GP Appraisals in a Pandemic: What Have We Learnt?

Dr Honor Merriman Looks at How the GP Appraisal Process Has Adapted in Response to COVID-19, and Assesses the Prospects for Further Modifications

In the early days of the pandemic in 2020, all doctors needed to work harder and differently, and many GPs had to work remotely; many healthcare professionals were also unwell, and some died. Although some people thrive on change, many do not, and appraisal 2020 was introduced in 2020 as a simpler model for medical appraisal. It prioritised discussions about how GPs are coping, and allowed their achievements to be recognised and celebrated.¹

The time that GPs were required to spend on gathering and submitting information was reduced, and the expectation for GPs to submit evidence of a minimum of 50 continuing professional development (CPD) credits each year was removed, as was the need to submit details of quality improvement (QI) projects in advance of the appraisal meeting.^1,2 It was estimated that GPs only need to spend about half an hour in preparation, and a template was produced to simplify this.² This article considers how well the changes have worked and whether additional measures need to be considered.

The Appraisal 2020 Model and Information Required from GPs

In advance of the appraisal, the template can prompt GPs to consider:

• the scope of your work—all your roles in which being a doctor is essential
• challenges, achievements, and aspirations over the past year
• personal and professional wellbeing
• reviewing the personal development plan (PDP)—for example:
  • what progress, if any, have you made with last year’s PDP?
  • are there goals that you want to carry forward?
  • what ideas do you have for next year’s PDP?
• CPD—for example:
  • how have you kept up to date across the whole of your scope of work?
  • what are the most significant things you have learnt?
  • have you identified any learning needs that you want to address, or key learning to be shared, and if so, what action have you taken as a result?
• evaluating and improving the quality of your professional work—for example:
  • what have you learnt from reviewing your practice?
  • have you made any significant changes as a result, and if so, how effective have those changes been?
• feedback from colleagues and patients—for example:
  • what have you learnt from any formal or informal feedback you have received, and what, if anything, have you changed as a result? 

GPs also need to provide several declarations, including on:

• health
• probity
• complaints
• performance—for example, you may be asked to bring items to discuss at the appraisal by the General Medical Council (GMC), the Responsible Officer (RO), or NHS England, or you may be asked whether are aware of any current performance concerns under investigation by any professional body.

An example of the appraisal template is included in Box 1.²

Meeting the GMC Requirements for Revalidation

The new appraisal model completely meets the GMC requirements for revalidation, which have not been altered.^3,4

Remote Appraisals

Appraisals are currently being conducted remotely rather than face to face, because of the COVID-19 pandemic. Any secure network can be used; in my experience, Microsoft Teams and Zoom are most commonly used, but WhatsApp may also be appropriate.

Experiences with the 2020 Appraisal Process

As a GP, preparation for my 2021 appraisal was easier than in previous years. I chose to make notes of my learning so that I could demonstrate updates in my knowledge in all my roles as a doctor, but I did not feel bound to estimate how many credits this would equate to. Although I was not required to note these items, it helped me to think through in advance what I might have left out. This meant I had started thinking about future learning goals before the appraisal meeting—ideas that I could discuss with my appraiser. It was a cathartic experience to set down how I had really felt during the pandemic and how I had adapted and learnt.

As a GP appraiser, I was not surprised to find that there were a variety of responses to the new format. Some people preferred to continue with the old system—these were GPs who were used to logging their learning as they went along. Most GPs just summarised their learning highlights; either approach was effective.

For those who had chosen not to submit any information about CPD, I was able to discuss with them how they had updated their knowledge in all of their clinical roles. GPs do not need to ‘bolster their case’, and appraisers should elicit how GPs stay up to date during the appraisal. I found that everyone had kept up to date on COVID-19 guidance and most GPs had stayed abreast of local changes to care pathways. Everyone had a procedure to check for the latest national guidance, for example in NICE guidance and clinical knowledge summaries.^5,6 Online learning and webinars have replaced face-to-face education meetings, and skills in telephone consulting have been a common CPD topic.

Some GPs chose not to take the opportunity to discuss their wellbeing and how they felt during the pandemic, instead viewing COVID-19 as an inconvenience, and declaring that they had carried on as usual. However, most welcomed the opportunity to discuss the problems they had encountered and how they overcame them. Some felt that they needed a change in direction for their career. Others were in need of ongoing support, and I was able to signpost them to local support services and to national schemes for healthcare practitioners.⁷ Discussing these topics helped to clarify the problems, so that appropriate further help could be advised and sought.

Because of the sudden change in work patterns, not all PDP items were completed as GPs needed to offer a different service. This seemed sensible, and setting up new services and running practices differently during the pandemic took priority. These QI projects have continued up to the present as we further adapt to working within the constraints of COVID-19.

What Are the Commonly Occurring Queries About the New Appraisals?

Will This Appraisal Model Continue?

Several GPs have expressed worries that they will be ‘caught out’ if they have not logged any CPD credist for 2 years and it later becomes a requirement. Currently, there are no plans to introduce a set number of CPD credits to be achieved.⁸ The GMC advises that ‘you must be competent in all aspects of your work, including management, research and teaching. You must keep your professional knowledge and skills up to date. You must regularly take part in activities that maintain and develop your competence and performance.’⁹ The appraisal 2020 model supports this approach, and allows GPs to consider the most effective ways to update their knowledge. In my opinion, this is a better stimulus for GPs to think about maintaining their practice, than the narrower CPD credits approach.

