BME doctors: From recruitment to embitterment

THE ELEPHANT IN THE ROOM: the Life and Times of a BME Doctor in the NHS - from Recruitment to Embitterment

Suresh Rao

These are my personal observations and experience of working for thirty five years in countries of three continents (India, Canada and UK). Till I became the President of the Indian Orthopedic Society of UK (IOS-U-K) around 2005 I had no reason to acknowledge the existence of discrimination in the NHS. I had passed all my examinations at the first attempt, I had become a consultant in the early 1990s at the same average age (about 37 years) of any UK born white male doctor in orthopaedics at that time. It was only after I had blown the whistle while actually observing the horrendous treatment meted out to my colleague orthopaedic surgeons did I actually personally experience racial discrimination in the NHS in its ugliest form.

I have now come to recognize that the traditional attitude to recruiting and retaining BME doctors and nurses into the NHS is no different from the ‘Discard After Single Use Only’ policy of the slave trade. There is little security or safety and no fairness of treatment. The system of incentives and reward for hard work and competence simply do not seem to apply to BME staff. Unlike others, the course of life of a BME professional whether doctor or nurse seems to follow several distinct stages.

1. Stage of Denial: We work hard to keep the home and family together, crediting our limited successes to the support of others. Any perceived failures are almost always attributed to bad luck, never to the possibility of discrimination.

2. Stage of Panic: Naively believing that blowing the whistle is good for the sake of our patients, we publicly voice our concerns forgetting that those responsible for the cock-ups in the establishment will not thank a BME for exposing their incompetence. Such persons will not hesitate in recruiting others even less scrupulous than themselves to intimidate and harass you for the loss of their ‘private empire’ style of working. They usually have no difficulty colluding with your colleagues who are probably already dreading the loss of their private practice to others. The establishment leviathan is now ready to turn against you for stirring up a hornet’s nest when you were least expecting this response.

3. Stage of silence: We are made to feel guilty for creating a conflict in the department where none had supposedly existed previously. We become vulnerable to subtle emotional blackmail by promising to avoid future conflicts and agreeing to behave in a more ‘civil manner’, i.e. accept that we should next time bring up any issues ‘face to face’ for a ‘negotiated’ resolution of ‘confusions and misunderstandings’ rather than going through the employer. We are later reminded of this sword of Damocles hanging on our heads and we become too frightened to think rationally, instead we too begin to behave like any victim would. We invite others to quash us underfoot like a worm by tacitly acquiescing to the rules of their game. This not only bolsters the opposition but also puts our relationship with our employer in jeopardy. We now enter a state of limbo in our career progression to the extent of even questioning our own achievements and wondering whether we had truly deserved our CEA points, if we managed to get any. We convince ourselves that this was just a favour granted to us by our generous employer but only with the benevolent support of our well-meaning colleagues. We begin to lose our self-esteem and any frame of reference we may have for our sense of self-identity, our moral character is disabled and allows us to do peculiar things we would never normally do. We are soon at risk of losing our raison d’être.

4. Stage of Escalation: Unfortunately a number of us cannot or will not read the writing on the wall. We may injudiciously allow the situation to escalate out of control and pave the way leading to our own harassment and intimidation at the hands of the abusers in the establishment. If this does not succeed to cow us down we are then threatened with disciplinary action including the possibility of instant dismissal for supposedly ‘serious charges’ including criminal prosecutions for what are really minor infractions. The establishment will not hesitate to dispense summary retribution through Dismissal Orders under ‘MHPS’ for trumped-up charges and enforce redundancy despite any findings of  the Employment Tribunals. It is not uncommon for us to be referred to the GMC by this stage as the latter is hand in glove with the Medical Directors against the BME and feels obliged to take up investigating all such matters despite no evidence being submitted by the Establishment, a clear case of disproportionately handing out injustices to BME.   

5. Stage of ‘Resolution of Conflagration’: this usually means a ‘negotiated settlement for enforced retirement’ and it is most diabolical that this sometimes comes about because the innocent BME cannot bear the humiliation of a criminal trial or a GMC hearing and will most likely be on the verge of deciding to commit suicide.

