Policy 2012
POLICY
Preventing Avoidable Harm and Promoting Patient Safety: The Doctors’ Dilemma
Sukhmeet S. Panesar and Rajan Madhok
Cite as: 
Panesar SS & Madhok R. Preventing Avoidable Harm and Promoting Patient Safety: The Doctors’ Dilemma. The Physician 2012; vol1:issue1:8-9

The last decade has seen considerable interest in patient safety globally, and specifically in the NHS in England. The landmark report in 1999 – To Err is Human 1 portrayed medical error as key public health challenge given that health care itself was the eighth leading cause of death; and this was followed soon after by two other seminal reports– Crossing the Quality Chasm 2 and Organisation with a Memory 3 which provided roadmaps for addressing the problems and how to minimise avoidable harm. As a result of concerted efforts since then considerable progress has been made in understanding the frequency of patient safety incidents, how these vary by care settings, the reasons underpinning the failures of care and most importantly in the development of interventions aiming to enhance the safety of care.
Despite these developments over the last decade however, significant concerns remain about the effectiveness of the approaches to minimise avoidable harm and promote patient safety in the light of continuing high profile failures, the most notable being the Mid Staffordshire Hospital incident recently. This begs two questions: Why are patients still suffering avoidable harm including deaths? And are we paying lip-service to the zeitgeist of patient-centeredness and safer care? The evidence provided by witnesses at the Francis Inquiry into failings at MidStaffordshire NHS Foundation Trust provide a chilling and compelling account of disinterest in high-quality patient care – ‘‘…one of the junior doctors told me that I needed to get my mum out of there as if she stayed in the Hospital much longer, we were going to lose her….he said that he was sorry about the way she had been treated…’’ 4
It will be interesting to see what the final report of the Inquiry, when it does get published, will have to say about not just Mid Staffs but also about the way in which the NHS has dealt with the issue of patient safety. Rather than indulge in speculation about the content of the final report, we would argue that the fundamental solution ultimately will lie with the clinicians; policymakers, funders, commissioners and providers can only help (or hinder, sadly) but unless the clinicians actively engage with the agenda by providing leadership and adopting best practice, we will remain in this quagmire. This is, however, easier said than done.
The last few years have seen increasing erosion of ‘power’ and ‘authority’ away from the doctors and in any case the culture of the NHS, which still embodies the ‘Who did it’ rather than ‘Why did it happen’ spirit does not give confidence to the clinicians that when they raise concerns that they will be taken seriously. Those who muster the courage to whistle blow and alert others to situations of unsafe care are penalised; the 6th Report of the House of Commons Health Select Committee stated that ‘The NHS remains largely unsupportive of whistle blowing, with many staff fearful about the consequences of going outside official channels to bring unsafe care to light.’ 5
How can we ensure that patient safety is in the DNA of the organisation when the mechanisms to promote this are fraught with danger; doctors who have cited poor unsafe care which has resulted in avoidable mortality have been prevented from returning to work.6
The NHS is not a learning organisation despite its rhetoric. Doctors therefore face a dilemma: on the one hand, all good (which is the majority) doctors recognise the need to minimise avoidable harm and are taking appropriate actions, and on the other hand, there are considerable barriers in their way. However, doing nothing is not an option.
Our patients deserve better and for the sake of our professional pride we must rise to the challenge. In any case, leadership is not about criticising or becoming disengaged, rather it is about making progress in the face of adversity. The recent NHS reforms do provide some opportunities.
Commissioning will be a key driving force for the provision of high quality health services and one way of ensuring this will be to inter-twine hard measures of safety into the fabric of the commissioning process. Measures such as complication rates, complaints, compliments, readmission rates, outcomes, mortality and morbidity data along with procedure specific data and patient experience questionnaires should be up for scrutiny in the commissioning process 7
Quality improvement measures such as clinical dashboards, 8 specialty score cards 9 and system ratings 10 are all important tools that need to be disseminated wider in daily practice. The introduction of revalidation for doctors offers another way to force the pace – proper revalidation cannot be delivered out with the overall clinical governance context. Of necessity organisations will have to ensure appropriate systems and procedures to enable doctors to revalidate.
The next few years will be testing times for all in the UK as the economic pressure continues and as the NHS changes start to embed. Indian doctors in the NHS can be a powerful resource for the good during these times, not just because of the large numbers but also because of their strong commitment to the NHS. We hope that BAPIO with its mission of promoting professional excellence will support them in their quest to minimise avoidable harm and promote patient safety everywhere. 11 ■
References
1. Kohn LT, Corrigan JM et al: To err is human: building a safer health system. Washington, DC: National Academy Press, 2000
2. Institute of Medicine, Crossing the Quality Chasm: A New Health System for the Twenty-first Century (Washington: National Academy Press, 2001)
3. Department of Health. An Organisation with a memory. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/
DH_4065083 Last accessed 15 October 2012
4. Witness statement of Julie Bailey. The Mid Staffordshire NHS Foundation Trust Public Inquiry. Chaired by Robert Francis QC. Available online at http://www.midstaffspublicinquiry.com/
5. Health Committee. Patient Safety. London: House of Commons, 2009
6. BBC News. Baby P clinic doctor Kim Holt to sue NHS. Available online at http://www.bbc.co.uk/news/uk-england-london-11368642 Last accessed on 13th October 2012
7. Strobl J, Madhok R. Commissioning for quality: experience in an English Primary Care Trust. http://www.emeraldinsight.com/journals. htm?articleid=17047668 Last accessed 15 October 2012
8. NHS Connecting for Health. Clinical Dashboards Toolkit 2009. http:// www.connectingforhealth.nhs.uk/systemsandservices/clindash/toolkit/about
9. Hammons D. Central East Local Health Integration Network. Orthopedic Quality Scorecard 2011. http://www.centraleastlhin.on.ca/uploadedFiles/Home_Page/Board_of_Directors/Board_Meeting_Submenu/5_3_-_June_29_2011_CEO_Report_to_the_Board.pdf
10. The Leapfrog Group. Leapfrog Hospital Safety Score 2012. http://hospitalsafetyscore.org/about-the-score/methodology.html
11. Madhok R, Roy N, Panesar S. Patient safety in India: time to speed up our efforts to reduce avoidable harm. http://www.nmji.in/archives/ Volume-25/Issue3/Editorial.pdf 

