Faculty Development

The links between the NHS appraisal scheme and revalidation has led to some concerns that, despite the Department of Health’s emphasis on appraisal being on the appraisee’s developmental needs, somehow ‘appraisal will root out poorly performing doctors’ (Department of Health, 2007a).  This reflects the inherent tensions and contradictions within the NHS scheme, which tries to combine managerial aspects of performance management with educational emphasis on development and improvement of quality (Taylor et al., 2002). These tensions are not unusual in appraisal schemes (Handy, 1993); however, they can lead to practical difficulties ‘on the ground’ and require both appraisee and appraiser to agree and define boundaries, and for the process to be as transparent as possible. If there is a conflict of interest, personality clash or other difficulty between an appraiser and appraisee, then either party can request a change. The reasons for change should be treated confidentially if requested by either party.

Handy (1993) notes that trying to combine managerial demands, performance review (especially if linked to pay or reward assessments), giving feedback on performance, and helping to plan personal and job objectives in one appraisal scheme is not ‘psychologically compatible’. People are generally reluctant to admit to failure if this affects promotion or salary, and the relationship between the appraiser and appraisee may interfere with what should be an impartial and objective process. Trusts have been challenged to develop schemes that aim to address all the demands from external bodies and their own internal quality assurance processes, while being useful for the doctors involved and helping them to prepare for revalidation.   

The tensions also highlight the importance for continuing ongoing performance review outside and apart from the appraisal process, so that issues are identified early and remedies and support are set in place. Establishing effective clinical governance procedures and audit, and developing organisational cultures and processes that promote openness and addressing of issues all help to counteract the potential for ‘dumping’ issues relating to poor performance into the appraisal scheme.

Other practical issues relating to appraisal include training for appraisers, providing time (and funding) for both appraisers and appraisees to prepare for the appraisal, and what to do if serious concerns are identified during the appraisal process. As noted above, issues concerning poor performance should be dealt with by local procedures for underperforming or incompetent doctors. There should be no major surprises during an appraisal and doctors about whom there are major concerns should not be undergoing routine appraisal. However, if an appraiser does identify exceptionally serious concerns that put patients at risk, the appraisal should be stopped and the concerns discussed with the appraisee. If concerns remain, then advice should be sought from the clinical governance lead so that procedures can be followed. If patients are not at immediate risk, the appraisal should highlight the doctor's strengths as well as weaknesses, and identify a new personal development and learning plan, action by the appraiser to assist this and a date for review. On some occasions, it may be identified that a doctor is inappropriately resourced, supported or developed to practise good medicine. In such cases, the appraiser should take action to support the doctor and protect his or her patients (Department of Health, 2007c).