GPs may fear criticism from medical appraisal, causing an aversion to clinical risk that piles more pressure on workforce capacity, but appraisal can actually lead to increased skills and care quality, writes John Sanfey

Woman with empty mind

GP reflection

Appraisal can contribute to a fear of criticism that leads some GPs to reduce their exposure to clinical risk; this can create a vicious cycle of reduced workforce capacity and increased pressure on GPs.

‘Now there is considerable support for the idea that it can become part of the solution’

But this negative cycle can be broken with a better understanding of the principles and purpose of medical appraisal.

Appraisal is intended to develop reflective practice skills – the very skills that equip a doctor to reduce clinical and personal risk – as well as improve quality.

Case for urgency

There is a consensus that general practice is seriously overburdened, and that it will take some years to deliver increased numbers of GPs, but there are reasons for greater urgency.

Firstly, it will be difficult to successfully implement the transformative, multidisciplinary plans recently published in the NHS Five Year Forward View without the active engagement of the clinical workforce.

‘The reflective capacity of individual clinicians remains a largely untapped resource within the NHS’

GPs in particular lack the “headspace” to think beyond navigating the day’s demands safely, without losing that all important sense of clinical excellence.

Secondly, the fear of medico-legal mishap increases with clinical demand, and many clinicians have responded by reducing their clinical availability, which only serves to increase the pressure on others.

Appraisal and revalidation contribute to many GPs’ fear, a fact that came to light recently when NHS England London area teams suggested GPs consider prioritising cancer cases in their appraisals. That triggered a useful debate on the perception of appraisal, and now there is considerable support for the idea that it can become part of the solution, rather than one of the problems currently swamping primary care.

Appraisal, revalidation and performance explained

  • NHS England is responsible for managing both the appraisal system and the performers lists of doctors.
  • Appraisal is the facilitated, professional self-development of doctors through reflective practice.
  • Lack of evidence of reflection is the commonest reason for deferral of a doctor’s revalidation.
  • Reflection is the process by which doctors identify appropriate areas for improvement, which range from simple learning needs and general quality improvements to the root cause analysis of serious untoward incidents.
  • Revalidation is granted when doctors demonstrate that they can be trusted to monitor and maintain their own performance with appropriate reflective insight.
  • Lack of insight is the most common reason for escalation in performance investigations – without insight, a doctor cannot explain convincingly how a particular adverse outcome is unlikely to recur.
  • Many of the events that lead to serious sanctions against a doctor have never been discussed in appraisal.

There remains a sense that doctors should not raise issues in appraisal that might be used against them during a performance or complaint investigation.

If doctors become better at reflection, the following outcomes should follow:

  • fewer deferrals of revalidation;
  • reduced need for escalation of performance procedures because more of the issues of concern will have already been addressed with better reflective skills by the time they come to formal proceedings;
  • more innovative quality improvement ideas from within clinical practice; and
  • general practice becomes more attractive for recruitment and retention, with increased capacity and clinical availability.

Doctors already reflect on clinical cases and generate improvement ideas in their practices, peer groups and clinical commissioning groups; but evidence from appraisal shows that these discussions and case studies are often hurried, superficial, private and undocumented.

The reflective capacity of individual clinicians remains a largely untapped resource within the NHS.

Developing networks

If individual clinicians were better at reflective analysis and more open to sharing and developing their insights within networks, not only would they be better equipped to self-monitor, but it would become possible to develop clinical intelligence networks that generate new quality improvement ideas more closely linked to the needs of clinical practice.

All the structures necessary to achieve this are in place, including an appraisal system designed to facilitate the self-development of doctors through reflective practice.

Health Education North West London (or HENWL), the London-wide local medical committees, several CCGs and the Practitioner Health Programme have all expressed an interest in working with London’s appraisers to develop ways of improving clinicians’ ability to learn from clinical incidents, cases etc, using existing opportunities including the annual appraisal.

‘Reflective practice has important potential benefits for both individual clinicians and the health service as a whole’

HENWL has allocated educational leads to each of north west London’s CCGs. Multidisciplinary team meetings are ideal for appraisers and educational leads to work with CCGs to learn to maximise learning from important cases. A similar capacity can be developed at practice level.

The Cancer Case Study in Appraisal initiative is a London-wide project with the dual purpose of improving cancer outcomes in the capital and demonstrating the power of a formal and disciplined case study.

Some GPs have already made contact with secondary care to discuss the implications of their reflection, and it is hoped that during 2015 there will be joint workshops provided to allow clinicians to distil and develop their analysis jointly with secondary care, commissioners and academics.

London-wide local medical committees have suggested jointly hosting events of this kind.

Unleashing latent potential

All of these initiatives represent the means to unleash and channel the massive latent capacity of reflective practice within the workforce, currently held in check by workload pressure and fear of the consequences of exposing areas for improvement.

Reflective practice has important potential benefits for both individual clinicians and the health service as a whole. Individual doctors who understand how to identify areas for improvement have the insight necessary to overcome future performance concerns that arise in the hurly burly of modern practice.

‘Clinicians will provide a rich source of clinical intelligence for academics and commissioners’

By having the confidence, time and headspace to share reflective speculation more openly through networks, clinicians will provide a rich source of clinical intelligence for academics and commissioners. 

Workforce capacity is likely to increase both immediately and long term as general practice becomes less frightening and more attractive in terms of recruitment and retention.

The action required to achieve this is simply to communicate that appraisal is the means to develop reflective practice skills, and revalidation the reward for showing them.

Dr John Sanfey is revalidation lead of the NHS England North West London Area Team