Suggestions to avoid such a fate:

This is difficult because everyone reacts to crises in completely different and unpredictable ways. Following is just commonsense, not rocket-science:

1.    Maintain good medical practice (and relations with colleagues)

2.    Know the law (including the latest version of MHPS and PIDA)

3.    Take advice from a mentor (and follow every step correctly)

4.    Anticipate trouble (band up together, join BAPIO and MDS)

5.    Use local procedures fully (keep meticulous documentation)

6.    Involve regulatory bodies at an early stage (NCAS, GMC, CQC, CPS)

7.    Remain vigilant and focused, be discreet, stay calm and never say die

The elephant in the room is discrimination, name it, call it out, learn to effectively deal with it and work to reduce its harmful effects on yourself and others.

Prof Suresh Rao

Consultant Orthopaedic & Trauma Surgeon

North Cumbria University Hospitals NHS Trust

Hon. Professor, University of Cumbria

(The above is from the talk given by Suresh Rao at a meeting in Manchester on 26 March 2013. All the content are the personal views of Suresh Rao)

©M HEMADRI

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A Discriminating View of the Doctors' Staffing Crisis in the NHS

We are going through extraordinary times for the NHS, especially so for doctors. From my perspective, this reflects the effect of not getting it right for everyone from the beginning.

The NHS as a care delivery model is fantastic. Tax funded, free at the point of care delivery, delivered at more or less the same standard across the country. It is so special, no doubt about the model/pathway.

The issue comes when it comes to staffing that delivery model. There was simply no staff at any time to deliver this model. So quite simply, as was always done in British history, the UK looked abroad for resources (the detriment to other countries by this policy is till today ignored by the UK). For healthcare the crucial frontline resource - the doctors were simply imported, poached, stolen (you can choose whichever word you want depending on the perspective) from abroad. India being a country which has medical education delivered in English following a British system of medicine was a natural target. For ages, even till today many IMGs end up as GPs in inner city and deprived areas. But it is the hospital medical hierarchy where the glaring disparity hits you.

There was always a surplus of registrar and senior registrar posts compared to the consultant posts (there was a permanent pyramid). Now that may be a problem in itself leaving people without opportunities. What happened from the mid 1970s onward, the demographics of the pyramid shifted. In the registrar and senior registrar grades there were mixed ethnicity with plenty of IMGs but very few of the IMGs went on to become consultants. The locals were in line for progression to a consultant post barring unforeseen circumstances and the IMGs were to remain permanently as registrars and senior registrars barring unforeseen circumstances, till they retired or died. These were later called staff grades and associate specialists. Name change and plenty of warm talk but the intention and roles remained the same. 


In the late 1980s and early 1990s I have heard numerous that local graduates holding registrar and senior registrar posts stated openly, loudly and clearly that they will put up with difficult conditions and low pay because it is only for a relatively short time before they became consultants. Meaning, that locals will progress on to higher pay and the IMGs will remain on the lower pay. This suited a brilliant care delivery model to be delivered at a low cost using a rubbish discriminatory unjust medical staffing model.


Of course, this strategy would have worked except that more consultants were needed and there were not enough local candidates. By late 1990s early 2000s the system woke up to this and created more medical school places and in my view with the hope that this local - IMG differential would continue. Where it went wrong primarily is that they underestimated the impact of women entering medical school, like most men, most women are excellent doctors but firstly they also want a good lifestyle (in contrast to men who in my view were often married to their careers) and more importantly physiology demands that many women choose to have children. So workforce planning went for a six; more IMGs were needed and the flood gates were opened in the early and mid 2000s. 


You see, now, suddenly, the pay for doctors is thought of as high, suddenly evening and weekends are no longer want to be considered as premium pay time. When medicine was overwhelmingly a white, male profession with IMG men manning the lower ranks these were not issues, doctors pay was relatively high compatible with their education and contribution, weekends were precious. The demographics change to equal number of women and a large number of IMGs and the values change.

The next wrong calculation comes from the fact if UK thinks they can import their way out of this mess. I don't know about other countries but many Indian young doctors are very wary of coming to UK; the training opportunities have increased in India, the economic opportunities have increased in India and lifestyle is improving in India - the exchange rate alone is no longer attractive.

