Appraisal and Revalidation Policy for Doctors at South London
and Maudsley NHS Foundation Trust
Version:
1.0
Policy Lead:
Dr Michael Holland
Policy Category:
Clinical/Human Resources
Date issued:
Review date:
Ratified by:
Governance Executive
Date ratified:
Name of responsible committee:
Target audience:
Senior Doctors
Approved by ………………………………..Committee.
Date:
Ratified by the Governance Executive.
Date:
Equalities Impact Assessment
Assessor: Dr Michael Holland
Date:
Child Safeguarding Assessment
Assessor:
Date:
HRA Impact Assessment
Assessor:
Date:
This policy document is subject to South London and Maudsley NHSFT copyright. Unless expressly indicated
on material to the contrary, it may be reproduced free of charge in any format or medium, provided it is
reproduced accurately and not used in a misleading manner or sold for profit. Where this document is
republished or copied to others, you must identify the source of the material and acknowledge the copyright
status.
Contents
Section
Page
1
Introduction
3
2
Purpose of Policy
3
3
The Aims of Appraisal
3
4
Summary of the Development of the Policy including Consultation
and Communication with Stakeholders
4
5
Roles and Responsibilities
4
6
Timing of Appraisals
5
7
Exceptions
5
8
Training Grade Doctors
6
9
Locums
6
10
When Must An Appraisal Meeting be Adjourned?
6
11
What is an unsatisfactory Appraisal?
6
12
Confidentiality
6
13
Complaints
7
14
Appraisal – The Link with Job Planning
7
15
Appraisal – The Link with Clinical Excellence Award Applications
7
16
Doctors in Difficulties
7
17
Doctors Involved in Disciplinary Procedures
7
18
The Future
8
19
The Appraiser Team
8
20
Revalidation: A 5-yearly Exercise
9
21
Quality Assurance for Appraisals and Revalidation
9
22
Procedure to be followed for Doctors who have not completed an
annual Appraisal
10
Policy Standards
11
Implementation and monitoring compliance
Associated Documentation
12
References
33
Appendices
Page 2 of 36
Section
Page
Appendix A
Equality Impact Assessment
Appendix B
Version Control Sheet
Appendix C
1
Plan for Dissemination of Procedural Documents Policy
Introduction
All doctors must undertake an annual appraisal in order to demonstrate and record that they
comply with good medical practice as recommended by the General Medical Council. The
process and content of this appraisal is being strengthened in order to meet the higher
quality that will be required for revalidation. This policy focuses principally on Consultant
and non-Consultant grade doctors’ appraisal. Medical Appraisal and Revalidation are
Contractual requirements for medical staff.
2
Purpose of Policy
The Appraisal and revalidation systems are supportive mechanisms focused on enhancing
local systems of quality improvement, they are also designed to assist in the identification of
performance issues so they can be dealt with at an early stage. The Appraiser will review
various sources of information with the doctor to gain a rounded impression of that doctor’s
practice and inform a mutually agreed professional development plan. Appraisal will identify
doctors who are struggling to provide the supporting information that is needed to
demonstrate achievement of generic and specialist standards. It will assist those doctors in
identifying support and developmental needs at an early stage, before there is any question
of concerns about patient safety. The Medical Director, as Responsible Officer, is personally
accountable to the Trust Board for ensuring that all Senior Medical staff are appraised and
any follow up action taken.
3
The Aims of Appraisal