Revalidation - 

Raising the bar higher


Joydeep Grover, MBBS FRCEM
Consultant in Emergency Medicine, Frenchay Hospital, Bristol

Cite as: 
Grover J. Revalidation- Raising the bar higher. The Physician 2012 vol1; issue1: 12-13

I have often wondered if the parents of the children having heart 
operations at Bristol in the early 1990s ever doubted the standard of care that their loved ones would receive. Most likely they did not; instead implicit trust was placed in individuals and the system; trust that would be betrayed. While it would be simplistic to ascribe medical mishaps to individual factors, a collection of such failings and poor governance sets the stage  for such events to recur.1
 Good medical practice (GMP)2 goes beyond keeping skills up to date, and includes attributes that were traditionally overlooked but are equally crucial to effective medical care. The principle that all practising doctors should maintain high standards throughout their career is not in dispute, but is revalidation in the proposed form the right solution?
Come the 3rd of December 2012, revalidation will be necessary to
maintain a licence to practise medicine in the UK. The GMC expects to revalidate licensed doctors by March 2016. For the nearly 250,000 doctors in the UK, the outlined framework of revalidation consists of four main identified domains: appraisal of skills, patient safety, communication and maintaining trust. These broad terms encompass a whole gamut of medical practice, and while this makes revalidation relevant, it also makes it very difficult to achieve in an objective manner.
The core method proposed for achieving successful revalidation is a series of annual appraisals that look at the four domains. GMC states that annual appraisals will be evaluated at a local level through a Responsible Officer, who would then be able to recommend revalidation of the doctor
every five years. The scope of the required annual appraisal is large. Each of the four domains is divided into three subdomains, each of which in turn has a number of attributes that need to be assessed. These total up to a total of 59 (fifty-nine) examples of principles and values linking in to GMP. This 
changes the concept of appraisal completely from being a formative assessment focusing on reflection and areas for improvement, to being a definitive report card, a completely different beast. It would require huge time and effort to compile the requisite data.
The Academy of Royal Medical Colleges, in their statement on the impact of revalidation, report that fewer than 50% of doctors expect to absorb revalidation in the current NHS time, with most expecting that revalidation related activities will take away valuable time currently allocated to service development, improvement and governance.3 They also report significant concerns about lack of support from employers, confusing
information and lack of clarity on goalposts. And this is before taking into account that 25% of all doctors report not even having an appraisal in the last year! Assuming the appraisals of the nearly 50,000 doctors to be revalidated every year are in order, allocating 15 minutes of the RO’s time
per doctor would require 12,500 hours of work every year just from the ROs.
This would require huge support from the employers who will have to fund
this activity. There is as yet no cost estimate of the process, either from the Department of Health, or indeed the GMC, but the costs involved are
likely to be substantial and implemented when there is significant pressure on the NHS to cut costs.
The impact of revalidation on speciality doctors and those who work less than full-time will be even greater. The rate of appraisal for speciality doctors is only 50%, and this group of doctors has long felt undervalued and unappreciated by their employers. With limited time allocated for activities outside of service provision, this group of doctors will find it especially difficult to achieve successful appraisal as their job plans do not provide adequate opportunity to address the four domains linked to GMP. A disproportionate number of speciality doctors belong to the BEM background and are 
International Medical Graduates, a group that has particularly felt hard done by both employers and regulators. There are genuine concerns that revalidation will perpetuate inequalities that this group has battled with over many years. 
The burden of appraisal and revalidation on doctors in less than full-time work will be proportionally larger as well, and may well be unachievable as they will have to provide a similar burden of proof for successful revalidation, while having disproportionately less allocated time to do so in. Most Responsible Officers will also be line managers for the concerned doctors. This raises concerns both about conflict of interest and lack of
transparency. Lack of objective criteria for both appraisal and revalidation have the potential to make unfavourable outcomes contentious. The fear is that revalidation may be used as a tool by the employers for disciplining or weeding out doctors and circumventing employment law. Failure to engage with revalidation will automatically lead to Fitness to Practice proceedings and this is never good news for the doctor involved, their employer, patients or even the GMC. Although the GMC expects ‘most’ doctors to be able to maintain their licence to practise, remedial measures for the ones who are not able to meet these criteria are conspicuous by their absence. The expectation is that remedial action will happen at a local level, funded by employers, but no assessment has been published about the costs involved with such an exercise or of the impact that this will inevitably have on service delivery. There is a valid concern about adverse outcomes for International Medical Graduates who have often found themselves at the receiving end of disproportionately higher rates of complaints, disputes with employers, and subject of FTP proceedings at
the GMC with a higher rate of adverse outcomes.
On the flip side, as the vast majority of doctors are expected to have no problems during revalidation, the effectiveness of the whole exercise is brought into question. Is revalidation going to end up merely being a rubber stamp, an extensive and expensive charade that will fail to fulfil the purpose that it is designed for? Would it have been successful in identifying Harold Shipman, the GP who had glowing testimonials from his patients and colleagues? Will it be able to prevent another Bristol heart scandal, where the medical directors ignored whistle-blowers and continued to support failing colleagues and a faltering system?
Doctors are the first to admit that revalidation is both essential and long overdue, but there remain many unaddressed valid concerns on the structure and implementation of this important change. It is essential that the GMC and employers gain the confidence of doctors in the initial phase of revalidation. Clear guidelines, transparent working and visible representation of minority groups will go a long way in gaining widespread trust of the doctors and making revalidation a positive process. Clarity in its implementation will also gain public confidence in both the GMC and doctors, which has steadily eroded over recent years. The alternative scenario of doctors who remain sceptical of their employers and the GMCs intent, and consequently fail to engage with revalidation, will be a huge opportunity wasted, perhaps for a
generation. At this time, when the NHS is going through financial and
political turmoil, the need for public support cannot be overstated. If we
continue to let our patients down - Mid Staffordshire is a recent case in
point 5 - the damage to the reputation of both the NHS and doctors may well be irretrievable. The stakes for the future of medical practice in the UK could not be higher. ■
References
1. Smith R (June 1998). “All changed, changed utterly. British medicine will be transformed by the Bristol case”. BMJ 316 (7149): 1917–8
2. Good Medical Practice, General Medical Council, 2006. ISBN: 978-0-901458-24-7
3. The Impact of Revalidation on the Clinical and Non-Clinical Activity of Hospital Doctors, September 2012, Academy of Royal Medical Colleges, http://www.aomrc.org.uk/revalidation/revalidation-publicationsanddocuments/item/academy-reports-and-resources.html
4. Revalidation of Doctors, Fourth Report of Session 2010-11, House of Commons, Health Committee, HC 557; http://www.publications.
parliament.uk/pa/cm201011/cmselect/cmhealth/557/557.pdf
5. Robert Francis QC (24 February 2010), “Volume I, Section G: Mortality statistics”, Independent Inquiry into care provided by Mid Staffordshire
NHS Foundation Trust January 2005 – March 2009, The Stationery Office,
p. 352, ISBN 978-0-10-296439-4, HC375-I, retrieved 9 November 2010,

