The power of professional clinical reflection

John Sanfey is the Revalidation Lead for NHS England, North West London Area Team and is the Chambers Lead Partner for Central South London, and instigated the cancer diagnosis and led it until recently.

Last year, the London appraisal teams asked GPs to prioritise cancer in their choice of case study within appraisal. There were three reasons: firstly, poor evidence of reflection is the most common reason for deferral of revalidation decisions. Secondly, cancer outcomes in the UK are below those expected in relation to similar countries, especially so in London. The third reason was that clinicians are often unfairly held to blame for the poor figures. The most positive solution to all these problems is for clinicians to become better at reflecting on clinical cases, and to use their professional reflection to drive development within the health service.

The appraisal teams made no attempt to collect information brought to appraisals, which remain private conversations, and rightly so. However, it is clear from appraiser feedback that a large number of useful observations on preventable cancer delays have been made, and that there is considerable potential to improve pathways. Many little delays result from clumsy interaction between primary and secondary care and should, in theory, be easily remedied.

Putting reflection to practical use is beyond the remit of appraisers, and we have handed over control of this whole initiative to the RCGP and the cancer commissioning services who have the full support of the CCGs, the secondary care providers, Londonwide LMCs, Macmillan Cancer Support and CRUK.

This therefore does create an opportunity for locum and salaried GPs to make a big impact on clinical care beyond their personal work. One-third of London GPs are locums; a case study is an excellent way to become involved in practices and CCGs, and to initiate quality improvement. After all, the whole point of the exercise is to create the circumstances where a single, well-reasoned clinical analysis has the potential to cause impact well beyond the personal practice of the individual who conducted the case study, and this can be done just as well by a locum as any other doctor. It is worth remembering that you can seek feedback from the practice or CCG long after a case study has been shared to see what changes have been made as a consequence. If those changes are objective, then you have completed a two-cycle audit. You can ask a practice for permission to scan the last twenty cancer diagnoses and look for a suitable case to study.

The essential element is good, individual case studies. If you have identified a potentially avoidable delay in a patient’s journey to cancer treatment, you can describe this event in an email to It is not necessary at this stage to have completed a full case study; a simple reply is sufficient for now. A GP facilitator will triage the responses and investigate how to put your observations to good use. In many cases this will mean helping you to think your cases right through to their logical conclusions in order to harvest the maximum impact from them.

A conference is planned for later in the year, which you may wish to attend. It will be an opportunity to review progress, share success stories, analyse your own cases and plan quality improvement in small multidisciplinary workshops.

You are encouraged to discuss these cases within your appraisal, but this remains a separate, private process. Appraisal is an opportunity to develop reflective skills and to think through quality improvement ideas with a colleague.

A copy of the current cancer case study template can be found here

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