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Health Policy 114 (2014) 128– 138

Contents lists available at ScienceDirect

Health Policy

j ourna l ho me pag e: www.elsev ier .com/ locate /hea l thpol

evalidation: Patients or process? Analysis using visual data

arilys Guillemina,∗, Julian Archerb, Suzanne Nunnb,amantha Regan de Bereb

Centre for Health and Society, Melbourne School of Population and Global Health, University of Melbourne, Level 4, 207 Bouverietreet, Parkville 3010, AustraliaThe Collaboration of the Advancement of Medical Education Research & Assessment (CAMERA), Plymouth University Peninsula Schoolsf Medicine & Dentistry, C408 Portland Square, Drake Circus, Plymouth PL4 8AA, UK

a r t i c l e i n f o

rticle history:eceived 4 October 2013eceived in revised form1 December 2013ccepted 11 December 2013

eywords:Kisual methodsealth policyedical profession

a b s t r a c t

Revalidation is a significant recent regulatory policy reform from the UK General MedicalCouncil and being considered elsewhere around the world. The policy aims to regulatelicensed doctors to ensure that they are ‘up-to-date and fit-to practise’. Fundamental to thepolicy is that the revalidation of doctors should benefit patients and improve doctor–patientrelationships. As part of an evaluation of the development of revalidation, 31 policy mak-ers involved in its development were interviewed in 2010–2011 and were asked to drawwhat revalidation meant to them. From this, 29 drawings were produced and this articlefocuses on their analysis. The drawings emphasised abstract systems and processes, witha distinct lack of interpersonal interactions or representation of individual patients anddoctors. Only 3 of the 29 images included individual patients and doctors. This deperson-

edical regulationevalidation

alisation of policy is examined with respect to the purported key objective of revalidationto benefit patients. Using a distinctively different modality, the drawings serve to confirmthe two key discourses of regulation and professionalism prevalent in the interview data,while highlighting the notable absence of the patient. The benefits and limitations of using

arch m

drawings as a rese

. Introduction

Revalidation, a new system of regulating doctors com-enced in the United Kingdom (UK) in December 2012. For

he first time all licensed doctors have to demonstrate thathey are ‘up-to-date and fit-to practise’ in accord with theuidelines issued by the General Medical Council (GMC).t is anticipated that the majority of doctors will haveeen initially revalidated by March 2016; this is informedy annual appraisals, followed by revalidation every five

ears. This is a significant reform in the regulation of aational medical workforce which has generated interestcross the world, sparking fresh debate in Canada [1] and

∗ Corresponding author. Tel.: +61 3 8344 0827; fax: +61 3 8344 0824.E-mail addresses: m.guillemin@unimelb.edu.au (M. Guillemin),

ulian.archer@pms.ac.uk (J. Archer), suzanne.nunn@pcmd.ac.ukS. Nunn), S.Regandebere@plymouth.ac.uk (S.R. de Bere).

168-8510/$ – see front matter © 2014 Elsevier Ireland Ltd. All rights reserved.ttp://dx.doi.org/10.1016/j.healthpol.2013.12.006

ethod are discussed for a health policy context.© 2014 Elsevier Ireland Ltd. All rights reserved.

Australia [2] about medical regulation programmes. How-ever the evolution of the policy has been controversial forover a decade, with its purpose and direction subject tomuch debate.

The interests of patients and ensuring that they receivethe best quality of care are espoused to be at the heart ofthe revalidation reform. This is indicated by the GMC:

Revalidation aims to give extra confidence to patientsthat their doctor is being regularly checked by theiremployer and the GMC. [3]

Benefits for patients

Over time we believe revalidation will improve the careyou receive from doctors, and will mean that you are

safer when you receive treatment from them. [4]

Given this, we were interested to examine if the focuson patients and improving patient care was central in

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the thinking of those who developed the revalidationreform. An evaluation of the development of the policywas undertaken and reported in 2012 [5]. This evalua-tion involved a textual analysis of relevant governmentreports, published institutional and professional responsesand academic peer-reviewed publications. In addition, theevaluation included interviews with leading policy makersinvolved in the process of developing revalidation. As partof the interviews these policy makers were asked to drawwhat revalidation meant to them; the drawings, which arethe focus of this article, provide an interesting perspectiveinto the development of this major reform.

