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Appraisals: how do we assure safety without asphyxiation?

by Dr David Zigmond FDA Founder Member & GP London

Appraisals: how do we assure safety without asphyxiation?

 ‘We can’t carry on like this!’ is now a familiar cry of impotent frustration throughout Welfare services. Clearly we need challenges to our dysfunctional order. Yet our officials’ responses are often redolent of the last gasps of Empire: draconian authority with officious nervousness. What is happening?

 This example – of General Practitioner Appraisals – is a telling microcosm.

Men reform a thing by removing reality from it, and then do not know what to do with the unreality that is left.’

GK Chesterton, Generally Speaking (1928)

 

The professional staff of our Welfare services – those concerned with our health, education and vulnerable care – have growing occupational malaise, disaffection and stress. These are less related to the volume of work and more about the changed ethos. And here is a conundrum: for these changes are consequent to recent drives to assure optimum standards, efficiency and probity, and the computer systems we then devise to assure conformity. These generating missions are not themselves contentious, but they do have the invidious vulnerability of Political Manifestos – that righteous intent, unless carefully shepherded, often turns into something quite different. Much tragic history forewarns us of this. Yet this is now happening, massively, in healthcare: our burgeoning safeguarding devices are often undermining other essentials – trust, goodwill and positive motivational energies. Colleagueial Welfare has become replaced by a forensically-minded managerialism.

 Our Welfare now displays myriad examples of this perverse evolution. This short piece samples merely one: the GP Appraisal. Like the iceberg’s tip, this identified problem can seem minor but to ignore its massive underlying bulk can be catastrophic. A closer look is a wise investment. Dialogue is captured as a key part of the narrative. This story tells us much about the conundrum we have created in the last decade.

 *

 2005: Colleagueial discourse

My first Appraisal. I filled in a form that asked sensible and often stimulating questions about my practice, attitudes and coping strategies. This could be completed either by computer or on paper. I chose the latter and phrased my answers carefully, using my favourite fountain pen. I found the process rewarding, meditative and not too long.

 Contact with my Appraiser, Dr L, was similar. When planning our meeting I suggested she sat in a surgery session with me, to witness how I dealt with a wide range of clinical encounters, my patients and staff. ‘What a good idea!’, she cheerfully replied.

 Dr L made some brief notes while carefully observing my consultations. The ambience was warm, but professionally boundaried and dispassionate.

Over a light lunch we discussed her observations and her many intelligent 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?

 Like some skilled consultations, the probing was deep and wide, but discriminating and deft: there was no sense of pressure or inordinate intrusion. ‘Thank you’, Dr L said on leaving. ‘I’ve learned a lot about you, but you’ve also given me many thoughts about my own practice.’

 

2015: Procedural compliance

Dr L’s kind of professionally discriminatory judgement has been perceived as too risky for some in government. Therefore we must devise processes that are standardised, computerised and both more extensive and comprehensive – those that can be procedurally rolled out and will eliminate the vagaries of personal discrimination. Professional and management cadres are recruited: millions of pounds are spent on computer programs and trainings. Compliance and standardisation will become mandatory fail-safes.

 On the telephone I am arranging my Appraisal with Dr P. I ask him if he will sit with me, in part of a surgery session.

 ‘It will be very useful for us both, to generate discussion’ I suggest.

 ‘Oh, I’d like to,’ he begins, ‘but the Director [of Appraisals] has expressly forbidden such things: we must all stick to the same protocol’ he commands, his voice tinged with appeasement.

 ‘What’s that? You’re not allowed to witness what I actually do, only listen to what I say I do? That sounds a madness of abstraction to me.’

 ‘Maybe, but rules are rules. I don’t make them and nor do you.’

 ‘And maybe that’s a cusp of a very large problem.’ I am inviting some colleagueial candour.

 Dr P declines. ‘Oh, and don’t forget to ensure your computer entries are complete’ he says with prefectorial closure.

 Dr P arrives late at the end of a work-worn day. I see his courtesy struggling through his fatigue. I sense also intelligence and kindness in him, but searching for living space. I tell him he looks tired. He nods fraternally and alludes briefly to how the ever-increasing demands of his job and the formulaic complexity of these Appraisals leave him little and fractious room to manoeuvre his professional life.

 This is demonstrated now: he is clearly pressed for time. ‘I think we’ll need to look at what you’ve entered onto the [computer] system first’ he says, weary but still amiable.

 We sit, side by side, gazing at the luminous informatics, the highly abstracted data from my humanly rich professional life. His gaze is steady but his breathing is interrupted by sighs as he periodically stops scrolling down my boxed and serried professional self-packaging to write some brief notes on a pad.

 He exhales a longer sigh as he turns toward me. ‘I can see three areas where you have not provided adequate evidence: your Professional Development Plan, your chosen drug audit and your learning hours diary. You haven’t provided the right kind of evidence, or in the right amount…’

 My sigh is shorter and sharper: ‘But I’ve never worked or learned in that way. I’ve always learned by In Vivo osmosis, dialogue and enquiry, rather than In Vitro prescription or pre-packaging: I learn informally and on the hoof. I’m sixty-eight years old, highly motivated and want to get up in the morning, to work; my staff are similar: they stay with me for years … look at my many years of exceptionally positive patient feedback and lack of complaints – together with my measured clinical performance – you can find all these – clearly and positively evident – in the public domain. Likewise my long, esteemed and creative academic career. Why would I, or should I, have a development or learning plan to meet a remote committee’s requirements?’

