ETHICS/EDUCATION

Appraisal e a developingprocessDavid Churchill

AbstractAppraisal has been in place for 8 years and is a contractual requirement

for career grade doctors. It will become central to the process of revalida-

tion laid down by the GMC. It is principally a formative process although

recently summative elements have been included. The enhanced

appraisal processes for revalidation includes multi-source feedback.

Evidence to date from multi-source feedback shows that communication,

team working, leadership and management are areas in need of improve-

ment. However, clinical skills, compassion and teaching are rated highly.

A successful appraisal requires a constructive approach from both parties

and thorough preparation. The outcome should be an achievable

personal development plan. If approached positively an appraisal will

produce benefits for both the individual and organisation.

Background

A First Class Service described appraisal in the overall context of

clinical governance in the NHS. Its was reinforced in Supporting

Doctors, Protecting Patients, which brought together proposals to

prevent doctors in England from developing problems.

The actual process of consultant appraisal was formally

introduced in 2001 and it became a contractual requirement in

2002. But a review of the process for the GMC, in advance of

revalidation, has described the implementation of consultant

appraisal as patchy. It is probably true to say that for many

different reasons consultants still have a degree of scepticism

about the role of appraisal in their career development.

Nevertheless the process is here to stay. The government and

GMC’s proposals for revalidation are in large part predicated on

enhanced annual appraisal, although what is meant by this has

yet to be completely described.

What is appraisal?

This might seem an unnecessary question. But the different

groups (clinicians, managers) within the NHS have slightly

different slants on the process.

Originally appraisal was sold to consultants as a formative

process, which leads to a forward looking and positive discussion

about career development. In simple terms it was to review

performance and develop a learning plan. It was on this basis

most consultants accepted the process.

Over time Trusts and other NHS employers began to see

appraisal as a way to direct consultants’ development to meet the

David Churchill MD FRCOG is a Consultant Obstetrician & Director of

Governance at the Royal Wolverhampton Hospitals NHS Trust, New

Cross Hospital, Wolverhampton, UK. Conflict of interests: none

declared.

OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 20:7 225

needs of the organisation and often the interests of both coincide.

Everyone wants to produce high-quality care that has successful

outcomes for patients. However, the potential for conflict exists

when target-driven business needs are interposed into the process.

Most recently the GMC’s plans for revalidation mean that

appraisal becomes, in part a summative process, a tool with

which to gather evidence on doctors in difficulty and to put into

place corrective measures.

However, if appraisal is to be of benefit to both consultants

and employers it has to remain mainly a formative process,

which informs development.

The process of appraisal

Documentation and Evidence

Collecting evidence and completing the documentation is the first

step in the process. The documentation has two purposes, first to

provide the appraisee and Trust with the information necessary

to undertake the appraisal, and second to collate the information

set out by the GMC to provide evidence for revalidation.

The GMC has distilled the content of Good Medical Practice

into four key domains, which form the basis of the

documentation.

The domains are:

1. Knowledge, skills and performance

2. Safety and Quality

3. Communication partnership and teamwork

4. Maintaining Trust.

Details of the standards and possible sources of evidence are

detailed on the GMC website. This documentation can be built

upon with local priorities if so required.

It is often not possible to examine every aspect of a consul-

tant’s job in one appraisal. It is acceptable to choose key areas of

importance to concentrate upon, e.g. highest clinical risk, local

priorities, etc., and still fulfil the requirements of revalidation.

Once completed the documents and the evidence should be

shared with the appraiser. This should be well in advance of the

appraisal interview to allow them to be studied. It is also useful

to agree an agenda for the interview to maximise the productive

time by concentrating on areas of importance. In constructing an

agenda it is useful to refer to the job plan and previous years

personal development plan.

The interview

The interview is the most important step in the whole process. Its

success depends on the planning, the skill of the appraiser and

the approach of the appraisee. There must be no surprises for

either participant.

Appraisers must be trained. They need to understand the

objectives of the process, the priorities of the Trust or department

as well as the requirements of revalidation. They need self-

awareness, particularly their own biases, and must be positive

and constructive even when problems have been identified. The

ability to listen actively and reflect back to the appraisee are

invaluable qualities. However, appraisers must not be afraid to

challenge or tackle difficult issues.

Appraisees will get the most out of the process if they

approach it constructively in a proactive manner. It is their

opportunity to get support for their development plans.

