Joint statement in response to Recommendation One of the Independent Neurology Inquiry

Joint statement from Charlie Massey, the Chief Executive of the General Medical Council, and Peter May, the Permanent Secretary of the Department of Health in Northern Ireland, in response to Recommendation One set out in the report of the Independent Neurology Inquiry.

About the Independent Neurology Inquiry 

The Independent Neurology Inquiry (INI) report, which was published in June 2022 highlighted serious failings within the health service in Northern Ireland. The Department of Health (DoH) and the General Medical Council (GMC) acknowledge that many patients and their families were let down. The DoH and the GMC are committed to supporting the work of the INI Implementation Programme to deliver the Inquiry’s recommendations, which will deliver improvements to healthcare services and systems and to restore public confidence and improve patient safety in Northern Ireland.

Responding to recommendation one

Recommendation one of the INI report stated:

The NI Department of Health and the GMC should issue a joint public statement for the benefit of public and patients making clear the extent to which they consider whether the processes of medical appraisal and revalidation, currently extant, are sufficient to ensure that aberrant practice will be identified. If those processes are in themselves inadequate, the statement should specify what mechanisms should be put in place to achieve this necessary objective. 

Our response 

The effective and consistent application of appraisal and revalidation, along with other processes outlined in this statement, are critical in ensuring that patient safety is the priority of all doctors and their employing organisation.

The processes of medical appraisal and revalidation are well-defined, but they alone do not, and will not, ensure aberrant medical practice is identified, or on their own, identify patient safety concerns. They are, however, important components of an overarching framework to ensure patient safety.  

We appreciate that medical appraisal and revalidation can appear complex to patients and the public. In this statement, we describe the purpose and key requirements of each, along with the role of Health and Social Care organisations which employ doctors and the DoH which hold these organisations to account, through their governance systems, in line with current accountability and financial management guidance. 

Clinical governance is not something which sits apart from the rest of the governance system in any organisation. Each Health and Social Care organisation, through its Executive Board, is responsible for overseeing and managing its systems and performance for organisational and clinical governance. 

Medical appraisal and revalidation are part of a robust governance system within the wider organisational governance arrangements of individual Health and Social Care organisations. There is a contractual requirement for doctors to have a yearly whole practice appraisal.

There is a statutory requirement for doctors to meet all the requirements within a revalidation cycle which is usually every five years. Every five years, the responsible officer will advise the GMC on whether a doctor is keeping up to date, giving good care and confirm there are no outstanding concerns about a doctor’s fitness to practise.

Medical appraisal 

Medical appraisal is a contractual requirement led by each Health and Social Care organisation and is an important part of clinical governance. While it underpins and forms part of the GMC’s regulatory process of revalidation, the policy and guidance on medical appraisal is provided and maintained by the DoH. This requires all Health and Social Care organisations to have robust systems in place for appraisal and processes in place to manage and escalate if doctors are not engaging with regular appraisal.

Doctors should participate in an annual ‘whole practice’ appraisal. This means that the doctor should declare all the places they have worked since their last appraisal and the roles they have carried out. They should collect supporting information from all of these roles to evidence they are up to date and fit to practice according to the values and principles of Good medical practice .

The GMC outreach advisers provide support to organisations through delivery of workshops for doctors at all levels to promote the understanding of professional standards.

It is essential that all organisations work together to make medical appraisal an effective and beneficial process that includes reflection, learning and professional and personal development. 

As part of the work to address the recommendations set out in the INI Report, the DOH will consider if any further action is needed to strengthen assurances about the processes underpinning whole practice medical appraisal. This will include a review of the appraisal process followed by any necessary updates to relevant guidance and processes.

Revalidation 

Doctors must regularly demonstrate that they are keeping their skills and knowledge up to date. This process is called revalidation and normally takes place every five years. Every licensed doctor must revalidate to show they are fit to practise and maintain their licence to work in the UK.

The process of revalidation was designed to close the ‘regulatory gap’ between the organisations that doctors work in and the GMC. It means that the GMC receives regular assurances about the fitness to practice of its registrants from a senior doctor known as a Responsible Officer. 

