Medical and dental appraisal and revalidation policy
Document control
- Policy owner: Responsible officer manager and people partner
- Corporate lead: Executive medical director
- Date approved by Joint Negotiating Consultative Forum(JNCF): November 2025
- Date ratified by Trust Leadership team: March 2026
- Date issued: March 2026
- Next review date: May 2026
Executive summary
The purpose of this policy is to support appraisal for doctors and dentists, and revalidation for doctors employed substantively at Leeds Community Healthcare NHS Trust.
This policy supersedes the ‘appraisal policy and guidance for consultants, SAS doctors, and dentists in Leeds Community Healthcare NHS Trust’. This policy will be underpinned by supporting guidance which will be available on the LCH intranet and on request from the Medical Education and Revalidation team.
The policy adheres to the principle that all qualified medical and dental staff will undertake annual appraisal in keeping with process agreed by the GMC, BMA, GDC, BDA and the Department of Health and will follow appropriate guidance and standards.
Equality analysis
Leeds Community Healthcare NHS Trust’s vision is to provide the best possible care to every community. In support of the vision, with due regard to the Equality Act 2010 General Duty aims, Equality Analysis has been undertaken on this policy and any outcomes have been considered in the development of this policy.
Table of content
- Introduction
- Scope
- Appraisals
- Responsibilities
- Appraisers
- Recruitment, selection and training of appraisers
- Appraisees
- Appraisal
- Timeline for the appraisal process
- Appraisal documentation
- Multi source feedback (MSF)
- Supporting information
- When an appraisal meeting should be adjourned
- Complaints arising from the appraisal process
- Links to revalidation and re-licensing
- Confidentiality
- Deferrals
- Non-compliance with the appraisal process
- Locum doctors and dentists
- New in post doctors
- Private practice and whole of practice appraisal
- Policy approval and ratification process
- Dissemination and implementation
- Review arrangements
- Associated policies
- References
- Appendices
1. Introduction
This policy applies only to doctors and dentist employed by Leeds Community Healthcare NHS Trust (LCH). Doctors and dentists who are currently in training are covered by separate guidance and processes in conjunction with HEE and the local deanery.
All doctors and dentists need an annual appraisal as per the terms and conditions of their contract and in the case of doctors for revalidation. This is in keeping with the process agreed at the time by the GMC, BMA, GDC, BDA, and Department of Health and Social Care.
2. Scope
This policy applies to all consultants, SAS doctors, salaried dentists and academics with honorary contracts employed or contracted by LCH. It is not routine for the trust to assume responsibility for facilitating appraisal or revalidation for a locum employed or contracted by the trust, but this can be facilitated at the discretion of the medical director.
3. Appraisals
Appraisal can be used for four purposes:
- To enable clinicians to discuss their practice and performance with their appraiser in order to demonstrate that they continue to meet the principles and values set out in relevant guidance (such as Good Medical Practice) and to inform the Responsible Officer’s (RO) revalidation recommendation to the GMC where appropriate.
- To enable clinicians to enhance the quality of their professional work by planning their professional development.
- To enable clinicians to consider their own needs in planning their professional development.
- To enable clinicians to ensure that they are working productively and in line with the priorities and requirements of the organisation they practise in.
4. Responsibilities
Within the appraisal and revalidation processes various roles and responsibilities have been identified.
The trust has overall responsibility to:
- ensure an effective appraisal and revalidation processes are in place
- staff are aware of this Policy and adhere to its requirements
- monitor appraisal and revalidation cycles
5. Appraisers
Appraisers are responsible to the RO for the quality of their appraisals, maintaining and submission of correct documentation and submission of the completed summaries of the appraisal discussion, personal development plans (PDPs) and appraisal outputs to the RO.
Appraisers should have sufficient time in the job plan for administration, preparation, carrying out the appraisal, post-appraisal sign-off and the necessary support and review arrangements. This is normally recognised as 0.25 PAs in the job plan if the appraiser is undertaking at least five appraisals, this will usually be identified within the supporting professional activities of the job plan. In normal circumstances, an individual appraiser should undertake approximately five appraisals per year, to maintain an appropriate level of quality and consistency.
