Nearly half of hospital doctors are still not being appraised properly a review finds, casting doubt over the organisational readiness of the NHS for medical revalidation in England.

Chief executive of the GMC, Niall Dickson, described the review of the preparedness for revalidation a “wake up call”. The GMC is intending to introduce revalidation in late 2012.

NHS medical director Professor Sir Bruce Keogh called on the healthcare sector to “get to grips” with its obligations on quality and safety.

Despite it being 10 years since appraisal was introduced for doctors, the review finds that only 56% of doctors in hospital trusts are completing and annual appraisal properly. While 64% of consultants are doing so, only 36% of staff grade doctors are.

The figures are considerably better in primary care where over 80% of GPs have completed appraisal.

Other worrying figures include only half of NHS organisations having a medical appraisal policy that meets the requirements of the Responsible Officer Regulations 2010.

And only two thirds of responsible officers are satisfied that their organisation is providing sufficient financial resource to support revalidation.

Professor Sir Neil Douglas, chairman of the Academy of Medical Royal Colleges, urged doctors to insist their employers facilitate a proper annual appraisal.

Prof Sir Bruce Keogh commented: “Good clinical governance and appraisal are the bedrock of high quality care and CQC would expect to see that organisations have appropriate systems in place to support these in order to ensure people receive care that is safe and meets their needs.

“All boards in the health sector must grip the issues and make rapid progress. Patients need to know their doctors are up to date and this means doctors need to get the right development and assessment, which they are entitled to as part of their contracts.”

The review’s more positive findings included 87.8% of appraisers having received appraiser training, and 83.2% having a process for investigating concerns about a doctors’ practice.

However, less than a third of healthcare organisations have a policy in place for re-skilling rehabilitation, remediation and targeted support

Professor Sir Neil Douglas, Chairman of the Academy of Medical Royal Colleges said: “The figures released today on the number of doctors having appraisals which are fit for the purposes of revalidation are a serious concern. As appraisal has been a requirement on consultants for over ten years this should not have been the case.

“Without effective appraisals the long proposed revalidation system which is to start next year will not work. That would be bad news for patients and not fair on doctors. As professionals, doctors should be insisting that their employers do give them proper appraisals on an annual basis.”

In the NHS Revalidation Support Team assessment, called A review of integrated clinical governance in the context of medical revalidation, designated bodies completed a self-assessment tool called Organisational Readiness Self-Assessment, designed to help organisations determine their readiness for revalidation.

Five hundred and seven designated bodies completed returns, providing a 90% response rate. The report outlines the progress made by March 2011 and the challenges that still remain.

Niall Dickson, chief executive of the GMC, said: “This report is a wake-up call to health service organisations in England - they must put in place the right systems for monitoring and supporting clinical practice. This is needed for revalidation but more fundamentally it is needed to ensure high quality, safe care.

“We expect to see further progress over the coming months and we believe revalidation is already driving improvement in clinical governance and appraisal which will benefit doctors and contribute to safer, better care for patients.”

Read the full review.

A new round of revalidation piloting has been launched this month to test out whether the guidance being developed to support appraisal is up to scratch.

The pilots will test the appraisal process described in the NHS Revalidation Support Team’s draft Medical Appraisal Guide, which aims to provide clear and effective guidance for medical appraisal. They will also examine how a model for revalidation will fit within existing organisational systems and processes.

Revalidation, which is set to be introduced in late 2012, will be based on a local evaluation of doctors’ performance through annual appraisal. The information from the appraisal will be fed to a Responsible Officer who will make a recommendation to the GMC, normally every five years, on whether to revalidate a doctor.

A strengthened approach to appraisal was recently criticised by an independent evaluation for taking longer to complete and its authors called for a simpler system.

The Revalidation Support Team claims to have acted on feedback from its Pathfinder Pilots to ensure the process is streamlined and simple, while remaining robust and effective. This year, appraisals will be recorded using an interactive PDF appraisal form.

Feedback will be used to help shape the final Medical Appraisal Guide and to inform the Departments of Health’s business case for revalidation and its implementation.

The appraisal guidance is being tested in a wide range of settings including NHS doctors in primary and secondary care, clinical academics, locum GPs and consultants, SAS doctors and consultants in mental health.

The pilot sites include NHS Leicester City, Newcastle Upon Tyne Hospitals NHS Trust, NHS London, West Suffolk Hospitals NHS Trust, Leeds Teaching Hospitals NHS Trust, English deaneries and DRC Locums.

Appraisals for the pilots will take place between 1 October and 23 December 2011, with the final Medical Appraisal Guide being published in March 2012.

Dr Nick Lyons, programme director for testing and piloting at the Revalidation Support Team, said: “We are working closely with the medical community to ensure we have a revalidation system that is efficient, streamlined and supports high quality care.

