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Q J Med 2001; 94: 235-236
© 2001 Association of Physicians
Editorial |
Consultant appraisal
Oxford Kidney Unit, The Churchill, The Oxford Radcliffe Hospitals NHS Trust, Oxford
Consultant appraisal will be an annual contractual requirement from April 2001. Not only will it be part of the GMC revalidation process, but refusal to participate will be a disciplinary matter that renders the individual ineligible for Discretionary Points or a Distinction Award. There will be no exceptions, so all consultants had better know about it.
Why, after more than 50 years of the NHS, has this requirement now emerged? First, there is now no longer automatic acceptance that all consultants are satisfactory. As the Lord Chief Justice, Lord Woolf said, ‘the automatic assumption of beneficence has been dented’.1 Most consultants are competent and beneficent most of the time, but this is no longer sufficient assurance. Second, self-regulation of the medical profession, through the GMC, is perceived to have failed. We have not helped ourselves by turning a blind eye to failing colleagues, and have occasionally been found out by our own hubris. Third, public confidence has been damaged by high-profile cases of incompetence, glibly and indignantly reported by the media, feeding the new ‘blame culture’. The ‘why appraisal?’ question is now of historical interest only.
These are negative reasons, but appraisal may actually improve the working lives of consultants and the running of the NHS. Appraisal is an accepted process in other spheres (including university clinical departments), and may prevent problems getting out of control and reduce the likelihood of employment disputes. In its purest form, appraisal is a confidential dialogue between an employee and an employer or representative, to review the work of the employee, provide an opportunity for feedback to the employee, chart their progress in the organization and to plan the resolution of any problems identified by either party.
The NHS has its own motives for introducing consultant appraisal.2 These include: reassurance that performance is within the agreed range of a standard, that skills and time are being properly used, and that the consultant is contributing to local priorities; identification of needs for resources and scope for development; promotion of participation in the wider NHS; and underpinning of the assessments required for revalidation by the GMC. The process is therefore going to be a hybrid of appraisal and assessment. Perhaps we should call it appraisement.
Parts of the process and some of the rules have been agreed. The Chief Executives of Trusts will be accountable for ensuring that all consultants are appraised. Appraisers must be trained in the process and be registered medical practitioners. The appraiser will usually be the lead clinician or Clinical Director, but can be a peer from a neighbouring organization. After identifying the content and allowing time to prepare, the interview will be conducted in private, the key issues and plans of action being documented and signed as having been agreed by both appraiser and appraisee. The appraisal document will be lodged with the Chief Executive and the Medical Director. It will not therefore be confidential.
The content will vary but will usually cover: (i) clinical performance (doing the job properly); (ii) teaching and research; (iii) personal and organizational effectiveness (getting on with patients and colleagues); (iv) other matters—health and personal issues. Clinical performance will include clinical activity: volume, outcomes and complications, concerns raised by complaints and adverse events. Evidence of participation in CME must be provided. The research item will include a description of projects and publications, and the time allocated to this element. The quantity and quality of teaching will be discussed, especially that which is a contractual obligation. Personal effectiveness will cover the consultant's performance in the organization: team working, interpersonal relationships and adherence to policies and protocols. ‘Other matters’ will be largely about personal issues such as ambitions, health, and retirement (and no doubt distinction awards and car parking).
An important question is who should appraise academic clinicians. They serve two masters: their universities for teaching and research, and their Trusts for their clinical work as honorary consultants. Although cumbersome, it would be best for the two institutions to appraise separately.
For most consultants, the process should be straightforward, constructive and non-threatening. Unfortunately, many of the important issues that will arise will be structural and difficult to change, e.g. workload and the stress induced by competing pressures. However, these will at least be in the open, and strategies for avoiding or minimizing problems can be agreed. The process should be more of a stock-take or health check than a diagnostic consultation. It is doubtful whether appraisal will help solve the problems of dysfunctional consultants, who almost invariably combine lack of insight with uncritical self-belief. Appraisal was not designed to rescue organizations from such individuals.
Aware that appraisal would soon be required, our unit decided to pilot an appraisal process. I am both a consultant who works in the unit, and its Clinical Director. We were reassured by a senior manager in a plc and a partner of an international firm of accountants, who viewed appraisal as normal practice. All six consultants, three NHS and three University, agreed to make their own assessments of the main domains of their work (supervision of ward patients, care of long-term dialysis patients, research, teaching and management), and for the Unit Manager to ask key staff about performance in those domains. He had experience of appraisal from his nursing background, was known to be discreet, and enjoyed the respect of all the consultants. They chose to present their own assessments as well, and to hear a summary of the feedback from the Unit Manager, but agreed that the Clinical Director could be present and comment. The Clinical Director underwent the same process. Consultant colleagues were invited to sit in.
Both the consultants and their work colleagues identified the same problem areas, but the consultants appeared surprised and almost embarrassed by the warmth of appreciation of those things that they did well. Praise seems to be a rare commodity in the NHS. No issues of which the Clinical Director and Unit Manager were unaware emerged. The conclusion was that it had been a worthwhile exercise, not least because it provided reassurance that the unit was probably functioning satisfactorily. Some previously vague issues had been identified as explicit problems for which solutions could at least be sought. The weaknesses were that the opinions of patients, consultant colleagues in other units, referring General Practitioners, and fellow consultants in the unit, had not been sought. Because there had been no difficult issues, the robustness of the process had not been tested.
Next time it will have to be by the book.
References
1. The Lord Woolf, Provost's Lecture Series, University College, 2000.
2. Central Consultants and Specialists Committee 2000. Consultant appraisal scheme.
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