Appraisers must receive formal training, from the trust, and a regular appraiser update. All appraisers are required to be trained in equality and diversity.
Appraisers will receive an annual feedback and review of their performance through the feedback form within the e-appraisal system. The feedback form is completed by the appraise at the end of appraisal. A representative sample of appraisal forms are audited by the RO team using the appraisal summary and PDP audit tool (ASPAT), the results of the ASPAT audit will be fed back to the appraisers. This will be an opportunity to discuss any areas of concerns and identify further training needs with all appraisers.
External assurance of appraisal systems will be undertaken as and when agreement is reached nationally on mechanisms for conducting this in line with CQC regulation and inspectorate responsibilities.
Any appraiser that is external to the trust must still abide by the trust standards and by carrying out an appraisal in the trust, agrees to participate fully in the quality assurance programme.
6. Recruitment, selection and training of appraisers
Expressions of Interest should have support from their service DMD, medical and dental Lead. Applicants should contact the RO team for an application form (appendix B,C). Successful applicants will need to attend a suitable approved training course as agreed with the RO.
Where appraiser roles are explicitly required to be a part of a lead clinician’s management role, this will be formally included in their job description and the relevant person specification will be amended accordingly.
Following appointment, a probationary period of 12 months will follow during which the new appraiser will undertake a minimum of 5 appraisals. After the first three of these appraisals, a formal review will be undertaken with the RO and
DMD for professional standards to assess progress, deal with any new learning needs identified, and confirm whether the appraiser is competent to continue.
Established appraisers will have access to ongoing support through the DMD and medical leads group. Regular appraiser forums will be held through the year to provide refresher skills training, group feedback and updates on LCH appraisal policy changes. Appraisers will be expected to include relevant learning objectives for developing their appraisal skills in their PDPs as a result of their own annual appraisal and declare their appraiser practice within their appraisal.
7. Appraisees
The aims of the appraisal policy are to ensure that all consultants, SAS doctors and dentists undergo a high quality and consistent form of annual appraisal achieved by:
- setting out personal and professional development needs and agree plans for these to be met
- reviewing regularly a doctors and dentists work and performance, utilising relevant and appropriate comparative operational data from local, regional and national sources
- considering the doctors and dentists contribution to the quality and improvement of services and priorities delivered locally
- optimising the use of skills and resources in seeking to achieve the delivery of general and personal medical and dental services
- identifying the need for adequate resources to enable any service objectives in the agreed job plan review to be met
- providing an opportunity for doctors and dentists to discuss and seek support for their participation in activities for the wider NHS
- utilising the annual appraisal process and associated documentation to meet the requirements for GMC revalidation against the ‘Good Medical Practice Framework for Appraisal and Revalidation’ and in the future for the GDC
- aiding preparation of the job planning process by reviewing relevant documentation prior to the job-planning meeting. Appraisal is therefore an important step in helping to prepare for the job planning meeting.
8. Appraisal
Every doctor and dentist in LCH is responsible for collection, preparation and presentation of their annual appraisal and should ensure that they record the full scope and nature of their work (including private practice and work outside of LCH). The portfolio must show evidence of appropriate personal reflection by the doctor and dentist.
Dentists are under an obligation to maintain a folder of information and evidence regarding their practice and participate in audit, quality improvement, professional development and educational activities. The portfolio of supporting information should reflect the breadth of the dentist’s practice, including information from all relevant roles and from all healthcare organisations (including private practice) and should conform to the GDC and Royal College standards.
For doctors and dentists in LCH a supporting letter (appendix A) should be obtained by the individuals relevant clinical lead which provides evidence of an individual’s involvement in their department. This should be submitted as part of the appraisees supporting evidence
Medical and dental appraisees are responsible for submitting their appraisal in the electronic appraisal system at least two weeks prior to their appraisal, to enable their appraiser time to read the information.
