Consultant appraisal, in simple terms, is about good medical care and job plan review.

It gives both appraisee and appraiser an opportunity to reflect on the consultant’s work.

The whole process should lead to the collection of evidence useful for revalidation and a personal development plan. This papre comments on national drivers such as the views of the Royal College of Physicians London (RCP) and the Chief Medical Officer (CMO) review of revalidation and on our approach in Leeds . Although this article is primarily for consultants, it is also of relevance to all doctors in training.

Appraisal in 2005
Appraisal should be separate from job plan review/ performance assessment, although there is inevitably some overlap. Eligibility for clinical excellence awards and pay progression with the new consultant contract are now dependent on having an appraisal. In Leeds , we have overtly linked appraisal to preparation for revalidation. Our aim has been to get consultants to take part in annual appraisal and to build portfolios that will be useful for the purposes of revalidation. The majority (90%) of our appraisers were clinical managers. We support the process with an intranet site which references useful documents. We have recently added minor modifications to the DoH twenty five page document (Forms 1-6) such as placing the appraisee’s name and the year of appraisal on each page.

The key reference document for all doctors is the GMC guidance in Good Medical Practice. This has recently been reviewed by the GMC and sets out standards of competence, care and conduct expected of all doctors, and it remains the Gold Standard. The Federation of Royal College of Physicians have elaborated on it and published Good Medical Practice for Physicians and the third edition of Consultant physicians Working with Patients (Appendix 1).

Revalidation in May 2005
In 2003, the overt link between appraisal and revalidation was highlighted by the GMC and personal responsibility of individual doctors was stressed for the first time. Revalidation provides a framework for appraisal. Each year allows refinement of the portfolio and over time, more and more evidence of good medical practice is accumulated. The GMC was set to introduce revalidation and licences to practice in April 2005 and suggested doctors would each have an electronic account where documents could be lodged. Then it all changed.

Shipman and the subsequent six reports by Dame Janet Smith will significantly affect the way all doctors work. The GMC proposals on revalidation are being reviewed by the CMO and undoubtedly will be toughened to include more “on the job” assessments (Appendices 2 and 3). Many such assessment methods are being used for junior doctors and it seems inevitable that systems such as those pioneered by the RCP for assessment of SpRs will also be used for consultants (JCHMT website see Box 1).

The CMO review should complete during 2005 and will undoubtedly focus on patient safety. It will also have an effect on the future role of the GMC in professional regulation. Only time will tell, if there is a move to a single NHS regulator for all groups of staff, but this must be a strong possibility.

Key evidence to provide in your personal portfolio
Considering each part of appraisal documentation referencing it to the DOH scheme: The Federation of Royal Colleges of Physicians of the UK has published a number of pieces of guidance (Box 1) on what should appear in your portfolio (Forms 1-6). Other useful links are shown in (Appendix 3 ).

Considering the two key parts of the appraisal documents, Forms 3 and 4: Form 3 is the main part of the appraisal documentation and your portfolio should contain evidence that will be vital to support your revalidation.

Good Medical Care (Form 3.1) focuses on learning from activity information, audit, use of guidelines and things that go wrong e.g. complaints and serious untoward incidents.

Accuracy of activity information – precise allocation of activity to an individual is something we must improve, in a world driven by clinical governance. A variety of data quality issues have been raised particularly in relation to clinical coding. Most consultants are interested in “their” information and passions rise about its accuracy. The media’s use or misuse of such information was highlighted in Ed Dunstan’s comments in the BGS March 2005 newsletter.

Simple activity data for physicians such as numbers of admissions, outpatients, readmissions and mortality rates is easily available. Ask your Trust for it and demand improvements in data quality. In Leeds , we also have information on pathology and radiology requests, and a profile of complaints and medico legal claims. Numbers of complaints against hospital doctors continue to rise and they are common in our specialty which has long lengths of stay. We have an A4 form which summarises any completed complaints and highlights what learning has occurred.

Consultants in Leeds now get monthly mortality reports and there is routine departmental review of cases. Every six weeks we review four deaths in detail, and this has led to improvements in practice. Attendance is registered and action notes form portfolio evidence.

Information in Form 3 need not all be learning from things that go wrong, e.g. include positive information such as your clinical excellence award application. In General Practice in Scotland , significant events can be achievements as well as learning from things that have gone wrong.

