There are some concerns in the UK that appraisal of doctors is becoming less developmental and more a process of performance management. If the aim of revalidation is quality improvement then appraisal needs to be a balance between promoting professional development and ensuring that the doctor is up to date and fit to practise in order to provide safe and effective patient care.
If the appraiser and appraisee know each other too well e.g. are friends in another context, if they usually work closely together or 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. It is therefore stressed in the UK doctors’ context that appraisal is carried out by a colleague who is not the doctor's line manager. These 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 appraisal, and what to do if serious concerns are identified during the appraisal process. As noted above, issues concerning poor performance of UK doctors should be dealt with by local procedures for underperforming or incompetent doctors. There should be no major surprises during an 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 and in the UK doctors’ system this would be from the clinical governance lead, appraisal lead, medical director or responsible officer, 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, 2007b). If there are known serious concerns about a doctor their responsible officer may insist that these are disclosed to their appraiser and that any specific learning needs are addressed in their personal development plan.
The appraiser and the doctor need to discuss the issue of confidentiality and to remember that the duty of patient care and safety is the highest factor.