GP Appraisal: A brief guide

GP Appraisal: A brief guide

NHS Education for Scotland

ggpp aapppprraaiissaall

1

aapppprraaiissaall sscchheemmeeggpp aapppprraaiissaallgp appraisalgp appraisalgp appraisal gp appraisal

A Brief Guide

2

1 . INTRODUCTION

This paper is the outcome of discussions between the Scottish Executive Health Department (SEHD), theScottish General Practitioners’ Committee (SGPC), the Royal College of General Practitioners in Scotland(RCGP Scotland) and NHS Education for Scotland(NES) formerly Scottish Council for PostgraduateMedical and Dental Education (SCPMDE).

2 . BACKGROUND

Against a background of the development of clinicalgovernance and quality assurance, the Minister forHealth and Community Care in Scotland signalled theintention to introduce appraisal for all GPs. A schemefor consultants is already underway and for GPs, the Scottish General Practitioners’ Committee hasaccepted, in principle, the concept of appraisal linkedto revalidation.

The Clinical Standards Board for Scotland wasestablished in April 2000 and subsequently becamepart of NHS Quality Improvement Scotland (QIS) inJanuary 2003. The Board endorsed practiceaccreditation as the preferred methodology of qualityassurance for practice-based primary care in Scotland. The practice accreditation standards havebeen developed in partnership by RCGP, SEHD, SGPCand other key stakeholders. In addition, the Directorsof Postgraduate General Practice Education haveagreed a national process for the accreditation of

GP Appraisal: A Brief Guide

3

training practices, which incorporates all the essentialcriteria included in the RCGP practice accreditationscheme.

The issue of general practitioners (GPs) whoseperformance gives cause for concern has beenaddressed on a Scottish basis. The Minister set up a short-life working group, which included keystakeholders. The report of the Working Group,entitled ‘Prevention – Better than Cure’1 was publishedin August 2001.

The General Medical Council (GMC) has decided that all doctors will be required on a regular basis todemonstrate that they continue to be fit to practise.This process has been termed revalidation. The GMCwill provide guidance on the principles and has askedMedical Royal Colleges to draft standards and criteriaappropriate to their specialty.

The RCGP has worked closely with the GeneralPractitioners Committee UK (GPC) to produceproposals for the revalidation of GPs: A Methodologyfor Recommending Revalidation for the GeneralPractitioner2 which is based on Revalidation forClinical General Practice3 and Good Medical Practicefor General Practitioners.4

1 Report of the Short Life Working Group on Identifying and Preventing UnderPerformance Amongst General Practitioners, SEHD 2001

2 A Methodology for Recommending Revalidation for the General Practitioner,RCGP/GPC 2000

3 Revalidation for Clinical General Practice, RCGP 20004 Good Medical Practice for General Practitioners, RCGP/GPC 2000

4

There are significant NHS organisational differencesbetween Scotland and England. There is, therefore, anopportunity to develop an appraisal scheme forGeneral Practitioners in Scotland which meets theclinical governance aspirations of SEHD, supports GPsin their preparation for revalidation and links with thepractice accreditation scheme.

It is known that the support offered by Primary CareNHS Trusts and NHS Boards to practices preparing andundertaking practice accreditation is variable acrossScotland. It is recognised that time will be required toprepare for, and undertake, annual appraisal. Formalnegotiations between SEHD and SGPC havedetermined a national agreement on how GPs will beresourced in Scotland for carrying out appraisal.

This introductory paper provides information on:

• how the scheme will operate

• how it will be organised and resourced

• how the complementary agendas outlined abovemay be dovetailed.

Further information and guidance will be issued as thescheme is taken forward.

3 . A IMS OF THE APPRAISAL SCHEME

The aims of the appraisal scheme are:

• to help the individual GP to identify educational anddevelopment needs


5

• to help assure the public that the GPs they see aresafe, up to date and delivering high quality serviceswithin the resource constraints of NHS Scotland

• to facilitate local NHS organisations to dischargetheir duty of quality assurance

• to consider and help optimise the GP’s contributionto the quality and delivery of services locally

• to contribute significantly to the mechanismsproposed by the General Medical Council for therevalidation of GPs.