Appraisers will be allocated by the RO office. If the appraisee or another person objects to the allocated appraiser they should discuss the circumstances with the RO team. If the appeal is accepted, the appraisee should be allocated an alternative appraiser. In cases where the RO and the appraisee cannot agree a suitable appraiser an external appraiser may be allocated by the regional responsible officer, their decision will be final.
An appraisee should have no more than three consecutive appraisals with the same appraiser and must then have a period of at least three years before being appraised again by the same appraiser. If, in exceptional circumstances, it is deemed appropriate for an appraisee to have the same appraiser for more than three consecutive appraisals, the justification for this will be recorded within the governance review processes.
An appraisee should not act as appraiser to a doctor or dentist who has acted as their appraiser; within the previous five years.
The RO will make provision for joint appraisal where appropriate; for example, in the appraisal of clinical academics.
Where an appraisee has any concerns about the appraisal process or wishes to make a complaint about their appraiser, they should discuss this with the RO or the deputy medical director for professional standards.
There are circumstances where it is appropriate to alter the frequency of appraisal, this will be decided by the RO. The RO will be responsible for keeping an accurate record of these decisions for future reference by either employer or the doctor concerned. Suitable arrangements must always be made to manage a doctor’s return to practice after a significant break.
Appraisal month may be varied by agreement between the doctor and the RO or the DMD for professional standards.
Doctors with a prescribed connection to NHS England are personally responsible for presenting their own supporting information, including patient and colleague feedback, in line with the requirements of the GMC guidance.
9. Timeline for the appraisal process
- The appraisal cycle runs from 1 April to 31 March
- All appraisal will review a complete year’s activity, unless agreed by RO or DMD
- The appraisee will have at least 6 weeks advance notice of the appraisal due date
- Preparation for the appraisal is included in protected time that is in the supporting professional activities (SPA) element of the job plan
- The doctor and dentist being appraised should prepare for the appraisal by identifying issues to raise with the appraiser, collecting relevant evidence for all activity including private work and by preparing a PDP
- The appraisee is responsible for submitting their input form or portfolio to their appraiser a minimum of two weeks in advance of the meeting date
- The appraisal meeting must be held in an appropriate environment. This will involve a quiet room and both the appraiser and appraisee must ensure that they are not disturbed during the appraisal meeting
- All appraisal documentation should be signed off by all parties within 28 days of the appraisal meeting
10. Appraisal documentation
LCH uses an e-appraisal system for appraisals for doctors who have a prescribed connection to LCH. On-going support is provided by the RO team.
For salaried dentists guidance has been produced.
For dentists, sections A and B should be completed prior to the appraisal meeting and submitted to the appraiser at least two weeks before the scheduled meeting. Sections C and D will be completed during and immediately after the appraisal meeting. Supporting information will be recorded in the e-appraisal system with support provided by the RO team to log the appraisal input and output forms electronically.
11. Multi source feedback (MSF)
The GMC state that doctors should seek feedback at least once per revalidation cycle. For those with multiple roles discussion should take place with their appraiser or the RO to determine how best to cover whole scope of practice.
12. Supporting information
Prior to the appraisals the appraiser should come to an opinion early on about whether there is sufficient supporting information to enable the appraisal to go ahead as planned, whether it should be adjourned, or whether a request for further information prior to the meeting itself is necessary.
Guidance on what to include in supporting information.
The following table contains guidance for both appraisers and appraisees on how to deal with poor quality supporting information and performance. If doubts persist it is recommended that the individual speak to the RO team.
| Good performance | Poor performance | |
|---|---|---|
| Good quality supporting information | Satisfactory appraisal | Satisfactory appraisal but performance concerns. Further actions needed, for example, PDP, medical manager, responsible officer, NCAS, GMC |
| Poor quality supporting information | Unsatisfactory appraisal. Adjourn within 3 months with clear agreement about what information is required | Unsatisfactory appraisal. Adjourn and consult medical manager, responsible officer, NCAS, GMC. |
13. When an appraisal meeting should be adjourned
On very rare occasions, an unexpected serious concern may come to light in the course of an appraisal. In such circumstances the appraiser should consider suspending the conversation, ensure appropriate support for the appriasee is
provided and should not complete the appraisal outputs. They should notify the RO as soon as reasonably practicable (using the appraisal postponement application form found at medical and dental leadership page), so that the matter may be addressed. The RO will decide within 28 days of receiving the form when and how the appraisal process should be reinstated for the doctor in question; and how the issues raised are to be addressed.
