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Introduction
What is appraisal?
Why introduce appraisal for consultants now?
Where does appraisal fit with GMC revalidation and clinical
governance?
What is in it for me?
How will the appraisal system work?
What about confidentiality?
What if I don't want to be appraised?
When will the new system be introduced?
Will I receive any support/training on appraisal?
Who will appraise me?
How will third-party-input work?
What kinds of evidence will I need to collect, and
where will I get it from?
How will I find the time?
What happens if my appraiser and I disagree?
Will identified training/development needs be resourced?
What do I do next?
Where can I get further information?
As a medical or dental consultant you are probably already aware that, earlier this year, the BMA and the UK Health Departments have now reached agreement on a national scheme for introducing regular appraisal for all consultants working in the NHS.
Consultants who believe in, and recognise, the benefits of continuing personal and professional development throughout their careers, will quickly come to appreciate the value of regular appraisal as an effective framework through which their development can be considered and supported.
The purpose of this leaflet is to provide some basic information about the new scheme and how it is to be implemented. It also tries to answer some frequently asked questions and explains how you can find out more.
Appraisal is not a process of assessment that one passes or fails, and the new scheme is not about scrutinising doctors to see if they are performing poorly.
Appraisal is about helping individuals to improve the way they work and the services they provide, themselves and with others.
Appraisal goes beyond simply judging individuals on what they have achieved over the past year. It offers a framework for planned, constructive, professional dialogue. It provides the opportunity for reflection about current performance and progress. This is used as a platform to set goals for future professional practice and development which will also contribute to the needs of the organisation in which the individual works.
Appraisal should therefore be a positive, constructive process which is mutually beneficial to both the individuals being appraised and also to the organisation in which they work.
Most organisations already operate systems of appraisal among professional staff groups. Indeed, many enlightened NHS organisations have already introduced appraisal for consultant medical staff. They believe that they should have access to the same sort of frameworks as other professional groups for supporting personal development within a constructive performance review process and aligning this with organisational needs. Such local arrangements are valued by the consultants participating in them.
In recent years health care and health improvement become ever more sophisticated, requiring the application of greater levels of knowledge and skills. In keeping with higher expectations from patients, the public at large, and indeed the profession itself, doctors increasingly accept that they must monitor, review, and improve (if necessary) their clinical skills and practice. Appraisal will be an important tool for meeting these requirements in a positive way.
In addition, the General Medical Council is in the process of introducing a compulsory revalidation process for doctors, the purpose of which is to monitor doctors' clinical performance, and NHS organisations themselves have to demonstrate high standards of clinical governance.
It is against this background that appraisal is now being introduced for all consultants.
Revalidation is the process whereby the General Medical Council will establish a doctor's fitness to practice and with it, the right to remain on the medical register. The process will have a five-yearly cycle.
The GMC has agreed, following discussion and agreement with the UK Health Departments and the profession's representative organisations to allow the appraisal process to be the principal vehicle through which the evidence required for revalidation will be collected and presented for senior hospital and public health doctors, provided the process proves to be satisfactory for this purpose.
Appraisal for consultants will produce much of the same evidence that consultants themselves will ultimately require for GMC revalidation. It therefore makes sense to run both processes side by side, thus avoiding duplication of effort. However, whereas the evidence will be used in an evaluative assessment in the revalidation process, its use in appraisal will be different. The revalidation cycle is essentially a retrospective process looking at clinical performance over the previous five years. In the case of appraisal, it will be employed in a formative way on a year-to-year basis to ensure development of professional practice and to set professional objectives.
Clinical governance has been defined as "corporate responsibility for clinical performance" and is a clear responsibility of all NHS organisations. They are required to fulfil this responsibility by pulling together and monitoring the systems that ensure services meet quality and safety standards. NHS organisations are also required to ensure that we learn from mistakes, and that we continually develop services to meet new demands and standards of care. The new consultant appraisal arrangements will be an important element in that overall process. Consequently, Chief Executives will be responsible for effective implementation and operation of consultant appraisal in their organisations.
