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BMA response to the Chief Medical Officer review on maintaining high standards of professional practice

May 2005

Overview
There are five headline points that we wish to emphasise.

1. Appraisal needs to be developed in conjunction with clinical governance. It is vital that local quality assurance systems are developed to identify problems that could be resolved at an early stage.
2. Strengthening appraisal and clinical governance systems will require investment. It is particularly important to develop local quality assurance systems that are able to generate standardised and fair information about individual practice and that can support revalidation.
3. There is a need to separate different levels of performance assessment and provide stronger links between them. Where there are serious questions pertaining to an individual’s fitness to practise medicine, these should be referred to the GMC but management and related issues pertaining to compliance with organisational systems and other matters should be dealt with by local management structures or alternative agencies in association with local professional advice.
4. The GMC has been a pioneer in developing regulation well beyond that in other countries and some time is needed for its changes to bed down. Any new system should be developed incrementally.
5. In strengthening the regulation of medicine care needs to be taken to avoid disincentives to take on high-risk procedures or patients, or to innovate more generally.

Introduction
The CMO’s paper raises a large number of fundamental questions. This paper sets out the BMA’s response and is the product of debates that have taken place across the full range of our committees.

We think it is important to state at the outset that the process of revalidation should be set in a framework of medical practice per se and not centred solely upon the NHS. The methodologies employed for the effective regulation, revalidation and quality assurance of the medical profession have to apply equitably and appropriately to all doctors on the medical register and not just to those who work within the NHS. This approach sits better with the government’s aim of encouraging a greater plurality of provision.

Questions on appraisal
Appraisal must be a process that is primarily formative and supports doctors in improving their practice. While a formative approach may seem in tension with the process of revalidation, the evidence that informs appraisal can be part of the assessment that leads to professional revalidation. We are of the view that revalidation should be a separate process but one informed by appraisal as a key contributing factor.

It is our view that whilst the same evidence may be used in appraisal and revalidation, it is vital that revalidation is distinguished from appraisal that should remain an educational and supportive process. The revalidation system should be structured so that the appraisal process can easily contribute to it. Performance assessments should be undertaken as infrequently as possible to keep interference with doctors’ clinical duties to a minimum. Clinical governance systems could be developed to provide standardised information about individual practice and these systems could support revalidation without subjecting the profession to excessive additional workload.

Although it got off to a slow start, in many trusts appraisal is becoming a more robust process that is supported by doctors. It will be improved by trusts supplying more data and a fair and contextual assessment of actual practice.

For most doctors, appraisal should be largely developmental with a quality assured assessment of educational plans and the quality of care being delivered. This would include sufficient evidence to satisfy those who are observing the process. For those doctors who seem to be having difficulty there would be a need for closer examination of credible data, depending on their field of practice.

Any arrangement put in place should not introduce an onerous workload or have intimidating undertones as this may pose a threat to recruitment and retention and would potentially encourage early retirement amongst older doctors.

Should doctors’ performance be assessed in addition to, or as part of, the annual NHS appraisal? What purpose should appraisal of clinical practitioners have: should it be primarily for governance, with a primarily summative structure and handling; or should it be, as at present, primarily for developmental purposes, with a primarily formative structure and handling? Can it be on both of these bases at the same time? How might small practices and departments be supported in this area? What form should assessment take?
What is the purpose of assessing doctors’ performance? Doctors want to be clear that all parties understand this purpose in the same way. In the light of the Shipman Inquiry, doctors hope that the point of assessment is not solely to try to detect criminal behaviour. Doctors agree that competence is normally distributed with some excellent doctors, some poor ones and the majority in the middle. The aim of assessment should be in part to identify those that are in the tail of performance and better understand the reasons why.

Part of the confusion in the development, assessment, and revalidation of doctors is that more is demanded of the appraisal model than it was expected to deliver. Appraisal is essentially a developmental process through which it is ensured that doctors are up to date, linked to education and training. The appraisal process has also become a process through which management tries to assess the performance of doctors within organisations. It has also been suggested as a vehicle for revalidation.

Trying to change appraisal so it is primarily formative with a summative element will be difficult and must be taken forward carefully or risk jeopardising the gains that already have been made by the now widespread acceptance and implementation of developmental appraisal. Given that appraisal should be primarily a developmental process, it is vital that a move to develop summative data does not change appraisal into something more threatening.

A summative element to appraisal could be provided if local quality assurance systems were developed so that they generated information that could provide an overview of key indicators.

