In the consultation document Supporting Doctors, Protecting Patients (Department of Health 1999), Sir Liam Donaldson, the Chief Medical Officer for England, set out a wide range of proposals to help prevent doctors developing problems. The aims of appraisal, which is at the heart of these proposals, are:
Appraisal is being introduced by the Department of Health in England* for doctors working in the NHS. The aim is to give doctors regular feedback on past performance and continuing progress and to identify education and development needs – it is part of a doctor’s career development. The drive for formal appraisal came from the introduction across the NHS of clinical governance outlined in the 1998 consultation document A First Class Service – Quality in the New NHS. At around the same time, several high profile cases of clinical failure convinced the General Medical Council (GMC) of the need to introduce a mechanism that would ensure the public could be confident that poorly performing doctors were being identified and early action taken in order to protect patients.
Consultant appraisals had been taking place at a local level in NHS trusts prior to their formal national introduction in April 2001. A national model for consultant appraisals was developed together with the British Medical Association to ensure a consistent and transparent approach and development of shared standards and practice.
* The
health departments in Scotland, Northern Ireland and Wales are also introducing
appraisal for medical staff.
Doctors now covered by appraisal schemes include:
Appraisal for other groups of doctors, including GP non-principals, doctors in training and locum doctors will be introduced in due course.
The general principles of appraisal can also be used by other groups of doctors wishing to begin the process of appraisal and to gather data for revalidation.
Appraisal – Content
Appraisal is based on the GMC’s document Good Medical Practice (General
Medical Council, 2001), which describes the principles of good medical practice,
and standards of competence, care and conduct expected of doctors in all aspects
of their professional work. These are:
The process should embody a positive and developmental approach, be fair, effective and well-informed, and where possible indicate how patient care and working within NHS organisations can be improved.
Appraisal should include data on clinical performance, training and education, audit, concerns raised and serious clinical complaints, application of relevant clinical guidelines, relationships with patients and colleagues, teaching and research activities, and personal and organisational effectiveness.
The
appraiser should have a good understanding of the work carried out by the doctor
being appraised. If a doctor has specialist aspects of performance, the
appraiser should be acquainted with the relevant areas.
The appraisal process
Every doctor undergoing appraisal needs to prepare an appraisal folder
demonstrating information, evidence and data to inform the process, which can be
updated as necessary. The process is not about acquiring new evidence or
information, but pulling together what exists already.
The doctor and appraiser will agree a written overview of the appraisal, which should include a summary of achievement in the previous year, objectives for the next year, key elements of a personal development plan, actions expected of the organisation, a standard summary of the appraisal and a joint declaration that the appraisal has been carried out properly.
Chief Executives of NHS organisations are accountable for ensuring appraisal takes place, that appraisers are properly trained to carry out this role and are in a position to undertake appraisal of a doctor’s whole practice, including clinical performance, and where appropriate, service delivery and management issues.
Support mechanisms for appraisal
An electronic Toolkit for GP appraisal is available, offering a number of levels of support for appraisers and appraisees, and bringing together advice, guidance, best practice, practical tools and access to a community of peers in the appraisal domain. The Toolkit is available at: www.appraisals.nhs.uk and is currently being developed for other groups of doctors.
A free CD-ROM video guide to GP appraisal is also available from the NHS Responseline, on 08701 555455 (quoting reference 28027).
Projects to evaluate the outcomes of the appraisal process and to identify good practice in appraisal will be undertaken in due course.
As part of the joint appraisal and revalidation initiative by the Department of Health and GMC, a website has been set up, dedicated to providing a one-stop-shop for doctors and others interested in information about appraisal and revalidation. The website is available at:
In addition, an initial national GP appraiser training programme was run in 2002 by the National Clinical Governance Support Team, funded by the Department of Health. In addition, a series of 14 regional workshops were held and a training video sent to every GP practice. The Department of Health has also released funding to the deaneries to support appraiser training.
In March
2002, the Department of Health appointed Dr David Graham, Postgraduate Dean for
Merseyside, to chair the steering group on the implementation of appraisal for
doctors.
