Dental practice workforce challenges in rural England: survey into recruitment and retention in Devon and Cornwall.

Introduction Devon and Cornwall have been identified as 'dental deserts' with limited NHS dental access and high levels of oral health inequality. Challenges around recruitment and retention of the dental workforce have been acknowledged as an important contributory factor.Aims The aim of this research was to explore the experiences of dental practices within Devon and Cornwall in relation to recruitment and retention of the dental workforce.Method A self-administered, online questionnaire was used to explore various aspects of workforce recruitment and retention. The questionnaire included categorical rating scale and free-text question formats providing quantitative and qualitative data.Results In total, 106 dental practices responded to the survey, providing a response rate of 36%. The vast majority of respondents (94%) considered recruitment and retention to be a major barrier to delivering NHS services. Additionally, 77% of practices had a current staff vacancy, 57% had a dentist vacancy and 48% had a vacancy for dental nurses. Thematic analysis led to identification of four main themes which were considered to influence recruitment and retention: NHS system; economic challenges; logistics; and support networks.Conclusion A large number of dental practices in Devon and Cornwall are failing to operate at capacity due to workforce shortages, which is affecting access to services in both NHS and private practices. Recruitment and retention of dentists and dental nurses appears to be the most challenging factor, with NHS practices affected more than the private sector.

The dental workforce recruitment and retention crisis in the UK.

The precarious state of NHS dentistry is widely acknowledged, yet there is limited progress in addressing the underlying issues. Further delays will undoubtedly impact patient care, leading to oral health deterioration and unnecessary suffering. This will predominantly affect the most vulnerable in society, resulting in greater oral health inequalities.The underlying issues contributing to the current NHS dental crisis are many, and they include: prolonged delays in contract reform; long-term underinvestment; private sector growth; and fewer dentists working full-time and/or in the NHS. In England, an NHS dental contract that fails to promote prevention or equality of access continues to have a deep and pernicious impact on the future of NHS dentistry. The devastating impact of the COVID-19 pandemic on access cannot be underestimated and neither should the effect of Brexit on the availability of workforce.The recruitment and retention of dentists, and other members of the dental team, is undoubtedly a major issue in terms of capacity and access to NHS dental care. These problems, seen across the UK, are a particular issue in England, with acute challenges within rural and coastal areas.There is an urgent necessity to develop coherent, multifaceted strategies, aided by the collection of clear and accurate workforce data, to tackle these issues.

Recruitment and retention in dentistry in the UK: a scoping review to explore the challenges across the UK, with a particular interest in rural and coastal areas.

Introduction There is currently reduced access to NHS dental services in the UK, particularly in England, with rural and coastal areas significantly affected. Recruitment and retention in dentistry has been highlighted as an issue contributing to the problem.Objectives To explore what is known or unknown about recruitment and retention of the dental workforce in the UK, with a particular focus on rural and coastal areas. We were keen to gain information relating to factors affecting recruitment and retention, geographical distribution of the workforce, anticipated challenges, strategies or proposals to assist workforce planning and the extent of empirical research.Methods Searches for peer-reviewed literature and reports were undertaken and included when they met the eligibility criteria. Data were extracted and the findings narratively synthesised.Discussion The findings suggested wide ranging recruitment and retention issues of the dental workforce in the UK. Most issues were associated with NHS dentists, followed by dental nurses across both the NHS and private sectors. The worst affected parts of the country were rural and coastal areas.Conclusion It appears from the evidence that there are many dental professionals discussing recruitment and retention issues, followed by stakeholders. However, there is limited research and data to initiate change.

Progress and challenges in the harmonisation of European undergraduate dental education: A systematic literature review with narrative synthesis.

INTRODUCTION: Harmonising education to support workforce mobility has been a policy objective for the European Union. However, alignment across varied national contexts presents challenges in dental education. METHODS: A systematic literature review with narrative synthesis. Searches of the electronic databases Embase [Ovid]; MEDLINE [Ovid]; Scopus; CINAHL; AMED and PsycINFO were conducted for relevant material published between 2000 and 2019 on undergraduate curricula, quality standards and learning outcomes in dentistry. RESULTS: Seventy-six papers met the inclusion criteria. Fifty-three papers were commentaries or editorials, twenty-one were research studies, and two were literature reviews on specific dental subfields. Eighteen of the research studies reported surveys. The literature contains extensive proposals for undergraduate curricula or learning outcomes, either broadly or for subfields of dentistry. Included papers demonstrated the importance of EU policy and educator-led initiatives as drivers for harmonisation. There is limited evidence on the extent to which proposed pan-European curricula or learning outcomes have been implemented. The nature and extent of dental students' clinical experience with patients is an area of variance across European Union member states. Arrangements for the quality assurance of dental education differ between countries. DISCUSSION: Harmonisation of European dental education has engaged educators, as seen in the publication of proposed curricula and learning outcomes. However, differences remain in key areas such as clinical experience with patients, which has serious implications if graduate dentists migrate to countries where different expectations exist. Mutual recognition of professional qualifications between countries relies on education which meets certain standards, but institutional autonomy makes drawing national comparisons problematic.