It will be increasingly critical that geriatricians refer to College guidance on standards both for their acute work and specialist work. In 2000, the BGS guidance on clinical governance suggested two standards which all geriatricians should attain ( Appendix 1 for reference document and Appendix 4 for content).

How many geriatricians know of these standards and how many include them in their portfolios? Similarly, what is the status of BGS Guidelines and policies and should BGS members reference them? A review of the BGS approach to clinical governance seems timely and will be brought before the Policy Committee in the coming months.

Maintaining Good medical practice (Form 3.2) has a range of available evidence from paper diaries to use of RCP electronic diaries with accompanying evaluations and learning. The BGS approach to CPD clearly will set standards and colleagues should use the information on the website.

Working Relationships with Colleagues (Form 3.3) is an area we need to develop. 360 degree assessment or multi-source feedback is now widely used and does provide objective views from a variety of sources. Many schemes are now available for consultants and doctors in training (Appendix 1). The GMC suggests such assessments are used as evidence for relations with colleagues and patients. Obtaining the feedback is relatively easy compared to giving the feedback in a supportive and constructive way.

Relationships with Patients (Form 3.4) again show wide variation in the information available with best practice providing an abundance of information given to patients and their relatives through too little or no information. The new general practitioner contract requires all GPs to carry out patient surveys on an annual basis.

Teaching and Training (Form 3.5) allows you to highlight your workload, but also can be supported by the use of student feedback and peer observation of teaching. Follow Follet guidance and all academics should have a joint appraisal from their Academic Head and an NHS colleague. This has a positive effect in raising understanding in the NHS of the difficult world of RAE and university politics that academics live in. Formal training roles in postgraduate education should be highlighted here, with evidence of their success e.g. results of peer review visits.

Probity and Health (Forms 3.6 and 3.7) - in Leeds we are starting to use standardised documentation for this, derived from Appraisal for Doctors in Training (Appendix 3 ). For each of these sections there is declaration form that the individual signs.

Research and Management - these sections may have more or less significance to any individual e.g. if an academic, the research output would be documented.

Summary of appraisal discussion (Form 4) – Remember this is an annual cycle and it is essential that at, or very soon after the meeting, you get a written record. Both you and your appraiser need to sign it off and this is a vital form. Without such a record you will not be revalidated. The actions identified should give a pointer to your PDP and objectives for the next year. Electronic storage of forms should be encouraged with individual consultants storing their evidence.

Appraisal philosophy
Finally, appraisal will become a way of life from student through to the end of your career. We need to make it a positive experience.

Appendix 1

Key Appraisal Links at the RCP

Good Medical Practice for Physicians
www.rcplondon.ac.uk/college/pa/prof_gmpfp.htm

Good Medical Practice for Physicians: acute medicine
www.rcplondon.ac.uk/files/gmpfp_ap01_acute.pdf

Good Medical Practice for Physicians: geriatric medicine
www.rcplondon.ac.uk/files/gmpfp_ap10_geriatric.pdf

Consultant physicians working with patients. 3r d ed. February 2005 www.rcplondon.ac.uk/pubs/brochures/pub_print_conphys3rded.htm

The pilot study into performance assessment methods JCHMT Newsletter - No 8 (January 2005) www.jchmt.org.uk/pubNews08.asp

Appendix 2

Likely assessment methods for revalidation

• What patients think of us - patient and carer satisfaction surveys
• What colleagues think of us - 360o or multi- source feedback
• Observed consultations and observed procedures

Appendix 3

Key appraisal/revalidation links at the Department of Health and GMC

Overview of appraisal

Appraisal for doctors in training in the NHS

Appraisal for NHS doctors with a private practice

Good medical practice

Revalidation postponement

CMO Review of Medical Revalidation: A call for ideas

Appendix 4

BGS Standards taken from clinical governance guidance 2000

Standard 1 : Patients under the care of an individual consultant geriatrician entering long-term institutional care from an inpatient setting should have documented evidence of a formal multidisciplinary assessment with consultant involvement prior to placement.

Evidence: audit of 10% sample of all institutionalised placements annually from any individual hospital.

Standard 2 : Patients seen as outpatients or day patients by an individual consultant or member of his or her team should have at least one recorded assessment of both their mental and functional status in the case records. Where clinically relevant (but not invariably) this will involve the use of a standard measurement scale (e.g. abbreviated mental test or Barthel Index [or equivalent]).

Evidence: Random audit of 20 sets of case notes annually by third party.

The BGS Clinical Governance Guidance suggests a threshold figure of 75% on both of these standards for further investigation.