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:
- Providing trained, skilled appraisers
- Properly resourcing the appraisal process through protected time and appropriate remuneration
- Supporting the individual to fulfil his or her identified action plan
- Being seen to use appraisal outcomes to inform trust strategy
- Engaging in useful evaluation, and improving the process as it develops.
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.