Of the thirteen GPs interviewed (nine male, four female), ten were GP principals, two were sessional doctors and one was a salaried GP. Study participants worked in a mixture of urban and rural practices across the west of Scotland with a spectrum of patient list-sizes. Six participants were involved in delivering either under-graduate or post-graduate training, and five were members of the regional educational programme which permitted free access to the peer feedback model (Table ).
Characteristics of Study Participants: Personal, Professional & Educational (n = 13)
Four core themes were identified in relation to the barriers and attitudes influencing engagement in the peer feedback model in the current context of appraisal and planned revalidation:
1. Value of the improvement activity (i.e. audit, SEA, consultation technique)
2. Value of external peer review
3. Value of the peer feedback model
4. Attitudes to external peer review (including appraisal)
A summary of the key barriers and attitudes related to each theme is outlined in Table .
Summary of key barriers and attitudes by theme
Value of the improvement activity
There was disagreement amongst participants as to the inherent professional or clinical value of all three improvement activities offered for peer review. Although most GPs could understand why these specific activities could enhance professional practice, others viewed some or all of them as not having a direct relationship to improving their day-to-day clinical work and so questioned their importance to them.
"Audit I am sure does improve systems, does raise the standards of personal practice but maybe not as, not as imminently as looking at a significant event or looking at yourself doing a consultation. Those are far more in your face, you know far more personal; they are far more likely to bring around a change in practice or a reflection about what you are doing" (GP2)
"They are some easily measurable things... they are measurable but I don't know that that necessarily reflects good practice" (GP1)
For some participants even though they acknowledged that the improvement activities discussed could enhance aspects of professional practice generally they did not perceive that it had or would lead to direct changes in their own practices specifically. They were confident in their own assumptions about the sufficiency of their experiences and abilities as a means to self-improve and keep up-to-date and did not appear highly motivated to participate in these specific improvement activities.
"It is highly unlikely at this stage that I am massively going to change my approach or change my style of operating which has clearly worked reasonably okay up to now" (GP4)
Value of external peer review
It was recognised that GPs can be exposed to many different models or styles of external peer review often without a full realisation that they are doing so. For some this was revealed in a limited and possibly conflicting understanding of the context, meaning and purpose underpinning peer review as an educational construct. For example, several GPs understood peer review to relate primarily to 'multi-source feedback' for which they displayed strongly negative feelings. Although this was not wholly accurate it nevertheless led to a biased perception of what 'peer review' entailed for them.
There was recognition amongst many participants that the possibility of external review of their professional activities by peers would be more 'challenging' than 'internal' review from GP partners or associates. For many this was thought to be clearly beneficial as it would enhance the validity of their work because it was perceived to be more objective and formalised - particularly if the peer reviewer was not known to the GP. In addition, it may offer a demonstration to any interested external authorities, or even their own patients, that their professional performance was of a sufficient standard.
Conversely, the concept of external review was thought by others to offer little additional benefit either as a quality assurance tool or as an educational activity. This was particularly so if study participants' immediate GP work colleagues had recognised educational expertise and knowledge that may be associated with being a professional appraiser, specialty training supervisor or holding a medical regulatory position with a relevant local or national organisation. Additionally, the notion of independent, external review was also regarded as "more formal review" which in turn was associated with "selection and control" aspects of regulatory medical assessment, rather than as a formative and developmental educational exercise.
"...the person who would be more detached, could look at the situation more objectively that is probably a good point also, again they wouldn't be biased by knowing you, probably more objective and that would probably be the best advantage I think really" (GP7)
"One of our partners is a CHCP [Community Health Care Partnership] chairman so he is usually ahead of changes in the game, we have got two appraisers... our Practice Manager is a QOF [Quality & Outcomes Framework] visitor... so we have lots of people who are on the ball learning things you know from the point of view of our practice" (GP4).
Value of the peer feedback model
The external peer feedback model was thought by many to be constrained by the defined, structured formats to be adhered to when performing and submitting the improvement activities under discussion. The act of complying with these formats was thought to miss the important nuances of daily professional practice that influenced contextual and performance issues and could only be fully appreciated and understood by those who worked in and experienced that particular environment.
