- Research article
- Open Access
- Open Peer Review
The implementation of medical revalidation: an assessment using normalisation process theory
© The Author(s). 2017
- Received: 21 October 2016
- Accepted: 7 November 2017
- Published: 21 November 2017
Medical revalidation is the process by which all licensed doctors are legally required to demonstrate that they are up to date and fit to practise in order to maintain their licence. Revalidation was introduced in the United Kingdom (UK) in 2012, constituting significant change in the regulation of doctors. The governing body, the General Medical Council (GMC), envisages that revalidation will improve patient care and safety. This potential however is, in part, dependent upon how successfully revalidation is embedded into routine practice. The aim of this study was to use Normalisation Process Theory (NPT) to explore issues contributing to or impeding the implementation of revalidation in practice.
We conducted seventy-one interviews with sixty UK policymakers and senior leaders at different points during the development and implementation of revalidation: in 2011 (n = 31), 2013 (n = 26) and 2015 (n = 14). We selected interviewees using purposeful sampling. NPT was used as a framework to enable systematic analysis across the interview sets.
Initial lack of consensus over revalidation’s purpose, and scepticism about its value, decreased over time as participants recognised the benefits it brought to their practice (coherence category of NPT). Though acceptance increased across time, revalidation was not seen as a legitimate part of their role by all doctors. Key individuals, notably the Responsible Officer (RO), were vital for the successful implementation of revalidation in organisations (cognitive participation category). The ease with which revalidation could be integrated into working practices varied greatly depending on the type of role a doctor held and the organisation they work for and the provision of resources was a significant variable in this (collective action category). Formal evaluation of revalidation in organisations was lacking but informal evaluation was taking place. Revalidation had not yet reached the stage where feedback was being used for improvement (reflexive monitoring category).
Requiring all organisations to use the same revalidation model made revalidation easy to integrate into existing work for some but problematic for others. In order for revalidation to be fully embedded and successful, impeding factors, such as a lack of resources, need to be addressed.
- Medical regulation
- Policy implementation
- Normalisation process theory
Organisations/ Designated body
Licensed doctors who are not trainees must:
- Have a connection to one organisation (known as a designated body).
- Take part in regular appraisal
- Collect supporting information for appraisal: 6 types
• CPD (annually)
• significant events (annually)
• review of complaints and complements (as occur)
• quality improvement activity
• feedback from colleagues
• feedback from patients
- Reflect on supporting information
All trainees must:
- Have a connection to either a Local Education Training Board or Deanery
- Supporting information and discussion of progress and learning needs as generated for curriculum and training programme.
Organisations are required by the GMC to provide:
- a RO new role, responsible for the revalidation recommendation)
- an up to date appraisal system and ensure every licensed doctor has a regular appraisal
- a sufficient number of trained appraisers
- clinical governance systems that can provide supporting information
- policies and systems for identifying and responding to concerns about doctors
- link with other organisations where doctors work, so information about their practice can be shared
RO makes one of three possible revalidation recommendation to the GMC:
- Deferral (request for GMC to provide more time for revalidation decision). Does not affect licence to practise.
- Non-engagement (can lose licence)
As the regulator the GMC is responsible for:
- setting guidelines
- Making the final revalidation decision based on RO’s recommendation (to revalidate; how much time to provide for deferral and whether to refer to a Fitness to Practise Panel)
- Provide an Employer Liaison Service to help responsible officers with revalidation and the management of concerns about doctors
Revalidation should be seen in a wider context where a shift has taken place in the public sector away from simply trusting professionals to self-regulate towards an active management model; amidst a growing broader culture of accountability . In active discussion since 1998, it is a policy which has polarised the medical community, proposing substantial regulatory change for the medical profession . Revalidation constitutes a change from reactive and incident led self-regulation, what has been called a ‘laissez faire and paternalistic “gentleman’s club”’, to a proactive approach .