A combination of these requirements _ revalidation, personal development and clinical governance _ has led to the mandatory introduction of a national appraisal scheme for consultants. While such an approach may not be ideal for all local circumstances and requirements, it does mean that appraisal becomes established practise applied through a consistent approach throughout the profession. Sensitive and flexible implementation of the national requirements can ensure that these are effective in meeting local needs.
Appraisal will only succeed, and be of value to individual participants, if they recognise that the process provides appraisees with opportunity and support for reflection, and constructive feedback on which personal and professional development can be based. Also, through this process, the appraisee can raise and discuss issues of concern relating to their contribution to the range and quality of clinical services provided.
Of course, at a more basic level, doctors who do not meet the GMC evidence requirements will not be revalidated and will therefore not be allowed to practise. However, dwelling on this would place appraisal in a somewhat threatening and negative context. Suffice to say that doctors are likely to get more out of appraisal overall if they focus on the developmental aspects of the process which will benefit their practice in the long run.
The official documents notifying the scheme to Health Boards and NHS Trusts in Scotland were NHS circulars PCS (DD) 2001/2 and 2001/7. If you do not already have copies of these, they can be obtained by contacting your Trust Medical Director or Director of Public Health Medicine in NHS boards. Alternatively, copies can be downloaded from the NHS in Scotland website www.show.scot.nhs.uk
At the core of the appraisal process will be an annual meeting between the consultant (appraisee) and his/her appraiser. The purpose of this meeting is to ensure the opportunity for constructive dialogue through which the doctor being appraised can reflect on his/her work and consider how to progress his/her professional development. These meetings will provide a positive process to give consultants feedback on their performance, to chart their continuing progress and to identify and plan for development needs.
The appraisal meeting should be arranged well in advance to afford the opportunity for the appraiser and appraisee to gather together the necessary data to support a meaningful and constructive dialogue at the meeting.
The content of the appraisal will be based on the headings contained in the GMC's "Good Medical Practice" document as well as relevant management issues, including the consultant's contribution to the organisation and delivery of local services and priorities.
The GMC's core headings are:
For the appraisal meeting to be successful, it will be important for both the appraiser and appraisee to prepare beforehand. The following questions should be thought through in advance of the appraisal meeting:
Documentation will be required to support and record the evidence, discussion and outcomes associated with the appraisal process.
Each consultant will be required to prepare an appraisal folder into which they will record information and insert evidence and data which will help the appraisal process. The first time round, the completion of the folder may take quite a bit of time and effort, but once set up, it can be updated as necessary on an ongoing basis.
NHS circular PCS (DD) 2001/7 encloses a set of six forms to support the appraisal process. These forms variously provide a framework for:
Copies of the six forms in Microsoft Word format, which can be used for electronic completion of the forms, are also available on the SHOW website.
As mentioned before, the Chief Executive has overall responsibility for ensuring appraisal of consultants takes place and he/she will receive copies of those completed forms which summarise the outcome of the appraisal.
Appraisal is a confidential process. The meetings will be held in private and the completed documentation will, at all times, be treated as confidential.
Only documentation summarising the appraisal will be seen by individuals other than the appraiser and appraisee. This will be restricted to the Chief Executive and Medical Director (and Clinical Director if he/she is not the appraiser).
Hopefully, when you have learned more about the new scheme, you will recognise the value of the process to you, and will decide that you are keen to participate.
In addition, appraisal is now a condition of the national employment contract for consultants and refusal to participate would be a breach of contract and a disciplinary matter. The national conditions of service are also clear that non-participants would be precluded from consideration under the discretionary point and distinction award schemes.
Finally, you must also bear in mind that the GMC has agreed to appraisal as the vehicle to revalidation, which will be necessary for a doctor to remain on the medical register and therefore maintain the right to practice.
The first appraisal cycle will commence in the year beginning 1 April 2002.
The period leading up to then should be used by consultants and appraisers to start thinking about preparing their appraisal folders and to familiarise themselves with the requirements of the process.
