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Appraisal of NHS consultants has been running for two years, and most general practitioners will have their first appraisal this year. If done properly, the process should enhance personal development and learning, but links with revalidation have led to fears about it being used only for assessment. The challenge is to produce a valued appraisal system that ultimately improves patient care
Appraisal should be a vibrant educational process. It is a means of preparing the ground for enhancing personal development and contributes to partnership between an individual and the employing organisation. Most importantly for health care, appraisal has been shown to be positively associated with patient care, with the association increasing with the quality of the appraisal.1 For doctors in the United Kingdom, appraisal is also going to be the main method of revalidation.2 We therefore need to be clear what appraisal is, in order to maintain its integrity as an educational tool. This article sets out what appraisal entails for NHS doctors and its potential benefits. It also explores some issues that could adversely affect appraisal and practical steps that will allow it to flourish.
Appraisal is a structured process of facilitated self reflection. It allows individuals to review their professional activities comprehensively and to identify areas of real strength and need for development. Appraisal is a formalised means of helping a professional move through the learning cycle (fig 1).3 Reflection forms the link between experience and the generation of ideas, which results in altered behaviour.
The existence of the NHS has facilitated the development of a standardised model of appraisal for all doctors. Although separate guidelines exist for consultants and general practitioners and some differences of approach (see bmj.com), the core process and intent is identical.4-6
Box 1: GMC's components of good medical practice7
The essence of appraisal is a confidential conversation, supported by preparatory documentation based on the General Medical Council's guidance on good medical practice (box 1).7 The appraisal conversation should be followed by a period of reflection, after which the appraiser gives feedback. An action plan is then agreed, which the appraisee can use to steer development and learning. Importantly, after anonymisation the development needs within the plan can also be collated and fed back to the organisation to inform local learning and planning of services (fig 2).
Box 2: Distinguishing different aspects of performance review
Appraisal (appraisee centred) Involves reflection:
Assessment (personal) Involves measurement:
Performance management (organisation) Involves comparison with others:
Revalidation (external/public) Involves licensing:
In many cases appraisal is really a combination of appraisal, assessment, and performance management. There are important distinctions between these three activities (box 2). An overall process of performance review may combine several or all of these components, and each has a legitimate function within such a framework. However, the developmental potential of appraisal is likely to be greatest when the conversation remains focused on self reflection. This is most easily achieved by keeping the processes separate. General practitioner appraisers, trained through the NHS Clinical Governance Support Team programme, are prepared for this8,9; the degree to which the distinction has been applied by those appraising consultants is less clear. The primary benefit of appraisal is personal insight, opening new avenues along which a previously entrenched issue can be explored (see bmj.com).
Appraisal for doctors has been introduced into a perceived climate of anxiety and possibly recrimination, which may influence the success of the process. For example, there are concerns that morale among doctors is low.10,11 Recent instances of poor practice such as the Bristol heart surgery case and retention of body parts without consent at Alder Hey have rightly or wrongly become synonymous with failing doctors and failing self regulation. In response, big changes to self regulation have been proposed, the central plank of which is periodic accreditation of all doctors.12,13 The GMC has now clarified that for most doctors evidence of robust appraisal will be the core requirement for revalidation.2
At first glance appraisal and revalidation may seem strange bedfellows; one is formative and confidential, the other summative and public (box 2). But the relation may be mutually beneficial: the use of a primarily educational process should lessen apprehensions about revalidation, while the discipline of revalidation should generate greater engagement with the appraisal scheme by both doctors and their employers.
There are also positive drivers for appraisal. The first is the use of personal development plans as a vehicle of lifelong learning. Appraisal is an effective way for individuals to identify their learning needs. The second is the emergence of clinical governance as a means of enhancing quality in the NHS.14,15 This development heralded a journey towards a culture where the NHS becomes aligned to deliver a patient centred, safe, and high quality service. Appraisal feeds into this ongoing culture change, recognising the value of individuals and providing them with a safe and sensitive channel through which to influence their organisation. Another aspect of the required cultural shift is the ending of the culture of blame and fear and the development of a “fair and just” or “learning” culture.16 Shame has been identified as an important factor preventing learning.17 Appraisal provides a confidential forum in recognition of this.
Nevertheless, the debate around appraisal is finely balanced; the experience of clinicians being appraised in these early years will be important in setting the degree to which it is valued. It is therefore important that those responsible for appraisal create the right environment by, for example:
The benefit of meeting these requirements is the emergence of a supportive working environment that allows doctors to engage confidently and honestly with appraisal. This resonates with the call from Edwards and Marshall for constructive dialogue to replace a historical state of mutual suspicion between doctors and managers.18,19 The question is whether appraisal can first of all overcome this suspicion and then facilitate the required dialogue, by opening a channel of communication between individual and organisation.
So, will appraisal deliver better health care? West described a clear association between appraisal and reduced mortality.20 Although West draws back from asserting a causal link, the existence of a healthy appraisal system can now be seen as an indicator of the health of an organisation, and hence its capacity to deliver high quality care. West observes that the degree by which mortality falls depends on the sophistication of the appraisal process. This adds to the need to evaluate the process and invest the resources it needs to flourish.
With this in mind, how is the NHS appraisal process to be evaluated? Some sense of this is emerging: the deaneries are to have a role in quality assurance, and the Commission for Healthcare Audit and Inspection will include appraisal systems in their inspections, thus ensuring a link to the star rating of the trust. Suitable indicators of the effect of appraisal on patient care also need to be agreed now. An outcome measure such as mortality might be appropriate, but a nationally agreed set of process measures might act as a suitable proxy and produce results sooner.
Appraisal for NHS doctors has the potential to be a vibrant educational process contributing to personal development
The prime aim of appraisal is to improve patient care
Appraisal will provide the main route to revalidation for UK doctors; this should be seen as a secondary function
For appraisal to flourish, responsibilities must be accepted at personal, local, and national levels
The NHS appraisal process must be evaluated and learn the lessons of experience
The presupposition of appraisal is that the NHS goal of improving patient care will be met by allowing staff to identify and fulfil their own development needs because the organisation and the staff share the same goal. We now have evidence that this is a legitimate assertion1,20; the challenge is to develop appraisal to fulfil this potential. This places responsibility at every level of the NHS to fund, support, participate in, follow up, and evaluate meaningful appraisal. The stronger we make this chain of responsibility, the greater the effect on the health care of patients.
A table comparing appraisal of GPs and consultants and examples of appraisal are available on bmj.com
I thank David Graham, Aidan Halligan, John Hasler, Jennifer King, Ron Cullen, Debbie Wall, and Adrian Jefferies for support with this article.
Contributors and sources: MC has been a fulltime general practice principal in South Birmingham for 10 years. His interest in education began with teaching general practice. A subsequent role on the board of the local primary care group introduced him to the principles of clinical governance. He has been involved with the NHS Clinical Governance Support Team and their programme to train GP appraisers. This article was written with no sources other than the references and observational comment from those acknowledged.
Competing interests: None declared.