Revalidation; the stick the General Chiropractic Council will use to beat traditional chiropractors with

October 4, 2010
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 image Revalidation is process which all health regulators are required to put in place to assure the public that doctors are up-to-date and complying with medical professional standards. Every five years throughout your professional life they will be this reassessment.

In the paper produced by the Department of Health in November 2008 they indicated that regulators must present a robust business plan demonstrating the benefits which will accrue from revalidation and the GCC have decided the best person to do this is David Byfield and the Welsh Institute of Chiropractic in Glamorgan. The DOH produced guidelines for revalidation.

Principle 10 (Demonstrating Benefits – effective in confirming fitness to practise) The structures and processes surrounding revalidation should knit together in a coherent, unbureaucratic and proportionate manner to ensure that resources invested yield valid and reliable outcomes together with the anticipated benefits to service users and health professionals”.[1]

In January 2010 the GCC produced a draft document  to present to the profession. The paper had been put together with the help of economics consultants) and  was supposed to present a robust business case demonstrating the benefits which would come to chiropractic patients  by introducing revalidation.The table below indicates the “estimated” savings made by  British patients of chiropractors.clip_image002 This chart gives an indication of the mind set of the visionaries planning the future of chiropractic in the UK. I guess to make the case for regulation chiropractic must be dangerous however  I have no idea As the way that these figures were developed.

By the second meeting in March, I am told the 10 year cost for radiation induced Cancer by chiropractors was reduced from £8,436,000 down to £340 over a ten-year period. “Unnecessary chronicity” apparently an invention of the GCC based on spurious “facts” , was reduced from £95,222,000 to 0 over a ten-year period!

How on earth could the regulator have tried to present such wildly inaccurate calculations in support of revalidation? The answer maybe that  elements within the GCC will use revalidation as a tool to medicalise chiropractic.

In putting revalidation out for tender this is how the GCC expressed its requirement “GCC decided at a very early stage of its thinking that it needed to develop a quality assured infrastructure for delivery of the revalidation scheme, to stand in place of the managed environment of the NHS and independent/voluntary sectors in which significant numbers of other regulated health professionals practise”.

The four UK professional associations supported the bid of the College Of Chiropractors for the revalidation contract, the GCC panel consisting of Grahame Pope (a Physiotherapist), Ian Dingwall ( a chiropractor) Paul Ghuman (Margaret Coats Gofor)and Margaret Coats, gave the contract to David Byfield as they did with the Test of Competency.

Below is the method and logic the GCC are using to justify revalidation. If revalidation goes through  it will be onerous expensive and ultimately unworkable. It will be the ordinary chiropractors in practice who will bear the brunt of this and the expense.

Without the intervention of the SCA and UCA  the original figures would have passed almost without notice. However Chiropractors have to face up to the fact their registration fees are going to fund this crap and they may not wish to be led to the GCCs medical utopia.


Sub-optimal Outcomes

Forecast number of patients that might be affected and the number of events

Question 11 of the survey we sent to chiropractors asked registrants to state what proportion of their patients could have had a better outcome if their care had been managed and/or implemented differently. It was emphasised that zero was an acceptable response.

Based on responses to this question, we have calculated through use of a weighted average that 4.15 per cent of patients experienced a sub-optimal outcome in 2009. The most common reason for the sub-optimal outcome was stated to be patient non-compliance (61.0 per cent of sub-optimal outcomes, on average) followed by inadequate care management (13.2 per cent of sub-optimal outcomes, on average).

Sensitivity analysis — number of events

The central estimate of loss due to sub-optimality is based on the survey responses that, on average, 4.15 per cent of patients experience a sub-optimal outcome. Of course, we do not assume that the statistic calculated from survey responses is completely accurate — all surveys with a response rate below 100 per cent are subject to some potential inaccuracy, and there is always a possibility that some individual replies may not be entirely correct. Therefore, in addition to calculating QALYs lost based on an estimate of 4.15 per cent of patients experiencing sub-optimal outcomes we will also utilise upper-bound and lower-bound estimates. As discussed with the Expert Group, the central estimate of the proportion of patients experiencing sub-optimal outcomes will be adjusted upwards and downwards by 10 per cent to give an upper bound of 4.565 per cent and a lower bound of 3.735 per cent.