The potential for revalidation to impact healthcare is, in part, dependent upon how successfully it is embedded into routine practice . Implementation may not be straightforward, however. The medical profession, because of its history of autonomy, has often been resistant to external regulation and has held a deep rooted cynicism towards management [7–10]. In addition, the small amount of literature that exists on revalidation has found much divergence of opinion over its purpose [5, 11].
Much research has attempted to understand the difficulties in embedding complex new policies and interventions in healthcare systems [12–15]. NPT is a framework that allows for systematic exploration of why some processes lead to a practice becoming successfully (or not) embedded (i.e. normalised) and sustained, by attempting to understand the intervention in relation to the work that people do. NPT has previously been used to explore the implementation of complex interventions such as technology in healthcare,  delivering digital health at scale,  and care pathways for elderly patients . It is based on the premise that ‘interventions become routinely embedded in their organisational and professional contexts as the result of people working, individually and collectively, to implement them’ . NPT proposes that if participants do not understand, support, or consider an intervention worthwhile, or compatible with their existing working lives, then the likelihood of successfully integres four key analytical domains (outlined in Table 3): coherence (i.e. participants understanding, sense making and value of an intervention); cognitive participation (i.e. commitment and engagement by participants); collective action (i.e. the work participants have to do to make the intervention function) and reflexive monitoring (i.e. the evaluative work people do to assess and understand the ways that a new set of practices affect them and others around them) . These domains are non-linear and interact dynamically to provide a comprehensive explanation of the implementation processes. NPT was designed to be applied flexibly, can be used at one or more points in a qualitative study, has been successfully used beyond its original field and provides a robust theoretical framework to understand the dynamics of implementation [19, 20]. The aim of this study was to understand, through the use of NPT, what issues contributed to, or impeded, the implementation of revalidation in practice and what lessons can be learned.
Design and data collection
We conducted a qualitative investigation of the initial stages of implementing revalidation in the UK, between 2011 and 2015, from the perspective of those who were responsible for its development and early implementation. We conducted seventy-one interviews with sixty UK policymakers and senior leaders at different points during the development and implementation of revalidation: in 2011 (n = 31), 2013 (n = 26) and 2015 (n = 14). The number of interviewees in each of our cohorts was determined, as is appropriate for qualitative research, by the notion of theoretic saturation . We found in 2015 that we reached saturation earlier, in part because of the extent to which issues had already been explored in depth in our earlier cohorts of interviews. The first set of interviews, from 2011, was conducted prior to the introduction of revalidation; the second set in 2013, shortly after the introduction of revalidation, and the final set in 2015, once the process of implementation had been underway for three years . The 2013 interviews in particular formed part of an inclusive stakeholder approach which reached out to employers .
The topic guides across all three interview sets focused around three main areas: individual roles and relation to revalidation, understandings of revalidation, its purpose and aims and predictions or experiences of revalidations impact. In addition, the first two interview sets also included a section on the measurement and evaluation of revalidation.
The interviews were conducted with policymakers and senior leaders based in the UK, selected using purposeful sampling. The aim was to recruit those who were closely involved in the development of policy and practice of revalidation. The interviewees were key actors in the development and design of revalidation, with some (n = 11) being interviewed at two time points and others interviewed once (n = 49). Interviewees at each time point differed as our aim was to interview the key actors at each stage, and who this was altered across the time period. In terms of NPT theory these participants could be described as the ‘sense makers’. Though an elite group, these individuals were central to the design of revalidation and the initial phases of implementation. They were also responsible for filtering information, expectations, and understandings of revalidation to the medical profession. They had the relevant knowledge and experience in regards to revalidations development and workings prior to and at each stage investigated and, in addition, a number (50%) were practising clinicians, some of whom were part of the first cohort to be put through revalidation (it was reported that many organisations chose to put senior doctors through the revalidation process first, which these participant’s experiences reflect). The participants’ affiliations to organisations are summarised in Table 2.
