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How will appraisals change after revalidation?

How will revalidation affect the existing appraisals process?

According to the GMC, to get a revalidation recommendation from a responsible officer GPs must have completed at least one appraisal with a responsible officer from their designated body. Guidelines for this appraisal may be more strict than the usual. During this appraisal the doctor must demonstrate that they have collected and reflected on the following in the last five years:

 – Continuing professional development. GPs undergoing revalidation will be required to gain a minimum of 50 CPD credits a year or 250 CPD credits over each five-year revalidation cycle.

– Quality improvement activity. Thus could be a clinical audit, review of clinical outcomes , case review, an audit of a teaching programme or evaluation of health policy or management practice.

– Significant events. Your appraiser will discuss how you logged the incident, what you learned from it and how you changed your practice to prevent similar events in future.

– Feedback from colleagues and patients based on GMC questionnaires.

– A review of complaints and compliments.

Once your appraiser/responsible officer recommends you to be revalidated, the GMC will confirm whether or not they accept the recommendation. You will need to go through revalidation again in another five years, but you should continue to have appraisals every year.

What can I be asked during an appraisal?

There is quite a lot of variation across England but one of the main things a GP will be asked is to provide evidence they’re keeping themselves up to date with educational and reflective work (CPD). GPs need to show they’ve done CPD, and that it’s been modules appropriate to their current role, including reflections on practice.

I’d recommend GPs do a range of CPD. There’s a tendency to work on what you are interested in, and I’m no different but your appraiser should point out areas for you to focus on that are outside your current expertise – without forcing you down certain training paths.

How long should I prepare for an appraisal?

I’d recommend that GPs prepare through the year – on-going preparation will save time. But this is a classic case of do as I say not as I do – so, really, at least three months.

What is off-limits?

Technically, nothing is off-limits during an appraisal. One of the problems in England is that GPs have no agreed process for appraisal that’s consistent across the country. My personal view is that it’d be nice to have guiding principles on paper, and then go from that over time. It’s an evolving process and using some of the models DH has, they’re introduced but introduced once we have evidence that’s been discussed agreed and rolled out in a proper way. That’s better than an appraiser or responsible officer deciding that something must be in an appraisal when there’s no great evidence it should be or that the request is even reasonable.

Making things mandatory when there’s no evidence to do so, for example having child protection or minor surgery training every year is not compulsory. GPs are professionals with a responsibility to make sure they’re up to date in both of those areas, and they will need to refresh their expertise on both issues, but not every year.

Some appraisers – and it’s not individuals but organisations such as the PCT – say that, instead of having to do something once every five years, you do everything every year, for instance running an audit on a particular patient group.  Demands like these are out of line and the LMC should be notified if such demands are made.

How do I know if my appraisal is being conducted in the right way and how might I whistle blow on the process if I think it’s not working?

The message for GPs is if your appraiser says something is mandatory, first ask them why, and where the decision comes from. If they don’t get satisfactory response to this question, take it to the LMC.

What we tend to hear is that, at meetings sometimes, things people advise are misinterpreted but the message is spread anyway. Further investigation into ‘mandatory’ appraisal areas usually finds there’s no evidence behind a demand, and that appraisers should have clarified what PCTs told them.

The GMC have previously said that appraisal standards should be agreed locally. I see why they recommended that but it has caused part of the confusion over what can and can’t be asked. There are examples of good practice where the LMC and PCT agree on appraisal guidelines, but others have misinterpreted the GMC.

The big issue within this transition time is where appraisal has become a measure of performance. Appraisals are to measure a doctor’s formative progress.  A summative appraisal is more of a summary assessment of your performance. For GPs the idea of summative appraisals is difficult anyway, as they are generally not employees of the bodies appraising them. In the GPC’s view revalidation is not going to be a performance management tool either, although it’s a professional requirement.

What is an enhanced appraisal?

There is no such thing as an enhanced appraisal, and the GMC has confirmed this.

But as I’ve just discussed, if you have an appraisal between now and April it might be helpful for you to ‘enhance’ it yourself by providing some of the evidence you’ll work with during revalidation. GPs by nature are high achievers and I have heard that some GPs have already begun to add this to the evidence they gather for their appraisal.

Start looking at and considering the requirement to do 50 credits of CPD that will be part of revalidation. There is no requirement to do so, but considering that reflecting on your practice counts; it would make sense for people to recognise they’re probably already doing quite a lot more CPD than they think. I’ve starting doing it myself, when patient comes in I look up online or in books – its education but if you log it assess what you study and the impact, e.g. reducing referrals or updated guidelines. That’s all CPD. That’s what I provide to mine and feedback is good. GPs think 50 credits is all going to courses but there’s variety of ways to learn, even peer review of patients if it changes your mind.

You could prepare some multi-source feedback – it is not mandatory to provide it now but it’s something you’ll need to consider in future.

Check with your appraiser, but it’s likely that commissioning work such as audits will count. I always include things like service redesign. Appraisal is not all about clinical work, it’s about developing service redesigning – and if it counts for appraisal it will also be considered during revalidation. In essence, revalidation is a check that doctors doesn’t just go into work and go home.

Does my appraisal count towards revalidation?

Yes. Appraisal will lead to revalidation, and is a building block of the process, but a good appraisal doesn’t automatically get you through the revalidation process. Clinical governance information from the PCO will also be used to make a revalidation recommendation. The good news is that GPs are already well ahead of secondary care colleagues in revalidation simply because of the wealth of data that you can gather on a GP.

NHS leaders will be the first group eligible to be revalidated from December 2012.  Most GPs won’t be in line for revalidation until April 2013 and those who will, are given at least three months notice of their revalidation date.

Is revalidation definitely going to happen?

It certainly looks that way, but the GPC still has a number of concerns about the process that we want to see resolved. My big concern about it at the moment is that GPs will retire before it hits and that’s extremely worrying, as the vast majority of GPs should have no concerns about being revalidated. It’s easy to achieve the standards; the only thing that might seem difficult or new is providing the evidence. GPs just need to think differently – they do things daily that they don’t realise contribute to their work.

How will the GPC clarify guidance on appraisals and revalidation over the next six months?

What we’re trying to do is set up a group with a number of stakeholders to ensure consistency in the appraisal process. We’ve had one meeting with GMC, RCGP and COGPED, and clearly we want further meetings with other stakeholders such as NHS Employers and the Department of Health. We will be assessing processes not only from the point of view of the appraisee but also the appraiser. The devolved nations work on a consensus view of the rules of appraisal at the moment, and I believe that’s the way forward for England.

Dr Dean Marshall is the GPC lead for revalidation and a GP in Dalkeith, Scotland