Clinical Governance in Action - (2005) Volume 13, Issue 3
Clinical Governance Director
CME Tutor
North East Lincolnshire Primary Care Trust, Grimsby, UK
Received date: 05 July 2005; Accepted date: 25 August 2005
The paper reflects on the experiences of a primary care trust in developing an appraisal programme. The initial objective was to utilise the positive opportunities of appraisal, in supporting both the individual general practitioner development and, as a positive consequence, the enhancement of local service delivery. The paper outlines the local approach, with the development of the personal development review (PDR) and details the experiences within Year 1, with the high level of uptake by local GPs, and reflects on the further progression of the programme in Year 2 and Year 3, with the impact of the updated national guidance and the anticipated linkage of appraisal to fitness to practise and revalidation. The paper details the objectives underpinning the local appraisal programme and reflects on what factors have contributed to the success to date. The developmental role of appraisal and its link to revalidation and registration are now perhaps less clear than they were a year ago. Further guidance is awaited to appropriately support the next step with regard to local appraisal programmes and their facilitation of individual GP development and, as a positive consequence, local service improvement and their appropriate links to the anticipated national revalidation process.
appraisal, engagement, flexible approach, group review, local approach, personal development review
What is appraisal?
Appraisal is an opportunity to consider progress regarding previous objectives and to discuss future aspirations
The role of appraisal
As Sir Liam Donaldson outlined, with the introduction of the General Practitioner (GP) Appraisal Programme, there are significant opportunities to be grasped. Within the update of 1 March 2002 he indicated that appraisal will be a positive and supportive developmental process, a constructive dialogue structured in such a way that those being appraised have the opportunity to reflect on their work and consider any developmental needs.[1] It offers individuals the chance to assess their career path and consider how they might gain more job satisfaction from their current role. By giving feedback on performance it provides the opportunity both to identify any factors that adversely affect performance, and to consider how to minimise or eliminate their effects.
Local approach
The local programme
As a locality we looked to utilise the proposed GP Appraisal Programme and the clear objectives by Sir Liam Donaldson to further support the local clinical governance agenda
Philosophy
By the introduction of a local appraisal system, in line with national guidance, we intended to further consolidate the local philosophy of clinical governance, in which we look to create a positive local environment that supports the development of all health professionals.
To deliver our philosophy it was essential that our local appraisal system had a number of key characteristics including:
•supporting personal development
•achieving local ownership and confidence
. engagement of GPs in the development of the local programme
•a practical and useful framework
•focusing on developmental outcomes
•integration into the overall clinical governance framework
•utilisation of local good practice.
Practical framework
To implement our philosophy in a practical manner, we provided our GPs with the opportunity to undertake what we described as a personal development review (PDR). The rationale behind the PDR was to effectively integrate the appraisal system with the personal development programme, already established for local GPs. The intention was for GPs, within their appraisal, to identify objectives that would then be delivered by the personal learning plan within the following year.
What is the PDR?
The PDR is outlined in Figure 1.
Figure 1: Personal development review
It was also acknowledged at this stage that if the PDRwas to achieve credibility and be seen to be useful, personal and support individual development, it was essential that it was supported, as appropriate, by the practice/primary healthcare team (PHCT) and primary care trust (PCT) development plans. This is outlined in Figure 2. North East Lincolnshire Primary Care Trust covers a population of approximately 170 000. There are 34 practices encompassing GP principals and their staff. Practices are aggregated into seven PHCTs, consisting of practice populations of approximately 20 000 (one team is a double PHCT).
Figure 2: Some of the multiple links within the development programme
The PDR programme was voluntary but the local approach to appraisal, with the establishment of PDR, created an opportunity for all local GPs to become involved in a sensible, effective and realistic appraisal programme, the development of which we felt would mirror the development of our local GPs undertaking the programme.
Choice
The PCT, by its GP appraisal policy, developed a local approach which it felt was a useful, realistic and integrated framework for supporting GP development. However, all GPs were given the choice of opting for the local approach or following the national programme. [2]
Flexible approach
At the start of the programme, we imagined that the majority of PDRs would be undertaken individually. However, within the consultation period, a number of practitioners highlighted that they may wish to undertake their PDR as a practice (see Tables 1 and 2). To maximise local expertise and experience, this was incorporated into the programme. However, within this format it was highlighted that it was essential, within the review process, that each individual generated their own PDR. We wished to support the group format as this reflected local good practice and also promoted the opportunity for support of each individual programme by the practice team, thus enhancing professional ownership of and confidence in our local appraisal system.
Table 1: Format of the PDR for GP principals
Table 2: Format of the PDR for salaried GPs
Year 1 experience 2002/2003
Content of the review
In linewith national guidance, the review addressed all elements of the framework of the General Medical Council’s (GMC’s) good practice core headings of:
•good clinical care
•maintaining good medical practice
•relationships with patients
•working with colleagues
•teaching and training
•probity
•health.