Revalidation:

• supports doctors to regularly reflect on their practice
• helps doctors improve the care they give, and to identify areas for development
• gives patients confidence that doctors are up to date
• provides assurance that doctors are regularly checked by a senior doctor
• helps identify improvements in organisations where doctors work, promoting the overall standard of healthcare.

Revalidation is not a way to raise or address concerns about a doctor’s practice, which should be addressed as soon as they arise. All doctors have a duty to report serious concerns about colleagues in line with GMC guidance.

Doctors must engage with the processes that support revalidation and meet the revalidation requirements set out in GMC guidance to maintain their licence to practice. If they do not do this, the GMC may take steps to withdraw their licence. 

Role of the responsible officer

The regulations regarding responsible officers, and the guidance that sits alongside these, are owned by the DoH. ‘The Medical Profession (Responsible Officer) Regulations (Health and Personal Social Services NI 2010)' give specified senior doctors (responsible officers) in certain organisations (designated bodies) functions that will ensure that all doctors work within a managed environment, in which their performance, conduct and behaviour are monitored against agreed national standards. Every doctor employed in a Health and Social Care organisation has a connection to a responsible officer.

The responsible officer is often the medical director of an organisation and is responsible for the clinical governance processes in their Health and Social Care organisation, focusing on the conduct and performance of doctors. They make recommendations to the GMC about each of their doctor's revalidation. 

Responsible officers work with the GMC to make sure:

• systems are in place to evaluate doctors' practice
• doctors have regular appraisals
• there are processes to investigate and refer any fitness to practice concerns to the GMC.

The responsible officer is required to ensure that doctors with whom they have a prescribed connection take part in regular appraisals, that processes are in place and implemented to investigate concerns, that concerns are referred to the GMC where appropriate and that compliance with any GMC sanctions and records of doctor’s fitness to practice evaluations are maintained. 

Responsible officers have an important statutory role in medical regulation. The effectiveness of revalidation depends greatly on the competence and skills of those doctors doing this role.

The GMC requires responsible officers to raise any cases of non-engagement with appraisal in their routine meetings with the GMC. This requirement is set out in the protocol for making revalidation recommendations. 

GMC employer liaison advisers engage in regular discussions with responsible officers to support the management of local concerns about doctors and provide advice about revalidation, supporting local clinical governance systems.

The role of the Department of Health and Health and Social Care organisations 

The application of medical appraisal and the processes that support revalidation are reported and monitored by the DoH through annual assurance and accountability mechanisms with each Health and Social Care trust. This includes annual reports, governance statements, annual quality reports, and assurance and accountability meetings. 

However, it is clinical governance systems, and the culture within health and cocial care organisations, which can support the implementation of best practice and the identification of unusual or aberrant practice. These statutory governance and performance management processes for Health and Social Care organisations are described in the Department of Health Framework document. This outlines the roles and functions of the various Health and Social Care organisations and the systems that govern their relationship with each other and the DoH.

The effectiveness of these systems depends on robust mechanisms for organisations to receive qualitative and quantitative information from various sources (such as Early Alerts, Complaints, Patient Safety Alerts and Serious Adverse Incidents) as well as systems for risk assessment and the triangulation of data and information received. 

Health and Social Care organisations are expected to provide training and education opportunities to support the continuous professional development for doctors, which in turn informs and underpins the appraisal, revalidation and job planning processes. 

Health and Social Care organisations should have systems in place to accurately capture the experiences of patients as well as their relatives or carers which should support organisational governance and be used to continuously improve patient safety. This includes identifying, collating and analysing information relating to the experience of patients receiving care. 

This information should support organisational governance to continuously improve patient safety including, but not limited to, a range of information about adverse and serious adverse incidents; complaints; and comments and compliments. It should also be used by doctors, Responsible Officers and/ or those conducting medical appraisal, revalidation and job planning processes. 

Conclusion

Together the DoH and the GMC will promote this joint statement to support a better public understanding of medical appraisal and revalidation and how these processes sit within wider local clinical governance systems, as they operate within and across Health and Social Care organisations. 

The DoH and GMC will promote, application of and compliance with these processes and ensure our collective oversight and monitoring arrangements support this. 

The DoH and the GMC are committed to supporting the work of the INI Implementation Programme to deliver the Inquiry’s recommendations, which will deliver improvements to healthcare services and systems and to restore and maintain public confidence and improve patient safety in Northern Ireland.