APPRAISAL FOR GENERAL PRACTITIONERS
Dr John Dean FRCGP, Medical Secretary, Devon LMC
SELECTION OF APPRAISERS BY GPs
SHOULD CONCERNS ARISE DURING APPRAISAL
All NHS GPs are now expected to participate in the national GP appraisal process, although participation is not yet a contractual obligation. Devon LMC has been involved in lengthy discussions with individual PCTs on how the process will be implemented and in the approval of appraisers. In principle, appraisal and self-directed learning offer benefits to GPs that were not readily available within the old PGEA system. It should help you to identify your professional learning needs in a systematic and holistic manner, and to manage your learning activities more productively. Whilst there is no doubt that it will involve GPs in more work, a full day of protected time will be funded by PCTs to enable you to prepare and take part in the appraisal process.
We intend to monitor how the appraisal process affects GPs, how much time it requires, how useful you find it and how effective it is in promoting positive change. In order to do this, we will be conducting a survey of your individual experiences and hope that you might be willing to participate in this appraisal evaluation process. The information obtained will help us to cost the process more accurately and will put us in a better position to negotiate its implementation in future years.
We have prepared the following notes, which you might find useful when preparing for appraisal. Your appraiser will also wish to help you, too. If you have any specific questions or concerns about the appraisal process, these can be addressed to your appraiser but, if they are of a sensitive or confidential nature, you may wish to consult the LMC first, preferably by e-mail, at john@dean.eu.com
The appraisal process consists of
· A half-day preparatory phase, during which three documents (Forms 1-3, described below) are to be completed and returned to the appraiser
· A half-day appraisal meeting with the appraiser, during which Forms 1-3 are reviewed and at the conclusion of which Form 4 and possibly Form 5 (see below) will be completed. A copy of Form 4 is sent to the PCT.
· A thirty-minute learning review during the course of the year; this may be conducted by telephone or at a face-to-face meeting
These steps are conducted in addition to the GPs normal professional learning, such as PGEA-accredited activities.
Every GP will have one day of fully-funded, protected time for appraisal. The first half-day is intended for preparation and the second for the meeting with the appraiser. In the first year, it is important that both the GP and appraiser have achievable and realistic goals. For most GPs, that will involve acquiring an understanding of the process of managing professional learning (need assessment, objective setting, evaluation, learning techniques, and the compilation and management of a personal learning plan) and the purpose and process of appraisal. For most GPs, it is unlikely that much more than this can be achieved.
Preparation for the appraisal should be completed during protected time that has been specifically set aside. The appraiser should ensure that the GP being appraised has up to 2 months advance notice of the date of their appraisal.
There are up to 5 forms to be completed as a part of the appraisal process and GP swill need to return Forms 1-3 to the appraiser before their appraisal meeting. The appraiser will review them in strict confidence. They are not to be shared with any other person without the express written consent of the GP. Form 3 also invites the GP to attach “supporting material”. As this is likely to involve a great deal of work, it might be better if such materials were available at the appraisal meeting and only returned in advance if there seemed to be a particular need to do so.
GPs should bear in mind, when sharing information with an appraiser, that the appraiser is the employee of the PCT and, although they have, to an undefined degree, a duty of care towards the learner, their primary responsibility is to implement the policy of the PCT and the Department of Health.
Good medical records facilitate good patient care. In the same way, good documentation of professional learning and appraisal facilitates effective and personally satisfying learning for the GP.
Documentation should serve the GP’s learning needs and should not be considered, or allowed to become a further bureaucratic exercise in form filling. However, the documentation required is extensive and may be daunting to many. Completion will get easier in future years. There are up to five forms to complete and a description of each and some guidance on their completion is given below.
Form 1 is a record of basic demographic and professional information.
Form 2 is a record of all current medical and professional activities undertaken by the GP.
Form 3 is described as “material for appraisal” and should be at the heart of the GP’s learning need assessment. It is a complex form and several parts of it are not relevant to year one. To be completed fully, many hours of self-assessment, using a wide range of techniques, is necessary. However, most GPs will not currently be familiar with, or experienced in the use of such techniques, so a pragmatic approach will need to be taken in year one.