4 . KEY PRINCIPLES

Annual appraisal for GPs will be a professional processof constructive dialogue, in which the GP beingappraised has a formal structured opportunity toreflect on his/her work and to consider his/hereffectiveness.

Annual appraisal will be a supportive, developmentaland formative process. It will allow the individual theopportunity to identify their educational anddevelopmental needs.

The content of the appraisal will be based on the coreheadings set out in the GMC document ‘GoodMedical Practice’, namely:

• Good Professional Practice

• Maintaining Good Medical Practice

• Relationships with Patients

6

• Working with Colleagues

• Teaching and Training

• Probity

• Health

Appraisal meetings will be conducted in private andthe key points of the discussion and outcome will bedocumented and copies held by the appraiser andappraisee and remain confidential.

The appraisal scheme should enable NHSorganisations to support GPs so that they contributeto delivering responsive, safe and high quality servicesand reach their full potential to the benefits ofpatients.

Annual appraisal will follow a standardised format and be delivered to agreed national standards.

The primary aim of appraisal is to enable GPs toconsolidate and consider areas for future personaldevelopment and to look to how these needs mightbe achieved. However, it may help recognise, at anearly stage, developing sub-optimal performance or illhealth which may be affecting an individual’s clinicalpractice. In such instances the process should assistthe GP in recognising potential problems and seekingappropriate help at an early stage. However, appraisalitself should not be used as the mechanism foraddressing such problems.


7

Appraisal must not be utilised to address seriousissues relating to performance that arise outside theappraisal process. These must be addressed timeouslyand separately from the appraisal process usingexisting mechanisms.

Appraisal will support the provision of evidence which will substantially contribute to a GP’s regularrevalidation. To this end appraisal discussions andevidence gathering should be sufficiently broad tocover the requirements of revalidation.

The impact and effectiveness of the national GPappraisal scheme in Scotland will be kept underreview.

5 . APPRAISAL – L INKS TO THE REVALIDATION FOLDER

The intention is to ensure that the appraisal schemefor GPs in Scotland largely meets the requirements forrevalidation. To this end, a first draft revalidationfolder for GPs in Scotland is currently being designedand agreed with the GMC. This will form a GMCrevalidation pilot. This folder is mapped onto thecriteria and standards outlined in the RCGP/GPCdocument ‘Good Medical Practice for GeneralPractitioners’ and sets out the evidence which wouldbe required and the standard against which theevidence would be assessed. It is anticipated that thefolder will continue to be developed on the basis offurther research and the evidence and standards maybe modified to increase clarity.

8

A number of criteria pertaining to practice organisationwill be assessed during practice accreditation visits.Where this is the case, a current practice accreditationcertificate (including a QPA award and training practiceaccreditation) will be taken as evidence of satisfactorilymeeting that criterion. Many of these criteria willprovide organisational and clinical information tosupport both annual appraisal and revalidation.

The folder will initially be based on the needs of GPprincipals5 or PMS equivalents preparing for revalidation.Further work requires to be undertaken to assesssuitability and to modify the model, where appropriate,to meet the needs of locum non-principals.

Support and advice in the preparation of evidence forinclusion in the revalidation folder from the appraiserwill be a major component of the appraisal interview.

RCGP Scotland is the host organisation in Scotland for aGMC revalidation pilot and they will produce a resourcepack to assist GPs in the preparation of theirrevalidation folder.

6 . APPRAISAL – GUIDANCE

Detailed guidance and documentation on the nationalappraisal scheme will be made available shortly to allGPs in Scotland.

5 A doctor on the medical list of a Primary Care Trust or NHS Board providinggeneral medical services to patients. Initially, appraisal will also cover assistants andassociates attached to GP principals.


9

7. THE APPRAISAL INTERVIEW – PREPARATION

Successful appraisal is dependent not only on theprocess of the appraisal interview but also on the preparation undertaken beforehand both by theappraisee and the appraiser.