Revalidation Implementation Advisory Board (RIAB)
General Medical Council (GMC)
Royal Colleges of:
Revalidation Support Team (RST)
NHS Health Trusts
Department of Health
Strategic Health Authority
British Medical Association (BMA)
Independent Doctors Federation
National Clinical Assessment Service (NCAS)
Court of Appeals
Revalidation Delivery Board
Royal Colleges of:
Academy of Medical Royal Colleges (AoMRC)
Health Watch and Public Engagement Association (HAPIA)
Independent health Advisory Service (IHAS)
Health Education England
Patient Liaison Groups
Royal College of Psychiatrists
Care Quality Commission (CQC)
NHS Clinical Commissioners
Health Education England
Ethical approval for this study was awarded by the Peninsula College of Medicine & Dentistry research ethics committee (no.12/13–122), Plymouth University Faculty of Health and Human Sciences & PSMD Research Ethics Committee (no. 15/16–486), and by the University of Manchester ethics committee (REC 15028).
Interviews were digitally recorded, transcribed and then imported into Dedoose qualitative data analysis software to assist with the organisation of data . A coding framework was developed using the four domains and sub-domains of NPT by using an adapted version of the NoMAD instrument (outlined in Table 3), which was developed to assess implementation processes (Normalization Measure Development is an instrument designed for assessing the implementation of complex interventions) . The adapted NoMaD instrument was applied to the transcripts by coding evidence of the sub-domains in Dedoose . Following coding, two members of the research team (AT and JF) analysed the data across the three interview stages, using the constant comparative method,  in order to understand changes and continuities over time. The inductive method of constant comparison analysis involved searching within individual transcripts, making comparison between transcripts within the same cohort, and comparing transcripts from different cohorts for conceptual similarities and differences. This method was combined with the deductive approach of using the four domains on NPT as a framework for the analysis. This approach was chosen as it allowed NPT to be practically applied to the data while allowing for themes to emerge from the data using the constant comparison method and inductive coding. Independent analysis of the transcripts was undertaken by two researchers (AT and JF). Dedoose was used to enable blind coding and verification of code application to check consistency of analysis. Coding and interpretations were also discussed at regular intervals throughout the analysis phase of the study, during collaborative meetings with all authors, to reduce bias.
NoMaD instrument as adapted for revalidation
How does revalidation differ from usual ways of working?
Do participants have a shared understanding of the purpose of revalidation?
How does revalidation affect the work for participants?
Can participants see the potential value of revalidation?
Are there key people who drive the revalidation forward and get others involved?
Do participants believe that being involved in revalidation is a legitimate part of their role?
Are participants open to working with others in new ways for the purposed of revalidation?
Are participants willing to support revalidation?
Can participants easily integrate revalidation into their existing work?
Does being involved in revalidation disrupt working relationships?
Do participants have confidence in other people’s ability to carry out revalidation?
Skill set workability
Do participants believe work is assigned to those with appropriate skills to carry out revalidation?
Is sufficient training provided to enable participants to enact revalidation?
Are sufficient resources available to support revalidation?
Do management adequately support revalidation?
Are participants aware of reports about the effects of the revalidation?
Do participants agree that revalidation is worthwhile?
Do participants value the effects revalidation has on their work?
Is feedback about revalidation used to improve it in the future?
Do participants modify how they work with revalidation?
In this section our findings are presented structurally around NPT’s four domains and follow the adapted NoMaD framework presented in Table 3, except that differentiation and individual specification are discussed together as they simultaneously featured in participants’ interview answers. The findings of the constant comparative method are presented in each of the domain sections as they appeared.
Coherence refers to participants’ understanding of an intervention and the sense making work they engage in to establish this. This includes how participants understand an intervention’s purpose, whether this understanding is shared, how they understand the intervention to be different from previous ways of working, perceptions of expected benefits, and the degree to which participants value and accept the intervention.
Differentiation and individual specification
For me it is actually really much more about the NHS looking at its processes and systems for ensuring quality and its systems of clinical governance and doing effectively what it said it would a number of years ago, which was good systems in place, good systems of clinical governance in place, appraisal for doctors in place, and really seeing revalidation as a side issue and a by-product of having all those good systems in place. (Int 12, 2011).
