A little more conversation: appraisal and revalidation

Spring is here and with it comes the start of the new appraisal cycle for many NHS trusts. Appraisal is a long established feature of medical contracts. The NHS staff survey has suggested over the years that although appraisals are being carried out, they aren’t always well structured or lead to personal development plans that make a difference to a doctor’s practice and patient care. Revalidation has increased the focus on doing appraisal well and the responsible officer regulations which came into force in 2011 place a statutory duty on organisations to provide appraisal.

As part of the revalidation process doctors must have regular appraisals, based on the General Medical Council’s core guidance for doctors, Good Medical Practice. They also need to keep a portfolio of supporting information about their practice. A responsible officer will make a recommendation to the GMC about a doctor’s fitness to practise every five years. Their recommendation will be based on the doctor’s appraisals and supporting information. The GMC will use that recommendation to make a decision about whether or not to revalidate a licensed doctor.

Close to home

Effective annual appraisal is the cornerstone to revalidation. The Medical Act describes revalidation as an evaluation of a doctor’s fitness to practise. Other methods of evaluation, such as doctors sitting an exam every five years or full performance assessments of doctors undertaken regularly by colleagues, were rejected in favour of appraisal. “We believe that the evaluation of a doctor’s practice should take place as close as possible to the organisation in which the doctor practises medicine and sees patients,” says GMC director of continued practice and revalidation Una Lane.

Another important consideration in the current financial climate is that appraisal already happens in the NHS and elsewhere and a significant number of trained appraisers are in place throughout the country. Revalidation is simply an additional output from appraisal, so it’s about building on existing and familiar processes.

Appraisal has benefits for organisations and for doctors. Trusts can be confident and assure the public that the doctors they employ are competent and up to date. Doctors will be able to demonstrate to their employers and patients that they are competent and up to date, and they can use it to drive up their own professional performance.  It also interacts well with job planning processes, themselves linking to organisational objectives based on the needs of patients.

The benefits of appraisal will only be realised if it is done effectively. Employers should have systems in place to ensure that all doctors take part in annual appraisal, that a sufficient number of trained appraisers are in place, and that doctors can easily access the clinical governance information they need.

The GMC’s Good Medical Practice framework for appraisal and revalidation was developed a number of years ago to support doctors through the appraisal process locally. “It [translates] the high level values and principles from the core guidance Good Medical Practiceinto a more meaningful framework for doctors,” says Una Lane. Doctors can use the framework to reflect on their practice and their supporting information, demonstrate that they are up to date and fit to practise, and identify areas of practice they could improve. “It’s not about slavishly going through any particular form,” adds Ms Lane. “It’s about giving doctors an opportunity on an annual basis to reflect and demonstrate how they’re continuing to meet those values and principles through their practice and through their work and care for patients.”

Making it happen

Trusts can improve their appraisal uptake rates by making it a clear organisational requirement. Boards have a key role to play here by recognising the importance of effective appraisal in supporting revalidation, developing services and staff, and assuring the public that services are of good quality. Trusts also need to ensure that appraisal is one of the requirements that managers are there to deliver.

Plenty of guidance is available to support everyone involved in delivering appraisal and revalidation. The NHS revalidation support team, which is helping to get organisations in England ready for revalidation, published the Medical Appraisal Guide. The guide aims to help doctors understand what they need to do to prepare for appraisal, giving appraisal leads, responsible officers and designated bodies guidance and suggestions on how to develop their own appraisal processes.

The guide was piloted on more than 1,000 doctors in October and December of 2011. “The pilot evaluation concluded that doctors found it useful and doable and appraisers and responsible officers had the confidence that it could be done consistently to a high level of quality,” says Dr Nick Lyons, programme director for testing and piloting at the revalidation support team. ”

He adds that while there was a relief amongst doctors that medical appraisal as outlined in the Medical Appraisal Guide would make the regulatory process of revalidation possible, they felt it would be useful to them personally by informing their professional development.

The support team has also produced guidance called Quality Assuring Medical Appraisal, for responsible officers on selecting, training and supporting medical appraisers. Top-up training is ongoing to ensure that existing appraisers are ready for revalidation, can deliver what’s set out in the Medical Appraisal Guide and understand the principles of revalidation.

One of the keys to effective appraisal is having good supporting information that’s specific and relevant to an individual doctor. Another element is to focus on the essence of good appraisal, which is about thinking and reflecting on how things have gone last year and how things might be done differently for the better next year.

“For me it doesn’t feel any more complicated than that,” says Bill McMillan, head of medical pay and workforce at NHS Employers. “Revalidation brings with it structure and processes that are needed for appraisal systems to be effective – this hasn’t always been the case before.”

Whose responsibility?

Doctors are required to bring six types of supporting information to their appraisal at least once in a five-year cycle: continuing professional development, quality improvement activity such as national clinical audits and case based discussions with peers, significant events, feedback from colleagues, feedback from patients (unless exceptionally deemed inappropriate), and a review of complaints and compliments.

Both doctors and organisations have responsibilities to produce supporting information. However, recording and reflecting on continuing professional development is exclusively the doctor’s responsibility. “It’s simply about recording those events that they attend or recording the learning that they undertake,” says Ms Lane. “But also perhaps most importantly recording what they did learn and what it means for them in terms of changes or improvements to their practice.”

Organisations should provide doctors with complaints, compliments, significant events and patient and colleague feedback, which the doctor should then reflect on. Online appraisal toolkits are available in many organisations which help doctors put together a portfolio of supporting information.

Supporting information will vary across specialties and roles and the Academy of Royal Colleges has published specialty specific guidance for its members on how to meet the GMC’s requirements.

For more information on revalidation, including details of all the guidance and resources referred to in this article, please visit www.nhsemployers.org/revalidation