David Zigmond is a London based GP, psychiatrist and psychotherapist. He has written extensively on the corrosive effects of the industrialisation of healthcare. He blogs regularly on his website and BMJ Blogs. His book, "If you want good personal healthcare - see a Vet" is available online.
This article first appeared in BMJ Blogs.
Current appraisal systems sacrifice more of value than they can assure. Clarifying why and how this happens gives us wider insights into our ill faring welfare systems.
“The more laws, the less justice”
Some healthcare management axioms seem incontestable: all our healthcarers should have a good standard of human and technical competence; these should then be held within a firm frame of moral probity. Therefore we need systems for professional appraisals, then validation.
Such is the easy rhetoric, but the meaningful implementation is proving much trickier. Generally, only those who administer the current appraisal system talk with conviction about its relevance or validity: the captive practitioners talk instead of obstructive rituals of submission, of unwisely prescriptive authority, and of a growing culture of forensic mistrust, even pre-emption.
This is not what was intended. What has happened and why? This decade spanning portrait may clarify.
2005: An early appraisal
I was asked some sensible questions about my practice, attitudes, and coping strategies on a paper form, which I completed in careful free text, writing with a favourite fountain pen. What was required was not tediously long or complex: my experience was meditative and calmly satisfying. Contact with my appraiser, Dr C, was similar. Dr C liked my idea of joining me in a morning surgery: she sat with unobtrusive but close attention as I encountered a wide range of human, administrative and biotechnical problems.
Later, over a light lunch, we discussed her observations and her many thoughtful questions. Satisfied quickly with my more administrative and biomechanical skills, we were able to linger with searching dialogue in healthcare’s often troubled thickets: how do I maintain my mojo and my interest over so many years? How do I deal with the many people whose needs are opaque or intractable? What is my way of expressing or resolving conflict? When do I turn to guidance or instruction? With whom?
I liked this appraisal: we generated and sustained a dialogue that was collegial and discriminating. Through this I sensed that the nature of my practice, and myself as a practitioner, were sharply but imaginatively perceived and understood. “Thank you,” she had said on leaving, “it has been very interesting seeing how you approach these problems. You have given me much to think about in my own practice too.”
Yet such human discrimination was too intelligently fragile to survive and Dr C’s professional discernment has been perceived as too risky by some in government. Therefore we must devise processes that can be procedurally rolled out and which will eliminate the vagaries of personal discrimination.
In the past 10 years, administrators, academics, and management consultants have all refined our new Shibboleths of systemisation and standardisation. Such mandates can then vaunt a comprehensiveness that assures the system is fail safe. To keep all this on track requires elaborate computer systems: these become the automated executives—to specify, prescribe, and monitor compliance from all.
Such mass management is certainly achieving compliance of a kind. More certain are the financial costs. Is this worthwhile? And are there other, more serious, costs?
2015: A contemporary appraisal
By now the civic engineers and their administrators have implemented our more extensive, comprehensive, and standardised system. In general practice it is called an “Appraisal Toolkit”—a term that implies a depersonalised world of defined and atomised tasks, all subsumed to a master plan.
Entering this Cyberland makes explicit the many tasks for submission. Dozens of boxes require answers in a form of electronic interrogation. There are systems of quantification for diarised professional and educational meetings and study time. Rigid formats ensure “correct” plans for professional development and patient complaints.
This mandated system of thinking and responding is very different from my long modi operandi: I have never had such development or study plans or diaries. Despite (I think because of) my professional self-motivation and autonomy, I have had an exemplary professional record as a frontline practitioner. For several decades I have had negligible contention with patients, consistently high satisfaction rates, and an esteemed creative academic output. Is this not substantial in vivo evidence of my competence, to learn and to do?
I ask Dr L, my new appraiser, if he will join me in a surgery session, to sample such evidence. He demurs, explaining that we must stick to the Toolkit format: improvisation is forbidden.
This seems to me a madness of abstraction: the system is not interested in what I do only what I say about what I do—self-constructed statements.
Dr L answers as the system’s apologist. He does not make the rules and nor do I. We must be wise enough to know when to be quiet. Then the increasingly frequent and fatalistic refrain of obedience: “Just do it; we’ve all got to. That’s the way it is.”
I cannot accept this. I need to ask Dr L how it is that we’ve become so passively compliant, so impoverished of autonomous spirit and intellect as a profession? My question is rhetorical, but Dr L’s answer is more interesting.
He draws a percipient sketch of our recent evolution and predicament: we have all become more nervous and mistrustful. So everyone is trying to stop or prevent bad things happening—or at least make gestures to pass muster. So, the public look to the politicians, who turn to planners and experts, who prod executive bodies, who then have to micromanage the practitioners . . . And here we are!
Where is that?
Our welfare services are being stymied in an unprecedented way by low morale, dissatisfaction, wearied antipathy, and alienation.
The perverse evolution of our professional appraisals is a microcosm of what has happened and why. Smaller still, my discourse with Dr L is like a biopsy: it bespeaks risks and loss far beyond.