Authors: Nikhil Khisty
Publication date: 02 Aug 2016
Nikhil Khisty examines the aims of medical appraisal in the context of the recommendations to link appraisal to pay progression
Medical appraisal has many purposes in the UK. Recently another one was added when the Review Body on Doctors’ and Dentists’ Remuneration (DDRB) recommended linking appraisal and pay progression.
NHS England’s Revalidation Support Team says that medical appraisals should enable doctors to achieve a range of objectives. These include:
demonstrating that they continue to meet the principles and values set out in the General Medical Council’s Good Medical Practice guidance
enhancing the quality of their professional work by planning their professional development
considering their own needs in planning their professional development
ensuring that they are working productively and in line with the priorities and requirements of the organisation in which they practise.
Formative and summative
Medical appraisal has both a formative and a summative element. The formative is concerned with professional development; doctors have always regarded the purpose of appraisal as primarily educational and developmental. 
The summative element is the requirement for all doctors to meet the minimum standards set out in Good Medical Practice. This enables the GMC to provide assurance that licensed doctors are fit to practise.  Performance review of doctors, aligned with healthcare organisations’ need to improve productivity, is also arguably summative if reviewed against defined targets.
These diverse aims are the result of attempts to accommodate stakeholders, who want appraisal to achieve different things, rather than a cohesive underlying framework.
The NHS Revalidation Support Team recognises that there is a “potential conflict of interest” when performance review is “combined” with appraisal. It says that performance review should generally be a part of the job planning process and separate from appraisal. But it also clarifies that “the outputs from each will inform the other.”
The DDRB recommendation of an “appraisal based pay system” with pay progression linked to “achievement of excellence (assessed at appraisal)” would further expand the scope of appraisal. In its recommendation, the DDRB cited a National Audit Office report that says medical appraisal is a key mechanism to review performance and fully realise the benefits of the consultant contract.
But linking appraisal with pay progression would result in substantial overlap between appraisal and job planning and create a conflict of interest for doctors. This would be particularly challenging for doctors who work for more than one employer. It would also undo the confidentiality of the appraisal, as employers would access doctors’ appraisal portfolios to decide on pay progression. This is despite the fact that the Revalidation Support Team recognises the importance of a “confidential appraisal discussion,” as it enables “some of the more difficult areas” to be considered.
The aims of an appraisal influence the discussion that takes place in that appraisal. Combining managerial demands, performance review (especially linked to pay or award assessments), feedback on performance, and planning personal and job objectives in one appraisal scheme is not psychologically compatible. People are generally reluctant to admit to failure if it affects promotion or salary, and the appraiser cannot be a judge and a counsellor at the same time.
The aims of appraisal also influence the process of setting objectives for the next year. If appraisal is linked to pay progression, then the objectives relevant to performance or pay progression could become more important than those aimed at professional development.
The DDRB report recommends that pay progression be contingent on “excellence identified at appraisal.” But it does not define excellence. Appraisal assesses whether doctors meet the minimum standards to remain fit to practise. It is not designed to, and cannot, identify individual excellence.
The chief medical officer noted in 2006 that appraisal may not serve the multiple purposes of detecting unsafe practice, quality assuring good practice, ensuring compliance with contractual duties, improving practice, and facilitating continuing professional development. This remains relevant as various stakeholders, including the DDRB, continue to have different expectations from the appraisal after the implementation of revalidation.
Frameworks for appraisal, a regulatory matter, and pay progression, an employment matter, must remain separate. The aims of appraisal are still not clear, and trying to bring together different, incompatible aims could compromise the integrity, quality, and efficiency of the medical appraisal. Such aims give confusing messages to the stakeholders. The purpose of appraisal must be appraised, as it cannot serve multiple, often conflicting, purposes.
Competing interests: I have read and understood BMJ policy on declaration of interests and declare that I have no competing interests.
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Nikhil Khisty acting associate medical director Lancashire Care NHS Foundation Trust