ROAN information sheet 12: Written reflective practice in appraisals

We have been asked by Responsible Officers in England to provide clarification over the use of written reflective practice in appraisals. This follows recent high profile discussion of this topic following the tragic death of a young boy, Jack Adcock, and the subsequent legal proceedings against Dr Bawa-Garba.

Further to the clarification here and a reminder of existing guidelines, we intend to follow this letter with more detailed dialogue and guidance at responsible officer network meetings. The aim is not to offer any commentary or assessment on the details of this case, but to aid and reinforce the positive culture of continued learning within the medical profession, the purpose of which is to increase quality of care for patients and families and to ensure a culture of openness and transparency.

A number of queries have been raised about the role of written reflections in court proceedings. In particular there are inaccurate perceptions regarding the role of written reflections in Dr Bawa-Garba’s trial. In fact, the Medical Protection Society has stated that Dr Bawa-Garba’s e-portfolio document ‘did not feature at all’ in her trial. An unsigned trainee encounter form was submitted as an attachment to her duty consultant’s evidence, but this was not considered by the jury at the trial. Furthermore, on the general point about the role of reflections, ‘the court was clear from the start that reflections were irrelevant to the facts of the case’.

It is vital that doctors maintain the practice of reflection, both written and oral, including at appraisal. Reflection is identified by the GMC as a core component of professional practice. It is an essential aspect of continuing professional development, and helps underpin quality and safety of patient care. Indeed, a doctor’s professionalism can potentially be called into question by their failing to demonstrate adequate reflective insight. The overall value of reflection is strongly positive for the doctor, the system and, foremost, for patients.

Doctors should write their reflections in a professional and factual manner. Guidance on this is available from several sources including the GMC and the Academy of Medical Royal Colleges. The identity of individuals should be anonymised as much as possible and the focus should be on learning and what might be done to improve. There are limits to the confidentiality of any written document; however the Medical Protection Society has confirmed that in their experience e-portfolio documents have never been obtained via court order1. It is similarly helpful to understand that the GMC do not ask doctors to produce reflective statements as part of their investigations.

The commitment towards a culture of openness is further underpinned by the statutory duty of candour regulation which requires that patients are informed when deficiencies in their care have led to harm7. This organisational duty mirrors the individual professional duty to reflect. The common principle is that transparency and openness maximise the potential to improve care and underpin the trust and confidence of patients and families.

Healthcare workers work in challenging roles, often under pressure in difficult situations. We all have a duty to make our care high quality, safe and compassionate. Honest and open reflection is a key instrument to this end, helping to underpin public confidence in our work.

Released February 2018.