Supporting Information For Annual Appraisal - Checklist



NHS England Checklist of Supporting Information for Annual Appraisal of GPs

|Doctor’s name | |Doctor’s GMC number | |

|Appraiser’s name | |Appraiser’s GMC number | |

|Date of Appraisal | |Birthday/appraisal month | |

|Revalidation date | |Doctor’s Area team or | |

| | |other designated body | |

|Date form received (office use) | |(office use) Appraisal Lead comments. | |

| | |Revalidation ready? | |

|Basic Supporting information required for appraisal |Seen |Comments |

|Quality Improvement Activity relating to the doctor’s individual practice. |Audit / data | | |

|(Examples of quality improvement activities include: clinical audit or data |collection and | | |

|collection and review, review of clinical outcomes, case review of discussions, |review | | |

|analysis of notes from consecutive consultations and evaluation of health policy or | | | |

|management practice) | | | |

| | | | |

|This will be shown under Section 8, if using the MAG form | | | |

| |SEA | | |

| |Case review | | |

| |Other activity | | |

|Significant Event / Serious Untoward Incident – (if named in any serious incident relating to the doctor’s| | |

|individual practice this must be discussed at appraisal (Write none if none disclosed) | | |

|This will be shown under Section 9, if using the MAG form | | |

|Log or diary of educational activities throughout including reflections, with estimated number of CPD | |No. of Credits |

|Credits | | |

|Review of any complaints-all formal complaints must be discussed, reviewed and learning and actions | | |

|identified (Write none if none disclosed) | | |

|Colleague Survey - results and reflections seen and discussed |One every 5 years | |If not done this year |

| | | |when last done ? |

| | | | |

|Patient Survey - results and reflections seen and discussed |One every 5 years | |If not done this year |

| | | |when last done ? |

| | | | |

|Probity Statement signed on MAG form |Every year | | |

|Health Statement signed on MAG Form |Every year | | |

|MAG/Output Statements |Agree |Disagree | |

|Statement 1 An appraisal has taken place that reflects the whole of the doctor's | | | |

|scope of work and addresses the principles and values set out in the Good Medical | | | |

|Practice. | | | |

| Statement 2 Appropriate supporting information has been presented in accordance | | | |

|with the Good Medical Practice Framework for appraisal and revalidation and this | | | |

|reflects the nature and scope of the doctor's work. | | | |

|Statement 3 A review that demonstrates progress against last year's personal | | | |

|development plan has taken place. | | | |

|Statement 4 An agreement has been reached with the doctor about a new personal | | | |

|development plan and any associated actions for the coming year | | | |

|Statement 5 No information has been presented or discussed in the appraisal that | | | |

|raises a concern about the doctor's fitness to practice | | | |

|Scope of practice |Activity |Seen |Comments |

|Review of all roles undertaken as a doctor The appraiser must identify any roles |Trainer | | |

|NOT reviewed | | | |

| | | | |

|Add any additional roles in the ‘other’ columns | | | |

| |Appraiser | | |

| |U/G teaching | | |

| |GPwSI | | |

| |OOH | | |

| |CCG | | |

| |Sports | | |

| |Other | | |

| |Other | | |

| |Other | | |

|Mandatory or other training required by the organisation but not a GMC Revalidation requirement |

| | |Done in last year |Included in PDP |

| *Certificate of CPR training |18 months | | |

| * Evidence of child-safeguarding training |Every year | | |

|* Please note that CPR and Safe-guarding are NHS England /Area Team training | | | |

|requirements , not GMC Revalidation Requirements, and should NOT be taken account of| | | |

|in the 5 ‘sign off’ statements on the MAG form, but gaps in training should be | | | |

|addressed on the next year’s PDP | | | |

|Exceptional Circumstances |Details |

|Breaks from work eg Maternity leave, sick leave, sabbatical etc|Specify duration and dates |

|Works less than 1 session per week in clinical GP/OOH work | |

|Under performance review eg with Area team, GMC or NCAS | |

|Other exceptional circumstances –please specify | |

|Comments –requesting that form is read in detail by clinical lead / reasons for disagreement with Output statements / other message to the lead |

| |

| |

| |

The appraiser must agree or disagree with the following statements when the appraisal has been completed

| |Agree |Comments |

|This appraisal has raised no issues that need following up by the |Y/N | |

|appraisal lead and/or Responsible Officer | | |

|This appraisal has raised issues that need following up by the appraisal |Y/N | |

|lead and/or the Responsible Officer | | |

|I confirm that I am aware of no conflict of interest with this doctor |Y/N | |

|that could influence the process of this appraisal | | |

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