a GP Appraiser and GP at Vine Surgery, Street, UK; b Mitarbeiter Lehre, Berner Institut für Hausarztmedizin (BIHAM), Universität Bern, Switzerland
All doctors in the UK must have an appraisal from a professional colleague every year. This article explains how the system works, its advantages and disadvantages, and asks whether Swiss doctors should consider developing a similar system.
Why should Swiss doctors be interested?
Some Swiss doctors will be aware that the United Kingdom (UK) has a mandatory, yearly appraisal system for all its doctors. This paper explains how it works and discusses whether Switzerland should consider a similar system.
The UK National Health Service
The National Health Service (NHS) was founded in the UK in 1948, with the aim that good healthcare should be available to all, however poor or wealthy the patient is. That principle still stands today and is one of the reasons that the NHS is so popular with British people. Medical care in the NHS is still ‘free at the point of use’ for all 64.6 million UK residents.
In the UK, family doctors are called general practitioners (GPs), and almost all of these work in the NHS. To become a GP there is a five-year training period after graduation, and then most GPs join a group family practice. Almost half of all fully trained NHS doctors are GPs, and they earn about the same as their hospital specialist colleagues. The UK has a ‘GP-as-gatekeeper’ system: all medical records are held by the GP who, with the patient, decides whether a specialist referral is necessary.
GPs give ‘cradle to grave’ care, and their work has expanded over the last few years: in an effort to reduce healthcare costs, more and more care of chronic diseases such as diabetes, asthma, heart disease and chronic kidney disease has been transferred from specialist to primary care.
Revalidation for doctors
The General Medical Council (GMC) is a statutory independent organisation whose role is to help protect patients, and improve medical education and practice across the UK . To be able to practice, all doctors in the UK must be registered with the GMC and have a licence. Revalidation of all doctors every five years was introduced in 2012, to raise the standard of patient care as well as to help identify any concerns about doctors at an early stage. In the revalidation process, all doctors have to show through annual appraisal that they are up-to-date and fit to practise in their chosen field. It is based on the doctor having an annual, local evaluation of their practice, called the ‘NHS appraisal’. The appraisal and revalidation system is compulsory for all NHS doctors, whether specialist or GP, newly qualified or senior professor. It also includes doctors who are in difficult-to-reach groups, for example locums and those not in regular employment.
Doctors who do not engage in the appraisal process satisfactorily are given a specified amount of time and support to reach the required standard. If they continue to fail to do so, they will be barred from clinical practice.
The NHS appraisal system
The NHS appraisal system looks at the doctor’s professional development, patient care and patient safety. The appraisal process consists of the preparation of supporting information and the appraisal discussion itself, resulting in a mutually agreed summary of the discussion as well as an individualised ‘Personal Development Plan’. The annual NHS appraisal meetings between the doctor and their allocated appraiser, a trained and skilled local senior colleague, typically lasts two hours. Usually doctors have the same appraiser for three consecutive annual appraisals. The appraisal covers four areas of the doctor’s practice:
1. Knowledge, skills and performance: maintaining professional performance and applying knowledge and experience to practice.
2. Safety and quality: contributing to and complying with systems to protect patients and responding to risks to safety.
3. Communication, partnership and teamwork: communicating effectively, working constructively with colleagues and maintaining partnerships with patients.
4. Maintaining trust: treating patients and colleagues fairly and without discrimination, and acting with honesty and integrity.
Preparing for the appraisal
Before the appraisal, doctors need to gather information about their continuing professional development (CPD) and the quality of their work over the past year. This includes six types of ‘supporting information’ (evidence) , and the doctor is expected to provide and discuss these at the annual appraisal:
– Continuing professional development: doctors need to achieve at least 50 hours of CPD a year. CPD can be reading (e.g., journals), discussions in GPs’ practices (e.g., case discussions), on-line learning and postgraduate medical education courses.
– Quality improvement activity: this may be a review of a clinical case, an analysis of prescribing or of referrals to specialists, a ‘significant event analysis’ (an analysis of something that went wrong, or could have gone wrong), or a ‘clinical audit’ (for instance the proportion of patients with hypothyroidism who have had thyroid function tests in the last year).
– Feedback from colleagues: every five years, the doctor has to obtain feedback from colleagues, using a standardised questionnaire which asks other GPs, nurses and staff for written, anonymous feedback.
– Feedback from patients: in this, every five years a random sample of fifty patients the doctor has seen are given a questionnaire. This is analysed independently, and lets the doctor compare their own results with the national averages.
– A review of complaints and compliments: for example, a delayed diagnosis or a ‘thank you’ letter from a patient; this gives the doctor the opportunity to discuss these with their appraiser, learn from them, and improve their practice where needed.
Doctors are expected to gather all this supporting evidence in an online ‘appraisal portfolio’. This portfolio usually also includes :
– A description of the doctor’s work and working environment, in particular any important changes since the last appraisal.
– The doctor’s personal development plans from previous years’ appraisal discussions.
– The doctor’s written commentary on their achievements, challenges and aspirations.
– A discussion of important issues affecting the doctor’s own health and/or that may put patients at risk, for example an alcohol problem.
– Certificates from recent resuscitation and child protection update courses.
Most GPs take about eight hours to gather the supporting information for their appraisal portfolios, and some find it burdensome. However, it is the doctor’s reflection on the information that will help the doctor and appraiser to identify of areas for development and improvement.