So we’ve seen a shift of mood that suggests that those people are really having better quality conversations with their appraisers. (Int 5, 2015).
I’ve heard about appraisal being described in the past as a sort of a cosy chat and I think it was about formalising that discussion, that opportunity and making sure that there was a serious reflection on things like feedback from colleagues, patients and significant events. (Int 14, 2015).
[Prior to] medical revalidation, what we had was … the ability to have a conversation that says I’m concerned about my practice in this area, it’d be helpful if I got some support in making sure that I’m okay in this area’. And I think with medical revalidation there is the slight danger that it might choke off the kind of open conversations that there was before because of the threat that that might lead to a deferral or it might lead to a fitness to practise. (Int 21, 2013).
One of the impacts of revalidation was, [previously] a lot of the large organisations didn’t have appraisals with their own trust grade doctors, with part time doctors, they didn’t know who was on their books, they had honorary contract doctors. And, I think revalidation tightened up the systems administratively, to actually see who owned and who we didn’t own, and some they did appraisals on…and you’ll see it in the figures, very low appraisal rates [pre-revalidation] for some groups, even in the NHS, such as consultants. (Int 3, 2015).
What revalidation brings in the opportunity to do it [appraisal] in a consistent way. (Int 21, 2011).
So strengthening those, let’s call them clinical governance systems, to share that information more widely. And we’re certainly seeing it through other drivers. The whole transparency agenda, in part, is being supported by revalidation but it’s not an explicit link. (Int 4, 2015).
It moves it from reacting to only when there’s a problem, to proactively trying to stop problems occurring, and broadly, improve standards. And that’s why I think it’s, in that sense, a good thing…So it’ll drive them in the right direction in terms of people’s capability, their clinical competence, it’ll drive them in the right direction in terms of probity. (Int 10, 2015).
In terms of communal specification, a shared understanding of the purpose of revalidation was not held within or across the three sets of interviews. In 2011, 2013 and 2015 the interviews demonstrated a disparity of opinions regarding the purpose of revalidation, with some participants perceiving the purpose to be regulatory (i.e. to deal with poor performance) while others regarded it as a way to raise standards.
If the systems not picking out the poorly performing doctors then the system’s not working. I think that has to be one of the primary purposes of the system is to identify poorly performing doctors and so you can look at the number of poorly performing doctors that are identified as a result of introduction of revalidation. (Int 3, 2013).
I think it will raise the standards of doctors significantly and steadily over the years that it’s going on. I think it’s got real potential to make a difference. (Int 4, 2013).
I think that it has got that kind of overall quality improvement function, and I’m sort of impressed by that, because I kind of hadn’t really believed that that was going to be the case. (Int 9, 2015).
When asked about revalidation (in particular its purpose and impact) most participants’ answers were about appraisal, suggesting that for many in conceptualisation revalidation was equated to appraisal rather than being perceived in its totality of components (see Table 1). This is important for coherence as it suggests a particular framing of revalidation which centres on the appraisal process.
The bureaucracy. The hoops that you need to jump through. You need for every operation that you do; you need a commentary on it…We are big, grown-up boys. It is that kind of thing. It costs. The more bureaucracy you put round these things, the more it costs. We do not introduce drugs into the NHS if they are not cost-effective. Well there needs to be a cost-effectiveness test to this as well. (Int 4, 2011).
I do think the attitude is changing, I think right at the beginning of revalidation, December 2012 there was quite a lot of hostility to revalidation of the appraisal processes. Over the passage of time I think that that is shifted away and people are saying okay it’s a system, it seems to be working, it’s not going away; we’ve just got to work with it. (Int 6, 2015).
Cognitive participation is the relational work that people do to support the implementation of a new intervention. This includes having key people to drive it forward and get others involved, the belief by individuals that it is a legitimate part of their role, their degree of openness to working with colleagues in new ways, and willingness to continue to support an intervention.
