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General Policy
Medical Director
Associate Medical Director's Directorate Manager
Members of NHS Fife's MARG
Medical Director/Nurse Director
04 April 2014
14 August 2014
12 December 2017

General Note

NHS Fife acknowledges and agrees with the importance of regular and timely review of policy/procedure statements and aims to review policies within the timescales set out.

New policies/procedures will be subject to a review date of no more than 1 year from the date of first issue.

Reviewed policies/procedures will have a review date set that is relevant to the content (advised by the author) but will be no longer than 3 years.

If a policy/procedure is past its review date then the content will remain extant until such time as the policy/procedure review is complete and the new version published, or there are national policy or legislative changes.


1.1 This policy replaces the current ‘Consultant and All Non Training Grade Doctors Appraisal Policy and Procedure’.

1.2 The aim of this policy is to deliver a transparent, fair and enhanced appraisal process which will provide the basis for revalidation for all General Practitioners, Specialty Doctors, Associate Specialists and any other Non Training Grade posts.

1.3 Appraisal and Revalidation should:

  • Confirm that licensed doctors practice in accordance with the General Medical Councils generic standards
  • For doctors on the specialist register and General Practitioners register, confirm that they meet the standards appropriate for their specialty
  • Identify poor practice which may require further investigation and remediation
  • Provide a focus for doctors’ efforts to maintain and improve their practice, resulting in a personal development plan (PDP) which prioritises the doctor’s development needs for the coming year

1.4 All General Practitioners, Specialty Doctors, Associate Specialists and any other Non Training Grade posts are required to undertaken revalidation every five years.


This policy applies to all consultants and non training grade doctors working within the Acute Services Division, Corporate Directorates, Community Health Partnerships and General Practitioners within NHS Fife.


3.1 Appraisal is a supportive mechanism focusing on enhancing local systems of quality improvement. It will allow recognition of good performance, provide feedback and assist in the identification of issues related to compliance with “Good Medical Practice” so that they can be dealt with at an early stage.

3.2 The appraiser will review various sources of information with the doctor to gain a rounded impression of that doctor’s practice and inform a mutually agreed personal development plan.

3.3 Appraisal will support doctors to ensure that information provided serves as evidence of achievement of generic and specialist standards. Where this cannot be achieved it will assist those doctors in identifying support and development needs at an early stage.

3.4 Every doctor is responsible for participating in an annual appraisal on their whole practice, so arrangements need to be made to share information from each of their employers, including private practice, on an annual basis.

3.5 Appraisals happen on an annual basis within each appraisal year. An appraisal is not considered to have been completed without timely sign off of a Form 4 (within 28 days of the appraisal meeting).

3.6 Revalidation will require a cumulative review of appraisal over a 5 year period.


4.1 The responsibility for medical appraisal and revalidation rests with the Medical Director, NHS Fife.

4.2 The responsibility for development, implementation and operation of the system of appraisal and revalidation is discharged through the Medical Appraisal and Revalidation Group, which is chaired by the Medical Director, NHS Fife.

4.3 Corporate and Clinical Directorates, Services or Community Health Partnerships, as appropriate, will be responsible for ensuring that the appraisal and revalidation process is coordinated and concluded for their consultant, specialty doctor and associate specialist doctors.

4.4 Consultant medical staff, specialty doctors and associate specialists will be responsible for participating in the appraisal and revalidation process; working with NHS Fife to help gather relevant data and completing all of the necessary documentation in order to reach agreement on their appraisal. This must be undertaken annually.


5.1 Medical Appraisal

5.1.1 Medical appraisal differs fundamentally from appraisal in other settings due to its link with external profession regulation and revalidation.

5.1.2 Medical appraisals are based on a doctor’s performance and compliance with the General Medical Councils Good Medical Practice:

Areas covered by appraisal

  • Improvement activity
  • Continued Professional Development (CPD)
  • Feedback from patients
  • Feedback from colleagues
  • Complaints, clinical incidents and significant events
  • Probity
  • Health

The attached procedure gives full details of the appraisal process for trained medical staff.

See attached annual (Appraisal cycle for appraisee within seconcary care document) for diagram.

Recording/personal development

  • Appraisee agrees appraisal date with appraiser
  • Complete appraisal documents including supporting evidence
  • Appraisee participates in 6 monthly review of PDP
  • Appraisee continues with agreedCEPD/personal development
  • Appraisee participates in appraisal
  • Appraisee completes appraisal record, form, appraisal summary (Form 4) and PDP with appraiser
  • Appraiser forwards appraisal records and summaries (Form 4) to Medical Director
  • Appraisee performs agreed CEPD/personal developments
  • Review/Consolidation
  • Preparation
  • Appraisal/personal development planning


6.1 Risks will include non-compliance and sub-standard quality of appraisals which could result in the Responsible Officer recommending an individual’s “license to practice” be continued or reviewed inappropriately.

6.2 These risks will be mitigated by a process of ongoing monitoring / review by the respective Clinical Directors, Clinical Leads, Appraisal Adviser, Medical Directors or Director of Public Health.


7.1 NHS Fife Medical Appraisal and Revalidation Procedure


8.1 Consultant Grade terms and conditions of service - 1 April 2007

8.2 Scottish Association of Medical Directors Guidance on Job Planning – September 2006

8.3 Guide to Consultant Appraisal

8.4 NHS Circular PCS (DD) 2001/2 and PCS (DD) 2001/7 – Annual Appraisal for Consultants

8.5 Job Planning Handbook

8.6 CEL 03 (2014) Medical Revalidation: Annual Appraisal Documentation

8.7 NHS Scotland “A Guide to Appraisal for Revalidation July 2012”