What practical measures would assist with establishing that a doctor continues to be able to provide competent and safe services? Should 360° reporting be introduced by the NHS as part of appraisal? Should there be a confidential reporting system? Should doctors record their experience, learning or educational events in a log-book? Who should be involved in the assessment process?
Indicators of performance should be established in agreement with the profession as assessment should be essentially, professionally led. To be effective, these indicators need a clear evidence base and should be measurable and relevant to their area of practise.

The practical information that will support safe practice will include doctors’ current records of care, which can be considered alongside other evidence, such as information gathered from local quality assurance systems, random samples of patient surveys and others outlined later in this response.

It is important to remember that consideration and reflection on practice does not only occur in annual appraisal and five-yearly revalidation processes. Doctors work in multidisciplinary teams where their practice, particularly decision-making, is continually observed by colleagues. These settings provide an excellent forum to review practice and discuss the lessons that can be drawn from shared experiences.

Healthcare organisations would do well to strengthen clinical teams and their ability to review and assess practice.

The foundation of an assessment process should be the organisation’s own quality assurance systems. There is a need to improve the data that informs the assessment process. We cannot emphasise enough the need for local information systems to be developed in order for appraisal to deliver revalidation properly and fairly.

Whilst “360° appraisal” has its merits, in this situation it may not produce the requisite information with regard to performance but simply indicate those doctors who are popular.

The assessment process should primarily involve doctors from the same field.

How can patients and the public contribute to the maintenance of standards and competence? Should their views about their medical treatment be sought routinely? Or on a sample basis?
Without wishing to sound as if we are reluctant to involve patients, we think it is worth asking whether patients are able to judge a doctor’s fitness to practise. As we have said, regulation will be most effective when the standards of practice are established and assessed by their peers.

Patients must be consulted on the relevance of these standards and measures of competence; they should have access to information that reassures them on these points. Ultimately, we believe it is very difficult for a patient to judge the competence of a doctor. Indeed, it is difficult for an untrained observer to ascertain much beyond the manner and demeanour of an individual.

Clearly, an individual’s ability to communicate effectively is important and the views of patients on the level of information they receive, whether they were helped to understand their post-operative care, for example, can help, but it is doubtful that patients could play a fuller part in assessment.

Much greater use could be made of the patient surveys that have recently been commissioned and have begun to report. There is perhaps potential for these to analysed in a more targeted way, particularly in secondary care, so that they offer a particular department or professionals caring for the same patients a picture of how their service is perceived. In general practice, the patient surveys used for the quality and outcomes framework (in the new GMS contract) will be included in appraisal and it would be logical to use this information to inform revalidation.

It is difficult to know how to capture the views of the public more broadly as individuals are not necessarily representative of the entire community and their opinions would be unlikely to capture this wider view.

How should lessons learnt from patient complaints be fed into the appraisal system? How can staff be encouraged to identify and report poor performance or unacceptable conduct?
It would be reasonable to expect that during an appraisal evidence is produced of how the doctor responded to patient complaints, what lessons have been learnt, and whether his or her practice has changed as a result. These lessons should then inform the doctor’s personal development plan. The difficulty is that the NHS is perceived by many who work in it as apportioning blame and the success of encouraging staff to identify and report poor performance will be dependent on the introduction of a ‘no blame’ culture.

It cannot be over-emphasised that only a “no-blame” culture will lead to lessons being learned about quality and enable non-defensive and sober reflection on ways problems can be addressed. Such cultural changes take a long time to embed themselves into the thinking of organisations as large as the NHS.

Most doctors would be comfortable with complaints data being brought into the appraisal but they will want to be clear about the purpose this information serves and how it will be analysed.

Revalidation
Doctors and patients alike consider this to be the critical issue. The whole form of revalidation changes according to its primary purpose.

The purpose of revalidation is to make registration more meaningful, thus ensuring doctors are safe to continue in practice. We support the view of the GMC outlined above and agree that any system should ensure the public’s trust that there is promotion of high standards of practice, detection of poor practice and strategies for developing an individual’s practise where this is needed. Revalidation must fulfil all these functions otherwise it will not succeed.

Moreover, revalidation must take place in an environment that is fair and supportive. Both a strength and weakness of revalidation is that it works with and builds on local quality assurance mechanisms. This goes back to our point about the need for much improved local information.

Whilst we are anxious to ensure that the public is well protected and that the system is as robust as possible, it will almost certainly be necessary to adopt an incremental approach to the introduction of revalidation if we are to avoid unacceptable disruption to medical care by setting performance thresholds that are too high. This would not only risk questioning the fitness to practise of an unacceptably and inappropriately large number of doctors but could also hasten the retirement of experienced, competent doctors who would feel that too much was being asked of them.

