This RCGP Guide to supporting information for appraisal and revalidation (April 2018) is based on the new GMC Supporting information for appraisal and revalidation (April 2018).

These key documents outline the types of supporting information required to demonstrate your continued competence across your whole scope of practice. There is no significant change to the six types of supporting information required by the GMC for a positive revalidation recommendation:

• Continuing professional development (CPD)
• Quality improvement activities (QIA)
• Significant events (SE)
• Feedback from patients or those to whom you provide medical services
• Feedback from colleagues
• Review of compliments and complaints
• The GMC requirements are necessarily broad enough to fit every doctor, no matter what area, sector or scope of practice.

GMC requirements and Academy of Medical Royal Colleges (AoMRC) guidance have been interpreted by the RCGP for all GPs, irrespective of their scope of practice, and recognising that GPs are specialist generalists dealing with uncertainty and complexity. There is still a need to remove inconsistencies in the interpretation of earlier guidance and to reduce the burden of the amount of documentation required to successfully revalidate. Each section is structured to highlight the GMC requirement(s) (in red), followed by the updated RCGP general practitioner specific recommendation(s) (in black). This document provides additional detail for GPs on providing the supporting information required by the GMC.

GPs should also understand the process of annual medical appraisal for revalidation as defined for GPs in England in the Revalidation Support Team’s Medical appraisal guide, for GPs in Scotland in NHS Scotland’s A Guide to Appraisal for Medical Revalidation, for GPs in Wales in the Wales Deanery’s All Wales Medical Appraisal Policy and for GPs in Northern Ireland in documentation provided by the Northern Ireland Medical and Dental Training Agency.

Summary of changes to GMC guidance that inform changes to this guidance

• The GMC has clarified that every doctor is required to engage with an annual medical appraisal that covers their whole scope of practice. However, there is no need to have five appraisals in a revalidation cycle if there are reasons why a doctor has an 'approved missed appraisal' or the revalidation cycle is not five years long. There is no need for 'catch up' appraisals.
• The description 'scope of practice' is clarified to ensure that you are providing an appropriate level of detail for the responsible officer to be assured that all parts of your scope of practice have appropriate supporting information and reflection over the five-year cycle, and the contact details for the clinical governance review of any parts of the scope of practice outside your designated body have been shared.
• The wide variety of types of quality improvement activities that are acceptable to demonstrate the regular review of practice – particularly for sessional GPs and those working in relative isolation - is emphasised so that it will be better understood.
• There is no need to provide documentary evidence of reflection on all your learning. Quality not quantity is emphasised. You should be selective and provide high-quality examples of reflection on your most significant learning.
• The GMC definition of significant events (SEs) as events that reach a significant level of actual or potential harm to patients is reiterated. Many GPs will not have been personally named or involved in any SEs needing declaration in any given year and should declare this where appropriate.
• The GMC requirement that you seek formal feedback about your practice using appropriate tools for your scope of practice, that are accessible to the respondents and fully compliant with all the GMC requirements once in the five-year cycle from colleagues and patients or those to whom you provide medical services is re-emphasised. It is important to think broadly about who are your 'patients' and your 'colleagues' and to ensure that this formal exercise (or formal exercises) covers respondents from the whole of your scope of practice.

Summary of changes to RCGP guidance

• Going forwards, locum GPs will need to provide contact details of all the practices where they have worked, so the RCGP recommends setting up a log to capture this information in real-time.
• The probity and health statements are reviewed to ensure that you reflect on the implications of the requirements in Good medical practice (GMC, 2013) for your own practice.
• The RCGP recommends that you confirm your indemnity provision and make a declaration of any conflicts of interest between your roles in every appraisal.
• With the current pressure on provision of healthcare services, the importance of looking after your own health and wellbeing in order to avoid 'burnout' and remain 'fit to practise' is highlighted. The RCGP recommends that, in every appraisal, you reflect on how well you look after yourself and the safeguards that are in place to ensure that your health does not pose any risks to patient safety. If you have declared a health condition, it is particularly important to discuss the safeguards that are in place to protect patients (where applicable).
• The requirement to demonstrate appropriate continuing professional development (CPD) to keep up-to-date for each part of your scope of practice over the five-year cycle is reiterated. The RCGP recommends that 50 credits per twelve months in work across the breadth of the GP curriculum over the five-year cycle will be sufficient to keep up-to-date to provide undifferentiated general medical services. If your scope of practice is restricted or unusual you may need to do less, or more, learning in order to keep up-to-date at what you do. In this case, you should reflect on what you have done, and why, and agree it at your appraisal and with your responsible officer if appropriate.
• The definition of a CPD credit is clarified: one credit = one hour of learning activity.
• The former recommendation that all credits should be demonstrated through a reflective note on lessons learned and any changes made as a result has been removed because it was being interpreted in a disproportionate way and adding to the burden of revalidation. You should still include reflection on your CPD, and highlight the most important lessons learned and changes made as a result, but you need not reflect on every CPD credit.
• The recommendation that you should review your personal practice every year, through appropriate quality improvement activities, ensuring that you cover the whole scope of your work over the five-year cycle, is reiterated.
• Because of the GMC definition of significant events as patient safety incidents, the learning opportunities that GPs historically called significant event analysis should be renamed learning event analysis. Learning from events should be considered a normal part of review of practice and examples included in quality improvement activities.
• If you wish to seek feedback from colleagues in the non-clinical parts of your scope of practice separately so that it is easy to interpret in context, this does not need to be GMC compliant, particularly in terms of anonymity or respondent numbers, as you only need to complete a formal colleague feedback survey compliant with all the GMC requirements once in the five-year cycle.
• GPs, who see many patients, and have many sources of patient feedback, should reflect during appraisal on feedback received from patients every year. This does not need to be GMC compliant, as you only need to complete a formal patient satisfaction survey compliant with all the GMC requirements once in the five-year cycle. You are not expected to undertake additional formal feedback surveys, but you are advised to reflect on the variety of sources of feedback already available to you, including informal comments and compliments.
• Where exceptional circumstances dictate that any of the GMC requirements or RCGP recommendations cannot reasonably be met, then you must include in your appraisal portfolio a reflective note containing an explanation, analysis of the implications and the response agreed with your appraiser and your responsible officer. For example, GPs doing low volumes of clinical work (less than 40 sessions over 12 months in work) or unusual or restricted scopes of practice should complete structured reflection that supports them in demonstrating how they remain up-to-date and safe, particularly considering any factors that exacerbate or mitigate the risk to patient safety. They should discuss their reflection at their appraisal. Where appropriate, additional mitigating factors should be planned and included in the new personal development plan (PDP).