Set out personal and professional development needs and agree plans for these to
be met
Regularly review a doctor's work and performance, utilising relevant and appropriate
comparative operational data from local, regional and national sources
Consider the doctor’s contribution to the quality and improvement of services and
priorities delivered locally
Optimise the use of skills and resources in seeking to achieve the delivery of general
and personal medical services
Identify the need for adequate resources to enable any service objectives in the
agreed job plan review to be met
Provide an opportunity for doctors to discuss and seek support for their participation
in activities for the wider NHS
Utilise the annual appraisal process and associated documentation to meet the
requirements for GMC revalidation against the nine headings of ‘Good Medical
Practice’.
Page 3 of 36
4
Summary of the Development of the Policy including Consultation and
Communication with Stakeholders
The policy was developed by the Trust Clinical Directors’ meeting through which it was
consulted and communicated to all senior doctors across the organisation.
5
Roles and responsibilities
5.1 Chief Executive - is accountable to the Board of South London and Maudsley NHS
Foundation Trust for ensuring the resources and systems are in place for robust medical
appraisal for employed / contracted doctors. S/he is accountable for ensuring that appraisal
and clinical governance systems are integrated and co-ordinated at both strategic and
operational level. The Chief Executive will ensure that indemnity is provided for appraisers in
South London and Maudsley NHS Foundation Trust.
5.2 Medical Director/Responsible Officer - is accountable to the Chief Executive and the
Board of South London and Maudsley NHS Foundation Trust for implementing and
managing the appraisal process including appraisal outcomes. The Medical Director (or his
nominee) will receive, review, act upon appropriately and securely store all form 4s and
PDPs. S/he will also be responsible for preparing an annual report on appraisal for the
Quality / Risk Management / Clinical Governance Committee and the Board of Directors and
for any actions arising from this. S/he will ensure that appraisers are properly recruited,
trained and regularly assessed to carry out their role. S/he will ensure that all necessary
administrative and managerial systems are in place to manage the appraisal system
effectively.
5.3 Clinical Director - is responsible for carrying out appraisals or identifying appraisers in
their service area and ensuring that appraisals are carried out in line with South London and
Maudsley NHS Foundation Trust policy. S/he will have overall responsibility for appointing
appraisers (see Appendix 1 for job description and application forms). In conjunction with
the general managers / service managers s/he will support the provision of data collection,
complaints, SUIs and other essential organisational information to the doctor to enable the
doctor to provide appropriate evidence for their appraisal and will contribute to the jobplanning meeting. S/he will also be responsible for making decisions on appraiser allocation
if there is any perceived or actual conflict of interest between an appraisee and an appraiser.
S/he will also be responsible with the academic department for arranging joint appraisals
where this is appropriate e.g. doctors with mixed academic / service roles.
S/he will also notify the Medical Director of any doctors who have not completed the
appraisal process in line with South London and Maudsley NHS Foundation Trust policy.
5.4 Appraiser - is responsible to the clinical director for carrying out appraisals to the
standards laid out in this policy.
Appraisers will receive formal training, have a job description and fulfil the criteria set out in
the person specification (Appendix 1). The Clinical Directors will confirm the support for
doctors who apply to be appraisers within their area. All appraisers are required to have
formal training in Equality and Diversity issues as specified in South London and Maudsley
NHS Foundation Trust’s Equality and Diversity Policy.
Appraisers will assess the portfolio of supporting information provided by the appraisee
against the attributes in Good Medical Practice and the current speciality standards set by
the Royal College of Psychiatry, with a view to identifying weaknesses and gaps so that
these can be addressed in the appraisee’s PDP. A review of the previous year’s PDP will
Page 4 of 36
also take place and where this has not been completed satisfactorily the reasons for this are
understood.
Appraisers will receive annual feedback and review of their performance using appraisee
survey forms (Appendix 2) and a review of a sample of form 4 / PDPs that they have signed
off. They will require ongoing training and their development needs will be identified in their
own PDPs.
The appraiser is responsible for ensuring that a signed off electronic version of form 4 and
the personal development plan is received by the Medical Director’s Office.
5.5 Appraisee – is responsible for collating and preparing supporting information for the
appraisal meeting. The portfolio must show evidence of appropriate personal reflection by
the doctor. The GMC has consulted recently on the proposed new framework for
revalidation which contains details of a revised set of attributes and domains based on ‘Good
Medical Practice’ with accompanying college specific requirements for supporting
information (see ‘Good Psychiatric Practice’, Royal College of Psychiatrists). Consultants
are encouraged to familiarise themselves with the content and nature of the proposed
specialist standards (see Appendix 6 for College Framework for Revalidation) in collating
their appraisal portfolio prior to revalidation being introduced (Appendix 7 Appraisal
Checklist).
The portfolio of supporting information provided by a doctor should reflect the breadth of all
of the doctor’s professional practice – including indirect patient care activities such as clinical
audit, management and advisory roles across all healthcare organisations (including private
practice). The appraisee is responsible for submitting their portfolio/electronic access to
their appraiser two weeks prior to the appraisal.
The appraisee is responsible for raising any concerns about the appraisal process in
accordance with this policy. S/he is also responsible for completing the appraisee survey
form (Appendix 2) as feedback at the end of the appraisal process.
The appraisee is also responsible for agreeing a date for the appraisal meeting with the
appraiser. If an appraiser wishes to use an appraiser that is external to the Trust then this
must be agreed in advance with the relevant clinical director. In addition in this circumstance
it is the appraisee’s responsibility to inform the appraiser that by undertaking the appraisal
the appraiser is agreeing to comply with this policy and to work within the standards set for
appraisers including participation in the quality assurance programme.
6
Timing of Appraisals
All Consultants and non-Consultant grade doctors employed by the hospital are expected to
undertake their annual appraisal in the 1st quarter each year. See Appendix 3 and 4 for
details of Appraisal process.
7
Exceptions
These are only acceptable for Consultants and non-Consultant grades new to the Trust and
have only been employed by SLaM for less than 9 months or for those on long-term leave or
sabbatical for over 3 months of the appraisal year. For these groups, appraisal may be
deferred to the following year at the latest in agreement with their Clinical Director.
Page 5 of 36
8
Locums
Locums who work at the Trust for more than six months should have a formal appraisal
before they leave. Locums who work at the Trust for shorter periods should have a brief exit
appraisal (see Appendix 8 for exit form). This should facilitate such doctors to maintain
high standards of medical care and to prepare for revalidation.
9
Training grade doctors,
The annual review of training constitutes their appraisal and the timing of this varies by
specialty and grade.
10
When Must an Appraisal Meeting be adjourned?
Where it becomes apparent during the appraisal process that there is a potentially serious
performance, health or conduct issue (not previously identified) that requires further
discussion or investigation, the appraisal meeting must be stopped. The matter must be
referred by the appraiser immediately to the Medical Director to take appropriate action.
Maintaining High Professional Standards in the Modern NHS policy may need to be
followed.
11
What is an unsatisfactory appraisal?
Guidance is given in the above policy on what is considered to be essential and optional
documentation that should be detailed in the portfolio (see Appendices 5, 6 and 7).
If any part of the essential documentation is not identified in a portfolio (unless a satisfactory
explanation can be offered by the appraisee) then this must be brought to the attention of
the appraisee prior to the appraisal meeting as indicated in Appendix 4 (the Appraisal
Process). This should provide an opportunity for the appraisee to produce the relevant piece
of information. If the information is not forthcoming and there is no satisfactory explanation
offered then the appraisal meeting should not go ahead and the Medical Director should be
informed.
An unsatisfactory outcome of appraisal may also arise from:
 failure to address issues that have been previously raised about clinical performance
or personal behaviour
 the appraiser’s judgement that there is inadequate evidence in any section of the
appraisal documentation.
 failure to complete the previous years PDP without adequate explanation.
Part of the developmental approach to appraisal should be in supporting the appraisee in
improving the quality of evidence year on year in the appraisal portfolio. It is only when there
has been a clear failure to respond to actions outlined in previous Form 4s that the appraisal
could be considered as being unsatisfactory. If the issues cannot be resolved with the
appraisee then the matter should be referred to the Medical Director.
12
Confidentiality

