Making it Unthinkable to Suspend Appraisals in a Healthcare Crisis
AUTHOR and Collaborators: DR SUSI CAESAR, Jools Mumford, Emma Pierce
THE CATALYST!!
“I've just read the email saying my appraisal is now cancelled for this year, which I find deeply disappointing as I was looking forward to having an opportunity to discuss how the year has been and all I've learnt.
Being able to discuss both professional and personal issues, particularly after all the last 12 months have thrown at me, in a protected caring environment is something I need to do so I wondered if there's any way that it can still go ahead.
The time is still blocked out in my work diary, or I could rearrange for another time. If you're too busy now to do this, I could ask the Appraisal Service for someone else to do it…”
GP to Appraiser, Wessex, April 2020
Background
Sir Keith Pearson (2017) highlighted the importance of appraisal reaching every doctor:
“Annual whole practice appraisal is at the core of revalidation and is the main mechanism by which revalidation will deliver benefits for patients and doctors … one of the most significant impacts of revalidation has been to embed whole practice appraisal as an annual requirement for all doctors.”
He showed how many doctors did not receive annual appraisals before the introduction of revalidation, and the approach was often “irregular and unstructured”. He found that appraisal is “valuable in itself … structured annual appraisal prevents a doctor’s skills becoming so out of date … without being given the opportunity to put things right”.
He also found that there was work to be done, particularly around the quality and consistency of appraisals. “… appraisal can provide evidence for a revalidation recommendation and support a doctor’s learning and development [but] success requires both a skilled appraiser and a well-prepared appraisee. Placing a regulatory framework on top of an appraisal process that was previously wholly developmental … has clearly presented challenges.”²
Testimonies
- “It felt good to have some space to reflect. If it wasn’t compulsory, I’m not sure I would make the time for it as there is so much going on, so I’m glad it remains compulsory.” (GP A, Wessex June 2021)
- “Superb appraisal. Has enabled me to reflect on my work and empowered me to have discussions with my surgery which will allow me to stay working as a GP.” (GP B, Wessex June 2021)
- “Appraisal 2020 was a challenging one for me as I had a break from practice due to the pandemic. I am returning to work now and the appraisal helped me to plan my return and what aspects of work to concentrate on.” (GP C, Wessex June 2021)
- “Many GPs with approved missed appraisals have said how much they missed their appraisal this year. Supported thinking time with a peer is hugely valued: there has been no other time when peer support has been needed more.” (Dr Honor Merriman, GP Appraisal Lead)
Discussion
In response to the Pearson Report, medical appraisal was incrementally updated with a focus on reducing the burden of appraisals for doctors. The aim was always to prevent it becoming simply a ‘tick-box’ exercise and make it a worthwhile and wanted part of a doctor’s annual work. Our catalyst comment shows that this was successful for some, indeed the majority in the RCGP survey 2019⁴, although a small proportion continued to complain about the burdens of regulation.
At the start of the COVID-19 pandemic, appraisals were suspended “to allow doctors, appraisers and the associated administrative teams to focus on clinical work and be deployed in the best possible way to support the COVID-19 emergency situation.” This suspension of appraisals led to a step-change opportunity to rebalance the appraisal process in the Medical Appraisal Guide 2020. This simplified streamlined appraisal process meets all GMC requirements while focusing on doctors’ wellbeing, reducing the burden of documentation and increasing support.
Prior to launch, McCartney and Tzortziou Brown questioned whether a focus on doctors’ wellbeing in appraisal was warranted, doubting whether it could “meaningfully respond to the reported increasing levels of stress and burnout … while fulfilling its regulatory role towards revalidation”.
Considering the new guidance, Caesar et al. responded and explained why a focus on wellbeing is always warranted and that “the core purpose of appraisal is not to revalidate. Appraisal cannot be ‘failed’. Its published purposes are clearly supportive and developmental … Appraisal, as a process reaching all doctors, is a proactive way to offer a safe place to discuss any concerns and be signposted to resources as needed.”
What Does Evaluation Tell Us?
How useful are appraisals in terms of considering your personal and professional development?
- Previous Appraisal Process – good - 84% - Very or Quite useful
- 2020 Appraisal Process - great - 91% - Very or Quite useful
The vast majority of doctors found their appraisal to be useful, even before the introduction of appraisal 2020, and this proportion is only increasing as appraisal processes improve, however, the big change is the proportion finding their appraisal very useful, increasing from just over a quarter to half of all GPs responding.
CONCLUSION
Testimony and evaluation show that appraisal can be valuable tool to help support and stimulate doctors throughout their careers. Doctors may tend to put their own needs last, so linking appraisal to revalidation and ensuring that it reaches everyone can help tackle inequalities of access to support.
In future, it should be unthinkable to suspend appraisal in a crisis because of the recognition that appraisal is an essential part of the support structure for doctors. We can support the personal and professional development of doctors with a quality improvement tool that is robust enough to facilitate better patient care.
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