A major trend in some organisations is that some ROs are put in place by the organisation, but the organisation from a Chief Exec and a corporate governance point of view, don’t support the doctor. Hence, the doctor feels isolated, and the company is focused on their business, running the service, making money, and the doctor is bringing to them issues around individual doctors, and they didn’t want to know all that. So, I’ve had two ROs in [area] who’ve resigned from their organisation as the RO, because they said they did not have the support of the Board to do their job properly. (Int 3, 2015).
Although everybody is subject to the kind of processes of revalidation and it’s kind of law for everybody now, I think it’s pretty clear that people are only really going to engage when they think they have to. (Int 1, 2013).
There’s still an element of people who I think are either not participating or are participating in a particular way, or a grudging way, that either they don’t have enough trust at local level or perhaps they don’t like how the appraiser is appointed, how they’ve been trained or what their attitude to you is; all manner of local baggage. That sort of culture does seem to be getting eroded. (Int 5, 2015).
We find, particularly doctors who are near retirement or doctors who have retired and then returned to practice, they sort of poo-poo revalidation in a way because they’ve never taken it se[riously]…they’ve never had to follow an appraisal system in most of their careers, you know; they’ve never thought that revalidation is required for them, would ever touch them and now it does. It’s a cultural…they’re not used to having to do something that a manager is asking them to do; it’s quite an alien thing for them. That’s quite a challenge for them. (Int 8, 2015).
The new Labour administration, for them it meant a means of control…they did want to bring doctors down a peg or so, there was this feeling that they are prima donnas and do want they want and so on… They brought in job contracts for consultants and all this sort of stuff, the sort of managerialism of trying to control. That was the approach used: regulation. (Int 8, 2011).
Others suggest that doctors, particularly consultants and older doctors, see revalidation as interfering with their professional independence. In addition it was reported that senior doctors would be reluctant to have an assessment conducted by doctors more junior to them, or administrative staff, as part of their appraisal process.
But in secondary care, I think what you’re seeing is, if you like, the individual consultant becoming less powerful and the employer, probably becoming more powerful. And doctors being treated … they’re treated more like employees than they once were - rightly or wrongly - and that’s the way it’s happening, it seems to me. (Int 10, 2015).
And I don’t see how a non-anaesthetist has the knowledge and skills to appraise an anaesthetist and I just think it’s too easy for the appraisee to pull the wool over an appraiser’s eyes if the appraiser doesn’t come from that specialty. (Int 3, 2013).
If you say to a doctor ‘how d’you feel about patients making a critical comments about your practice?’ they start to be very defensive. And I think one of the real challenges we’ve got is how to develop a language that enables doctors and patients to talk to each other in a much more mature way it would take the relationship from one kind of subservience to one of joint empowerment and that really I think is a major task that you have at the moment. (Int 12, 2013).
The positive side has been that it’s provided a new network of senior doctors, who are talking to each other … they are emerging as a new professional elite … (Int 3, 2015).
Collective action is the operational work that people do to enact an intervention. This includes whether an intervention can be easily integrated into individuals existing work, if individuals have confidence in others abilities to use the intervention, the provision of sufficient training to enable staff to implement the intervention and the supply of sufficient resources.
I think there has to be still greater professionalism and the professionalism starts with the trusts attitude to appraisal and you know this has to be something that’s recognised. Primary care you get paid for it, I’m not saying you need to get paid for it, but you need time off to do appraisals properly now that often isn’t the case. (Int 24, 2013).
I think it takes an inordinate amount of time to prepare for each year’s appraisal. (Int 7, 2015).
So, locum doctors often are not engaged, or haven’t got access within organisations to CPD, they often have to solve it themselves, so if they’re not able to meet the CPD requirements. If you’re a locum, and you’re doing one shift, you possibly aren’t able to get patient feedback. (Int 3, 2013).
