The GMC’s current appraisal system fails to provide assurance that a doctor remains capable of maintaining safe and effective practice because it is not backed by objective data, says Nadeem Moghal
Appraisal is a decades old manifestation of Fredrick Winslow Taylor’s view of how to measure and improve the worker.
It took the Shipman scandal to link previously poorly valued appraisals to revalidation, turning a contractual requirement into a mandatory expectation through regulatory revalidation for UK doctors in 2012.
The annual appraisal will apparently show that the doctor is capable and safe. Five consecutive appraisals and you are revalidated, retaining the licence to practice.
Whilst we persist with this annual ritual, the private sector from whence all this spawned is beginning to retreat, recognising appraisal as an opportunity cost no longer worth the resources. There are more responsive, engaging and objective ways to appraise, develop and manage staff.
The General Medical Council’s appraisal system is meant to provide assurance to the employer, the regulators, the patient and population that the doctor remains capable and safe to maintain practice.
There is of course value in appraisal, appreciating what went before ie nothing – a moment to reflect and have protected conversations; value that is very appraiser skill dependant.
Lack of objectivity
There is, nevertheless, a structural and fundamental flaw with the GMC constructed appraisal; it is a self-reporting form. A self-reporting form compounded by being devoid of almost any objective data.
The current appraisal cannot provide assurance. Assurance demands objective evidence to back up statements – data to corroborate.
Examine the data submitted. The arbitrary minimum 50 continuous professional development hours evidenced by certificates of attendance to conferences and courses is apparently enough to prove capability.
Doctors have become hungry collectors of certificates of attendance to self-selected conferences and courses. I have a conference certificate for 50 hours (physically impossible, but who’s counting); for giving two talks, and spending the rest of the time a tourist.
But don’t tell the GMC (probity alert – I didn’t claim the hours). Selecting articles read, with the briefest of reflection, if at all, is also evidence of something, all self-reported.
Clinical audit data is also self-selected self reporting; the doctor selects the patient cohort, audits their own work, often work done by a trainee in a dependant hierarchy. Then there is the 360 feedback data submitted in the fifth year when the revalidation button is on.
The arbitrary minimum 50 continuous professional development hours evidenced by certificates of attendance to conferences and courses is apparently enough to prove capability
The doctor chooses who will provide that feedback – colleagues and patients; today is my clinic for seeking feedback… More self-selected self-reporting.
The resulting personal development plan is typically filled with annually repeated fixed statements to do more CPD, and be better with mandatory training compliance.
The appraiser, responsible for testing the validity of the self-reported form, has little if any independent data for triangulation. Assurance without objective data is only self-reported reassurance. Appraisal becomes a pretence or even (unintended) deceit of all those seeking assurance.
A trust board seeks assurance through the Responsible Officer annual report describing appraisal compliance in the organisation – presumably non-executive directors assuming a link to patient safety.
Genuine non-compliance for reasons of belligerence is now extremely rare – losing your licence to practise is a strong motivator of compliance. The board thinks it is assured – of process, not safety, nor value.
On the whole, doctors detest the tick box exercise and only deal with the appraisal bureaucracy when the clock has run down to the last moment.
This regulator-driven national industry is a monster bureaucracy; doctors at Oxford Univeristy Hospitals Foundation Trust at a conservative calculation will be spending at least 9,333 hours, equivalent to 1,167 working days, 2,333 programmes activities, approaching a million in salary equivalent, per year.
This does not include variable additional payments for being an appraiser, RO, designated RO, and appraisal management team resources, and no calculation of the regional and national appraisal workforce turning the bigger cogs.
The appraiser, responsible for testing the validity of the self-reported form, has little if any independent data for triangulation
Now, scale that across all healthcare providers, NHS and private. A huge opportunity cost.
What the GMC is in effect telling the employer, the regulators, the patient and population – that the appraisal self-reporting form, almost devoid of objective data, is sufficient assurance of good medical practice and the right to retain the licence to practice.
The patient and the population can apparently rest assured because at the very least, another Shipman is now less likely to happen. Really?
Or even that the process proves capable safe practice. Really? Doctors can and should be trusted to show integrity when submitting the self-reporting form, but it is by definition reassurance, not assurance.
Provide meaningful assurance
The GMC is not going to let go of appraisals. The GMC has accepted the findings of the evaluation of the first cycle and now aims to focus on improving the quality of appraisal content – the factory is very busy, now improve the product.
The report makes no concrete recommendations on how. But there is a way.
There are dozens of measures already in place in every building, that describe every kind of doctor. Measures generated by simply working in a building, engaging with colleagues and patients, describing the key domains of medical professionalism.
Whilst we persist with this annual ritual, the private sector from whence all this spawned is beginning to retreat, recognising appraisal as an opportunity cost no longer worth the resources
These already existing measures are a better descriptor of professionalism for conversations and developmental use by the doctor with the appraiser, service lead, and medical director. Only when there are measures, is measurable improvement possible.
If the next GMC appraisal-revalidation cycle is about raising the quality and value of the appraisal product, providing meaningful assurance to all stakeholders, including the doctor, and especially the patient, then an objective, evidence-based approach is necessary, and possible.
Only then will the current appraisal pretence stop. Trust me, I know.
I am apprised, have appraised and was once a Responsible Officer. One day I will share all those measures around a doctor.