GPs have a right to privacy and are not obliged to talk with the appraiser about any particular issue. Some will find particular questions within Form 3 quite threatening or even offensive, requiring them divulge information or personal feelings that they do not wish to share. In such cases, the GP should refuse to complete the particular item and should not be pressured to divulge more than they wish. If either party is concerned about confidential issues that are not recorded on Form 3, the LMC can provide independent and confidential assistance. This might be by offering the GP advice and support, or by informing the appraiser (without divulging the facts of the matter) that the withholding does or does not represent a cause for concern. More often than not, this will involve issuing a statement that the GP concerned is acting quite reasonably by not providing information.
In several places, it suggests that you attach documents, such as audit results and course documents. It is worth keeping them within your appraisal file but, particularly if they are extensive, you might not wish to photocopy them all to send to the appraiser in advance of the appraisal meeting.
The Department of Health guidance notes make the following points.
“…typically you are asked to provide:
· a commentary on your work
· an account of how your work has improved since your last appraisal
· your view of your continuing development needs
· a summary of factors which constrain you in achieving what you aim for.
It is not expected that you will provide exhaustive detail about your work. The material should convey the important facts, features, themes or issues, and reflect the full span of your work as a doctor within and outside the NHS. The form is a starting point and framework to enable you and your appraiser to have a focused and efficient discussion about what you do and what you need. It is a tool, not an examination paper or application form, and it can be completed with some flexibility. Common sense should be exercised if you feel you are repeating yourself, or if you want to include something for which there is no apparent opportunity. And if a section or a page really needs only a word or two there is no need to do more.
The work you put into completing this form is your main preparation for appraisal, and the value of your appraisal will largely depend on it. It will also be an important part of your appraiser’s preparation.”
Although it is unlikely to be of relevance to most GPs, on a point of principle, it is questionable whether one can be compelled to provide information about professional activities outside of the NHS, such as provision of private (non-NHS) medical services to a school, nursing home or factory. However, if they form an important part of your professional life, it is in your best interests to consider them within your professional development activities and include any identified needs within your Personal Development Plan (PDP, see below). You may wish to explicitly exclude information about non-NHS work from Form 4 (a summary document submitted to the PCT), as you are entitled to maintain your professional and commercial confidentiality.
The following paragraphs consider Form 3 in detail and provide guidance for GPs on its completion.
1. The first section refers to “Good clinical care” and asks several questions about your current clinical practice.
“Commentary: what do you think are the main strengths and weaknesses of your clinical practice?” It suggests a range of resources that the GP might refer to in order to answer the question. If these are not available or not relevant, they do not need to be undertaken before the appraisal. It might be appropriate to consider some of them as part of the forthcoming year’s programme of audit and clinical governance activity.
“How has the clinical care you provide improved since your last appraisal?”Clearly, for most GPs, this cannot be answered in year one.
“What do you think are your clinical care development needs for the future?” There are a range of techniques that can be used to identify these needs, such as those suggested in the “Commentary” section. If you do not have suitable resources available this year, simple reflection, preferably with the help of a colleague, might be the pragmatic approach to follow this year. Set aside time to consider all aspects of clinical care that you provide and list those that you have found challenging and why they were challenging. The challenge may have arisen because you are interested in that area of care, not just because you find it difficult. The GP should record a short list, probably no more than three items, of very specific statements of development need. Specificity is essential – “more about diabetes” is useless. A more appropriate item might be “evidence-based decision making in the choice of oral hypoglycaemic agents”. Only by recording very specific objectives can the GP have any hope of evaluating whether they have achieved them. Even with the example given, it requires thought to identify objectively whether the GP does, indeed, know anything more about the subject.
“What factors in your workplace, or more widely, constrain you significantly in achieving what you aim for in your clinical work?” Form 3 exhorts us, “It may be constructive to focus on issues that can be addressed locally”, suggesting that we should exclude nationally-derived constraints from our consideration. Whilst it is helpful to focus on things that can be changed through local efforts, do record important issues that affect your clinical work that our outside your own and PCT control.