POLICY - Implications of the NHS Bill

Professor Terence Stephenson BSc BM BCh DM FRCP FRCPC
Nuffield Professor of Child Health, Institute of Child Health, University College London, Chair, Academy of Medical Royal Colleges.

cite as: 
Stephenson T. Implications of the NHS Bill. The Physician 2012 vol1; issue1: 14-15

The NHS Bill is now the NHS Act, ushering in huge potential changes in medical services across England and with potential knock-on effects across the UK, despite the diverging healthcare systems in the four nations. The publication entitled Never Again by Nicholas Timmins, a senior fellow at the Institute for Government and the King’s Fund, asserts why the then health secretary believed that never again – or at least not for the foreseeable future – will the NHS need to undergo another big structural change. By placing the reforms within primary legislation, the bar has been raised. Traditionally, newly-elected governments rarely spend valuable parliamentary time undoing the legislation of the previous administration. They want to push on with their own reforming, and hopefully vote winning, measures rather than look back to the past. Whilst at present the Labour Party is committed to repealing the NHS Act, it is more likely that if elected, they will run with those new structures which work and leave those which don’t to simply wither from lack of resources.

Although the exact numbers are constantly changing, the NHS Commissioning Board will devolve approximately £80bn of public money to over 200 Clinical Commissioning Groups, each buying health services for populations from as small as 70,000 to as large as 1 million people. General practitioners have been given a huge role in determining whether this will work on the ground. It is envisaged that all NHS Trusts (there are over 150 acute trusts and over 50 mental health trusts in England) will achieve Foundation Status by 2014 and their performance will be judged by Monitor (finances) and CQC (quality of care) with the disappearance of Strategic Health Authorities. Local Authority social care and education will sit down with NHS health to hammer out local priorities in Health & Wellbeing Boards, in theory held to account by local HealthWatch ‘consumer representatives’. Locally, public health doctors will sit within the Local Authority whereas Public Health (England) will have the wider remit of nationwide issues, eg pandemic readiness. The potential roles of Clinical Senates and Clinical Networks are still under discussion.

The £20bn savings in the NHS have been described as cuts, but in fact under the last Comprehensive Spending Review the NHS was given a ‘flat’ settlement of around £110bn. ie no uplift with inflation. Therefore, the £20bn represents ‘efficiency savings’ necessary to pay for new, expensive treatments, to cover inflation and to deal with the secular drift to an older population requiring more medical care. The irony is that as medical and scientific ingenuity develop new treatments and technologies, financial costs and public expectations may also rise. Whereas vaccines, for example, may save both lives and costs, by preventing disease and reducing the demand on primary and secondary care, it is doubtful
whether the same could be said of MRI scanning. Approximately 40% of the NHS budget is spent on the salaries of over
1 million employees. One way to make ‘efficiency savings’ in the NHS is, paradoxically, to reduce access to care. For example, if operating lists for hip replacements are reduced and waiting times are allowed to rise, the NHS expenditure may go down (assuming fewer staff are employed). However, social care costs may rise if these patients need more assistance in the community to fulfill their daily activities. This is a danger of the ‘silos’ of government departments when the desire to protect one budget has unforeseen consequences on another part of the welfare state. However, there are other pressures which suggest government, and beyond April 2013, the new NHS Commissioning Board will find it difficult to balance the books by a reduction in services. The final Francis Inquiry report into Mid-Staffs has now been delayed until early 2013, after which the Secretary of State will have to respond formally to Robert Francis’ recommendations. Whilst the nursing and medical professions are likely to be in the firing line along with the regulators (eg CQC, GMC, NMC), the Secretary of State has already pledged to make long-term conditions and those suffering from dementia two of his four big priorities for the remainder of this parliament. This would suggest that Francis’ recommendations in regard to these two groups will not be ignored lightly. The challenge becomes greater by the day. 
By 2030 there will be 2.6 million UK citizens aged over 85, instead of the current 1.1 million, and it is predicted the number of people suffering from dementia will have doubled to 1.4 million. It may be that the direction of travel will be to enhance care in the community, “the best care as close to home as possible”, but costs will not be kept down unless this is accompanied by a further reduction in secondary care beds. The last two decades have seen a reduction by one-third of inpatient capacity in the UK, highlighted recently in the RCP report Hospitals on the edge? The time for action, with ever shorter lengths of stay and a tendency to re-admissions (‘revolving door medicine’). Over those two decades, numbers of admissions have increased by one third. The RCS and Age UK have also drawn attention in their recent report Access all Ages to implicit rationing of surgery on the basis of age, and there will be pressure to treat on the basis of clinical need and objective risk/benefit, ie on ‘biological age’ rather than ‘chronological age’.