Headlines

The GMC says

Quality not quantity: It is important that your supporting information covers your whole scope of practice, is of sufficient quality to support your learning and development, and helps you reflect to identify areas for improvement and strengths in your practice. We do not set a minimum or maximum quantity of supporting information you must collect.

The GMC and RCGP recommend that, as a GP, you maintain a focus on the quality rather than the quantity of supporting information in your appraisal and revalidation portfolio by demonstrating:

• An appropriate level of detail in describing your scope of practice.
• Reflection on the probity and health statements and the domains of Good medical practice (GMC, 2013).
• Annual reflection on continuing professional development (CPD) learning activities across a balanced programme appropriate to your scope of practice:
  • If you undertake the full range of general medical services in undifferentiated primary care (normal general practice), the RCGP recommends that you demonstrate at least 50 CPD credits per twelve months in work, covering the whole breadth of the RCGP curriculum over the five-year revalidation cycle, irrespective of how many sessions you work.
  • If you no longer provide the full range of general medical services, or have exceptional circumstances to declare, you may sometimes record fewer than 50 credits, provided that you document appropriate explanation and reflection, which is discussed with your appraiser and agreed with your responsible officer.
  • One CPD credit = one hour of learning activity.
  • All your learning activities, including learning arising from quality improvement activities (QIA), significant events (SE), feedback from colleagues and patients, and compliments and complaints, as well as personal reading and professional conversations, are eligible for CPD credits providing that you document your reflection on your learning from them appropriately.
  • Learning activities should normally be a mixture of consolidation (things you already know), targeted learning (for example, triggered by a case or a learning event, or an area of interest or need) and opportunistic exposure to new learning (to ensure you keep up-to-date with 'unknown unknowns').
  • There is no need to document or write reflective notes on every learning activity you undertake (prioritising reflection on your key learning from the past year is recommended).
  • In order to avoid professional isolation, the RCGP recommends that over the five-year cycle, you should provide evidence of some learning activities taking place with colleagues outside your normal place of work, or reflect on why this is not possible and discuss it with your appraiser.

• Annual reflection on ongoing review of your work across your whole scope of practice:
  • The RCGP recommends that you include representative quality improvement activities (QIA) every year to demonstrate how you review the quality of your work and reflect on the standard of care you provide by reflecting on cases, data, events and feedback
  • You should provide a balance of different types of QIA over the five-year cycle, including reflection on your personal outcome data, where available, and examples of initiatives that have led to quality improvements in practice.
  • Normal GP learning event analysis (LEA) (formerly called significant event analysis (SEA)) should be included as a form of quality improvement activity, and include learning from positive events and good practice, as well as events where things could have been done better, with the phrase 'significant events' reserved for adverse patient safety incidents as defined by the GMC in their guidance:
  • It is important that you consider the impact of your quality improvement activities and review whether changes you made have made a difference to the quality of your practice.

• Reflection on the analysis and review with colleagues of all significant events (SE) as defined by the GMC, in which you have been personally named or involved since your last appraisal
  • If you have not been involved or named in any significant events, you must declare this.

• Reflection on feedback from patients and those to whom you provide medical services using a feedback tool compliant with the GMC requirements at least once in every five-year cycle:
  • It is important to ensure that you choose, from the ever-increasing range of feedback tools, a GMC-compliant tool that is appropriate for your scope of practice and accessible to the whole range of respondents / patients.