To me it seems that the establishment does not want medicine to be an elite profession as it was when it was white male dominated. This makes it distinctively unattractive. There was always discrimination, there still is; the difference now is that there is FOI, there is corporate social responsibility and transparency. In the past we knew IMGs failed exams but we did not know the numbers, we always accepted that we did not reach the necessary standard, we were expected not to reach the standard, we were brought up being told that we could not reach the standard. None of that bullshit anymore. We know the numbers which are spread immediately all around the world by email, whatsapp, fb and twitter. We are asking questions; does the Indian IMG paeds reg trained in UK and taking the exam in UK have a higher failure rate in the UK version of MRCPaed than the Indian paed trainee who takes the exam in India never having worked a day here? Does the MRCGP International AKT MCQ have a longer time to answer their question than MRCGP UK which puts IMGs at risk of failing a 'purely knowledge exam'? We suspect an adverse use of linguistic bias. We know that Scottish, Irish etc need a grade c in English equivalent to IELTS 6.5 but IMGs need an English standard much higher, yet found fault with their language. We know the students in England do not need English A levels to get into med school. The standard for IELTS for IMGs was not set by administering to a group of local FY2s, it was actually set by an equivalent of a large focus group sitting around a table and deciding what was an acceptable standard; what a marvelous way of standard setting (accompanied by truck loads of stats on why that kind of standard setting was valid, the whole lot I found dubious, okay, to put it politely, it was very highly subjective)

The senior doctors including senior IMG doctors seem to have a distinct mentality that is not quite in sync with the younger doctors and their aspirations. The true cost of discrimination against women, discrimination against IMGs is now biting back.

A fabulous care delivery model designed six decades ago by the local population for the local population in UK did not consider the career prospects of IMGs and did not care that women were not part of the game for a long time are now completely flummoxed when IMGs are waking up and women are demanding a different kind of atmosphere. 


I wait to see if the lessons from past atrocities will be learned, I wait to see if because of the change in demographics medicine will be deliberately made into a lesser profession. I am not optimistic about the people becoming just. Why am I not optimistic? Let us look at the current routes into UK for IMGs - the MTI and the PLAB.


The whole MTI premise is based on getting people into UK to fill in rotas. It would be very difficult to provide any proper training in two or three years; especially when MTI doctors are not deanery numbered trainees for whom there is still to some extent funding for training. When I look around, I find that most new entrants into UK are in rota fodder posts and not in any proper training posts. I am not sure if there are large number of MTI doctors who are undergoing specialised training  (say for instance in pancreatic transplants), I suspect most of them are at SHO and junior registrar levels.

Let us say that a doctor goes back to India after MTI and applies for a job in a corporate hospital in competition with a CCT holder - who will get the job? Let us say an MTI completed doctor applies for a job anywhere else in the world (middle east, australia, etc) what kind of a job will (s)he get on the basis of MTI? Has anyone asked these questions? My personal feeling is that in most of the cases a typical MTI doctor after the completion of the time and leaves UK as per the rules is unlikely to be a strong candidate for any job anywhere in the world (I am sure there will be exceptions to this assumption).


So what is the use of MTI posts? 


The next is PLAB route doctors who more often than not spend years in a variety of non-training posts. My advice to young doctors who come to UK after PLAB process is 'take a formal training post or do not take a post at all in the UK'.


If still doctors from India want to come to UK via MTI or accept a non-training post via PLAB then the only logical reason for that would be to use UK as a temporary staging post to analyse and access opportunities in the rest of the world eg prep for USMLE etc.

UK should stop looking at IMGs as rota fodder. The system should change to provide every doctor who enters UK only formal training posts with the intention of making them a consultant or a GP; there may be some who eventually choose not to practice as a consultant and take up a senior non-consultant post, that would be a matter of personal choice and not a systematic denial of opportunity. This means at junior levels there are only training posts. Well, will this ever happen, I wish it would but I am pretty certain it won't. The system is designed for and habituated to exploitation of the IMGs; that system is unlikely to shock itself by changing even when it faces its own existential crisis.

So unless there is a technological solution there is going to be an ugly muddle impasse in the NHS for a long time to come.

©M HEMADRI

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My mini e-book 'Standardised Management Conversation' is available - click http://www.amazon.co.uk/Standardised-Management-Conversation-Hemadri-ebook/dp/B018AWBJTU 
till 31 December 2016 all my earnings from the sale of this book will be donated to charity  http://successinhealthcare.blogspot.co.uk/2015/11/standardised-management-conversation.html

 

Yvonne, BME, Women & King's Fund

On 22 October 2015 the Kings Fund announced that it has appointed Marcus Powell as its new Director of Leadership Development ( http://www.kingsfund.org.uk/leadership/kings-fund-appoints-new-director-leadership-development ) King’s Fund CEO Chris Ham put out a tweet about it. That provoked a set of tweets from Yvonne Coghill who seemed to be disappointed on why Vijaya Nath who was the acting director of leadership development did not get the substantive post.