The detailed discussions that take place during an appraisal are confidential to the
appraiser and appraisee. However, if something emerges during this discussion that
has a significant potential effect on patients’ safety (for an example, an appraisee
reveals that they are dependent on recreational drugs), then the appraiser is obliged
Page 6 of 36
to share this information with the Medical Director under the principles of Maintaining
Medical Excellence.
13

Prior to an electronic appraisal system being put in place Form 4 should be copied to
the Medical Director. The contents of Form 4 may be shared with the Chief Executive
and the relevant Clinical Director.

The consultant appraisee is responsible for keeping their original appraisal
documentation for five years (until used for revalidation). Any information shared
with the Medical Director or other trust managers must be kept securely in line with
the trust’s policy on data protection.

In the future, in terms of preparing for revalidation and for purposes of assurance,
appraisees may be required to show the Medical Director/Responsible Officer the
contents of Form 3, including supporting documentation to enable the responsible
officer to make an evidence-based decision regarding the recommendation for
revalidation.
Complaints
Any consultant who has concerns about the process of their appraisal should raise the issue
directly with the Medical Director. Formal complaints will be handled via the trust’s
Grievance Policy. Consultant appraisees will be surveyed annually for feedback on the
quality of their appraisal.
14
Appraisal - The Link With Job Planning
Consultants should take their Personal Development Plan from their appraisal to their annual
job planning meeting to inform the discussion. Departmental objectives agreed in job
planning should similarly inform a Consultant's PDP in a cyclical fashion.
15
Appraisal - The Link With Clinical Excellence Award Applications
All Consultant appraisals should be complete by the end of the 1st quarter which is normally
the time for applying for Clinical Excellence Awards. Only Consultants with an appraisal and
an agreed job plan within the preceding year are eligible to apply for Clinical Excellence
Awards.
16
Doctors in difficulties
Where the Appraisal exercise indicates a doctor is in difficulties, the Medical Director in
collaboration with Clinical Directors and General Managers will formulate an action plan at
the first available opportunity to resolve the situation according to current relevant policies
and guidelines.
17
Doctors involved in disciplinary procedures
Appraisal is important for all doctors, but crucial for those facing performance or disciplinary
procedures. Regular appraisal should continue for such doctors. It must be kept separate
from any performance or disciplinary procedures, and a medical manager directly involved in
such procedures should not also appraise the doctor concerned. Another experienced
consultant appraiser should take on this role in these circumstances.
Page 7 of 36
18
The Future
A new electronic format for Consultant appraisal will become available over the next year to
18 months, and this will be shared with Consultants and appropriate training provided at the
time.
19
The Appraiser Team:
 The Trust must ensure that individuals performing the role of Appraiser are
consistently educated and developed to a common agreed set of competencies
19.1




19.2
Appraiser Core Skills
Emphasis on positives and on developmental actions
Praise the good, use open questions and appropriate challenge, encourage reflection
and self-understanding
Ensure Clinical Governance, performance and other presented information is
relevant
Recognition of issues that require delay in the appraisal process or which might halt
appraisal
Person Specification and Job Description:
See Appendix 1
19.3
Selection, Training & Retention of Appraisers.
The recruitment of Appraisers will be coordinated by the Clinical Directors and Associate
Clinical Directors of each CAG.
Each appraiser will be expected to carry out about 10 - 12 appraisals per year.
Regular training sessions will be held for current appraisers once every 5 years.
All new appraisers will need to receive “Revalidation ready” training prior to appraisals in
2012/2013 and all appraisers will have received “Revalidation Ready” training prior to
2013/2014 to continue to work as an appraiser.
Difficult cases need to be discussed with either the Associate Clinical Director or Clinical
Director of the doctor concerned.
Appraisers will be expected to include relevant learning objectives for developing their
appraisal skills in their PDPs as a result of their own annual appraisal.
NHS consultants undertaking formal appraiser roles will be expected to discuss formalising
their workload on appraisals within their annual job plan review with their clinical director.


