Markella Boudioni MSc BSc (Hons)
Senior Research Fellow
Susan McLaren PhD BSc (Hons) RGN
Professor of Nursing
Ferew Lemma MD MPH PhD DLSHTM
Senior Research Fellow
Centre for Leadership and Practice Innovation, Faculty of Health and Social Care, London South Bank University, London, UK
Received date: 20 October 2005,Accepted date: 9 December 2005
Objective To explore the experiences and impact of implementing a primary care workforce development strategy on appraisal, personal development plans (PDPs) and identification of continuing professional development (CPD) needs for health professionals in primary care.Design Formative explorative evaluation based on semi-structured interviews and focus groups. Setting Primary care trusts and general practitioner (GP) practices in South East England. Results Appraisals were used as the primary mechanism to identify not only the CPD needs of individuals but also to link them strategically to particular roles within the organisation and to the needs of the practice setting. Recipients of the strategy generally expressed a favourable opinion of the appraisal process. Implementing a workforce development strategy across three health economies provided a number of challenges. A number of creative methods were described to support the training of appraisers,and the implementation of appraisal and professional development plans.Conclusions The results from this study suggest that the choice and skills of the appraiser have an important impact on the outcome of the process.Successful management of appraisal implementation,including the training and support of differentprofessional groups, is an important goal in achieving changes in practice to deliver a quality service. A mixture of conventional and innovative approaches to support both appraisal training and implementation can be used with varying degrees of success.Generating effective personal and practice development plans (PPDPs) linked to individual appraisal is a priority for the future.
appraisal, primary care workforce de-velopment strategy
Over the past decade annual appraisal has become commonplace for NHS staff and has evolved to become a key component of workforce management. For some health workers, appraisal is now a contrac-tual requirement as well as being viewed as good practice. Appraisal is closely linked to the concepts of ‘lifelong learning’ and ‘continuing professional devel-opment’ (CPD), both of which underpin the drive to improve the quality of patient care. Indeed as has been stated ‘the new primary care-led NHS requires continuing professional development for all primary care practitioners and managers’.
For general practitioners (GPs) in England, ap-praisal has been defined as a ‘professional process of constructive dialogue in which the doctor being ap-praised has a formal structured opportunity to reflect on his or her work and to consider how his or her effectiveness might be improved’. While appraisal traditionally focuses on the individual, the Chief Medical Officer’s review of professional development recommended the integration of professional (indi-vidual) learning, with organisational development in the form of personal and professional development plans (PPDPs). The need to learn from adverse NHS events has also identified the need for individual ap-praisal to inform safe organisational systems. Conse-quently, there has been some drive towards personal professional portfolio development linked to the needs of each practice, but one-to-one appraisals, focusing on professional development and personal fulfilment remain widespread.[1,7]
The goal of implementing a workforce develop-ment strategy in primary care, to deliver a systematic and consistent approach to PPDPs, personal develop-ment plans (PDPs), CPD and appraisal, is not without its challenges. A number of deaneries and organis-ations throughout the UK have attempted to im-plement and evaluate a range of approaches to meetthis policy agenda and report varying degrees of success.[8–10]
Overview of the strategy
In 2003 the Kent, Surrey and Sussex (KSS) Deanery, along with the local workforce development confed-eration/strategic health authority created a primary care workforce development strategy in an attempt to ensure that the future workforce would be fit for purpose in terms of professional knowledge, lifelong learning skills, recruitment and deployment. At the heart of the strategy was improved service quality through workforce development of all groups of staff, focusing on the implementation of an appraisal sys-tem linked to PDPs, CPD and improved recruitment and retention. Primary care workforce tutors, lifelong learning advisors, patch associate GP deans and related support staff were key to the process of implemen-tation and thereby in the management of change in local environmental cultures of lifelong learning. GP tutors, whose role was in a state of transition at the time of this study, also played an important role in facilitating CPD, which was seen as one of their many responsibilities. This paper reports the process and impact of the strategy on the appraisal process.
The objectives for the study included (1) to explore the experiences and impact of implementing a primary care workforce development strategy on appraisal, the development of PDPs and identification of CPD needs; (2) to describe approaches to implementing the appraisal process; and (3) to make recommendations for future training and development work.
This study formed part of a wider exploratory survey designed to evaluate the impact of the implementation on the KSS Workforce Development Strategy. A formative evaluation framework was utilised for the wider project, since the intent was to provide feedback to commissioners and the other strategic groups respon-sible for rolling out the strategy.[13,14] An exploratory, qualitative evaluation of the experiences of GPs, practice nurses and practice managers (study recipients) and the implementers of the strategy is presented here.
Participants and methods
Twenty-four Primary Care Trusts (PCTs) in Kent, Surrey and Sussex were approached to take part in the study. A total of 22 PCTs agreed to participate follow-ing Multi-centre Research ethics Committee (MREC) and local governance approval.
Potential participants from the implementation group were purposively selected from PCTs and the postgraduate deanery according to their professional role in delivering the strategy. In order to maintain confidentiality and anonymity of the implementation group (some of whom might be readily identifiable from specific roles), participants are only referred to as ‘implementers’. Potential participants from the recipient group, i.e. GPs, practice managers, and practice nurses, were randomly selected from website listings within the public domain.