When you’ve got 65 hospitals with 300 doctors scattered all over them where do you get the appraisers from? Which it will come as no surprise that in fact it’s quite easy to find appraisers who are trained and skilled in the bigger centres, but you end up sometimes with the position as we have where you’ve got a hospital with five or six connected doctors – ones that are connected to us – and nobody within 50 miles […] And you end up talking about people driving 50 miles each in different directions and meeting somewhere in the middle to have an appraisal. (Int 2, 2015).
I think good doctors will do it but those who are not good want to bend the system it’s very easy for them. (Int 25, 2013).
It’s like school, if you remember school, you always knew who was going to be the hard teacher and the soft marker. So, some of the locum agencies have had external ROs appointed, and when they found the external RO was actually being too rigorous in their requirements. Because, they had doctors who were coming in once a year, flying in from overseas, who they wanted to revalidated, and the RO wouldn’t revalidated them, the locum agencies just dumped the RO and get another one. (Int 3, 2015).
I think doctors are learning very quickly what the minimum requirements are to complete a portfolio to get through revalidation…Doctors will very quickly learn how to use the system for their own benefit, and calibrate it according to how they want it to be. Because, they have managed to keep external review out, for example, patient feedback has been tokenistic, and it can be once in every five years. (Int 3, 2015).
Skill set workability
The quality of appraisal is hugely variable. I have an excellent one at the moment but it’s hugely variable and the amount of information you have to put varies between appraisals as well. (Int 7, 2015).
The quality assurance of the appraisal documentation is lacking, and this is something which I think we really do need to grasp for the future, we need to make sure that appraisers are appropriately managed and calibrated and the supporting information is certainly calibrated so that we’re consistent. And this basically creates a bad reputation for revalidation on the basis that the headlines are, well, Doctor X was revalidated but his practice is in special measures, he’s single handed, he has no concept of what an audit is and what clinical quality improvement looks like. (Int 13, 2015).
The concerns about time involvement are entirely justified. The IT systems in the NHS in all four nations is not up to providing the information that people wish to be able to bring to an appraisal process. (Int 7, 2011).
Reflexive monitoring refers to how participants evaluate an intervention, the collection and use of feedback and reports and how the intervention changes over time. This includes being aware of the impact of an intervention, an agreement that the intervention is worthwhile at an individual and collective level, and feedback about the intervention for future improvement.
Reports on the effects of revalidation (systemisation in NPT terms) raised by participants in the interviews were predominantly informal, based on personal and colleague discussion and anecdotes. Formal systemisation (i.e. feedback collected or reviews undertaken formally by organisations with the purpose of assessing revalidation) appeared to have not yet been undertaken for the majority, which reflects the infancy of the intervention and also its complexity. Indeed, several participants remarked on the difficulty of assessing the impact of revalidation on performance and within organisations. These reports varied significantly by data set.
Communal and individual appraisal
I think the main impact, even at doctor level is cultural, so yeah, probably behaviours and attitudes…my views about it have changed quite a lot and I was quite doubtful that it would change things much and I was also quite irritated, as most doctors are, by the sort of tick boxes stuff, so the process stuff, and even still I find the stuff I have to do for NHS England quite onerous in terms of the paperwork burden. But I can, what I can see now is that having got quite a lot of the nuts and bolts of the process kind of going smoothly around appraisal particularly, I’m actually starting to see the benefits and the doctors that I manage have kind of stopped fighting it. (Int 9, 2015).
I think some organisations have seen the benefits of revalidation, in terms of how it can support governance, how it can bring together quality improvement, significant events, and it can contribute to patient care in their hospital. And, some have seen that and have resourced the role, and put in place a system, ROs, deputy ROs, revalidation managers. (Int 3, 2015).
I think employers would say to us that it still feels to them over engineered and they’d like a bit more streamlining. I don’t think that’s going to happen in the first cycle … I think people will be inclined to say, can we just tone this down a bit? Right now I don’t think the employers expect any change any time soon but I think if they were asked that’s what they would say to us. (Int 5, 2015).
