3. GP Appraisals

GP Appraisals

This PatientPlus article is written for healthcare professionals so the language may be more technical than the condition leaflets. You may find the abbreviations list helpful.

The concept of appraisals, their value and purpose has been around for a long time within organisations and businesses. Appraisal by one's peers and clinical mentors began as part of educational supervision and employer career monitoring. However, it will in an amended form be part of a reaccreditation (or recertification) and revalidation process.

Revalidation is a process by which doctors will demonstrate at regular five-yearly intervals that they are up-to-date and fit to practise. It should involve reflection and, to be effective, should relate to a doctor's performance.

The issue of revalidation has assumed great prominence in recent years since the conviction of Dr Harold Shipman and the subsequent inquiry. This sparked major concerns about patient safety, the regulation of doctors and public confidence in the regulatory processes.

In the NHS Plan of June 2001, annual appraisal was confirmed as a contractual obligation. The 'obligation' relates to the concept of clinical governance, the maintaining of standards of care and public confidence in the delivery of healthcare. It concerns not just GPs but also other doctors, including consultants and career grade doctors.

Primary care groups and primary care trusts (PCTs) began introducing the scheme in April 2002. From 1st April 2013 the responsibility was taken over by NHS England in England.[1] Locally, the process is organised and monitored by Responsible Officers (ROs) - these are individuals who are given the responsibility to liaise between NHS bodies and the General Medical Council (GMC) on revalidation and appraisal issues on behalf of Clinical Commissioning Groups (CCGs). The process of appraisals for GPs can be embraced as an opportunity for personal and professional growth and development.

See separate article Revalidation - Current State of Play, which explains more about the context of appraisals within revalidation and reaccreditation.

This article is written from the perspective of the English appraisal system. It is recognised that there is some variation between the various UK countries. For more details of the process in the other countries, please see the 'Further reading & references' section.

There a number of definitions of appraisal:

  • Appraisal is a process of facilitated self-review supported by information gathered from the full scope of a doctor's work.[2] 
  • The Department of Health defines appraisal as follows: 'Appraisal for GPs is a professional process of constructive dialogue, in which the doctor being appraised has a formal structured opportunity to reflect on his or her work and to consider how his or her effectiveness might be improved.'[3] 
  • According to the Advisory, Conciliation and Arbitration Service: appraisals 'regularly record an assessment of an employee's performance, potential and development needs. The appraisal is an opportunity to take an overall view of work content, loads and volume, to look back on what has been achieved during the reporting period and agree objectives for the next.'

NHS England identifies the following aims of appraisal:[1] 

  • To enable doctors to discuss their practice and performance with their appraiser in order to demonstrate that they continue to meet the principles and values set out in the GMC document Good Medical Practice and thus to inform the RO's revalidation recommendation to the GMC.
  • To enable doctors to enhance the quality of their professional work by planning their professional development.
  • To enable doctors to consider their own needs in planning their professional development.
  • To enable doctors to ensure that they are working productively and in line with the priorities and requirements of the organisation in which they practise.

It is also worth considering that appraisal should not be:

  • 'Just a paper exercise with forms to fill in.' Appraisal requires appropriate time, resources and support. If these are not available then it is likely to be ineffective.
  • Synonymous with assessment. The latter can be defined as 'measurement of an individual's performance at a particular point in time, usually against predetermined standards'.[4] 

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The GMC requires six types of supporting information that a doctor will be expected to gather. Although not all of this information will need to be presented at each appraisal it is expected that evidence relating to all the areas will be covered at least once over the course of each five-year cycle:[5] 

  • Continuing professional development
  • Quality improvement activity
  • Significant events
  • Feedback from colleagues
  • Feedback from patients
  • Review of complaints and compliments

Obtaining supporting information in these areas will be sufficient to cover the four domains of the Good Medical Practice Framework for Appraisal and Revalidation:

  • Knowledge, skills and performance
  • Safety and quality
  • Communication, partnership and teamwork
  • Maintaining trust
  • The right setting - senior management commitment to develop a good and effective appraisal system for all staff; engaging all involved - eg, study days.
  • Training of appraisers and appraisees - having experienced being an appraisee before being an appraiser helps.
  • Preparation - arrange well in advance; adequate time for meeting; no interruptions and in a private secluded area.
  • The meeting belongs to the appraisee - they should be committed and attend with well-prepared thoughts.
  • Confidentiality.
  • Outcomes - a summary of the meeting in the form of action points should be set which forms the basis of the personal development plan (PDP); each outcome should be 'SMART' (see below)

SMART outcomes[6] 

SMART outcomes or objectives
S - specific
 Relate to specific tasks and activities, not general statements
M - measurable
 Should be possible to assess whether or not they have been achieved
A - attainable
 Should be possible for the doctor to achieve the desired outcome
R - realistic
 Within the doctor's capability
T - timed
 The next appraisal date, or earlier, should be agreed as the time for reviewing the achievement

The old appraisal toolkit has been changed to reflect its new relationship with the revalidation process. Forms 1-4 have been replaced by three stages:

  1. Inputs to appraisal
  2. Confidential appraisal discussion
  3. Outputs to appraisal
Appraisal documentation
Inputs Purpose

Personal details

 Contact details, date of appraisal, designated body.