2. The second section refers to “Maintaining good medical practice” and asks several questions about your professional development activities over the past year. This will include formal courses attending, but should also include clinical governance activities, personal study, reading and examples of “learning from experience”.
“Commentary - what steps have you taken since your last appraisal to maintain and improve your knowledge and skills?”This section is fairly explicit. List all of your professional development activities here, including formal courses attended, but should also include clinical governance activities, personal study, reading and, perhaps, some short notes that describe examples of “learning from experience”.
What have you found particularly successful or otherwise about the steps you have taken?This section might be useful, in that it asks you to record what worked and what didn’t with regards to your learning activities. If you found reading about a particular subject helpful, record the fact. If a course was useless, record the fact and explain why. Hopefully, this section will help to prevent you wasting your time on fruitless learning activities and to focus on the things that work for you. There are a variety of reasons why particular learning experiences are less useful than others. Some reasons are personal – we all have different “learning styles”, so some GPs will find courses useful where others might learn best from personal study. Other reasons relate to what we are trying to learn – it’s difficult to learn minor surgery or psychotherapy skills from a lecture – practical teaching and learning is more effective for acquisition of most skills. Don’t labour too long over this section, but don’t miss the opportunity to avoid choosing the same fruitless approaches to learning year in, year out.
What professional or personal factors significantly constrain you in maintaining and developing your skills and knowledge? Simply record what stops you from learning what you need to learn. It might be that you can’t identify a suitable course or other learning activity. If you are single-handed, or in a small practice, it might be difficulty in getting a locum or funding time out of the practice. “Lack of time” is a perfectly reasonable reason to record, but be prepared to explore the reasons behind it with your appraiser.
How do you see your job and career developing over the next few years?” Recording aspirations may help turn them to attainments. Once again, Form 3 is strictly confidential between you and your appraiser, so you should be able to use them as a “sounding board” to help you in your career development, whatever direction it might take.
3. The third section refers to “Relationships with patients” and asks several questions about communicationissues with patients. These should be viewed in the broadest sense. Reflection on your consultation skills is a part of the content considered here, but so are your practice leaflet, appointment system, repeat prescribing arrangements, complaint procedure and all other aspects of the patient-practice interface. It is a potentially enormous undertaking to review all of these issues. Choose something simple to look at in the first year. Your choice should be guided by experience. If your appointments are always booked days in advance, that’s a clue! There is no doubt that many GPs will see these questions as potentially threatening. In this first year, only explore issues that you are comfortable with and are prepared to discuss openly.
“Commentary - what do you think are the main strengths and weaknesses of your relationships with patients?” The answer to this question is unlikely to change greatly from year to year, although it is worth thinking about what we do well and what we could do better. Do not feel obliged to “soul search”. You are not required to share any materials with your appraiser, so do not feel that you must provide them with information about complaints or significant events unless you believe that it would be helpful to you in your professional learning.
“How do you feel your relationships with patients have improved since your last appraisal?” This question cannot be answered in year one. It is worth reflecting on whether you feel anything has changed in the patient-practice interface during the past year.
What would you like to do better? What do you think are your current development needs in this area?” You should be prepared to include anything that you record here in your PDP as a “learning need”.
“What factors in your workplace or more widely constrain you in achieving what you aim for in your patient relationships?”A wide range of issues could be recorded here, ranging from workload, to constraints imposed by premises, to staffing issues and physical resources such as telephone and IT requirements.
4. The fourth section refers to “Working with colleagues” and asks several questions about communication issues and relationships with colleagues. This might include partners, practice employed staff, the extended team, colleagues in secondary care, and NHS managers.
“Commentary - what do you think are the main strengths and weaknesses of your relationships with colleagues?” The answer to this question is unlikely to change greatly from year to year, although it is worth thinking about what we do well and what we could do better. Do not feel obliged to “soul search”. You are not required to discuss anything with your appraiser if you do not wish to do so, so do not feel that you must provide them with information about interpersonal difficulties unless you believe that it would be helpful to you in your professional learning.
“How do you feel your relationships with colleagues have improved since your last appraisal?”This question cannot be answered in year one. It is worth reflecting on whether you feel anything has changed in your professional relationships during the past year but, again, you are not obliged to share this information with the appraiser.