In addition, we wish to stress the importance of revalidation being introduced after full and careful consideration thereby avoiding any inappropriate or misguided responses that neither improve patient care nor give a fair opportunity for the profession to demonstrate their skills.

Effective regulatory systems do not work well in a culture of name, blame and shame. Such an atmosphere is not conducive to the self-reporting of performance or health problems, nor will it encourage colleagues to do so if they feel that the response to such an action will not be fair and proportionate in respect of the colleague they have reported.

What should be the core purpose(s) of revalidation? Are the GMC correct when they say that the purposes are to contribute to raising standards by requiring doctors to demonstrate that they have reflected on their practice; and to protect patients by securing confirmation that doctors are up to date and fit to practise, by providing a backstop where local systems do not exist, or exist but are inadequate; and through robust quality assurance mechanisms?
The core purpose of revalidation is to ensure that a doctor is up-to-date and competent to continue practising. If they are not they should receive additional support and then be re-assessed. The minimum standard for doctors should be the same standards as those used for summative assessment.

Part of revalidation should be a routine examination of whether a doctor’s performance is in line with expectations. Through appraisal it should be developmental and seek to draw in outliers to the normal distribution and explore the reasons for differences from the mean.

Unless doctors are sure what revalidation is all about it is difficult to comment on any method proposed. The purpose has to be crystal clear.

Revalidation should be about what individuals do rather than what they say they do. In this context, we want revalidation to be an assessment of performance rather than an examination of theoretical knowledge. Proposals to examine doctors every five years or even annually do not fit with the proposals to move away from examinations and towards competency-based assessment. Junior doctors and staff grade and associate doctors get on the Specialist Register through assessment of their experience.

Doctors rarely practise in uniform ways and the aim of revalidation should not be to enforce this.

Fair and constructive appraisal with resourcing of targeted individual instruction locally as well as nationally would be a significant start that could be refined over time.

We think there is considerable potential to develop local quality assurance systems, particularly in team settings. The Cincinnati Children’s Hospital counts the number of errors presented at radiology meetings by each radiologist per year and “normalises” that number to reflect the number of days worked and reports that have been generated. Anyone appearing more than two standard deviations above the normalised mean is notified and reported to the Radiologist in Chief. These reports then serve as a basis to discuss practise.

An answer to this will be needed because it will influence data requirements, how ‘success’ and ‘failure’ are handled and how the process is presented to the public and to the profession. Should the emphasis be on securing public trust, on promoting CPD and the raising of standards, on detecting impairment, or on a combination of these aims?
It is important that the process of revalidation is not solely focused on data relating to an individual, but also takes account of the system within which individuals work. The insights and practice changes that result from internal and external clinical meetings are a source of data that should be included in an individual’s revalidation folder.

It is not only doctors but organisations that need to change if public safety is to be maximised. Managers should exhort departments to consider rigorous documentation to establish “normal values” for reporting discrepancies in practice.

There is a need for organisations to encourage learning through planned reflection on group practice by clinical teams, looking at the structures by which colleagues are linked, the processes that guide their interaction and ways in which information could be better shared.

If these kinds of meetings are to work then there needs to be some measure of psychological safety otherwise people will not talk openly. Discrepancy meetings are an extremely important way of learning from discrepancies and errors that otherwise would remain hidden. However, discrepancy meetings are subject to a lot of different biases, e.g. hindsight bias, information bias, the format of presentation of images, outcome bias, case selection bias and faulty data collection.

In the light of this, what should the broad structure of revalidation be? Should it be a screening (‘assessment level 1’) process aimed at identifying practitioners at risk of having a fitness to practise problem; or aimed at actually identifying dysfunctional practitioners (case finding, or ‘assessment level 2’); or, as the legislation currently provides, aimed at evaluating fitness to practise (diagnostic or ‘assessment level 3’)?
It is crucial that the revalidation process is not used in response to unsubstantiated claims or insinuation. Revalidation should be a positive process about registration, reflective practice and CPD, not simply a method for identifying ‘bad’ doctors as this is primarily the responsibility of local structures that must impinge much sooner than at the end of a five-year cycle.