 ‘Because we need evidence of your competence and safety to practice.’ Dr P emphasises the key word as if it has qualities of divine inviolability.

 ‘What sort of “evidence” are we talking about? Filling out complex forms or doing drug audits only gives you evidence of compliance to your process, it tells you nothing about my competence in consultations – unless you employ very doubtful and indirect inferences.’ I pause. ‘Look, here’s another thing: my work often involves having to think imaginatively and autonomously, because often things are not what they seem, or complexity requires a creative compromise … my responses are then very different from compliance, yet are essential to another kind of competence … and then, so often, our current didactic management or learning plans are then inimical to such complexity. Compliance becomes the smaller part of my competence.’

 ‘The evidence we require is clearly stated in the [computer] questionnaire.’  Dr P escapes complexity and shields himself with an official line.

 ‘Yes. And I am saying that completing all that on your terms tells you very little about me apart from my capacity to be adaptive and obedient. You’ll find out much more about me, and much more quickly, by sitting in surgery with me – seeing how I encounter problems and engage with people. I’m saying that your witness is much more valid than my self-documentation: that the first can lead to a view of my operational competence, but the second will lead you only to my ritualised compliance. I’m saying that this current system of Appraisal is leading to an increasingly false conflation of the two – we are coercively accruing more and more “evidence’ which is becoming less and less authentic or meaningful. Apart from being wasteful, specious and frustrating, it becomes exhausting, demoralising or even dangerous…’ My head of steam is now driving a turbine.

 ‘Oh’, Dr P arches an eyebrow. ‘How is that so?’

 ‘Yes … because if we have specious compliance it then subtracts very significantly from our best attentions, energies and efforts in our difficult work elsewhere. Eventually, with cumulative submissions of this kind, we lose both our personal spirit and skills…’

 Dr P is tiring: ‘Look we really don’t have time for this kind of discussion…’

 ‘Oh! So we have time to cavil about computerised diaries, but no time to pursue “this kind of discussion” – an unplanned, authentic dialogue about important matters that will surely tell you more about me than any computerised diary…’

 Dr P now cuts across me: ‘I think I told you on the phone that we expect your computer entries to be complete and satisfactory at the time of Appraisal.’

 ‘Ah. So the Appraisal is largely an inspection of computer compliance, which then is equated with broader competence and probity. “Don’t contaminate our pure abstractions with real consultations or conversations.” Is that it?’

 ‘I think you’re being unrealistic, behaving in this way.’ Dr P’s judgement sounds to me patrician, yet kindly: a headmaster of an old fashioned liberal-progressive school wanting to contain a rebellious teenager.

 ‘But this system of Appraisal is itself eschewing some very important reality: you ask me for abstracted “evidence”, but decline direct experience; you want computerised diaries, but have no time left for live, exploratory dialogue. The system then goes on to conflate competence with compliance. What kind of reality is that? And what kind of “realism” is required to comply with a system that is straying so far from such other realities? So, is compliance competence? Is sanity conformity? Is ethicality obedience?’

 I do not expect Dr P to answer these questions, but I do want him to take them home with him.

 Dr P’s engaged energies are slowing and stalling: ‘Look, I agree with many of your ideas, but that’s not the point…’

 ‘What is the point, then?’ I want him to yield more.

 ‘Well, most of us know that all of this sort of thing has become pointless and burdensome. But we’ve all just got to do it. Get on with it. That’s how it is…’

 ‘But why?

 ‘Well, I don’t make the rules – I just try to administer them fairly…’

 ‘And the rules, how and why are they made?’

 ‘I suppose everyone is trying to control – or at least reassure or prevent – bad things happening. The public look to the politicians who turn to planners and experts who prod executive bodies who then have to micromanage practitioners…’

 ‘So there’s a kind of cascade of anxiety ending up with a thick, obstructive – often toxic – sediment of largely meaningless compliance in which we all have to live?’

 ‘In a way, that’s it.’ Dr P seems a little relieved to reach some kind of compact agreement, but maybe he merely wants to go home.

 ‘I’m sure we can do much better than this.’

 ‘Maybe, but certainly not now…’ Dr P reaches for his coat and bag. ‘But do complete your computer entries correctly, otherwise we can’t proceed. I’ll expect to hear from you soon.’

 *

 As Dr P leaves I am aware of my vividly mixed reactions. I instinctively like Dr P: he is a decent man, a sympathetic Commissar. But I dislike the way he had been compromised and corrupted. And the system we have that controls us both? I feel the kind of anger that accrues with powerlessness. For the pyrrhic victory of our current system is that fewer and fewer of us have any kind of agency or real audience, and no one is really in charge: ‘We’ve all just got to do it.’

 There is a word for this: Technototalitarianism. 1

 -----0-----

 ‘Conquering the world on horseback is easy. Dismounting and governing, that is hard

Genghis Khan, c 1162-1227

 Reference

  1. Journal of Holistic Healthcare, vol 2, issue 4, Nov 2005

 

Interested? Many articles exploring similar themes are available via http://davidzigmond.org.uk

 

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