Portfolio careers and low volumes of clinical work

Doctors who do low volumes of clinical work - or low volumes of undifferentiated primary care - are still providing very valuable services to patients but need to be confident that they can demonstrate that they remain up-to-date and fit to practise at what they do when they may have a relative lack of experiential learning. By working through the Academy of Medical Royal Colleges Factors for consideration template (external PDF) you are supported in demonstrating your continued competence and describing the safeguards that are in place to protect patients. The Factors for consideration template is based on the idea that how much clinical work you need to do to remain clinically up-to-date and fit to practise is variable and depends on several factors, including:

• your prior knowledge and experience
• how recently you reduced your volume of clinical work
• your scope of practice in the role
• how well supported you are and the governance arrangements for your role
• the CPD and QIA you are able to do in your role
• your engagement in annual appraisal
• other medical activities you are doing which may provide overlapping experience.

It is structured as a tool to help you think through how these factors apply in your circumstances. Many GPs report relief and reassurance after working through the template and realising that their practice is well protected.

If you do some NHS clinical work every year, and fulfil the requirement to have an annual appraisal, you will remain connected to the NHS primary care responsible officer (RO) in the area where you do the majority of your NHS clinical work. There is no minimum amount of NHS clinical work required, but 40 sessions per twelve months in work is a threshold below which you may be expected to reflect on how you remain safe for such a low volume of clinical work.

Whether you do a low volume of NHS general practice or a low volume of clinical work in any area, below 40 sessions per year, we recommend that you complete a factors for consideration template in respect of this low volume area and include it for discussion at your appraisal. You are asked to think about the factors that ensure that you remain up-to-date and safe for what you do in your clinical work and to put safeguards in place as part of your PDP if you identify any risk to yourself or to patients.

ROs have some discretion in how they view different scopes of practice, and therefore the options available to you may look different in different parts of the UK. For example, GPs practising in Northern Ireland are not required to complete the structured reflective template. We would always recommend speaking to your RO or appraisal lead if you are planning on changing your scope of practice and are not sure about the potential implications for your appraisal.

Every separate place where you work has a duty to supervise and support you in your role there. If you have a portfolio career, involving multiple employers or organisations, you may be subject to some form of local ‘appraisal’ or performance review. Where this happens, we recommend that your appraisal portfolio should include a signed-off summary of that discussion and outputs and any reflective notes on them, rather than the original supporting information. You should not be appraised twice on the same material, but you should discuss your reflections on the outcomes of such as review at your main appraisal.

You should include contact details for the appraiser and relevant organisation for parts of your scope of practice appraised elsewhere. Your responsible officer can then follow up on that part of your work if they need to.

If part of your scope of practice is not appraised elsewhere, the GMC requires the six elements of supporting information described in their guidance and reflections about that part of your practice to be shared in the portfolio and discussed in the main medical appraisal for revalidation before a positive revalidation recommendation can be made.

Your appraiser is trained to provide a whole scope of practice appraisal for any type of work that you may undertake which requires a UK licence to practise. If your medical appraiser for revalidation suggests that they are unable to provide a whole scope of practice appraisal, you should discuss this with your RO as soon as possible.

We do not recommend that you seek sign-off statements from third parties that there are no concerns about your practice in all of your roles every year. Your appraiser may recommend you bring a 'statement of no concern' or a letter demonstrating you are in 'good standing' from other employers as part of demonstrating a revalidation-ready portfolio for your RO to be assured by. If this is not available before your last appraisal in a revalidation cycle, we recommend providing contact details for your employers that the RO can use as required.

Instead, you should reflect on how the safety of patients is being assured and the governance, clinical or otherwise, of the systems you are working in. You should always know how to report on a significant incident and how you would find out if there was a complaint about you. It is important that you have declared all the different parts of your scope of practice and provided appropriate supporting information for them. It is also important that you ensure that your responsible officer (RO) knows how to contact the clinical governance leads from any part of your scope of practice that is not overseen by your main designated body so that they can seek the assurance that they need when they need it.

In Northern Ireland, your RO asks that before each annual appraisal, you complete a Form CP2a for any role that requires a licence to practice where you have a manager or a supervisor e.g. out-of-hours GP work, private GP (employed) GP Trainer, GPwER working outside practice GMS provision. If you do not have a clinical supervisor or manager, and the work is independent, then the Independent Clinical Practice ICP form should be completed. Examples of such roles include self-employed private GP, medical charity work, sports doctor, completing diving and aviation medicals.

We recommend that any governance concerns arising about a doctor should be communicated to the RO as and when they arise, by those responsible for the governance surrounding a doctor’s work. It is crucial that concerns can be dealt with in a timely fashion rather than waiting for the next appraisal discussion.

In some cases, a doctor will be working in an environment where there is no external governance, and the reporting of any issues will depend on the professionalism of the doctor. Significant Events and complaints can arise in every type of practice, and the GMC requires that all such patient safety incidents and complaints should be declared and reflected on at appraisal. We recommend that GPs talk to their RO, whenever they have a governance concern, to agree the best way forward and because the RO will often be able to signpost appropriate resources or courses of action.