• Reflection on feedback from colleagues using a feedback tool compliant with the GMC requirements at least once in every five-year cycle:
  • It is important to ensure that there are appropriate respondents from across your whole scope of practice, over the five-year cycle, whether they are all included in your one formal GMC compliant feedback, or whether you seek and reflect on feedback separately for a specific role (eg an appraiser seeking feedback from appraisees).

• Reflection on other sources of feedback from patients, whether formal or informal, solicited or unsolicited, where appropriate, on an annual basis.
• Reflection on all complaints in which you have been personally named or involved, as and when they arise:
  • If you have not been involved or named in any complaints, you must declare this.

• Reflection on any compliments you have received.
• Reflection on anything else you have been specifically asked to bring to the appraisal
  • If your responsible officer has asked you to bring specific information to the appraisal, such as routine clinical governance information provided by your organisation, or the outcomes of an investigation or complaint, then you must do so, so that you can discuss your reflections on it with your appraiser, and your appraiser can record it in the summary of the appraisal.

The GMC says

Reflection: Appraisal is a supportive and developmental forum, giving you the opportunity to reflect on your professional practice over the past year. Reflecting on your supporting information and what it says about your practice will help you improve the quality of care you give your patients and the services you provide as a doctor. You will not meet our requirements by simply collecting the required information. Ongoing reflection on your practice is central to revalidation and should form part of the preparation for your annual appraisal. Your appraiser can facilitate further reflection, as needed, but it is your responsibility to demonstrate examples of your reflective practice.

The GMC requirements, AoMRC guidance and RCGP recommendations, all highlight the importance of reflection on supporting information, not just the capture of raw data in a portfolio. Reflective practice is central to the annual appraisal process because the quality of your medical practice is maintained and improved by thinking through what you have learned and what you will do differently as a result. There are two stages to reflection in appraisal: firstly, your thoughts about your supporting information, captured in your reflective notes in your portfolio and, secondly, the facilitated reflection with the appraiser during the appraisal discussion, when your individual reflection may be put into context and developed into your plans for the future.

The RCGP recognises that the word 'reflection' itself means different things to different people, and there are many different models of reflection, so that there has been anxiety about how to document reflection appropriately without the recording of it becoming disproportionate. For doctors, professionalism means engaging in a continuous process of self-assessment and personal and professional development. We are trained to think about what we do all the time, and to have the insight to acknowledge gaps in our knowledge or skills, recognise when something could have gone better, and take steps to address our learning needs. This process may be so ingrained in the reflective practitioner, that it is hard to bring thoughts and reflections to the level of conscious awareness to write them down. This may be one reason why the documentation recommended for appraisal has been perceived, in some cases, as burdensome, especially if it is applied in a disproportionate way. The focus should be on practising as a reflective professional, not on documenting reflection obsessively, especially if the documentation detracts from time spent with patients, colleagues, friends or family.

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 to 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.

Learning and development: The GMC says

Focus on learning: At your appraisal you must discuss with your appraiser the changes you have made or plan to make, and any areas of good practice you intend to maintain or build on as a result of your reflections on your supporting information and appraisal discussion. We do not require you to document the detail of every event. You should focus on what you have learned and what changes you need or want to make.

Link to improvement and development planning: Reflection supports your development and continuous learning and will help you to identify improvements you can make to your practice. You must consider the learning needs and opportunities identified through the appraisal process in discussion with your appraiser and agree how this feeds into your personal development plan and continuing professional development activities for the following year.

The annual appraisal process is structured around continuous professional development through reviewing the progress made with your previous year's personal development plan (PDP) and agreeing new PDP goals arising from the appraisal and discussion.

The RCGP recommends that you focus on agreeing supportive and well-structured PDP goals that will contribute to your personal and professional development and help you maintain and improve the quality of your practice and your patient care.

Information about your practice

In your appraisal portfolio, you must provide:

• your personal details including your GMC reference number
• details of the organisations and locations where you have worked as a doctor since your last appraisal, and the roles or posts held
• a comprehensive description of the scope and nature of your practice
• a record of your annual whole practice appraisals, including confirmation whether you are in any revalidation non-engagement, licence withdrawal or appeal process
• your personal development plans and their reviews.

The GMC requires you to keep your basic personal details up-to-date and to include them in your appraisal portfolio.

Other 'appraisals'

If you have a portfolio career, you may have a separate performance review or 'appraisal' for some specific post(s) in your scope of practice, in addition to your main medical appraisal for revalidation. It is good practice to include the outputs of such meetings as supporting information in your appraisal and revalidation portfolio, so that your appraiser knows that that role has been reviewed and your reflection on the outcomes can be discussed.

Supporting information required by the Responsible Officer

The responsible officer may be aware of some clinical governance information, such as outcome data, or the results of an investigation or complaint, and request that you bring the information to your annual appraisal so that your reflection on it can be shared with your appraiser. It is important that your appraiser records whether any such information was included, and the outcomes of any discussion that took place in the summary of your appraisal.