14. Complaints arising from the appraisal process
Complaints and grievances arising from the appraisal process should be raised in the first instance with the RO or the deputy medical director for professional standards.
Complaints will be investigated and where possible resolved by the recipient within 28 days. A written reply will be provided to the complainant at this time. In addition to this complaints and grievances may also be discussed with the
director of workforce and development, with the agreement of the complainant, if necessary to determine the best course of action or to assure the complainant of the integrity of the process.
Complainants who are not satisfied with the outcome can refer the complaint to the chief executive of LCH. An anonymised report of complaints will be included in the annual report.
15. Links to revalidation and re-licensing
The appraisal process is the vehicle through which the GMC’s re-licensing requirements will be delivered for doctors. Completion of the appraisal portfolio as outlined in this policy will provide sufficient evidence to support the process of
revalidation. In addition the evidence collected within this process should also be sufficiently broad to cover the essential requirements of revalidation as developed by each of the Royal Colleges. Completion of satisfactory annual
appraisal over a five year period will therefore be a crucial factor in enabling the relevant RO to make a positive affirmation of fitness to practice to the GMC.
16. Confidentiality
Appraisal summaries for doctors and dentists with a prescribed connection to the trust and MAG forms for non-designated body doctors who have been appraised in LCH, will be held in electronic format by the RO team. The appraisal should not take place without the previous form being available to the appraiser prior to the meeting. If this is not provided by the appraisee it will be automatically emailed to the appraiser on request to the RO team. Consent for this to be done is implicit in participation in appraisal.
For doctors and dentists who have a connection with another designated body, it is expected that they will provide the RO team in LCH a copy of their form 4 when completed. LCH would also expect evidence of revalidation and evidence that the doctors scope of practice for work undertaken at LCH is covered in the appraisal discussion.
The details of who has access to appraisal summaries, PDPs and appraisal outputs or is described on the electronic appraisal system.
17. Deferrals
LCH requires all employed doctors and dentists to undergo an annual appraisal. There may, however, be exceptional circumstances when a doctor or dentist may request an appraisal be deferred such that no appraisal takes place during one
appraisal year.
Instances when, a doctor or dentist may request a deferment of an annual appraisal:
- Significant breaks in clinical practice due to sickness or maternity leave
- Significant breaks in clinical practice due to absence abroad or sabbaticals.
Doctors/dentists who have a break from clinical practice may find it harder to collect evidence to support their appraisal, particularly if being appraised soon after their return to clinical practice. However, often an appraisal can be useful when timed to coincide with a doctor/dentist’s re-induction to clinical work.
Appraisers will use their discretion when deciding the minimum evidence acceptable for these exceptional appraisals.
As a general rule it is advised that doctors or dentists having a career break:
- In excess of 6 months should normally be appraised within 6 months of returning to work.
- Less than 6 months should try to be appraised no more than 18 months after the previous appraisal and wherever possible so that an appraisal year is not missed altogether.
Each case can be dealt with on its own merits and LCH is mindful that no doctor or dentist must be disadvantaged or unfairly penalised as a result of pregnancy, sickness or disability. Doctors or dentists are likely to have to produce the required total amount of CPD credits stipulated for the five year revalidation cycle, if they have had some periods of leave during these five years.
Non-participation, without good reason, in annual appraisal will be considered a disciplinary matter and will lead to discussion with the GMC employer liaison advisor and may lead to termination of the practitioner’s contract. This policy aims to ensure that these circumstances are dealt with in an appropriate, timely and consistent manner, minimising bureaucracy and ensuring all doctors and dentists benefit from appraisal at a time which meets their professional needs.
