Revalidation wave hits European doctors

It may be a function of a growing lack of trust in physicians or merely a product of the ever-increasing demand for more professional accountability.

Whatever the reason, a revalidation wave appears to be sweeping Europe that may soon force most doctors on the continent to demonstrate their competence if they wish to maintain their licence to practise.

While some nations like Germany and France have had revalidation schemes for years, doctors in the United Kingdom will only start undergoing revalidation in 2012. Over a five-year period, all British physicians are expected to be re-evaluated. Spain plans to introduce a revalidation scheme in the near future, while several other European Union member states are either examining whether to introduce revalidation or to make their current revalidation programs compulsory.

Drawing the most attention and heat to date has been the UK General Medical Council’s (GMC) proposal to require revalidation. It drew the ire of the British Medical Association in late May as being “overly bureaucratic and cumbersome,” costly and ineffective as a means of culling incompetents from the physician pool.

That prompted the government to announce earlier this month that it would defer introduction of revalidation for a year. In a letter to the GMC, Andrew Lansley, the UK’s health secretary, wrote that he did “not yet have sufficient confidence that there will be time properly to gather and evaluate evidence on all aspects of revalidation and to amend plans in the light of the current pilots in the NHS [National Health Service].”

Dr. Peter Rubin, chairman of the council, responded that “the decision to extend piloting of revalidation will ensure these systems are sufficiently robust without being burdensome or bureaucratic for doctors or employers.”

In November 2009, the GMC introduced compulsory licensing to practice across the UK and announced that it would require periodic renewal through revalidation so as ensure that physicians engaged in life-time learning to keep their skills up to date. Revalidation, it argued, was needed to “assure patients and the public, employers, and other healthcare practitioners that licensed doctors are up to date and fit to practice” and is “about promoting public confidence in the profession and encouraging self-reflection and professional development among doctors.”

As proposed, revalidation will involve a local appraisal of a doctor’s performance in the workplace, against national standards set by the GMC. To that end, the GMC outlined the core requirements of medical practice and structured them into a framework of generic standards against which doctors must provide a portfolio of supporting evidence demonstrating that they meet the standards in such domains as “Knowledge, Skills and Performance, Safety and Quality, Communication, Partnership and Teamwork and Maintaining Trust.” The required evidence may differ for each domain and may include such things as proof of training or assessment of skills, continuing medical education, audit (a quality improvement process), validated tools for feedback about doctors’ practices and anonymous records.

Each licensed doctor will be linked to a “Responsible Officer,” who will be in charge of making a revalidation recommendation to the GMC if he has no concerns about the doctor’s practice. That officer would be a senior doctor in the organization where the physician seeking revalidation works.

Professor Mike Pringle, Clinical Lead for Revalidation in the Royal College of General Practitioners, says the rationale for revalidation is to ensure fitness to practise. “It cannot be right that a young doctor becomes fully registered at about 30 years old and then has no further check for 35 years or more. Revalidation is a positive demonstration that a doctor is keeping up to date and continues to be fit to practise. The system must be simple, fair and affordable. That is what we have designed it to be. It must also stimulate the characteristics of a good doctor — reflection, development and improvement.”

Pringle says doctors are warming to the notion, or at least becoming resigned to it. “The debate has moved from “why?” to “how?” and “when?” he says. “Most view it as inevitable while few are enthusiastic. The views from both GPs and hospital doctors are similar.”

Others cast the response as decidedly unenthusiastic. Shreelatta Datta, chairman of the British Medical Association’s Junior Doctor Committee, says “there is currently no consensus regarding the implementation and running of revalidation for UK junior doctors across the four nations. … To ensure that implementing revalidation is successful, all stakeholders must be consulted, with a clear and realistic timeframe for implementation.”

Also unclear is what impact revalidation schemes will have on professional mobility within the European Union. Currently, Europe’s legal framework does not address periodic revalidation in order to ensure sustained levels of competence across time, despite the published evidence about the scale of medical errors and the increasing recognition that some skills decline over time in some aspects of care.

Moreover, there are wide disparities in the revalidation schemes that do exist. Those extend to their nature, their oversight (in terms of the organization responsible for implementation) and the processes by which it is undertaken. The variations are often the product of cultural and systemic differences, such as the degree to which government is involved in professional regulation or the role of payers like social insurance funds.

Some countries, like Portugal, do not have any form of revalidation requirement.

In others, like Belgium, revalidation is not compulsory, although a system based on continuing medical education requirements and peer review is in place. But Belgian doctors are legally obliged to maintain certain standards and are given a financial incentive to pursue revalidation. Such accreditation allows them to charge higher reimbursable fees to patients.

Germany and the Netherlands, by contrast, have compulsory revalidation schemes. German doctors are regulated through their professional associations, the regional chambers, and need to obtain 250 Continuing Medical Education points every five years. The penalty for not complying with these requirements is reduced reimbursement from the regional associations of social health insurance physicians. In the Netherlands, doctors are also subject to continuing medical education requirements but the revalidation scheme also includes a visit by peers every five years. Dutch doctors may be struck off the medical register for failing to comply with revalidation requirements.

Dr. Renee Weersma, a member of the Dutch committee which oversees revalidation of general practitioners, says “we used to have a special committee that made the rules for GPs and another one for hospital specialists, but since the first of January 2009 we have one single committee. This is aimed at enhancing team work between hospital specialists and GPs. The rules are made up by professionals representing the professional societies and our government (Department of Health) has to approve.”

“If, for example, a GP fails to comply with revalidation requirements, they have the possibility to reeducate themselves, by either becoming a GP trainee again or working under the supervision of another GP,” Weersma says. “Sometimes, they may end up in court, and even all the way to the European court. As far as I am aware of, most cases of GPs being struck off the medical register are older GPs at the end of their professional life.”

Meanwhile, Spain is proposing to introduce validation later this year. The scheme, comprised of three phases of increasing complexity, will include certification of good standing by a doctor’s respective college and employer, continuing medical education requirements and a competency assessment.

Spanish Medical Association President Dr. Juan José Rodriguez Sendín says the scheme will be voluntary until the third and final phase, which will include the assessment of both cross-sectional and specific competencies and is expected to be implemented by 2013.