As cash-strapped PCTs see cuts in appraisal funding as a soft option and the CMO questions its role, doubts are emerging about the future of the system
What does the future hold for GP appraisal?
Ever since annual appraisals for GPs were introduced in 2002, there has been an element of confusion about their role.
They were conceived as a mechanism for supporting the learning and development of GPs. Then the GMC hijacked them for revalidation, proposing that appraisal folders could be used as evidence for that process.
GPs, who were worried that appraisal would become a pass/ fail exercise, rather than being purely developmental, strenuously resisted the move.
But the GMC's plans were then made immaterial by the Shipman Inquiry's criticisms of the link between appraisal and revalidation and the Chief Medical Officer's subsequent report, Good Doctors, Safer Patients.
To add to the confusion some cash-strapped PCTs have this year seen funding for appraisals as a soft target.
Gloucestershire and Harrow PCTs have withdrawn funding for appraisers. South West Kent and Maidstone and Ealing PCTs are refusing to compensate locums for the time they need to prepare for and attend appraisals.
All this has led to doubts about the future for appraisal. Will GPs end up having to pay for it? And is it worth doing in the first place?
Steve Mercer, chief executive of Avon LMCs, says the situation in his area is confused. Four PCTs had announced that appraisals were stopping but they are all are now denying this.
'We are hearing stories that appraisals have been extended to 18 months, and there is a moratorium for a few months while that period goes through,' he says. 'Others are saying we are doing them but it has slowed up, so we are only to be doing a limited number.'
The Department of Health sent a strongly worded letter to all strategic health authority primary care leads in England last month reminding them of their contractual duty to provide a funded system of appraisal. But the PCTs which have stopped funding have yet to reverse their decision.
Dr Laurence Buckman, GPC deputy chair, says these PCTs are breaching a direct ministerial order and 'should be very careful'.
Dr Richard Fieldhouse, chief executive of the National Association of Sessional GPs, advises that GPs should not fund their own appraisals, so should withdraw from the scheme until their PCT does so.
But he adds that some locums are concerned they will not get any work if they are not appraised.
GPs are supposed to have to completed an appraisal to remain on the performers' lists. But if their PCT is not funding it, this requirement is in question.
Dr Fieldhouse says: 'Our suggestion to those who are really concerned and don't mind not getting paid is to, over the next 12 months, increase your rates by a percentage that will give you effectively £300-400 extra.'
As for what happens to the appraisal process in the future, Sir Liam Donaldson's report says it has to be standardised and quality assured and to include an element of 360-degree feedback.
'Appraisal is a sound process,' he says. 'But, as presently designed, it cannot serve the multiple purposes of detecting unsafe practice, quality assuring good practice, ensuring compliance with contractual duties, improving practice and facilitating continuing professional development.'
Amanda Watson, GMC head of registration and education, says a more robust standardised system would be beneficial to GPs. She says: 'If you are working in an organisation that is not giving you a good and robust appraisal then when it comes to revalidation you are not going to be able to be revalidated by that route, which is going to mean probably much closer scrutiny of you by the GMC.'
GPs certainly want appraisal to stay, but do not believe it can or should be used to identify doctors who may put patients at risk.
Dr Brian McKinstry, senior research fellow in general practice at the University of Edinburgh, who has researched GPs' views of appraisals, predicts that recertification and appraisal will become two separate processes in light of the CMO's report.
He says: 'If the purpose of appraisal is educational or personal development to help you identify the areas you need to spent time on, paying for it might be reasonable.
'If the system is designed to identify doctors with particular problems and intervene in the interests of patient safety that is not something GPs should be paying for. The problem is at the moment is that it isn't clear what appraisal is for.'
• Appraisals: a benefit not a threat, page 32
What the CMO says on appraisal
'Appraisal, as currently designed, does not set out to identify
poor practice or judge how
good a doctor the appraisee actually is.'
'For a process of revalidation to
be effective it must be built upon more than the current system
of NHS annual appraisal.'
The process of NHS appraisal should be standardised and regularly audited, and should in the future make explicit judgments about performance against the generic standards,
as contained within the doctor's contract.
The relicensing process should be based on the revised system of NHS appraisal and any concerns known to the General Medical Council affiliate.
An independent organisation should be commissioned to design and administer the 360-degree feedback exercise required for appraisal and licence renewal.