Using NPT as a framework we have identified the key factors contributing to and impeding the implementation of revalidation across the time period under investigation. Understandings of revalidation and the effect it has on practice, consensus of purpose, organisational support, ease of integration and resistance from doctors were the key factors identified and shall be discussed in detail later in this section. We have shown that there has been considerable latitude in how revalidation has been implemented, most likely due to the novelty of the policy, with variability in how revalidation has been understood, the work that has been done to support revalidation and how revalidation has been operationalized. This variability was evident across all three time periods investigated.
Revalidation was frequently conflated with appraisal, reflecting perhaps the fact that appraisal had been used by many organisations as an existing and familiar foundation from which to build revalidation and to develop doctors’ understanding of the process. But this focus on appraisal meant that a more holistic understanding of the revalidation process was often missing from participants’ accounts, which could be detrimental to the reach and embedding of revalidation in organisations. The focus on appraisal also highlighted differences in ways of working brought about by revalidation, in particular formalisation and a shift from formative to summative review. The recognition that revalidation had resulted in some improvements to the appraisal system helped to reduce scepticism, but negative experiences of appraisal tended to be attributed to revalidation. The lack of consensus over the purpose of revalidation may be an emergent property of implementation, reflected in the fact that over the time period under investigation coherence with regard to revalidation developed, and is likely to continue to do so as both doctors and organisations become more familiar with revalidation in practice. Despite the focus on appraisal, in their internalisation of revalidation participants showed a more holistic acceptance of the process. The acceptance was however, expressed towards the principles of revalidation and its purpose, while resistance was reported in regards to the application of the process in practice within organisations because of the difficulties and burden experienced by doctors. Improved clarity and consensus on revalidation’s purpose would likely help to remove some of this resistance by reducing the extra work caused by uncertainty about the process.
The sense makers of revalidation, such as responsible officers and appraisers, appeared to have committed to the policy and its implementation and were situated as the key individuals driving revalidation forward within their organisations. However, when not supported by adequate resources and infrastructure, their ability to drive implementation was substantially limited. Cultural resistance was identified as an impeding factor to implementation. Hierarchical boundaries and traditions meant not all doctors were willing to work with others for the purposes of revalidation, with resistance from some to appraisers being of a different grade or specialty. Some doctors also felt that revalidation diminished some of their professional status and positioned them as more like other employees. Older doctors were described as being particularly resistant to revalidation and facing the biggest cultural shift. But reports of such resistance did decrease over the time period suggesting that as these cultural changes become normalised, in combination with new doctors more familiar with reflexive practices entering the profession, this particular impeding factor may decrease.
Many of the identified impeding factors to the implementation of revalidation fell under the category of collective action. Difficulty in integrating the work of revalidation into existing work was central to this, with three main factors being cited: the ‘one size fits all’ model, a lack of training, guidance and information on the requirements of revalidation at all levels of the medical profession, and insufficient infrastructure and resources (time/staffing levels especially) to support the intervention. While the latter two factors did decrease over time as organisations and individuals became familiar with the process, the limitations on resources and skill sets were the biggest reported sources of resistance to revalidation and caused the process to be perceived as burdensome by some. These issues could be mitigated by making the process easier (and less time consuming) for doctors and reducing variability in the appraisal process and the collection of supporting information. There were also wider concerns about variability and a lack of robustness in appraisal and revalidation processes within and between organisations. The majority of those interviewed noted that it was not the principle of revalidation that was in contention but rather the difficulty of integrating it into working practices. The removal of obstacles, be it data collection issues or lack of time to carry out the required work, should help reduce this resistance and further help in the normalisation of the intervention.
The difficulties noted in part result from the ‘one size fits all’ model of revalidation which contains some implicit assumptions about the nature of organisations and existing organisational systems and processes. If revalidation is to be fully embedded in a heterogeneous range of organisational settings and forms and into the practices of all doctors then this issue needs to be addressed, either through a more flexible revalidation process or through the tailoring of the process to different contexts.