Participants were offered the choice of either a face-to-face or telephone semi-structured interview, and implementers were also offered the opportunity to take part in focus group interviews. The decision to offer a choice of interviews was based primarily on the pragmatic issue of maximising access to participants over the large geographical area of the study. Interviews were conducted by three of the authors (LW, MB and SM) and two part-time research assistants. The use of multiple interviewers can raise questions about the reliability and quality of interviews when undertaken by different individuals. To minimise this problem, the research team, all of whom were experienced in undertaking semi-structured interviews, met frequently throughout the study to reviewthe ongoing analysis of interview data and to further develop and refine the interview schedule.
A total of 60 interviews were completed; 31 with GPs, practice nurses and practice managers (see Table 1), and 29 with staff responsible for implementing the strategy. Two focus groups were also conducted with key informants responsible for implementing the strategy (see Table 2). Interviews were conducted at a time and place suitable to participants, lasted between 30 and 60 minutes and were tape-recorded.
All interviews were transcribed verbatim and checked for accuracy against transcripts by interviewers. Tran-scripts were returned to half of the participants for validation, comments on accuracy, and to clarify the potential use of confidential material. Members of the research team content analysed the data using a structured framework, which resulted in the identifi-cation of key themes, codes and categories. This framework was used to code the bulk of the interview data, with codes and categories being revised and modified as the analysis progressed. The final thematic framework was agreed by members of the research team.
The results from this study reveal the contrasting experiences of the appraisal process for different professional groups.
Satisfaction with appraisal
Appraisals were considered effective in setting personal goals, acknowledging achievements and identifying CPD needs for all professional groups. The latter often provided a framework for development of PDPs and was linked to the identification of CPD requirements to meet personal and practice objectives (see Box 1).
Another area that affected satisfaction with the appraisal process concerned the choice of the appraiser. As one GP pointed out the ability to make such a choice led to the ‘appraiser being very helpful, supportive and facilitative’. A GP and a practice manager also articulated the belief that the focus and direction of the appraisal process should be driven by the appraisee, although this sentiment was not explicitly expressed by other groups of participants.
A small number (i.e. 3) of participants explicitly reported dissatisfaction with the appraisal system. The common problem they identified was poor execution of the appraisal process, which, in the words of one participant, was summed up as ‘amateur’, however this may merely reflect a lack of appraisers that were experienced in some contexts. The other source of dissatisfaction identified in three cases was that participants waited for their appraisals for more than 12 months.
Linking appraisal to CPD and PDP needs
Appraisals were used as the primary mechanism not only to identify the CPD needs of individuals but also to link them strategically to a particular role within the organisation and the wider needs of the practice setting. This led a number of participants to identify that the provision of support to meet CPD needs was a fundamental requirement in any appraisal system. Support in this regard included feeling personally supported and understood; financial support; support of colleagues; support of the practice manager and GPs; support of the wider organisation – i.e. the PCT; and support of dedicated deanery staff, e.g. primary care workforce tutors (see Box 2). In addition, it was recognised that support needed to be given to appraisers to enable them to fulfil their roles. Appraisers, one GP observed, were the ‘backbone of the CPD process’. As well as supporting appraisers, part of the KSS strategy involved the appointment of primary care workforce tutors and lifelong learning advisors to underpin the development of the workforce strategy and provide additional support. Participants in this study had not experienced any support from these roles directly, but acknowledged their existence.
The challenges of implementing appraisal
Implementing a workforce development strategy across three health economies provided a number of chal-lenges. Within the strategy one of the key priorities was to promote a culture of lifelong learning through the implementation of appraisals and development of PDPs. Key members of the implementation group accomplished this in various ways (see Box 3).
A number of challenges to implementing a common appraisal system were identified in the implemen-tation group. Implementers utilised several approaches to operationalise appraisal systems linked to develop-ment planning, which were largely based on appraisal training. Summaries of learning needs identified in the development plans were used to inform training programmes to meet the needs of uni- and multi-professional groups working in general practices and PCTs. However, within some PCTs, the appraisal system was not thought to be sufficiently robust to identify individual needs, and so team learning needs were identified instead with management support. A range of more formalised systems were subsequently described for the implementation of appraisal training and support; these encompassed initial awareness-raising sessions with GP practice staff and the pro-vision of inclusive appraisal training to a wide range of professional groups in GP practices and PCTs through workshops. Documentary templates to record the appraisal process and outcomes were offered as a method of supporting the implementation strategy (see Box 4).
A number of approaches and tactics were described specifically in relation to the implementation of appraisal within GP practices. These included the use of clinical governance as a mechanism to support appraisal, partnership working between tutors to provide action learning sets for appraisers and project management techniques used by leaders responsible for setting up appraisal systems. Some very creative support methods were identified including ‘toolkits’ to link appraisal to the PDPs of practice nurses, data-bases of courses and website information compiled to support the personal development planning and work of GP appraisers, and induction programmes for new practice nurses.