The GMC says

Whole scope of practice: You must declare all the places you have worked and the roles you have carried out as a doctor since your last appraisal. You must collect supporting information that covers the whole of this practice. It's important you identify your whole scope of practice so you can make sure your supporting information covers all aspects of your work. Your supporting information must cover any work you do in:

• Clinical (including voluntary work) and non-clinical (including academic) roles
• NHS, independent sector and private work.

You have a professional obligation to give an honest and comprehensive picture of your whole practice for revalidation. You must make your responsible officer and appraiser aware of all the places you have worked as a licensed doctor since your last appraisal.

As a GP, you need to clarify your scope of practice because you are required to provide supporting information to demonstrate the quality of your work against the standards in good medical practice (GMC, 2013). This is for the scope of practice that you actually do, not what you qualified for. It is important to think broadly and include all clinical roles, whether in:

• The NHS or private practice.
• Working for a charity or in a voluntary capacity, paid or unpaid.
• You also need to include all non-clinical roles for which you need a UK licence to practise, such as teaching and training, academic, leadership, management and medico-political roles.

Any separate role which requires a licence to practise for a different organisation, employer, or as an individual, needs to be included so that the responsible officer (RO) knows where to seek assurance that you are fit to practise. Include the contact details, where applicable, for each organisation to facilitate the transfer of information to the RO, and to be aware of the clinical governance arrangements in place. The RO may request confirmation from each part of your scope of practice, outside the designated body, that there are no outstanding clinical governance issues, concerns or investigations before making your revalidation recommendation.

The requirement to provide details of all the places you have worked as a licensed doctor since your last appraisal has been clarified and will be important, particularly to locum GPs who may work in many practices. The RCGP recommends that you keep a log of all the places that you work and provide the contact details in your appraisal portfolio. If you undertake any additional work that goes beyond the core GP curriculum, then you need to consider this as a separate scope of practice and provide supporting information about how you remain up-to-date in that work.

In those circumstances where you have had a separate internal in-post performance review, or 'appraisal' for a specific part of your scope of practice, it is normal to include the outputs from this review, and your reflections, as 'additional supporting information' in your main annual medical appraisal for revalidation.

Where you have several different responsibilities within the same part of your scope of practice, it is appropriate to reflect on these elements with your appraiser, but they do not need to be declared as separate 'scopes of practice'. They do not require separate supporting information, or clinical governance review, because they are not provided for a different organisation, or independently. Reflection on appropriate supporting information over the five-year cycle needs to take place at the level of separate posts for different employers, or independently, not every responsibility that you may have.

Over the five-year revalidation cycle, you need to reflect on how you keep up-to-date, review what you do and what feedback you have had, as well as declaring all GMC-level significant events and complaints, for every role that forms a separate part of your scope of practice.

The RCGP recommends that you reflect on any unusual or exceptional circumstances that may affect your ability to demonstrate your continued competence in the usual way and discuss it at your appraisal. For example, GPs doing low volumes of clinical work (less than 40 sessions over 12 months in work) or unusual or restricted scopes of practice should complete structured reflection that supports them in demonstrating how they remain up-to-date and safe. Where appropriate, additional mitigating factors should be planned and included in the new PDP.

Health

The GMC says

A statement of health is a declaration that you accept your professional obligations about your personal health under Good medical practice.

Good medical practice gives the following guidance:

• Registration with a GP – you should be registered with a general practitioner outside your family to ensure that you have access to independent and objective medical care. You should not treat yourself (paragraph 30).
• Immunisation – you should protect your patients, your colleagues and yourself by being immunised against common serious communicable diseases where vaccines are available (paragraph 29).
• A serious condition that could pose a risk to patients – if you know that you have, or think you might 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 ask for and follow their advice about investigations, treatment and changes to your practice that they consider necessary. You must not rely on your own assessment of the risk you pose to patients (paragraph 28).

As well as signing the health statement, if appropriate, the RCGP recommends that you should reflect on your responsibility to be appropriately immunised, registered with a GP outside your own family and to protect patients from any risks posed by your health. If you have a health condition that could impact on patient care, it is best practice to reflect on any reasonable adjustments that you may have made to ensure that patient safety is not compromised.

To maintain your 'fitness' to practise, you have a responsibility to look after your physical, mental and emotional wellbeing. The RCGP recognises the significant pressures on the health services GPs provide and recommends that you discuss the structure of your work and your work/leisure balance with your appraiser to ensure that your basic human needs are being met. It may be useful to consider how you would know if you were becoming unwell and what the warning signs that you might need to seek help would be.

Probity

The GMC says

You will also need to make a probity statement. Probity is at the heart of medical professionalism and means being honest and trustworthy and acting with integrity. Not providing honest and accurate information required for your appraisal will raise a question about your probity.