Doctors who think they may need to defer their appraisal will have to complete an appraisal postponement application form available from the RO office to be discussed with the DMD for professional standards. The applicant will be informed in writing of the decision within seven working days. As noted in section 6, appraisals may be deferred at the specific request of the RO where a doctor or dentist is already under investigation for concerns that have been raised.
18. Non-compliance with the appraisal process
The DMD for professional standards will be asked by the RO to carry out an investigation as to the reasons why the individual doctor or dentist has not completed an appraisal. A report on the investigation will be submitted to the RO and appropriate action will be taken.
Doctors and dentists who have not completed an annual appraisal will not be eligible for routine pay progression or Clinical Excellence Awards unless deferment on exceptional grounds has been agreed with LCH.
Doctors and dentists who have not completed an annual appraisal will be included in the exception report (to include reasons, for all missed or incomplete appraisals and all missing PDPs) provided to the LCH Board by the RO and to NHS England within the annual organisation audit (AOA).
19. Locum doctors and dentists
Where locum doctors and dentists are employed by LCH, the medical lead should ensure there is a system in place for recording the locum’s contribution and performance and feeding timely information to the locum’s own RO or agency at the end of the assignment. LCH will not routinely appraise locum doctors or dentists if they are contracted by LCH at the time their appraisal is due, this should be undertaken by their employer. Appraisal should reflect the whole practice of a locum, and temporary staffing agencies need to be engaged with the process both in receiving information from locum employers and supplying information where the agency is not a prescribed connection. For doctors or dentists employed as locums directly by LCH there should be a discussion with the RO team about the appropriate action.
20. New in post doctors
Doctors who are employed by LCH who are new in post should be appraised within six months of starting with the Trust. The RO team will request a transfer of information from the individuals previous employer. Information on new starters will be managed by the RO team from data shared by the LCH Workforce team.
21. Private practice and whole of practice appraisal
Where a doctor or dentist carries out any other work evidence must be provided by the individual for their appraisal to ensure a ‘whole practice appraisal’. This evidence should include information on the nature of individual’s clinical practice which may be different to that in LCH together with their involvement in complaints, incidents or any human resources process, as well as positive aspects of practice.
Consideration should be given to how colleague and patient feedback should be collected to reflect all of a doctors practice.
Absence of supporting information from other practice settings will risk the satisfactory completion of annual appraisal. It is good practice that this evidence is referenced in the output form so that all parties are aware that the appraisal
covered that scope of practice.
Where the responsible officer is not in LCH it is expected that individuals working in LCH are able to demonstrate a satisfactory annual appraisal and revalidation.
22. Policy approval and ratification process
This policy will be ratified by the nominations and remuneration committee on behalf of the LCH Board.
23. Dissemination and implementation
Dissemination of this policy will be via the LCH website medical and dental leadership intranet page.
24. Review arrangements
This policy will be reviewed in three years by the author or sooner if there is a local or national requirement.
25. Associated policies
- Disciplinary policy and procedure
- Grievance policy and procedure
- Freedom to speak up policy
- Maintaining high professional standards in the modern NHS
- Managing concerns with performance policy
- Managing personal relationships in the workplace
- Personal and professional development policy
- Professional registration policy
- Managing attendance policy
- Information governance policy
26. References
- Trust assurance and safety: The regulation of health professionals 2007
- GMC, Good medical practice: Duties of a doctor, 2013
- British Dental Association appraisal guidance
- NHS Employers: Appraisal tools and tips
- Quality Assurance of Medical Appraisers, version 5 (Jan 2014)
- Supporting doctors to provide safer healthcare: Responding to concerns about a doctor’s practice, version 2 (Mar 2013)
- Training specification for medical appraisers in England, version 2 (Apr 2012)
- The Good Medical Practice Framework for appraisal and revalidation
- Supporting information for appraisal and revalidation (Feb 2019)
- NHS England medical appraiser policy version 2, April 2015
- Clinical academic appraisal following the Follett Principles (2001)
- The reflective practitioner: Guidance for doctors and medical students (2018)
