Two years after the formal introduction of NHS revalidation, NASGP appraisal and revalidation lead and locum GP Sara Chambers recounts her experience of appraisal, and how this has fed into the development of NASGP's AppraisalAid.
Over one fifth of licensed doctors will now have been revalidated, and on the surface all seems to be running smoothly. Most doctors, so far, seem to be getting positive recommendations, although the deferral rate is running at 18% and there are rumbles that the coming years could be more challenging as “less engaged and more difficult doctors with performance issues” enter the system.
How has the experience been for sessional GPs, especially the estimated 17,000 GPs who work as locums?
Information is difficult to find. Even the number of locums is an estimate, as this group of GPs is not officially counted. However one can imagine that for many freelance GPs, gathering sufficient supporting information to satisfy your appraiser and Responsible Medical Officer (RMO) to make a positive recommendation to the GMC to revalidate you holds some special challenges, particularly in the areas of quality improvement activities, significant event audit and colleague feedback.
I am a GP locum working in up to 40 different practices a year, and was revalidated in August 2013 and if you would like some unsolicited advice on how I found the experience, the preparations I made and how it has changed my approach to appraisal then please read on. There is a happy ending.
No bells or whistles
My first revalidation surprise was the lack of fanfare involved in this much anticipated event. In fact, it wasn’t an event - just an email from the GMC telling me the good news. I had pictured interviews and handshakes but revalidation, at the business end, is a virtual process. Your appraiser signs off that you have presented sufficient supporting evidence at your appraisals, and the RMO then has to decide whether to make a positive recommendation to the GMC using information from your appraisals and local knowledge of any performance issues. The recommendation goes to the GMC, who check their own records and then have the final say on whether you are revalidated.
From dreaded appraisal to meaningful learning
You can see from this that appraisal is essential to the revalidation process. So appraisals have shifted slightly from a formative process with cosy, supportive chats to a summative event, having a monitoring edge, though many appraisers seem keen to maintain their supportive role.
Having discovered that my revalidation date was fast approaching, it focused my mind to sharpen up my approach to appraisals. I’m of a certain age, I have had 10 appraisals and would not consider myself an early or easy adopter of IT gadgetry. In bygone years, my appraisals were paper exercises involving scattered piles of A4 and old cuttings from journals which spent most of the year collecting dust before being hastily assembled into a clunky appraisal toolkit the month before my appraisal. It was a headache, felt like a separate task in addition to my real learning activities, and I always felt short-changed that the CPD credits I struggled to record did not really capture the daily learning moments – the quick chat with a specialist about Bell’s palsy, looking up how to manage restless legs etc - all those activities that we all do and just see as part of the job.
If you recognise yourself in this begrudging and haphazard approach to appraisal, then take heart. Two years on, I now firmly believe that if you get excited about learning new things and like to turn that into better care for your patients - which let’s face it, is most of us - then appraisal does not have to be an onerous or irrelevant annual task.
Getting things done
You need a system for capturing all that learning you do automatically on the job. I desperately needed this to boost my recording of CPD credits. But now, unexpectedly, it’s become more than just making my appraisal easier. It has changed the way I work . Nowadays, rather than my appraisal learning being something stagnant I tuck away and dust off once a year, my learning record is a living, breathing entity which I carry with me via cloud-based document storage. It has become something of a second brain that I constantly refer to, amend and use in consultations. And everytime I use it, I can easily record my activity and add up those CPD points. Except now I don’t think of this as appraisal work - it’s just what I do.
Sure, there is still some administrative humbug getting this transferred into the electronic toolkit but the stress and time involved have been reduced tenfold.
Quality improvement creativity
Some quality improvement activities (QIA), such as prospective audit, can be done alone, and very useful they can be. But the key to many activities is having colleagues either through links with practices, GP learning groups, GP locum chambers or virtual colleagues via organisations like the NASGP. Ideas, discussion, case reviews, group projects, evidence of working with others and just some fun and moral support, all of which can be turned into rich pickings for supporting evidence in your appraisals. Similarly, you cannot engage in a significant event audit in isolation.
Leading up to my revalidation, QIA was still under the shadow of the requirement for full cycle audit. This was obviously a fearsome logistical challenge for locums and one that often did not lead to meaningful learning or change for freelance GPs. However, the grip of audit is loosening and the door is open to many other activities. My appraiser was bowled over by a log of patients of interest I had seen and followed up on outcomes, developing some into case reviews or condition-based reviews.
So my other epiphany was that as locums, we are the experts at how we work. No-one else really knows what we do. There is no prescribed list of QIA we must undertake. We have the opportunity to really shape the type of quality improvement evidence we take to our appraisals, making it both meaningful to us and our patients, whilst also meeting our appraisal and revalidation requirements.
The NASGP has developed AppraisalAid; CPD and appraisal resources to support freelance GPs, as well as tips on developing your own mobile learning capture system and ideas for QIA. There are probably as many good ideas for QIA as there are sessional GPs and it would be wonderful if any of you with ideas would share with your colleagues.
Enjoy your appraisals. Really.
Sara was a salaried GP for 4 years, and has worked as a locum GP since 2001 in over sixty different GP practices. As well as NASGP’s appraisal and revalidation lead, and mother to twins, she is also the brains behind NASGP’s Practeus platform.
Sara’s an avid reader, especially fiction, history and trains (yes, trains); loves walking, pilates and beans on toast with cheese.