How appraisal can work for non-principals
Dr Rebecca Viney explains how to make the most of this new opportunity set to start in a few weeks
The Department of Health clearly states in its guidance that appraisal is 'a formative and developmental process it is about identifying developmental needs, not performance management'. In April of this year, the GMC issued guidance on the licensing and revalidation of doctors. It confirmed that one of the routes to revalidation is to be able to show you have worked in a managed environment (a PCT) and have participated in a robust annual appraisal.
Appraisal acceptable to the GMC must be based on the principles of Good Medical Practice and must be operated within a quality assurance system. I suggest the appraisal route to revalidation will be
the most practicable and convenient option for you.
A couple of years ago at a GMC revalidation meeting I said I felt 'there was not enough flour to bake the cake' for GP non-principals, as they were outside mainstream education, audit and the information loop from PCTs. I now
believe appraisal and revalidation could be one of the most significant advances in continuing professional development for all GPs. For the first time our everyday activity and experience of practice can be recognised and valued. Also for the first time GP non-principals should have the same opportunities as their principal colleagues with access to resources to enrich and improve their careers.
However, there are still barriers that hinder the development of appraisal. The single most important hurdle that remains is the lack of inclusion of GP non-principals in the information cascade via the supplementary list.
An appraisal system needs to be put in place that is supported, meaningful and relevant, in order to be of a high enough standard to benefit both the GP, offering a high-quality best practice service to patients, and to satisfy revalidation standards.
How is the process to be implemented?
In order to aid an informed debate, the Department of Health commissioned the School of Health and Related Research of the University of Sheffield to provide a report on extending appraisal to all GPs to include GP non-principals and to explore what possible models could be used to facilitate the process of appraisal for non-principals.
This was recently published on the National Association of Non-Principals website (www.nanp.org.uk/cpd/appraisal).
We are now awaiting directions on how best to make appraisal work for all non-principals.
We expect their directives and possibly some toolkits to be published in the next few weeks and all non-principal appraisals will start soon afterwards.
Why do GP non-principals need to be considered differently from principals?
For GP non-principals working regularly in one practice it is possible for the appraisal process to be similar to the process for principals see the existing model (www.doh.gov.uk/gpappraisal).
However, some GP non-principals, such as locums or out-of-hours GPs, may require assistance, suggestions and examples on how to provide evidence of their Good Medical Practice that fits their method of working, rather than a different kind of appraisal.
What are the specific issues for non-principals?
· Requirement for a framework or toolkit giving examples of appraisal best practice.
· Adjustment of the appraisal forms, where relevant, to meet the needs for GP non-principal appraisal.
· Information that teases out the relationship between appraisal, performance management and revalidation.
· Ensuring there are mechanisms in place to address the educational and information needs identified at the appraisal.
· Confidence in the knowledge that the appraiser is properly trained and has an appreciation and understanding of the work of non-principals and of the barriers that they may face.
· Equality of opportunity for non-principals to be trained and appointed as appraisers.
· Understanding that the appraisal is not in house and is not confused with any annual appraisal that may be undertaken as part of the terms and condition of employment.
· Understanding that if you work in more than one PCT, clarification is needed on which PCT is responsible for the appraisal and ultimately, therefore, for assisting in meeting identified learning needs.
· Clarification of what should happen to the appraisal 'timetable' if you are on sick or maternity leave.
· The setting up of local frameworks that will help reduce the isolation of GP non-principals and include them in mainstream education and the information cascade from PCTs.
· Confidence that appraisal is to be no more or less exacting than for principals.
· Knowing that the aim of appraisal continues to be reflective and developmental and is not used as a device to prove fitness to practise.
· Knowing that the appraisal system will be thoroughly evaluated right from the start.
What can I do now to help my appraisal?
· Remember it will be formative and developmental, it is there to help you and the first one will be less exacting than in the future as appraisers and appraised find their feet.
· If you are offered the opportunity to train as an appraiser, take it.
· Use the resources and publications available.
· Start to assemble a folder that records experiences. A good PDP will have tools to collect the following information.
1 Meetings attended, and how they have changed your practice.
2 PUNs and DENs (see personal learning plans).
3 How research reading changed your practice.
4 Significant events and how they changed your practice.
5 An audit or a process of improvement.
How can a locum do audit?
Traditionally audit involves a standard of care being set and data being collected to assess how a doctor performs against this standard. Then changes are made to reach the standard of care set and their outcome is assessed by a repeat data collection. For example:
· Set a standard for best practice for your doctor's bag, drugs, headed paper, equipment, referral information, patient notes; assess your bag; review the contents; repeat the assessment assessment of your bag contents for best practice.
· Keep a log of all referrals over a set period of time; review and reflect on outcomes six months later (paper-frugal practice is probably required) to define your learning needs.
· Set a standard for emergency care; do you have penicillin, aspirin and adrenaline? Know where the panic button in your surgery is, know where the oxygen and resuscitation equipment are kept. When were you last trained in resuscitation?
More guidance is available from: Gibbons AJ, Dhariwal DK. Audit for doctors: how to do it. BMJ 2003;327:1-2.
How can I demonstrate patient feedback?
Complaints and thank-you letters are good evidence but patient questionnaires can prove you are an exemplary GP. For example, GPAQ is a patient questionnaire developed at the National Primary Care Research and Development Centre. More details can be found in Making a Start with Appraisal, a guide for GP non-principals on the NANP website or by visiting the GPAQ site www.gpaq.info/index.htm.
What should I say about my health?
There is a question about your health on the appraisal form. You should make a statement to the effect: 'At this moment in time I am fit to practise medicine during the time I am at work and my health does not interfere adversely with my relationship with my patients'.
This allows for intermittent illnesses and part-time working due to ill-health. If you are fit to work, you can sign the statement whatever your medical problems. Currently there are no other ways of assessing doctors' health, although I am sure one day we will all have access to a proper occupational health service.
The way forward
Remember, there is no evidence on the best way to undertake GP appraisal so a plurality of approach needs to be taken. Appraisal should be done in protected time and entail a confidential, one-to-one, supportive, constructive dialogue with a trusted GP colleague.
The outcome should be that the appraiser and appraised agree a written overview of appraisal that should include essentials of the PDP. The appraisal will include a synopsis of previous years' achievements and identify the individual's needs that will be addressed through the PDP. Good luck!
How fitness to practise medicine will be judged
· Good clinical care
· Maintaining Good Medical Practice (including personal development plans and continuing professional development)
· Teaching and training, appraising and assessing
· Relationships with colleagues
· Working with colleagues
· Probity (integrity and past criminal convictions)
Useful information sources
For Making a Start with Appraisal a guide for GP non-principals. NELG
Official NHS appraisal website which has many toolkits and new forms that have been made more appropriate for non-principals