Published: 21/11/2002, Volume II2, No.5832 Page 28 29
Annual consultant appraisal has a key role in good patient care, but it is difficult to initiate.
Anna Ledgard and colleagues report
Effective consultant appraisal is an essential part of good patient care and the clinical governance agenda. But how is it working on the ground?
The British Association of Medical Managers has defined appraisal as an individual process that supports quality assurance of the individual, reviews performance, acknowledges achievement and identifies skill gaps.
1But many in the NHS see it as a thinly disguised means of controlling and restricting practitioners' professional freedom.
Nonetheless, there is growing evidence of a link between effective appraisal systems and patient outcomes. Research conducted at Aston business school found strong associations between human resource practices and patient mortality generally.
2The Centre for Health Leadership Wales has been tracking the progress of hospital consultant appraisal in Wales for the past year. The research looked at how individual organisations set about implementing appraisal during the first year and participants' perceptions of the process. The study included all 15 acute trusts in the country.
The centre held a conference in Swansea in February which was attended by 48 managers and doctors. They were asked to complete a questionnaire which covered the appraisal process, training received, potential obstacles to the introduction of appraisals and the impact of appraisal on consultants, colleagues and patient care.
Forty-four of the conference participants completed the questionnaire.We also held three focus groups with the aim of collecting qualitative data. Twenty seven people participated in these including medical and clinical directors, chief executives, consultants and human resources managers.
Many felt there was a gap between the theory of appraisal and the way it was working out in the NHS.
In essence, respondents described an appraisal process that was a blend of the key facets of appraisal and assessment.
A lack of clarity about the working definition of appraisal needs to be resolved at a national level.
Failure to do so is likely to result in disillusionment.
Just as worryingly, it could mean that people only pay lip service to appraisal, leading to a dilution of its potential impact on patient services, the individual and organisational performance.
The process for conducting appraisal differed between organisations depending on their size and structural arrangements. And, inevitably, trusts were at different starting points.Most organisations had a hierarchical approach to appraisal and used General Medical Council documentation. But this was not considered flexible enough to be used by all specialties. It was also considered long and repetitive. Concerns were also raised about the appraisal process for clinicians who held joint NHS/university posts and those who undertook private, as well as NHS, work.
Participants were unsure about whose responsibility it was to appraise these consultants and whether the outcomes should be shared. The Department of Health has issued an appraisal scheme for consultants employed jointly by the NHS and universities. This will not address all joint appointments - for example, public and private sector contracts, and GPs employed as associates or locums.
All trusts in our study provided training for appraisers and appraisees, and this was mainly delivered by external consultants using role play undertaken by professional actors. Appraisers generally received more comprehensive training, lasting up to 1.5 days, compared to appraisees, who received a maximum half-day training session.
Participants felt that establishing a cycle of ongoing appraisal training was important to establish a common understanding of the aims of the process.
The role of the appraiser is critical. Creating the right culture is not just about the climate established at an executive leadership level in the organisation.While this is clearly important, the outcome of the appraisal interviews will be influenced by the way it is conducted in practice. In a hierarchical organisation, the appraiser holds a leadership position, but we know that leaders have different personal styles.
A key issue for all appraisers will be the development of highly effective interpersonal skills and the ability to modify their style in response to the needs of their appraisee. A study by the former Pinderfields and Pontefract Hospitals trust, which identified the aptitudes required by clinicians if they were to be effective in the non-clinical aspects of their role, is particularly relevant here.
3Appraisees need to have a clear understanding about the process and be prepared to gather evidence to demonstrate their achievements or personal development needs in advance of the appraisal.Our study showed that the quality and accuracy of information supporting the appraisal process was a key issue. Information was often considered to be inadequate or simply non-existent.
There was also a lack of clarity about the standards against which performance was to be measured.
Our study also found concerns about what was done with issues raised during the appraisal. These will be wide-ranging and may highlight corporate or organisational issues that are constraining clinical practice or service delivery.
The view that appraisal will allow obstacles to service delivery to be aired increases the expectation that these concerns will be acted on - yet at present there is no feedback loop in place to ensure that attention is given at an executive leadership level to such issues.
One respondent in our study said: 'I am very supportive and enthusiastic about the process, but we will need to address their concerns otherwise we will lose credibility.'
This research also raised concerns about whether training funds would be available to support any personal development plan.
There was also vigorous debate about the need to reconcile the development needs of the individual with those of the organisation.
Those with corporate managerial roles saw the appraisal process as a way of aligning personal development plans with corporate objectives.A number of clinicians, on the other hand, felt that constraining the personal development plan in this way could be demotivating and lead to dissatisfaction.But it needs to be pointed out that ignoring the link between individual and organisational objectives and doing nothing to address individual concerns is likely to have the same result.
Preparation was identified as a key facet of an effective appraisal system.One trust had established a dedicated administrator to support appraisers by preparing paperwork and meeting schedules.Others had established a mechanism for providing the documentation electronically which reduced unnecessary paperwork and photocopying.But most trusts expected that the process would be absorbed into existing workload, and this inevitably had an impact on patient services.
One trust developed a 360-degree patient feedback questionnaire, which it offered consultants as part of the appraisal process.The questionnaire was used in a random selection of the consultants' clinics to elicit patient feedback about their clinical experience.Though the process was time-consuming to administer, participants found the feedback very helpful.
Many respondents felt appraisal represented just one more time pressure.One said: 'The process will have benefits through quality assessment and identifying and reducing poor performance, but the time constraints will impact on waiting times and waiting lists.'
Unless this issue is addressed, appraisal will continue to be viewed by some as an add-on, and not a prerequisite of the role.
But our study has shown that if appraisal is to be effective, it has to be supported by sufficient resources.These include protected time both for preparation and the actual appraisal meeting, administration support, and financial support for implementation of agreed personal development plan activities.
1British Association of Medical Managers. Appraisal in Action, 1999.
2West MA.HR in the NHS.
Department of Health, 2002.
3Goodson-Moore J, Judkins K, Johnson R, Thorn J, Short J.With due respect.
Health Service J. 2000 Jun 29;110(5711):30-1.
A study of consultant appraisal in Welsh trusts revealed concerns about lack of protected time and uncertainty about how issues raised should be handled.
The research showed it is important to ensure that issues raised are addressed by the organisation.
Resources must be made available to trusts to offer protected time for the process, and adequate training.
Anna Ledgard is division head, Centre for Health Leadership Wales.
Beverley Thomas is service development head, Bridgend local health group. Siobhan McClelland is research head, Centre for Health Leadership Wales. Iain Robb is senior lecturer, Wales University college of medicine.