Excellent review scheme for critical incidents but insufficient for revalidation.

I want to consider the potential use of the Scottish Audit of Surgical Mortality (SASM) scheme for revalidation of surgeons. Revalidation is an important policy initiative in the United Kingdom from the medical profession’s regulatory body, the General Medical Council. It is aimed at ensuring that doctors remain up to date and fit to practise, and is also a way of restoring and retaining the public’s trust in doctors. The policy is in some difficulty, and the government has ordered a review of how revalidation can be made to work. The Royal College of Surgeons of England and the Senate of Surgery recommend that surgeons include results of clinical outcomes and record of audits (including morbidity and mortality) in their evidence for revalidation. To this end, the SASM scheme, which looks at avoidable deaths, seems to be a potentially valuable contribution to the process. The SASM scheme can be regarded as a peer review of critical incidents. Peer review is an important component of revalidation. The clinical ownership and engagement in the SASM scheme is striking, and there is evidence of the iterative development of standards. There is also clear evidence of improvement resulting from collaboration between clinicians and hospitals. The disadvantages are that no benchmark is established because the denominator is not known and outliers would not be detected. The analysis concerns itself with the process of surgical care that involved individual surgeons, teams, and the institution, whereas revalidation is an assessment of the individual doctor concerned. Although patients are involved at a strategic (board) level, lay involvement does not seem to exist at other levels. Surgeons elect members of the management group; this generic procedure (as used by the GMC) was criticised by Dame Jane Smith in her fifth report on the case of the general practitioner Harold Shipman (who was convicted of killing some of his patients and is thought to have killed hundreds more.) Although no evidence exists, this might suggest that the procedure is perceived as a relatively closed process and that it may not meet the modern day requirements of principles of assessment, transparency, and lay involvement. Revalidation is more than just a record of continuing professional development or taking part in clinical audit. The doctor must also show that his or her clinical performance is not unacceptable—the “patient safety” test. It is significant that participation in SASM is voluntary and that a small number of surgeons do not participate. The reasons for this are not clear, but for the purposes of revalidation a proved and consistent refusal to participate in a national clinical audit scheme focusing on outcomes for surgeons could be a cause for concern. In conclusion, participation in the critical incident scheme described would be insufficient by itself to revalidate a surgeon. Revalidation should not be its primary purpose. Instead, it is an important and thoughtful scheme with the potential to develop into a more robust and widespread confidential reporting and learning system to tackle patient safety by focusing on systems improvement.