Obviously, the process will not be perfect from day one. In a whole range of areas, participants' comfort with, and their ability to make best use of, the new process will develop with experience. However, if the right degree of effort is applied to its introduction we might reasonably expect that after two or three years the appraisal of consultants will have become a well-established process that is valued by all participants.
Yes. To kick-start a training and development programme, a series of awareness-raising sessions will be offered to all consultants between January and April 2002. The sessions will build on the work of the consultant body who have contributed to the production of this guide. We recognise that a number of local NHS organisations have already begun programmes of training for consultants. Based on advice from Trusts and Boards, the awareness-raising sessions will target the most appropriate areas.
The training programme will be delivered in conjunction with local NHS organisations and the plan is for the design and delivery to be carried out in partnership with the Scottish Council for Postgraduate Medical and Dental Education and other key stakeholders.
During the year 2001, consultant nominations were requested from Trusts to form a Scottish Core Group. About 80 consultants now form this group, and a further 80 nominations have been sought so that a group of 160 consultants can be intensively trained by April 2002. This process will allow for all NHS organisations to have their own consultant appraisal "champions" to support the training process locally.
All consultants in Scotland will receive appraisal training by October 2002. Work is currently being progressed on identifying appropriate learning materials that will be made available as soon as possible.
Firstly, it is a clear requirement that appraisal of a consultant will always be carried out by another consultant on the medical or dental register.
The recommended framework for "cascading" consultant appraisal is the medical
management structure. Ideally, therefore, consultants would be appraised by
their respective clinical directors who,
in turn, would be appraised by the Medical Director.
In many situations, however, it will not be that simple. For example, the number of consultants in a clinical directorate may be too great to expect the Clinical Director to be the appraiser for all of them. In such circumstances, local discussions will be required to agree an effective and acceptable "cascade" structure. For example, if there is a structure of "lead consultants" within a directorate, they might be identified as appraisers.
Special arrangements will also need to be made for the appraisal of clinical academics or consultants who regularly work in more than one trust. In both cases, the consultant concerned should still only have one appraisal and one NHS appraiser, but there will have to be input from the university or other trust. The precise arrangements will have to be agreed between the organisations concerned and with the individual doctor to be appraised.
In circumstances where a clinical director is not a registered consultant, the consultants within the directorate will be appraised by either the Medical Director, or an appropriate consultant selected by the Medical Director. In either of these cases, however, the Clinical Director will be fully consulted before the appraisal meeting takes place to ensure that the appraiser and appraisee are aware of, and consider, all relevant issues at the appraisal meeting.
As you can see, Trusts have a lot of work to do to develop their appraisal cascade structures and this should be actively underway at this time.
Your Chief Executive is ultimately responsible for ensuring that an appropriate appraiser is identified and that the person nominated is properly trained to undertake the role.
In addition to the situations described above, there will be other circumstances where third-party input to the appraisal process will be required. For example, a single-handed practitioner at a hospital is likely to have an appraiser from a different clinical specialty. In these circumstances, arrangements will have to be made to identify a professional peer from another hospital or trust to contribute to the specialist professional aspects of the appraisal.
In all of the situations where a third party is involved, discussion will need to take place between the nominated appraiser, the appraisee and the third party, as to how this contribution will be integrated into the appraisal process. This may be through consultation and discussion before the appraisal meeting, or on the basis of an agreed contribution to the meeting itself.
The appraisal process is not intended to require the generation of significant amounts of new evidence or information; rather it should aim to capture relevant information that already exists. What goes into the folder will, in many cases, be available from clinical governance activity, the job planning process and other existing sources. However, action is likely to be required in many trusts to ensure that systems are developed or refined to enable data to be readily accessed to support the consultant appraisal process.
The process itself may assist consultants to identify the data they would consider relevant to their specialty or personal clinical practice that would be usefully brought to their appraisal. One result of the appraisal process will be to identify areas where there are gaps to be filled or where perhaps data need to be better collated or presented. This is likely to be more apparent in the early years after appraisal is launched, and some requirements may have to be specifically addressed over time with the assistance and support of your Trust.