This reminded me of my interaction with Kings Fund in October 2012. It could give a background on why Chris Ham did what he did now. It could help us understand the difficulty involved in obtaining justice and equality to various sections of the society.

I have experienced the TMP at the King’s Fund in 2009, it is possibly the best programme in leadership and personal development for healthcare professionals in UK. So I have an interest in King’s Fund and its activity. I have always wondered on why the various brilliant activities have not delivered the outcomes to the UK that King’s Fund would have liked to see.

That is when I discovered that the King’s Fund General Advisory Council which is appointed by HRH Prince Charles did not have a single member who was from the Black or Minority Ethnic segment of our population. Here is a highly respected think tank which is well aware that BMEs make up a significant section of the population and are a major part of the engines that run the healthcare system in UK yet did not have the maturity or the insight to realise that the General Advisory Council was exclusively white.

I then found that the General Advisory Council that I refer to was appointed in December 2010. Chris Ham took over as Chief Executive of the King’s Fund in April 2010. The General Advisory Council is appointed by the President on the recommendation of the Chief Executive.

I wrote to the President of the King’s Fund HRH Prince Charles, raising my concerns about the lack of inclusivity at a high profile place which he heads as President.

The private secretary to Prince Charles responded stating that the appointments are a matter for the Chief Executive and passed it on to Prof Chris Ham; the letter also said that Chris had ‘will wish to be in touch with you about the points that you raise’. When I saw the letter I knew that things would change.

Of course Prof Chris Ham then wrote to me to say that he aimed to strengthen representation from BME groups and ‘will achieve this’ ‘from January 2013’

When I saw this letter, I knew that the King’s Fund General Advisory Council would have BME members from January 2013 and it did. If I remember right, Lord Adebowale and two (or three) others were promptly appointed. The current General Advisory Council seems to have numerous BME members. 

When I saw that letter from Prof Ham, I also was a little bit uncomfortable, the letter is office speak and officialdom in its content. There was no regret for the lack of insight and BMEs were seen as representatives or representation.

BMEs in such councils if they are representatives, they are representatives of what or whom? Of other BME people in the country? Do white people in the council appointed to represent other white people in the country? I do not think so.

I did not pursue this further. I am not sure if I should take any part of the credit for putting BME in the GAC of the King’s Fund or blame myself for becoming part of what could be seen as a tick box exercise and not challenging it at that time?

I do not want any BME ‘representatives’, I want people who are there and happen to be BME. We have to challenge this narrative which implies that the majority is there by a certain credential and BME are there to represent.

Yvonne, Vijaya and BME members of the General Advisory Council – I hope I have given you some background to the story of how organisations function; not that you did not already know it, in which case I have provided some specifics about King’s Fund. I am absolutely certain that the BME members of the GAC are very worthy to be there but for a minute put aside your uniform, put aside your membership and clarify if you are representing BMEs in healthcare or you are people interested in healthcare who happen to be of BME origin. The easy answer is for the BME to think that they are the later category and the King’s Fund to say so; that will be comfortable for everyone. The reality is such questions need no answers, they need serious mature deep thoughtful reflection followed by explicit tangible action.

I am confident that the new Director of Leadership will do a great job for the King’s Fund but if he wants that to translate into a great job for British healthcare, his agenda, span, scope of action just became much greater.

©M HEMADRI

Follow me on Twitter @HemadriTweets

 

PS: I have already spoken about lack of BME presence in Berwick report and predicted that it may not have a desired impact on UK healthcare http://successinhealthcare.blogspot.co.uk/2013/08/don-berwick-report.html

Yo BAPIO - What is that Moral Victory thing?

This article was first published in Sushruta Vol 7 Issue 1 by BAPIO

It is now very well known that BAPIO filed for a judicial review of the MRCGP examination, especially with regards to the CSA component; well there is no point beating about the bush, BAPIO lost the case.