Total loss of QALYs attributable to preventable failings

To quantify the impact of a sub-optimal outcome, we first use the results of the UK BEAM trial to estimate the pre-treatment EQ-5D score of chiropractic patients.

To estimate the loss suffered by these patients as a result of the sub-optimal outcome it is necessary to know the gain that could have been made had their care been optimal. For the purposes of quantification we assume that patients experiencing a sub-optimal outcome still derive some benefit of their chiropractic care, but that this benefit is lower than it would otherwise have been. In particular, we assume that patients experience a QALY gain equal to that which would be achieved through best care in general practice, but that they do not obtain the ‘added value’ experienced by most patients that receive chiropractic care. Hence, we assume the QALYs lost through the sub-optimal outcome is equal to the difference between QALYs gained by the group which received best care in general practice in the UK BEAM trial and the group that received a package of care which included spinal manipulation and exercise.

It is also necessary to have an estimate of the typical amount of time over which a patient would experience a sub-optimal outcome. We fully acknowledge that some sub-optimal outcomes could be experienced for short periods (for example if a patient receiving symptomatic care visits their chiropractor the following week and the chiropractor resolves the issue) whilst others could be experienced for far longer (for example if the sub-optimality is ‘hidden’ to both chiropractor and patient). However, the Revalidation Working Group agreed that, for the purposes of this work, it would be reasonable to assume that the sub-optimality is typically experienced by the patient for a period of one month (i.e. 0.083 of a year).

Sensitivity analysis — duration of sub-optimality

The central estimate of loss due to sub-optimality is based on an assumption, agreed with the Revalidation Working Group, that sub-optimal outcomes would typically persist for one month. Of course, in some cases the sub-optimality would be resolved more quickly that this, whereas in other cases the sub-optimality may take longer to be resolved and, in the extreme, may never be resolved. As a result of the uncertainty in our central assumption, we wish to consider what the potential losses would be under different assumptions. On the advice of the Working Group, we therefore also calculate the loss on the assumptions that the sub-optimality would persist for two weeks (i.e. 0.038 of a year) and alternatively that the sub-optimality might persist for six weeks (i.e. 0.115 of a year).

Given the estimate derived above that 4.15 per cent of patients might experience a sub-optimal outcome, in 2009 the central estimate of QALYs lost as a result of this event is:

QALYs lost = Number of patients (1,005,000)

*Percentage of patients with a sub-optimal outcome (4.15%)

*Missed improvement in QALYs through sub-optimality (0.051)

*Duration of sub-optimality in years (0.083)

= 177 (rounded to nearest QALY)

Sensitivity analysis — number of events

Using the lower bound estimate of the proportion of patients that experience a sub-optimal outcome, the number of QALYs lost is 159. Using the upper bound, the figure is 194 QALYs lost.

Sensitivity analysis — duration of sub-optimality

Using the lower estimate of the duration of sub-optimality discussed above, the number of QALYs lost is 81. Using the higher figure, the figure is 245 QALYs lost.

Monetary value of QALY loss

NICE does not have a threshold or a cut off point above which no treatment will be approved and has been clear that this is not the case. Each treatment is considered on a case-by-case basis. Generally, however, if a treatment costs more than £20,000-30,000 per QALY, then it would not be considered cost effective. Consequently, the following estimates of the monetised value of adverse events and sub-optimal outcomes in chiropractic are based on a value of £30,000 per QALY.

Quantification of this risk assumes that, as an upper bound, 4.565 per cent of patients experience a sub-optimal outcome each year. As a lower bound, we assume that 3.735 per cent of patients are affected in this way. It is assumed that the number of patients will increase by approximately 38,800 per annum over the next 10 years and hence the number of sub-optimal outcomes increases by between 1,455 and 1,804 per annum.

Based on these assumptions, the central estimate of the annual monetised QALY cost of sub-optimal outcomes rises from £5.46m in 2010 to £7.12m in 2019. The present value of the cost of this risk over 10 years, calculated with a real discount rate of 3.5 per cent, is approximately £51.86m.

Sensitivity analysis — number of events

As an upper bound, the present value of the cost of this risk over 10 years is approximately £58.21m whilst the lower bound estimate is approximately £47.63m.

Sensitivity analysis — duration of sub-optimality

As an upper bound, the present value of the cost of this risk over 10 years is approximately £71.86m whilst the lower bound estimate is approximately £23.74m.

