Revalidation for doctors in the United Kingdom: the end or the beginning?

The process should celebrate what we do well while showing that we are accountable

Proposals for the revalidation of doctors in the United Kingdom were released last week in a consultation document from the General Medical Council (GMC).1 Elsewhere, notably in Canada and the United States, it is routine for doctors to undergo recertification at regular intervals to show that they are maintaining their skills and are competent. The purpose of revalidation is to reassure the public that their doctors are competent and abide by high ethical standards. Revalidation will be the culmination of an ongoing review of professional performance that should aid doctors in developing their skills while at the same time identifying at an early stage those who are performing poorly.

All doctors in the United Kingdom will undergo revalidation whether they work within or outside the NHS, are in training, or are in temporary employment. The stakeholders in revalidation include the individual doctor, the NHS, other healthcare providers and purchasers, the medical royal colleges, and, most importantly, the public. The challenge for doctors over the next year or so will be to reconcile the needs of all parties while at the same time ensuring that a robust and fair system of revalidation ensues.

The stages of revalidation will include collecting evidence of competence and performance, performing regular review of this evidence, and having a group of medical and lay people make recommendations for revalidation or recommending that the doctor's registration should be reviewed by the GMC.1 The precise details about who should take responsibility for each stage (especially who makes the recommendation to revalidate) will need to be agreed. Ultimately, revalidation pertains to individuals and must be tailored to them to assess what is relevant to their profile of practice. The precise route of revalidation may vary from person to person.

Ideally, the process will be based on the existing structures for health care and education. For those working in the NHS, there is a framework of corporate and individual responsibility for giving patients the highest standard of care (clinical governance). Thus, all NHS hospital and primary care doctors will soon be subject to regular appraisal and will need to have a personal development plan. This will form the central plank of revalidation, and trusts, as employers, should be responsible for this part of the process. However, annual appraisal and review for doctors in the NHS is currently patchy and in its early stages of development. Work needs to be done to make sure that annual review is formative, developmental, supportive, and linked to the requirements of the continuing professional development schemes of the professional bodies.

All the medical royal colleges in the United Kingdom have set up continuing professional development schemes and have jointly produced a generic folder that provides the means for individual doctors to show that they have participated in professional development and personal development planning.2 The royal colleges and specialist societies will provide guidance on what type of evidence is needed for revalidation in their specialty and will elaborate the principles of revalidation set out in Good Medical Practice, a code of practice developed by the GMC. The royal colleges and specialist societies will set standards of practice and will also provide support and retraining for those who fail to meet them. They will need to develop ways of ensuring that the standards can be applied fairly across disciplines and different localities.

Special arrangements will have to be made for doctors who practise outside the NHS and collegiate structure; colleges, local trusts, or deaneries may agree to set up systems that enable these doctors to be revalidated. In primary care, the formation of primary care trusts provides an organisational structure that will facilitate annual review as well as planning for personal and practice development.3 Postgraduate deans will be responsible for recommending the revalidation of doctors who are in training.

Setting up a revalidation process that provides a sensitive method of picking out poorly performing doctors early, while simultaneously providing the stimulus for improvement for the majority, will be a challenge. Many doctors are currently de-motivated and under stress. We urgently need to promote a culture in which doctors can enjoy practising medicine and keeping up to date and are valued by their employers for doing so. Managers can support the process by building time for development and revalidation into service contracts and day to day practice, and healthcare purchasers should invest in education to underpin the clinical service. At the very least, resources will be needed to allow doctors the time to keep up to date, reflect on and review their practise, and collect the benchmarking data needed for assessing performance standards.

For some, revalidation may seem like the end: the last straw that tips them into early retirement or a cynical monitoring mode that is mechanistic rather than meaningful. Ideally, revalidation should be a new beginning. It should provide the stimulus that allows the medical profession to review its culture, allows doctors to practise in a supportive environment where they can give and receive feedback openly, allows them to learn from their mistakes, and, when periodically reviewed, be reassured that they are doing a good job.