The new structures brought into play by the NHS Act were designed partly to encourage a bigger role for the private sector in providing healthcare. Historically, less than 10% of healthcare in the UK has been provided by the private sector, mostly outside the NHS with the patient paying directly or via an insurance scheme. An expansion in private healthcare provision is not, however, necessarily synonymous with an expansion in this ‘fee for service’ type of private health industry. It can also take the form of care which is free to the patient at the point of delivery, with the taxpayer reimbursing the private sector for the care which the private company provided.

So much for the Act. Most of the medical profession seem to be of the view that these organisational changes, of which this is the twentieth in as many years, do not go to the heart of the problems of the 2012 NHS. Most doctors think that what we urgently need is service re-design. Reports over the last couple of years from the RCPCH, RCOG and RCP have all flagged up the difficulty of maintaining high quality, acute services across over
200 sites in the UK. Whilst there is an undeniable need for 24/7 hospitals in remote and rural areas, many of our hospitals are, for historical reasons, within 30 minutes’ drive of another hospital. Does London really need 40
acute hospitals? In medicine, there is often a relationship between quality of outcome and volume of caseload. There needs to be more of a public debate about treatment as close to home as possible vis a vis care which delivers world class results. The designation of fewer, larger trauma centres; eight acute stroke centres for London instead of 32; and seven safe and sustainable paediatric cardiac surgery sites for England instead of 11 illustrate the benefits which can accrue. Highly technical, high-risk specialities need to be co-located with sufficient critical mass to ensure 24/7 cover and optimal training of tomorrow’s specialists. Doctors recognise these are not easy issues for MP’s, elected by and accountable to a local community who will not relish a reduction in services locally unless we as doctors articulate the benefits. Talking about hospital closures is a distraction – most sites will still offer local outpatient clinics and ambulatory care for part or all of the day. However, that does not mean every site needs to have inpatient beds and the full panoply of intensive care and all acute services 24/7. Of course, to make these changes work well, we will need
prompt and well-trained retrieval and transfer services, and local health care services must be able to perform initial resuscitation and stabilisation of any unexpected cases on site.

Facing up to these competing challenges of economic austerity, more expensive care, organisational change and service re-design, I believe the medical royal colleges have much to offer. The colleges speak for the great majority of the UK’s 200,000 licensed doctors on behalf of safe, high quality care for patients and the public. They are charities, not trade
unions, and their members carry a wealth of experience and professional expertise. They are well-placed to provide expert clinical advice in dealing with these 21st century challenges. Indeed the Academy of Medical Royal Colleges is working with the NHS Confederation and National Voices on a project to identify the principles and good practice which should underpin the changes required by service redesign.

What will the NHS look like 10 years from now? The optimist in me says that if we can finally overcome the IT nightmare that was NPFIT and deliver a joined up patient e-record, things could be much better. Like the ‘cloud’ for my laptop, tablet and smartphone, it would be wonderful if every time I had a consultation, anywhere in the UK, with any doctor, nurse or pharmacist, that my basic medical history was available with my current medications. General Practice has had such systems for 30 years. Why do hospitals still lag behind and could this information be available beyond my own GP? 

Could I not carry my own information on a smart card? Tele-medicine may also enable better care initiated by the patient at home. Already pilot studies have shown that diabetic patients can upload their daily blood sugar results by telephone or internet and receive advice on management. Near patient monitoring for coagulation studies and blood pressure could allow similar innovations, avoiding the need for attendance at health services. Looking specifically at the future for doctors, in ten years revalidation should be bedded in and, hopefully, working to improve standards. It has been a long time coming, but being able to reassure the public that their doctors are fit to practice has to be the right thing. In ten years we should also be seeing the fruits of whatever emerges from the current hugely significant “Shape of Training” review of postgraduate medical education now underway. The pessimist in me worries that by 2030 the UK is predicted to have 11 million obese adults. Already, one-third of school-age children are overweight or obese. If nothing is done to avert this trend, the demands on the NHS for management of type 2 diabetes, hypertension and heart
disease could swamp the service. In addition to these well-recognised associations with being overweight, obesity is now also recognised as a major risk factor for cancer. The Academy of Medical Royal Colleges will publish a report early in 2013 setting out the views of the medical profession on this hugely important public health issue.

Many challenges lie ahead for those of us who work in the NHS. But the NHS remains the envy of many countries because it provides care on the basis of need, not the ability to pay. Other countries spend a larger percentage of GDP on health but often the difference is largely accounted for by transactional costs - the bureaucracy required so that
the healthcare provider can ensure that the patient’s insurer is billed for every last needle and plaster used during the patient’s care. Analysis by the Commonwealth Fund in the United States shows that the NHS provides unparalleled value for money. Since there is not likely to be more money in the near future, that is something to be proud of. ■ 

REVALIDATION

cite as:
Dickson N. Revalidation- The need of the Day. The Physician 2012 vol1;issue1: 16-17