From the interviews, policy makers claimed that thefocus of revalidation is on improving the patient expe-rience, patient safety and quality improvement of thedoctor–patient interaction. As one participant stated:

[revalidation] has to be about the best interests of thepatient. This is not just about ‘the doctor’ or any otherclinician for that matter in the other professions; it hasto be about, “What does this mean for patients?” It isabout the culture and the ethos of doing your best forthe patient but striving continuously to do better. . .thatdesire to improve outcomes for patients that, I think,has to be at the heart of it. (Member of NHS QualityImprovement Scotland in: [5])

The overarching narrative of revalidation and the pol-icy makers stated that the aim and underpinning premiseof revalidation is principally about improving health carefor patients. However in a formal analysis of the spokendiscourse, revalidation was shown to have two key driversthat can be broadly defined in terms of professionalism andregulation. The history of revalidation has been the workingout of these contrasting agendas over time.

1.1. What is revalidation?

Revalidation in the UK shares common goals with manyother developed countries in seeking to improve patientcare through the ongoing review of individual medicalpractice [6]. Revalidation is however a uniquely nationalsolution, informed both by the structure of healthcare pro-vision in the UK and the historical authority of the separatemedical institutions. Revalidation represents the first sig-nificant challenge to a system of medical self-regulationthat was established in the UK through the 1858 MedicalAct. It testifies to a lack of fit between a system of regula-tion focused on individual conduct and the modern practiceof medicine which is “dominated by complex structuralissues.” [7]

The development of revalidation as a regulatory systemhas been shaped by a number of key events [8] and pro-vides a useful discussion of the contingent factors that haveled to the erosion of a collegial system through new formsof managerial control. Waring et al. [9] identify three rea-sons for these regulatory shifts; firstly, the liberalisation

of the market and increasing pressures on public services;secondly, a loss of trust in medical expertise; and thirdly,examples of serious medical malpractice, followed by highprofile public inquiries.

y 114 (2014) 128– 138 129

The idea of developing a process for the ongoing reviewof doctors in the workplace was put on the agenda by theMerrison Committee in 1972 which recommended that:

“the GMC mount a study of the desirability of anannually issued practice certificate on the lines of thatrequired by solicitors. The chief point of such a schemewould lie in requiring doctors to make a declaration oftheir continued fitness to practise.” [10]

In May 1998 the GMC published a new edition ofGood Medical Practice, a statement of generic medical stan-dards which formed the foundation of quality assuredpractice and explicitly linked standards with registration.It is from this point that the debate began in earnestwithin the profession. A spate of high profile medicalmalpractice incidents, serious enough to prompt Govern-ment inquiries, placed regulation firmly on the politicalagenda. These incidents included poor clinical perfor-mance and accountability at the Bristol Royal Infirmary(1996–1998), negligent practice by gynaecologist RodneyLeadward (1996), and most significantly, the arrest oftrusted and popular GP, Harold Shipman (1999), for themurder of at least fifteen patients. Importantly, these casesnot only located poor individual practice but also a profes-sional culture that was perceived as lacking accountability.An already hyped media were quick to blame the ineffec-tiveness of the GMC as the regulator. However it shouldbe noted that the GMC plans to link revalidation to annualappraisal were criticised by the author of the ShipmanInquiry Fifth Report [11].

As a direct outcome of the Shipman Inquiry, Chief Med-ical Officer for England Sir Liam Donaldson undertook abroad review [12] of medical regulation that identified thethree key aims of revalidation: relicensing, recertificationand remediation, and set out a plan for its implementa-tion. In response, the GMC produced a series of consultationpapers under the general heading of Revalidation: The wayahead [13,14]. These papers set out a process of enhancedstandardised appraisal with colleague and patient feed-back, augmented by clinical governance data such as auditand significant event case reviews.