The process for the selection of Appraisers will ensure that doctors with the
appropriate expertise, skills and commitment are selected for this important role.
The OMD will keep a database of Appraisers which will be maintained by periodic
review by the MD and Clinical Directors. The aim is to ensure a full establishment is
kept by organising selection and on-going training as required
Page 8 of 36

19.4


19.5



19.6
National guidelines (Assuring the Quality of Training for Medical Appraisers, GMC,
NHS Appraisal Support, etc) will be followed regarding curriculum, approved training,
etc.
Assurance of Indemnity
It is appropriate for appraisers who are not acting negligently to be indemnified for
their actions by the Trust.
The Trust will provide explicit assurance of indemnity for the appraiser.
Performance Review & Development.
Senior Medical Staff with Appraiser functions will have that area included in their
Appraisal.
The Appraiser Team will have periodic meetings to ensure standards are maintained
APPRAISAL TRAINING FOR APPRAISEES
All newly employed consultants / SAS doctors will be provided with an initial staff induction
course which will include generic training on appraisal and the operation of the South
London and Maudsley NHS Trust scheme specifically.
20
Revalidation: A 5-yearly exercise
Revalidation is based on Appraisals over a five year period. It is designed to improve the
quality of patient care by ensuring that licensed doctors remain up to date and continue to be
fit to practice:
a. To confirm that licensed doctors practice in accordance with the GMC’s generic
standards
b. For doctors on the specialist register and GP register, to confirm that they meet the
standards appropriate for their specialty and
c. To identify for further investigation, and remediation, poor practice where local
systems are not robust enough to do this or do not exist.
All Medical Staff (Consultants, SAS, Trust Doctors and all non-training posts) within the Trust
are expected to go through revalidation every five years. The Deanery will be responsible for
revalidation of doctors in training posts.
21
Quality Assurance for Appraisals & Revalidation
Internal Quality Assurance (QA) of appraisal comprises:
 Assurance of the process.
 Assurance of work of appraisers.
21.1
Assurance of the Process
Assurance of the process will be carried out as part of the annual report to the Board of
South London and Maudsley NHS Trust produced by the Medical Director/Responsible
Officer (see Appendix 9 for structure of annual report).
Regular review of South London and Maudsley Trust’s appraisal system, policy and
supporting guidance will be undertaken each year using the Organisation Readiness Self
Assessment. This will include regular formal feedback from both appraisers and appraisees
on the management of the appraisal system as a whole. For appraisees this will be
achieved through the use of the routine Appraisee Feedback Questionnaire (Appendix 2).
Appraisers will be asked for feedback as part of their annual review process.
Page 9 of 36
21.2
Assurance of the Work of Appraisers
QA of appraiser work is delivered through:
1. Recruitment and selection – through the Medical Director / Clinical Directors.
2. New Appraisers having a probationary period.
3. Review of appraisers’ performance through regular feedback questionnaires from
appraisees (Appendix 2).
4. Annual appraiser paper-based review – using analysis of form 4 / PDPs produced.
5. Three yearly face to face formal appraiser reviews.
6. Annual appraiser updates (formal group training and appraiser support).
7. Review of complaints and significant events relating to appraisers.
External assurance of appraisal systems will be undertaken as and when agreement is
reached nationally on mechanisms for conducting this in line with CQC regulation and
inspectorate responsibilities.
South London and Maudsley NHS Trust does not currently have a policy to undertake any
formal assessment (anonymised or otherwise) of supporting information in the appraisal
portfolios of individual doctors. This policy will be reviewed annually to ensure South London
and Maudsley NHS Trust keeps in line with national policy on this issue.
22
Procedure to be followed for Doctors who have not completed an annual
Appraisal
An exception audit will be completed annually (see Appendix 10) and the clinical director
will be asked by the Medical Director to carry out an investigation as to the reasons why an
individual doctor has not completed an appraisal. A report on the investigation will be
submitted to the Medical Director and appropriate action will be taken.
Doctors who have not completed an annual appraisal will not be eligible for routine pay
progression or local clinical excellence awards unless deferment on exceptional grounds has
been agreed with South London and Maudsley NHS Foundation Trust.
Page 10 of 36
Associated Documentation
Appendix 1
APPRAISER JOB DESCRIPTION, PERSON SPECIFICATION & APPLICATION FORM
JOB DESCRIPTION
Overall Purpose:
 To carry out appraisals in line with South London & Maudsley NHS Trust Appraisal
Policy.
Key Areas of Responsibility
 Responsible to the Medical Director.
 To carry out appraisals in line with the standards set out in the South London &
Maudsley NHS Trust Appraisal policy.
 To report any serious concerns in line with HR policies and procedures.
PERSON SPECIFICATION
Essential / Desirable
Education
Medical Degree
E
GMC License to Practice
E
On GMC Specialist Register
E
Completion of Appraisal Training completed prior to
appraisals performed
E
Registration and experience
Has been subject to a minimum of 3 medical appraisals,
not including those in training grades
E
Experience of managing own time to ensure deadlines
are met
E
Involvement in
Improvement
D
medical
education
or
Quality
Page 11 of 36
Knowledge
Interpersonal and communication skills
E
Understanding of the appraisal purpose, process and its
link to revalidation
E
Understanding of equality and diversity best practice,
data protection and confidentiality legislation and
guidance
E
Knowledge of responsibilities of doctors as set out in
Good Medical Practice
E
Knowledge of Royal College of Psychiatrists specialty
standards and CPD guidance
E
Knowledge of educational
relevant to appraisal
D
techniques
which
are
Understanding of learning needs assessment
D
Knowledge of local professional development and
education structures
D
Expertise, Skills and Aptitudes
Excellent written communication skills
E
Objective evaluation skills
E
Commitment to ongoing personal education and
development
E
Good working relationships with professional colleagues
and stakeholders
E
Ability to work effectively in a team
E
Motivating, influencing and negotiating skills
E
Page 12 of 36
APPLICATION FORM
PERSONAL DETAILS
Name:
Job Title:
Speciality/Directorate:
GMC Number:
EDUCATION DETAILS
Date of First Degree:
Date of appraiser training &
give details of the course:
EXPERIENCE AND PERSONAL QUALITIES – give a brief outline in each section taking
into account the essential and desirable criteria in the person specification
Knowledge
Expertise, Skills and
Aptitude
Applicants Signature:
______________________________________
Date:
______________________________________
Page 13 of 36
Appendix 2
Medical Appraisal Feedback
Name of Organisation/Trust
Name of appraisee
Date of appraisal
Name of appraiser
Duration of appraisal
meeting
The organisation
Poor
Borderline
Average
Good
Very good
1
2
3
4
5
The management of the appraisal system
The access to the necessary supporting information
Comments to help the organisation improve the process
The appraiser
Their preparation for my appraisal
Their skill in conducting my appraisal
Their skill in reviewing progress against last year’s PDP
Their skill in providing challenge to help me review my practice
Comments to help your appraiser improve their skills
The appraisal discussion
The new PDP reflects my main priorities for development
The appraisal was useful for my professional development
The appraisal was useful in preparation for revalidation
Comments to help improve the appraisal discussion
This policy document is subject to South London and Maudsley NHSFT copyright. Unless expressly indicated on material to the contrary, it may be reproduced free of
charge in any format or medium, provided it is reproduced accurately and not used in a misleading manner or sold for profit. Where this document is republished or
copied to others, you must identify the source of the material and acknowledge the copyright status.
Appendix 3
The Appraisal Process:
Medical appraisal differs fundamentally from appraisal in other settings due to its elemental
link with external professional regulation and revalidation.
Medical Appraisals are based on a doctor’s performance in four main dimensions as
described in the GMC’s Good Medical Practice:
Skills & Knowledge
Safety & Quality
Relationships with Patients and Colleagues
Maintaining Trust
Areas covered by the Appraisal