Initial contact should take place three months beforethe interview and agreement reached on the contentof the interview and on a date for the appraisalinterview. It is crucial that adequate time is set asidefor the process and that the interview is free ofinterruption. In addition, time is required for theappraisee to prepare for the interview and to gatherany documentation which has been agreed as part ofthe appraisal process.

Generally the appraisee will produce documentationon the following:

• a brief outline of professional commitments (part of revalidation folder)

• a personal assessment of changes the appraiseewould like to make in the forthcoming year inrelation to their job and reflecting any practicedevelopment

• evidence of continuing professional development(CPD) activity (consistent with the requirements ofrevalidation)

• a self-assessment of the appraisee’s own educationalplans

10

• a summary of any complaint(s) (consistent withrequirements of revalidation)

• evidence required for the agreed area(s) of reviewthis year (consistent with requirements ofrevalidation).

Apart from personal assessments, it is envisaged thatmuch of the material will have been assembled forpractice accreditation or be available from existingsources, for example medical prescribing informationand clinical audit.

It is intended that the appraisal process will, over aperiod of five years, result in the production of all theevidence required for revalidation with the exceptionof any relevant professional activity outwith the scopeof GP appraisal.

8 . THE APPRAISAL INTERVIEW – FORMAT

Appraisal interviews will be conducted annually by atrained General Practitioner (appraiser) at the premisesof the GP, unless agreed otherwise, who is beingappraised (appraisee). The appraiser and appraisee willagree the content of the interview in advance and theappraisee will have prepared material for discussion atthe interview. Protected time should be set aside forthe appraisal interview which may take up to twohours.


11

9. THE APPRAISAL INTERVIEW – CONTENT

The agenda for the interview will be agreed.

Current professional commitments will be reviewed,with educational needs specific to the job descriptionidentified. For example if the appraisee is the mainprovider of diabetic care in the practice there may bespecific needs in relation to that activity.

The description of the job that the appraisee does willbe reviewed and updated annually and will form partof the content of the revalidation folder.

Educational needs and priorities in relation to the jobdescription including any personal or practicedevelopments will be discussed. An opportunity willbe given to highlight any adverse conditions thatcurrently exist which prevent high quality care beingprovided.

Educational activity from the previous year will bereviewed. In subsequent years this will involve areview of achievements against the previously agreedpersonal learning plan.

Evidence of educational activity will be required forthe CPD record in the revalidation folder.

The appraisee will have considered their own personaldevelopment and educational needs in advance of theappraisal. A number of tools are available to assist

12

with this task which will be published in the appraisalhandbook.

It is recognised that complaints are often verystressful events for practitioners and there should bethe opportunity to discuss the complaint and anylearning points in a supportive environment. Duringthe interview, the appraisee will present within thefolder all formal complaints relevant to theirprofessional practice during the past year in theformat required for the revalidation folder.

The appraisee will provide evidence in at least one ofthe following five categories in the format requiredfor the revalidation folder. This list is not yetdefinitive and will be based on further discussionswith the GMC:

• review of prescribing and referral

• review of patient survey and/or communication skills

• review of significant event analysis/random case/problem case report

• review of clinical audit

• review of peer feedback.

Any issues arising will be discussed and any identifiedneeds will be included in the personal developmentplan.

It is anticipated that all of the five areas of evidenceabove will have been discussed over a period of fiveyears. The GMC have intimated that revalidation willcommence in 2004 or 2005. The requirements for GPs


13

who have had less than five years to prepare forrevalidation will be made explicit by the GMC and this will be taken into account in the design of theappraisal content.

As already stated, it is anticipated that some of therequired information will be provided to the appraiseeby the Primary Care NHS Trust, NHS Board or otherNHS agency, e.g. Primary Care Information Group ofthe Information & Statistics Division.

There will be an opportunity for the appraisee todiscuss any other issues with the appraiser.

The appraiser and appraisee will sign off the formaloutput from the appraisal including the educationalplan for the forthcoming year.

10 . THE APPRAISAL INTERVIEW – OUTCOME

The detail of the appraisal interview will beconfidential to the participants.