� 2010 Elsevier Ltd. All rights reserved.

ETHICS/EDUCATION

Some consultant’s jobs span more than one organisation, for

example, academics with university and NHS commitments. In

these instances the appraisal may be carried out jointly by both

organisations or if this is not possible then parts of the agenda

should be split and assessed separately.

The outcome

A successful meeting results in the production of a personal

development plan (PDP) and progress towards revalidation. The

PDP must have clear objectives with actions and the need for

resources must be detailed. It may not be possible to meet all the

objectives in one year. This is more likely when there are

significant constraints upon a service. In these situations, busi-

ness cases will need developing and then piloting through the

management structures of the Trust. It therefore may take more

than one appraisal cycle to resolve such issues.

Multi-source (360 degree) feedback

Multi-source feedback (MSF) will form part of the enhanced

appraisal process for revalidation. It consists of anonymous

feedback from colleagues and patients using standardised ques-

tions. Evidence is provided on clinical practice and personal

interactions. In some Trusts it is already in use as part of the

overall appraisal process. Many consultants will view this

process with some suspicion; for those trained more recently

who will be used to this sort of feedback, the addition of patient

questionnaires will be new to them.

The results of MSF from 554 consultants have been collated

and have shown that there are rarely problems with clinical

skills, availability, compassion, responsibility and teaching.

However, 1 in 12 doctors did appear to have problems with

communication, team working and, leadership and management.

The specialties where these issues appeared to be of greatest

problem were psychiatry, A&E, medicine and its sub-specialties.

These issues reflect the rapidly changing work patterns and are

being dealt with through postgraduate and undergraduate

medical education curricula.

There are limitations to MSF. It is not a process, which reveals

individuals who have problems, which are not already known.

Nor should it be used as part of the disciplinary process or

a means of determining promotion. Its real benefit is in providing

the individual with the evidence on which to reflect on his or her

practice and skills.

Pitfalls of appraisal

It must be remembered that it is not possible to fail an appraisal.

However, it may feel like that if preparation is poor. For busy

clinicians, collating appraisal evidence is not at the top of their

list of priorities. Employers must stress its importance and

OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 20:7 226

provide the time for it to be carried out. It has been calculated

that a minimum of 4 h, for both the appraisee and appraiser, is

the minimum required for a successful process. In addition

employers need to commit resources for consultants to complete

agreed continuing professional development (CPD) programmes.

Some worry about the confidentiality of the process. Only two

people should see the documents in total, the appraisee and

appraiser. A summary document may be seen by the chief

executive or medical director to assure them that the process has

been followed and contractual commitments met. Breaches of

confidentiality must be treated in the usual way through the

disciplinary processes.

Where disputes arise during the appraisal interview, there are two

routes that can be taken. One is to agree to differ for the time and re-

arrange a meeting after both parties have had chance to reflect upon

the issue concerned. Alternatively a third party such as the medical

director or his or her deputy can continue with the appraisal.

Notwithstanding the concerns and the rules put in place to

reassure consultants, both parties must take appropriate action to

protect patients when serious concerns are raised.

Summary

The process of appraisal is being strengthened for revalidation. It

was envisaged as a purely formative process but over time it has

taken on some summative elements. However, if the true bene-

fits of appraisal are to be achieved it must be viewed as a process

to develop the individual. Clearly, employers will want an

alignment with the strategy of the organisation but in most cases

the two are compatible. A

FURTHER READING

Chambers R, Wakley G, Field S, Ellis S. Appraisal for the Apprehensive e

a guide for doctors. Radcliffe Medical Press, 2003.

Department of Health. A first class service. London: Department of Health,

1998.

Department of Health. Supporting doctors, protecting patients. London:

Department of Health, 1999.

Department of Health. Medical revalidation e principles and next steps.

London: Department of Health, 2008.

Evans CC. Consultant appraisal. Clinical Medicine 2003; 3: 495e6.

http://www.gmc.uk.org/doctors/licensing/revalidation_gmp_framework.

asp (accessed November 2009).

Mason R, Powar S, Parker-Swift J, Baker E. 360-degree appraisal: a simple

pragmatic solution. Clinical Governance: An International Journal

2009; 14: 295e300.

Waller DG. Consultant appraisal: pitfalls and how to avoid them. Clinical

Medicine 2003; 3: 569e72.

� 2010 Elsevier Ltd. All rights reserved.