Abstract
By the time you read this I might be on holiday. I say ‘might’ because the organization of our family holiday, which is unwisely left to me, traditionally scores high marks for strategy but low marks on implementation. Incidentally, this is also the soundbite verdict on Lord Darzi's review of the NHS – and most other policy documents ever produced.
Talking the talk is always far easier than walking the walk, a ready criticism that editors of medical journals are all too familiar with. The masters of the art of high strategy and low implementation are policy wonks at the World Health Organization, whose main – and probably reasonable – defence is that implementing change to improve the health of over six billion people is a monumental task that requires overall direction but the attention to detail of others. The Chief Medical Officer's report on the next steps in revalidation relies on the same philosophy.
The most notable element of Liam Donaldson's latest policy document is the acceptance of the ‘three Rs’: relicensing, recertification and revalidation. These are not new but the timescales laid out in Sir Liam's report are short for the sea change that is envisaged, and it relies on co-ordinating local organizations like Primary Care Trusts, professional organizations like Royal Colleges and regulatory organizations like the General Medical Council. This is before we begin discussing its acceptability to doctors.
All practising doctors will receive their license to practise in 2009. Licensing at this stage will be little different to medical registration, except that it is renewable – with the renewable element dependent on recommendations from local employers such as PCTs. This is bad news for retired doctors whose privilege to prescribe will be lost unless they go through the relicensing and revalidation process.
Doctors on the specialist register and GP register will in addition be required to pass the recertification process, which will allow them to practice in their chosen specialty. Relicensing will be in the control of local bodies, based on appraisal, and incorporate a core appraisal module, common, to all based on the GMC's recommendations for good medical practice. This core module is yet to be devised by the GMC. Recertification will be based on hard patient outcomes and be governed by the relevant Royal College or specialist association.
Hence, relicensing will be sufficient for some doctors to revalidate every five years, while doctors on specialist and GP registers will need to be relicensed and recertificated for the purposes of revalidation. Ideally the two processes will be timed to coincide with the five-yearly revalidation cycle. Patient feedback will be central to both relicensing and recertification.
The Bristol and Shipman Inquiries left regulators with no alternative to strengthening appraisal and revalidation, and Sir Liam's report is at pains to highlight the positive aspects of the new processes in terms of professional development and improved trust between doctors and patients. The wisdom of these initiatives cannot be doubted but the strategy was the easy part – although it may not have felt like that to the negotiators trying to align Government, Royal Colleges, GMC, BMA and NHS. The implementation of revalidation for doctors, however, will be an immense challenge, not least because co-ordinating these disparate organizations and 150,000 doctors is hard to imagine.
Many doctors will be bewildered by these changes. What is the need to change a system that works, except for rare individuals, to a system that is equally unable to guarantee that a Harold Shipman would be detected? How can so much change be implemented by so many disagreeing organizations so soon, when the NHS has a history of failing to implement the simplest changes? What is the feasibility of collecting hard patient outcome data to inform recertifiation within a few years when such data barely exist? Does it make sense to hand so much power to Primary Care Trusts, Royal Colleges, specialist societies and the GMC, all organizations that doctors are often suspicious of?
The recommendations for revalidation are the most important change in medical regulation for more than a hundred years. The Government's aim is that they will ‘contribute to the quest to make health care both safer and higher quality’. But they will need to be implemented apace to meet the deadlines of licensing by 2009 and piloting of recertification by 2010. The greater challenge, however, will be to satisfy doctors that the three Rs are reliable, rewarding and required.