The role of appraisal in the regulation of doctors

You cannot choose your designated body or who your responsible officer (RO) is. There is a strict hierarchy of connections set out in legislation.

There are tools on the GMC website which will help you to identify which designated body you should be connected with (usually your employing trust or health board if you work in the NHS, or postgraduate deanery or equivalent if you are a trainee).

We recommend that you check your designated body is correctly assigned on GMC Online and that you update your connection promptly whenever there is a substantive change in your circumstances, e.g. going from being a trainee to becoming a consultant or SAS doctor.

It is your responsibility to ensure that you keep your connection up-to-date and have an annual appraisal.

If you work in an organisation that does not have designated body status but is a managed environment there might be a Suitable Person - this is an individual who undertakes a similar role to an RO and can provide the GMC with a revalidation recommendation about you. You should refer to the  GMC guidance on Suitable Persons.

Where there is no obvious connection to a designated body, physicians may in some circumstances be able to join one, such as the  Independent Doctors Federation or the  Faculty of Medical Leadership and Management.

This may be especially relevant for doctors who have retired from mainstream clinical practice but still wish to work in some capacity that requires a GMC licence.

They will then provide your RO and appraisal. These services are often provided for a fee (separately or part of membership). There are also independent appraisal providers who offer medical appraisals (for a fee) that your designated body may find appropriate for the purposes of revalidation.

If you don’t have a designated body, and cannot find a Suitable Person, you  can revalidate directly with the GMC.

Appraisal is not a pass/fail assessment. Appraisal is part of a formative and developmental process.

It provides the opportunity and protected time each year to reflect with the help of a trained appraiser, who should also encourage you to consider your personal and professional development needs and how best to meet them.

The appraisal is also about helping you to develop a portfolio of supporting information that meets your needs and enables your responsible officer to make a revalidation recommendation to the GMC at the end of a five-year cycle.

If any shortcomings in the portfolio are identified during appraisal, these should be addressed in a supportive way and objectives to overcome them should be included in the agreed personal development plan (PDP).

Appraisers do not have the authority to make your revalidation recommendation. Their role is to facilitate your reflection, support and stimulate your development and help you present an appropriate portfolio of supporting information for your responsible officer (RO) to consider.

Part of their role is to provide a comprehensive summary of the evidence supplied to represent you to the RO and show that you are complying with the requirements for revalidation.

Your responsible officer has the statutory responsibility for making a revalidation recommendation to the GMC.

Their decision is based on their determination about whether you have sufficiently engaged in annual appraisal, provided a portfolio of supporting information that meets the GMC requirements, and whether there are any outstanding concerns for any part of your scope of work.

The GMC will make the revalidation decision about whether to continue your licence to practise.

Potential issues relating to poor performance, conduct or health are almost never first brought to light during appraisal. They are usually discovered through clinical governance processes and become part of an entirely separate investigative process that takes the doctor outside revalidation.

If either the appraiser or appraisee reveals a performance concern issue for the first time during the appraisal, the  GMC duties of a doctor requires that action is taken to protect patients. The appraisal would be stopped, and advice would need to be sought.

Where a performance concern is readily known prior to appraisal it should be included for reflection and discussion between the appraisee and appraiser.

The appraisal provides the opportunity to reflect on the matter from a developmental point of view. The appraiser should not be judgemental – this is for the local governance process in managing any performance concerns.

It is your responsibility to act in accordance with your GMC Duty of Care to report concerns. Your appraiser should provide you with support and can signpost the correct steps for you to take.  The GMC guidance states:

‘(Paragraph 19) All doctors have a responsibility to encourage and support a culture in which staff can raise concerns openly and safely.  (Paragraph 20) Concerns about patient safety can come from a number of sources, such as patients’ complaints, colleagues’ concerns, critical incident reports and clinical audit. Concerns may be about inadequate premises, equipment, other resources, policies or systems, or the conduct, health or performance of staff or multidisciplinary teams. If you receive this information, you have a responsibility to act on it promptly and professionally. You can do this by putting the matter right (if that is possible), investigating and dealing with the concern locally, or referring serious or repeated incidents or complaints to senior management or the relevant regulatory authority.’

Appraisers are instructed that they should not go beyond the limits of the appraisal role to adopt other people’s concerns. Third party information is not good evidence, and an appraiser could be open to criticism if they repeat something potentially defamatory or destructive to someone’s livelihood, without any first-hand evidence.