What attributes (knowledge and skills), behaviours and attitudes should doctors have to demonstrate to maintain their registration? Are there any other relevant attributes which should be assessed?
It is not straightforward for doctors to demonstrate the various attributes of professionalism. Ten years ago, together with the GMC, the Committee of Postgraduate Medical Deans, the Council of Heads of Medical Schools and the Royal Colleges, the BMA explored the eternal values of the medical profession.

Many, such as trust, openness, compassion, integrity are, to an extent, intangible. Other competencies, such as effective relationships with colleagues are also difficult to evidence. It could be argued that the only documentation that might relate to working relationships would be generated by a negative episode or tensions. If there were good relationships there would be no need for this to be documented.

The performance of doctors should be tested against those of an acceptable doctor as defined by the GMC in Good Medical Practice. However, this should be interpreted by speciality-specific commentaries on Good Medical Practice that have already been undertaken by several medical Royal Colleges.

There is a danger that when the state advocates for patient rights through regulation they can also constrain the patient-doctor relationship through increased codification of its various aspects. There are large areas of professional practice that cannot be codified. It could be argued they should not be set out because this would inevitably weaken them. A key part of professional practice is "judgement". This is necessarily a subjective concept.

We do not say these things so as to avoid scrutiny, only to explain how difficult it would be to codify every desirable attribute of a doctor and measure them.

How should the required standards be set? Should there be objective criteria? How should these be identified and measured?
The required standards should be set in consensus groups within each discipline and after testing and assessing those standards, with those working within the discipline, these standards should be consulted on with patient groups and others. The criteria should be objective and measured by the same mechanism after appropriate research and peer review and in agreement with the profession.

Trusts could usefully provide consultants with data, from current HES systems, that would help them reflect on their working practices. Examples include, numbers and types of cases, outcome records, drug usage, details of complaints and so on. GPs already have to produce similar data if they participate in the new GMS Quality and Outcomes Framework. An appraisal provides an opportunity for the doctor to examine all this data critically and reflect upon its nature with their appraiser.

Should there be a core evidence set for revalidation? How should it be defined?
Core evidence should be determined for revalidation and should be defined via the mechanism outlined above. Each discipline should examine and clarify its understanding of excellent versus unacceptable. Work on this has already been published by several Royal Colleges.

For revalidation to be objective, fair and reassuring to the public the process must involve factual questions that will help assure medical managers that doctors’ knowledge is up-to-date and their practice safe. A mixture of methods would help inform this. For example, a random analysis of anonymous patient consultation records and where appropriate peer-observation of consultations. Anything less will not and should not reassure patients.

We need to be honest about the poverty of data that is currently employed to evidence competencies and work to improve its quality.

How should ‘failure to revalidate’ be handled, in the light of topics I and II above? How can we avoid ‘double jeopardy’, with repeated assessments?
The majority of doctors are keen to improve their skills and can be educated to improve their performance. Some may function better in a restricted or supervised environment. Retirement may be the more appropriate course of action for a very few. However, in a five-year process, “failure to revalidate” should not be a surprise to either those managing the process or the doctor in question. Those doctors identified as having seriously deficient practice should already have been identified and appropriate remediation initiated, but failure to revalidate should be a matter for the GMC’s fitness to practise division. Repeated assessments would only interfere with the work of all doctors and new systems of assessment should not be introduced which would add further unnecessary burdens on doctors to the detriment of patient care.

Doctors already practice in an environment with multiple jeopardy. They can be pursued within their practice or trust, by their contracting organisation, the NHS discipline structure and the courts. They are amongst the most regulated of the professions. We are keen to ensure that Revalidation does not turn into yet another layer of threat for doctors, whilst reassuring the public that the doctors who treat them are acceptably competent. We want to balance local regulation with central observation to diminish the perception of threat to the profession.

Fitness to Practise
When a doctor’s fitness to practise has been called into question what arrangements should there be to protect the public? How should the GMC monitor the compliance of conditions it has imposed on a doctor? Are there any extra safeguards for a doctor being retrained above those required for a doctor in training?
As we have said, revalidation should ensure that a doctor is up-to-date and competent to continue practising. The process should be able to identify those who need additional support before re-assessment.

If a doctor presents an immediate danger to patients then he or she should be suspended pending further investigation. However, if doctors do not present an immediate danger, then patients and the public do not need to be informed at this juncture as the concerns may be unfounded.

Where there has been a restriction on practice, the GMC should monitor the compliance of conditions through local evidence from nominated and mutually acceptable observers. Retraining often needs different mechanisms from those of general training and may involve greater intensity and closer supervision. Those who help struggling doctors under these circumstances need to be very carefully selected and quality assured at a high national level so that the strength of their observations can be gauged.