•The development of an action plan, to be implemented by the GP’s personal development plan.
•Mutually signed off by reviewer and reviewee.
Reporting mechanism
The PDR itself is confidential. However, to demonstrate the undertaking of the review and facilitate appropriate support of the outcome, a brief report was generated.
This was retained by the reviewee, and a copy forwarded to the clinical governance lead. The written summary included:
•a synopsis of achievement in the previous year
•an action plan with clear objectives to be pursued by the reviewee over the next year – this to form the key elements of the personal development programme
•actions expected of the PCT to address needs in the local context
•a joint declaration that the PDR has been correctly undertaken.
Creation of a network of reviewers
Within the consultation process a recurring theme was the suggested development of a network of reviewers across the PHCTs. It was anticipated, given feedback, that in the majority of cases, the PDR would be undertaken by an identified reviewer from the host PHCT. However, the choice of reviewer was to be determined by the GP undergoing their PDR, and could be selected from any one of the reviewers within the PCT (11 in total).
Support for the reviewers
Our local approach to appraisal, the PDR, has been very much a process of evolution. This is further highlighted by our PHCT approach to the implementation of the programme, with the development of a team of reviewers across the PCT. Those GPs identified by their PHCTs as potential reviewers were initially resourced to undertake a local training programme, and following the onset of the PDR programme met regularly with the continuing medical education (CME) tutor and clinical governance lead for feedback and ongoing support.
The practical support structure for our local appraisal system, with the CME tutor and clinical governance lead working together to support the group of reviewers, has been fundamental to the success of the programme. Encouragingly, the model we developed locally reflects the suggested model of approach outlined in the paper of Dr Amar Rughani Supporting GP Appraisal – a working document for the South Yorkshire & South Humber Deanery.[3]
Uptake
All local GPs undertook the PDR programme. The first year programme culminated in an open meeting for GPs, which was a further opportunity to reflect on the first year’s experience and consider the appropriate next steps for the development of our local programme. In conjunction with establishing Year 2 of the programme, the meeting considered the options available for supporting the action points identified by GPs to be undertaken by their PHCTs and PCT to facilitate the delivery of their personal learning plans.
Detailed below are the key action points that were agreed within this meeting.
Key points
•Consolidate the developmental approach and supporting framework: it was supported to maintain the developmental nature of the programme and consolidate the key characteristics that were felt to have led to the success to date:
– developmental approach
– links between CME tutor and PCT GP appraisal lead
– utilisation of the PHCT structure
– network of reviewers
– the opportunity for both individual and group reviews, building on good practice.
Next steps
•Link to revalidation: A Licence to Practise and Revalidation for Doctors published by the GMC in 2003 highlighted the opportunity to utilise appraisal by individual doctors to demonstrate their fitness to practise and hence to achieve a licence to practise.4 It is, however, important to acknowledge that all doctors have the choice to use either the appraisal or an independent route.
The consultation period undertaken within North East Lincolnshire PCT endorsed the view that it is both logical and helpful, given our local establishment of an appraisal programme, to advocate to our GPs that they may satisfy anticipated future revalidation requirements by the use of the local scheme.
•Updated documentation: inthe light of the guidance provided within A Licence to Practise and Revalidation for Doctors, there was a requirement for documentation utilised within our local scheme to be updated.[4] In line with our local philosophy, we chose to utilise the South Yorkshire and South Humber appraisal documentation.Within Section 4, this documentation incorporates a personal development plan. This was selected as it would allow an individual doctor undertaking their PDR to also undertake the personal learning plan, therefore providing the opportunity to undertake and ‘sign off’ the personal learning plan. The integration of the personal learning plan within the PDR was clearly a further extension of making the appraisal programme practical and useful. However, this created a significant challenge to the practical undertaking of the appraisal, while also putting a greater responsibility on the reviewer. The role and input of the CME tutor have been essential within this. An ongoing training programme has been developed to support our reviewers to facilitate the effective generation of a personal learning plan as appro-priate within the appraisal.
With the reviewee’s consent, all personal learning plans are shared with the CME tutor. The facilitatory role of the CME tutor and his support of the reviewers has, we feel, amplified the tutor’s historic direct input to the establishment and/or further development of personal learning plans for individual GPs. By this arrangement, the historic one-to-one relationship between the CME tutor and GP has, where appropriate, converted to a number of GPs, with the catalyst being the reviewers undertaking the PDRs. However, all local GPs who elected to, or where it was identified as an action plan of their personal learning plan, made additional arrangements to meet with the CME tutor to support their ongoing personal development.
The Year 2 experience and beyond
Within the first year of the programme, our principal objective was to gain the professional confidence and ownership of the local scheme by GPs, utilising relatively simplified reporting arrangements with the principal focus of gaining awareness of the significant opportunities that an appraisal programme linked to a personal development plan would provide. With the introduction of the updated documentation within Year 2, understandably there were some reservations that this perhaps was now becoming a more bureaucratic process.