In early 2009 the GMC had set up the Revalidation Pro-gramme Board to give strategic leadership of the roll out ofrevalidation across the UK. The first pilots, across ten areasin England with 3000 doctors taking part, were announcedby the Secretary of State in January 2010. The purposeof the pilots was to test the components of revalidation.Even then central government delayed full implemen-tation for a further year over concerns of readinessuntil revalidation was formally launched on 3 December2012, a full ten years since the GMC was empowered tointroduce it through the Medical Act Amendment Order2002.

Commentators from both within the medical profession[15] and outside [5,7,16] all acknowledge that the pro-posed changes to medical regulation divided the professionand placed considerable strain on the historical relation-ship of trust between the Government and the profession.

The rhetoric of both the Government and the professionplaces the patient at the centre. In contrast, the debatesthat have informed revalidation’s history to date have been

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rofessional debates about policy, professional gover-ance, and leadership, with the patient largely absent.

In this paper we argue that the visual data collecteds indicative of the contradictions which existed in theevelopment of the revalidation reform. Although the pol-

cy documents and interviews clearly indicated the needor revalidation to be patient-centred, the visual data repre-ent revalidation in terms of abstract complex systems androcesses, largely devoid of the interpersonal. Visual data

s useful in its ability to reveal how people understand par-icular phenomena or conditions. As reported by Guilleminnd Westall [17] visual data can reveal what may otherwiseemain unsaid or silenced. In the case of revalidation, theisual data serves to augment the interview data. The fol-owing section outlines the project methodology, payingarticular attention to the visual methods used. The analy-is of the drawings is then presented and examined. Theignificance of this is examined, both conceptually withespect to the use of these methodologies, as well as itsignificance for the roll out of revalidation.

. Methods

.1. Sample

The study methods for the policy evaluation areescribed in detail in Archer et al. [5]. In summary, theample comprised key policy makers involved in the devel-pment of the revalidation policy. Forty-four leaders fromhe main UK stakeholder bodies were invited to take partn an interview. Of these, 31 (70%) agreed to participate.hese participants represented over 20 stakeholder groupshich included the General Medical Council, the Academy

f Medical Royal Colleges, the British Medical Association,HS Employers and the Departments of Health. To ensurerivacy and confidentiality, participants are only referredo by their stakeholder affiliation. Ethical approval for theroject was granted from the Peninsula College of Medicine

Dentistry human research ethics committee.

.2. Data collection

Participants took part in an individual interview with aember of the four person research team. The interviewsere semi-structured, and participants were asked about

heir understanding and experiences of the developmentf revalidation. Interviews took place in 2010–2011. Allnterviews were audio recorded and transcribed verbatim;nterviews were generally one hour’s duration.

At the beginning of each interview participants weresked to draw what revalidation meant to them. Partici-ants were provided with paper and coloured pens and

nvited to draw, and notably, to then describe their draw-ng. This method of data collection is consistent with that

escribed by Guillemin [18]. Of the 31 participants, all butve produced a visual image; 26 participants drew at leastne image, and 2 participants each drew 2 images. Thisroduced a total of 29 images which were analysed.

y 114 (2014) 128– 138

2.3. Data analysis

Thematic analysis was used to analyse the interviewdata [19,20]. The aim of this method of analysis is togenerate themes and provisional hypotheses that aresolidly grounded in the data. The data from the inter-view transcripts were organised into a system of codedpatterns and categories. From these coded patterns, pro-visional hypotheses were proposed. The hypotheses weresystematically checked across each of the transcriptsto ensure the validity of the hypotheses being gener-ated.

The visual data were analysed using the method ofinterpretive engagement [21]. This method of analysisbuilds on critical visual methodology as proposed byRose [22]. Interpretive engagement was developed forthe analysis of visual data that is generated by partici-pants in the process of undertaking research. It involvesthree interrelated stages of analysis, which pay particu-lar attention to the research participant, image, researcherand audience. In the first stage, the focus of analysisis on the individual participant’s image and the par-ticipant’s description and reflection on the image andcontext of its production. The second stage involves aclose and detailed comparative analysis of the completecollection of images from participants, as well as par-ticipants’ and researchers’ reflections of the image andprocess of image production. The final stage involves inter-pretation of the visual images through re-contextualisingthem into the broader context, and consideration of theaudience/s of the images. In this case, it involved repo-sitioning the interpretation of the images in the largercontext of revalidation. This method of visual analysis pro-vides a rigorous and systematic process leading to rich,credible, and detailed interpretations of the drawings pro-duced.

