The two basic questions concerning Revalidation are ‘Why is it happening?’ and ‘What will it involve?’ A further question we should ask ourselves is ‘What can we get out of it?’
Why is it happening?
Revalidation comes out of the Shipman Enquiry and the various initiatives it has spawned, including the Foster Review. The government decided it needed to be seen to be doing something to “prevent another Shipman”. In reality, there is nothing a government can do that will prevent a doctor killing patients. So instead of doing something that will be effective, it can only do something – whatever it can actually do, rather than whatever will actually work. It really doesn’t matter what, as long as it deflects political flak.
The Department of Health (DoH: what a brilliant abbreviation – straight out of The Simpsons!) has decided that it is self evident that whatever is inflicted on doctors must also be A Good Thing for every other healthcare profession. So we have to undergo a process whose ostensible purpose is to stop doctors killing patients!
It is important to realise that the purpose of this process is purely political and that it is in Alice in Wonderland territory as far as logic is concerned. It has been imposed on the GOsC and there is absolutely nothing they can do to prevent it happening.
What will it involve?
The DoH has, naturally, focussed entirely on the NHS and developed a revalidation model based on “360 degree appraisal”. As a profession mainly comprising self-employed practitioners in private practice, many of them single-handed, the DoH’s NHS model is as inappropriate to Osteopathy as it can possibly be.
So the GOsC has decided to develop a model that is appropriate to Osteopathy: one that will not place an unrealistic burden on individual osteopaths, and that will provide a positive benefit to the profession as a whole. To that end the GOsC started consulting with as wide a range of the profession as possible, through the network of GOsC regional reps, the colleges, and the BOA.
It is a principle of Revalidation that it should address risk. Where doctors are concerned the principal risks to the public are of death or serious disability due to either incompetence, neglect or malice. Osteopaths have, in comparison, a remarkably unexciting record when it comes to killing and disabling our patients!
The government’s Better Regulation Executive set out the principles of “Better Regulation”; that it should be:
- Proportionate
- Accountable
- Consistent
- Transparent
- Targeted
The GOsC is committed to ensuring that the Revalidation scheme meets these criteria in terms of the risks posed to the public by osteopaths. Any scheme that is targeted at and proportionate to the risks we, as a profession, pose cannot be too onerous. Any scheme that is consistent, accountable and transparent, is one we need not fear.
I feel the current discussion document is not sufficiently closely targeted and that it is still a bit too big. If it looks too big, people will tend to try to work out what they think the GOsC wants as an answer, rather than thinking properly about the questions in relation to their own practice. Being forced to reflect on your own practice is always a useful process, if not always a comfortable one!
The issues are about identifying the relevant risks and determining in what way the scheme should provide a benefit to the profession.
Some people are alarmed by the remediation component and see it as a sinister way for the GOsC to control the way we practice. In fact, this is a required principle outlined in the government’s Non-medical Revalidation Working Group’s report. Its purpose is to ensure that anyone “caught out” by the Revalidation process should have a chance to remedy the situation as simply and easily as possible; no-one need fear being struck off because they didn’t fill out their revalidation form properly.
What can we get out of it?
I feel that, since Revalidation is being (quite unnecessarily) foisted upon us, we should subvert the process as far as we can, to ensure that we get something out of the effort we will, inevitably, have to make.
The most useful thing the Revalidation process can do for us as a profession is to force us into doing clinical audit. If we have data from 20% of the profession every year that would provide a massive database from which real evidence about real osteopathic practice can be obtained. If we are ever to justify ourselves to the medics and the policy-makers, then that is precisely what we need. But, to be realistic, the only way we will get it is by being forced to do it. Do I perform routine clinical audit on my own practice? No. Why not? Because I am busy and there is always something else that is more urgent than setting up the system to do it. Making it part of Revalidation would certainly get it to the top of my priority list pretty quickly!
