Thursday 24 July 2008


I am behind the times. Jobbing Doctor and Mental Nurse are ahead of the game and already have blogged comprehensively about the scrullious IWGC site that notionally informs folk on a doctor's performance, and the process of formal revalidation as a mechanism to oversee doctors' performance.

Although I've not blogged about the IWGC website I've commented on various blogs. For the record, my thoughts are that Bacon's site is unhelpful. It's not balanced or representative or useful views that enable patients to make informed choices. It's a place to rant and, from a position of anonymity, damage named individuals who can't respond to or explain or give their side of events. I work with families who are abusive to my patients. This month alone, and we're only 3 weeks in to it, has generated 3 referrals to me of patients who are being seriosuly abused by their relatives (with police involvement) and a few others where malign care (but not criminal) is an issue. These patienst are incapacitated and will not comment on web sites about me. The families see me as mean and 'orrible, stopping them having the house/punch bag/money/sex they want. They no doubt see me as meddling and obstructive and unhelpful. They are in a position to be vocal and look to apportion blame, without looking too hard at themselves.

In mental health this issue is particularly relevant. I often do what's unpopular with relatives.

This month I had a family who want their mum bundled in to a care home, the CMHT and I (and their mother) feel she should be managed in her own home. She's given support and she's in her own home, where she's more oriented, and happy. But I'm the nasty doctor who leaves her in her home even though she's getting worse and worse.
I think I've done a good job of patient centred care.
Family could say I don't listen and I do nothing.

This month I had a family who wanted their mum to stay in her house so she wouldn't go in to care and the house wouldn't get sold to pay for it. She was wandering at night, getting lost and wandering around half naked trying to find family at 2.00am. She doesn't live in the sort of area where you want to leave your door open and wander around on a Friday or Saturday night at 2.00am. Risks are unmanageable, she's had, "negative life events," she's lost valuable items, most of her money and is covered in bruises. She's accidentally set things on fire a few times, not attending to risks that her cigarettes pose, including setting her clothes on fire once. She has dementia and is incapacitated with respect to considering her needs, risks and deciding on future care. No donee, no deputy, no LPA, no advance decision. Best Interest meeting is held. Outcome : 24 hour care. Care home found, she's placed, she's happy there.
I think I've done a good job of patient centred care.
Family could say I don't listen and I don't let them care for their own mum and I bundle people in to homes without giving them a chance.

Often in mental health I address what people need. Invariably they're happy with this and oddly I've had no complaints but have had verbal and written compliments recently, but this perplexes me since I'm frequently not doing what they want. And there's the crux. In health care, we address clinical need. This is not always the same as addressing what people want.

My post on Jobbing Doctor's comments summarises my feelings on revalidation :

Appraisal takes me several full days, job planning another full two days, so a week a year of my time is pretty much tied up in this bureaucracy as it is. Also about 2 days of my secretary and about one day of the neighbouring hospital's Medical Director. 2 clerical staff spend 2 full days pulling records of every clinic attendance (and non-attendance), every referral, every admission, calculate length of stay, every home visit, all work done.

At present the system's pretty excessive, to my mind.

Revalidation will add to the time necessary to collect the data. If a lot of multisource feedback is sought (e.g. from a representative sample of patients) then the time invested necessarily increases further. Then, to gather a portfolio of evidence for good practice, which will be copying and pasting most of my annual appraisal file but will still need additional material that's in other areas such as CPD peer group records and the like.

I won't get paid for doing this revalidation. None of my staff will get paid for supporting this process. The opportunity costs (of erroding clinical time) are, as you suggest, substantial.

A lot of time and money will be invested.

How will it benefit doctors?

How will it benefit patients?

If health management had to be even half as evidence based as health care delivery, my world would be such a better place.


Bright-eyed said...

As a relative newcomer to the blogging scene, it has been an eye-opener reading the posts of the various doctors with regards to the seemingly ridiculous policies the government have been responsible for. Worrying times as med student as to what kind of organisation I'll be working for in the future.

On other matters, I'm enjoying your blog and the title led me on to the article on Wikipedia for the Divine Comedy - fascinating stuff!

Anonymous said...

I don't know why the Government thinks top-down control, people whose job it is to create paperwork for other people and paperwork will make the NHS any better.

Less central control and more local control focusing on the priorities of local areas is what is needed and what will improve the NHS ten fold.

Anonymous said...

I believe the revalidation will be an add-on to the appraisal process rather than parallel process.

In my psychic world I see a piece of pro-forma paper being sent to GMC with ticks on it.

The interesting thing for me that no one seems to have considered yet - what of the supervisor who signs you off as competent - only to discover through the media you've been hoarding dead patients in your attic?

Is there going to be an accountability (to GMC/employer) on the supervisor signing off such a thing?

The Shrink said...

Bright-Eyed, welcome! I can lose myself in Wiki for hours, amazing what stuff you can bimble through!

Oliver, yes, local control is better, local steer is best. For clinicians on the shop floor to be able to effect the best treatment for their patients, and thus truly have control of care, surely has to be the best option.

Tainted Halo, yes, revalidation will indeed consist of copying and pasting most of my appraisal stuff. As that currently fills a lever arch file, any more bureaucracy really isn't realistic. At present the doctor signing off on the appraisal has responsibility for this and can be held to account. This is impacting on how things work, e.g. junior doctors in training haven't had placements signed off as satisfactory and have to redo them because the Consultant wouldn't sign them off. The Dean asked it to happen, still wouldn't sign. This has caused headaches in the training scheme but is how it should be - the signature isn't an automatic rubber stamp, it's only done if the supervising doctor really is happy that the person they're assessing (student or Consultant colleague) is up to scratch.

InEx said...

A good post full of good points.
The IWGC website is just plain daft.
Medics should be allowed to get on with being Medics - There are a few bad ones I know but I very much doubt this revalidation as proposed would stop another Shipman.
Can I say Shipman on here..........?

Anonymous said...

But isn't your neck of the woods a much better world than the rest of us? :)
I recall the advent of s25 supervision - which was because no-one was doing the s117 aftercare provisions properly and so in comes the 'tweaking' section with accountability.

GMC revalidation adds an extra layer and allows for ongoing monitoring - Correct me if I'm mistaken, but appraisals only stay with an employer - a GMC review would stay with the GMC. Locums would presumably not get very consistent appraisals if any and no idea how a GP running their own private sole-practitioner practice might get either a managerial or peer appraisal or revalidation.

Unknown said...

Hi - I read you continuously - was wondering if you could give some input on my post here
If you don't want to be giving random medical advice online, I'd be happy with an email. I was wondering about the real indications for antipsychotic use in the elderly and maybe about those sort of semi-delusions that so many seem to have. Any literature you can point me to?

Molan Parker said...

Your blog really share good and useful information for the new doctors. The situation should be given a serious thought especially when the doctors appraisal has been implemented by government as it seems to further make the conditions worse.