3. Results

The use of visual data is helpful in examining par-ticipants’ understandings of conditions or phenomena.Together with the interview data and policy documents,the drawings reveal the different forms of understandingof revalidation held by the policy makers involved in itsdevelopment. Analysis of the drawings and the partici-pants’ descriptions of their drawings revealed a number ofinteresting findings. The first key finding was the represen-tation of revalidation primarily as a complex and abstractsystem and inter-related processes. This leads to the sec-ond feature of the drawings in their distinct omission ofindividual patients and doctor–patient interactions; withthe exception of three drawings, patients were noticeablyabsent. The third characteristic was the distinctive lack ofcolour and imagery in the drawings. Of the 29 images, in25 drawings participants only used one colour, predomi-nantly black. Only two of the 29 images did not use words;the majority of the drawings strongly featured words or

phrases. As we go on to discuss, despite their differentmodality, the drawings worked to confirm the participantverbal interview data highlighting the lack of patient cen-tred discourse.

M. Guillemin et al. / Health Policy 114 (2014) 128– 138 131

Fig. 1. Drawing 1 by member of the National Clinical Assessment Service.

3.1. Revalidation: system and processes

The first point arising from the analysis of the drawingswas the prominent depiction of revalidation as abstract andsystem-based. In some ways this is not surprising consider-ing that a key aim of revalidation is to develop a systematicquality review and assurance programme. However, whatis interesting is the juxtaposition of this with the focuson patients and patient care underpinning the revalidationreform. It must be remembered that those who producedthese drawings were key players in the development of therevalidation policy and its emphasis on patient care.

Systems are often characterised by interrelated ele-ments, inputs and outputs and feedback mechanisms, oftenwith related subsystems. Depicting revalidation as a systemin this way was most apparent in the following drawings.

This participant, a member of the National ClinicalAssessment Service, produced two drawings (Figs. 1 and 2),the first showing a series of labelled arrows in red andblack, labelled from left to right as ‘revalidation’, ‘per-formance failure’, and ‘remediation’. The lines depictedprocesses within the operating system of revalidation. Thesecond drawing depicted a triangle with the three sideslabelled ‘education’, ‘reg’ (regulation), and ‘mgt’ (manage-ment), again in red and black, with connecting arrows. The

participant described their drawing in terms of schemaswith interconnections between what they perceived werethe key elements of revalidation, for example, ‘fitness to

Fig. 2. Drawing 2 by member of the National Clinical Assessment Service.

practice’, ‘appraisal’, ‘safety’ and ‘licensure’. What is inter-esting here is the level of abstraction, from both thespecificities of revalidation, and the people involved,namely patients and doctors. In many ways this drawingcould be a representation of many different systems withvery little specific reference to revalidation.

Fig. 3 is a drawing of a complex system showing thekey elements, from bottom-up, of doctors and patients inindividual organisations situated in an increasingly com-plex system and advancing science; influencing this wereincreasing community expectations, of “service at large”,government, as well as safety and quality standards. Thiswas positioned alongside the current system of medicaleducation and specialist training, regulated by the collegesand GMC. This drawing only used black, and like the previ-ous two figures, comprised interrelated abstract elementswith connecting arrows. In comparison to Figs. 1 and 2, thisdrawing addresses the specificities of revalidation, high-lighting the key players including government, doctors,patients, GMC, community and medical schools. However,the drawing more closely resembles a ‘mind map’, ratherthan a depiction of what this participant may consider tobe the heart of revalidation.

