Professor Alan Maynard on the need to address clinical revalidation and manage poor performance

A decade after the problems with Shipman in Manchester and Yorkshire, Wisheart at Bristol, Neale at Northallerton and Ledward in Kent, we still have no comprehensive system of revalidating doctors. The practices of these four doctors killed and injured scores of patients. Expensive and expensive public inquiries identified systematic failures in governance processes, and made strong recommendations to change the way in which doctors were licensed to practice.

As well-recognised, other professions with a capacity to kill and maim customers have much more rigorous systems of appraisal and reaccreditation. Airline pilots, who if they crash their Boeing 747s can kill hundreds, are tested every six months to ensure their skills remain high and their addictions and any other health and behavioural problems are identified.

Why are we so slow developing methods to identify the (hopefully few) doctors who are not fit to practice? The doctor production process is long, complex and unsatisfactory. After five years, the medical student graduates and enters further training (the F1 and F2 years). The junior doctors are now “licensed to kill” in that they can prescribe and do other procedures under some degree of supervision from their elders and betters in their trade.

After the F1 and F2 years when the trainees hopefully know something about how to treat patients - for an entertaining description of these years, see Pemberton 2008 (Reference 1, below) - there is a competition for higher training posts in hospitals.

Those successful in pursuing this route, usually five years of hospital swapping to get experience, are then tested and if successful get their CCT, which enables them to apply for consultant posts. Then subject to the vagaries of local hospitals selection processes, doctors can be appointed to consultant posts for life

The EWTD dilemma
The content of the training years is increasingly affected by the European Working Time Directive (EWTD), which means hospitals by next year cannot let juniors work more than 48 hours. The anal British, with their high regard for the law, are enforcing the EWTD but - as you may have experienced when abroad - countries such as Greece, Cyprus and Slovenia are ignoring these legal requirements.

The main reason for their denial of the law is that they cannot afford to do otherwise. The Brits, having suffered over-funding from the Blair-Brown Governments, are pushing ahead with the EWTD law.

One consequence of this is that doctors are appointed to the consultant grade much earlier - nearer to 30 years of age, as compared with 40-year-olds getting such posts 15 years ago.

Work-life balance – a matter of life or death?
The nice issue is whether these early appointees are sufficiently experienced to cope with working as consultants. They are learning some nice habits as part of the EWTD and advocacy of a “good work-leisure” balance.

In particular having been inculcated during training with a more 9-5 mentality, they are reluctant to work outside allotted hours. This poses some nice challenges for “hospital at night” policies to ensure adequate staffing out of hours. Hopefully individual trusts and the Maoists at the Department of Health are performance-managing adverse incident and mortality rates when medical cover is less!

Compared to other practitioners, hospital consultants are more regulated than some of their peers. They are subject to annual appraisal and have CPD requirements from their Colleges. But what of other groups?

General practitioners are weakly appraised by colleagues. PCTs now have considerable powers to performance-manage GPs. It is likely that there are some who are not performing adequately, but there is scant evidence to substantiate the efficient management of these problematic practitioners by PCTs.

Another vacuum in the regulatory process is that of non-consultants in hospitals e.g. staff grades and locums. Here, there appears to be no national system of performance management. These doctors provide a lot of medical cover, and are in principle supervised by consultants. In practice, that supervision may be illusory due to EWTD and other pressures in local hospitals.

Policymakers inside the profession and in Whitehall recognise these problems, but progress in resolving them is slow. The causes of this are numerous, and include lack of political will and poor medical leadership in the Department of Health and professional regulatory agencies.

As ever the advice is caveat emptor: buyer beware. Doctors can save your life and offer superb care to patients. But a small minority have the capacity to condemn you to an early tomb.

Reference
Pemberton, Max (2008) Trust me - I’m a junior doctor, Hodder Paperbacks, 2008. ISBN: 0340962054