What arrangements are needed for doctors whose fitness to practise fails to meet the necessary standard? Is retraining a realistic option for all doctors? Who should pay for this? What arrangements should be for doctors to move to other duties and to provide exit strategies?
Retraining should be the desired option in most cases. Again, we would stress that any arrangements which allow doctors to move to other duties or provide exit strategies require careful consideration to ensure they are humane and have the profession and the public’s acceptance.

The fact that GPs are self-employed should make no difference to who pays for their retraining. GPs who work for the NHS should have retraining funded on the same basis as all other NHS doctors, i.e. paid for by the NHS.

What else is needed to provide patients and the public with the assurance they need to maintain confidence in the competence and safety of medical practice?
Government assurances that the new system will be properly funded will engender public confidence that a new system of regulation is developing incrementally.

This means that resources must be identified both for the process of revalidation itself but also for any remedial action arising from it.

How should information on practitioners’ fitness to practise be held and made available, including information from appraisal, revalidation and fitness to practise (including local disciplinary procedures)? Should this be a single national database or a collation of local NHS and other databases (e.g. the GMC register)?
We support a single national database held by the GMC that contains details of those doctors who are fit to practise. No doctor should be removed from the list unless they have been deemed unfit to practise. We are unhappy that the GMC have chosen to remove a doctor’s name from their website where a complaint has been received as this will invariably be interpreted by the public as a statement of guilt.

In the light of Dame Janet Smith’s recommendations, the issue of access to the list, by whom and what level of detail, needs to be addressed. As a minimum, the published list should not allow any room for misinterpretation.

Should the GMC continue to be a complaints-handling body which receives complaints directly from any source, or should it be a body to which complaints are normally only referred by healthcare organisations and other public bodies where they have passed a threshold indicating that the doctor may be unfit to practise?
Normally, we would expect that complaints should be dealt with locally, in the first instance. However, we support the GMC continuing to be a complaints handling body which receives complaints directly from any source as well as specific referrals to it from other bodies, but as the regulatory environment becomes better coordinated, we would expect the GMC to handle only the most serious cases and for different bodies to better coordinated.

We think it is important that clear distinctions are made so that concerns over an ability to practise medicine are referred to the GMC, but that problems that are essentially to do with how an individual works within the organisational system are resolved locally by management.

There is a need to clarify which level should address issues relating to performance. It is important that not every problem is pushed upwards to the GMC. Employers should resolve problems that are to do with non-compliance with organisational systems, for example. We believe the GMC should be able to pass complaints back to a local level if it feels that this might be a more appropriate place for the resolution of the complaint.

Will the complaints portal recommended by Dame Janet, together with appropriate public information about the differing aims of complaints procedures and fitness to practise procedures, resolve current public uncertainty about how and where to make a complaint; or is better role-definition for the various organisations involved, expressed where necessary in legislation, essential?
A complaints portal may have merit but we believe that the current complaints system works well in the vast majority of cases although it could be strengthened with appropriate public information. We would therefore prefer patients to be able decide where to direct a complaint, and for complaints to be handled by those best equipped and skilled to do so. We would also expect that, in the vast majority of cases, it would be appropriate for complaints to be handled locally.

Future design of medical regulation
What should the regulation of the medical profession look like?
A national standard and a national body are needed to oversee revalidation and we believe that this body should remain the GMC. The potential for wide variation in standards and practices would be too great if the process were undertaken locally.

What should be the role and structure of the General Medical Council in the future? What should the primary purpose of the Council (which is currently composed of 35 members) be – governance and policy development, i.e. more like a publicly accountable Board – or delivery, i.e. directly involved in exercising the GMC’s powers and functions? In either of these settings, what should its size be and how should members be appointed? If its function is governance and policy development, who should carry out the work of the Council on delivery? If its function is delivery, how should these powers be delivered? In fitness to practise, the following key components - setting standards of conduct, policy and procedural rules; investigation of complaints; case presentation; adjudication - are currently delivered by the GMC. How should these elements be organised in the future?
The GMC has been a world-leader in redesigning regulation and has gone much further in opening up the UK medical profession to transparent assessment than elsewhere.

Fitness to practise already informs registration, education and standards and the GMC sets the parameters for getting on the register, for staying on the register through revalidation and it would seem anomalous for another organisation to then handle removal.

The BMA believes that the GMC should not be subjected to yet another reorganisation until the success and effects of the recent changes have been assessed. Some time should be allowed to bed down the changes.