We recommend that appraisers record that concerns have been raised at appraisal in the summary of discussion. This should not include details about the concern but should include written advice about the next steps and actions agreed with the appraisee, with an appropriate note in the comments box to make the responsible officer aware that a concern was raised.

You are expected to engage fully in the annual appraisal process to revalidate successfully. However, there is no requirement to have five annual appraisals before a revalidation recommendation can be made.

There are many reasons for having approved missed appraisals, such as maternity leave or sick leave. You could be given a revalidation due date that is less than five years from your first appraisal. It is important that any missed appraisals in the revalidation cycle are agreed by your responsible officer (RO) as being necessary and appropriate.

Before the RO can make a positive recommendation to revalidate, you must have collected all the GMC supporting information required to provide assurance that you are up-to-date and fit to practise and reflected on it at your appraisal.

This is likely to take at least two appraisals – one to define what you need and design a PDP that supports you in achieving it all, and the second in which to reflect with your appraiser on all your supporting information, in particular your colleague and patient feedback.

Only your responsible officer can decide whether or not to recommend that your revalidation date should be deferred.

It is possible that, if you have not engaged sufficiently with the appraisal process, or taken appropriate opportunities to ensure that you are ready for revalidation, the RO would decide that it was more appropriate to tell the GMC you are failing to engage with revalidation.

Deferral is a neutral act and usually used in circumstances where more time is needed to demonstrate your continued competence, either because your portfolio of supporting information and reflection at appraisal is not yet complete, or because your practice is currently under investigation due to a significant event or complaint.

Your existing licence to practise continues, allowing you additional time to meet the GMC requirements for supporting information in full, or for a local process to be completed.

If you feel that your revalidation date should be deferred, for example because you are struggling to collect all the supporting information, you should discuss your options and the reasons why with your RO or appraisal lead at the earliest opportunity. This will help to demonstrate that you are engaged with the process.

There are a variety of ways to allocate your appraisal month. Many appraisal systems spread appraisals through the appraisal year based on having your appraisal in your birth month, as recommended in the NHS England Medical Appraisal Logistics Handbook.

This is often seen as the default position. However, in other designated bodies, the appraisal policy may have a different way of allocating your appraisal month.

There might be an ‘appraisal season’, during which everyone has their appraisal. There are therefore many situations where your appraisal may not be in your birth month.

In addition, even if it starts in your birth month, your appraisal month might move after a period of maternity or sick leave, and you may resume a rolling twelve-monthly appraisal period with the new month as your appraisal month.

You are advised to check when your appraisal will be due when you move from one designated body to another. Your new responsible officer may ask you to change your month to ensure that you fit in with the local appraisal and revalidation policy and process.

GMC statutory guidance states that to maintain your licence to practise you must ensure that you have an annual medical appraisal and demonstrate your continued competence across your whole scope of practice.

Your responsible officer has a statutory responsibility for ensuring that the appraisal process is fit for purpose, but you must play your part in engaging fully with the process.

There is currently no GMC guidance that lays out exactly how you should demonstrate your engagement if you are not going to be in work at the time when your appraisal is due.

Most responsible officers (ROs) have a process whereby those doctors who are going to be on maternity or sick leave, or away on a sabbatical, can let the RO know their circumstances so that a postponement of the appraisal month, or an approved missed appraisal, can be agreed. It is best practice to do this in advance to demonstrate your engagement with the process.

If you are planning a significant period of time out of work for any reason (including, but not restricted to, sabbaticals, elective surgery or maternity, paternity or adoption leave), you should be proactive in planning your annual appraisal, by having a conversation with your RO (or local appraisal lead).

There will often be occasions when you have a significant break from practice due to maternity or parental leave, sickness or sabbaticals. Your RO has the option of deferring your revalidation recommendation to allow more time to collect the supporting information you need.

The Academy of Medical Royal Colleges has issued a Return to Practice Guidance (2017) for doctors and employers regarding the process to undertake for arranging a return to work after a period of absence.

Revalidation assesses your fitness to practise as a psychiatrist. There are no GMC requirements that relate to the number of sessions you need to work.

For any part of your scope of work, no matter how little time is spent on it, the GMC expects you to reflect on how you:

• keep up-to-date at what you do
• review your practice to demonstrate your continued competence at what you do
• seek out and respond to feedback from colleagues and patients about what you do

To a certain extent, CPD can substitute for volume of clinical practice and experiential learning, but the less experiential learning possible, the more CPD is likely to be needed to keep up-to-date.

You need to be confident that you can demonstrate that you practise safely in every role you undertake, no matter how little of that work you do.