Good clinical care
Maintaining good medical practice
Relationships with patients
Working with colleagues, and teams
Teaching, training and research
Probity
Health
Management Activity as appropriate
Clinical Governance: Evidence
The Trust must ensure that robust and properly resourced and supported systems of
clinical governance (including appraisal) and arrangements are available to enable
doctors’ Continuing Professional Development. Doctors must also be able to monitor
their practice through performance information, including clinical indicators relating to
patient outcomes, through feedback from patients and colleagues and in a range of other
ways.
A model dataset of Clinical Governance, and other relevant evidence is currently being
developed and will be appended once complete.
Trust Protocol for Appraisals (guidance)
The Appraisal process is comprised of five (5) Phases:





Phase 1: Preparation work by appraisee
Phase 2: Preparation work by appraiser
Phase 3: The Appraisal Interview
Phase 4: Notification & return of papers (including evaluation of Appraiser by
Appraisee)
Phase 5: Review & Reporting by the Medical Director & Clinical Directors
This policy document is subject to South London and Maudsley NHSFT copyright. Unless expressly indicated
on material to the contrary, it may be reproduced free of charge in any format or medium, provided it is
reproduced accurately and not used in a misleading manner or sold for profit. Where this document is
republished or copied to others, you must identify the source of the material and acknowledge the copyright
status.
The Annual Cycle: Appraisals are carried out in 1st quarter each year.
Phase 1:

Clinical Directors will assign appraisers for consultants. It is expected that the
appraisee will change appraiser after 3 years. If an appraisee feels that there is a
potential conflict of interest (e.g. Personal/family relationship; sharing of close
business/financial interest; reciprocal appraisal; line management) between them and
their assigned appraiser they should raise this with their Clinical Director (or with the
Medical Director if the Clinical Director is the assigned appraiser). Another appraiser
will be offered under these circumstances. Doctors on academic contracts should
have a joint hospital/Medical School appraisal with appropriate appraisers from both
organisations.

The appraisee should contact the nominated appraiser and book the appraisal with
the appraiser and notify the Clinical Director.

Consultants are strongly advised to complete the template electronically rather than
by hand (the first two sections can be cut and pasted from one year to the next to
save time).

Consultants are advised to save (electronically, or on paper) appropriate
documentation throughout the year leading up to appraisal. For example, certificates
confirming CPD activity, student feedback from the medical school, reflective notes
written on challenging cases, or following a response to a complaint.

Consultants should review their previous year's personal development plan and the
objectives it contains in order to ensure they include appropriate documentation to
demonstrate that objectives have been achieved.

Consultants must include information from their full breadth of practice including for
example work at other NHS and private hospitals and expert witness work within their
single annual appraisal.

It is important to include any and all nationally benchmarked quality measures that
apply to one’s practice compared with one’s own data.

All complaints, litigation, serious untoward incidents, high risk incidents, patient
feedback and external reviews of practice involving the consultant from the previous
year must be included in the appraisal and reflective notes written, where
appropriate. The Trust is currently developing systems to deliver trust-held data
regarding practice of the Consultants.

All documentation to be included in the appraisal portfolio must be appended to the
correct section and indexed in a way to facilitate access for the appraiser.

A provisional Personal Development Plan should be completed prior to the appraisal,
including personal objectives for the year ahead. These should relate to the
departmental objectives in the Consultant’s job plan. It is inadequate for a PDP to
only contain objectives relating to plans continuing professional development for the
year.
Page 16 of 36

Health:
A positive statement, confirming compliance with recommended immunisations (for
example, flu vaccine) is preferred. This may also include compliance with age and
gender associated National Screening Programmes (including sight tests for
example).
Please note doctors are at higher risk than the general public of dependence on
substances such as alcohol. If you have any concerns in relation to dependency, the
doctor should be advised where to seek advice and assessment as necessary.