Is Colleague and Patient Feedback Still Needed for Revalidation?

The need to present feedback from patients and colleagues has been questioned by several GPs because gathering it can be regarded as an onerous task, but it is still required for revalidation. Some GPs have been unable to source patient feedback during the pandemic, and for those who and need this for a revalidation that is due, the RO will recommend that the GMC defer revalidation, to allow time for these to be completed in the following year. This will not have a detrimental impact on good standing with the GMC. NHS England and NHS Improvement advises that, once it becomes possible to start the process of collecting feedback, patient surveys conducted via email are prefererable during the pandemic. The patients selected should be identified by an independent third party, and the results collated and analysed independently.¹⁰ Formal feedback should be collected in the form of a survey, but any additional feedback should be noted because it is also informative. The GMC explains:‘The purpose of reflecting on feedback from your patients is to help you to understand their experience of your practice. Patients have a unique perspective and their feedback can help you to identify areas of strength or opportunities for improvement. It can help you develop greater insight and self-awareness and challenge assumptions.’ ⁴

Do Complaints Need to Be Discussed?

Any formal complaints that GPs have received need to be discussed during the appraisal. Details of complaints should be anonymised by both the GP and their appraiser, and the discussion should be focused on learning from the event and any resulting changes in practice.¹¹ The GMC says: ‘You must declare and reflect on all formal complaints made about you at your appraisal for revalidation. You should also reflect upon any complaints you receive outside of formal complaints procedures, where these provide useful learning.’ ¹²

Will the Appraisal Be Shorter in Length?

It has become apparent that some doctors expect their appraisal to be much shorter in duration in the revised format. Although the written preparation required by the appraisee has been reduced, the appraisal meeting is not expected to take less time than in the past. The new format of appraisal was implemented to meet the needs of doctors working during an ongoing pandemic. The intention was for the administrative preparation to be less burdensome, but not particularly for it to be shorter. The appraisal meeting still provides rich and meaningful discussion and lasts a similar length of time, depending on what the appraisee wishes to discuss or explore further. Generally, there is greater emphasis on verbal reflection and on health and wellbeing at the appraisal, during what has been an extremely challenging time for everyone.

Have Requirements for Evidencing Quality Improvement Changed?

In the new appraisal model, no information about QI is needed in the pre-appraisal submission, but it will be discussed during the meeting. QI can take many forms and there is no change from the earlier advice. Tools for QI include:¹¹

• reflective case review
• learning event analysis
• review of personal outcome data
• search and do
• plan, do, study, act cycles
• clinical audit.

Demonstrating Competence in All Roles

There has been no change to the information GPs should provide about demonstrating competence; for each of their roles as a doctor, topics that can be covered in the appraisal discussion include:

• an outline of the role
• how am I qualified to carry out this role?
• how do I maintain my knowledge and skills in this role?
• do I have evidence of QI in this role?
• what has gone well in this role?
• what have been the challenges in this role?

Using the Template on its Own

Some GPs have only submitted the completed template² in advance of their appraisal meeting. Using the form is acceptable, but it must be included in the appraisal website of your choice—for example, Clarity—so that the required four declarations can be made, and the appraiser can include the detail needed in the summary of discussion document.

Appraisals for GPs in Different Circumstances

GPs Returning from Practice Abroad

Some GPs who left the NHS to work abroad before the pandemic began have had problems in returning to work in the UK. The travel situation is now improving, but it has affected the ability of some GPs to return to NHS practice and to collect information about their NHS practice, since they have not been able to do any. Feedback surveys for revalidation must be from NHS practice, not from practice abroad. In the past, absence from NHS practice for 2 years or more may have required a period of refresher training.¹³ For the moment, cases will be considered on an individual basis within each designated body.

GPs Who Undertake a Low Volume of Work

For GPs who undertake 40 sessions or fewer per year, the appraisal process remains the same, because the expectation is that they need to maintain the same clinical standards. However, these GPs are asked to complete a separate document before their appraisal,¹⁴ which helps them to reflect on their pattern of work and aims to provide support and reassurance.

GPs Nearing Retirement

GPs nearing retirement are a risk to the maintenance of the workforce. Work is in progress in several areas to encourage these GPs to join the National GP Retention Scheme¹⁵ and to offer them career counselling.¹⁶ Often, GPs who wish to retire early still have much to offer. A discussion about other available roles may allow them to use their skills and experience while reducing the number of 12-hour days they do.

Appraisals in the Future

Nothing ever stays the same, and in the face of a pandemic that seems never-ending, we have no idea of when we will be able to revert to less changeable ways of working.

In the immediate future, remote appraisal meetings will continue as the norm and so will the requirement for GPs to provide less information in advance of their appraisal. The GMC framework for appraisal and revalidation will also remain. A focus on the wellbeing of the GP has been a welcome change and, in my opinion, must stay.

Changes to the Performers List regulations¹⁷ may impact GP appraisal, and it is possible that there will be a change to the format of patient and colleague feedback. In the meantime, we should continue to value and support each other.

Dr Honor Merriman

Senior Appraiser and Clinical Advisor, NHS England and NHS Improvement South East Region