Many GPs develop second roles or have caring responsibilities that draw them away from regular GP work.

There may be periods travelling, voluntary work or development of new special interests. These GPs may fear removal from the performer’s list owing to insufficient clinical work, or failure to ‘pass’ appraisal, with different regions having different approaches, and decision-making processes which can appear to lack transparency and consistency.

It is important that GPs, as a precious resource, are able to make informed professional choices which help them to sustain enthusiasm for their metier, and sustain safe practice without risking punitive consequences.

As clinical work reduces, GPs can feel less adaptable about where they work and the environments (walk in centres, hubs) and the clinical problems they feel comfortable managing (acute rather than chronic, no on call, or out of hours only).

Keeping up to date can feel unmanageable and support networks become tenuous. How do you keep yourself safe when doing very little? Is it just erosion of confidence or competence? Is general practice just a door you want to keep open?

These important questions have all fed into new guidance about GPs undertaking a low volume (defined as fewer than 40 sessions per annum) of NHS general practice clinical work published June 2018.

It focuses on supporting the professionalism and insight of the doctor rather than regulatory intervention and has been produced by NHS England, in collaboration with the BMA GPs committee, the Royal College of GPs and the GMC.

If your clinical work drops below 40 clinical sessions a year, your appraisal will now include an additional tool. This SRT (structured reflective template) is intended to facilitate reflection by the appraisee, and discussion within the appraisal, about your ability to provide safe quality care for patients, where necessary with the aid of mitigating interventions.

You have a professional responsibility to maintain your skill set and knowledge base, and this tool aims to help you demonstrate this. It is not a pass or fail assessment, but a QIA (Quality Improvement Activity) which helps to inform a PDP (personal development plan).

For many this reflective exercise will be contained entirely within the appraisal discussion and process without the need for direct discussion with the RO (responsible Officer). The RO remains nevertheless available for advice at any point in the appraisal year.

They are available specifically in the lead up to this discussion and also following the appraisal if the appraiser or doctor have any concerns. In most cases the RO will be able to provide reassurance that the PDP is appropriate or supplement the discussion with additional advice, to which a local medical committee representative can be a party if the doctor so wishes.

The SRT sets out the following criteria to look at factors that may increase the potential for risks to patient safety and trigger mitigating action and the provision of support for the doctor:

• Volume of work in the scope of practice (over 12 consecutive months)
• Spread of clinical work (i.e. breaks)
• Previous experience
• Overlap in relevant experience from a different role
• Duration of period of low volume work to date and in the future
• Nature of the clinical work
• Integration, benchmarking and access to support
  CPD
• Approach to own clinical risk management
• Personal Development Planning.
• The full guidance gives expanded commentaries on the ten factors, a more detailed account of the process and the full SRT.

ADDENDUM (6.11.20): Since publication of this guidance and tool a simplified appraisal has been introduced whereby no supporting information is required for appraisals between October 2020 and September 2021. This means that for doctors working low volumes of clinical work, the prompts included in the low volume SRT can be discussed during the appraisal discussion without any prior documentation being submitted. You may still find it helpful to have a look at the template prior to your appraisal meeting.

Paula Wright is the north east representative for the sessional GPs committee, and has extensive experience of appraisal, and supporting appraisal processes for sessional GPs.