The vast majority of doctors are good doctors – they have the skills and experience to deliver first-class care, and the range of interventions at their disposal is wider than it has ever been. But just as their capacity to do good has never been greater, the risks associated with medical care are also greater than ever. Revalidation is a response to those risks and opportunities. It is recognition of the critical role doctors play, and recognition too that safety and quality should be the organising principle in healthcare.
Doctors remain the most trusted profession in the UK. Among 15 Ipsos Mori polls of public trust over the last ten years, doctors have consistently been at the top . This is clearly reassuring. Yet it is clear that trust is much more likely to be questioned. The days when patients assumed that all doctors were universally good have gone. It is ironic then that many patients believe there is already a system in place for making sure that doctors are competent and up to date. They know airline pilots and other key professionals in safety-critical industries are regularly checked and assume doctors must be the same.
Of course no such system exists, and only when revalidation becomes a reality will every doctor with a licence to practise become part of such a scheme. If it works, revalidation has the potential to underpin the trust the public has in doctors, reinforcing it and providing patients with further assurance that the doctor treating them is competent and up to date.
Over time we believe it also has the potential to help identify problems
in some doctors’ practice earlier than is now the case. Giving practitioners the opportunity to collect information about the care and treatment they provide, including feedback from patients and colleagues, will provide them and their appraiser with an overview of their practice. Equally important is that all doctors will become part of a governed system, which is not only concerned with the standard of their practice, but is also required to make sure that every doctor is able to access the data needed to evaluate that practice. For most doctors, perhaps the greatest potential benefit is in the
opportunity it will provide for self-reflection - the chance to review their own practice and identify areas for development and improvement. As more comparative data becomes available it will also enable individual practitioners and teams to benchmark the outcomes of their practice against others, something we know is a major driver for improvement. All this must be good for both patients and doctors.
Nevertheless, revalidation is not a panacea. It will not solve all problems nor is it likely to produce instant results. We are not planning to shut down our fitness to practise operation, and no-one is suggesting that the system will be perfect. There will be glitches and we need to learn from them. Given the scale of what is involved - a programme covering 230,000 doctors and hundreds of organisations - it would be surprising if there were not lessons to be learnt for everyone involved.
The one thing we can say with some confidence at this stage is that even before it gets underway, revalidation has prompted a major strengthening of appraisal schemes and the vital systems which govern clinical processes. 

Niall Dickson

The evidence from countless inquiries has demonstrated  that good clinical governance is a prerequisite for safe, effective 
healthcare. To that extent, revalidation has already made its mark. There have been some concerns that we will require all doctors to revalidate immediately - that is not our intention. The idea is to roll out the process over the next few years. But our message to doctors is that while we do not expect every practitioner to be ready to revalidate now, everyone should be getting ready.
For most licensed doctors, being ready for their first revalidation 
means they need to have had one annual appraisal, with our core 
guidance Good Medical Practice as its focus, and that they have 
collected the various pieces of supporting information. They should also have had objective feedback from patients and colleagues.
Our ability to deliver revalidation, which will safeguard patients and
help doctors improve the care they provide, relies on us being able to
maintain the trust and confidence of everyone involved. This includes the patients we are seeking to safeguard, and the doctors we approve for revalidation. This requires us to be, and to be seen to be, fair, open and transparent in everything we do. We have engaged extensively with those who have an interest in our work across the UK. From this we know there are concerns that revalidation may have an unfair or disproportionate effect on particular groups of doctors, including locums, doctors working overseas, doctors working part-time and doctors who take career breaks.
On this, first it is worth noting that revalidation has the potential to 
drive more consistency and fairness in evaluating a doctor’s practice. The process should help to ensure that all doctors receive an annual appraisal and the support they need to reflect on their work. We are working with others to put in place safeguards that will help make sure that the process is fair. We know that some doctors are concerned that some elements of revalidation have the potential to be 'unfair’. I want to address each of these concerns and set out what we are doing, in partnership with others, to respond. 

First, some doctors are concerned that access to appraisals and supporting information may be harder for particular groups of doctors, such as locums (in primary and secondary care). We have seen that by making a doctor’s revalidation dependent on them receiving a regular appraisal, revalidation is helping to drive up rates of appraisal and improve 
access for all doctors. NHS employers have also produced supplementary guidance aimed at reminding employers of their responsibilities towards locum doctors, and we have said publicly that we will not penalise doctors
if their employers or responsible officers fail to prepare for revalidation or put in place ineffective systems of appraisal. 

Secondly, we need to ensure flexibility for doctors who find revalidation challenging because they are absent from work due to ill health, periods of time overseas, or career breaks to care for family. To ensure flexibility, we will have the power to vary a doctor’s revalidation date in response to individual circumstances. Responsible officers will also have the ability to defer their recommendation if the doctor has not been able to gather all the supporting information by the time a recommendation is due. 

THE NEED OF THE DAY

Deferral does not signal anything negative - it is a neutral act - and in
those circumstances the doctor would continue to hold their licence. We have also made it clear that we will not penalise doctors if they have been unable to engage with revalidation because of ill health.
Thirdly, doctors have, perhaps understandably, expressed some
concern about bias in feedback that they may receive from patients.  GMC patient and colleague questionnaires have been subject to detailed research by the Peninsula Medical School, which has enabled us to identify particular limitations. As with any questionnaire of this kind it is
important to take into account any bias when interpreting and providing
feedback. We have made this clear in the instructions that accompany our questionnaires and in more detailed guidance to help appraisers interpret and handle the results. Remember too that the questionnaires are just one piece of information that feeds into the appraisal process - useful though they will be as a development tool, it would be a mistake to place too much weight on them. In any event, the evidence is that patient feedback on all types of doctor and from every background is 
overwhelmingly positive. And finally, a key fairness challenge will be to make sure the recommendations from responsible officers are consistent. To tackle this, we have drawn up clear guidance on how to assess evidence and make recommendations. Responsible officers will themselves be subject
to revalidation like all other licensed doctors, and will receive regular
appraisals to check and review their recommendations. It is also worth
noting here that designated bodies (which employ responsible officers)
are subject to the 2010 Equality Act.
We believe these safeguards should ensure that revalidation is delivered fairly, openly and transparently. But we will need to evaluate its impact to make sure it is working fairly and to learn how it can be improved. As a result we will be conducting a programme of evaluation, supported by commissioned research, to assess its impact, including the 
impact on different groups of doctors. In tandem with this, there will be a separate quality assurance programme. We will collect and analyse data about the recommendations that responsible officers are making, to ensure they are consistent and fair.
Revalidation will not be perfect and there are bound to be glitches
in a programme of this size, but with goodwill on all sides, the medical profession and the UK health system will have created an assurance system that can be developed and improved over the years. Revalidation is about underpinning the trust patients have in their doctor. Once it is fully implemented, patients should have confidence that the doctor who treats them will have demonstrated on an ongoing basis that they are competent and fit to practise. This is good for patients and for the profession. ■

Niall Dickson joined the General Medical Council as Chief Executive and Registrar in January 2010. He leads the Senior Management Team, which is responsible for the day to day running of the GMC. Niall is a member of the Department of Health’s End of Life Care Implementation Advisory Board and former member of the Cabinet Office Honours Committee (Health). 

