Appraisals are not intended to 'police' bad doctors, but to help keep standards in
the profession high, writes
Dr Jim Sherifi
The principles behind GP appraisal lie not
so much in the need to police doctors following the Shipman affair but more in the GMC's pamphlets Duties of a Doctor and
Good Medical Practice (2001)1. The former
provides a broad job description, the latter unambiguously and objectively defines what does and does not constitute acceptable medical practice, under seven broad headings.
1. Good clinical care
• Clinical care
• Keeping records, writing reports and keeping colleagues informed
• Access, availability and providing care out-of-hours
• Treatment in emergencies
• Making effective use of resources
2. Maintaining good medical practice
• Keeping up to date and maintaining
3. Relationship with patients
• Providing medical services information
• Maintaining trust
• Avoiding discrimination and prejudice against patients
• Handling events when they go wrong
4. Working with colleagues
• Working with colleagues and in teams
• Referring patients
• Accepting posts
5. Teaching and training
• Teaching, training, appraisal and assessment
• Financial and commercial dealings
• Providing references
7. Health and the performance of other doctors
• Protecting patients when their own health or the health, conduct or performance of other doctors puts patients at risk.
Although there is no universal appraisal form that has been adapted across all PCTs, most have produced templates based on the above. These headings provide a structure on which the individual GPs can reflect and provide comment and documentary evidence in support of their performance.
The Department of Health agreed in principal with the GPC to facilitate the appraisal process by:
• prescribing that appraisals should be done once a year;
• setting by ring- fenced and funded time; the equivalent of three sessions for the appraisee, two for the appraiser for the appraisal to be adequately performed;
• allocating a budget to PCTs for the exclusive use of appraisals;
• entrusting PCTs with the administration of the process, including the appointment of fully trained appraisers.
The ethos of appraisal was that it should be an annual opportunity for doctors to meet their peers in order to reflect, in a formative manner, on their year's working practice. Anecdotal reviews have suggested that most have found this a positive experience with unexpected benefits including the chance to speak confidentially about concerns and perhaps to build a mentoring relationship. It offered individuals an outlet and dialogue away from the sometimes claustrophobic relationships in a practice.
To gain the most from the experience of appraisals, doctors need to understand and embrace the reasoning behind the process. It was never intended to act as a policing or punitive measure. Indeed the appraisal document2 says: 'Appraisal should not be completed on doctors where there is concern.'
There is some provision for appraisers, in agreement with the appraisee, to report concerns to the PCT.
Once the appraisal is complete, the only documents that have to be returned to the PCT are those confirming the appraisal took place and perhaps an abbreviated personal development plan detailing areas where the individual may wish to undertake some improvements in the following year.
Filling in the forms should not be left to the last minute. The standards set should be kept in mind during daily practice and examples of excellence or disappointment recorded on a daily, weekly or monthly basis. Never be afraid of noting down perceived 'failures'. More often than not it will be useful or rewarding to share those experiences with the appraiser, who invariably has experienced similar setbacks. The appraisal is an excellent forum for exchanging bad as well as good clinical practice.
In due course, appraisals will contribute to revalidation – which may also include:
• prescribing data (PACT)
• records of patient complaints
• patient satisfaction questionnaire
• clinical audits
• significant event audits
• personal development plan and a record of educational meetings3.
Such records are easy to keep or obtain with minimal extra effort. A useful tip is to have a concertina file labelled with the 18 headings suggested in Good Medical Practice into which relevant documentation can be dropped as and when it comes to hand.
What is the future of appraisals? Surprisingly, within three years of its acceptance, the process seems to be under threat from two fronts. On the one hand, as PCTs not only seek to assert their independence from the Department of Health but also try to grapple with budget deficits, funding is being withheld, and appraisals are being temporarily suspended. On the other hand, delays in the introduction of revalidation for doctors in general practice, of which appraisal was to be one of the central planks, has led to some questioning the policing relevance of appraisals. However neither of these concerns should detract from the use of the appraisal template as a thought-provoking benchmark against which doctors should be continuously comparing their performance. After all, none of us is too good to improve!
Dr Jim Sherifi is a GP in Sudbury, Suffolk
1 GMC Good Medical Practice 2001 edition
2 Para 99 GMC Developing medical regulation April 2005
3 Para 132 GMC Developing medical regulation April 2005