title: The general practitioner workforce crisis in England: a qualitative study of how appraisal and revalidation are contributing to intentions to leave practice.
abstract: The general practice (GP) workforce in England is in crisis, with declining morale and job satisfaction, increasing early retirement and declining interest in training to become a GP. We recently reported on factors that are influencing this, with appraisal and revalidation emerging as an unexpected finding; 28.6 % of GPs stating an intention to leave general practice within the next 5 years included this as 'very important' or 'important' to their decision. In this study we undertook a secondary analysis to identify how the experience of appraisal and revalidation might be influencing intentions to leave general practice.
  
  
  
  Qualitative analysis of free text comments made by GPs in a survey of career intentions. All comments that included mention of appraisal or revalidation were extracted. Emergent themes were identified and a coding framework devised.
  
  
  
  Forty-two participants made comments that related to appraisal and revalidation. Compared to all 1192 participants who completed the main survey, they were older (76.2 % compared to 46.2 % aged 50 years and older), with more years' general practice experience (80.0 % compared to 48.0 % with >20 years' experience) and more likely to state an intention to retire within 5 years (72.2 % compared to 41.9 %). Key themes were appraisal and revalidation as: a bureaucratic, inflexible exercise that added to an already pressured workload; an activity that has little educational value, relevance to professional development or quality of care; and an issue that contributes to low morale, work-related distress and intentions to leave general practice. Revalidation was depicted as a cumbersome tick-box exercise that had little to do with quality of care or protecting patients. There were no comments that countered these negative views.
  
  
  
  While the representativeness of these comments to the experience of GPs as a whole cannot be judged, it is likely that that they reflect the concerns of GPs whose experience of appraisal and revalidation is influencing their intention to leave general practice. Through its impact on GP morale and burnout, the current appraisal and revalidation system in England appears to be contributing to the workforce crisis. The findings indicate that the appraisal system may be in urgent need of re-design to increase its relevance to individual GPs' experience and seniority, clinical activities being undertaken and professional development needs.
authors.affiliation: Primary Care, Warwick Medical School, Coventry, CV4 7AL, UK. jeremy.dale@warwick.ac.uk.
authors.forename: Jeremy
authors.initials: J
authors.lastname: Dale
authors.affiliation: Research Fellow, Warwick Medical School, Coventry, CV4 7AL, UK.
authors.forename: Rachel
authors.initials: R
authors.lastname: Potter
authors.affiliation: Teaching Fellow, Warwick Medical School, Coventry, CV4 7AL, UK.
authors.forename: Katherine
authors.initials: K
authors.lastname: Owen
authors.affiliation: Davenal House Surgery, Bromsgrove, B61 0DD, UK.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Leach
mesh_terms: D000328:Adult; D000367:Age Factors; D000368:Aged; D001291:Attitude of Health Personnel; D002321:Career Choice; D002568:Certification / Q000379:methods*; D004502:Education, Medical, Continuing / Q000592:standards; D004739:England; D005260:Female; D058006:General Practice / Q000592:standards*; D058005:General Practitioners / Q000523:psychology*; D006801:Humans; D033182:Intention; D007588:Job Satisfaction; D008297:Male; D008875:Middle Aged; D009013:Morale; D036301:Qualitative Research; D012179:Retirement; D013997:Time Factors; D000078329:Workforce
keywords: Appraisal; Family practice; General practice; Retirement; Revalidation; Workforce