Medical appraisal and revalidation: can it improve patient care?

Revalidation for all doctors in England, following the process defined in the Medical Appraisal Guide,1 finally started in December 2012 after ten years’ experience of developmental appraisal in the NHS. There has been significant debate about preserving the formative nature of the appraisal conversation in the context of the recent need for the appraiser to make explicit some of their professional judgements within the appraisal meeting.2 These include judgements which evaluate the portfolio of supporting information and whether it shows that the doctor is ‘on track’ to revalidate; deciding whether there are any emerging patient safety issues or performance concerns; and assessing whether the doctor has engaged appropriately in the appraisal process in reviewing his or her full scope of work.3 Appraisers need to gain ‘a rounded impression’4 of the doctor being appraised in order to agree a personal development plan (PDP) and to judge progress towards revalidation. As Wakeling and Cameron5 recognise, the appraiser and his or her skills ‘will become even more pivotal in “enhanced” appraisal’, or what is now referred to as ‘medical appraisal for revalidation’. Up to now the issues surrounding medical appraisal for revalidation have largely been considered from the perspective of the doctor being appraised, engagement in the process and the evidence presented, with little account being taken of the role of the appraiser, who now has to manage both formative and summative aspects.5 Lyons6 has argued that, in spite of concerns such as those found by Wakeling and Cameron,5 appraisers have not experienced role conflict to the extent predicted by the debates, though there is a lack of research into how appraisers balance these opposing demands. Thus, it may be argued, the spotlight is moving from engagement to practice, illuminating the knowledge and skills required by appraisers to manage the different elements of medical appraisal for revalidation. This next chapter is set within a broader agenda of the quality assurance of appraisal services. Ultimately, under the umbrella of revalidation, practice across health sectors needs to be bench-marked by those delivering it. This is to ensure that all doctors revalidate to the same standards, as it is acknowledged that currently appraisal systems are variable.7 This shifting agenda is already evident and strands of work are emerging which describe the development of advanced appraiser skills;8–12 make explicit the knowledge and skills required for the role13,14 and formally recognise them.15 Other work facilitates bench-marking through the development of quality assurance tools;16–18 and demonstrate cross-sector working, for instance in training appraisers.19 In the light of this shift in focus towards practice and process, we argue that there needs to be a similar shift in research and development activity concerning appraisal. Up to now research concerning the benefits of appraisal is sparse and generally based upon self-reported perceptions of change by doctors being appraised.20 One of the key aims of appraisal for revalidation is the promotion of quality improvements in patient care through the professional development of doctors.1 Although the benefits of appraisal for doctors are recognised, demonstrating that it drives improvements in patient care is difficult. Hitherto the focus of research has been on the individual doctor, with change being defined in the context of the individual’s practice. There is a pressing need to look at the outcomes of appraisal not only from the individual’s perspective, but also in terms of the wider context of a practice, locality and the healthcare system: ‘[W]e owe it to patients and all other stakeholders to demonstrate that a process that impinges on time devoted