Appraisal for general practitioners – what have we learned?

In this article published in Clinical Governance Review 2003, John Hasler summarises the learning to date from the introduction of appraisal for GPs.

• There is confusion over the main purpose of NHS appraisal and its connection with revalidation
• Appraisal should cover the way doctors behave as well as how they carry out the technical aspects of their work
• The climate in which the appraisal takes place is important
• General practitioners should already have the skills necessary to conduct an effective appraisal since these are similar to the ones they use in their clinical consultations
• Primary care trusts should consider what kind of resources they may need to put in place to deal with the outcomes of appraisals

Background

By now, GPs should have had their first appraisal. In practice, some may not have done, since the setting up and training has taken a while to complete. Moreover, some primary care trusts (PCTs) are still short of an adequate number of appraisers and setting up the system across England has been a major exercise set against the background of other major changes. Initial evidence from one PCT suggests that appraisal has been generally helpful for the first batch of GPs.

Definitions

Many GPs believe that the main aim of appraisal is some kind of performance management check of their delivery on targets and other requirements by the PCT. This is due to confusion over the different uses of appraisal in various organisations and the type of feedback doctors have often had in the past (which has not always been helpful). In spite of the fact that appraisal has been introduced against the backdrop of publicity surrounding failing doctors, its stated aim in the NHS is principally developmental and it is important to be clear that too much time spent on performance management will drive out the developmental aspect. Appraisers and the doctors being appraised need to understand this before the process begins.

There is concern on the part of many GPs that the passing of paperwork to the General Medical Council (GMC) for the purpose of revalidation compromises confidentiality. It is important to be clear that what the GMC seems to be interested in is the process of reflection on professional practice and not some kind of total quality check. More information on this is given on the website www.revalidationuk.info.

The importance of behaviour

If you ask a group of GPs to list the attributes of an excellent doctor, they will produce a long list, much of which is about the way a doctor behaves. This is supported by evidence that many of these attributes, such as consultation skills and teamwork, affect patient care.^1,2 The official list of criteria for NHS appraisal does not convey this richness and there is a danger that clinical care is simply appraised by means of audits and critical incidents. Many of the difficulties faced by GPs (and other doctors) relate to decision making, relationships and communication with others (whether patients or colleagues), drive and motivation, flexibility and resilience. It is crucial that these matters are included in an appraisal. Indeed, they are often matters that doctors wish to discuss.

The importance of climate

One of the most important factors determining the outcome of an appraisal is the relationship between appraiser and appraised. Mutual trust and respect are essential ingredients. There is evidence that the climate at work affects the performance of the workforce.³ Equally, climate affects the appraisal process, and perhaps the most important ingredients are the combination of support and challenge. PCTs therefore have to establish systems of pairing up appraisers with those being appraised that take account of this.

Skills

West has emphasised that those who conduct appraisals and identify training needs must be sufficiently skilled.⁴ Many GPs are concerned that they may not have the ability to conduct and appraisal but in fact these skills are similar to those used during a consultation. They include indepth listening and reflection, asking a combination of different kinds of questions, making sense of the answers, and giving feedback in an appropriate way. It needs a measure of sensitivity and an understanding of what facilitates a sensitive discussion. We have seen some excellent appraisals conducted by GPs during practice training sessions. What has sometimes been more difficult is turning development needs into action plans.

Resources

A number of development needs should be identified at the end of an appraisal and it is important that the PCT responds appropriately where necessary. Some of these needs will be to do with further training. This may be a clinical or interpersonal area, such as assertiveness, introducing change or communication skills. Indeed, very often the real development need for those with ideas for improvement of the practice is how to persuade others to adopt their ideas. It is also important that the combined, anonymous development plans are made available for the PCT board and those responsible for future development. There is a feeling sometimes that PCTs have simply left GPs to get on with it.

Conclusions

In spite of a high degree of suspicion on the part pf GPs, appraisal seems to be taking shape. In one PCT in Devon, preliminary findings have shown that the two most appreciated results have been the opportunity for reflection and reassurance that they are doing a good job. A number of GPs said they had found it more constructive and useful that they thought it would be. In contrast, most complained of the bureaucracy and paperwork and time involved. What is essential now is that the PCTs monitor their appraisal systems so as to ensure they continue to develop.

References

1. Grol R, Mokkink H, Helsper-Lucas A, et al. Effects of the vocational training of general practice consultation skills and medical performance. Medical Education 1989; 25: 512-21
2. Borril C, West MA, Shapiro D, Rees A. Team working and effectiveness in health care. British Journal of Health Care 2000; 6: 364-71
3. Brown SP, Leigh TW. A new look at psychological climate and its relationship to job involvement, effort and performance. Journal of Applied Psychology 1996; 81: 258-68
4. West M. How can good performance among doctors be maintained? British Medical Journal 2002; 325: 669-70