Dr Honor Merriman highlights five things GPs need to know about the updated requirements for supporting information for appraisal and revalidation

merriman honor

Dr Honor Merriman

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Read this article to learn more about:

  • updated guidance on essential supporting information for appraisal and revalidation
  • a new requirement for locum GPs
  • distinguishing between ‘significant events’ and ‘learning events’
  • recording high-quality reflective notes and quality improvement activities.

 

In April 2018, both the GMC1 and RCGP2 published updated guidance on supporting information for appraisal and revalidation. The GMC’s guidance sets out requirements for the supporting information licensed doctors must collect, reflect on, and discuss at appraisal for revalidation,1 while the RCGP guide provides specific details to enable GPs to fulfil the GMC’s requirements.2

GPs are now in the second cycle of revalidation and the Pearson Report3 demonstrated that the process has started to make a positive impact on clinical practice. The report also highlighted that many doctors have found the process cumbersome and in need of clarification and simplification.

The updated guidance focuses on the essential supporting information that is required for appraisal and revalidation and removes the need for excessive detail. This article focuses on five key requirements that GPs should be aware of.

1. Supporting information must cover the whole scope of practice

Supporting information is required for all roles carried out by the GP, encompassing all clinical (including voluntary), non-clinical (including academic), NHS, independent sector, and private work.1 Supporting information includes reports from workplace-based assessments carried out by organisations other than the GP’s designated body, feedback, and evidence of keeping up to date in all roles.

Locum GPs must record details of all practices where they have worked each year in their appraisal record (this is a new requirement for 2018).2

The RCGP also recommends that GPs declare any conflicts of interest between their roles in every appraisal.2 This aligns with the probity declaration required each year.

2. Focus on quality, not quantity

There is no upper or lower limit on the amount of supporting information; however, the GMC advises that the supporting information should be of sufficient quality to:1,2

  • demonstrate coverage of the whole scope of practice over the 5-year cycle
  • support learning and development
  • help reflection to identify areas for development and strengths in practice.

The RCGP makes recommendations about recording high-quality reflective notes (see Box 1).

Box 1: RCGP recommendations about reflective notes2

The RCGP recommends that you should provide a relatively small number of representative, high-quality documented examples of your reflective practice in your supporting information for appraisal and revalidation. You should not try to document your reflection every time something new is learned, looked up or discussed, but you do need to ensure you have demonstrated your continued competence across your whole scope of practice. Before including an additional piece of supporting information in the portfolio, you should ask yourself what it adds to what is already there.

Royal College of General Practitioners. Royal College of General Practitioners: RCGP Guide to supporting information for appraisal and revalidation (updated 2018). RCGP, 2018. Available at: www.rcgp.org.uk/-/media/Files/Revalidation-and-CPD/2018/RCGP-guide-to-supporting-information-2018.ashx?la=en

3. Demonstrate learning through CPD credits and reflection

For GPs who provide the full range of general medical services in undifferentiated primary care, the RCGP recommends that:2

‘50 credits for every 12 months in work across the breadth of the GP curriculum over the 5-year cycle are sufficient to keep up to date to provide undifferentiated general medical services.’

One CPD credit is defined as 1 hour of learning activity. Attendance certificates at events are not essential; learning should be demonstrated through an appropriate reflective note.2

Many GPs have different work patterns, so the RCGP advises that if the work is restricted or unusual the GP may need to do less, or more, learning to keep up to date. The GP should reflect on what they have done, and why, and agree it at appraisal (and with the responsible officer if appropriate).2

Each entry in a learning log does not need a reflective note in order to be valid and to show maintenance of good medical practice. Reflection on some key items or on the learning as a whole is essential to show lessons learned and subsequent changes to practice. It is helpful if the GP provides an overview of the main learning that has taken place each year. 

4. Significant events are learning events unless serious harm has, or may have, resulted

Historically, there has been some confusion about what should be included as a significant event in the appraisal and revalidation portfolio, as the GMC and RCGP had different definitions for the term. The RCGP has now aligned with the GMC terminology and created a new definition, ‘learning events’, to describe events that the RCGP previously referred to as significant events. Examples of these events are provided in Box 2.