Another depiction of the system of revalidation wasillustrated in Fig. 4. In this drawing, there was a bank of

computer screens on the left with arrows pointing to thedoctor in the centre. This individual doctor was drawnas a saint, with a halo above their head. To the right of

132 M. Guillemin et al. / Health Policy 114 (2014) 128– 138

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Fig. 3. Drawing by membe

he doctor was a panel of people, labelled as the GMC.elow were the general public who the participant notedre supposed to benefit from the doctor’s “saintliness”. Thearticipant described this drawing as “the individual doc-or’s relationship with the regulator, the GMC, and this ishem proffering their evidence to show, to demonstrateheir saintliness, shall we say. This (revalidation) is a systemhat supports them in doing that” (Member of the Northern

reland Executive). This is a more focused system drawingompared to Figs. 1–3; there is concentrated attention onhe doctor and the GMC, with the general public depicted

Fig. 4. Drawing by member of the N

evalidation support team.

as a mass in the foreground with no apparent connectionto the system.

Integral to all systems are processes. Nineteen of the 29images either depicted processes and/or the term ‘process’was used to describe their images. The following figureswere typical of these drawings.

Fig. 5 is a linear process drawing depicting all doctorsbecoming up to date and fit to practise through the pro-

cess of revalidation. This drawing shows two boxes: one onthe left is labelled ‘all doctors’ and the one on the right islabelled ‘fit to practice; up to date’. What connects these

orthern Ireland Executive.

M. Guillemin et al. / Health Policy 114 (2014) 128– 138 133

he UK R

Fig. 5. Drawing by member of t

two boxes is the process of revalidation. Centrally pos-itioned in this drawing is a linear process of revalidation.Unlike some of the more complex system drawings, this isa simple linear process showing the work of revalidation intransforming all doctors to becoming up to date and fit topractise. This drawing reduces the complicated elementsand relationships of process of revalidation, as depicted inFig. 3, and focuses our attention on the potential transfor-mative role of the process of revalidation.

Fig. 6 shows a bell curve to demonstrate the process ofrevalidation, with the majority under the bell curve being‘middling doctors’. This participant described their drawingin terms of revalidation helping to improve doctors’ stan-dards of ability and competence, with one outcome beinga shift of the bell curve to the right towards ‘very gooddoctors’, and leading to ‘general improvement’. The sec-ond outcome of revalidation would identify ‘bad doctors’,the ‘worst 5–10%’. This drawing has similarities with Fig. 5,in showing the potential ability of the process of revalida-tion to shift bad doctors to middling doctors to very gooddoctors. The emphasis in Figs. 5 and 6 is on the work ofrevalidation in improving doctors; both depict this as linearprocesses, largely uncomplicated by other factors.

Notably, the revalidation as system and process cate-gory also included participants who chose not to drawimages but used words or phrases in their drawings empha-sising revalidation as process; this is illustrated by thisparticipant’s words: “Revalidation is a process which shouldenable a doctor to demonstrate their ongoing competen-cies in their field of practice (competencies and field maychange over time). It is a process which should enable thedoctor to demonstrate their professionalism. It will not nor

should it find the Shipmans” (italics added) (past memberof the Academy of Medical Royal Colleges).

In summary, all the drawings or statements in thiscategory represented revalidation as abstract systems and

evalidation Programme Board.

processes. Although some drawings were complex anddetailed, in all cases those producing images depicted whatthey perceived to be the key elements of revalidation andtheir inter-relationship. It is also interesting to note thecentral foci (or lack of) of these drawings. Four out of thesix of these drawings in this category fill the available spacewith no clear central focus, while in the remaining twodrawings, the central focal point is the doctor (Fig. 4) orthe process of revalidation itself (Fig. 5).

3.2. Revalidation: doctor–patient interactions

In analysing drawings it is equally important to examinewhat is absent as much as what is present in the drawings.In this case, a notable absence in most of the drawings isindividual patients, or doctors relating with patients. Of the29 images generated, only three depicted revalidation pri-marily in terms of individual doctor–patient interactions.Although these three depictions varied, what is clear fromboth the drawing and the participants’ descriptions wastheir highlighting of revalidation in terms of doctor–patientinteractions.