A statement of probity is a declaration that you accept the professional obligations placed on you in Good medical practice in relation to probity. Good medical practice gives guidance on issues of probity as follows:

• Research (paragraphs 17 and 67)
• Holding adequate and appropriate insurance or indemnity (paragraph 63)2
• Being honest and trustworthy (paragraphs 65–67)
• Providing and publishing information about your services (paragraph 70)
• Writing reports and CVs, giving evidence and signing documents (paragraph 71)
• Cautions, official inquiries, criminal offences, findings against your registration, and suspensions and restrictions on your practice (paragraphs 72–76)
• Financial and commercial dealings and conflicts of interest (paragraphs 77–80)

As well as signing the probity statement, and acknowledging where there is an ongoing investigation or disciplinary matter, the RCGP recommends that you confirm that you have adequate and appropriate indemnity cover across the full scope of your work, and declare any potential conflicts of interest in your appraisal portfolio, and reflect on the potential probity challenges raised in Good medical practice with your appraiser.

Every doctor is required to demonstrate how they keep up-to-date across their whole scope of practice.

The GMC says

The purpose of carrying out and reflecting on continuing professional development (CPD):

• To help you keep up-to-date and competent in all the work you do.
• To maintain and enhance the quality of your professional work across your whole practice.
• To encourage and support specific improvements in practice.

The GMC's requirements

• You must carry out CPD activities every year.
• Your CPD activities must cover the whole of your practice, and be tailored to your scope of practice and needs.
• Your learning needs and plans for your CPD should be reflected in your personal development plan for the coming year.
• CPD should focus on outcomes or outputs rather than on inputs. You must reflect on what you have learned from the activity and how this could help maintain or improve the quality of your practice.

You must reflect on your CPD activities and discuss them at each annual whole practice appraisal.

If you provide the full range of general medical services in undifferentiated primary care, the RCGP recommends that you demonstrate at least 50 CPD credits per twelve months in work, irrespective of the number of sessions worked. Over the five-year revalidation cycle this should cover the breadth of the RCGP curriculum, including clinical, managerial and leadership skills. If this has not been possible, for any reason, you should provide an explanation, analysis of the implications and make plans to redress the balance (if appropriate). This should be discussed with your appraiser, included in your new PDP, and agreed with your responsible officer.

• One credit = one hour of learning activity.
• Emphasis should be placed on the quality of the CPD. 50 hours of learning activity does not guarantee that all educational needs have been met. You should do as much as you need to do to keep up-to-date across the whole of your scope of practice.
• If you provide a restricted range of services, rather than the full range of general medical services in undifferentiated primary care, it may be appropriate for you to provide fewer than the recommended 50 CPD credits per twelve months, provided that a detailed explanation and justification is reflected on during the appraisal, documented by your appraiser and agreed with your responsible officer. You will need to demonstrate that you will not be asked to work outside the scope of practice for which you have kept up-to-date.
• For periods of work that are more or less than twelve months, such as when your appraisal month has changed, or there has been a significant period of time out of work, such as maternity or sick leave, the RCGP recommends that you should demonstrate a number of CPD credits proportionate to the time you have spent in work, and provide an explanation during the appraisal, which the appraiser should include in the summary of discussion. It is not appropriate to try to do 'catch up' CPD just to accumulate CPD credits although you must do enough to regain and maintain your competence at what you do.
• When you feel you have any particular learning needs you should target appropriate CPD to meet those needs.
• Keeping a structured learning log to capture CPD credits throughout the year is recommended. There are helpful apps available which can support you to include key elements such as date, title, time taken, and reflection on key lessons learned. It is best practice to consider impact on practice and any changes made as a result of learning.
• There is no need for you to scan, or provide, copies of certificates for appraisal and revalidation where learning has been demonstrated through an appropriate reflective note (although it may be best practice to keep certificates for mandatory training defined by an employing organisation, so that you could provide them on demand).
• The importance of demonstrating impact is emphasised by the opportunity to claim CPD credits for time spent on all learning activities associated with demonstrating impact and implementing changes.
• You are encouraged to reflect on any impact that your learning (from any CPD, QIA, SEs, feedback, complaints or compliments) has had on your practice and to include it in the CPD log as separate learning activity, allocating accurately the time taken.
• It is best practice to document a balance of learning methods and experiences over the five-year cycle. You should consider your individual learning needs and wants (personal learning), your targeted needs (based on cases, data, events or feedback) and non-targeted general updates (to identify and meet 'unknown unknowns').
• It is best practice to ensure you include participation in CPD with colleagues inside and outside your normal place of employment over the five-year cycle. Team-based learning strengthens the team. Attendance at external events ensures that your practice is calibrated with others and avoids professional isolation.
• Emphasis should be placed on the quality of the CPD activities rather than simply on the number of hours spent.

Quality improvement activities

Every doctor is required to demonstrate how they review the quality of their work across their whole scope of practice.

The GMC says

The purpose of collecting and reflecting on quality improvement activities: 

• To allow you to review and evaluate the quality of your work.
• To identify what works well in your practice and where you can make changes.
• To reflect on whether changes you have made have improved your practice or what further action you need to take.

The GMC's requirements

• You must discuss with your appraiser or responsible officer the extent and frequency of quality improvement activity that is appropriate for the work you do.
• You must be able to show you have participated in quality improvement activity that is relevant to all aspects of your practice at least once in your revalidation cycle. However, the extent and frequency will depend on the nature of the activity.
• You should participate in any national audit or outcome review if one is being conducted in your area of practice. You should also reflect on the outcomes of these audits or reviews, even if you are unable to participate directly.
• You should evaluate and reflect on the results of the activity, including what action you have taken in response to the results and the impact over time of the changes you have made, and discuss these outcomes at your appraisal.
• If you have been unable to evaluate the result of the changes you have made or plan to make to your practice, you must discuss with your appraiser how you will include this in your personal development plan for the following appraisal period.