The Link with Revalidation
For NHS doctors, appraisal will also be the method for gathering revalidation evidence.
While appraisal was being developed, the GMC made proposals to licence and revalidate all registered doctors. This means that all doctors must have a licence to practise to treat patients or prescribe for them. Every five years each doctor who wants to remain in practice must present evidence to the GMC that they are competent in their field of practise and have kept up to date. This will allow the doctor’s licence to practice to be renewed.
In order to avoid unnecessary bureaucracy, the Department and the GMC agreed that a single set of documentation would be used for appraisal and revalidation. For doctors within managed organisations, five sets of completed annual appraisal forms can be submitted to the GMC as evidence to support revalidation. Alternatively, the evidence gathered for the appraisal process could also be submitted to the GMC as evidence to support revalidation.
Whilst appraisal is designed to help doctors identify development needs and produce personal development plans, rather than assess performance, evidence of participation will show the GMC that the doctor is discussing the quality of his or her own work and keeping up to date. This is a powerful indicator of fitness and overall qualification to practise medicine.
The agreed national documentation (available at www.doh.gov.uk/appraisal) includes a personal development plan based on the needs of the individual and the needs of the NHS organisation where they work. This commits NHS employers to support development because they need to help their doctors to get revalidated.
The Appraisal Process
Successful appraisal depends on both the parties giving their contribution some thought beforehand. Both parties should give themselves enough time to produce, exchange and consider any documents necessary for the appraisal - a few weeks rather than a few days in advance is best. GPs should have at least two months notice of their appraisal appointment. Where, for whatever reason, a third party needs to contribute to an appraisal - or, indeed, where a special appraiser has to be called in - this should also be discussed and agreed well in advance.
We suggest that it would greatly help the process if both the appraiser and the appraisee thought through the following questions before the interview:
AL(MD)6/00, (Department of Health 2000) paragraph 13, explains that 'To be successful, the appraisal scheme must be introduced with an appropriate level of support to appraisers and appraisees. Adequate time should be allocated for the preparation…'. It is essential, therefore, that adequate time is allocated, both for the appraiser and the appraisee. Employers must recognise that preparation time and time for carrying out the appraisal are instead of, rather than additional to the consultant’s existing duties and workload, and therefore should take place during usual working hours. In order to prepare for appraisals, individuals should be explicitly released from other duties for a specified period of time and GPs should be given protected time. It must be recognised that appraisees undergoing their first appraisal will require further time for work involved in setting up their appraisal folders.
Using the appraisal documentation
The Chief Executive has overall accountability for ensuring appraisal takes place and will receive copies of the forms summarising the outcome of the appraisal; Forms 1-4 – (Form 4 only for GPs).
Form 5 for GPs is an optional form to provide a fuller account of the appraisal discussion than is covered in Form 4.
Concerns arising during appraisal
It would be exceptional for serious concerns about performance to be first raised in an appraisal. However, both the appraiser and the appraisee need to recognise that as registered medical or dental practitioners they must protect patients when they believe that a colleague's health, conduct or performance is a threat to patients (GMC Good Medical Practice paragraph 23; GDC Maintaining Standards paragraph 2.4). If, as a result of the appraisal process the appraiser believes that the activities of the appraisee are such as to put patients at risk, the appraisal process should be stopped and action taken. The appraiser must refer the matter immediately to the senior clinician/clinical governance lead and [PCT] chief executive to take appropriate action. This may, for example, include referral to any support arrangements that may be in place. If the situation is then remedied the appraisal process can continue. Nothing in the operation of the appraisal process can over-ride the basic professional obligation to protect patients.
Work to assess the effectiveness of NHS appraisal systems for doctors will be carried out as the arrangements roll out.
The areas to be evaluated will include:
· Quality
of training for appraisers and appraisees
· The number of doctors undergoing appraisal
· The quality and fitness for purpose of the appraisal process
- for doctors
- for NHS trusts
- for patients
· The strength of the link between appraisal and revalidation
Learning & Personal Development
Department of Health
April 2003