In 2008, he chaired a cross-party commission on accountability in health for the Local Government Association (LGA). He is a trustee of the Leeds Castle Foundation. His honorary awards include being a Fellow of the Royal College of Physicians and as Fellow of the Royal College of General Practitioners.

opinion
Challenges for the National Health Service

Raj Kathane MD, FRCPsych 
Retired Consultant Child and Adolescent Psychiatrist and Past President of BAPIO

cite as: Kathane R. Challenges for the National Health Service. The Physician 2012 vol1; issue1: 18-21

The theme of the BAPIO conference this year is very timely and appropriate. UK’s most beloved institution, the NHS is very much at the crossroads. This article highlights some of the challenges that the NHS faces over the next several years. It is important to note that delivery of health services in all the nations around the world has been going through a sea change balancing, on the one hand, the new technologies and on the other, the struggle to keep costs down and keep services affordable. The economic down turn which started in 2008 and shows no signs of abating, certainly not in the western countries, has made it imperative for policy makers to re-think again and again, this delicate balancing act. During the boom years from 1997 to 2005, the NHS had seen phenomenal injection of cash, giving rise to much-needed investment in new hospitals, manpower, wages, hi-tech equipments, IT systems and so on. However, with stark reality staring in the face, the current Prime Minister had to announce that there was little prospect of any significant new funding coming to NHS until about 2020.
So what are the challenges? Capacity v. Demand:
Because of the noble founding principles of NHS (‘...free at the point of delivery…..’) it was inevitable that the population would have high expectation about their demands to be met, what ever the demands. Over the years this has been seen in such extreme phenomena as calls for GP home visit for really trivial complaints, calls for ambulance services for completely inappropriate reasons etc. It is imperative for NHS to be able to provide appropriate level of service for appropriate priority. This stretches the NHS’s capacity to deliver in the face of growing demand.
Another factor that stretches the Capacity is the size of the population and demographics. Since the inception of NHS in 1948, the population of UK has grown from approximately 47 million to the current figure of just over 62 million 1. At the same time, life-expectancy has increased significantly from around 65 in 1950, to about 80 in 2010 2. The increasing age of the population puts even more demand on the NHS services as the number of illnesses / conditions (such as cancers, coronary heart disease, dementia, fractures etc) that need to be treated, needs more bed-days because of longer healing time. Apart from such ‘natural and expected increase’ in age-related conditions, there are other trends which stretch demand: exponential increase in alcohol intake in the teen-age population has been much publicised in the recent past, but a more recent report identifies that long term, heavy drinking among the ‘babyboomers’ generation is putting a far bigger burden on the health service. Alcohol-related in-patient admissions among 55 to74 year olds cost NHS £825 million in 2011; among the 16-24 year olds, that figure was about £64 million.
This cost is driven up by nearly 8 times more admissions in the older age group, compared to the younger. 3, 4, 5, 6 Burden of chronic diseases: Just taking one example of diabetes, recent estimates 7 are that in the UK, 3.8 million people have type II diabetes and 7 million are at risk of developing it. Type-II diabetes is occurring at earlier age. Type-I diabetes is occurring with greater frequency. There is an epidemic of obesity—this is a world-wide phenomena. It is expected that 25% of the world’s population will be obese; this will add 1 billion extra obese people. When Aneurin Bevan founded NHS on the 5th of July 1948, the implication was that the NHS was meant to be for the citizen of the UK.
Back then, UK certainly was the island nation, travel from the mainland Europe was not as easy as it is now and the immigration—both for pleasure and for work—not a big factor as it is now. Lack of these factors then made it easier for NHS to deliver. During the 80s and 90s immigration from non-EU countries increased, and as the word got around that it was possible to get free treatment in the NHS, many took advantage. Similarly, with the EU expanding during the early years of this century, we saw a similar phenomenon of immigration from the Eastern Europe. It is possible that some of these factors are under control now, however, unlike many other western countries, in UK, there is no requirement, at the point of requesting medical help, to show or confirm the citizenship or otherwise any medical insurance, if one is not a UK citizen or resident.
Integration of Health and Social Care: As the demands for services to the elderly and people with mental illness increase, it is inevitable that there should be greater integration between Health and the Social Care.
Technology: Advances in medicine and technology are happening at ever increasing pace and at exponential rate. New technology is expensive as are new drugs. These advances increase life span and whilst this is generally desirable, it also increases demand as mentioned above.
Social Networking: Increasingly, the phenomena of technology based social networking (not the old fashioned, ‘go and meet my friends’) is going to play greater role in human interaction and therefore will influence the delivery of health services.
Competition:
The dictum of market-forces and assumption that competition drives down prices has been relentlessly applied in the NHS. The usefulness of this approach has been limited but nevertheless has created another tension between different care giving systems and has created much instability. This reduces staff morale significantly.
PFI:
Another variation of the above was the development of the Private Finance Initiative (PFI). In the opinion of many analysts, this approach has been wasteful of public purse. Size and Budget of NHS: NHS is the world’s 4th largest employer. It employs 1.7 million people 8 of these about half are clinically qualified, there are 39,000 GPs, about 411,000 nurses, 104,000 medical and dental staff employed in the hospitals and community health services and about 18,500 ambulance staff. Only Chinese army, the Indian Railways and WalMart supermarket chain employ more people directly. In 1948, at inception, the NHS budget was £437 million (£9 billion in today’s money). By 2011/2012, the budget has grown to £106 billion. Surprisingly, no accurate figures are available about how much of this is spent on staff salaries. The figures vary wildly from 38% to 55% to 70%. If, as is widely believed, nearly 2/3rd of the budget is spent on salaries, it is self-evident that to keep the Health Service affordable, there needs to be significant trimming of all these costs.
