Bad cases make bad law, and the case of Sir Liam Donaldson is becoming a very bad one indeed.
One of Sir Liam’s greatest concerns has been concern with issues of professional performance. So he will have welcomed Dame Janet Smith’s reports into Harold Shipman. The fact that Shipman is an entire one off, who actually performed very well as a GP is not noted. Shipman was not in any sense a representative of the profession when he carried out his murders. Shipman’s actions are his own, and he must carry the can for them. There is no reason that doctors should live their professional lives as an attempted expiation for Shipman’s crimes. Realism says shit happens, and that Shipman was shit. It does not say anything about anything else.
However the Shipman case is regularly trotted out by the bureaucrats and other twaterati as the justification for a nasty new affliction called PROBOPHILIA. This illness is characterised by the sufferer’s fundamental inability to believe that any professional can do his job if left alone. Professionals to these twats are irresponsible and reckless, and highly dangerous. They must be thoroughly inspected and regulated as without this they might actually get on and practise some real medicine.
Not if the twaterati and other probophiles have their way. No the goal must be “reflective practice” and evidence of “reflection in action” No case is complete when the patient leaves the room. It must be analysed, and reflected upon, and you should wonder if you could have done anything different, or whether the room was too hot or too cold. A reflective journal should be kept, and Personal Development Plans (PDP) drawn up as well as copious records of room temperature and anything else that might just be relevant. And it should all be reviewed with a supportive colleague in appraisal sessions. The fact that these are only once a year is bitterly to be regretted.
The fact that such reflection sets the twaterati’s pulses racing with excitement does not alter the fact that navel gazing is largely an abysmal use of time. Look long enough into the abyss and it starts to stare back into you.
And anyway there are other patients to see, and access targets to meet. So if I reflect sufficiently on my reflections I reach the conclusion that rumination does not get patients seen, staff home, or let me get to the end of the day in peace!
So we have a process that on reflection is time consuming to little purpose.
Now Sir Liam has been the driving force behind the introduction of appraisal into the NHS. At one level it makes sense. In its current form it takes about 6 hours preparation and about 2-3 hours for the appraisal interview. It’s currently a formative (supportive, peer to peer review) process and it is supposed to lead to reflection and some changes in practice. Evidence as to whether it achieves useful change in practice or not is very limited so far. It’s also taking about 12 hours of doctor time per appraisal. Applied over the 130000 doctors in the NHS it’s a large number of doctors taking a lot of time away from patient care. Are the patients getting a good deal from this NHS investment?
Well if it leads doctors to sort out their rough edges it may help. But if all it achieves is identification of the lacunae in medical systems (which there is no political will to acknowledge or fill in) then little action will follow from the appraisal. It doesn’t matter at present- an unachieved PDP goal is simply deferred or dropped next time around and some equally useless goal substituted for it. But reflection on why a goal was a noble failure is fascinating, but ultimately it’s intellectual cud chewing.
At least appraisal is up and running. It’s probably of some use to some doctors, and may help patients indirectly by keeping doctors saner and better supported.
However we now have the impending approach of three linked but separate policies of relicensing, revalidation and recertification
Relicensing comes from the work of Sir Donald Irvine who pointed out that doctors get their GMC licence for life and never have to prove they deserve this again. He may have a point here. The GMC has some idea of what it is asking for with relicensing. Relicensing is about the doctor as a doctor and maintaining his or her right to practice medicine signified by GMC registration.
There’s going to be a five yearly relicensing cycle, beautifully illustrated by this diagram which to most doctors looks like a circular saw into which poorly performing doctors will be fed as punishment. One colleague said it reminded him of a Masonic Pentagram.
Recertification is about the doctor as a specialist. It is supposed to answer the question “Is the doctor still fit to practice in his or her speciality?” (General practice is a speciality, just like cardiology or gastroenterology) It’s not clear how this differs from relicensing, or maybe relicensing is subsumed within it?
Potentially we could end up with a mess in which a doctor is recertified but not relicensed or relicensed but not recertified. Quite what would happen in such a scenario is currently unknown.
Recertification (the specialist part) is going to be the responsibility of the ever popular and deeply loved Medical Royal Colleges. Yes, Twaterati Towers will swing into action.
The problem the royal colleges face on recertification is that the process they use has to convince several masters. So it has to convince the GMC that it is valid. It has to convince ordinary doctors that it is fair, accurate and not too onerous. It has to convince the DH and the public that it is sufficiently onerous. And it cannot take too much time as there aren’t enough spare doctors to cover sessions missed whilst we go and revalidate ourselves. “The patients couldn’t be seen as the doctor was being revalidated” doesn’t make much sense really does it?
IF challenged legally, the revalidation process has to be robust enough to demonstrate its reliability as a process, and the process is likely to be challenged legally either by a disgruntled doctor wanting his certificate back, or by an aggrieved relative saying, “You recertified this doctor last year and this year he’s gone and killed my old mother. Why didn’t you anticipate this problem sooner?”
The colleges are going to have great fun finding a way past all these potential problems. They also don’t want to do revalidation by means of an exam, although there will be “explicit standards” and “pass-fail criteria” Any test of my performance against a pass/fail criterion is an exam- no matter what you call it. They’ll need the medical equivalent of a flight simulator for pilots, but no-one seems to have come up with one yet.
And collecting a big girly folder of appraisal evidence and personal development plans is useless. I write well enough to fill several such folders…but it would give anyone reading it little real idea of how well I did or did not treat patients in practice. And anyway there isn’t enough time in the world to
read all the guff doctors would produce if necessary. Just who will the time to read it and assess it thoroughly? And if anyone has the time to do this why aren’t they doing something more important?
However the circles are squared eventually, and at present the concept that the profession is going to be revalidated by means of relicensing, recertification, re this, re that and re the other, is faintly ridiculous. The confusion around these issues (which has been present ever since they were mooted over 10 years ago) is still present, and the initiative is at risk of “slippage.” I wonder if it will slip away before or after Sir Liam’s departure?
(P.S. Apparently a similar re-accreditation scheme was suggested for barristers some years ago. For some reason it got dropped).