That means that the MRCGP was ruled to be a fair examination, by indirect inference it may be assumed that other examinations were also likely to be fair. BAPIO members, BME doctors, IMGs can be reassured that things are rosy and live in joy. I was just about to do that when I found that Prof Rajan Madhok, Chairman, BAPIO tweeted ‘JR judge says: moral success but not legal victory! So our laws go against our morals? Crazy’ It is true. The judge said BAPIO had a moral victory.

So what is that moral victory thing? It is just a judge being polite?

Pause. Reflect.

To understand this, we have to go back to 7 June 1893. One Mr MK Gandhi who had a first-class ticket and was travelling in a first-class rail compartment was thrown off the train. He had a legal right to be on that train but he still lost his seat in the train; Gandhiji had a moral victory. The rest was history and what a history it was.

The judicial review has set off a number of changes which we are beginning to hear about. The GMC is now considering seriously introducing a common licensing examination for UK graduates and IMGs (similar the concept of USMLE). The GMC is introducing English language competency tests for EU doctors (where there is cause for concern). The time allowed for the AKT MCQ examination of the MRCGP is being increased. There could be changes to the way CSA is conducted and assessed. There are numerous other changes and many Royal Colleges and medical educational establishments are engaging with BAPIO and its partners.

The RCGP and GMC activities considered in the Judicial Review were ruled legal. Yet they and other institutions are making changes that further cause of equality. BAPIO contends that these changes would not have happened at this juncture and at this pace, without the Judicial Review? Are we beginning to understand the concept of a legal loss and a moral victory?

By the way, Gandhiji protested and was allowed to travel the next day by first class. In the continuation of the same journey he was beaten by a driver, banned from hotels and subjected to other forms of abuse.

BAPIO should be under no illusion that things are or soon will be rosy. The path is strewn with thorns and BAPIO should be prepared for its skin to be pricked in this journey. What does BAPIO want? BAPIO wants, what you have always wanted. A level playing field, no bias, high standards, fair assessment and equal opportunity to progress.

Here are some suggestions on the specifics that BAPIO should be asking for

1) Real patients rather than role players

2) Increased number of BME/IMG examiners

3) Two examiners on each station

4) Video recording of the session.

5) Improved training of the candidates.

6) Improved training of the trainers and holding to account of trainers with poor record of success of their trainees.

7) Feedback and mentoring for those who fail

8) Removal of hawk examiners/trainers (especially those who have negative impact on BME/IMG doctors)

9) Removal of dove examiners/trainers (especially those who have a negative impact on BME/IMG doctors)

10) Testing and continued monitoring of sub-conscious bias in examiners/trainers.

11) Examiners with extreme bias not to be selected, examiners with non-extreme bias to be provided training followed by monitoring.

12) Pass-fail threshold and other standard setting (such as ARCP/RITA progress) should be tested for impact on various populations with protected characteristics and where there is no evidence of impact on patient outcomes the thresholds should be adjusted to reduce any possible negative impact on doctors with protected characteristics.

13) Objective assessments/examinations for summative, pass-fail, high-stakes situations/examinations/assessments (with any subjective assessments reserved for formative processes)

There are many more ideas that will benefit the system.

If BAPIO decides to ask for these and more, you can be assured BAPIO will be vilified and denounced. The hope is, after the abuse is done, the changes would happen, even if they were slow.

A couple of thousand of years before Gandhi, we hear of one Jesus Christ, who lost a legal case and was crucified; he seemed to have won the moral case quite convincingly. Time will tell, but BAPIO’s moral victory may turn out to be a very strong force for change.

M HEMADRI

 

Don Berwick Report

Don Berwick NHS patient safety report - will it work?

It will. Though there is a blind spot to watch out. 

A blog from a particular perspective

Don Berwick report 'A promise to learn, a commitment to act, improving the safety of patients in England' has been published (https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/226703/Berwick_Report.pdf). There is all round praise which is well deserved. The entire report is full of gems of wisdom. As a practising clinicians who also values work life balance, I have still managed to fast read the report, I will read it again in detail. As a student of improvement science I am sure I will learn a lot from the report. I am a fan of Don Berwick, I have heard him speak a number of times and every time I am not only moved but I always come away with great learning. It was one of the cherished moments in my professional life when I shook his hand at the Forum in London in April 2013 and he walked with me to personally introduced me to Sir Brian Jarman.

Don's report is pretty comprehensive as expected, I hope the report will be effective.

