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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. GP appraisals were introduced in 2002 but in 2012 became a part of the process of revalidation. Initially a formative, supportive process, they now have the dual role of providing evidence required for revalidation.
Revalidation is a process by which doctors must demonstrate at regular five-yearly intervals that they are up to date and fit to practise. It is based mainly on evidence from five years of appraisals. For more information, see the separate Revalidation article.
Aims and principles
NHS England defines medical appraisal as a process of facilitated self-review supported by information gathered from the full scope of a doctor's work. As part of the revalidation process, appraisals are key for doctors to demonstrate they are fit to practise, as well as being an opportunity to consider professional development needs. GP appraisals are undertaken annually at a meeting between a doctor and an individual (usually, but not invariably, a doctor) who is trained as an appraiser.
Essential elements of appraisal include:
- Protected time.
- The right setting, where the meeting can be free from interruptions and private.
- Adequate preparation by both appraiser and appraisee.
- Confidentiality - now somewhat compromised by the fact that the documentation must be reviewed by the appraisal team and potentially the General Medical Council (GMC). Nevertheless, the appraisal discussion remains confidential and, unless there is a concern raised about patient safety or fitness to practise, an appraiser may choose to word the summary of the discussion in such a way as not to disclose private information where appropriate.
- Adequate training for appraisers, and administrative and senior colleague support.
- Quality Assurance processes.
The appraisal process involves:
- Preparation: the appraisee gathers supporting evidence as stipulated by the GMC (see section below) and evidence of reflection. At least two weeks before the meeting, this evidence is submitted to the appraiser who must then familiarise themself with this information.
- Appraisal meeting: this is a confidential discussion between the doctor and appraiser, based on the scope of work over the past year (including achievements and challenges) and plans and aspirations for the future.
- Outputs: together, doctor and appraiser create a personal development plan for the next year. The appraiser writes a summary of the discussion (which must be agreed by the doctor being appraised) and signs a number of statements confirming that a satisfactory appraisal has taken place which fulfils GMC requirements.
The appraisal team
Appraisers are individuals with suitable experience who have been selected and trained in the role. NHS England lays out core training and follow-up requirements. Appraisers no longer have to be GPs in practice themselves, or even medically qualified, although most appraisers are. Appraisers are supported by an administrative team and by a senior appraiser or appraisal lead. They have regular feedback, both on the appraisal process from their appraisees and on their outputs by their senior appraiser. Appraisers are now usually allocated by the organisation, rather than individuals choosing their own appraiser. However, where there is a conflict of interest or where a doctor is uncomfortable with their allocated appraiser, there is an option to ask for a change.
Senior appraisers and/or appraisal leads support the Responsible Officer (RO) in their role of liaising between NHS bodies and the General Medical Council (GMC) on revalidation and appraisal issues. The RO makes a recommendation of revalidation for each GP every five years if they have provided satisfactory evidence of being up to date and fit to practice through the annual appraisal process, and if there are no outstanding investigations or concerns. Revalidation started in 2012, and in April 2013 NHS England took over responsibility for appraisal and revalidation in England.
The GMC lays down clear guidance with regard to the evidence it requires in order to revalidate doctors. For GPs, the Royal College of General Practitioners (RCGP) provides further detail.
Essentially, doctors must provide:
- General information about what they do in all aspects of their work
- Evidence that they are keeping up to date, maintaining and enhancing the quality of your professional work
- Evidence that they are regularly reviewing their practice and evaluating the quality
of their professional work
- Evidence of feedback on their practice, ie how others perceive the quality of their professional work
The appraisal is based on GMC core guidance "Good Medical Practice" (GMP). Evidence is organised into four domains which demonstrate essential professional values:
- Knowledge, skills and performance.
- Safety and quality.
- Communication, partnership and teamwork.
- Maintaining trust.
In order to demonstrate they are complying with this guidance, each doctor must build a portfolio of evidence to show they are meeting the requirements. There are six types of information each doctor must collect:
- Continuing professional development (CPD). The GMC does not specify any particular number of hours or credits required but the RCGP advises a doctor should provide evidence of at least 50 hours/credits of CPD. (One credit = one hour of learning activity demonstrated by a reflective note on the lessons learned and any changes made.) Courses, meetings, journals, web-based learning and the Patient's Unmet Needs (PUNs)/Doctor's Educational Needs (DENs) system are all possible methods of learning. Evidence should be presented in a way which can be related to the domains of GMP. It is expected there will be a variety of learning methods demonstrated.
- Quality improvement activity (QIA). This includes activities such as audit, case reviews, evaluation of policies or review of clinical outcomes.
- Significant events. These are reviews of unintended or unexpected events, in which the doctor was personally involved, which could or did lead to serious harm of one or more patients. Where there has not been a critical significant event, it is appropriate to acknowledge and celebrate this. However, doctors are expected to show evidence of participation in and awareness of significant event analysis processes (including less critical or serious events) and document reflection on these within the QIA section.
- Feedback from colleagues. (This must be by the use of a standard GMC-approved questionnaire. One formal survey is required every five years.)
- Feedback from patients. (As for colleague feedback.)
- Review of complaints and compliments.
In addition to this, each doctor must describe the scope of his/her roles and practice and must complete declarations with regard to probity and health. The RCGP recommends that doctors should reflect on their responsibility to be appropriately immunised, registered with a GP outside their own family and to protect patients from any risks posed by their health. Doctors should also reflect on the potential probity challenges raised in GMP, such as whether they have adequate and appropriate indemnity cover across the full scope of their work, any possible conflicts of interest between roles, business interests, etc.
