The concept of appraisals, their value and purpose has been around for a long time within organisations and businesses. Appraisal by one's peers and clinical mentors began as part of educational supervision and employer career monitoring. However, it will in an amended form be part of a reaccreditation (or recertification) and revalidation process. Revalidation is a process by which doctors will demonstrate at regular five-yearly intervals that they are up-to-date and fit to practise. It should involve reflection and, to be effective, should relate to a doctor's performance. It is expected that from 1st April 2009 GPs will have started collecting evidence to support their revalidation, which is expected to go live in April 2011.

The issue of reaccreditation has assumed great prominence in recent years since the conviction of Dr Harold Shipman, and the subsequent inquiry. This sparked major concerns about patient safety, the regulation of doctors and public confidence in the regulatory processes.

In the NHS Plan of June 2001, annual appraisal was confirmed as a contractual obligation. The 'obligation' relates to the concept of clinical governance, the maintaining of standards of care and public confidence in the delivery of healthcare. It concerns not just GPs but also other doctors, including consultants and career grade doctors. Primary care groups and primary care trusts (PCTs) began introducing the scheme in April 2002.

The process of appraisals for GPs can be embraced as an opportunity for personal and professional growth and development. However, the introduction of appraisals for GPs has been inconsistent across the country, both in quality and content, and this may have contributed to a less than enthusiastic reception by some.

See separate article Reaccreditation - Current State of Play, which explains more about the context of appraisals within revalidation and reaccreditation.

What is appraisal?

There a number of definitions of appraisal:

• Appraisal is a two-way process of reflection of an individual's performance and, for doctors, it forms an important part of continuing professional development (CPD). It is continuous process and forms an established aspect of numerous organisations to date. For doctors, appraisal allows time to reflect on one's performance and then plan further education and training needs for personal development and growth.¹
• The Department of Health defines appraisal as follows (2002):²
  'Appraisal for GPs is a professional process of constructive dialogue, in which the doctor being appraised has a formal structured opportunity to reflect on his or her work and to consider how his or her effectiveness might be improved.'
• According to the Advisory, Conciliation and Arbitration Service, appraisals 'regularly record an assessment of an employee's performance, potential and development needs. The appraisal is an opportunity to take an overall view of work content, loads and volume, to look back on what has been achieved during the reporting period and agree objectives for the next'.
• The School of Health and Related Research (ScHARR) report 'Appraisal for GPs' defines appraisal as a process for:¹
  • Exploring expectations, priorities, and setting and aligning individual and organisational objectives at a local level
  • Reviewing progress towards achieving previously agreed objectives and agreeing future objectives
  • Recognising, acknowledging and valuing achievements
  • Exploring what is needed from the organisation to help and support the individual

It is also worth considering that appraisal should not be:

• 'Just a paper exercise with forms to fill in.' Appraisal requires appropriate time, resources and support. If these are not available then it is likely to be ineffective.
• Synonymous with assessment. The latter can be defined as 'measurement of an individual's performance at a particular point in time, usually against predetermined standards'.¹ Assessments can form part of appraisal if appropriate; however, it is better that they be separated from the appraisal such that it is validated prior to the discussion.³

What does appraisal cover?

This is based on the General Medical Council's document Good Medical Practice and covers the following core principles:

• Good medical practice
• Standards of care
• Competency
• Expected conduct of doctors

Elements of an appraisal process

• The right setting - senior management commitment to develop a good and effective appraisal system for all staff; engaging all involved, e.g. study days
• Training of appraisers and appraisees - having experienced being an appraisee before being an appraiser helps
• Preparation - arrange well in advance; adequate time for meeting; no interruptions and in a private secluded area
• The meeting belongs to the appraisee - they should be committed and attend with well prepared thoughts
• Confidentiality
• Outcomes - a summary of the meeting in the form of action points should be set which forms the basis of the personal development plan (PDP); each outcome should be 'SMART' (see below)
• Regular review of appraisal systems⁴

SMART outcomes¹

Documentation

• Forms 1-3 are filled out by the appraisee prior to the meeting; form 3 requires a fair amount of thought.
• Form 4 is filled out by the appraiser, and the appraisee agrees to it. These forms are then copied and passed on to the trust or primary care organisation. Form 4 summaries should be kept by the PCT and the appraisee also.
• Form 5 is an optional form for the appraisee to keep a more detailed account of the meeting. It does not have to be forwarded to any other persons.

In February 2007 the NHS Clinical Governance Support Team and the National Association of Primary Care Educators jointly decided on core valid and verifiable evidence for the appraisal process. They also divided up evidence as personal and organisational (both necessary) and as optional evidence, where the appraisee can decide on what to include.This requires the following forms at the following times:³

Who should be the appraiser?

Senior doctors who are on the medical register should carry out appraisals. For general practice this applies to GPs who have worked for three years as a non-principal or principal.² However, it helps if they are motivated and they should undergo training beforehand. Newly appointed appraisers should be supported for their first three appraisals and it is anticipated they participate in between 3-20 appraisals per annum. Appraisers should be changed every two consecutive years. Appraisees can request for a different appraiser if they wish - this is important, as that person should be someone they trust and respect. Appraisal work should be balanced out within a practice if this is possible.

Quality assurance of the appraisal system

• The appraisal system needs to be regularly evaluated and quality assured
• A self-assessment audit is available for organisations⁵
• An appraisal guide with advice may be useful

Document references

1. BMA; Appraisals a guide for medical practitioners; Oct 2003.
2. ABC of GP appraisal; National Association of Primary Care Educators
3. Evidence for Medical Appraisal; Statement of NAPCE/CGST conference; Feb 2007.
4. Appraisal for GPs; Department of Health; Feb 2007.
5. Assuring the Quality of Medical Appraisal; Clinical Governance Support team; NHS; July 2005.

Internet and further reading

• NHS Appraisals website
• RCGP Learning Guide to Professional Development

Acknowledgements