Patricia is a management adviser, trainer and facilitator in general practice. She is a Fellow of the Chartered Institute of Personnel and Development and was a practice manager/ partner for 11 years
T 01279 777371
Practice managers and partners often complain about the performance of one or two of their staff, which is quite understandable. As a former manager of some 40 staff, I can certainly identify with their frustrations.
In any team, you will have the stars who are totally committed to their job, are one step ahead of the others, put in 110% all the time, are always smiling and are a joy to work with. Then you have the "plodders" – those who do the work (usually willingly) but are never going anywhere in the practice and don't particularly want to. Such staff members are usually perfectly pleasant to work with, even if they aren't going to set the world alight.
Then there are those who do cause problems, such as staff who are frustratingly inconsistent. Sometimes they are fine; quite often they are not. They make mistakes, but not always. They can be great with patients but then have a dreadful attitude (which you can't quite put your finger on, let alone articulate) – if, for example, they happen to have got out of bed on the wrong side or there has been another of their interminable family crises. They drive other members of the team, and you, mad. You want to do something about it, but what?
You have limited support from the GP partners who also find these team members frustrating. But when you put on a determined face and present a plan of action, the partners back off with: "Oh well, they aren't too bad really …"; "They always bring me a nice cup of coffee …"; "They have been here a long time …"; or "They are having problems at home …", and so on. Then there are the members of the same team who are apparently desperate for you to go in, guns blazing, and sort out Mrs Snailpace. However, when it comes to the crunch they don't want to get involved or back you up or for there to be a bad atmosphere.
Argh! At this point, many managers give up and get stuck into the accounts (safer territory than managing staff) or some very time-consuming IT issue that has been sitting at the bottom of their in-tray for three months. Or they might go and see the bank manager who has been trying to set up a random meeting with them for months about "managing your account better". If really desperate, they might even go to another primary care trust (PCT) meeting about practice-based commissioning (PbC), which they know will be chaired by the most boring person they have ever met.
On a more serious note, managers and employers often complain about people's performance, but are not so good at tackling it. There is no doubt that well-structured performance management can produce higher productivity, increased quality, fewer mistakes and higher motivation, but it is time-consuming and can be difficult to implement, requiring full commitment from all stakeholders and a more active people-management style.
How does it work?
Performance management should be seen as a continuous process of monitoring and feedback supported by formal reviews. The strategic vision and goals of the practice provide the starting point from which group and individual goals should flow.
Managers often carry out performance reviews for only those staff who raise concerns, but this conveys the message that others in the organisation can be taken for granted or somehow do not matter as much. Far better to set up performance review meetings – not the same as appraisals – for the whole organisation.
These reviews should take place at regular intervals to reflect on past performance with an emphasis on continual improvement and development, feeding into the individual's personal development plan. The meetings need to be constructive, nonthreatening, open and honest, with the employee doing most of the talking. The stress should be on these meetings being learning opportunities both for the employee and the manager, rather than punitive or inappropriate faultfinding missions.
The real starting point for managing performance has to be with the job design. A well-thought-out job description and person specification provide clarity for the employer and the employee about the skills and competencies needed to perform the job, as well as what the job involves, the levels of responsibility and the expectations.
This is equally important for a current employee changing their role or being promoted within the practice. Often this important step is ignored and arrangements are loosely agreed, so that the employee can find themselves in an ill-defined role or with inadequate skills to meet the requirements of the new job.
Once in post, the employee's performance is usually proactively guided and monitored for the first few weeks or months, but these interactions tail off as the individual's confidence and abilities develop, ending up with occasional informal chats and an annual appraisal. True performance management is more than this.
It needs to be thought of as one step beyond the appraisal but does not necessarily replace it. Performance management is more meaningful, more structured and potentially more beneficial to managers, teams and individuals. It is not only about focusing on the employee's performance in their job, it is also about ensuring that managers themselves are aware of the impact of their behaviour on people they manage. It involves establishing a culture where individuals and teams take responsibility for their continuous improvement. It also involves managers clarifying what they expect individuals to do, and about individuals communicating how they feel they should be managed and what they need to do their jobs efficiently.
