who get much more developmental support from informal peer-based mentoring ('hidden appraisal'?) than from the formal mechanism.
I suspect the dynamic tension between bureaucratic survival - revalidation, and self-actualisation -personal & professional development may never be fully resolved; they are at opposite ends of Maslow's hierarchy, after all!
Perhaps, if the first one or two appraisals in the 5 year cycle were easily adequate (however that were defined) to confirm satisfactory performance, one could have a 'free-form' appraisal - with the appraisee setting the agenda, focusing on his/her priorities? An alternative way would be to allow the appraisee or appraiser one 'joker' they could play once per cycle to do the same thing.



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