In terms of governance, we are of the view that there should be a medical majority on its Council and that these members should be elected rather than appointed so as to avoid patronage and ensure the confidence of the profession.

Do we have the right balance between regulation and freedom to practise (including innovation)?
The balance between regulation and freedom to practise is critical and there are concerns that the profession is over regulated. This accords with complaints within the NHS of inappropriate scrutiny and a growing tendency to inspect that threatens to interfere with the delivery of healthcare. Similarly, the Donaldson review could produce over-regulation that might intimidate doctors, rather than providing opportunities for innovation. This might lead to early retirements and could distract doctors from clinical care that would have a detrimental effect on patient care.

Doctors are concerned that any new system for revalidation will be time consuming and over-bearing. If too much time is spent by doctors in meeting the demands of regulation, this will reduce the time available for clinical care. For this reason, it is critically important that the process of professional assessment is tied in as closely as possible with systems of quality assurance in the NHS and providers in the independent sector. Processes for regulating high professional standards should contribute to and not diminish service delivery.

In all of the questions posed, the emphasis is strongly orientated towards the individual doctor. The questions do not set out to challenge the environment within which doctors work, the responsibilities of organisations and managers and the resources available locally to enable all parties to deliver the best care to the patients in their charge. Doctors need to work in an environment that enables them to work to the highest professional standards.

Doctors sometimes have very different views from managers about how to improve health services. In a lot of what has been written about "new" professionalism, "patient-centred professionalism" and other labels there is an assumption that doctors are the main barrier to improvement. Doctors would, of course, deny this. The issue is how to confront and resolve the different perspectives that managers and doctors have.

Doctors are often alienated from and marginalised from organisational improvement. An important point to make in the regular citing of Bristol and Alder Hey as examples of the decline in professionalism is that researchers and inquiries have come to view that the key problems in quality improvement are cultural and system wide. The quality failures were not exclusively the fault of health professionals, but reflect dysfunctional organisational and inter-professional relationships (including management).

Staff should also be encouraged to identify and report poor performance or unacceptable conduct as they see it and they will if they can be reassured that the trust has systems to help colleagues that are not punitive and offer mentoring support or training that would appear to their colleagues as extended study leave and a supportive process.

What alternative models are there in other fields of endeavour in the UK or elsewhere? How could these be adapted for the medical profession in the UK?
It is our view that the GMC sets a very good example for the rest of the world, despite its perceived shortcomings. We are not in a position to recommend other models except to repeat our belief that models based on a no-blame culture will be most effective. We remain convinced that the standard of medical care in the UK remains high.

Should the regulation system be made more accountable and intelligible to the public? What should be the relationship between the GMC and Council for Healthcare Regulatory Excellence (CHRE)? How should the effectiveness of that relationship be evaluated? Should the GMC be made directly accountable to Parliament, as Dame Janet has recommended?
We agree that the regulation system should be made more accountable and intelligible to the public. The relationship between CHRE and the GMC should be constructive and mutually helpful. Improved cooperation should lead to improvements for patients whilst ensuring the system is scrupulously fair to doctors.

We strongly believe that medical regulation should remain distinct from that of other professionals. Doctors have the ultimate clinical responsibility for patients and work in a more complex framework than others, which requires medical-led regulation.

We do not have strong views on the GMC being directly accountable to Parliament but can see that the proposal has merit and would allow the GMC to report to a specially constructed select committee.

Concluding comments
The vast majority of doctors provide high quality clinical care to their patients. There is a need for a reliable and practical system of revalidation for all doctors in a form that will confirm this but crucially also seek to improve their performance. Any new system for revalidation needs the confidence of the public. We believe this is best achieved through a transparent professionally-led process.

Any revalidation system should demonstrate that a doctor holds a licence to practise. It should be capable of identifying doctors whose performance is unacceptably poor. It is difficult for the GMC to do this in isolation and it is important that the different elements of the assessment environment are clearly distinguished from one another and that there are better links between them.

The GMC’s role is to maintain the register of licensed doctors and promote high professional standards. It may remove a doctor’s license, restrict their practice or recommend remedial action.

Local quality assurance systems and clinical governance processes should provide the “firewall” that protects patients. If the introduction of a new system for revalidation is to be successful it is crucial that local quality assurance systems are better resourced. It is also vital that these systems are able to generate information on clinical management and practice to inform assessment and appraisal. When quality systems become inculcated in everyday practice, revalidation and assessment systems will not place unnecessary burdens on doctors.