Despite a number of successful innovations to facilitate appraisal and personal development plan-ning, a number of concerns were expressed. One tutor had experienced difficulty gaining access to PDPs from local GPs although support from the PCT helped resolve the matter. A desire to have access to PDPs raised a number of insecurities around the appraisal process and created challenges to the ongoing im-plementation of the strategy (see Box 5).
Despite the challenges and problems encountered, successful management of appraisal implementation with different groups was considered to be among the most important achievements in delivering the strat-egy (see Box 6).
In any large, multi-professional organisation, the task of appraisal, CPD and personal development planning falls to personnel who are presumed to have the requisite knowledge, skills and training. Indeed, the results from this study suggest that the choice and skills of the appraiser have an important impact on the outcome of the process for appraisees.
The key limitations of this qualitative, exploratory evaluation, relate to the small sample size and limited generalisability of the findings to the wider study population. In addition, the results reported here focus primarily on the perceptions, experiences and cultural values associated with implementing a deanery-wide appraisal system, and not on outcome measures or endpoints of the appraisal and CPD processes perse.
There has been little guidance to date on who should be appointed appraisers and the knowledge, skill set and experience they should possess. In one survey, GPs sought appraisers who were themselves experienced and practising clinicians, preferably with experience as teachers or trainers but not necessarily academics. Successful management of appraisal im-plementation encompassing the training and support of different professional groups was therefore con-sidered to be an important goal for changes in the development of service and practice by the strategy implementers. Appraiser training was one of the key strands of the KSS strategy, and data from the im-plementation group illustrated that a variety of con-ventional and innovative approaches have been adopted with varying degrees of success including one-to-one training, GP appraisal learning sets, toolkits to link appraisal and PDPs, website development, provision of support to GP tutors to implement appraisals, and development of document templates to systematise and record the appraisal process. Multi-professional workshops were also used to good effect, an approach used successfully elsewhere when implementing PDPs into general practice. The implementation strategy therefore reflected a multidiscipline, multi-system, multi-focused approach.
One of the key challenges in developing effective PPDPs linked to individual appraisal and personal development planning is not only to identify, but also to record existing knowledge and skills, and future CPD needs of the entire primary care workforce. The implementers in this study identified this as an im-portant issue, and helped to develop documentary templates and systems to enable recording and access of key information. However, the notion that PDPs could be accessible to PCTs and not just the appraisee and appraiser was understandably met with resistance in some quarters. Implementers reported that this resistance was either due to a perceived challenge to GPs’ independence, or an expressed insecurity about not achieving the goals outlined in a PDP. Arguably, it is essential that PDPs and CPD needs are made explicit and linked to the needs of the practice setting if effective PPDPs are to be developed in the future. One way to accomplish this aim is through a trans-parent and accessible system that identifies priorities and at the same time respects confidentiality and professional integrity.
The success of implementing the KSS strategy per-haps rested first and foremost with the implemen-tation group. That some participants reported that they had not received direct support of the strategy implementers may, at face value, be of concern. How-ever, given the small sample size in this study and the large geographical area covered by the deanery staff, this finding was not surprising. In an evaluation of a similar strategy in the Wessex region, only 42% of their 277 participants reported receiving adequate support from GP tutors and/or facilitators.
Most respondents in the recipient group reported favourably on satisfaction with the appraisal process. While most recounted their experiences in relation to individual needs and agendas, Acknowledgements was also given to the need to link individual PDPs with the needs of the practice and thereby, implicitly, to PPDPs. The provision of support, in all its forms, to underpin the appraisal and CPD process was viewed as a key facilitating factor for participants, and mirrors findings from a survey of GP principals and GP tutors undertaken in the Wessex region. That NHS health-care organisations have a requirement to support CPD in all healthcare professional groups as part of the clinical governance agenda may account for the gen-eral ethos of support experienced in this study.
However, few recipients mentioned a relationship characterised by ‘high challenge and high support’ which others have found optimises the learning op-portunities for appraisees. On the contrary, some participants echoed the sentiment found in another study which found that a perceived benefit of ap-praisals was simply to reflect on individual perform-ance with a supportive colleague. While this may characterise a more conventional approach, if ap-praisal, PDP and CPD strategies are to be fully effec-tive, consideration may need to be given to fostering a ‘high challenge–high support’ environment in pri-mary care where it does not already exist.
Overall, despite some residual challenges to resolve, the evidence gained from both implementers and recipients suggests that appraisal, CPD and personal development planning are becoming well established within the culture of primary care within the KSS Deanery. Further studies are needed to evaluate the impact of appraisal and CPD systems on actual changes to service delivery and the organisation of care.
The research team gratefully acknowledges the finan-cial support of the commissioners, Kent Surrey and Sussex Postgraduate GP Deanery on behalf of the deanery, workforce development confederation and strategic health authority for Kent Surrey and Sussex. We also acknowledge the patience, co-operation and time of the study participants across the KSS health economies. The chair of the project steering group, Mr D Selling and Professor A Tavabie, provided helpful advice at different stages of the project.