Evidence of reflexive monitoring was limited within the interviews, reflecting the relative novelty of revalidation at the times they were undertaken. Given that revalidation was not introduced until 2012, it is unsurprising that there was virtually no impact reported in the 2011 interviews which predated this. Most discussion and awareness of revalidations impact came in the 2015 data set, which had taken place at the furthest point along the revalidation timeline. Despite this there was evidence that the sense makers of revalidation within organisations were starting to think about how the process of implementation had unfolded, both to highlight problems and to suggest improvements. Revalidation was discussed as a work in progress, needing improvement but now accepted by the majority of doctors. Given the controversial nature of revalidation and the length of time it took from conception through policy debate and development to the commencement of implementation, we might conclude that its introduction has been less problematic and contested than might have been expected. While there was some professional resistance, it was mostly directed at practical difficulties arising as doctors and organisations undertook revalidation for the first time; however, the principle and purpose of revalidation was generally accepted and valued.
We have in this paper investigated the initial implementation of revalidation from the perspective of those responsible for its development and introduction, specifically policy makers and clinical leaders. Further research into the practice of revalidation needs to focus more on the experiences and perspectives of those engaged most directly, particularly doctors as appraisers and appraisees and managers and other clinical professionals involved in enacting revalidation. Nevertheless, our findings complement earlier research into the development of revalidation and some components such as appraisal [2, 5, 10] and provide some of the first direct evidence of its implementation and impact.
Our main theoretical contribution has been to extend the use of NPT to explore the implementation of a broad and complex policy, with wide ranging implications for an entire profession, and the wider healthcare system. Much previous work using NPT in healthcare has addressed the implementation of micro level interventions [25–27]. This expanded application of NPT has highlighted a number of factors which seem to have affected the implementation of revalidation. The four dimensions of the framework (see Table 3) had an intuitive relevance and provided a useful explanatory framework for understanding the implementation of revalidation. There is scope to apply NPT more widely to complex social interventions and policy initiatives at the organisational and system level in future.
Our analyses are exploratory and based on qualitative interviews conducted with elite individuals in the profession which means these findings may be of limited generalisability in relation to other professionals who are not as directly involved in the initial development and design of revalidation. Furthermore, the perspectives of doctors who do not occupy elite or leadership positions of implementing and delivering revalidation may well differ from the perspectives captured here. Interviews were carried out in the early stages of introducing revalidation; therefore, factors contributing to and impeding the implementation of revalidation are likely to have moved on in the time period since data collection. In addition, other theoretical approaches  may have led to different insights and have offered additional explanations of the implementation of revalidation.
Our findings suggest that, over the five year period between the first and final interviews, revalidation gradually became more embedded and accepted in the medical profession. This related in particular to the normalisation of revalidation, familiarisation with the process and the acknowledgement and experience of benefits brought by the intervention. However, it had not yet become fully embedded and scepticism about the process and reluctance to engage were still apparent. This was most related to practical difficulties and under resourcing of the process, particularly in some organisational settings.
This paper is an output from independent research commissioned and funded by the Department of Health Policy Research Programme (PR-R9–0114-11,002 Evaluating the development of medical revalidation in England and its impact on organisational performance and medical practice).
The views expressed are those of the authors and not necessarily those of the Department of Health.
Availability of data and materials
The datasets used and analysed during the current study available from the corresponding author on reasonable request.
AT and JF were the lead writers and editors of the manuscript and of data analysis and interpretation. JT and CH carried out data analysis and interpretation. KW, AB and JA undertook data collection. JA, KW and SRB conceptualised and designed the project from which this manuscript has been developed and acquired its funding. All authors contributed to revisions of the manuscript and approve the final version.
Ethics approval and consent to participate
Ethical approval for this study was awarded by the Peninsula College of Medicine & Dentistry research ethics committee (no.12/13–122), Plymouth University Faculty of Health and Human Sciences & PSMD Research Ethics Committee (no. 15/16–486), and by the University of Manchester ethics committee (REC 15028).
All participants provided informed consent for themselves prior to being interviewed.
Consent for publication
The author(s) declare that they have no competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
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