The appraiser and appraisee should agree a writtenoverview of the appraisal which should minimallyinclude:

• a synopsis of achievement in the previous year

• the key elements of a personal learning plan (whichmay be shared with the Director of Postgraduate GPEducation)

• objectives to be pursued by the appraisee over the

14

next year including provisional timescales and plansfor review

• areas to discuss with the Primary Care NHS Trust orNHS Board to address needs in the local context orwider system.

The agreed standard appraisal report required forrevalidation will be signed by the appraisee and theappraiser and placed in the revalidation folder.

The Primary Care NHS Trust or NHS Board will benotified that the appraisal has successfully takenplace. The nationally agreed payment for participationin, and completion of, appraisal will then occur. It isanticipated that successful completion of a personallearning plan and evidence of learning activity at theappraisal will result in the payment of thePostgraduate Education Allowance (PGEA). Where anappraiser feels there is insufficient evidence oflearning activity for the PGEA to be authorised, theappraisee may elect for his/her case to be referred tothe National Appraisal Co-ordinator. This will ensurethat decisions on PGEA in relation to personal learningplans are consistent across Scotland. Existing PGEAarrangements under the Statement of Fees andAllowances (SFA) will remain meantime and GPsshould continue to utilise this system until their firstappraisal has been completed.

In the very unusual event of significant cause forconcern arising with regard to the appraisee’s health,conduct or performance, the Medical Director of the


15

Primary Care NHS Trust or NHS Board will be notified.It is anticipated that the appraisee and appraiser willagree this. It must be recognised that as registeredmedical practitioners appraisers have a responsibilityto raise any concerns which put patients at risk. Thesemust be addressed and referral to the GMC mustoccur if patient safety is likely to be compromised.

It is anticipated that the learning needs identifiedwithin the plan can, with the agreement of theappraisee, be forwarded to the Director ofPostgraduate General Practice Education to assist inthe commissioning and provision of postgraduateeducation in the Region. This will be anonymised andamalgamated by each appraiser based on theoutcome of all the appraisals he/she has conducted.

Building on practice accreditation, annual appraisalprovides an ideal opportunity to link thedevelopment needs of the practice with the personaland educational needs of the individual. It isenvisaged that the appraiser will generally conductthe appraisal interviews with all the GPs in thepractice and will, with the agreement of the practice,feed back any identified needs, for example staffingissues, to the Primary Care NHS Trust or NHS Board.

An aggregated and anonymised report on appraisaloutcomes should be collated and submitted annuallyto the Primary Care NHS Trust or NHS Board by theMedical Director covering clinical governance and

16

organisational or service themes requiring action orinvestment.

1 1 . THE APPRAISER

The aim will be to appoint individuals who arecommitted to appraisal, are keen to be involved andwho have the capacity and capability to do the work.

The appraiser will be a GP. The appraiser will beappointed to the practice. If the appraisee is unhappywith the designated appraiser, he/she may request thatanother be assigned.

It is anticipated that an appraiser will undertake up totwenty-five appraisal interviews per year (based onone weekly session). The appraiser will generallyappraise all GPs within a practice. This will allow theappraiser at the request of the practice to feed backany generic issues which were raised during theappraisal process which could be considered by thepractice, Local Health Care Co-operative (LHCC) or itssuccessor (Community Health Partnership), PrimaryCare NHS Trust or NHS Board.

The quality of the appraisal and the quality assuranceof the process are key issues for the success of thescheme. It is important that appraisers are selectedthrough an objective, open and transparent selectionprocess. Each will receive training in generic appraisalskills, the agreed appraisal process and the criteria and


17

standards required by the GMC. If during training itbecomes clear that any individual is unsuitable to bean appraiser, they will not be offered a contract.

In addition, the appraiser must be supported in theirrole. There will be continuing professionaldevelopment needs for the appraiser in relation tothis role. In addition, there will be objectiveassessment of the appraiser’s performance and amechanism for constructive feedback.