Fig. 7 shows a drawing of a smiling doctor on the leftwith a smiling woman and child on the right, with an equalssign between them. This participant, a member of the RoyalCollege of General Practitioners, described their drawing as“Happy doctor revalidating. . . Happy doctors equals happypeople, happy people equals happy doctors”. This draw-ing was also one of only two of the 29 drawings that didnot include written words. In addition, this drawer wasnoteworthy for including themself; the participant stated:“Happy doctor. Don’t have hair you see, because I don’t

have hair?”. There are a number of important points tonote in this image. Firstly, is the central positioning of therelationship between the doctor and patient, representedby the equal sign. Secondly, is the overt emphasis on the

134 M. Guillemin et al. / Health Policy 114 (2014) 128– 138

mber of

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Fig. 6. Drawing by me

ndividual doctor and patient; these figures are large andll most of the available space. The person producinghis image is sending a clear message to the audiencef the importance of the doctor–patient interaction inheir perception of revalidation. The third point is theersonal depiction of the drawer in this image; this signi-es a personal identification with revalidation and what iteans.

Fig. 8 displays a drawing of a medical register, with a

octor’s name and registration number, with a revalida-ion date of 12/1/2016. On the left of this was a hand with

finger pointing to the register, with the question “Is my

Fig. 7. Drawing by member of the Royal

the Shipman Inquiry.

doctor safe?” being posed. When asked by the interviewerwho the hand belonged to, the participant was noticeablyambiguous, indicating that it could be the GMC, the public,the media, employers, or a patient and a doctor. Althoughthis drawing is not as clear in its depiction as Fig. 7 itnonetheless emphasises the relationship between doctorsand patients. In asking the question “Is my doctor safe?”, thefocus is on the individual patient and their desire for assur-

ance about the safety and quality of their doctor. UnlikeFig. 7, any personal depiction of the producer of the image isabsent. The central focal point is a generic medical registerwith a list of doctors’ names and registration numbers.

College of General Practitioners.

M. Guillemin et al. / Health Policy 114 (2014) 128– 138 135

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Fig. 8. Drawing by member of t

In Fig. 9, there is a drawing of two stick figures that theparticipant identified as a doctor (with stethoscope on theright) and a patient. Attributed to the patient was a thoughtbubble, which stated: “Thinks: I know you know what youare doing today Doc, and are you really up to date”. Inthis image, the participant notably started by drawing thepatient, and affirmed that “this is what it boils down to.” Thedrawing itself is not prominently portrayed, in contrast toFig. 7, and is positioned in one corner of the page. An impor-tant analytic feature to note here is both the process ofproducing the drawing and the participant’s commentaryon their drawing. This participant commenced by drawingthe patient, suggesting this was a primary considerationfor them when thinking about revalidation. This is con-firmed by their accompanying statement: “this is what itboils down to.” The thought bubble is attributed to thepatient, further acknowledging the primary focus of thepatient for this participant. The interaction between doctorand patient is key in this drawing, with a notable absenceof other external elements of revalidation.

These three images, although considerably different intheir depictions, all emphasised the relationship betweenindividual doctors and patients, and were in sharp contrastto the revalidation as system and processes drawings. Inthese three images, there is a distinct absence of abstractor conceptual elements. The focus is on the personal andindividual, either for the doctor or the patient, and theinterpersonal, namely between doctor and patient.

3.3. Use of colour and words

When asked to draw, participants were given a selec-

tion of four coloured pens to use. It is interesting that of the29 drawings, 25 drawings only used one colour, predomi-nantly black. Participants made little effort to utilise colourin a creative or personalised manner in their drawing; the

onal Health Service Employers.

use of black appeared primarily functional. Of additionalsignificance in the drawings was the use of words ratherthan imagery; only two of the 29 drawings did not includewords (Figs. 4 and 7). The use of words in the drawings var-ied; they ranged from sentences, single words, to labelledsystem diagrams or concept maps. The two drawings thatdepicted images and did not include any words were there-fore notable in their difference. This affirms the overridingdepiction of revalidation as depersonalised and abstracted.

