Editor’s note: This is a commentary on Wright C, Richard SH, Hill JJ, et al. Multisource feedback in evaluating the performance of doctors: The example of the UK General Medical Council patient and colleague questionnaires. Acad Med. 2012;87:1668-1678.
Beginning in December 2012, all UK doctors will be required to complete a periodic revalidation process conducted by the General Medical Council (GMC) to retain their licence to practise medicine. For the first time, all licensed doctors will have to demonstrate once every five years—based on annual appraisals—that their knowledge, skills, and experience are up-to-date and that they are fit to practise. Revalidation will also include multisource feedback (MSF) from patients and colleagues at least once every five years. Just as the capacity of doctors to do good has never been greater, the risks associated with medical care are also greater than ever. Thus, the purpose of revalidation is to support doctors in the delivery of high-quality and safe care to patients.
A formal system of appraisal and revalidation also lets patients know that their care is safe and professional and that their doctors receive feedback on their performance on a regular basis. Revalidation should provide further assurance to patients that the doctors who treat them are up-to-date and fit to practise.
Appraisal and Feedback
In the new system, revalidation will be based on an annual appraisal process rooted in the GMC’s core guidance, “Good Medical Practice.”1 At appraisal, the doctor must demonstrate that he or she has collected and reflected on the information outlined in our guidance, “Supporting Information for Appraisal and Revalidation,”2 including continuing professional development, quality improvement activity, significant events, and a review of complaints and compliments.
Colleague and patient feedback are also elements of the supporting information that a doctor will need to bring to the appraisal process at least once every five years. Using a validated questionnaire enables colleague and patient views about a doctor’s practice to be gathered in a systematic way. The feedback is intended to help doctors reflect on their practice and support their professional development by providing them with information about their practice through the eyes of those they work with and treat.
As detailed by Wright and colleagues3 in this issue of Academic Medicine, the questionnaires we have developed to help employers and doctors collect feedback are based on the values and principles in “Good Medical Practice.”1 Before Wright and colleagues undertook the work reported in this issue, the questionnaires were subject to in-depth GMC-commissioned research over several years and tested with thousands of doctors, patients, and colleagues. We supported the analyses of these instruments because it is important to understand how MSF works in practice. The research concluded that the GMC patient and colleague questionnaires were sufficiently robust instruments for use as formative assessment tools in the preliminary roll-out of revalidation.
Wright and colleagues’ research is also the basis for some of our guidance, including “Guidance on Colleague and Patient Questionnaires,”4 in which we recommend that doctors collect feedback from at least 34 patients and nominate 20 colleagues (10 medical and 10 non-medical) to provide feedback, aiming to receive 15 responses from colleagues overall if they employ the GMC questionnaires. Wright and colleagues found that seeking the views of 15 colleagues is a realistic measure, and we believe it is feasible for doctors to source this feedback in the 12 months before their appraisal. With this number of responses, doctors should achieve a good overall view of their performance. However, these figures are not mandatory, and the picture of a doctor’s practice would simply be less complete with lower numbers.
We have published the final versions of our patient and colleague questionnaires on our website. It is not mandatory for doctors to use our questionnaires—others are available—and we have produced criteria to help organizations and doctors select the tool that meets their needs for feedback.5
Wright and colleagues also concluded that the questionnaires “should not be used as stand-alone tools for making judgements about a doctor’s fitness to continue to practice medicine,”3 and the GMC shares this view. MSF for the purpose of supporting revalidation is not about rating or scoring doctors or comparing them against one another. It is a way of helping doctors find out what their strengths are and what areas would be most beneficial for them to focus on in their continuing professional development.
MSF is one part of a wider picture of a doctor’s practice. We are also clear that MSF is not intended to be used alone to judge a doctor’s fitness to practise or to involve a high-stakes, summative assessment. We see this kind of feedback as simply another piece of information that should support the doctor in his or her professional development. Any conclusions about a doctor’s practice should take into account all of the supporting information included in the appraisal process and the wider practice context. No single piece of supporting information should be considered in isolation.
The Value of MSF
Medical practice relies on trust between doctors and their patients, and between doctors and their colleagues. For the vast majority of doctors, feedback from patients and colleagues will be overwhelmingly positive, but such feedback will provide opportunities for doctors to learn about their practice. MSF is useful information for any doctor in terms of their personal and professional development, and we think most doctors value the opportunity to reflect on what others have to say about their practice.
