Viewpoint: Why appraisal is doing more harm than good

A GP appraiser says appraisal takes too much time and effort, which takes GPs away from patient care, and has done little to improve practice. It's also driving some GPs to leave the profession. So is it time it for a rethink?

(Photo: iStock.com/pixelfit)
(Photo: iStock.com/pixelfit)

I am a semi-retired GP and an appraiser. I do locum work and keep up a special interest and I do appraisals, as I have done since they started.

As an appraiser I have enjoyed talking to doctors about their work, its successes and difficulties, and I have learned quite a lot from them. I think that I have been a useful sounding board and sometimes I have made suggestions that doctors have found useful.

When I started appraisal, doctors could choose their appraisers. It required a small amount of preparation from both parties and a shortish written summary afterwards. The main focus was on the meeting. I looked forward to doing appraisals, and also to my own appraisal. 

The problems with appraisal

That emphasis is now reversed. Doctors have to spend a significant amount of time and effort documenting CPD, audits, significant events and complaints, as well as scope of practice documents and 360-degree feedback.

They are allocated their appraiser, often with no regard for matching age and experience. These changes have made appraisal a burden to doctors.

Sadly the result has been that several really good local GPs in their fifties have packed in work altogether rather than continuing on a part-time basis. This is a terrible loss in the many underdoctored parts of England.

A similar process has occurred for appraisers. We now have to complete a long and very detailed form, (part of which is oddly titled as a ‘summary’ on Clarity or similar packages) and tick lots of boxes on probity etc. Then we upload it into another software system and tick lots of boxes that repeat exactly the same statements that we have already made.

At irregular intervals these summaries are scored by someone who checks them for ‘excellence’, which seems to be the parroting of certain set phrases about how the doctor has completed their PDP, looked at feedback (and reflected on it), been ‘challenged’ about their CPD, reflection etc, confirmed (once again!) the absence of probity issues, whether the PDP is sufficiently ‘smart’, etc.

SMART PDPs are particularly stupid, since trivial subjects are often perfectly SMART, while really useful personal development ideas are often a bit vague and hence neither specific, nor measurable so not acceptable to the appraisal hierarchy. Many appraisers just adapt a standard template that they cut and paste into each summary, often before the actual meeting, in order to avoid a low score that will cause hassle.

The tiresome aspects of appraisal have been exacerbated by an almost constant process of changing the rules. For example, when the 50 CPD credits rule was introduced, credits could be doubled for impact. After a few years that changed and they cannot.

The rules around significant events, quality improvement activities, PDPs, and scope of practice letters have also changed. Generally this has been necessary because the initial rules were badly thought out, or GMC guidance has changed, but not surprisingly doctors have been confused and this has further dampened enthusiasm.

There is now a considerable bureaucracy involved in checking appraisal and revalidation which also employs quite a few doctors, who are thus lost to clinical work during their time as mandarins.

Are there any benefits?

That is the downside. Are there any benefits?

I used to think that the doctors found it useful, but most of my colleagues now deny that and say its  a waste of their time. When revalidation was introduced it was said that it would help find the bad apples, but of course there is in fact nothing at all that is objective about appraisal, apart from the five-yearly feedback which is hardly reliable.

There is nothing to stop doctors getting ‘colleague’ feedback from mates down the pub and patient feedback forms can be scrutinised by the doctor before deciding which ones are to be submitted.

I had hoped that appraisal would encourage GPs to keep up to date and do quality improvement projects. Unfortunately my experience as a locum tells me that the well-known problems of poor prescribing, medical records without decent summaries, overuse of imaging etc have, if anything, worsened.

My answer? Let’s abolish the whole idea, keep some useful doctors working rather than retiring and get the bureaucrats doing something less harmful.

  • The author is a GP appraiser who wished to remain anonymous

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