Mental health and wellbeing interventions in the dental sector: a systematic review.

Introduction UK dentists experience high levels of stress, anxiety and burnout. Poor mental health can lead practitioners to exit the profession, contributing to workforce and service loss. Therefore, there is a need to focus on interventions to protect the mental health and wellbeing of dental teams. Three levels of intervention can be deployed in the workplace to support mental health and wellbeing: primary prevention, secondary prevention, and tertiary prevention.Aim The aim of this systematic review was to identify evidence on interventions used to prevent, improve or tackle mental health issues among dental team members and dental profession students in countries of very high development.Methods This systematic review was conducted according to a predefined protocol and reported according to PRISMA guidelines. The MEDLINE, Embase CINAHL, DOSS, Scopus, and PsycINFO databases were searched. Prospective empirical studies were considered for inclusion. The Effective Public Health Practice Project Quality Assessment Tool (EPHPP) was used to assess the methodological quality of the included studies. The identified interventions were categorised according to level of prevention.Results The search yielded 12,919 results. Eight studies met the inclusion criteria. All of the studies concerned dentists or dental students. There were no studies for other groups of dental professionals. No primary prevention-level studies were identified. Secondary prevention-level studies (n = 4) included various psychoeducational interventions aiming to raise awareness and improve coping skills and led to significant improvements in stress levels and burnout of dentists and dental students. Tertiary prevention-level studies (n = 4) mainly employed counselling which was shown to be beneficial for dentists and students experiencing psychological ill-health.Conclusions Mental wellbeing awareness should be put at the centre of dental education and the workplace. Leadership and innovation are required to design primary-level interventions which can be implemented in the UK dental sector, with its distinct organisational and service characteristics.

Optimising the delivery of remediation programmes for doctors: A realist review.

CONTEXT: Medical underperformance puts patient safety at risk. Remediation, the process that seeks to 'remedy' underperformance and return a doctor to safe practice, is therefore a crucially important area of medical education. However, although remediation is used in health care systems globally, there is limited evidence for the particular models or strategies employed. The purpose of this study was to conduct a realist review to ascertain why, how, in what contexts, for whom and to what extent remediation programmes for practising doctors work to restore patient safety. METHOD: We conducted a realist literature review consistent with RAMESES standards. We developed a programme theory of remediation by carrying out a systematic search of the literature and through regular engagement with a stakeholder group. We searched bibliographic databases (MEDLINE, EMBASE, PsycINFO, HMIC, CINAHL, ERIC, ASSIA and DARE) and conducted purposive supplementary searches. Relevant sections of text relating to the programme theory were extracted and synthesised using a realist logic of analysis to identify context-mechanism-outcome configurations (CMOcs). RESULTS: A 141 records were included. The majority of the studies were from North America (64%). 29 CMOcs were identified. Remediation programmes are effective when a doctor's insight and motivation are developed and behaviour change reinforced. Insight can be developed by providing safe spaces, using advocacy to promote trust and framing feedback sensitively. Motivation can be enhanced by involving the doctor in remediation planning, correcting causal attribution, goal setting and destigmatising remediation. Sustained change can be achieved by practising new behaviours and skills, and through guided reflection. CONCLUSION: Remediation can work when it creates environments that trigger behaviour change mechanisms. Our evidence synthesis provides detailed recommendations on tailoring implementation and design strategies to improve remediation interventions for doctors.

'You're just a locum': professional identity and temporary workers in the medical profession.