4. Discussion

In this article we have shown that paying seriousattention to visual data offers a rich understanding of reval-idation, in this case from the perspective of key policymakers involved in its development. We argue that theanalysis of the visual data demonstrates the contradictionswhich existed in the development of the revalidation policy.Although policy documents frame revalidation as patient-centred with an emphasis on improving doctor–patientinteractions, this focus is largely absent from the visualdata. Rather, revalidation is primarily represented in anabstract form as systems and processes. In this section wediscuss the relevance of this, as well as highlighting thebenefits and limitations of using visual data, both generallyand in this specific study.

Revalidation in the UK is the most significant revision ofmedical regulation since 1858, with international interestin the reform being expressed. Its introduction was pre-ceded by over a decade of robust discussion and debate,often riddled with controversy. Analysis of the key dis-courses in the development of revalidation identified twomain themes: regulation and professionalism [5]. The first

of these, regulation, seeks to identify incompetent doctors,the second, professionalism, aspires towards a professionaldevelopment model to improve the competence of all doc-tors. These two discourses could be seen as divergent and

136 M. Guillemin et al. / Health Policy 114 (2014) 128– 138

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Fig. 9. Drawing by a past mem

ontradictory and has been a source of debate over theistory of the development of revalidation. However, athe centre of the debate has been ‘the patient’ used as aiscursive device or glue which has acted to maintain anccord between the other two discourses. This focus is onndividual patients (rather than the collective public) andheir local relationships with their doctors; this is about thenterpersonal rather than the abstract. But to cite earlier

ork [5]:

The co-existence (of the discourses of regulation andprofessionalism) has been supported by a shared dis-course around the patient yet we found little patientcentred policy. It has been hard to demonstratethat revalidation in its proposed form originates frompatients, has been shaped by patients or is explicitlycentred directly on patient care. p. 51

The drawings produced by those involved in develop-ng the revalidation policy act to triangulate the findingsrom the interview data of the distinct absence (with threexceptions) of individual patients and doctors. We foundhat the dissonance between the discourses of policy was

irrored in the drawings of our participants. We postu-ate that the same ‘distancing’ when using patients as ahetorical strategy is played out in the drawings. By draw-ng systems and processes rather than patients or the act ofatient care, the participants represented a rather deper-onalised approach to policy creation [23].

What does this mean for the future of revalidation andndeed medical regulation more broadly? Contributing tohis particular health policy reform was a sense of erod-ng trust between doctors, the medical profession andociety. Reports from inquiries of significant and serious

edical malpractice, most notably the cases of Harold

hipman [11], Kerr and Haslam [24], and Richard Neale25], fuelled a perceived erosion of trust in the medi-al profession. Although this was not the only driver for

the General Medical Council.

revalidation, rebuilding trust in doctors and providing reas-surance of medical competence is fundamental. Rebuildingtrust requires a focus on the interpersonal, in this caseindividual doctors and patients. For it to be successful,revalidation needs to be patient-centred, with patientsbeing present and active, rather than absent or deperson-alised entities. A systems approach to such a major policyreform is, at least initially, vital for its successful implemen-tation as revalidation is a complex system with interrelatedpractices and processes. We do not dispute this and so itis not surprising that the drawings of the revalidation pol-icy makers highlighted these processes. However, it is thenoticeable absence of individual patients and their doctorsthat is the point here. If the system is predicated on assur-ing good patient care then the individual interactions ofdoctors and patients must be at the centre of the system ofdata collection, analysis, synopsis and reflection. It is onlyin this way that standards can be assured and ultimatelybetter care be supported.