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  • http://spinaljoint.com Richard Lanigan

    Got this from Pulse last week.http://www.pulsetoday.co.uk/story.asp?storycode=4127412&cid=Latest_headlines_1_181010&sp_rid=NDQ2MTAyNDk4OAS2&sp_mid=35892337
    some interesting points in the discussion. The medical profession are as pissed off as the chiropractic profession. What we have to remember regualatory reform came about because of Bristol and Shipman and it was easier to bring in the changes in a developing regulatory body like ours and Margaret Coats was the person to do it.

    GMC presses ahead with core elements of revalidation despite survey revealing major doubts

    18 Oct 10

    By Ian Quinn

    The GMC plans to keep all the core elements of revalidation, despite admitting more than half of doctors and patient organisations are not convinced the profession can cope with the administrative burden heading its way.

    The council unveiled results of nearly 1,000 consultation responses to its plans, and claimed majority support for each of the separate elements, including collection of CPD points and more controversial proposals for 360-degree feedback from colleagues and surveys of patients about individual doctors.

    GMC chair Sir Peter Rubin said the council saw no need to drop any of the main elements, and though he confirmed plans revealed by Pulse to streamline the proposals, he claimed they would only need to be ‘refined’.

    The news will come as a blow to the scheme’s critics, and dash hopes that controversial elements such as colleague surveys might be dropped, not least for lack of a validated feedback tool.

    The consultation results were revealed as the Department of Health pledged its commitment to revalidation across the UK, with a joint statement from the GMC and the four administrations pledging commitment to introducing revalidation, and to having all systems ready by summer 2012.

    Earlier this month the RCGP, which will work with the GMC on plans to scale back revalidation, admitted the scheme was now unlikely to start until 2013 and that the Government had considered scrapping it altogether.

    Professor Rubin said: ‘There is no overriding message that we need to discard the main features of the proposed model for revalidation. ‘It is clear further work is required to refine a number of the proposals, so we can deliver a model that is proportionate and has the confidence of the profession.’

    The GMC said it could not provide Pulse with a breakdown of responses from doctors, which it is thought would have shown much greater opposition than the report recorded overall.
    Click here to find out more!

    But even the figures it has produced, which include responses from everyone from royal colleges helping draw up the plans to patient groups, show doubts over potential bureaucracy. Asked if it was practical for doctors to amass the required information, 46% said yes, but 24% said no and 30% were unsure.

    The report said patient and colleague feedback was a key area of concern, with some respondents questioning the value of patient feedback and fearing doctors could face ‘malicious’ claims from colleagues.

    ‘Concerns about conflicts of interest were also raised; respondents felt particular relationships meant feedback could not be objective.’

    The GMC has previously indicated the amount of multi-source feedback required from colleagues may be halved, but appears to have no plans to drop it altogether.

    Niall Dickson, GMC Chief Executive said the Government’s backing for revalidation was ‘very significant’.

    He added: ‘We are now moving into the implementation phase and the commitment of the administrations in every part of the UK to drive this forward is critical. We will continue to listen and learn from individual doctors and from the piloting to make sure we have a system that is robust but also straightforward and cost-effective.”

    Health Secretary Andrew Lansley said: ‘I would like to thank the GMC for the work they have done to address the issues raised following their consultation. The extra time for piloting will make sure we can test and streamline the system and get it right.’

  • Paul

    “D. Byfield stated we need “full integration in national health care systems and to accept responsibility associated with mainstream status.” I am fine with this statement and I do believe that we must move with the times. Especially given the title of one of Ernst’s most recent articles, “Deaths after chiropractic”. We need to do something to calm public and medical sector opinion.”

    of course we do – why dont we just abandon chiropractic and become the physiotherapists that manipulate and use xray that Byfield and his merry bunch want us to be.

    Happy little medics….