“Participants in the pilot will have a very real opportunity to help shape the future of revalidation by providing their feedback. These pilots will help ensure that revalidation systems are right for all doctors, regardless of their specialty or the context in which they practice.”

The strengthened appraisal process that will underpin revalidation has the potential to improve the quality of care but it takes longer to complete, an independent evaluation finds.

Doctors took 18 hours to complete the new appraisal process in the revalidation pilot studies as compared with 12 hours previously.

The evaluation report also highlighted the need for a simpler system, and a better approach to remediation with struggling doctors.

Doctors struggled to provide supporting information on all 12 of the appraisal attributes, such as showing respect for patients and acting with honesty and integrity. The evaluation recommends that more work needs to be done to on establish which attributes are necessary for appraisal and to rationalise the information requirements for those attributes.

However, 96% of organisations involved in the pilots expect revalidation to lead to improved quality of care.

The pilots - which ran from April 2010 in 10 sites and involved 3,000 doctors - tested the proposed systems of appraisal for revalidation for practicality, efficiency and supporting quality care.

Health secretary Andrew Lansley said: “Patients and the public have a right to expect that their doctors’ skills are up-to-date and that they are fit to practise. Maintaining rigorous standards is critical to offering good care.

“It is encouraging to see that 96% of the pilots recognise that revalidation will improve the quality of care. It is important to ensure that the extent of the benefits of revalidation are justified in relation to the costs. These findings will allow us to identify the areas on which we need to focus in the additional year of piloting.”

While the organisations and responsible officers were very positive about the potential benefits of revalidation, appraisees and appraisers were less impressed. These differences in perception need to be understood if revalidation is to be successfully rolled out, the report says.

Dean Royles, director of the NHS Employers organisation, said: “It is important that the next phase of pilots continue to reflect employers’ requirements for a workable system that can both reassure the public of the continued quality of doctors and also ensure that doctors keep their practice up to date, safe and effective.”

Revalidation is due to be introduced in late 2012.

Niall Dickson, chief executive of the GMC, commented: “We want better safer care for patients - to achieve that we must give doctors the space to reflect on their practice, to gather information about their performance and to benchmark their results.

“We have already streamlined the system following earlier feedback from the pilots, and this report will give us further insight as we prepare for roll out. Doctors need to find the process both rewarding and effective. The next year of preparation will help to make sure the system works well for all doctors, wherever they practise.”

Read more on the evaluation.

Senior doctors who assess the performance of juniors and medical students are failing to use the new portfolio-based performance appraisal systems fully, research shows.

Forty six consultants and GPs were interviewed for the research and all claimed the new portfolio-based performance appraisal systems were superficial, box-ticking exercises.

None of them fully complied with the appraisal system’s requirements and they all continued to use the traditional method of assessment by day-to-day performance.

Portfolio-based performance appraisal systems have been brought into undergraduate and postgraduate medical training over the last decade as a way of formally logging the progress of medical students and junior doctors, who fill it in as a record of their progress during their training and which is signed off during appraisals. They are also increasingly being used to demonstrate a doctor’s continued fitness to practise.

One interviewed doctor said: “You fill in the forms in a workman like, dotting the Is and crossing the Ts fashion. But it’s all for the look of the thing. It doesn’t mean that you actually have done what you are meant to have done, or for that matter believe in what you have written past a very superficial level.

“You tend to bend the paperwork because you have checked out that everything is OK in your own way. So you are just complying with the bureaucratic need to get the paperwork done.”

Research author Dr Martyn Chamberlain, of the University of Chester, said that 19 of the 46 interviewed were ‘non-compliers’ who ignored the trainees’ portfolios when assessing them, and filled them in as a tick-box exercise based on their own assessment of them.

Another 17 were ‘minimalists’ who held some meetings with juniors and students to check the portfolio, but these were held at irregular intervals and were informal.

And the remaining 10 doctors were ‘enthusiasts’ holding regular meetings. However, “although they used portfolio documents to assess and guide them, like the non-compliers and minimalists, enthusiasts reserved the right to assess students as and how they thought fit,” the research says.

Portfolios were criticised by some doctors for placing as high a priority on trainees publishing case reports, and auditing hospital procedures against good practice, as upon their gaining practical medical skills.

None of the doctors had been formally trained in appraising and there was a “relegation of educational obligations behind service and research commitments”.

Commenting on the research, Stephen Campion, chief executive of the HCSA, called for improved appraisal training.

He said: “Appraisal, if it is to work properly requires the person being appraised to accept the views of the appraiser. For that to work, the appraiser needs to be effectively trained in the art of undertaking appraisals. Sadly, in many cases neither pre-requisite is fulfilled.

“Neither party is necessarily given the tools to do the job properly. That is a recipe for failure and unfair on both participants. More often than not the tick box approach is used because the true value and purpose of an appraisal system is not appreciated by either party or the bureaucracy they serve.”

Dr Chamberlain called for further independent research because of appraisal’s central role in revalidation.