Drawings, and visual research more broadly, has gainedincreasing recognition as a valid and informative researchmethod, particularly over the last two decades [22,26–28].The benefits of using visual data, and specifically draw-ings, are that it provides an avenue of expression forresearch participants through means that are not word-based. This is particularly advantageous in situations wherethere are communication difficulties, or vulnerable partic-ipants involved in sensitive research dealing with painfuland difficult experiences. In this situation drawings andvisual research methods provide a powerful and informa-tive means of communicating what would otherwise beunsayable [17]. The revalidation study participants werenot obviously vulnerable, and indeed many held pos-

itions of considerable power and authority. However, therequest to draw may have worked to disrupt the normsof engagement. The use of visual research methods offersparticipants the opportunity for reflection using an open

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and creative mode of expression. For researchers this offerspotential to generate other ways of understanding, ratherthan be limited to expected knowledge claims. However,it is important to note that visual data does not purport toreveal some kind of true knowledge or understanding, nordoes it aim to necessarily confirm or validate understand-ing gathered through other methods, such as interviews.Rather its objective is to generate potential new meaningsand interpretations from the images themselves. In visualresearch (and indeed qualitative research more broadly)the aim is not to produce one ‘true’ definitive interpreta-tion but to seek multiple interpretations that may changeover time (or remain relatively stable).

The use of drawings in this study has demonstratedoverwhelmingly participants’ representation of revalida-tion as a depersonalised complex, abstracted system andprocesses. Although this is both consistent with the inter-view data and may be somewhat unsurprising, what ithighlights is the possible ways that revalidation could beunderstood and indeed is represented by three participants– as personalised and focused on interactions betweenpatients and doctors. One of the major benefits of visualresearch methods is the requirement for participants tocrystallise their thoughts and understandings in visualform, giving us access to both the product of their visualrepresentation and their reflections on its process of pro-duction. Paying attention to both the drawing itself andobservation of participants’ process of production offersdifferent forms of data for meaning-making. Using this cre-ative form offers potential to both disrupt and open upknowledge claims.

Although using visual research methods in this studyoffered considerable benefits, it also presented limitations.The first of these are the relatively small number of par-ticipants. However, it is noteworthy that they representedover 20 key stakeholder groups including the General Med-ical Council, the Academy of Medical Royal Colleges, theBritish Medical Association, National Health Service (NHS)Employers and the Departments of Health; all were seniorleading figures in revalidation at the time of the study andin revalidation’s history. The second point is the lack ofcolour and imagery portrayed in the drawings. One expla-nation of this is who the participants were. Most of theparticipants were doctors, while others included bureau-crats and lawyers; all were very senior and experiencedprofessionals involved in leading a major policy reform. Itis possible that they were more accustomed with linearor concept map representations in relation to their exper-tise and experience, rather than creative imagery. This mayhave influenced their tendency to use words rather thanimages, and focus on systems and abstract representations.Another explanation for the lack of colour and imagery isa methodological one. Only four coloured pens were pro-vided which may have proved a limitation. Furthermore,the interviews were carried out by four different interview-ers with different levels of experience in using drawings asa research method. This lack of familiarity may have influ-

enced the way that participants were asked to draw and theinstructions they were given. These different levels of expe-rience on the part of the interviewers may also have shapedthe power relations between participants and researchers

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which could have affected the drawings produced. Despitethese limitations, we argue that the findings from the visualdata are convincing and work to confirm the lack of patientdiscourse from the interview data.

This study has examined the perceptions of key pro-ponents in the development of revalidation, in termsof interview and visual data. In this paper we offer anovel and valuable research method with which to under-stand policy-in-formation. The use of drawings, and visualresearch methods more broadly, provides a beneficialadjunct to other more traditional research methods suchas interviews. This method offers the potential to gen-erate different kinds of knowledge that can inform thestudy of health policy from the perspective of those activelyinvolved in its formation. This study has provided a histor-ical insight of revalidation in its development; in this way itis retrospective. Revalidation has now commenced. It willbe important to follow the implementation of this policyreform and revisit the policy makers and those chargedwith its implementation, using visual research methodsas a beneficial tool to examine how understandings aboutrevalidation evolve. In particular it will be interesting toexamine the role of ‘the patient’ as a discursive device inthe ensuing roll out of revalidation.

Acknowledgements

We are grateful to all the participants for their time andassistance. In addition, we want to acknowledge the helpfulcomments of the anonymous reviewers of this article. Thisproject was funded by the Health Foundation, an indepen-dent charity working to continuously improve the qualityof healthcare in the UK. The views expressed in this reportare those of the participants and the authors and do notreflect those of the Health Foundation.

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