Professor Peter Rubin, Chair of the GMC, responds to the questions put to him by OnMedica members.
Professor Rubin, I’d first like to thank you for taking the time to talk to OnMedica. We have asked our members to put forward some questions and they are very keen to hear your responses. We will begin with the topic of revalidation, as that seems to be one of the major concerns for our members.
The BMA has stated that confidence in revalidation is seriously undermined and has asked the GMC to radically rethink the system for UK doctors. There is concern from our members that the current system is over bureaucratic, cumbersome and that ultimately it will take doctors away from treating patients. In addition, there are concerns as to whether proper funding and protected time will be guaranteed before this is introduced. As Chair of the GMC, how would you respond to these comments?
I think the first and most important thing to say is that we at the GMC know that most doctors in this country are good doctors. When that is your starting point, it determines a lot about your approach to revalidation. We, like the BMA, are very committed to revalidation being workable at the front line. At the moment, there are 218,000 doctors who are licensed to practice, so we need a system of revalidation that is going to be workable for 218,000 doctors. Therefore, we too want it to be as simple and straightforward as possible. The reason that we have been piloting and consulting so much is that we want to get it right.
We at the GMC know that most doctors in this country are good doctors
Our view about how to keep this as straightforward as possible is that revalidation is based essentially on two things; one is an annual appraisal and the other is multi-source feedback, or 360o appraisal. I have been appraised by my university since 1988 and by my NHS Trust since 2002 and I know that many doctors are, just like me, already being appraised annually. The appraisal needs to be a reflective process. Undoubtedly, there will be some doctors identified in the appraisal system who need remediation and more training, but for the vast majority of doctors, it will be an opportunity for the appraiser to commend the doctor. For the second part, the multi-source feedback, we think this should happen once every five years, as the revalidation process is a five-yearly cycle. I’ve had 360o appraisals in two different contexts before, and found them both to be extremely valuable. I think that one of the useful things that we at the GMC can do, is to encourage people that 360o appraisal should be, for most doctors, a very positive experience. It is an opportunity to be offered praise, which I’m sure is often not done very well by the NHS.
In conclusion, we want the revalidation process to be simple, straightforward and useful for doctors and we agree with the BMA that we do not want it to be a bureaucratic process.
Keeping to the topic of revalidation, how would you respond to the assertion by some clinicians that a robust evidence base is actually lacking for revalidation, both for reducing malpractice and increasing quality of care?
The two words that we are using all the time in revalidation, are pragmatism and incremental
The gold standard for an all singing, all dancing, appraisal system would require, in many instances, information which we simply don’t have at the moment. This is something that we have always known. In addition, there are a lot of specialties in which information and data are very hard to obtain. For example, unlike in surgery, where the outcomes are very quantifiable, it is much harder to collect data in some specialties, such as old age psychiatry. This is why we have been keen to have a long gestation period before the birth of revalidation. We’re very keen not to run before we can walk. The two words that we are using all the time in revalidation, are pragmatism and incremental. We want a pragmatic approach to begin with and an incremental development of the revalidation and appraisal process.
What form do you think revalidation will take? Will there be a knowledge test?
Categorically not. We’ve always been opposed to the idea of a knowledge test. We want a process that looks at how the doctor is performing in practice, and one that finds out whether they are keeping up to date. We feel that multisource feedback, when properly conducted, will be the key to that. This, combined with a properly conducted appraisal process, should be sufficient for achieving the purpose of revalidation, which is to ensure that doctors are up to date with practice and to identify the very small number of doctors that may require assistance and re-training.
What is your response to the letter from the Health Secretary, Andrew Lansley, indicating his intension to extend the piloting period for revalidation for a further year?
The first thing to say is that we are very pleased that the Secretary of State for Health has reaffirmed his commitment to revalidation. As he rightly says, the public expect doctors to be revalidated. The public would not understand if the medical profession were not prepared to show that they are up to date in their areas of practice.
We regard this as a positive affirmation that the new government is committed to revalidation
We also recognise what Andrew Lansley is saying about the NHS in England and the degree of preparedness for the revalidation system. This is something that we too have been aware of, which is why we’ve always emphasised that revalidation will be phased in over three to four years. We know that not everywhere in the UK is ready for revalidation, so we do recognise a number of the points being made by Andrew Lansley in his letter. We are also very pleased to see that he is going ahead very quickly with the introduction of legislation to appoint Responsible Officers, because they are the key to ensuring that revalidation works on the ground. So, in general, we regard this as a positive affirmation that the new government is committed to revalidation.
With regards to GMC subscription fees, one of our members has asked why doctors have to pay the annual subscription, rather than the State, on behalf of our patients?
