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New era of five-yearly doctor checks starts 
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http://www.bbc.co.uk/news/health-19992538

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New era of five-yearly doctor checks starts

Regular checks on doctors' skills will start from December, heralding the biggest shake-up in medical regulation for more than 150 years. The UK's 220,000 doctors will have annual appraisals, with a decision taken every five years on whether they are fit to continue working. But it will be April 2016 before the vast majority of the first round of checks have been done. The health secretary said it was about addressing "deficiencies" in skills.

Jeremy Hunt said that if doctors failed to satisfy the standards of the General Medical Council (GMC) they would be prevented from practising. But he said the new system was about identifying where there were "gaps" in knowledge or skills and giving doctors a "chance to put those issues right". He said the vast majority of doctors "do a brilliant job" but when the government carried out a survey last year of 300 health bodies there were "serious concerns" with 0.7% of doctors - a figure Mr Hunt described as "significant". "At the end of the day if the GMC is not satisfied that someone is up to speed then, yes, they will be prevented from practising," he told BBC Breakfast. He said this would give the public confidence that the UK had the most thorough regulatory process for its doctors.

The move comes after years of discussions about the way doctors are monitored. At the moment there are no mandatory checks on the performance of individual doctors, a situation which has been compared unfavourably to the airline industry where pilots face regular, on-going assessment. Annual appraisals do happen in some places - particularly for medics in training - but they are by no means routine. There is, of course, a system of registration which the GMC is in charge of. When serious complaints are made about performance, the GMC can start disciplinary procedures. But this system essentially only picks up problems when things have gone wrong. Revalidation has been designed to ensure issues are dealt with before they reach that stage.

GMC chief executive Niall Dickson said: "This is an historic moment. It is the biggest change in medical regulation for 150 years [since the creation of the GMC]." He said the system should help improve quality, but he admitted the health industry had been "slow to recognise" the importance of such checks. The introduction of regular checks - dubbed a medical MOT - has been talked about for more than 30 years. Serious consideration started being given to the issue in the mid-1990s.

But over subsequent years scandals like that of the family GP and serial killer Harold Shipman and the deaths of the Bristol heart babies led to reviews and re-evaluations about what the process was intended to do. Government and GMC officials have also had to have detailed discussions with the British Medical Association (BMA). Dr Mark Porter, chair of the BMA's Council said it supported revalidation. He added: "It is important to recognise, that while revalidation will undoubtedly enhance the rigorous testing that doctors undergo, clinicians are already offering patients a very high quality service and robust systems are currently in place to deal with any concerns. "There is too much bureaucracy in the NHS and so we have to be careful that revalidation does not add to this unnecessarily."

Dean Royles, director of NHS Employers, said: "It is a very positive step forward and should herald greater patient safety and build confidence. "Patients need and expect this. It has been a long time coming." NHS medical director Professor Sir Bruce Keogh added it was a "powerful opportunity" to ensure standards of quality and professionalism are kept to across the country.

Each NHS organisation from hospitals to local networks of GP practices will have a responsible officer, such as a medical director, in charge of revalidation. They will assess the annual appraisals along with feedback from patients and colleagues to make a recommendation about revalidation to the GMC every five years. Minor issues that do not constitute a risk to safety may lead to revalidation being deferred for a short period, but major problems will result in the doctor not having their licence to practise revalidated. Such a scenario could also lead to disciplinary procedures being started by the GMC, the ultimate sanction of which is being struck off the medical register.

During piloting and testing of the new system, concerns were raised over the performance of 4.1% of doctors. In 2.4% of cases the issues were judged to be lower level, such as lateness, in 1% they were medium level, which included problems with behaviour including rudeness to patients, while in 0.7% the problems were serious and would have had an impact on safety.

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Mon Oct 22, 2012 1:43 pm
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Yes but would any Dr Shipmans really be stopped by such measures? They might become even more careful. All it might do is create a culture of box ticking doctors who pass the tests but abandon patient care.

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Mon Oct 22, 2012 1:58 pm
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Revalidation was initially planned as a way of stopping further Shipmans. The problem is that Shipman was an excellent doctor, loved and respected by patients and colleagues. He just happened to be a killer too.

A lot of doctors are against revalidation because of the extra amount of paperwork involved. It means it detracts them from clinical time so if you think it's difficult enough to see your GP, it'll become harder. The other issue is the five-year cycle. A lot of doctors are now planning to retire early to avoid being hit by revalidation, which will mean fewer experienced doctors.

The way it will work is they will appraise all doctors over a five year period so someone might be appraised this year or next and then won't be assessed for another five years. You'll need to show you're up to date with medical knowledge by going on courses, doing audits or case discussions, a colleague questionnaire and patient satisfaction questionnaire, as well as appraise complains/compliments. Collecting this evidence takes time and effort - I know because much of my GP training has been spent doing exactly this. Some of it is a pointless exercise and I hated it. Doing exams was a much easier way of showing I was up to date and "safe".

Still, as long as Joe Schmoe thinks something's being doing, that's all that matters.

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Mon Oct 22, 2012 1:59 pm
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Amnesia10 wrote:
Yes but would any Dr Shipmans really be stopped by such measures? They might become even more careful. All it might do is create a culture of box ticking doctors who pass the tests but abandon patient care.