A significant event is defined by the GMC as: ‘any unintended or unexpected event, which could or did lead to harm of one or more patients.’1

What used to be referred to as a ‘significant event’ by the RCGP (events or incidents which may be positive, neutral, or adverse) should now be referred to as a learning event. Learning from events should be considered a normal part of review of practice. GPs need to declare all events in which they have been personally involved that lead to changes in their clinical practice. GPs should also be able to explain how these events are captured in the organisation(s) where they work, and how reports are discussed and actioned.

Box 2: Examples of events to be discussed in an appraisal portfolio

Example significant event

A 19-year-old male attends a GP surgery with symptoms of fever, vomiting, and headache. The GP elicits signs suggestive of meningitis and decides to give benzylpenicillin 1200 mg, pending hospital admission. The GP fails to check if the patient has any allergies and, because of a penicillin allergy (noted in the patient’s medical record), the patient has an anaphylactic reaction for which he needs resuscitation before the ambulance arrives.

This incident, which caused serious harm to the patient and required life-saving intervention, is a significant event and needs urgent investigation. The process by which this should be done is detailed in the NHS England Serious incident framework (see www.england.nhs.uk/wp-content/uploads/2015/04/serious-incidnt-framwrk-upd.pdf).4

Example learning event

A patient requests a referral for physiotherapy for a long-term back problem. The GP completes the referral form and files it in the notes, but fails to let the practice secretarial team know that there is a form that needs to be sent off, so the patient is not sent an appointment. Consequently, the patient makes a complaint to the practice.

This incident should be considered a learning event. The practice team discussed the event and agreed measures to prevent the same error happening again in the future. When responding to the complaint, the GP was able to apologise and assure the patient that this would not occur again.

5. Record activities that demonstrate quality improvement

Doctors are required to demonstrate how they review the quality of their work across their whole scope of practice over the 5-year cycle. Examples of quality improvement activities (QIAs) are listed in Box 3.2

Box 3: Quality improvement activities2

Quality improvement activities may take many forms, including, but not restricted to, taking action as a result of:

  • cases—reflective case reviews
  • data—large scale national audit, formal audit, review of personal outcome data, small scale data searches, information collection and analysis (‘search and do’ activities), plan/do/study/act (PDSA) cycles
  • events—learning event analysis (LEA) and significant event review (see the definition of a significant event)
  • feedback—improvement activities undertaken as a result of the outcomes of reflection on your formal patient and colleague feedback survey results, other solicited and unsolicited feedback, compliments and complaints.

Royal College of General Practitioners. Royal College of General Practitioners: RCGP Guide to supporting information for appraisal and revalidation (updated 2018). RCGP, 2018. Available at: www.rcgp.org.uk/-/media/Files/Revalidation-and-CPD/2018/RCGP-guide-to-supporting-information-2018.ashx?la=en

There is no fixed number of QIAs recommended by the RCGP, as some will be brief interventions and others will be very significant projects. GPs should choose the best examples of their routine primary care learning event analysis to include as QIAs to demonstrate how they review and learn from both positive and negative events and incidents.2

GPs working solely as peripatetic locums may choose to use reflective case reviews as QIAs, as they may have limited access to data.

For GPs whose scope of practice involves specific clinical skills (such as minor surgery, joint injections, cervical smears, intrauterine contraceptive device/intrauterine system insertions) the RCGP advises that: ‘it is appropriate and necessary to maintain an ongoing log of personal outcome data and reflect on the outcomes at least once in the revalidation cycle.’2

GPs should assess and reflect on their own health

One important aspect, which is not discussed in the updated guidance, is the need for GPs to reflect on their own health. At appraisal, GPs are required to make a statement of health declaring that they accept their professional obligations about their personal health in line with the GMC’s Good medical practice.2,5 The GMC requires doctors to assess the risks posed by their own health and confirm at appraisal (see Box 4).5