“What would you like to do better? What do you think are your current development needs in this area?”You should be prepared to include anything that you record here in your PDP as a “learning need”.
“What factors in your workplace or more widely significantly constrain you in achieving what you aim for in your colleague relationships?” This is a highly sensitive area and exploring it might be difficult. Do not feel obliged to reveal interpersonal difficulties unless you are willing to document and address them.
5. The fifth section refers to “Teaching and training” and asks several questions about the GPs activities as a professional teacher or trainer. Clearly, this is not relevant to many GPs and should be recorded as such. Non-teachers or trainers working in training practices (post-graduate and under-graduate) should complete the section as is appropriate to their contact with learners under their teacher or trainer colleague’s supervision. As most GPs with appointments as GP trainers and undergraduate teachers already participate in a far more rigorous process of appraisal connected specifically to this work, this seems to be an example of unnecessary duplication.
“Commentary - what do you think are the main strengths and weaknesses of your work as a teacher or trainer?”
“Has your teaching or training work changed since your last appraisal? Has it improved?”
“Would you like to do more? What would you like to do better? What do you think are your current development needs?”
“What factors constrain you in achieving what you aim for in your teaching or training work?”
6. The sixth section refers to “Probity” and asks several quite remarkable questions about your honesty and professional integrity. Some GPs will find these questions an offensive intrusion and they are phrased in a way that seems to assume impropriety is the norm. If GPs have concerns about their own “probity”, or that of a colleague, they might prefer to discuss it with the LMC, rather than with an appraiser. It is worthwhile reviewing one’s personal and practice systems, in order to avoid accusations of impropriety, but the results do not have to be shared with others, unless there is an overriding legal duty to do so. If GPs have no such concerns, they should complete the section “having conducted a review of my personal and practice probity, no action is required in this area”, rather than be required to indulge in fruitless soul-searching with an appraiser.
“What safeguards are in place to ensure propriety in your financial and commercial affairs, research work, use of your professional position etc? Have there been any problems?”
“Has the position changed since your last appraisal or in the last year?”
“Do you feel the position needs to change? How?”
“What factors in your workplace or more widely significantly constrain you in this area?”
8. The eighth section refers to “Management activity” and asks several questions about the GP’s management activities outside of the practice. Clearly this will not be relevant to most GPs, who should mark it “not applicable”. It should be completed by GPs who have a role in a PCT, for example, or who officially undertake advisory work for a Strategic Health Authority, an NHS Trust, or a national organisation.
“Please describe any management activities you undertake that are not related to your practice or the practice in which you work. How would you describe your strengths and weaknesses?”
“Do you think your management work has improved?”
“What are your development needs?”
“What are the constraints?”
9. The ninth section refers to “Research” and asks several questions about the GP’s research activities. Clearly, this will not be relevant to most GPs, who should mark it “not applicable”. It should be completed by those who undertake any form of research as a part of their normal work as an NHS GP. This is particularly relevant to those GPs who undertake personal academic research, perhaps as a part of their work in pursuing a further degree. GPs who undertake research work in private practice (not as a part of their contracted NHS work with the PCT) may choose to include it but are not obliged to do so. They should bear in mind any confidentiality agreements that they have with third parties before disclosing confidential material. Any publications can be recorded, as they are, by definition, in the public domain.
“How would you appraise any research work that you do?”
“Do you feel your research skills have improved?”
Do you have development needs in this area to reflect in your updated Plan?
What are the constraints?
10. The ninth section refers to “Health” and asks a single question.
“Do you feel there are any health-related issues for you that may put patients at risk?” It seems most unlikely that any GP will first give a positive answer to this question in an appraisal. All GPs have a professional duty to protect their patients and are obliged to seek help if they develop a health problem that might have the effect of putting their patients at risk. This might include drug or alcohol problems, or contracting hepatitis B. If such a problem does arise, the GP would be best advised to self-refer to the GP Occupational Health Service. More information about this service is available from the Medical Secretary or LMC secretariat.
The next, brief sections are meant to provide an overview of what learning occurred last year, what is planned for next year and what obstacles exist that might hinder effective learning.