Probity:
A positive statement should include comments regarding

-
Sponsorship by commercial companies, for example, to attend courses or
conferences
-
Any private practice activities with a statement confirming these do not
impinge on NHS employed time
-
A declaration of any business interests or any other outside interests which
might be perceived as a potential conflict of interest with NHS work. Please
note, any doctor facing any criminal charge or conviction is obliged to tell the
GMC about this directly.
Working with colleagues:
It is expected that every doctor working at SLaM should perform a multi-source or
360 feedback once every 5 years. This is in line with the expectation that this will be
a mandatory element of revalidation in the future and in the belief that this constitutes
good practice.

Relationships With Patients:
The inclusion of patients in 360 feedback may pose more difficulties in some
specialties than others. It is expected that doctors should include patient or carer’s
perspective in their 360 feedback. Where difficulties occur in collecting this
information this should discussed with the appraiser. Work is still in progress
(nationally) to determine whether and how this can work for specialties. The Trust is
rolling out systemic patient feedback processes in all clinical areas and feedback
gained from this is suitable to include in the appraisal portfolio. Please ensure patient
identifiable data (names, addresses and hospital numbers) is not included in the
appraisal portfolio.

Research:
If a Consultant is research active, he or she should include a statement regarding
compliance with research ethics policies in the appraisal. Local and national
presentations and publications should be listed here and any grounds obtained.

The portfolio must be forwarded to the appraiser two weeks prior to the date of
appraisal.
Page 17 of 36
Phase 2: Preparing to appraise a Consultant colleague

Ensure that the meeting is planned to take place in an undisturbed room and allow
two hours for it.

Read the appraisal file carefully before the meeting and make notes of specific
questions you wish to ask. Look at the previous year’s PDP and see if there is
evidence that the objectives have been met. Look at this year's PDP to see if the
objectives are realistic.

The PDP must address specific areas where the consultant needs to improve or
develop performance and should be compatible with the strategic plans of the Trust

If you are in a different speciality, check in advance with the Clinical Director or
someone within the speciality as to what benchmarking data you should expect to
see in the appraisal for that speciality.

Remember to include the full range of the doctor’s practice (NHS and private)

If there does not appear to be good documentation to support the appraisal process,
then discuss this urgently with the appraisee and the Clinical Director before the date
of the meeting. It may be necessary to postpone the appraisal while the appraisee
collects more information at the direction of the Clinical Director.

Do talk to the relevant Clinical Director and General Manager before the appraisal to
see if they have specific issues that you should discuss during the appraisal. If there
is a personal or professional reason why you do not want to appraise this doctor, tell
the Clinical Director as soon as you are asked to do the appraisal.

Indemnity: consultant appraisers who have been appointed by and who work to the
Trust’s appraisal policy will be indemnified by the trust for this work.
Phase 3: The Appraisal

The appraisal should be free from any interruptions.

The appraisee should present his/her portfolio to the appraiser.

The appraiser should ensure that good, legible documentation is present.

It is important for the appraisee to demonstrate to the appraiser that the previous
year’s objectives have been met or if not what the reason was for this.

The appraiser should draft comments for form 4, step by step, as they go through the
appraisal.

Form 4 must include positive statements, not just comments such as “fine” or “no
concerns”.
Page 18 of 36

Under the “Action” section for each topic there should be a positive statement. It is not
appropriate to leave this blank or to write “no action”

The appraiser’s comments in this section should broadly cover the doctor’s range of
practice.

At the end of the appraisal, the appraiser and appraisee should review and finalise the
objectives in the new PDP.