Given the current pressures on clinicians working in general practice, it is important for GPs to consider how they remain well. A health structured reflective template may help GPs to focus reflections on their own health (see Box 5).6 If details are not recorded in the appraisal portfolio the GP appraiser will want to encourage discussion in the appraisal meeting.2

Box 4: Risks posed by your health5

  • If you know or suspect that you have a serious condition that you could pass on to patients, or if your judgement or performance could be affected by a condition or its treatment, you must consult a suitably qualified colleague. You must follow their advice about any changes to your practice they consider necessary. You must not rely on your own assessment of the risk to patients
  • You should be immunised against common serious communicable diseases (unless otherwise contraindicated)
  • You should be registered with a general practitioner outside your family.

General Medical Council. Good medical practice. GMC, 2013. Available at: www.gmc-uk.org/-/media/documents/good-medical-practice—english-1215_pdf-51527435.pdf

Box 5: Health structured reflective template6

Name of doctor:

GMC No:

Date:

The following are health issues which commonly apply to doctors:

  • Are you registered with a GP?
  • Have you attended your GP in the past year?
  • Have you self-prescribed in the past year, or asked a colleague to prescribe?
  • Have you bypassed the normal NHS referral process in the past year?
  • Do you have a chronic illness?
  • Are you in pain?
  • Have you had a recent bereavement?
  • Are you experiencing stress at work or elsewhere?
  • What are your coping strategies for stress?
    • Do you actively self-care and consider work-life balance?
    • Do you have adequate holiday and study leave (and do you actually take this entitlement?)
    • What is your network of support at work and outside work? (Consider friends, colleagues, mentors, support groups)
  • Are you concerned that you may have a dependency on alcohol or drugs?
  • Are you involved in a complaint?
  • Are you sleep-deprived?

Select an issue, from this list or otherwise, in terms of your health affecting your ability to provide clinical care in the last year.

  • What is/are the issues?
  • How have I approached this in the past?
  • What could I do in the next year to improve things?
  • Final outcome after discussion at appraisal:

(Complete at appraisal considering how your approach will improve patient care.)

National Association of Primary Care Education. The Leicester 2007 conference statement on essential evidence for appraisal: health structured reflective template. Adapted from Whittet, S. Health and probity in appraisal: what do you ask? Available at: www.gpappraisals.uk/reflection.html

Summary

The revised GMC and RCGP guidance provides clear advice for GPs about the supporting information needed for appraisal and revalidation. The emphasis is on focused but comprehensive information; quality not quantity. In the busy GP working day this should prove a welcome reduction in the amount of time spent recording revalidation activities in detail.

Dr Honor Merriman

GP and Senior Appraiser, Oxfordshire

References 

  1. General Medical Council. Guidance on supporting information for appraisal and revalidation. GMC, 2018. Available at: www.gmc-uk.org/-/media/documents/rt—supporting-information-for-appraisal-and-revalidation—dc5485_pdf-55024594.pdf
  2. Royal College of General Practitioners. Royal College of General Practitioners: RCGP Guide to supporting information for appraisal and revalidation (updated 2018). RCGP, 2018. Available at: www.rcgp.org.uk/-/media/Files/Revalidation-and-CPD/2018/RCGP-guide-to-supporting-information-2018.ashx?la=en
  3. Pearson K. Taking revalidation forward—improving the process of relicensing for doctors. GMC, 2017. Available at: ­­­­www.gmc-uk.org/-/media/documents/Taking_revalidation_forward___Improving_the_process_of_relicensing_for_doctors.pdf_68683704.pdf
  4. NHS England. Serious incident framework. NHS, 2015. Available at: www.england.nhs.uk/wp-content/uploads/2015/04/serious-incidnt-framwrk-upd.pdf
  5. General Medical Council. Good medical practice. GMC, 2013. Available at: www.gmc-uk.org/-/media/documents/good-medical-practice—english-1215_pdf-51527435.pdf
  6. National Association of Primary Care Education. The Leicester 2007 conference statement on essential evidence for appraisal: health structured reflective template. Available at: www.gpappraisals.uk/reflection.html