The key to audit is building in to what you do every day in practice. That way it isn’t a massive effort. I have been using the BOA’s Data Collection Tool for the past year. It collects data on new patients and I have integrated the questions it asks into my history-taking. I don’t even have to think about it, and recording the data (on the provided spreadsheet) takes less than 20 seconds. Practically effortless, and now I have data on every new patient I have seen for the past year
If a clinical audit tool were standardised in every practice in the UK, we would have a fantastic resource.
I agree that Revalidation cannot hope to achieve protection of the public.
Audit might be useful but it does nothing to protect the public as evidenced by The Shipman enquiry you refer to!
CPD, audit and regular contact with colleagues were all satisfactory in Dr Shipman’s case as the report found:
. “I observe that Shipman did not show any sign of professional isolation. He became involved in organisations outside the practice. While at the Donneybrook practice, he was an area surgeon for the local St John Ambulance, secretary of the Tameside and Glossop Local Medical Committee and a member of the Tameside FPC. When working at Market Street, he regularly attended professional development events, was active in local medical politics and was an enthusiastic member, latterly treasurer, of the West Pennine SPA. Shipman was also known to be keen on introducing new ideas to the Donneybrook practice. The Market Street practice was regarded by the WPHA as being innovative and advanced. At Market Street, Shipman and his staff performed regular medical audits, which impressed the WPHA Primary Care Clinical Audit Group (WPPCCAG). The following comment was made in January 1998 after a practice audit visit by a member of the WPPCCAG:
‘Great to see a single-handed enthusiastic GP with a rolling programme of audit. Practice nurse also very enthusiastic and takes part in audit. We think it would be very useful for you to have an audit assistant and hope you follow this up. Keep up the good work.’
This comment is indicative of the way in which his participation was regarded.” Dame Janet Smith DBE
My point is not that Audit helps to protect anyone from anything (it doesn’t), rather that since revalidation can never stop another Shipman*, we may as well forget the protective aspect (which isn’t going to be effective anyway) and concentrate instead on perverting this ridiculous process to create something of value to us instead.
The value of audit is that it can provide us not only with useful information about our own practice, but also (if it includes outcome data) starts to build an evidence base for osteopathic practice.
Since it is unrealistic to expect revalidation to go away (all the political parties seem to be committed to it) we may as well try to make something positive out of it.
*This whole revalidation business reminds me of locking stable doors after the horse has bolted. Except that in this case, after the horse has bolted (Shipman has killed his patients) the government isn’t even locking the stable door (which would have stopped the horse from bolting if it had been done earlier), but is draining the duck-pond instead (which wouldn’t have stopped the horse from bolting anyway).
Martin
Audit should then be encouraged and I agree that in this way, it is possible and potentially productive to make the process of revalidation positive (PPPPP!). However, in my view, audit should remain voluntary. (In my case too the advantage of it becoming compulsory is that it will happen whereas I may otherwise have chosen not to undertake it!)
We can and perhaps should forget the protective aspect of it, but why do the GOsC present it to us as having this function if it does not? Is this not misleading both Osteopaths and the public?
If we as Osteopaths did whatever we can actually do, rather than whatever will actually work our practices would fast decline!
Simon
I think audit might have a protective role – but it would be as a contribution to protecting osteopaths by throwing up areas we are not aware of in which we might be at risk. (Here I am thinking of, for example, legal obligations in areas of equality or health and safety where we are failing to comply with the law out of ignorance.)
The GOsC’s attitude seems to be that for osteopaths the areas of risk are patently not in harming (let alone killing) patients, but in a conflict between the expectations of the public (I should not need to undress/treatment should be comfortable and show instant benefit) and the osteopath (I cannot possibly do my job properly unless you undress to your underwear/treatment may be uncomfortable (or even painful) and your body may need time to adapt).
So my impression is that the GOsC sees “protection” as a two-way street, protecting both the public and the osteopath from misunderstanding and conflict.
, which I think is a very positive way of approaching it.
If Audit helps improve patient/Osteopath communication it would indeed be positive.
Anything that clears up or prevents misunderstandings is undoubtedly beneficial.
I had not appreciated that the GOsC had the interests of Osteopaths in mind as well as the Public. Thank you for clarifying this.