The appraiser should complete Form 4, preferably electronically and both appraiser and
appraisee should sign and date a copy of this. It is the appraisee’s responsibility to send
the copy of the completed Form 4 (including both the commentary on last year’s PDP
and this year’s PDP) to the Medical Director, ideally within a week of the appraisal being
completed.
Phase 4: Notification and Return of Papers
Once electronic systems for appraisal are implemented this process will be fully automated
via the electronic system.
o
o
o
o
o
Once the Appraisal interview takes place, Forms 1 (Background details) and Form 4
(Summary of Appraisal Discussion with Agreed Action and Personal Development
Plan) are sent by the Appraiser to the OMD (Office of the Medical Director). The
OMD may request a complete copy of the Appraisal document if the Forms 1 and 4
have insufficient details of the discussion.
The OMD will record any required paperwork and send the Appraisee and Appraiser
a receipt accordingly notifying other groups in the Trust as required (HR, Operational
management, etc. ) that the Appraisal process for the individual has been completed
The Appraisee will send the Evaluation of Appraiser form to the OMD
Appraisees should keep all the documentation related to their appraisal for at least
five years, since they may need to produce it in order to support their revalidation.
Appraisers will be asked their views on the appraisal process and the preparedness
of appraisees (anonymously) in order to inform future training and improvements in
the process.
Phase 5: Review and Feedback by Medical Director (MD)
As Appraisals paperwork arrive at the OMD, regular Review & Feedback meetings are held
between the MD, Clinical Directors, Appraiser and any other relevant member of staff, in
order to review Individual Summaries and prepare any necessary feedback and actions
accordingly.
Page 19 of 36
Appendix 4
Appraiser Allocation Process
YES
Is Clinician on
Academic contract
with IoP?
NO
Appraiser requires
joint appraisal
Has Clinician had
same appraiser for
3 years?
YES
Appraisee
requires new
Appraiser
NO
Clinical Director assigns
Appraiser and notifies
appraisee
Appraisee notifies
Clinical Director
YES
Is there potential
conflict of interest?
NO
Go To Appraisal
Process
Page 20 of 36
Appraisal Process
At Least 6 weeks
before
At Least 4 weeks
before
At least 2 weeks
before
Clinical Director
Allocates appraiser
Appraisee contacts
Appraiser and books
time for appraisal (CD
notified of date)
Portfolio and Supporting
documentation forwarded
to appraiser for review
Appraisal documentation
updated as required
Is appraisal
documentation
complete
NO
YES
Appraisal Interview
Within 28 days
of Appraisal
interview
Within 1 week
of Appraisal
sign off
Form 4 Signed off
Copy of Form 4 and PDP
sent to Office of Medical
Director
Page 21 of 36
Appendix 5
Documentation required for Appraisal
Domain
Knowledge, Skills and
Performance
Information
Check
CPD Record
S12 Approval
Case Based Discussion
record (10 per 5 year cycle)
Clinical Audit (2 per 5 year
cycle)
Multi-source feedback (1 in
first 3 years of revalidation
cycle)
Safety and Quality
SUI reports and reflective
notes
Complaints
notes
and
reflective
Compliments
Communication,
Partnership and Teamwork
Maintaining Trust
Probity Declaration
Page 22 of 36
Appendix 6
Page 23 of 36
Page 24 of 36
Page 25 of 36
Page 26 of 36
Appendix 7:
Appraisal Checklist for documentation:
GMC Registration Number
Medical Qualifications
Description of Practice
-
Title
-
Role
-
Job Summary
-
Job Plan for each year
Description of voluntary roles undertaken in capacity as doctor
Appraisal for each year
Description of Indemnity
Last Year’s Personal Development Plan
Statement of Concerns and their resolution
Statement of Probity including interests and gifts
Statement of Health to confirm ability to undertake practice as described
Registration with GP
Clinical Audit
Case Notes Audit
Case Based Discussion (2 per year or 10 in 5 years)
Structured Review Template
Complaints and Concerns
Incident reporting
CPD certificates and Mandatory training record
(Including on-line e-learning modules)
S12 Approval
Multi-source feedback
Patient feedback
Page 27 of 36
Appendix 8:
Exit report for locum appointments. The completed report should be forwarded to the locum doctor and their Responsible Officer.
1
Details of locum doctor:
Name
Contact details [email/phone]
GMC Number
2
Details of locum agency [if appropriate]:
Name of agency
Contact details [email/phone]
3
Details of the locum’s Responsible Officer:
Name
Contact details [email/phone]
4
Details of locum role performed:
Title/grade/Specialty
Description of duties [if not standard for the role]
Name/address of the Trust/organisation
Dates
5
Details of person completing the report:
Name
Title/Role
GMC Number [if appropriate]
Contact details [email/phone]
6
The doctor’s performance was:
Unsatisfactory
Borderline
Satisfactory
Please describe issues or concerns
Good
Excellent
7
The doctor’s conduct/behaviour was:
Unsatisfactory
Borderline
Satisfactory
Please describe issues or concerns
Good
Excellent
8
Would you be happy for this doctor to be employed in
the same role in the future:
Yes/No
If no, please describe reasons
Additional optional information:
9
GMC Domain 1: Knowledge skills and performance
Unsatisfactory
Borderline
Satisfactory
Good
Excellent
10 GMC Domain 2: Safety and quality
Unsatisfactory
Borderline
Satisfactory
Good
Excellent
11 GMC Domain 3: Communication partnership and
teamwork
Unsatisfactory
Borderline
Satisfactory
Good
Excellent
12 GMC Domain 4: Maintaining trust
Unsatisfactory
Borderline
Satisfactory
Good
Excellent
This policy document is subject to South London and Maudsley NHSFT copyright. Unless expressly indicated on material to the contrary, it may be reproduced free of
charge in any format or medium, provided it is reproduced accurately and not used in a misleading manner or sold for profit. Where this document is republished or
copied to others, you must identify the source of the material and acknowledge the copyright status.
Appendix 9
Annual Medical Appraisal Board Report
1. Management of Appraisal and Revalidation
- Brief description of Individuals responsible for Appraisal and Revalidation in South London & Maudsley NHS Trust
2. Activity Levels

Total number of doctors for whom the organisation has responsibility for appraisal and revalidation, reported by grade and Clinical
Academic Group. This should include part-time and temporary appointments (including locums), those on long term leave, career
breaks, suspensions, etc for whom the organisation has responsibility.

Subset: Number of doctors who have had a completed appraisal in year, reported by grade and CAG, including the groups above.

Subset: Number of appraised doctors for whom a PDP has been agreed, reported by grade and CAG, including the groups above.

Exception audit, with reasons, for all missed or incomplete appraisals and all missing PDPs.

Total number of doctors completing revalidation cycle and total numbers of recommendations completed.

Total number of doctors in remediation, performance or disciplinary procedures.
3. Quality Assurance of Appraisal Process

Outline of processes to assure quality of appraisal process.

Outline of work done to address previously identified areas for development.

Summary of annual self assessment report with areas for development in the next year.
This policy document is subject to South London and Maudsley NHSFT copyright. Unless expressly indicated on material to the contrary, it may be reproduced free of
charge in any format or medium, provided it is reproduced accurately and not used in a misleading manner or sold for profit. Where this document is republished or
copied to others, you must identify the source of the material and acknowledge the copyright status.
4. The Learning Needs of Individual Doctors

Summary of anonymised collated development needs (with special reference to patient safety).