Scope and nature of work

 Should include all roles and positions in which the doctor has clinical responsibilities and any other roles for which a licence to practise is required, including work for voluntary organisations, private or independent practice. managerial, educational, research and academic roles.

Supporting information

 This should be structured according to the four domains of Good Medical Practice (see above). Six types of supporting information have been identified by the GMC as described above.

Review of last year's PDP

 A commentary on last year's PDP and any issues arising from last year's appraisals is appropriate here.
Outputs  

PDP

 This will be completed on the day and will identify a new list of personal objectives, with agreed timescales and ways of recognising that goals have been achieved.

Summary of the appraisal discussion

 The written summary should include an overview of the supporting information and any accompanying comments from the doctor, the extent to which this relates to the scope and nature of the doctor's work and key elements of the appraisal discussion itself. The summary should be structured according to the four domains of Good Medical Practice.
Appraiser's statements

The appraiser makes a series of statements to the RO that will, in turn, inform the RO's revalidation recommendation to the GMC. The appraiser should discuss these with the doctor.

The appraiser's statements should confirm that:

  1. An appraisal has taken place that reflects the whole of a doctor's scope of work and addresses the principles and values set out in Good Medical Practice.
  2. Appropriate supporting information has been presented in accordance with the Good Medical Practice Framework for Appraisal and Revalidation and this reflects the nature and scope of the doctor's work.
  3. A review that demonstrates appropriate progress against last year's PDP has taken place.
  4. An agreement has been reached with the doctor about a new PDP and any associated actions for the coming year.
  5. No information has been presented or discussed in the appraisal that raises a concern about the doctor's fitness to practise.

If the appraiser and the doctor cannot achieve an agreement on any statement, the discussion should be recorded in the appraisal documentation to enable the RO to understand the area(s) of contention. Disagreement does not necessarily mean that revalidation will not occur.

Several appraisal toolkits are available online to assist in the completion of the appraisal documentation, all of which are based on the Medical Appraisal Guide model form produced by the NHS Revalidation Support Team.[7] CCGs, deaneries and employers may be able to advise doctors on the most appropriate for their locality and specialty.[8][9][10] 

Senior doctors who are on the medical register should carry out appraisals. For general practice this applies to GPs who have worked for three years as a non-principal or principal.[11] However, it helps if they are motivated and they should undergo training beforehand. Newly appointed appraisers should be supported for their first three appraisals and it is anticipated they participate in between 3-20 appraisals per annum. Appraisees can request a different appraiser if they wish - this is important, as that person should be someone they trust and respect. Appraisal work should be balanced out within a practice if this is possible.

  • The appraisal system needs to be regularly evaluated and quality assured.
  • A self-assessment audit is available for organisations.[12] 
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Further reading & references

  1. NHS England; NHS CB Medical Appraisal Policy (draft document awaiting final approval), 2013.
  2. Appraisals; BMA
  3. A Guide to GP Appraisal; NHS Appraisal Toolkit
  4. Appraisal: a guide for medical practitioners; BMA, 2003
  5. Ready for Revalidation, Supporting information for appraisal and revalidation; General Medical Council, 2012
  6. Smith D et al; Appraisal and Revalidation – Your Questions Answered, London Deanery, 2013
  7. NHS Revalidation Support Team; Medical Appraisal Guide, 2013.
  8. Appraisal Toolkit; Clarity Informatics, 2013
  9. Appraisal Toolkit; GP Tools, 2013
  10. Appraisal Toolkit; Severn School of Primary Care, 2013
  11. ABC of GP appraisal; National Association of Primary Care Educators
  12. Quality Assurance of Medical Appraisers - Recruitment, training, support and review of medical appraisers in England; Revalidation Support Team, NHS UK, 2013
Original Author: Dr Gurvinder Rull Current Version: Peer Reviewer: Prof Cathy Jackson
Last Checked: 07/05/2013 Document ID: 2207  Version: 23 © EMIS

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.

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