In summary the appraiser should:

• have good or even exceptional interpersonal skills

• be committed to the concept of appraisal

• be respected by the local medical community andhave the confidence of the Medical Director

• be trained to undertake appraisal

• be fully familiar with the documentation and processof the appraisal scheme

• have a good knowledge of the appraisee’s job andthe context and circumstances within which it isperformed

• be available throughout the year to give advice andsupport

• have a positive relationship with the appraisee

• have the authority and credibility to influence widerorganisational decisions.

18

12 . DEVELOPING THE APPRAISAL PROCESS

All GPs in Scotland will need to be familiar with thenationally agreed scheme. This is a vital first step insuccessfully introducing appraisal. An appraisalhandbook, which will provide detailed information on the appraisal process, is currently being finalised.Appraisers will provide advice to appraisees inadvance of the appraisal to ensure the appraisee iswell prepared. In addition a number of ‘awarenessraising’ sessions will be run by NES.

The appraisal process will be developed on the basisof current best practice taking account of experiences,for example in the other home nations and for otherstaff groups in the NHS. In addition, the process willrequire to be modified to take account of any specificchanges in the requirements for revalidation.

13 . SUPPORTING THE PROCESS – ORGANISATIONALSTRUCTURE

The importance of ensuring avoidance of unnecessaryduplication between a number of inter-linked nationalinitiatives including appraisal, revalidation, practiceaccreditation and the continuing professionaldevelopment agenda is recognised.

Nat iona l Leve l

NHS Quality Improvement Scotland, as the successorSpecial Health Board to CSBS, will externally qualityassure the scheme.


19

Responsibility for the development and internalquality assurance of the scheme will be theresponsibility of NES. NES has established a NationalAppraisal Implementation Group to oversee thescheme. This group will include representation fromall the key stakeholders namely the SEHD, RCGPScotland, SGPC, Directors of Postgraduate Medical and Dental Education, Medical Directors and ChiefExecutives of Primary Care NHS Trusts or NHS Boardsand lay representatives. It will be essential that thegroup maintains strong and effective links with theGMC to ensure that the appraisal scheme developedfor GPs in Scotland is compatible with thearrangements for revalidation.

A National Appraisal Co-ordinator has been appointedto oversee the introduction of the scheme, supervisetraining and develop quality assurance mechanisms.The Co-ordinator will be employed by NES and reportto the National Co-ordinator for Primary Care at NES.

Loca l leve l

Appraisal will be delivered at Primary Care NHS Trustor NHS Board level. At this level the national groupformat should be replicated in the local appraisalgroup. The local group will include the MedicalDirector of the Primary Care NHS Trust or NHS Board,as chairman, and representation from LHCCs, the GPSub Committee of the Area Medical Committee, theRCGP Faculty and the Director of Postgraduate

20

General Practice Education. There will be at least twolay members on the group. This group must linkclosely with the local clinical governancearrangements.

The placement and accountability of the appraisers isan important issue and has been the subject of muchdiscussion and negotiation. It is proposed that a LocalAppraisal Adviser be appointed on a sessional basis tooversee the operational delivery of appraisal in eachPrimary Care NHS Trust or NHS Board. This would beanalogous to the situation with regard to auditfacilitators and local audit committees. The Adviserwill work closely with the Medical Directors ofPrimary Care NHS Trusts, NHS Boards and withPostgraduate Directors. The Local Appraisal Adviserwill report to the National Appraisal Co-ordinator andto the local appraisal group. This ensures that thescheme remains national and that the direct costs ofappraisal are clearly identified and separately funded.

The Local Appraisal Adviser will be responsible for the recruitment and selection of the GP appraisers in collaboration with the local stakeholders. This will always include the Chairman of the GP SubCommittee of the Area Medical Committee andMedical Director or their nominees.

Appraisers and Local Appraisal Advisers will becontracted and paid through the Primary Care NHSTrust or NHS Board and will be accountable to theChief Executive through the Medical Director.


21

Appraisers will be required to operate within theagreed template of the appraisal scheme, which willbe monitored by NES. Primary Care NHS Trusts andNHS Boards will be responsible for GP Appraiser salarycosts. Appraisers will be able to claim travel costs inrelation to appraisal.