At a time when most of the countries in EU are going through severe austerity and therefore cuts in services and salaries, UK, being affected by the same strong and adverse financial winds, policy makers will be seriously considering how to make NHS leaner and to provide more value-for-money. The Government has declared that NHS must find savings of £20 billion by the end of this parliament in 2015. The following are main options:
Make staff work for longer: the pension age for public service workers has recently been increased from 65 to 68. This has seen the first industrial action (July 2012) in 40 years by doctors (although it was poorly supported).
Reduce the numbers of higher salaried posts: A workforce survey of the Royal College of Physicians suggests that the number of ‘subconsultant’ posts has quadrupled in the past 4 years.
Redundancies and reduce or freeze salaries: On 15 July, a consortium of 19 NHS Foundation Trusts in the South West of England, who employ some 60,000 staff (about half of them medics) declared that they were to introduce pay cuts of up to 5%, an end to overtime for nights, week ends and bank holidays, reduced holiday leave, forcing staff to work longer shifts and slashing sick pay rates. It is called the ‘South West Pay, Terms and Conditions Consortium’ 9
Policy Exchange, a powerful and influential Conservative think-tank has suggested 10 that national pay bargaining for public sector workers should be scrapped in favour of locally negotiated pay linked to performance and automatic annual pay increases and progression points should be also be ditched. It suggests that incentives should be used to boost productivity. .The previous secretary of Education had lent a strong support to such an initiative to be applied to teaching profession.
What should the NHS and the country do?
Reducing Administrative Wastage:
NHS desperately needs a settled period in which the staff can get on with the job of assessment and treatment of patients without having to constantly worry about the major changes in the structure of NHS. It is widely believed that the current change from the PCT to Clinical Commissioning Groups (CCG) is untimely, unnecessary and wasteful and that the need for this change had never been convincingly demonstrated. Even if this change were to bring about some savings to the NHS, did it justify the huge amount of money that is being spent to bring about the change not to speak of the disruption to the well-established care-delivery systems and administrative structures as well as the adverse effect it had on the morale of the staff as they started moving around from Trust to Trust looking for better job security in the face of the perceived insecurity?
Prevention:
‘Prevention is better than cure’ says the old adage. This has never been truer than in the current age. NHS was been set up to treat illness and not as a Health or Wellness regime. Over the past few decades, the emphasis has been shifting: there have been campaigns for smoking cessation, vaccinations for children, reduction of alcohol intake and binge drinking, intake of fruits, vegetables and fibre for prevention of colon cancer, winter flu jabs for children and the vulnerable elderly just to name a few; however could even more be done for prevention? It is heartening to note that the Government intends to winter flu vaccine to all children by 2014. Although this is likely to cost £100 million, the projection is that it will prevent 11,000 fewer hospitalisations and possibly 2000 deaths, the combined cost of which would be vastly more. National Survey on Diet and Nutrition suggests (11) that over the past 25 years, British eating habits have not changed significantly. Only 30% of adults and 10% of children eat the recommended amounts of fruits and vegetables. These figures are even lower in people in receipts of social security benefits. In fact the recommended amounts of ‘5-a-day’ are only recommended minimum: the true advisable figures are nearer to 8-a-day. Should the government give fruits-and-vegetable vouchers / coupons to the people on benefits to increase their consumption, at the risk of being branded as a nanny state? And what about discount vouchers for fitness / wellness clubs (to positively encourage fitness and exercise-taking) for population, dependent on good level of monitoring for attendance?
Treatment at home:
Hospitals are expensive and can often lead to HAI (Hospital Acquired Infections) especially in the vulnerable, elderly population. The NHS will have to find increasingly innovative ways of treating people at home and reducing the hospital stays. More and more procedures will be performed by minimally invasive and key-hole surgery. [See: C f WI predictions under Manpower Issues below].
Tele-medicine:
Technology, which creates new problems (see above), could also come to the rescue. Could NHS employ the services of doctors and other personnel / professionals who work in the Health Service but stationed outside the UK? Take for example the advances in digital revolution. Imaging (old fashioned x-rays for you!) is now digitised and these can be viewed and commented upon by experts several thousand miles away.
There are already examples of this happening, for ex., the Post Graduate Institute (PGI) in Chandigarh, India are offering radiological services to UK hospitals. Another aspect of the tele-medicine is how new technologies can and will be used to deliver health service. Following are some examples: NFC (Near Field Communications) technology will be used to monitor patients’ vital signs and obtain live health data by phone, using NFC sensors, while the patient is at home. Automated computer systems already send reminders to patients to attend their out-patient appointments—could these be set up to send regular reminders to selected patients to take their medicines? Such selected patients are those with dementia, mental illness and those on complex regime of multiple medications. There is good deal of evidence that taking medications in a timely fashion reduces the incidence of relapses and deterioration.
Outsourcing:
I understand that it is a common practice in the USA for clinicians to do dictation using the digital equipments, the dictation is then sent to countries like India or Malaysia for typing and the finished document is sent back to USA in time for the start of the next day, to be checked by the clinician, signed off and posted. As the wages paid to the typists in the out-sourced countries are a mere fraction of those paid to the country of origin (in our case, UK), this saves on salaries; but will create another problem of unemployment in UK. Charging for certain non-essential treatments such as removal of tattoos, or failed appointments (DNA) by the patients, if done wilfully or neglectfully. Proving this will be problematic and administration of this may turn out to be more costly in the long run. It will also mean that in return, to be fair to the patients, hospitals should not cancel scheduled operations and other procedures. Trusts run by private organisations and Trust mergers / take-overs: Monitor’s Chief Operating Officer has predicted that by 2015 many Foundation Trusts would be financially weaker. When a Trust runs in financial difficulties with big debts, it is thought that some times they could be run more profitably by private organisations. Hinchinbrook hospital in Huntingdon is one such example. Following from its success, the South London Healthcare Trust, which runs hospitals in Woolwich, Orpington and Sidcup, which had reported a deficit of £65 million in 2011/12, became the first to be put in to administration by the Health Secretary with an administrator being appointed who has formally asked all interested parties—NHS and private—to show expression of interest to run the services 12.