Form 3 needs to be completed to this point before the appraisal meeting. It will then form the basis of discussion for the appraisal meeting, and for completion of the GP’s PDP and Form 4.
The final section is a form of contract, to be signed by both GP and appraiser, probably at the appraisal meeting.
“We confirm that the above information is an accurate record of the documentation provided by the appraisee and used in the appraisal process, and of the appraisee’s position with regard to development in the course of the past year, current development needs, and constraints.”
Form 4 is to be completed during or immediately after the appraisal meeting. It consists of a summary of the appraisal discussion for each of the first ten sections described above and the GP’s PDP. This document is not confidential and a copy will be sent to the PCT. GPs will need to bear this in mind when completing the form. They should not be pressured into including information that they do not wish to share with the PCT. In cases of disagreement, the GP or appraiser might wish to seek confidential and independent assistance from the LMC.
It is a contractual requirement for GPs and appraisers to complete the form but there is no requirement to provide any specific information. It should be enough to fulfil the contractual requirement by recording “confidential issues identified and action agreed”. Where the information is not sensitive and where action by the PCT might assist, there is no reason why full details should not be provided.
The PDP comprises part of Form 4 and has the potential to become an extremely useful document for every GP. The PDP is the index of professional learning. Within this record, the GP can record professional learning needs, specific learning objectives, the learning experience undertaken, how it was evaluated and what further action, if any, is needed. It belongs to the GP and is not imposed on them. It is not a straightjacket, to be rigidly adhered to, but a dynamic guide that may change as the plan unfolds. The PDP is the “story” of the GPs learning activities, an important reference for them in the future and evidence that might be used in some future process of revalidation.
Most GPs will need help in acquiring the knowledge and skills, and developing the new approach to learning necessary to develop and maintain a PDP. In the first year, it is probably a realistic objective for the appraiser to help every GP to understand the principles involved in drawing up their PDP, even if they have not yet had time to acquire and use the learning need assessment techniques required. In year two, the appraisal might focus upon how the learning planned in year one proceeded, what went well and what went wrong. At all times, the focus is upon the process of learning, not the content.
Form 5 is intended to provide a detailed record of the appraisal meeting. Its use is entirely optional and its contents are strictly confidential between the GP and the appraiser. It is not shared with the PCT.
GPs should prepare and maintain an appraisal folder, a systematic record of all the documents, information, evidence and data that will help inform the appraisal process. It can become a sort of “learning portfolio”, a record of both the learning process (needs and how they were identified, evaluations, etc.) and of all professional learning activities (courses attended, personal study records, etc.). Once the folder has been set up it can be updated as necessary. The documentation will facilitate access to the original documents in the folder in a structured manner, and record both what the appraisal process concluded from them and what action was agreed as the outcome following discussion.
Your appraiser should be an experienced professional educator and will have attended a special training course about the NHS GP appraisal scheme. All appraisers in Devon are appointed with the explicit approval of both the PCT and LMC, and you should be able to have confidence in their knowledge, skills, impartiality and willingness to help you to identify your professional learning needs.
You should be provided with a list of appraisers by your PCT, from which you should select the appraiser you would like to work with. In the unlikely event that you find none of the appraisers acceptable, you should contact the LMC for guidance. This should only very rarely be necessary. The LMC will, in confidence, ask the reasons why the appraisers offered by the PCT are thought to be unsuitable and, if appropriate, will assist the GP and PCT in identifying a suitable appraiser, from a different PCT area if necessary. Although the PCT CEO has the authority to impose an appraiser on any GP, by using the approach described above it should never be necessary for them to exercise this power.
OUTCOMES OF APPRAISAL
The following statements are taken from the Department of Health guidance notes.
“The appraisal should conclude by setting down, as an action plan, the agreements that have been reached about what each party is committed to doing. This should include the essentials of the personal development plan (PDP).
The appraisal should identify individual needs that will be addressed through the PDP. The plan will also provide the basis for assessment of resource needs and clinical governance issues within a practice.
