Abuse of NHS Doctor’s Appraisal System

Some in the NHS  wish to use GP appraisals as a reference system, to check for suitability for a particular job by asking to GPs to send in their appraisal output data or “copy of appraisal”.  There are also administrators who wish to use doctor’s appraisals as a management tool for audit and performance in line with other work sectors’ appraisal systems.  The reply must be no to any request send copy of appraisal or appraisal summary to employers.  Doctors are already concerned about reflection in their appraisals after the Dr Hadiza Bawa-Garba case.  This new use as a reference tool would make matters much worse.

It was discovered in March 2021 that the GMC seemed to support the employers’ new stance  with a statement on GMC web site Appraisal documentation is confidential. When requested, doctors should share summary appraisal outcomes with the organisations where they work (in addition to their designated body) but they should not be expected to share their full appraisal portfolios on a routine basis.”    It turns out (March 2021) that the GMC now recognises that this wording is an error and will be changed.  The thrust of this essay remains true. I have been assured of this after representation to the GMC by the RCGP Revalidation team on my behalf.  My view is that, if anything, doctors could provide the appraisal statement which is a few tick boxes that in effect states that we have had an appraisal.  The statement is very different from the appraisal summary which is the detailed nub of the appraisal and should never be shared, nor should any other part.

Appraisals, if used as references by NHS Trusts, other employers or GP practices, will compromise the appraisal process and could break revalidation.  A salaried GP would certainly not want to share their appraisal  with their workplace and practice manager. Appraisers will start designing the appraisal output to reflect a new status as a reference for third parties to view, and not as the appraisal output is currently assumed to be; a confidential, reflective document, while appraisees will not mention serious issues.   

Below is the letter that started my concern I received after some months working via an agency.  I had worked in that area since 1993, and appraised locally.  I was licensed and revalidated:   

Hertfordshire Community NHS Trust   1st  August 2018                                                  Dear Dr Bulger   Re: Appraisal Output request for Gerard Bulger  As you will be aware the Responsible Officer regulations came into force in 2012. As the Deputy Responsible Officer for the Designated Body Hertfordshire Community NHS Trust (HCT), I am accountable for seeking regular assurance that Doctors who work for HCT in any capacity are up to date and fit to practice across their whole scope of work.  As such and in accordance with the HCT process Non Designated Body Doctors’ Governance Process’ approved in January 2017 by the Workforce and OD Committee, I kindly ask that you provide your last appraisal output form no later than 8th August 2018.As you will be aware the Responsible Officer regulations came into force in 2012. As the Deputy Responsible Officer for the Designated Body Hertfordshire Community NHS Trust (HCT), I am accountable for seeking regular assurance that Doctors who work for HCT in any capacity are up to date and fit to practice across their whole scope of work.”  

In March 2021 I got another request, a CQC inspired compliance list from another employer which included a demand for “copy of my appraisal”, as if standard and matter of fact.  My reply to both reply was no.  The employers can check references, my place on performers’ list (so therefore appraised) and can check I am licensed and revalidated on line.  The Trust or any other employer have no right to demand to see my appraisal output (which, as it happens is suitably glowing, so I should show it off); the  principle is that that appraisals are also private reflections.

West Herts Trust  tried to apply to NHS England for the appraisal data is if I was moving responsible officer that is moving area, using the RO to RO form (MPIT). NHS England’s response was robust and the request refused.  The data cannot be used by anyone other than the doctor’s one and ONLY responsible officer.  NHS England’s Programme Manager replied to me in 2018:” We would not consider sharing your appraisal documentation with any employer and it should not be used in the manner in which your organisation is suggesting. I am happy to write to them on behalf of your RO to confirm your fitness to practice and that you are fully engaged with the appraisal programme.  That is all..”

These requests are a nasty extension of the use of the appraisal system output as a reference and a management tool.  This is not appraisal’s purpose, which is about probity, reflection, developing a personal development plan for licensing and revalidation.  No doctor should volunteer to send their appraisal output to anyone outside their own Responsible Officer’s team.

West Herts implied in the letter that in effect a doctors could have more than one GMC responsible officer, so each Trust could view appraisals outputs. 