It is anticipated that Primary Care NHS Trusts and NHSBoards will also provide local administrative supportfor the Local Appraisal Adviser and appraisers in orderto ensure the efficient running of the scheme.

14 . SUPPORTING THE PROCESS – QUANTITY

There are currently around 3,700 GP principals inScotland. The number of non-principals is not exactlyknown but it is estimated that there may be around1,000 additional non-principal GPs to appraise.

GP registrars are regularly appraised as part of their GP training year. GP retainees are required to have an annual appraisal with their mentor as part of therequirements of the scheme GP retainer scheme.However, it is anticipated that retainees will becomepart of the new appraisal scheme.

Primary Care NHS Trusts and NHS Boards will beresponsible for arranging appraisal of salaried GPsdirectly employed by them and should use the samemechanism as for other GPs. The quality of theappraisals will be the responsibility of the Primary

22

Care NHS Trust or NHS Board but they must alsosupport employed practitioners in their preparationfor revalidation.

It is estimated that eventually between 4000 and4400 appraisals of independent GPs will take placeeach year.

Experience from work undertaken in educationalappraisal in general practice6 suggests that one sessionof GP time per week can support up to 25 appraisals.This allows for:

• preparation for the appraisal

• appraisal interview

• writing up

• support and contact with appraisee where necessaryafter the interview

• support and networking with other appraisers• education and development of the appraiser.

Between 160 and 180 sessions of GP appraiser timewill be required in Scotland.

6 Dr Malcolm J Valentine:‘Are facilitated personal learning plans a feasible and effective way forward forContinuing Medical Education in general practice?’;MD Thesis; University of Aberdeen; 2001.


23

15 . SUPPORTING THE PROCESS – QUALITY

It is important that the appraisals follow astandardised format of consistent high quality acrossScotland. Standardised documentation, agreed by theNational Appraisal Implementation Group, is beingfinalised for use. Feedback on the process of theappraisal and on the performance of the appraiser willbe a necessary part of quality assuring the process.

The appraisers will be important in advising andsupporting the individual GPs in the revalidationprocess. It is necessary that the advice being given isconsistent and accurate. Appraisers will thereforerequire to be supported in this activity as well as theprocess of appraisal interviewing.

16 . APPE ALS PROCEDURE

In the unlikely event of a lack of consensus betweenthe appraisee and appraiser, the following processshould be followed:

• the appraisee should raise concerns about their ownappraisal with the appraiser in the first instance

• if concerns remain, the appraisee should discussthem with the local appraisal adviser who will try tofind an informal resolution to the problem throughdiscussion and mediation

24

• if this fails, the Medical Director of the Primary CareNHS Trust or NHS Board should be informed andreferral may be made to the local appraisal group forconsideration

• where concerns or views relate to the appraisalscheme as a whole, the proper route is to appeal to the National Appraisal Co-ordinator.

17. SUPPORTING THE PROCESS – T IMETABLE

The aim is to have the first GP appraisals taking placein Scotland before the end of March 2003. It isanticipated that there will be a gradual roll-outprogramme orchestrated by NES and fully operationalby December 2003.

18 . SUMMARY

It is crucial that the appraisal process for GPs inScotland should provide a high quality, consistentservice to support colleagues in their day-to-daypractice and in their preparation for revalidation.Appraisal organised along the lines set out in thispaper will enhance the clinical governancearrangements throughout NHS Scotland, in part byfurther linking the unique practice accreditationscheme with appraisal and revalidation.

w w w . s c o t l a n d . g o v . u k

9 780755 907625

I S B N 0 - 7 5 5 9 - 0 7 6 2 - 0© Crown copyright 2003

Further copies are available from The Stationery Office Bookshop, 71 Lothian Road, Edinburgh EH3 9AZ Tel: 0870 606 55 66

This document is produced from 100% elemental chlorine-free,environmentally-preferred material and is 100% recyclable.

Astron B29035-03-03

Documents

GP Appraisal: A brief guide