Indicators and targets to be accomplished need to be defined and agreed. These can be expressed by tasks to be completed by certain dates or standards of performance to be achieved. It can be more difficult to quantify standards, but an example would be the speed of response to requests or meeting certain defined standards of behaviour.
Useful tools to assist performance management include competency frameworks or checklists that describe what the employee needs to be able to do to perform the job well. They can include behavioural competencies, IT skills, technical skills and knowledge-related capabilities.
Measuring performance provides another challenge for managers, who should be careful not to measure the wrong things just because they are easy to identify. Using too few measures may discredit the process into a meaningless tickbox exercise, whereas using too many can make the process laborious or confusing. Measures could include: numbers of tasks accomplished; outputs; meeting defined targets; measures of patient satisfaction; the satisfaction of internal customers in the organisation (eg, GPs, nurses and other practice staff); and the achievement of financial targets (eg, the Quality and Outcomes Framework and enhanced services targets). Measures might also include the employee's own satisfaction and that of colleagues in the same team.
An important part of developing an individual's skills and knowledge is coaching. This is usually the responsibility of the manager or supervisor and will take place during the review meetings, but should also be carried out continually throughout the year.
Being able to coach effectively comes naturally to some people, whereas others may need training to improve their skills. It is about encouraging, supporting and empowering individuals. It involves creating the right environment and establishing an excellent rapport, encouraging the individual to express their feelings about how they are doing, adding your own honest feedback (which should be balanced and constructive), exploring ways together to help the individual improve, and providing ongoing support and encouragement.
Organisations that introduce performance management may wish to keep the process separate from salary reviews, believing that linking these discussions to pay can create unnecessary tensions or unrealistic expectations.
Other organisations, particularly in the private sector, use performance management linked to pay and other rewards. These organisations believe performance-related pay (PRP) stimulates motivation and provides a tangible link between the individual's performance and their rewards. This approach is usually highly successful in environments where there is an emphasis on company outputs such as sales targets, or in organisations where high flyers are particularly motivated by financial rewards. It may be less appropriate for practices with fewer "high flyers" and where there may be less clarity about how individual performance impacts on the financial success of the practice.
Nevertheless, it would seem entirely appropriate to reward those individuals who achieve higher performance, by whatever indicators. Some practices, perhaps moving away from the traditional and now defunct "Whitley" rates, have adopted a system of pay that includes a basic hourly rate for the job with a top-up dependent on performance. This approach moves away from paying staff more just because they have been there longer and recognises instead each individual's actual performance.
Interestingly, practices that have introduced PRP have found it to be popular not only with the manager and partners, but also with the staff.
Of course, it does require the manager to explain how the level of pay has been arrived at and raises possible contentions from staff who feel unfairly treated.
Finally, the practice manager's own performance should not be excluded from performance management. Many managers tell me their annual appraisals are meaningless or poorly handled by embarrassed or reluctant GPs. Often the manager has to provide the lead in his or her own appraisal and finds the process frustrating or a waste of time.
Being a good manager means wanting to improve constantly. No one becomes a good manager overnight, and experience in the job helps to develop management skills. Managers who have been doing the job for a long time should never become complacent, but should always look towards improving their personal effectiveness. The practice manager is a key player in the practice, so it is vital that managers participate in their own performance reviews with employers.
PRP is an area that is arguably more appropriate for managers where there is an obvious link between the manager's individual performance and the profitability of the practice. Many GPs have set up systems to reward managers, typically involving bonus payments over and above basic salaries that are based on the practice's income.
Sometimes these payments are measured in some way against levels of partner drawings. It would seem fair and reasonable that managers who directly contribute towards the financial success of the practice are rewarded in recognition of this. For the benefit of all concerned and to maintain probity, it is very important that this approach is done in a structured way, ideally through proactive performance management.
This will provide GP partners with the reassurance that their manager's pay has been linked to the achievement of performance targets, and it will provide the manager with the security of a systematic and equitable approach, unlikely to be challenged by a renegade partner who may have a habit of throwing doubt on less robust partnership decisions!