Reducing the stress of appraisals for consultants

by Helen Fidler

The amount of time doctors spend assessing their work has become cause for concern.

Location: UK
Published: Thursday 4 February 2021
helen fidler

Consultants view their annual appraisal in widely disparate ways.

For some, it is a great opportunity to discuss their personal development and how their employer can help them deliver better care to their patients and make their working lives happier.

For others, it is a bureaucratic waste of time, focused more on ‘ticking boxes and jumping through hoops’ than with any relevance to real life. And a few see it as a perverse distraction from precious hours that could be spent with patients and a threatening and hazardous process that must be ‘passed’ to allow them to continue working.

For me, the main stress is working out how to collect all the forms and uploading them in the correct section while receiving ‘you are non-compliant’ emails regarding manual handling mandatory training. Our trust’s ‘tool’ – SARD – says it all in the initialism: ‘Strengthening the Appraisal and Revalidation Database’ (with a clear focus on the database).

There are seven steps, 11 sections and up to six subsections in each. This time consuming form filling has long been recognised as a problem – the Keith Pearson report, and Matt Hancock himself have both expressed considerable concern about the time spent on bureaucracy by doctors.

Enter COVID in March 2020, and the unimaginable increase in doctor hours required by our patients. The GMC quickly re-set revalidation dates a year ahead for those due to revalidate in 2020-2021, and appraisal was suspended briefly before restarting, at employer’s discretion, in October 2020.

The Academy of Medical Royal Colleges realised immediately that when appraisal re-started it had to be very different, and to be implemented considerately and effectively by reducing the pre-application documentation required. Secondly, with high rates of moral distress and burnout amongst consultants there had to be a new focus on mental health and wellbeing.

And, so ‘Appraisal 2020’ was born. This has only nine brief questions, two of which are about personal and professional wellbeing and goals.

The aim was to provide a professional de-brief for the misery of this year. The form is refreshingly simple and straightforward with minimal documentary evidence being required – and for me, no struggling to save and upload CPD certificates that are lost in a maelstrom of emails.

Verbal reflection carries the same weight as your previous written reflection and, so long as you engage with the process the GMC has confirmed that you remain on track for revalidation.

This appears to be going down a storm in primary care. I sit on the Academy of Medical Royal Colleges task and finish group looking at the outcomes from Appraisal 2020 and there is good preliminary data from GPs that it is working well (Kew, 2021).

Disappointingly, no data has yet been presented from secondary care but there are many reports that things are not working quite so well for consultants. First, each trust can choose what appraisal form it uses and neither NHSE nor the GMC can mandate responsible officers to use the new light touch system.

So some responsible officers are simply ignoring it on the assumption (likely to be incorrect) that everything will revert to the old style appraisal once COVID is ‘over’. Or even worse, asking consultants to fill out both systems which paradoxically makes things even more bureaucratic.

For some, the wellbeing focus is sabotaged by an appraiser who you would never choose to confide in or who tries to shoe horn performance review and job planning into the meeting despite guidance to the contrary.

Trusts, responsible officers and appraisers are very variable in whether they encourage their consultants to switch to the new system and some are actively discouraging them on the (entirely untrue) grounds that the lack of written supporting information will affect their revalidation.

Appraisal is owned by lots of different organisations, so appraisal processes are difficult to change. The GMC, NHSE and their Higher Level Responsible Officers can all set high level guidance and promote the Appraisal 2020 process, but Trust ROs have a pretty free hand in what they do with appraisal locally.

My own personal bugbear, mandatory training, is something that is not part of the GMC requirements at all. Trusts have historically had free reign to add employment requirements despite the fact that they frequently scupper the culture of appraisal so that reflection and wellbeing take secondary importance.

Additionally, an over-emphasis on governance makes an open discussion about wellbeing pretty unlikely. Yes, you can admit you have an alcohol problem but if you do so the governance side of the appraisal meeting will kick in.

Like Janus the two faced Roman God, the opposing duality of discussing wellbeing at the same time as proving you are indubitably safe to practice is unlikely to work. In my opinion,the wellbeing and governance discussions should clearly be had separately.

Preparation work ahead of these discussions around governance must be minimised for doctors. Data should be collected by Trusts themselves, giving doctors more time to actually engage meaningfully in reflective practice.

So what are the take home messages for appraisal this year? The BMA is working closely with GMC, NHSE and AoMRC to ensure the glitches in Appraisal 2020 are ironed out and implementation happens (with feedback to inform what comes next) in all sectors, including secondary care.

Here are four main things to bear in mind when thinking about your own appraisal:

  • Encourage your organisation to introduce the Appraisal 2020 process (further information and templates are available from the AoMRC website). It’s much quicker to prepare, and you can then spend time thinking reflectively with a focus on your own wellbeing. It is hoped that Appraisal 2020 will be the basis for appraisal in the future so don’t be afraid to use it
  • Engage with your annual appraisal and make it work for you. Remember that it is not a pass/fail process, or a screening tool. It is a quality improvement tool that should provide support and facilitate your development. You don’t need certificates, although focused written reflection on any significant events or complaints should be included
  • Ask for an appraiser who you can have a meaningful wellbeing discussion with and remember the emphasis is on your mental health and personal and professional goals, so focus the discussion on what is important to you
  • Look out for surveys from us and use them to share how Appraisal 2020 is working for you and your organisation. Feedback is essential to know what works and what could be better. We want to keep what is valuable for the long-term. If you’ve any thoughts or comments in the meantime, please do share them with Grace Brown, Senior Policy Advisor in Regulation at the BMA: [email protected] 

Consultants deserve an appraisal process that actually works for them, reduces the exodus and ameliorates the workforce crisis, and results in a constructive and pleasant conversation that improves of our working lives. Appraisal 2020 has the potential to do exactly this – but only if it is embraced and executed properly.

Helen Fidler is deputy chair of BMA consultants committee.