  • http://info@wimbledonclinic.co.uk Niall

    If revalidation is as broad an approach within the other professions like physiotherapy and osteopathy (like the revalidation consultation document would have us believe) – what are they doing/proposing for revalidation?
    D. Byfield stated we need “full integration in national health care systems and to accept responsibility associated with mainstream status.” I am fine with this statement and I do believe that we must move with the times. Especially given the title of one of Ernst’s most recent articles, “Deaths after chiropractic”. We need to do something to calm public and medical sector opinion.
    Are pitch seems very long winded, time consuming and costly.
    Do the maths: 3325 in UK at present that’s 660 patient reviews having to be marked each year. That’s a lot of work? Who is going to pay?
    Also don’t forget this number will increase per annum as both AECC and WIOC turn out >60 new Chiro’s each year. That’s 120 + anybody joining the registrar from abroad.
    I attended the WIOC and had to submit a reflection portfolio – they take ages…… 10-20hrs, where are we going to find the time. Between work CPD and other courses and running a business. This is crazy!
    Taking all this into account I really don’t think that by getting us to evaluate and reflect on past treatments is going to change actual treatment outcomes – I would say we should have some form of testing standards of clinical knowledge and to update practitioners, both new and old, about current changes in chiropractic. I know this should happen as part of CPD but does it? If anything should be mandatory for revalidation it’s standards of the basics (anatomy, X ray guidelines, risks, neurology, current research on common treatments)

  • Barney

    Spendidly put Richard as indeed it is what one does with the knowledge that counts. No patient EVER asked me where I qualified; they come 97 per cent of the time on personal recommendation. Thank you for your contribution.

  • http://spinaljoint.com Richard Lanigan

    @not there yet: I take a different view: In the Art of War Sun Tzu advises “know your enemy”. One of chiropractors biggest problem is they spend their lives around like minded chiropractors, this has polarisd the profession. You will graduate knowing David Byfield, Sue King, et al better than most. (How is Pete MacCarthy give him my regards)

    I was trained at AECC, I have visited Life College, Palmer , Sherman, CMCC, even Glamorgan and if I was starting out again I would go back to AECC, and if I was going somewhere else it might be an Osteopathy school just to avoid the ass holes our profession seems to produce in abundance.
    Its Mommies and Daddies that make great chiropractors not chiropractic colleges. AECC provided with me with information, what you do with that information is down to you and having the courage of your convictions to go with what you know is right and ethical.

    So stay at Glamorgan visit lots of chiropractors in practice, keep and open mind and be the chiropractor you want to be. Not the one David Byfield or Sid Williams want you to be.

  • Amit Patel

    I could not have said it better Paul!!

    Notthereyet…there is no point flogging a dead horse… cut your losses and get transfered…

  • Paul

    You’re right – transfer to Barcelona

  • Notthereyet

    As a student at WIOC all this makes me wonder why I am bothering.

  • Amit Patel

    I just hope they dont do there own tax returns…… because that would be worrying,,,,

    As the weeks go by I start to lose more faith in the GCC and really wonder what I am getting for my £1000 per year? If anyone has a good answer to this question please let me know…. !

    I am seeing my MP soon, it will be intresting to see what he thinks of this latest development…..

  • dazed

    regardless of the methods of ‘costing’ QALYs it is the content and application of the proposed scheme that need to be examined. There are real costs to the chiros – time out of clinic to process the paperwork will reduce income whilst overheads will still need to be met. These costs should be offset against the QALY £ calculation. Then there is likely to be a charge on each registrant for the adinistration of the scheme, plus additional costs for anyone needing to go through the second and third stage.

    Added to this the spectre of needing to finance CHRE when it is privatised – and my prediction is that the costs will not be apportioned across the regulators with any regard to the number of registrants. I bet the GCC passes the costs on directly to those still on the register.

    All this and bankers are still getting 7m bonuses. It makes me sick.

  • http://spinaljoint.com Richard Lanigan

    @JR this is what I had to say in May about what byfield said at the conference. http://www.chiropracticlive.com/?p=646

    You would have to say if the profession wants to be part of the NHS, prescriping and treating back pain, he is right.

    I hear many chiropractors talking the talk, very few walking the walk. Chiropractors fund the GCC, Byfield, Breen, Brown et al have outlined their vision for chiropractic, traditional chiropractors have a clear choice, do they continue to fund the medicalisation of chiropractic? or do they have the courage of their convictions?

  • Barney

    ZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZ

    The statistics are midn boggling and totally unrealistic

  • J.R.

    I would be interested to hear your opinion of David Byfields speech justifying the changes in Chiropractic. I read it on the ECU’s blog at http://www.ecupresident.org/2010/09/what-will-it-take-to-gain-acceptance.html

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