Internationally, there has been substantial growth in temporary working, including in the medical profession where temporary doctors are known as locums. There is little research into the implications of temporary work in health care. In this paper, we draw upon theories concerning the sociology of the medical profession to examine the implications of locum working for the medical profession, healthcare organisations and patient safety. We focus particularly on the role of organisations in professional governance and the positioning of locums as peripheral to or outside the organisation, and the influence of intergroup relationships (in this case between permanent and locum doctors) on professional identity. Qualitative semi-structured interviews were conducted between 2015 and 2017 in England with 79 participants including locum doctors, locum agency staff, and representatives of healthcare organisations who use locums. An abductive approach to analysis combined inductive coding with deductive, theory-driven interpretation. Our findings suggest that locums were perceived to be inferior to permanently employed doctors in terms of quality, competency and safety and were often stigmatised, marginalised and excluded. The treatment of locums may have negative implications for collegiality, professional identity, group relations, team functioning and the way organisations deploy and treat locums may have important consequences for patient safety.

Challenges to well-being for general practice trainee doctors: a qualitative study of their experiences and coping strategies.

PURPOSES OF THE STUDY: To identify the challenges to well-being experienced by general practice postgraduate trainees and to explore how the trainees respond to those challenges. STUDY DESIGN: Qualitative focus group study with doctors in their final year of general practice training (n=16). The participants in the study were recruited from one training scheme in South West England. Data were thematically analysed. RESULTS: Participants reported challenges to well-being relating to dysfunctional relationships with colleagues and patients, their workload, a perceived lack of support at work and also physical environmental challenges. They identified response strategies focused on cognitive processing, physical self-care, focusing on their professional purpose, building supportive relationships and adapting their working environment where possible. Additionally, there were factors that could support trainee well-being, including personal factors such as adaptability and self-awareness, but also external and organisational factors, such as culture, supportive colleagues and organisational adaptability in relation to workload management. The importance to trainees of the idea of being a 'good doctor' arose repeatedly in the data, as did the importance of the organisational environment. Participants reported finding their training placements in secondary care environments particularly challenging. CONCLUSION: This research highlights the strategies that general practice trainees use in response to challenges, but also that the responsibility for maintaining well-being cannot be borne by individuals alone. This study identifies that supportive approaches by healthcare organisations and educators are vitally important to general practitioner trainees' well-being.

Reviving clinical governance? A qualitative study of the impact of professional regulatory reform on clinical governance in healthcare organisations in England.

BACKGROUND: Until recently, processes of professional regulation and organisational clinical governance in the UK have been largely separate. However, the introduction of medical revalidation in 2012 means that all doctors have to demonstrate periodically to the regulator that they are up to date and fit to practise, and as part of this process doctors must engage with clinical governance activities in the organisations in which they work. OBJECTIVE: To explore how the recent implementation of medical revalidation has affected the arrangements for clinical governance in healthcare organisations in England. DESIGN: Thematic analysis of interviews with 62 senior clinicians and non-clinicians in management or senior administrative roles, from a range of healthcare organisations in England. RESULTS: Revalidation has engendered changes to clinical governance systems, resulting in: increased doctor engagement with clinical governance activities; new or improved systems for access to clinical governance data for doctors and leaders within healthcare organisations; and more leverage - through the Responsible Officer role - to enforce engagement with clinical governance. Organisational context has been an important mediator of the impact of revalidation on clinical governance. CONCLUSION: Revalidation has increased alignment between systems for organisational and professional oversight and accountability, resulting in increased scrutiny of clinical practice. However, it is still a matter of conjecture whether this will in turn lead to improvements in medical performance.

Is Collecting Patient Feedback "a Futile Exercise" in the Context of Recertification?

OBJECTIVE: Patient feedback is considered integral to maintaining excellence, patient safety, and professional development. However, the collection of and reflection on patient feedback may pose unique challenges for psychiatrists. This research uniquely explores the value, relevance, and acceptability of patient feedback in the context of recertification. METHODS: The authors conducted statistical and inductive thematic analyses of psychiatrist responses (n = 1761) to a national census survey of all doctors (n = 26,171) licensed to practice in the UK. Activity theory was also used to develop a theoretical understanding of the issues identified. RESULTS: Psychiatrists rate patient feedback as more useful than some other specialties. However, despite asking a comparable number of patients, psychiatrists receive a significantly lower response rate than most other specialties. Inductive thematic analysis identified six key themes: (1) job role, setting, and environment; (2) reporting issues; (3) administrative barriers; (4) limitations of existing patient feedback tools; (5) attitudes towards patient feedback; and (6) suggested solutions. CONCLUSIONS: The value, relevance, and acceptability of patient feedback are undermined by systemic tensions between division of labor, community understanding, tool complexity, and restrictive rule application. This is not to suggest that patient feedback is "a futile exercise." Rather, existing feedback processes should be refined. In particular, the value and acceptability of patient feedback tools should be explored both from a patient and professional perspective. If issues identified remain unresolved, patient feedback is at risk of becoming a "futile exercise" that is denied the opportunity to enhance patient safety, quality of care, and professional development.