"...the disadvantage of external feedback would have, it wouldn't it would only have what it saw on paper whereas internally the people can have a feel for what you are doing and how you are doing it, so its finer details but it is also sort of the 'wishy-washy' more difficult to define aspect of what you have done and how you have done it, only internal people would be able to pick up on." (GP12)
For some GPs their internal working environment was thought to offer numerous opportunities for 'robust' peer review from a range of clinical and also managerial colleagues. They therefore perceived very little advantage in engaging with the external peer feedback model, the preparation for which they thought to be unnecessary, overly formal and added workload.
"At our meetings in the surgery alone there is probably about thirty or forty folk at it... so it's a pretty good appraisal in itself... within the practice I think there is enough people that we get pretty good feedback" (GP10)
"I cannot be bothered with all that extra bits because I don't need it... and well God ok, that I haven't looked at everything but I just haven't sat down and written it all bit by bit... but people will argue, 'well if you don't do it properly it is just sloppy, la la la la', fine, I don't need the formalization anymore thank you very much" (GP9)
In contrast, those GPs who could foresee a benefit in the peer feedback model did so because of the perceived advantage that could be gained through the process of formalising the external review of aspects of their professional performance for regulatory reasons, rather than the potential educational and developmental impact which may be accrued.
"I daresay one of the benefits value wise will be strengthening my appraisal and revalidation folder in terms of ticking all the right boxes there" (GP6)
Attitudes to external peer review (including appraisal)
A lack of professional trust in the true purpose and potential integrity of both the external peer feedback model and the national appraisal system was clearly evident for a significant minority of participants. Previous experience of high stakes assessment processes as part of specialty training led to some expressing negative attitudes to participation in a formative external feedback system. For others a willful non-participatory attitude was formed because of a perception that the system is 'disciplinary' in nature, or is potentially so, or is simply not to be trusted because of the healthcare role of the organisation which hosts the peer feedback model (the national body responsible for the education and training of the healthcare workforce in Scotland):
"I ended up having to do a second audit [for summative assessment during GP training] having failed one on almost a technicality. I think that may have put me off the process...I didn't really go through a positive feedback process" (GP4)
"Big Brother... I don't see it as helpful at all, I don't see anything that suggests from anything that I have been involved in to suggest that they are actually trying to help..." (GP6)
For others, external review was thought of more favourably if it was considered to be 'true peer review' which was associated with face-to-face feedback. This type of feedback was considered to be much more valuable than the existing system of providing a personalised written report summarising reviewers' developmental comments on the standard of the improvement activity undertaken.
"...it certainly would be useful to know that that somebody was working in General Practice and not maybe somebody who was you know in a ivory tower as an academic GP you know, and wasn't you know and didn't have their feet on the ground sort of thing" (GP10)
"...but I think verbal feedback is useful, without verbal feedback (the written report) I think it would be worse because I think with verbal there is interaction, any misunderstandings could be rectified then" (GP9)
A range of marketing and resource perceptions about barriers to non-engagement were also identified such as a lack of awareness of the peer review system; time to participate, financial cost and equipment constraints; and unfavourable geographical locations (where potential participants felt isolated from the central co-ordinating office for peer review). These perceived pragmatic difficulties were raised by, and on behalf of, sessional and out-of-hours doctors by participants. These particular peripatetic GP groups were thought to have greater challenges to overcome when arranging to video-tape consultations or undertake clinical audits before submitting this evidence for peer review.
"...the difficulty with them [video-taped consultations] is I suppose the timing and the amount of work required..." (GP3)
"it is not my practice, I am there as an employee, hired locum for that session, and so obviously before I think before I would be sending it off I would need to clear that with the Partners and other people involved before I sent it out to an external source" (GP1)
Current experiences of the national appraisal system also influenced attitudes to peer review and whether to proactively engage with the separate peer feedback model. Most participants recognised the existing appraisal system as a form of external peer review. However, for some, experiences of this system were associated with a perceived lack of learning and improvement opportunities in relation to the time and resource invested, while for others this form of external peer review was slightly more challenging but had a minimally positive impact overall.
"...so far I have had three appraisers, and if that is what an external person offers thank you - good night...the last guy was slightly better, the first two were a waste of space... so that has not encouraged outside support" (GP7)