This summer we welcomed a statement of support from nine UK patient organizations for the introduction of revalidation. The organizations highlighted the importance of patient feedback and said:
Patients are a key resource in helping to improve medical practice. The scope and frequency of patient feedback in the initial revalidation model is, in our view, too limited, but it does establish the principle of patient feedback in the process. We know that many doctors already collect feedback from patients for their appraisals and we expect that all doctors will utilise this resource to help them improve their own practice.6
This statement highlights the expectation patients have of involvement in the revalidation process, and their role in providing feedback to doctors should not be underestimated. After all, patients are and should be at the heart of health care and are therefore well positioned to provide doctors with an “end-user” view of the care and service they receive, which can only help doctors improve their practice.
As revalidation matures, we will look to involve patients and patient organizations in developing various mechanisms for including patient experience in the appraisal process and to develop and improve the model we currently have. Doctors may believe they know what their colleagues and patients think of the service they provide, but without feedback they cannot be sure, and MSF can only help them to focus on areas that may need attention. This is positive for doctors’ professional development as well as for patient care and experience.
Benefits of Revalidation
Revalidation is not a peripheral engagement of the medical profession—it is one small but vital component in building a safer, higher quality health care system. It is about underpinning the trust patients have in their doctors and the wider health care team involved in their care. With a formal system of revalidation in place, doctors who have a licence to practise will have demonstrated on an ongoing basis that they are competent and fit to practise in the area of medicine in which they work, benefiting not only patients but the profession as a whole.
An early and important effect of the new revalidation process has been its role as a driver to ensure that employers and those who contract with doctors have robust systems of appraisal and clinical governance in place. In our experience, previous inquiries into poor standards of care have revealed institutions where clinical governance was weak. A huge amount of work has gone into putting the systems in place to be ready to support revalidation across the four countries of the United Kingdom, and we are now ready to begin the process of consistent appraisal and revalidation.
Another significant benefit of formal revalidation is improved patient safety. In relation to patient safety and the importance of appraisal, the National Health Service (NHS) Institute for Innovation and Improvement concluded in a 2007 report that there is “evidence that appraisal is a key aspect of [human resources] impacting on patient mortality.”7 The publication cites research by Borrill and West8 which reported a “strong association between the sophistication and extensiveness of staff management practices in NHS hospitals and lower patient mortality….” They state, “having an appraisal system in place was found to have the single strongest effect upon patient mortality.”8 Borrill and West found that appraising 20% more staff and training about 20% more appraisers would be likely to lead to 1,090 fewer deaths per 100,000 admissions in NHS hospitals. This research provides evidence that strong appraisal and robust clinical governance systems are vital in ensuring patient safety and supports our reasoning for using appraisal as a key measure of a doctor’s fitness to practise for revalidation.
Over time we believe revalidation will help to identify problem practice at a much earlier point and, for all doctors, will help encourage self reflection. Both patients and doctors will benefit from this because it will help to improve the care patients receive.
Initial interest in developing a formal UK revalidation process emerged in the 1990s. By 2005, the GMC had relatively advanced plans for such a process. However, in 2005, the conclusion of the Shipman Inquiry, an independent public inquiry following the 2000 conviction of a physician for the murder of 15 of his patients, sparked a major government review of clinical governance proposals in the UK health care system. The result is probably a more robust system, but the review meant further delay in establishing a formal revalidation process.
The current revalidation process is a UK-wide program affecting over 230,000 licensed doctors and hundreds of organizations. Delivering change on this scale took time, and it has taken even more time to refine and test the plans.
Revalidation is not a panacea, and we are not claiming it will produce instant results, but it will be the first nationwide system of its kind anywhere in the world. On the other hand, we have to acknowledge that revalidation, in large part, is only requiring the health system to do what it should have been doing for many years. Annual appraisal has been included in most doctors’ contracts since the early 2000s, yet until now the NHS’s record in providing appraisal for all doctors in the service has been inconsistent. Our hope is that the new system will ensure consistency and quality in the appraisal and feedback process.
A Step Toward Better Feedback and Better Care
Looking forward, we want to evaluate the effects of revalidation and to learn lessons as it rolls out. It will not be perfect, and there are bound to be glitches in a program of this size, but with goodwill the medical profession and the UK health service will have created a quality assurance system that can be developed and improved over the years.
We have carried out a significant amount of research, testing, and piloting to make sure our proposals for revalidation work in practice, and that the process is simple and straightforward for doctors. One of the main reasons we tested and piloted the questionnaires is to ensure that they are reliable, and the research, including the work by Wright and colleagues, concluded that they are.
Revalidation is about doctors demonstrating that they adhere to the values and principles of their profession, that they reflect on their practice, and that they improve the quality of care they provide year on year.
Other disclosures: None.
Ethical approval: Not applicable.