Identifying and managing concerns about GPs in England: an interview study and case-series analysis.

BACKGROUND: Underperforming doctors have been the focus of sustained interest from the media, policymakers, and researchers. GPs are more likely to be the subject of a complaint than any other type of doctor in the UK, and the management of concerns in primary care needs improvement, yet more is known about how concerns are managed in secondary care. AIM: Although formal policies for NHS England's management of concerns are clear, little is known about how these are put into practice. This study explores how concerns are identified, investigated, and managed at a regional level. DESIGN AND SETTING: A qualitative study of the management of concerns in primary care across eight area teams. METHOD: The study comprised two main strands: in-depth interviews with NHS England staff; and the analysis of case file data. RESULTS: The process for raising concerns was identified as inconsistent and disparate, with potential weaknesses to address. The concerns process was flexible. A trade-off between adaptability and consistency was evident, but the correct balance of the two is difficult to establish. Performance concerns were most common, followed by behaviour. Conduct was the next most frequently raised concern, and a small number of health cases were identified. Outcomes of cases appeared to be dependent on the doctor's engagement and response rather than necessarily the nature of a concern or the consequences of a doctor's actions. CONCLUSION: The way practices handle complaints and concerns remains unexamined, even though they are a key route for patient complaints.

Reflective Practice for Patient Benefit: An Analysis of Doctors' Appraisal Portfolios in Scotland.

INTRODUCTION: Reflective practice has become the cornerstone of continuing professional development for doctors, with the expectation that it helps to develop and sustain the workforce for patient benefit. Annual appraisal is mandatory for all practicing doctors in the United Kingdom as part of medical revalidation. Doctors submit a portfolio of supporting information forming the basis of their appraisal discussion where reflection on the information is mandated and evaluated by a colleague, acting as an appraiser. METHODS: Using an in-depth case study approach, 18 online portfolios in Scotland were examined with a template developed to record the types of supporting information submitted and how far these showed reflection and/or changes to practice. Data from semistructured interviews with the doctors (n = 17) and their appraisers (n = 9) were used to contextualize and broaden our understanding of the portfolios. RESULTS: Portfolios generally showed little written reflection, and most doctors were unenthusiastic about documenting reflective practice. Appraisals provided a forum for verbal reflection, which was often detailed in the appraisal summary. Portfolio examples showed that reflecting on continued professional development, audits, significant events, and colleague multisource feedback were sometimes considered to be useful. Reflecting on patient feedback was seen as less valuable because feedback tended to be uncritical. DISCUSSION: The written reflection element of educational portfolios needs to be carefully considered because it is clear that many doctors do not find it a helpful exercise. Instead, using the portfolio to record topics covered by a reflective discussion with a facilitator would not only prove more amenable to many doctors but would also allay fears of documentary evidence being used in litigation.

Reforming regulatory relationships: The impact of medical revalidation on doctors, employers, and the General Medical Council in the United Kingdom.

In 2012, medical regulation in the United Kingdom was fundamentally changed by the introduction of revalidation - a process by which all licensed doctors are required to regularly demonstrate that they are up to date and fit to practice in their chosen field and are able to provide a good level of care. This paper examines the implications of revalidation on the structure, governance, and performance management of the medical profession, as well as how it has changed the relationships between the regulator, employer organizations, and the profession. We conducted semi-structured interviews with clinical and non-clinical staff from a range of healthcare organizations. Our research suggests that organizations have become intermediaries in the relationship between the General Medical Council and doctors, enacting regulatory processes on its behalf and extending regulatory surveillance and oversight at local level. Doctors' autonomy has been reduced as they have become more accountable to and reliant on the organizations that employ them.

Patient and public involvement in medical performance processes: A systematic review.