Consultants will need to consider which documents they will require to collect for the appraisal process in light of the circulars and other guidance they receive. Many of the Royal Colleges have already issued guidance on good practice within their specialty. This sort of "portfolio" may be useful when thinking about information and documentation needs for appraisal.
It is recognised that, to be done effectively, the new appraisal arrangements will require a significant investment of time by both consultants and their appraisers. This is likely to be greatest in the initial year when consultants are preparing their appraisal folders for the first time.
Employers have been instructed that they must recognise that the preparation time and time for carrying out appraisals are not additional to consultants' other duties and responsibilities, and therefore should be included during usual working hours. This is an issue that Trusts will be required to address locally, according to their particular circumstances.
If something cannot be resolved between you, there will be an opportunity for a further meeting to take place involving your Medical Director or Director of Public Health Medicine.
It would be unrealistic to say that this will happen every time for every consultant because the appraisal process does not create a new "pot of gold" to pay for training. However, what appraisal can do is ensure that a robust discussion takes place about the relative priority and benefit of fulfilling identified training and development needs, both for the individual consultant and the service within which he/she works. This should ensure an equitable and targeted approach to allocating the available resources. The other benefit that can emerge from the discussion is to consider alternative ways of addressing training and development needs.
If you have not already got copies of the PCS circulars referred to at the start of this guide, you should get these as soon as possible and familiarise yourself with the details of the new requirements. They are available on www.show.scot.nhs.uk. Like many of these circulars, they can be pretty heavy going, but it is important that you understand what you will be required to do. In particular, you need to acquaint yourself with the various forms involved in the process. You should also start thinking about what will need to go into your appraisal folder and how you will gather this material.
No doubt once you have looked at all the documentation you will have questions that are not answered in this guide. At least some of these will relate to local issues that are specific to the implementation of the consultant appraisal requirements within your Trust or Board. You should address these questions to your Medical Director or any other nominated contact that has been notified to you.
If you would like to understand more about the processes and benefits of appraisal, there are numerous references you could follow up. A few suggested ones are:
Appraisal for Medical Consultants - a handbook of best practice by Dr Steven Wilkinson and Dr Kwee Matheson
The Use of Evidence in the Appraisal of Doctors
by Wilkinson, Sanger and Matheson
Both of these booklets are published by Earlybrave Publications Ltd. (www.earlybrave.com)
This booklet was prepared on behalf of the Consultant Appraisal Design Group, the membership is as follows:
Dr Ann Maree Wallace, Lothian Health Board
Dr Bill Anderson, North Glasgow University NHS Trust
Professor Andrew Calder, Academy of Royal Colleges and Faculties in Scotland
Dr Clifford Eastmond, Grampian University Hospitals Trust
Dr Richard Metcalfe, South Glasgow University Hospitals NHS Trust
Dr Charles Lind, Ayrshire and Arran Primary Care Trust
Dr William Reid, Tayside University Hospitals NHS Trust
Dr Rob Murdoch, South Glasgow University Hospitals NHS Trust
Dr Karen Watson, West Lothian Healthcare NHS Trust
Dr Roger White, Ayrshire and Arran Acute Hospitals Trust
Dr Matty Lough, Ayrshire and Arran Acute Hospitals Trust
Dr Alan Connacher, Tayside University Hospitals NHS Trust
Mrs Lyndsay Lauder, Argyll and Clyde Acute Hospitals NHS Trust
Ms Liz O'Neill, Lothian University Hospitals NHS Trust
Ms Elizabeth Kelly, Scottish Executive Health Department
Dr Robin Cairncross, Scottish Executive Health Department
Dr Hugh Whyte, Scottish Executive Health Department
Ms Lorna Clark, Scottish Executive Health Department
Mrs Kerry Chalmers, Scottish Executive Health Department
Mr Steven Haddow, Scottish Executive Health Department