The Blind Spot

My problem with the report is not the content, my problem is with the membership of the advisory group. It is elementary in leadership that while what is said does matter, how it is said and who said it really matters more. Why do you think football celebrities endorse non-sports products?

The committee was happy that they were independent.

The advisory group was made up of 17 persons whose expertise is unquestionable. 4 of them were Americans from the Boston-Harvard area; with 3 of the 4 Americans from the same organisation. 12 out of 17 were non-NHS, the 13th was NHS Scotland. No Europeans. No one else from the US aside or instead of this close knit group.

9 of the 17 were women - finally it looks like we are recognising that the half the real world is indeed made up of a gender who are not male, well done. 

17 out of 17 seem to be white. 

Don Berwick is no stranger to England, he is no stranger to inclusive leadership. Don was obviously so dedicated to answering the questions put to him that his human limitations prevented him from recognising that in London when he walks the streets 50% are foreigners, 40% are Black and Minority Ethnic. If Don entered any hospital he may have noticed that about 40% of doctors are from BME origins and in London nearly 40% of healthcare staff are of BME origin and about 10% of this country are from BME backgrounds. Don's report speaks about adequate staffing. Where do you think that comes from? We are hearing reports of urgent recruitment of rota fodder to deal with the A&E staffing crises from countries like India, Don and his committee would recognise Indians are part of the BME group.

The Quality Chasm and Leadership Deficit

Who speaks to whom matters. Constituencies matter. Don is now a politician, he will do well to remember that his country's president won his office on the black vote (though certainly not exclusively on the black vote). If Don looked and did not find an person who has some expertise in quality and safety who also happened to be non-white he should have mentioned that a part of the system failure that he talks about.

The report talks about culture and fear. Amongst the most afraid in day to day clinical practice are BME doctors who face a higher rate of referral to their regulator; they are also thought to have higher rate and higher intensity of sanctions by their regulator. BME doctors also face extraordinarily adverse pass rate in their specialist examinations, unlike in Don's country.

It is not as though the committee did not have a BME connection. It did have a most profound and tragic BME connection. Lisa Richard Everton, a patients' representative on the committee lost her husband Paul Everton due to a lethal overdose at Heartlands. Paul Everton was black. Don would know that in our much revered NHS BME's get poorer health outcomes.

I was actually hoping to have interactions, debates or arguments on the technical aspects of improvement and patient safety issues with Don; I am sure I will in the near future. Instead I am talking about leadership, culture, inclusivity and race. On my initial reading, the report excels and succeeds at the theoretical and technical aspects where the content experts lead by example. The report fails in its operational aspects especially in the context of what the manpower constituency might recognise, mirror and reflect, the report and its committee fails by example

The inability to include or cope with a real mix of normal people is the biggest wall that prevents our already good NHS from achieving even higher standards. A different committee with some persons who have BME style thinking (as opposed to just simply being from a BME origin) in it would not have made any difference in the content of the report, I suspect it might have made a difference in the sincerity and speed of adoption. I am not a race warrior, this blog is not about race, regular readers of this blog would already know that. This blog is about contextual leadership which in essential for success in healthcare.

I remain a fan of Don Berwick, I do not write this in protest or complaint. I write this due to a genuine concern that Don, a person whom I admire and his recommendations should not fail. I write out of a genuine desire that the NHS should cross the quality chasm by overcoming the massive leadership deficit that it faces.

© HEMADRI

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PS: I recommend the report. It is up to us, normal NHS staff to make sure that we take this report to the front line and deliver it there to benefit our patients.

Revalidation - GMC must make it objective as soon as possible

The shortest overview of revalidation

GMC is commencing the process of revalidation for doctors in December 2012. The revalidation demands that we have evidence of 

1) Continuing professional development

2) Quality Improvement Activity

3) Significant events

4) Feedback from colleagues

5) Feedback from patients

6) Review of complaints and compliments

These six will populate the annual appraisal which apart from its main domains include the personal development plan, probity and health

Based on the above, the responsible officer will make a 'judgement' on whether the doctor can be recommended for revalidation. The GMC will then make a decision on whether the doctor has been successfully revalidated.