BACKGROUND: Patient and public involvement (PPI) continues to develop as a central policy agenda in health care. The patient voice is seen as relevant, informative and can drive service improvement. However, critical exploration of PPI's role within monitoring and informing medical performance processes remains limited. OBJECTIVE: To explore and evaluate the contribution of PPI in medical performance processes to understand its extent, purpose and process. SEARCH STRATEGY: The electronic databases PubMed, PsycINFO and Google Scholar were systematically searched for studies published between 2004 and 2018. INCLUSION CRITERIA: Studies involving doctors and patients and all forms of patient input (eg, patient feedback) associated with medical performance were included. DATA EXTRACTION AND SYNTHESIS: Using an inductive approach to analysis and synthesis, a coding framework was developed which was structured around three key themes: issues that shape PPI in medical performance processes; mechanisms for PPI; and the potential impacts of PPI on medical performance processes. MAIN RESULTS: From 4772 studies, 48 articles (from 10 countries) met the inclusion criteria. Findings suggest that the extent of PPI in medical performance processes globally is highly variable and is primarily achieved through providing patient feedback or complaints. The emerging evidence suggests that PPI can encourage improvements in the quality of patient care, enable professional development and promote professionalism. DISCUSSION AND CONCLUSIONS: Developing more innovative methods of PPI beyond patient feedback and complaints may help revolutionize the practice of PPI into a collaborative partnership, facilitating the development of proactive relationships between the medical profession, patients and the public.

The impact of patient feedback on the medical performance of qualified doctors: a systematic review.

BACKGROUND: Patient feedback is considered integral to quality improvement and professional development. However, while popular across the educational continuum, evidence to support its efficacy in facilitating positive behaviour change in a postgraduate setting remains unclear. This review therefore aims to explore the evidence that supports, or refutes, the impact of patient feedback on the medical performance of qualified doctors. METHODS: Electronic databases PubMed, EMBASE, Medline and PsycINFO were systematically searched for studies assessing the impact of patient feedback on medical performance published in the English language between 2006-2016. Impact was defined as a measured change in behaviour using Barr's (2000) adaptation of Kirkpatrick's four level evaluation model. Papers were quality appraised, thematically analysed and synthesised using a narrative approach. RESULTS: From 1,269 initial studies, 20 articles were included (qualitative (n=8); observational (n=6); systematic review (n=3); mixed methodology (n=1); randomised control trial (n=1); and longitudinal (n=1) design). One article identified change at an organisational level (Kirkpatrick level 4); six reported a measured change in behaviour (Kirkpatrick level 3b); 12 identified self-reported change or intention to change (Kirkpatrick level 3a), and one identified knowledge or skill acquisition (Kirkpatrick level 2). No study identified a change at the highest level, an improvement in the health and wellbeing of patients. The main factors found to influence the impact of patient feedback were: specificity; perceived credibility; congruence with physician self-perceptions and performance expectations; presence of facilitation and reflection; and inclusion of narrative comments. The quality of feedback facilitation and local professional cultures also appeared integral to positive behaviour change. CONCLUSION: Patient feedback can have an impact on medical performance. However, actionable change is influenced by several contextual factors and cannot simply be guaranteed. Patient feedback is likely to be more influential if it is specific, collected through credible methods and contains narrative information. Data obtained should be fed back in a way that facilitates reflective discussion and encourages the formulation of actionable behaviour change. A supportive cultural understanding of patient feedback and its intended purpose is also essential for its effective use.

Policing the profession? Regulatory reform, restratification and the emergence of Responsible Officers as a new locus of power in UK medicine.

Doctors' work and the changing, contested meanings of medical professionalism have long been a focus for sociological research. Much recent attention has focused on those doctors working at the interface between healthcare management and medical practice, with such 'hybrid' doctor-managers providing valuable analytical material for exploring changes in how medical professionalism is understood. In the United Kingdom, significant structural changes to medical regulation, most notably the introduction of revalidation in 2012, have created a new hybrid group, Responsible Officers (ROs), responsible for making periodic recommendations about the on-going fitness to practise medicine of all other doctors in their organisation. Using qualitative data collected in a 2015 survey with 374 respondents, 63% of ROs in the UK, this paper analyses the RO role. Our findings show ROs to be a distinct emergent group of hybrid professionals and as such demonstrate restructuring within UK medicine. Occupying a position where multiple agendas converge, ROs' work expands professional regulation into the organisational sphere in new ways, as well as creating new lines of continuous accountability between the wider profession and the General Medical Council as medical regulator. Our exploration of ROs' approaches to their work offers new insights into the on-going development of medical professionalism, pointing to the emergence of a distinctly regulatory hybrid professionalism shaped by co-existing professional, managerial and regulatory logics, in an era of strengthened governance and complex policy change.

Towards an understanding of how appraisal of doctors produces its effects: a realist review.

