NHS appraisal is a formative process with which many GPs across the UK are already very familiar. In many ways, it’s similar to an annual car service, tuning up our performance to pretty much the best it can be. Servicing a car is generally time-consuming and expensive, and relatively subjective in that the quality of the service can vary between different garages. But there’s probably little variance in what most of us would recognise as a good service for our car. And continuing this analogy, revalidation is very similar to a yearly MOT - albeit every 5 years rather than annually. Just like an MOT, revalidation is a summative assessment - you pass or you fail - and is based on a well defined minimum set of requirements. With an MOT, each constituent criterion is also pass or fail. Broken indicator? Fail. Crack in windscreen 9mm in the A-zone? Pass. 10mm? Fail. It’s all very clear cut, and based on years and years of experience of how legislation has made for safer roads. But in that respect, NHS revalidation is very different. It’s extremely difficult, if not impossible, to quantify most of what GPs do. We are, after all, not machines, and neither are our patients. What we do, what we deal with, every day, is infinitely variable. Unlike the car - a simple machine designed 100 years ago by humans - human illness is the result of 4.5 billion years of evolution. We can’t even agree on the best management of a sore throat! A summative process based on something as subjective as the behaviour of ill people has never been done before (at least, not in any modern, democratic civilised country) and is based on criteria that in many, if not all, cases is incredibly subjective and is likely to change considerably over the course of just one revalidation cycle of 5 years.
Which all leaves many of us feeling frustrated and confused at having to participate in a scary new process that just doesn’t seem to be promising what it’s supposed to deliver. So, considering that not one single GP has officially been revalidated - how could they when it’s not yet even started? - what’s one to do?
Fortunately for us, NHS appraisal forms the basis of professional coaching to get as many of us through revalidation as possible. So, given that there are so many unknowns with revalidation, and that the people of this country, through government legislation, have demanded of us that we must take part in this process, we have little choice but to participate.
For GPs, the single most important factor that will define how straightforward or not the evidence we’re expected to collect for appraisal - and thus revalidation - will be, is whether or not one is ‘practice-based’. If you consider yourself as in some way ‘belonging’ to a particular practice or managed organisation, such as an out-of-hours centre, GP surgery or GP locum chambers (GP locum chambers are often described as ‘virtual practices’), or some certain locum agencies, then it’s probably relatively safe to say that you’re in good company, and that there are already established systems and processes that you will be able to tap into for support. But if you’re an independent locum, handling all your own bookings, feedback, complaints, education, etc, you are, very likely, going to need to surround yourself not only with some nifty ways of collecting this sort of evidence, but also to show, at some stage, that you have sufficient mechanisms in place to ensure that, should you be involved in an adverse incident at a practice, you are not conveniently excluded from the practice’s own examination of the incident.
As any summative process has to apply equally to all those it assesses, and NHS revalidation is designed to assess the performance of doctors working in teams, a non practice-based GP, such as a conventional independent locum, will need, in many cases, to produce evidence with other colleagues as part of a team. In other words, rather than NHS revalidation having two different standards, it’s down to every GP to make sure they make allowances in the way they practise to ensure the evidence they produce is compatible with everyone else.
The requirements for revalidation as laid out by the GMC require evidence from six different domains, and although it’s possible to collect all of this evidence on one’s own, you may find it easier and more rewarding as an organised group.
As a group, “crowdsource” local educational events and divide up the ones to attend. Take notes and share the learning with your colleagues, either online or at regular group meetings. Remember that reflecting on what you’ve learnt, and sharing that learning, all increases the educational impact and boosts the credit for it.
Audit, basically. Go for a few prospective audits rather than a long-winded conventional one. Agree some topics, create some paper or electronic proformas, and collect the data as a group. Once you have enough data, go through the usual process of analysis, reflection and change, then repeat the cycle, and work on the final outcomes, again as a group.
Feedback from practices; requests from managers who don’t want to book you again; prescribing errors; breakdown in patient management: anything like this that you come across - whether it’s feedback about you or from you - you should record and then work through with your colleagues. Involve as many relevant parties as needed, and always produce a final outcome or resolution that is owned by all those involved.
As a group of colleagues, develop a combined set of terms and conditions that ensures practice managers always give each of you a unique username and password. So much easier if you can employ someone to enforce this on your behalf. That way, all your notes are attributable to you only, not a dozen other ‘anybodies’ who could have written in the notes. You’re now in a position to ask other GPs to give you some valuable feedback. And ask the other members in your group to feedback on how you reflect on significant events, etc in your regular meetings.
Get a manager, or someone in your group, to kit you all out with something to formally identify you to patients. Name badges, doorplates, or what a lot of chambers tend to do is create laminated cards with a short precis explaining you’re a real GP, something about you to hand out to every patient. Now you’ll be in a really good position to collect patient feedback - they can identify and relate to you, rather than complain that they were “expecting to see a GP, not just a locum”.
Complaints & Compliments
Unless you and your colleagues’ bookings all go through the same person, you’re unlikely to find out if a practice has specifically asked not to book you again. It’s all too easy for a practice to head a complaint off at an early stage by reassuring the patient that they’ll never book the locum again, with the locum never having had the opportunity to learn from the experience. Again, when you’ve worked through the complaint with the relevant people, discuss it with the colleagues in your group, recording all your reflections and learning points.
No one had ever described revalidation as fun, but at least by doing it as part of a team it has less chance of being a nightmare. So if you haven’t done so already, it might be worth having a think about which of the other GPs you know you’d like to share revalidation with.
This article was first published in the October/November of the NASGP Newsletter