The RCGP recommends that you demonstrate the ability to review and learn from your medical practice by reflecting on representative quality improvement activities (QIA) appropriate to your scope of practice and circumstances every year, with a spread of QIAs across your whole scope of practice over a five-year cycle.

No fixed number of QIAs is recommended, as some will be very brief interventions, and others will be very significant projects. The RCGP recommends that you keep in mind the principle of providing documentation that is reasonable and proportionate and does not detract unduly from patient care, while ensuring that your QIA covers the whole of your scope of practice over the five-year cycle and demonstrates clearly how you review and improve the quality of your practice every year. If in doubt, use your professional judgement about what is appropriate and discuss your plans for the coming year with your appraiser.

You are advised to think about the quality not quantity of your QIA.

If you have not been able to evaluate or reflect on the impact of any QIA, then plans to do so should form part of your agreed PDP for the coming year.

Changes made should be shared and strengthened where they are an improvement, or reversed where they are not.

QIA 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 SE below)
• 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.

For some parts of your scope of practice, particularly relating to specific clinical skills such as minor surgery, joint injections, cervical smears and IUCD/IUS insertions (where applicable), 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.

If you are in a role where there is organisational, regional or national outcome data provided, the RCGP recommends that you demonstrate how you reflect on your personal involvement and respond to the information provided about your performance for your appraisal.

You do not need to have undertaken data collection personally, but your reflection should describe your personal involvement in the activity and what you have learned about your own performance in relation to current standards of good practice, including what changes you plan to make as a result, or how you will maintain high standards of performance.

Where appropriate to your scope of practice, the RCGP recommends you choose the best examples of your routine primary care learning event analysis to include as QIA to demonstrate how you review and learn from both positive and negative events and incidents.

All significant events, in which you have been personally named or involved, that reach the GMC defined level of harm, must be reflected on and declared as significant events (see below). It is likely that in many cases the learning from them will also lead to quality improvement activities.

Significant events

The GMC says

The purpose of collecting and reflecting on significant events:

• To allow you to review and improve the quality of your professional work.
• To identify any patterns in the types of significant events recorded about your practice and consider what further learning and development actions you have implemented, or plan to implement to prevent such events happening again.

The GMC's requirements

You must declare and reflect on every significant event you were involved in since your last appraisal.

• Your discussion at appraisal should focus on those significant events that led to a change in your practice or demonstrate your insight and learning. You must be able to explain to your appraiser, if asked, why you have chosen these events.

Your reflection and discussion should focus on the insight and learning from the event, rather than the facts or the number you have recorded.

What is a significant event?

For the purposes of this guidance a significant event is any unintended or unexpected event, which could or did lead to harm of one or more patients. This includes incidents which did not cause harm but could have done, or where the event should have been prevented.

Formerly, there was some confusion about what should be included as significant events (SEs) in the appraisal and revalidation portfolio. This GMC guidance makes clear the definition of a significant event. In order to avoid confusion, the RCGP has agreed that the learning events, previously called significant events, in primary care, which may be positive, neutral, or adverse events or incidents, will no longer routinely be called significant events. The new terminology more accurately reflects the use of learning from events in primary care and avoids the potential negative connotations of being 'significant'. Learning event analysis in primary care is a form of QIA (see above) and may involve events that are routine in practice but worthy of analysis to see what can be learned and improved.

• You must be aware of the GMC definition of significant events.
• Like all doctors, you must declare and reflect on all significant events in which you have been personally named or involved, and your reflections and actions agreed as a result must be provided in this section of supporting information and discussed during your annual appraisal.
• Not all significant events need to be discussed in detail – you should choose those that have led to important learning and changes that have an impact on your practice.
• All significant events should be written up on a standardised pro forma, and analysed to look at how actions and conditions interacted in contributing to the outcome. Where possible, it is appropriate to consider any changes that can be made to protect patients. Such significant events should be discussed with colleagues to maximise and share learning according to GMC requirements.
• If you have not been personally named, or involved, in a significant event during the year, you should sign the statement to confirm there were none and include a reflective note about the systems that are in place to ensure that such events would be recognised and reported.
• It is best practice to demonstrate that you are aware of how significant events are captured in all the organisations within which you work, across the whole of your scope of practice. You should know how to report any significant events that you become aware of and how to ensure, as far as possible, that you find out if you have been named, or involved, in any.
• All relevant data included in the appraisal and revalidation portfolio should be anonymised to remove third party identifiable information. This may include the identification of rare conditions or specialist clinics. For this reason, although the reflective note should always form part of your appraisal portfolio, specific original supporting information relating to significant events in which you have been named, or involved, may sometimes appropriately be submitted separately or reviewed in paper format, which your appraiser should then reference in the appraisal summary

Patient feedback

The GMC says:

The purpose of gathering and reflecting on this feedback:

• To understand what your patients and others think about the care and services you provide.
• To help you identify areas of strength and development, and highlight changes you can make to improve the care or services you provide.
• To evaluate whether changes you have made to your practice in light of earlier feedback have had a positive impact.