There is plenty of guidance on GMC website : http://www.gmc-uk.org/doctors/revalidation.asp

Concerns about the background for revalidation

While the issue of periodic quality assurance of licensed doctors has been discussed for a long time, the common view is that the current revalidation efforts commenced after the Bristol enquiry and gathered momentum after the Shipman enquiry. Bristol was an outlier, there was no trend that many hospitals or many cardiac surgery units were having unacceptably bad outcomes. Shipman was an outlier, there was no trend that many doctors were behaving or beginning to behave in a Shipman like manner. Outliers need to be analysed properly so that outliers can be stabilised to a performance level compatible with other performers within the general system. Quality principles would suggest that outliers should not trigger a process change for the whole system. Process change for a system could be triggered by an unacceptable trend (there are other reasons to change the process as well, but outlier is generally not one of them). To create a process change on the basis of outliers is thought to result in unnecessary expense and wasted effort.

This does not mean that we cannot learn from outliers, undoubtedly there are extraordinarily important lessons to be learned from Bristol and Shipman.

Linking the background to current revalidation method

Bristol is about performance and Shipman is about behaviour. We can safely assume that this is what the GMC seeks to assure. Quality assurance needs to be demonstrated in an objectively measureable manner.

Revalidation criteria - Not Objective

The six areas of evidence that the GMC asks for seem to be mostly subjective.

Continuous professional development (CPD) is generally accepted as a reflection of time spent on courses and conferences or other learning opportunities. It is certainly not a measure of the knowledge or skills gained or updated though that might happen. Some professional bodies have not defined the time needed to be spent on CPD. Hence while CPD is often measured and entered as a number it is a measure of time spent rather than a number to show the knowledge or skills gained. It could therefore be argued that CPD is either subjective or fit for purpose for revalidation if the intention was to validate or assure knowledge and/or skills.

Quality Improvement Activity: within this areas a range of activity is included. Activity is neither outcome nor achievement. Therefore activity is again time spent rather than gains (or losses) measured. An important point in quality improvement activity is that people fail more often than they succeed, that is the nature of quality improvement. Doctors, hospitals and the GMC should be comfortable with that. This could be potentially be an objective criteria but currently it could probably be considered unsure.

Learning from significant events and review of complaints and compliments are about self-reflection and reflective writing. It is obviously subjective. Feedback from colleagues and feedback from patients though done through validated tools by external or independent service providers is essentially the conversion of subjectivity into a scale to be able to measure.

Are subjective criteria relevant?

Absolutely yes. But only when looked along with objective criteria. Any form of quality assurance process must include subjectivity. The current criteria for revalidation seems mostly subjective and hence the concerns.

Why are objective criteria important?

We are talking about doctors who are essentially already very highly qualified and doing an extremely complex job under phenomenally varying conditions. We are taking about professionals on whom we have already spent somewhere between half-a-million to a million pounds before they are employed to do their role. Revalidation is about making a decision about their careers which could potentially be halted. To make such major decisions on mostly subjective criteria would not make sense. Further, there are planet loads of data already gathered and analysed and hence objective criteria are possibly already available if we wanted to use them.

Next is the issue of who may potentially be adversely affected to a higher degree than most. When subjective criteria are used there is a risk that often the weak, the easy targets and usual suspects may be affected. This has been seen in a few exam situations where certain sections of candidates pass the objective knowledge and skill components but fail the subjective elements of vivas, communication, simulation etc. There is a fear that it is possible that IMGs and BMEs (and SAS) doctors  would be affected by the level of subjectivity involved in revalidation.

There are good reasons behind these fears which relate to the culture and history of healthcare institutions and the culture and mind-set of BME/IMG doctors which is not explored here.

Increasing objectivity

Testing knowledge has traditionally been done by examinations. Americans revalidate their doctors on the basis of an objective examination of knowledge. This while reducing bias increases the validity of assurance of knowledge. Skills assessment could quite relevantly be based on performance data. Speaking from a hospital doctor perspective, this should be quite easy to do with some minimal tweaking on how data is gathered. Operational performance data is either the best or as good as any other indicator of a doctors skill.

Increasing objectivity still would not resolve the underlying issue of a process change for all doctors based on outliers and not trends. The GMC also needs to resolve other issues. Is revalidation a quality assurance process or a quality improvement process? Because the theory and the tools for assurance are different from improvement

Revalidation is important. It is likely that as it stands the revalidation process is heavily subjective. Given the importance of healthcare of the nation it would be advisable to quickly move to mainly objective criteria. We are where we are, let us make it better and fit for purpose.

©M HEMADRI 

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