You beat me before I could post my reply but yes it wouldn't stop anything. All it does is ensure those who are good at paperwork pass.

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Mon Oct 22, 2012 2:00 pm
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More paper work = less working time to do useful work.

My Dad's well glad he's just retired from the medical profession.

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Mon Oct 22, 2012 2:56 pm
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cloaked_wolf wrote:
Amnesia10 wrote:
Yes but would any Dr Shipmans really be stopped by such measures? They might become even more careful. All it might do is create a culture of box ticking doctors who pass the tests but abandon patient care.

You beat me before I could post my reply but yes it wouldn't stop anything. All it does is ensure those who are good at paperwork pass.

There has to be a better way to protect patients from potential rogue doctors, as few as there are. I would have thought a small team of statisticians to analyse doctors death rates would be cheaper and probably more effective, and could be extended to nurses at will. It could identify lousy surgeons as well. None of this really should be a hindrance to medical staff, and would not allow doctors to stop keeping check on each other.

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Mon Oct 22, 2012 3:40 pm
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Well, given the teaching profession have to suffer through Ofsted inspections, I'm not sure this is entirely worthless. I only hope it's rather better handled than Ofsted though.

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Mon Oct 22, 2012 3:58 pm
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ProfessorF wrote:
Well, given the teaching profession have to suffer through Ofsted inspections, I'm not sure this is entirely worthless. I only hope it's rather better handled than Ofsted though.

Do you honestly believe it will be better run?

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Mon Oct 22, 2012 4:20 pm
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ProfessorF wrote:
Well, given the teaching profession have to suffer through Ofsted inspections, I'm not sure this is entirely worthless. I only hope it's rather better handled than Ofsted though.

It won't be. You know this to be the case.

What I'd want to know is how doctors will be assessed. For example, the article refers to "being late" as an infraction. It seems to have no reference to the clinical abilities of the doctor. For example, can a GP correctly diagnose a condition and offer the correct form of treatment? Is that doctor up to date with clinical procedures?

I then find myself troubled by the fact that as we go further into specialisms, then how the hell does an inspector check that the doctor is up to speed? What I'd the doctor is the top specialist in the country in his field? How do you test clinical knowledge, or skills when that person is writing the books on the subject?

We can, and should, compare this to OFSTED inspections, but unlike teachers, it's much harder to examine and inspect a doctor's knowledge unless you are a specialist in the field, and have knowledge equal to or greater than the person being inspected.

In which case, it's down to knowing procedures, forms, turning up on time, not playing golf when you have an appointment (this really happened to me). That judges doctors against the wrong criteria.

Yes, a doctor needs to be up to date, but how this is inspected, assessed and judged is not, to me anyway, clear.

And, like OFSTED (who seem to answer to no one), who watches the watchers?

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Mon Oct 22, 2012 4:27 pm
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Amnesia10 wrote:
There has to be a better way to protect patients from potential rogue doctors, as few as there are. I would have thought a small team of statisticians to analyse doctors death rates would be cheaper and probably more effective, and could be extended to nurses at will. It could identify lousy surgeons as well. None of this really should be a hindrance to medical staff, and would not allow doctors to stop keeping check on each other.

But how do you analyse death rates? Patients are managed in teams. These can vary as staff change so the same consultant team can be excellent one year and be lousy the next. As for lousy surgeons, there was a plan to rank surgeons based on morbidity/complications. Do you know what the surgeons' (albeit private) responses were? They would decline any surgery they didn't feel was risk free. Hence a surgeon who only did simple surgery on fit and well patients would rank higher than a surgeon who did complex surgery on very poorly patients. Being ranked low would mean fewer operations and less private practice despite being a better surgeon.

paulzolo wrote:
What I'd want to know is how doctors will be assessed.

This is why doctors would prefer exams - more robust and more of a level playing field. I have run late in the past. I once ran an hour late. Why? Because in front of me the patient was someone I'd never met, who had previously had issues and was now actively suicidal. I had to arrange for them to be admitted to the pyschiatrists. The next two people complained when I saw them. Their diagnoses? Sore throat due to viral illness. If I'd been assessed on that day, I would have had a crap score for running on time. Not everything can fit into neat ten minute slots.

At least exams can be updated and require doctors to revise so they are abreast of the best current practice in all areas. To me, it looks like I would have to attend 50 hours' worth of education eg lectures, courses etc. You just have to show you're learning new stuff. But typically the doctor doing the assessing (I believe) will be in the same area so a surgeon will assess a surgeon, a GP will assess a GP. You're not assessing the sum of their knowledge. I can show I'm up to date by going on a few courses (indeed I went on an update course that covered all new research and guidelines in the past twelve months) and then writing them up.
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In which case, it's down to knowing procedures, forms, turning up on time, not playing golf when you have an appointment (this really happened to me). That judges doctors against the wrong criteria.

Which is why most doctors are against it.

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Mon Oct 22, 2012 6:53 pm
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I could see it causing more inadvertent problems than it actually solves. I'd certainly be concerned about the 'incident rate' around the five year mark, there's already questions about how well whistleblowing gets handled, right down to, 'Here's some money and a legal gag for these internal accusations to go away.'

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Mon Oct 22, 2012 11:16 pm
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