NHS England does not accept appraisal documentation in paper format. There is no single electronic platform accepted across England. (There is in Scotland and Wales - see the 'Further reading & references' section, below.) A variety of electronic toolkits are in use including:
- The Clarity and RCGP Appraisal Toolkit.
- GP Tools.
- The NHS Revalidation Support Team's Medical Appraisal Guide (MAG) Model Appraisal Form, which illustrates the requirements of an electronic toolkit for appraisal but which may also be used as a free toolkit.
Reflection and impact
The GMC and RCGP stress the importance of reflection within appraisal documentation. The emphasis is on doctors showing that they have thought about what they have learned and what they need to do differently as a result. Where practice has changed as a result of learning, this should be documented (impact to practice). A confusing system where credits could be doubled if impact was demonstrated was scrapped in 2016 but documenting impact to practice is still crucial.
The RCGP states that there is no longer any need to scan certificates of attendance as proof of learning. Thoughtful reflection documented on the toolkit is much more worthwhile evidence that learning has taken place.
GPs often have difficulty understanding what they are supposed to write in the "reflections" section. Put simply, it is writing down the take-home messages from a learning event, ie "What have I learned today that is going to change my practice?" Answering the following questions would constitute thorough reflection:
- Reaction: What do I feel about what I learned? (Was it helpful, thought-provoking, reassuring ...?)
- Learning: What did I learn that I didn't know before; particularly, what did I learn which will change my practice?
- Change: What do I need to do differently as a result of what I have learned?
- Results/Impact: What has changed as a result of what I learned? (This part of the reflection may need to be completed subsequently. The rest is more useful if completed soon after the learning event.)
The appraisal meeting
Appraisal meetings take approximately two hours but vary considerably. There is a confidential discussion based around the documentation which has been submitted and the issues of importance to the doctor being appraised. There will also be a discussion about health and probity issues considered relevant to the doctor's work.
As a doctor, it is unusual to have two hours to focus on oneself and, as such, should be valued and used as more than simply a tick-box exercise. Furthermore, an appraiser will advise and support their appraisee towards building a portfolio which demonstrates they are fit for revalidation.
Should any serious concerns about patient safety be identified by either the doctor or the appraiser, the appraisal should be halted and further advice sought from a senior member of the appraisal team or Responsible Officer (RO).
The personal development plan (PDP)
Prior to an appraisal, doctors may write a proposed PDP. During the appraisal meeting this will be discussed with the appraiser and may be modified, or added to, as a result. It should be clear from the summary of the appraisal why the items in the PDP have been chosen and they should arise from the appraisal discussion.
The PDP objectives should be SMART, that is:
- Specific: they should relate to specific tasks/activities, not general statements.
- Measurable: it should be possible to assess whether they have been achieved.
- Achievable: it should be possible for the doctor to achieve the desired outcome.
- Relevant: objectives should be appropriate for the current role and situation.
- Time bound: there should be a clear time frame set in which to achieve objectives.
Summary of the appraisal
Following the appraisal, the appraiser writes a summary of the evidence submitted and the discussions at the appraisal meeting. This sets out for the doctor being appraised what they have achieved and what plan has been agreed for the following year. It also acts as a summary for the RO to see where the doctor is with regards to being ready for revalidation. Appraisal summaries are reviewed and quality assured in order to keep them fit for purpose.
Before signing off the appraisal, the appraiser must agree (or not) with the following statements:
- An appraisal has taken place that reflects the whole of the doctor's scope of work and addresses the principles and values set out in Good Medical Practice.
- Appropriate supporting information has been presented in accordance with the Good Medical Practice Framework for appraisal and revalidation and this reflects the nature and scope of the doctor's work.
- A review that demonstrated progress against last year's Personal Development Plan has taken place.
- An agreement has been reached with the doctor about a new Personal Development Plan and any associated actions for the coming year.
- No information has been presented for discussion in the appraisal that raises a concern about the doctor's fitness to practise.
If the appraiser and the doctor cannot achieve an agreement on any statement, the discussion should be recorded in the appraisal documentation to enable the RO to understand the area(s) of contention.
Quality Assurance of appraisal
The GMC has produced governance principles to support revalidation. NHS England has set out a comprehensive series of policies for quality assurance of the appraisal and revalidation processes which involves bench-marking, calibration and checking consistency across the country. Procedures include:
- Annual organisational audit completed by ROs.
- Framework of quality assurance for ROs.
- Quality assurance of appraisers, involving:
- Standard specifications, contracts and training guidance.
- Competency frameworks.
- Review of feedback from appraisees.
- Quality assurance of summary outputs.
- Regular mandatory training.
- National, regional and local appraisal networks.
Further reading and references
GP Appraisal and Revalidation; Northern Ireland Medical and Dental Training Agency (NIMDTA)
Shaping the future of medical revalidation – interim report (January 2016); UMbRELLA (UK Medical Revalidation Evaluation coLLAboration) appointed by the GMC
Appraisal; NHS England
Appraisals; British Medical Association (BMA)
Supporting information for appraisal and revalidation; General Medical Council (GMC), March 2012
RCGP guide to supporting information for appraisal and revalidation (2016); Royal College of General Practitioners, March 2016
The Good medical practice framework for appraisal and revalidation; General Medical Council (GMC), 2013
Medical appraisal Policy; NHS England. Version 2.0, April 2015
Medical appraisal guide (MAG) model appraisal form; NHS England
Medical Revalidation - Quality Assurance; NHS England
Effective governance to support medical revalidation; General Medical Council, 2013