The detail of the appraisal discussion will be confidential to the participants. The appraiser and appraisee should agree a written overview of the appraisal that should as a minimum include:
· A synopsis of achievement in the previous year
· Objectives (an action plan) to be pursued by the appraisee over the next year
· The key elements of a PDP for the appraisee
· Actions expected of the PCT to address needs in the local context or that of the wider system
· A standard summary of the appraisal as recommended by the GMC for the individual’s revalidation folder (yet to be finalised)
· A joint declaration that the appraisal has been carried out properly
The key points of the discussion and outcome must be fully documented and copies held by the appraiser and appraisee. Both parties must complete and sign the appraisal summary statement and send a copy, in confidence, to the senior clinician/clinical governance lead and Chief Executive of the PCT. All records will be held on a secure basis and access/use must comply fully with the requirements of the Data Protection Act.
The appraiser and GP should make arrangements at least once more during the course of the year for about 30 minutes in order to review progress in relation to the actions and PDP. This could be arranged and resolved via a telephone call rather than an actual meeting.
The senior clinician/clinical governance lead should collate and submit an aggregated and anonymised report on appraisal outcomes annually to the PCT Chief Executive. The Chief Executive should discuss this report with the PCT Board. The report must not refer, explicitly or implicitly, to any individuals who have been appraised. The report should highlight emerging training and development needs, and organisational or service themes requiring action or investment. It should also review the overall process and operation of the appraisal scheme.”
The appraisal process should be a formative, educative exercise, not an exercise in bureaucracy. There must be a sensible approach to the documentation, which is primarily for the benefit of the learner, not the appraisal system.
The following procedures are taken from the Department of Health guidance notes.
“There should be clear agreed local procedures for resolving individual concerns about appraisal which fit within the following national model. The process must be able to address any worries or complaints from individual GPs about the fairness and consistency of the scheme, the appraiser, and the outcomes of the appraisal or the use of information.
An individual GP’s concerns about his or her own appraisal should be raised in the first instance with the appraiser. If personal concerns remain, the GP should discuss them with the senior clinician/clinical governance lead for the PCT. The senior clinician/clinical governance lead should in the first instance try to find an informal resolution to the problem through discussion and mediation, involving others as appropriate.
In the exceptional circumstances that concerns can not be resolved in this way, the PCT senior clinician/clinical governance lead (or Chief Executive) might convene an appropriately constituted panel, chaired by a Board member, to consider the matter further.
Where concerns or views relate to the appraisal system itself, these should be raised with the PCT Chief Executive. Where there are worries or complaints, the GP will have the right to representation (e.g. from his or her LMC).”
These procedures must also involve representatives of the profession (the LMC) at the first stage, not just when all other avenues have been exhausted. If concerns arise as a result of your appraisal, contact the LMC for advice.
A web-based resource for appraisal has been developed for the Department of Health and is described below.
“The NHS Appraisal Toolkit is undergoing development and piloting as an on-line resource that brings together advice, guidance, best practice, practical tools and access to a community of peers in the appraisal domain. It will be released generally from autumn 2002. It provides a range of background material about appraisal. It will help both the appraiser and the GP with the process of appraisal, by adding context; guiding the GP through the process, taking the information that the GP enters onto the system and producing it in the format of the standard appraisal form; producing an electronic appraisal record (EAR) and giving decision support to the process. The toolkit can be used in immediate preparation for appraisal, or, perhaps more usefully, can be returned to many times during the year to support the reflection. It can be accessed at www.appraisals.nhs.uk”
Although the content of the toolkit appears to be good, GPs should consider very carefully before they use it. It was intended that GPs and appraisers store all appraisal data, including highly confidential material, on the hosting server. However, it is worth remembering that no web-based information storage system can be considered absolutely secure. In recent years, a number of banks have had their allegedly secure web access for customer accounts hacked and this system is no more secure than a bank’s.
GPs may be encouraged to use this toolkit by their appraiser, as it will facilitate easy transfer of the various forms from one to the other. GPs should consider carefully whether they wish to place sensitive information on this system, as it is not completely secure and it is difficult to foresee any such system linked to the Internet being adequately secure in the near future.
If you have any comments or suggestions about the appraisal process, appraisers or these guidelines, please let us know. Your feedback will help us to refine appraisal, to the benefit of both patients and GPs.
John Dean
February 2003