This was, to some extent, offset by the opportunity to practically integrate the personal learning plan as part of Section 4 within the appraisal or PDR.
With Year 2 of the programme, the PDR programme was again utilised by local GPs. We did, however, experience some slippage within the completion of the programme. This, we feel, was strongly influenced by two factors – the increased training requirements for our network of reviewers and the required commitment of local GPs to complete updated documentation.
At the time of writing we are coming to the close of the third year of the programme. Again we have experienced a degree of slippage, which very much reflects the issues highlighted above. Anecdotally there has also been some confusion concerning the historically established understanding of the arrangements between appraisal and revalidation, following national coverage of the review undertaken by Dame Janet Smith as part of the Shipman Inquiry.
What factors have contributed to the success to date of the programme?
From the outset we looked to achieve local professional confidence and ownership of our local approach to appraisal, the PDR. This, we feel, has been facilitated by a number of key components.
•Engagement of local GPs: from the outset, when the draft PDR programme was proposed, we have engaged local GPs, whose feedback influenced the initial programme and, via annual reviews and further feedback, has facilitated the appropriate ongoing refinement of the programme. This has also allowed the most effective integration of updated national guidance, while maintaining the local identity of the appraisal programme.
•A developmental approach to the programme: reflected by the utilisation in Year 1 of simplified reporting documentation with, in the light of the updated national guidance and later fitness to practise documentation, a progression to a more comprehensive documentation format. The stepped approach achieved early local confidence and ownership which have supported the later progression of the programme.
•Identification of reviewers for the programme by each PHCT: as the reviewers were identified by their PHCT, not all had historically been directly involved in GP education or a lead role for the PCT. This provided an opportunity to expand the cohort of local GPs taking a lead responsibility for the development of their peers and, as a positive consequence, the wider primary care trust. These reviewers were trained by the CME tutor, supported by the GP appraisal lead. Utilising the PHCT structure in this way also enhanced the ownership of the programme by making it more of a ‘bottom-up’ process.
. Utilisation of group reviews: with the establishment of the programme we took the opportunity of sharing local good practice by utilising the experience of some local practices who had already undertaken personal learning plans as a practice group.
We felt it was logical to build on this, as this would improve the professional confidence and ownership of the programme and practically allow each GP within their practice to support their colleagues delivering the action points identified and agreed within their group review.
The introduction of group reviews for appraisal also augmented the practical philosophy underpinning the programme that the PDR should support the day-today working of individual clinicians. Their sharing of individual objectives and proposed action plans within their group review would allow this to be practically supported on a day-to-day basis.
In addition, this approach, as was anticipated, has strongly supported the links of the GP’s appraisal to the practice and, where appropriate, PHCT development plans, therefore again ensuring a joined-up approach both for the individual, and for the practice team members as a whole (see Figure 2). Also, it has been noted that those GPs undertaking group review have undergone, where appropriate, a challenge process of their individual personal learning plan to ensure it is in tune with the development of their practice. This, on reflection, does not appear to have created a negative tension with regard to the individual’s personal development but perhaps has led to a degree of realism and also, as outlined above, the opportunity for practical support from peers as well as, by publicly identifying their objectives, the motivation to deliver within the timescales.
In addition, group reviews have highlighted the opportunity for other benefits of sharing, including sharing personal learning, aspirations and hopes for the future so that work can be mutually advantageous to the practice, and to avoid unnecessary repetition of work unless that was desired by individuals. Interestingly also within group reviews, partners have in a positive way highlighted with surprise the hopes and aspirations of each other, and this may not have come to light in any other arena. It is surprising how little insight some doctors have into the positive impact they have on other members of the practice, and the group reviews provide the positive opportunity of highlighting this.
. Evolution of group reviews: within Year 2 of the programme, the adoption of South Yorkshire and SouthHumber appraisal documentation presented a potential practical challenge to the dynamics of the group review. However, this was overcome by the framework detailed below:
– the appraisal paperwork is completed as individuals (preferably on a computer, to provide the opportunity for effective yearly updating of the documentation)
– it is shared by the GPs before the reviewer visits (strongly recommended)
– it is sent to the reviewer for perusal prior to a protected time meeting. This allows the reviewer to compare with last year’s personal learning plans to pick up themes that are occurring throughout
– it is sent to the reviewer for perusal prior to a protected time meeting. This allows the reviewer to compare with last year’s personal learning plans to pick up themes that are occurring throughout
– the appraisal is signed off and a copy of Section 4 is sent to the clinical governance lead as confirmation of the process
– individuals can have an additional individual appraisal along the conventional lines, and this is to ensure that if there are areas which they prefer to remain personal and private, they have that opportunity.
•The relationship between the PCT GP appraisal lead and the CME tutor: this effective working relationship provided the opportunity for the PCT mainstream clinical governance programme to be effectively supported by the CME tutor.