Medical tourism: Already, there are examples of patients from the western countries going to places like India, Singapore and Malaysia on a package of medical treatment (such as cataract removal or hip replacement) combined with recuperation and tourism to popular places. This often turns out to be quite cheap, certainly at a fraction of a cost of doing the same procedure privately in the UK, and there is the feel-good factor of exotic holiday and good weather. The down side of this is that in the event of complications arising after the event and after return to UK, it will be the NHS that will be expected to deal with the problem.
Learning from India: There are examples in India where procedures are performed very cost-effectively, for ex., a hospital in Bangalore performs many heart operations in rapid succession or in tandem or in parallel and Aravind eye Hospital System in several locations in India claim to perform eye surgery very cheaply and effectively, mostly for the poor people. Such models of care, often derided in the west as ‘sausage-factory model’ may offer very effective models to emulate and should not be discounted. Expanding to other countries: Undoubtedly, UK offers one of the best medical care in the world with exceedingly high quality. The Care Quality Commission (CQC) in UK is an extra-ordinary development to ensure highest quality of medical care. UK is therefore uniquely placed to offer to the other countries, where health service is not so well developed, examples of good practice and high quality at the same time earning some capital for own use. Manpower Issues: Until 1995, there was a general agreement that UK was training far fewer a number of doctors than was required for servicing the NHS, therefore the Government in 1997 decided to open up more medical schools and increase the number of places in the existing schools; and to allow immigration of qualified doctors from other countries to fill the gap in the interim. This picture has changed rapidly: in 12 short years:
CfWI (Centre for Workforce Intelligence), an influential body has estimated 13 that if the NHS continues to recruit and train hospital doctors at the rate it is doing now, by 2020, there will be a 60% over-supply of doctors eligible to become Consultants, thus leading to very considerable frustration in the trainees who would have a natural expectation to become Consultants as career progression. Perhaps, as a result of this, the UK Universities are planning to reduce the number of medical places from current 4000 to 1000. This will open up the possibility of private medical schools operating in UK, as it happens in countries like India.
What lies at the distant horizon and beyond?
Targeted and tailor-made medicines:
For many years, pharmaceutical industry has said that the days are near when drugs will be formulated to suit an individual patient’s unique needs, taking in to account their DNA and genetic structure so as to eliminate side-effects. Similarly, that drug delivery systems will evolve to target individual tissues (such as a cancerous growth) rather than the current ‘scatter-gun’ approach. What lies ahead with the relatively new nanotechnology and nano-machines? Leicester University is already performing ‘computed autopsy’ which does away with traditional ‘surgical cutting autopsy’: could future systems be perfected, along the same lines, to make automated diagnoses?
High Technology:
Although, advances in technology are expensive, paradoxically, high technology can also come to the rescue. This year’s Nobel Prizes in Physics and Medicine are most significant: the prize in Physics [Haroche and Wineland—“…on measuring and manipulation of individual quantum systems without destroying them…”14 ] showed that it will soon be possible to construct unimaginably powerful quantum computers, which are expected to hit shop-floors around 2020 or earlier. The famous futurologist, Ray Kurtzweil has been predicting 15 that singularity between humans and machines is likely to happen sometime around 2025. This is the state when the processing power of a computer will be equal to that of the human brain and ‘machine intelligence out-paces the biological brain’. Computers will therefore be able to write programs for themselves and also evolve to make themselves better. This means computers will be able to design and run system—including hospital systems that may not need human input. Diagnosis and treatment could be automated……… and much more.
The Prize in Medicine [Gurdon and Yamanaka) “… for the discovery that mature cells can be reprogrammed to become pluripotent….” 16 ] means that some time in not too distant future, damaged organs will be repaired or replaced by patient’s own tissue, with no need for transplant or recourse to immuno-suppressant drugs. There will be no need to hook up a patient with failing kidneys to dialysis machines 3 times a week or for diabetic patients to take medicines for the condition because the necessary cells will be regenerated by reprogramming the ordinary mature cells through the stem cells pathway. The combination of the above two (and such other) developments creates a possible picture that doctors as we know them now, may not be needed. All the ‘algorithm-based’ specialities and branches of medicine
could be replaced by intelligent machines. Skill-based ‘hands-on’ specialities (such as surgery) will have progressively reducing dependence on humans and may eventually vanish. There was the famous case, in 2005 of the Italian surgeon performing a surgery on his patient in Italy, using a computer and a robot, as he guided the robot while being in an operating theatre in New York. Tele-surgery and Robotic Surgery it seems, is already here, just Google it! Who knows what the Science and Art of Medicine will look like in 2030—it is just about 15 short years away! ■

References:
1. UK Census Records
2. OPCS Office of Population Census and Survey
3. Alcohol Concern:
4. NHS Information Centre: 2011
5. National Treatment Agency and National Drug Evidence Centre, Statistical Release October 201
6. UK Faculty of Public Health October 2012
7. Diabetes.org / statistic
8. NHS England Statistics
9. BBC News and Sunday Times 15 July 2012
10. Policy Exchange documents: [Local Pay, Local Growth, 04 September 2012]
11. National Diet and Nutrition Survey (NDNS) –Food Standards Agency statistics. www.food.gov.uk and www.dh.gov.uk/publicationsandstatistics
12. BMJ 01 September 2012, vol 345, p.2
13. Centre for Workforce Intelligence NHSEmployers.org and C f WI.org/ publications
14. Citation, Nobel Prize for Physics, Royal Swedish Academy of Sciences, 09 October 2012
15. Ray Kurtzweil: 2005, The Singularity is Near. Publisher Viking Penguin.
16. Citation, Nobel Prize for Medicine, 08 October 2012 
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