The appraisal discussion
The appraisers – experienced, respected and motivated GPs who have been on a special training course – have regular meetings to discuss best appraisal practice and to standardise their approaches. The appraisal discussion is confidential, except in the rare cases that the appraiser identifies a serious ongoing risk to patients or thinks that the GP is not well enough to practice. Having reviewed the doctor’s supporting information, the appraiser is able to support, guide and constructively challenge the doctor – a very important part of the appraisal process.
The Personal Development Plan
An important outcome from the appraisal is the doctor’s Personal Development Plan (PDP). In this, the doctor and appraiser decide on the GP’s main learning goals . This is made up of at least three agreed objectives, which should relate to specific activities, be measurable and attainable, and include what the doctor both wants and needs to learn. The PDP document records what the objectives are, how they will be achieved (personal study? lecture? discussion with colleagues?), when they will be achieved by, and any potential barriers to achieving them. Doctors know that the PDP, and evidence of completion, will be reviewed a year later: What was achieved? What wasn’t achieved, and why?
The NHS appraisal – formative or summative?
One controversial aspect of NHS appraisal is whether it should be ‘formative’ (designed to help the doctor to identify their strengths and weaknesses, and to discover areas that need further development) or ‘summative’ (evaluate the doctor’s learning and performance, compare it with a standard or benchmark, and then give a pass/fail decision) . Should it be a way to help all doctors to improve? Or should its main aim be to identify ‘bad’ doctors?
How much does it cost?
The majority of costs are paid by the NHS, for instance the payments to appraisers, which are typically £500 (CHF 650) per appraisal. The appraised doctors themselves have to pay for use of online appraisal platforms, typically £50 (CHF 65) a year.
What are the advantages?
Appraisal at its best is a supportive, positive and motivational experience. There is evidence that appraisal of doctors in the NHS is leading to changes in doctors’ and healthcare organisations’ practice that results in safer and better care for patients , and it can help doctors to have a good sense of perspective on their work and work-life balance. It provides an opportunity for doctors to reflect on their continuing professional development and their career. Importantly, the appraisal system helps reassure the general public that all their doctors are taking part in regular, effective learning activities that keep them up-to-date with guidance on best practice.
Examples that we have seen of how our own British colleagues have been helped by their appraisals include:
– a doctor who, despite doing an excellent job, had become low in mood and was losing confidence found that the positive feedback given by his appraiser helped him to recover and believe in his ability again;
– a younger colleague who had difficulties in her relationships with her colleagues was given advice on how to use a mediator to resolve the issues;
– a more senior doctor was able to use the appraisal preparation process to identify that he had a gap in some specific medical skills, and the appraiser was able to advise him on how best to work on those.
And what are the disadvantages?
Being appraised is not something that most British GPs look forward to – they feel that they work hard and do their best, so being challenged, even constructively, can be an uncomfortable experience. Some resent the amount of effort and time needed to prepare for their appraisals, which is on top of their normal workload. There is a financial cost to the NHS, and there are concerns that the appraisal and revalidation system may not identify all the doctors who are giving care that is below an acceptable standard.
How do the Swiss and UK systems compare?
In Switzerland, continuing medical education (CME) is mandatory for all doctors who are holders of a Swiss or foreign ‘Weiterbildungstitel’, who have completed their residency and are now working in a medical profession in Switzerland. The Schweizerisches Institut für ärztliche Weiter- und Fortbildung (SIWF) recommends 80 hours of continuing medical education each year, and, as in the UK, doctors need to be able to provide evidence for 50 hours of that. This allows Swiss doctors to renew their postgraduate training diploma (Fortbildungsdiplom). Without this diploma, they may get a warning or a penalty of up to 20,000 CHF, and they may lose the right to claim payments from their respective health authority and health insurance companies. In the UK, doctors who do not fulfill the requirements for appraisal and revalidation may lose their licence to practice.
The biggest difference between the two systems is that UK doctors, as well as needing to provide evidence of their continuing medical education, must have a yearly face-to-face appraisal from a senior colleague, give evidence of how they have responded to feedback from patients and colleagues, discuss any health issues that may affect their ability to practice safely, and declare any conflicts of interest.
Should Swiss doctors consider introducing an appraisal system?
The benefits that British patients and their doctors have gained from appraisal are likely to be just as applicable to our Swiss medical colleagues and the Swiss health system. We suggest that Swiss health organisations consider developing and evaluating an appraisal model that is relevant to their, their patients’ and their doctors’ needs.
Image d'en-tête: © Adonis1969 | Dreamstime.com;
Adresse de correspondance
Med State Exam MD DRCOG MRCGP
GP Appraiser and GP at Vine Surgery
Hindhayes Lane Streeet
UK-Somerset, BA16 0ET
1 General Medical Council. About the GMC: General Medical Council; 2016. Available from: http://www.gmc-uk.org/about/index.asp
2 General Medical Council. Supporting information for appraisal and revalidation. London: General Medical Council; 2012.
3 NHS England. Doctor’s medical appraisal checklist. Leeds: NHS England; 2016.
4 Tasker F. BMJ Careers – How to prepare a personal development plan. London: British Medical Journal; 2015 [21 July 2017]. Available from: http://careers.bmj.com/careers/advice/How_to_prepare_a_personal_development_plan
5 Khisty N. BMJ Careers – Appraising appraisal. London: British Medical Journal; 2016 [21 July 2017]. Available from: http://careers.bmj.com/careers/advice/Appraising_appraisal
6 Pearson K. Taking revalidation forward: improving the process of relicensing for doctors. London: General Medical Council; 2017.
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