The GMC's requirements

• At least once in each revalidation cycle you must collect, reflect on and discuss feedback from patients about their experience of you as their doctor.
• If you do not have patients you should collect feedback from others to whom you provide medical services. If you believe you can't collect such feedback, then you must agree with your responsible officer that you do not need to.
• Those asked to give you feedback must be chosen from across your whole scope of practice.
• You should use standard questionnaires that have been validated and are independently administered to maintain objectivity and anonymity. You must agree any alternative approaches with your responsible officer.
• You should not personally select those asked to give feedback about you, and you should make sure the method used for collecting feedback allows responses to be obtained from a representative sample.
• You must reflect on what the feedback means for your current and future practice, and discuss it at your appraisal.

One of the principles of revalidation is that patient feedback should be at the heart of doctors' professional development. There is an ongoing GMC review into how patient feedback opportunities can be made more accessible to all patients and more valuable in how and when feedback is made available to doctors.

RCGP recommendations specific to patient feedback for GPs

• Although the GMC requires only one formal GMC-compliant patient feedback exercise in a five year cycle, patient groups have expressed the view that, for most GPs, who see many patients every day, this is inadequate and does not allow patients sufficient voice. All sources of feedback from patients, both formal and informal, are important triggers for reflection. In addition to the formal GMC-compliant patient survey, carried out once in the five-year cycle, the RCGP recommends that you reflect on some of the many other sources of feedback from your patients and on your relationship with your patients annually at your appraisal.
• Patient participation groups, the 'friends and family' test, the national patient survey, suggestions boxes, ad hoc comments and compliments, among others, can all provide valuable sources of patient feedback to reflect on. The RCGP does not recommend that you should engage in additional formal solicited patient feedback surveys (unless you have made a specific change that you wish to review) as this would be a disproportionate burden and more than is required of doctors from other sectors.
• For patient feedback to be as valuable to the GP profession as possible, it should be possible for patients to give feedback when something has happened that they want to give feedback about so that good practice can be celebrated and improvements can be made. While waiting for the outcomes of the GMC review into patient feedback in revalidation, GPs can influence the debate by considering how to create opportunities for patients to give real-time unsolicited, and ad hoc feedback into their practice in a way that is realistic and does not create additional burdens.

Colleague feedback

The GMC says

The purpose of gathering and reflecting upon colleague feedback:

• To understand how the range of people you work with view your practice.
• To help you identify areas of strength and development, and highlight changes you could make to improve the care or services you provide.
• To evaluate whether changes you have made to your practice in light of earlier feedback have had a positive impact.

The GMC's requirements

• At least once in your revalidation cycle you must collect, reflect on, and discuss at your annual appraisal, feedback from your colleagues.
• The colleagues who are asked to give feedback must be chosen from across your whole scope of practice, and must include people from a range of different roles who may not be doctors.
• You must choose colleagues impartially and be able to explain to your appraiser, if asked, why you have chosen the colleagues who have given your feedback.
• Wherever possible you should use standard questionnaires that have been validated and are independently administered to maintain objectivity and confidentiality. You must agree any alternative approaches with your responsible officer.

You must reflect on what the feedback means for your current and future practice.

Questionnaires and surveys

Feedback from patients (and those to whom you provide medical services) and colleagues should be obtained using appropriate questionnaires that are accessible to all appropriate respondents and meet the standards set by the GMC. Acceptable questionnaires must:

• be consistent with the principles, values and responsibilities set out in the GMC's core guidance: Good medical practice
• be piloted on the appropriate population to demonstrate that they are reliable and valid.
• reflect and measure the doctor's whole scope of practice.
• be administered independently from the doctor and their appraiser to avoid conflicts of interest or the appearance of bias.
• provide appropriate and useful information that will support the development of the doctor and help the doctor to reflect on their practice and identify opportunities for professional development and improvement.

RCGP recommendations applicable to all formal solicited patient and colleague feedback