BMA: Responsible Officers (ROs) are the individuals within designated bodies who have overall responsibility for helping you with revalidation. A designated body is the organisation (likely to be your main employer) that will support you with your appraisal and revalidation.  You only have one designated body and one Responsible Officer irrespective of how many organisations you are contracted with or employed by. Only UK organisations can be designated bodies, because the legal rules that determine this – the Responsible Officer regulations – only cover the UK.

GMC: Taking Revalidation Forward  the GMC has the following statement in Sir Kieth Pearsons recommendations (Appendix B)
9 Responsible officers should make sure that the revalidation process for individual doctors is not used to achieve local objectives that are not part of the requirements specified by the GMC. 

LMC: “believes this is a gross misuse of the appraisal process and that there are no such requirements for outputs to go to new employers”

GPC: An employee should not be requesting this information and you do not need (nor should you) share it. All they need to know is that you are on the performers list (which you can only do it you are keeping up with appraisals and revalidation. 

During my time as an appraiser I assured my doctors that the appraisal process was confidential, and that the only person who may see it would be their one and only responsible officer and their appraiser.  A doctor has one, and only one GMC Responsible Officer, no matter how many employers he or she has.

We have understood that appraisal remains a formative and reflective process. The output has no pass or fail unless there are clinical risks found or the doctor is not engaging.  The purpose of appraisal is to demonstrate continued probity, learning and reflection to keep a license.  The doctor’s one R.O. can approve for revalidation after five years.

A Trust can check that a GP had had a recent appraisal, that he is licensed, revalidated and on the GP performer’s list.  Should a Trust need to know that a doctor is suitable for a particular job this is achieved by references and interview.  The appraisal data would be a poor way to do this.  To provide appraisal data to third parties is an extension of the appraisal and revalidation system beyond its scope and purpose.

GPs must refuse to send appraisal output demanded by employers. They have no right nor reason to see it. 

Gerry  Bulger



Doctors Cause Crime

Prison Healthcare

There has an exponential in the use of gabapentin and pregabalin medication amongst prisoners over the last decade. These drugs are now almost exclusively used by those with other dependencies in prisons. During this time of increasing use of these gabapentinoids and other prescribed medications, we saw seeing an increase of violence in prisons. This violence may not be due to illicit Spice use and the past reductions in the number of security staff.

I am the suspicious that us doctors may not be doing any good. Doctors do not have any medication to treat crime, but our best of intentions may now be causing criminal side effects.

Many of my prisoner patients have recognised themselves in the following scenario:

You have a criminal tendency, making you feel nervous, or you may have heroin habit, whereby you have to “find” £100+ a day for that. This make you very nervous, an anxiety state. You go to your kind GP who gives you diazepam at least, but clonazepam is your preferred benzo choice (10x more potent). You now feel relaxed and invulnerable. You feel better inside yourself, but you are now worse to others.  Relaxed you can thieve more. Then there is that paradoxical aggression these medications give, so that knife you have with you is now more likely to be used. Of course you prefer the similar effects given by the gabapentinoids, the new benzos, which you can seek for that old ankle fracture and back pain. Gabapentinoids can give a high on their own, make heroin highs better and cheaper, and any spare capsules can be sold on.

Your life is now a mess, and you feel grief, guilt and remorse. These are uncomfortable sensations, which should protect you from more damaging high-risk behaviour. These feelings are depressing and annoying. Your GP now adds in an SSRI for your “depression”, but you may seek Mirtazapine, as you cannot sleep (perhaps partly caused by the cocaine), and you may want a bit of weight on. The anti-depressant detaches you from your emotions (that’s partly how they work in depression), releasing you from guilt and remorse.  

You now have ideas that others do not like you, you have no insight as to why that is so. Your mood swings are violent, disinhibited, so now you now have added quetiapine or olanzapine to the cocktail. These major tranquilisers were designed to stop the overthinking in a psychosis and schizophrenia, but here the tranquilisers block thought, further imagination and hope and they also make you fatter.

With this concoction of these prescribed medications you now are free of anxiety, grief, guilt, remorse and hope. You are detached and have no feelings for others. You now have full blown Iatrogenic Antisocial Personality Disorder with multiple convictions.

Weight goes on and on, blood sugar rises. You are now diabetic.

Full latest prison blog is here