GP perceptions of appraisal: professional development, performance management, or both?

Abstract

GPs' perceptions of the tension between the professional development and revalidation aspects of the current GP appraisal scheme were analysed. Evidence was gathered from focus groups representing general practice in Northern Ireland. The results indicate that there is support for the professional development aspects of appraisal but the link with revalidation is problematic, thereby potentially undermining GP support for the scheme. Greater clarity about the precise nature of the linkage is required to avoid a process that fails to fully satisfy the requirements of either appraisal or revalidation.

INTRODUCTION

Appraisal can be implemented in a variety of ways.¹ It can focus on professional development, performance management or assessment. Some evidence indicates GP support for appraisal if it is focused on professional development,² but they are apprehensive about a scheme that attempts to link professional development and assessment or revalidation.³ We report on the views of appraisers, appraisees and GP medical educationalists, in a pilot scheme in Northern Ireland.

METHOD

Three focus group interviews were held between April and June 2003. The first consisted of GPs who had been appraised; they were selected to reflect a range of the total study population, namely those GPs who had been appraised in the pilot study (n = 7). The second group consisted of GP tutors who had acted as appraisers (n = 10). The third consisted of the GP team who had planned and delivered the appraisal training (n = 3). Focus group methodology was used to identify each group's responses, to generate qualitative data and to highlight needs. Participants were asked to reflect on the strengths and weaknesses of the appraisal training, the nature of their experience within the interview, their opinion of the links with revalidation and their overall perception of appraisal. Each focus group lasted for 2 hours and was audiotaped for subsequent transcription. These transcriptions were examined by two of the authors to identify emergent themes that were then agreed.

RESULTS

Appraisers and appraisees agreed that the process could be useful and that it encouraged them to reflect in a structured way on their professional role and development. It recognised achievement and identified good professional practice, while target setting encouraged action and facilitated organised learning.

Both groups highlighted perceived weaknesses in the scheme. They drew attention to: the irrelevance of some of the exemplar material to the average GP; the uncertainty as to whether resources would be made available to implement action plans; the unsatisfactory nature of some aspects of the documentation; and the total emphasis on professional development and competence as opposed to the need for personal development as well. In relation to revalidation one appraiser recognised some value in the link:

‘It provides a real focus and motivation for GPs during appraisal to reflect on what they have to do to meet the challenges of the future.’

Most participants, however, argued that this summative element was problematic because it could encourage economy with the truth, particularly on health issues and general competence, strategic form filling rather than honest analysis, and it seemed at odds with the spirit of appraisal as professional development. Furthermore, concern was expressed at the lack of consistency and uniformity in the process, which could undermine its usefulness in revalidation:

‘I would be really reluctant to look at myself in a cold professional way if I felt my deliberations were going to be scrutinised for revalidation purposes.’ (Appraisee.)

‘I'm confused over what revalidation might require in terms of standardisation and documentation. I'd need more training on this.’ (Appraisee.)

DISCUSSION

Appraisal and revalidation are intended to be complementary processes, however, the responses in the study indicate that GPs are sceptical about the advisability of merging processes with conflicting aims. It should be noted that the responders in the study were volunteers and therefore even greater scepticism could be encountered in the wider GP population.

The availability of corroborative material provides the opportunity to maintain and restore the formative and supportive nature of appraisal. For example, clinical governance material and underperformance structures, possibly supplemented by quality and outcomes data from the new contract, could provide the basis of the assessment elements of revalidation, thereby removing this role from the appraisal process. Indeed, a criterion model has been developed by Bruce et al,⁴ which allows folders of evidence to be used solely for revalidation purposes.

How this fits in

Appraisal is developmental not disciplinary. Annual appraisals are now obligatory for GPs and are a key element in revalidation. Appraisal can be a positive experience but further clarity about the process and linkages is needed. This study provides qualitative data from a range of stakeholders highlighting concerns about the implications of merging professional development and assessment. It also lends support for the need to separate the formative and summative elements of the processes.

This raises the question why a scheme has been introduced, which, by combining professional development and assessment, conflicts with the available evidence.^5,6 As Van Zwanenberg indicates:

‘Formative appraisal and summative revalidation are seen as uneasy bedfellows.’⁷

Funding body

Department of Health, Social Services and Public Safety Northern Ireland

Competing interests

None