Summary of constraints and progress in addressing constraints previously identified.
5. Other Developmental Needs of Individual Doctors

Summary of collated ‘other’ developmental needs e.g. stress management.
6. Performance Review, Support and Development of Appraisers

Summary of training provided, including feedback on training from appraisers.

Compliance with guidance on curriculum for initial training.

Arrangement for support and development of appraisers.

Arrangement for performance review of appraisers.
7. Organisational Development

Summary of issues that need to be addressed by organisation in the systems supporting appraisal and revalidation

Clinical Information systems

Clinical risk/patient safety systems

Clinical audit systems

Report investigation and management of performance concerns
Page 30 of 36

Complaints management systems

Continuing Professional Development systems
8. Summary
1. Summary of important issues
2. Recommended actions
Page 31 of 36
Appendix 10
Results of exception audit to identify reasons for all missed or incomplete appraisals
1
2
3
4
Numbers
Appraisee factors:
a
Absence of appraisee at the end of the appraisal year [so not possible to rearrange within year] e.g. maternity/sickness leave
b
Incomplete portfolio or supporting information [GMC Guidance will be available in 2011]
c
PDP/Summary not signed by appraisee within 28 days of the appraisal meeting
d
Factors relating to lack of time of appraisee
e
Lack of engagement of appraisee
f
Other appraisee factors [description]
Appraiser factors:
a
Unforeseen absence of appraiser at the end of the appraisal year [so not possible to rearrange within year]
b
PDP/Summary not signed by appraiser within 28 days of the appraisal meeting
c
Factors relating to lack of time of appraiser
d
Other appraiser factors [description]
Organisational factors:
a
Administrative/management factors
b
Factors relating to function or failure of electronic portfolio or information system
c
Insufficient numbers of trained appraisers
d
Other organisational factors [description]
Recommendations:
Page 32 of 36
References:
1. Good Psychiatric Practice – Royal College of Psychiatrists, May 2009
2. Assuring the Quality of Medical Appraisal and Revalidation
3. Appraisal and Revalidation for Consultant Psychiatrists in the NHS; A report from the
Special Committee on Clinical Governance – D Roy, May 2004; Royal College of
Psychiatrists
4. Good Practice Guidelines for Appraisal; L. Mynors-Wallis, D Fearnley; Feb 2010;
Royal College of Psychiatrists
5. Department of Health (2007). Trust, Assurance and Safety: the regulation of health
professionals in 21st Century.
6. Department of Health (2008). Medical Revalidation – principles and next steps.
Report of the Chief Medical Officer for England’s working group.
7. General Medical Council (2006). Management for Doctors
8. General Medical Council (2006). Good Medical Practice.
9. General Medical Council (2002). Research: the roles and responsibilities of doctors.
This policy document is subject to South London and Maudsley NHSFT copyright. Unless expressly indicated
on material to the contrary, it may be reproduced free of charge in any format or medium, provided it is
reproduced accurately and not used in a misleading manner or sold for profit. Where this document is
republished or copied to others, you must identify the source of the material and acknowledge the copyright
status.
Appendix A - Equality Impact Assessment Summary
To be completed and attached to any procedural document when submitted to the
appropriate committee for consideration and approval.
Yes/No
1.
Comments
Does the policy/guidance affect one group
less or more favourably than another on the
basis of:
 Race
 Ethnic origins
travellers)
No
(including
gypsies
and
No
 Nationality
No
 Gender
No
 Culture
No
 Religion or belief
No
 Sexual orientation including lesbian, gay
and bisexual people
No
 Age
No
 Disability - learning disabilities, physical
disability, sensory impairment and mental
health problems
No
2.
Is there any evidence that some groups are
affected differently?
No
3.
If you have identified potential
discrimination, are any exceptions valid,
legal and/or justifiable?
No
4.
Is the impact of the policy/guidance likely to
be negative?
No
5.
If so can the impact be avoided?
6.
What alternatives are there to achieving the
policy/guidance without the impact?
7.
Can we reduce the impact by taking
different action?
Page 34 of 36
Name of person completing the EIA:
Dr Michael Holland
Date:
26/7/11
If you have identified a potential discriminatory impact of this procedural document, please
also include the full Equality Impact Assessment that was carried out at the beginning of
policy development and any associated documentation.
For advice in respect of answering the above questions, please contact Kay Harwood on
kay.harwood@slam.nhs.uk.
Appendix B
Version Control Sheet
Version
Date
Author
Status
Comment
Page 35 of 36
Appendix C
Plan for Dissemination of Procedural Documents Policy
To be completed and attached to any document which guides practice when submitted to
the appropriate committee for consideration and approval.
Title of document:
Date finalised:
Previous document already
being used?
Appraisal and Revalidation Policy for Doctors at South London
and Maudsley NHS Foundation Trust
1/8/2011
No
Dissemination lead:
Print name and
contact details
Dr Michael Holland
Ext 82415
If yes, in what format and
where?
Proposed action to retrieve
out-of-date copies of the
document:
To be disseminated to:
How will it be
disseminated, who
will do it and when?
Paper
or
Electronic
All Doctors
A group email will be
sent to all doctors. Dr
Holland will attend all
MAC meetings
Trustwide to
disseminate
Electronic
Comments
Page 36 of 36