The most important thing that all doctors buy with their annual retention fee is our independence. I cannot emphasise that strongly enough. We are the independent regulator of the medical profession and that is fundamentally important. The GMC does four things; we maintain a register of medically qualified professionals, we regulate all medical education, we set the standards by which we practice in a whole range of areas, and of course we carry out the fitness to practice procedures. Our independence in all these four areas is of huge importance to the medical profession.
We are the independent regulator of the medical profession and that is fundamentally important
The other elements that are bought with the annual retention fee include a modern organisation that offers a website which gets nearly 7 million hits a year, a call centre which receives 900 calls a day, each of which is answered within 20 seconds and seen to completion by the person who answers the call.
The last point about the annual retention fee is that we are very conscious that we are spending doctors’ money. We are a charity and we are accountable to the Charity Commission, so as well as being very transparent about our costs, we are very cost-conscious and we are always looking for ways to reduce our costs.
PCTs are in the process of pressurising GPs to reduce referral rates in a way which could be viewed as offering financial incentives for not referring. Apart from this sounding morally wrong and posing an ethical dilemma to a GP, this could potentially lead to bad practice and poor patient care. What is the GMC’s view on this, as it has the twin duty of safeguarding patients and also ensuring good medical practice?
Our view would be very simple, that a doctor must always act in the best interests of the patient. If the best interests of that patient are served by referring that patient for a specialist opinion, then that is what should happen.
Can we expect any key changes to postgraduate medical education and training since the merging of PMETB with the GMC earlier in the year?
As of 1st April, the responsibility of regulating postgraduate medical education training came to us, so we will be continuing the work of the PMETB. We now have the responsibility of determining the content and the outcomes of postgraduate medical education. However we will be very keen to ensure, as we have done over the years with undergraduate medical education, that the content and outcomes continue to move with the times. We have regulated undergraduate medical education since 1858, and we have regularly updated the guidance that we issue regarding what should be in the undergraduate curriculum, because the world changes and we are very keen that medical education changes at the same time. We will take that same approach with postgraduate medical education.
We cannot rely on ad-hoc experience to produce the specialists of the future
Something that I am personally very keen to see evolving in this country, is a more structured approach to training. There has been a long tradition in the UK of postgraduate medical education taking the form of an apprenticeship. There are many benefits to an apprenticeship, as you can learn from role models, but it can also be haphazard and ad-hoc. If postgraduate medical education and training is to continue to achieve very high standards, and particularly within the constraints of the European Working Time Directive, then we have to ensure that the training of doctors is of high quality and that they are not simply learning by experience, but are being properly supervised and trained. Early on in my position as Chair of PMETB, the Chair of one of the Royal College’s specialist advisory committees that oversee training for the Colleges, made a comment to me which really struck a chord: “The issue that we have to address in the UK is that we have too many doctors who are experienced but not trained.” I thought that that was a very succinct way of explaining a very complex issue. Whilst not in any way criticising postgraduate medical education and training in the UK, the fact of the matter is that we cannot rely on ad-hoc experience to produce the specialists of the future.
Many of our members are unsure of the procedures that take place when complaints come through to the GMC from patients. Could you perhaps outline the process?
In 2009. the GMC received about 5,500 complaints
Firstly, I must say that I know how difficult it is to receive complaints. Like any doctor working at the front line, I've been on the receiving end of complaints. I have been pursued in the courts on a case that lasted for five years before it was closed with no case found to answer, so I do understand that this is a concern for many doctors. In 2009, the GMC received about 5,500 complaints. Around 2,500 of these were turned around and sent back within about two weeks because they were simply not appropriate for the national regulator. Many complainants misunderstood what we do, thinking that we were an NHS complaints body, which we are clearly not. Other complaints were really well below the threshold of issues that the national regulator should be involved in.
What most patients want is honesty, an explanation, and if appropriate, an apology
My advice to all doctors is that where things haven’t gone right - and you cannot be in medicine without things going wrong from time to time - it is vital to be very upfront. You must make it very clear from very early on, what went wrong and why. You must then explain what you are personally going to do to ensure that this does not happen again in the future. What most patients want is honesty, an explanation, and if appropriate, an apology. Taking these simple steps often closes issues down very early on.
How can you reassure doctors that patient safety and quality of care will not suffer as a result of the huge budgetary cuts that we are currently facing?
As a regulator during this period, we will take great interest in the quality of care. We regulate individual doctors, but we also of course regulate medical education. We will be particularly interested to ensure that medical education and training continues to be carried out to a high standard. We all know that there are financial challenges ahead, but financial challenges can often be addressed by a creative approach to how an organisation runs. I have seen big financial challenges happen in the past. It does sometimes need creative thinking and changes to the way that people operate, but at the end of the day, we will be there as the regulator to ensure that high standards are maintained.
For further information on the role of the GMC, please visit their website.