CONTEXT: Revalidation was launched in the UK to provide assurances to the public that doctors are up to date and fit to practice. Appraisal is a fundamental component of revalidation. Approximately 150 000 doctors are appraised annually, costing an estimated £97 million over 10 years. There is little understanding of the theory of how and why appraisal is supposed to produce its effects. A realist review of the literature was utilised to explore these issues, as they generate context-mechanism-outcome (CMO) configurations, resulting in the creation of theories of how and why appraisal of doctors produces its effects. METHODS: A programme theory of appraisal was created by convening stakeholders in appraisal and searching a database of research on appraisal of doctors. Supplementary searches provided literature on theories identified in the programme theory. Relevant sections of texts relating to the programme theory were extracted from included articles, coded in NVivo and synthesised using realist logic of analysis. A classification tool categorised the included articles' contributions to programme theory. RESULTS: One hundred and twenty-five articles were included. Three mechanisms were identified: dissonance, denial and self-affirmation. The dissonance mechanism is most likely to cause outcomes of reflection and insight. Important contexts for the dissonance mechanism include the appraiser being highly skilled, the appraisee's working environment being supportive and the appraisee having the right attitude. The denial mechanism is more likely to be enacted if the opposite of these contexts occurs and could lead to game-playing behaviour. A skilled appraiser was also important in triggering the self-affirmation mechanism, resulting in reflection and insight. The contexts, mechanisms and outcomes identified were, however, limited by a lack of evidence that could enable further refining of the CMO configurations. CONCLUSION: This review makes a significant contribution to our understanding of appraisal by identifying different ways that appraisal of doctors produces its effects. Further research will focus on testing the CMO configurations.

Implementing medical revalidation in the United Kingdom: Findings about organisational changes and impacts from a survey of Responsible Officers.

Objective To describe the implementation of medical revalidation in healthcare organisations in the United Kingdom and to examine reported changes and impacts on the quality of care. Design A cross-sectional online survey gathering both quantitative and qualitative data about structures and processes for medical revalidation and wider quality management in the organisations which employ or contract with doctors (termed 'designated bodies') from the senior doctor in each organisation with statutory responsibility for medical revalidation (termed the 'Responsible Officer'). Setting United Kingdom Participants Responsible Officers in designated bodies in the United Kingdom. Five hundred and ninety-five survey invitations were sent and 374 completed surveys were returned (63%). Main outcome measures The role of Responsible Officers, the development of organisational mechanisms for quality assurance or improvement, decision-making on revalidation recommendations, impact of revalidation and mechanisms for quality assurance or improvement on clinical practice and suggested improvements to revalidation arrangements. Results Responsible Officers report that revalidation has had some impacts on the way medical performance is assured and improved, particularly strengthening appraisal and oversight of quality within organisations and having some impact on clinical practice. They suggest changes to make revalidation less 'one size fits all' and more responsive to individual, organisational and professional contexts. Conclusions Revalidation appears primarily to have improved systems for quality improvement and the management of poor performance to date. There is more to be done to ensure it produces wider benefits, particularly in relation to doctors who already perform well.

Understanding how appraisal of doctors produces its effects: a realist review protocol.

INTRODUCTION: UK doctors are now required to participate in revalidation to maintain their licence to practise. Appraisal is a fundamental component of revalidation. However, objective evidence of appraisal changing doctors' behaviour and directly resulting in improved patient care is limited. In particular, it is not clear how the process of appraisal is supposed to change doctors' behaviour and improve clinical performance. The aim of this research is to understand how and why appraisal of doctors is supposed to produce its effect. METHODS AND ANALYSIS: Realist review is a theory-driven interpretive approach to evidence synthesis. It applies realist logic of inquiry to produce an explanatory analysis of an intervention that is, what works, for whom, in what circumstances, in what respects. Using a realist review approach, an initial programme theory of appraisal will be developed by consulting with key stakeholders in doctors' appraisal in expert panels (ethical approval is not required), and by searching the literature to identify relevant existing theories. The search strategy will have a number of phases including a combination of: (1) electronic database searching, for example, EMBASE, MEDLINE, the Cochrane Library, ASSIA, (2) 'cited by' articles search, (3) citation searching, (4) contacting authors and (5) grey literature searching. The search for evidence will be iteratively extended and refocused as the review progresses. Studies will be included based on their ability to provide data that enable testing of the programme theory. Data extraction will be conducted, for example, by note taking and annotation at different review stages as is consistent with the realist approach. The evidence will be synthesised using realist logic to interrogate the final programme theory of the impact of appraisal on doctors' performance. The synthesis results will be written up according to RAMESES guidelines and disseminated through peer-reviewed publication and presentations. TRIAL REGISTRATION NUMBER: The protocol is registered with PROSPERO 2014:CRD42014007092.