• You must reflect on feedback relating to the whole of your scope of practice over the five-year cycle.
• You must complete a minimum of one formal solicited colleague feedback exercise and one formal solicited patient feedback exercise, each compliant with the GMC questionnaire requirements, over the five-year cycle.
• You may be asked by your appraiser to explain your choice of respondents and how they were selected to provide your formal feedback. You must be able to demonstrate they were chosen objectively and on the basis that they were able to provide the most valuable feedback as well as that you have sought feedback across your whole scope of practice. Your appraiser will be able to support you in planning how to select an appropriate range of patients and colleagues to give a full 360-degree view of your practice and avoid any conflicts of interest or appearance of bias.
• As the number of appropriate tools increases, the RCGP no longer recommends any particular tools. Instead, you are advised to choose a suitable tool, or tools, that meets all the GMC requirements, is appropriate to the scope of practice about which you are seeking feedback, and is accessible to the whole spectrum of respondents.
• If you have made significant changes as a result of feedback, it is best practice to repeat the feedback exercise to facilitate reflection on the impact of the change. Therefore, the RCGP recommends that you choose to complete the formal patient and colleague feedback in the first three years of the revalidation cycle in order to allow time for this if appropriate.
• The RCGP recognises the value of compliments as a form of unsolicited feedback from patients, those to whom you provide medical services and colleagues. You should include your reflective note on any compliments, rather than original material, in the electronic portfolio, due to the difficulties with anonymising data. Keep any original cards, letters or e-mails, if you wish, securely in a separate portfolio which you can share with your appraiser so that they can be commented on in the appraisal summary.
• In exceptional situations, you may have difficulties in undertaking your five-yearly formal colleague feedback exercise or your five-yearly formal patient feedback exercise in a way that fulfils all the GMC requirements. In such cases, you will need to provide a detailed reflective note explaining the circumstances. It would be best practice to agree that the proposed process for seeking feedback is appropriate for revalidation with your appraiser and your responsible officer before undertaking it.

RCGP recommendations specific to colleague feedback

• In addition to your clinical roles, you will need to gather feedback specific to other parts of your scope of work, such as teaching, training, appraising, management and leadership roles.
• Your colleague feedback over the five-year cycle must cover your whole scope of practice, so you may choose to include colleagues from all the different parts of your scope of practice, including your non-clinical roles, within your one formal GMC-compliant colleague feedback exercise.
• Alternatively, you may choose to limit the GMC-compliant colleague feedback exercise to colleagues who are able to give you a full 360-degree view of your clinical roles and to seek and reflect on colleague feedback about non-clinical areas of your scope of practice separately, using more specific tools.
• If you seek feedback from specific non-clinical roles that form part of your scope of practice separately, questionnaires do not always need to fulfil all the GMC requirements. For example, you may reflect on non-anonymised feedback, or have fewer respondents. You should aim to collect valuable feedback to inform your reflection and improvements in your practice and discuss your choices with your appraiser to ensure they are appropriate.

Review of complaints and compliments

The GMC says

The purpose of gathering and reflecting on compliments and complaints:

• To identify areas of good practice, strengths and what you do well.
• To identify areas for improvement, lessons learned and any changes to be made as a result.
• To demonstrate you value patients' and others' concerns and comments about your work by making changes as a result of the feedback you have received.

The GMC's requirements

• You must declare and reflect on all formal complaints made about you at your appraisal for revalidation. You should also reflect upon any complaints you receive outside of formal complaints procedures, where these provide useful learning.
• You do not have to discuss every complaint at your appraisal. You should select those that evidence your insight and learning into your practice, and those that have caused you to make a change to your practice. You must be able to explain to your appraiser, if asked, why you have chosen these complaints over others as part of your appraisal discussion.
• At your appraisal, you should discuss your insight and learning from the complaints, and demonstrate how you have reflected on your practice and what changes you have made or intend to make.

You should follow the same principles for collecting, discussing and reflecting on compliments.

Compliments

• You should reflect on any compliments you have received annually as part of your reflection on patient (or colleague) feedback.
• You should include a reflective note, rather than original material, in your submitted appraisal portfolio, due to the difficulties with anonymising data, and keep any original cards or letters, if you wish, securely in a paper portfolio. Such original data, if shared with your appraiser, can be referenced in the appraisal summary to preserve the anonymity of the sender without defacing the source material.

Complaints

"This guidance defines formal complaints as complaints received about you or your team that have been formally acknowledged or recorded by you or the organisation to which it was sent." (GMC, 2018 p.25)

• Complaints should be seen as another type of feedback, allowing doctors and organisations to review and further develop their practice and to make patient-centred improvements.
• All organisations where doctors work should have appropriate complaints procedures, which should include all doctors who work in that organisation, including locums.
• You should be aware of the complaints procedures for all the organisations in which you work and be kept fully informed of all formal complaints in which you are named.
• You should include your reflection on all formal complaints in which you have been named, or involved, in your appraisal every year, although if the complaint is not yet resolved your reflection may be incomplete.
• Your reflections should consider how the complaint arose, your response and any further actions taken, or to be taken (and the results of those changes once available).
• You do not have to discuss your reflection on every complaint at your appraisal if it has been fully discussed elsewhere but you should always declare all complaints.
• You may not have been personally named, or involved, in any complaints during the year, in which case you should declare that.
• If a complaint in which you have been named goes on over several years, you do not need to reflect on it in detail at every appraisal if no significant progress has been made, but you should acknowledge that there is an ongoing complaint every year in your annual declaration, and include reflection about it at least once in every revalidation cycle.
• All relevant data included in the appraisal and revalidation portfolio should be anonymised to remove any third-party identifiable information. For this reason, although your reflection on any complaint should always form part of your appraisal portfolio, specific original supporting information relating to complaints should be shared with your appraiser separately, and discussed at appraisal so that your appraiser can comment on it in the appraisal summary.