Abstract
BackgroundIn 2012, the UK introduced medical revalidation, whereby to retain their licence all doctors are required to show periodically that they are up to date and fit to practise medicine. Early reports suggested that some doctors found the process overly onerous and chose to leave practice. This study investigates the effect of medical revalidation on the rate at which consultants (senior hospital doctors) leave NHS practice, and assesses any differences between the performance of consultants who left or remained in practice before and after the introduction of revalidation.MethodsWe used a retrospective cohort of administrative data from the Hospital Episode Statistics database on all consultants who were working in English NHS hospitals between April 2008 and March 2009 (n = 19,334), followed to March 2015. Proportional hazard models were used to identify the effect of medical revalidation on the time to exit from the NHS workforce, as implied by ceasing NHS clinical activity. The main exposure variable was consultants’ time-varying revalidation status, which differentiates between periods when consultants were (a) not subject to revalidation—before the policy was introduced, (b) awaiting a revalidation recommendation and (c) had received a positive recommendation to be revalidated. Difference-in-differences analysis was used to compare the performance of those who left practice with those who remained in practice before and after the introduction of revalidation, as proxied by case-mix-adjusted 30-day mortality rates.ResultsAfter 2012, consultants who had not yet revalidated were at an increased hazard of ceasing NHS clinical practice (HR 2.33, 95% CI 2.12 to 2.57) compared with pre-policy levels. This higher risk remained after a positive recommendation (HR 1.85, 95% CI 1.65 to 2.06) but was statistically significantly reduced (p < 0.001). We found no statistically significant differences in mortality rates between those consultants who ceased practice and those who remained, after adjustment for multiple testing.ConclusionRevalidation appears to have led to greater numbers of doctors ceasing clinical practice, over and above other contemporaneous influences. Those ceasing clinical practice do not appear to have provided lower quality care, as approximated by mortality rates, when compared with those remaining in practice.
Highlights
In 2012, the UK introduced medical revalidation, whereby to retain their licence all doctors are required to show periodically that they are up to date and fit to practise medicine
Figure shows estimated hazard ratios (HRs) and 95% confidence intervals (CIs) for different case-load groups relative to the group with lowest case-load in 2008. (PDF 60 kb) Additional file 2: Stratified analysis of time to exit by consultant age
Hazard ratios (HRs) and 95% confidence intervals (CIs). (PDF 516 kb) Additional file 7: Difference in mortality rates between leavers and stayers by specialty and time period; outcomes are assigned to first consultant in admission spell. (PDF 504 kb) Additional file 8: Association between risk factors and mortality consultant works in medical specialty
Summary
In 2012, the UK introduced medical revalidation, whereby to retain their licence all doctors are required to show periodically that they are up to date and fit to practise medicine. Systems of medical regulation exist around the world, to protect patients and assure the public of the competence and quality of medical practitioners. Confidence in the medical profession ranks higher than many other areas of life [1], but the public trust upon which self-regulation relies has apparently been eroded in recent years, in all social institutions, including health care systems [2]. In the UK, public outcry over some failures of medical regulation (most notably errors by paediatric cardiac surgeons in Bristol [4] and the activities of a prolific serial killer in general practice [5]) resulted in reforms of previous regulatory processes. Self-regulation was widely deemed ineffective, and the profession left ‘fatally vulnerable to the problem of “bad apples”: those unwilling, incapable or indifferent to delivering on their professional commitments and who betrayed the trust of both patients and peers’ [6]
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