I know this has come up a bit in the Practice Index forum lately and I spoke to Robyn Clark, a Managing Partner, about it before today’s session. We frequently talk about how GP partners are taught how to be doctors, but not necessarily managers or employers. So, our first piece of advice is to get them to do some appraisal training. They all have their own appraisals so they should have some idea of the process, but GP appraisals are very clinically focused even if you’re a partner. There’s an appraisal module in the HR Masterclass, part of the Practice Index Learning Package if you’re a subscriber, so I’d recommend starting there.

Another option available to managers who are IGPM members is to use the IGPM appraisal toolkit. Partners quite often don’t understand the full breadth of the manager role, and a lot of the time they only know what you should be doing if it’s something they want you to be doing! The toolkit is mapped to the ten domains of the IGPM accreditation framework, so it really does give a full overview of the manager role. It also provides guidance for the appraiser on how to make the most of the appraisal meeting and how to set SMART objectives for the appraisee.

I’m sure there are other tools available, so do have a good look around to see what works for you. But from our experience, being able to provide structure to the meeting by using something like this helps make it a more meaningful experience and makes the appraiser more confident in what they’re doing.

I’m nervous about carrying out appraisals as I don’t like to be put on the spot and I’m worried my staff will use the opportunity to ask for a pay rise. Any tips on how I can overcome this?

I think we all worry about this at times, probably more so with certain individuals who are very good at fighting their own corner. My first piece of advice is that if the appraisal meeting is not a pay review, you can just go ahead and say that! Explain that any requests for a pay review can be noted and will obviously have to be discussed with the partners, but don’t commit to anything in the meeting. Give yourself the time to go away and consider the request and how you will respond to it.

A top tip for being able to prepare for what the appraisal meeting might throw at you is to get the employee to complete a pre-appraisal questionnaire and send it to you about a week before the meeting itself. This gives you time to read over how they think they’re doing, and any other issues that they’re likely to bring up in the meeting, giving you time to prepare a response.

Just remember, there’s always the opportunity for staff to throw us a curveball – you just have to feel able to say that you’ll consider what they’ve said and come back to them. You don’t have to make any quick decisions in the moment if you don’t feel comfortable to.

I have a staff member who’s been underperforming for a while now. Am I allowed to bring this up in their appraisal?

Best practice would be that this was brought up as soon as it was apparent there was an issue. An appraisal should be a chance to summarise feedback previously given. It’s not a good place to commence brand-new feedback. For that reason, I’d hope that these issues had been discussed before, and the appraisal can cover the progress made since those initial conversations, and be used to set further objectives towards achievement going forward. That’s not to say you can’t use an appraisal to discuss a particular area that needs improvement – part of the meeting is to give feedback on performance, but ideally it shouldn’t be a “surprise, you’re failing!” type of conversation!

What’s the best way to give constructive feedback at an appraisal which the person really listens to and doesn’t get upset about?

I’m not going to pretend otherwise; this can be very hard. As mentioned already, feedback given at appraisal shouldn’t really be ‘new’. It should be a summary of, and potentially an update on, feedback given previously.

The key points are:

1. Be specific about what you’re saying. Provide evidence where possible. Think about who, when, what, where and how. “There are problems with your attitude” is, by itself, a really vague, unhelpful way of giving feedback. It’s much better to explain that “since December, I’ve spoken to you twice in supervision about my concerns about what I’ve overheard you say to patients on the phone. Let me remind you about when those conversations were and what exactly I heard you say.”
2. State why you’re concerned. For example, “In my opinion, the two examples I’ve just given both showed you speaking rudely and cutting patients off when they were trying to express concerns.”
3. State what you want to happen next. “I’d like us to discuss how you feel calls have been going since my last feedback on this, and what, if any, further support you would like to help things continue to go better in future.”

You’ll notice that I’ve ensured the feedback is framed in the expectation that the employee will have their own input and perspective on the conversation, and it’s very important to listen to this. It’s also important to recognise if things HAVE been improving since previous feedback.

Maybe this will help you to keep appraisal tears and drama-free, or maybe not. Sometimes people just do get emotional. Try not to let this frighten you. Provide a safe space where they can let that emotion out, if needed. That in itself might help the employee to get to a point where they can take things properly on board.

Can you advise how best to discuss any constructive comments passed on by colleagues without naming the colleagues (as this just causes issues within the team)? Can you provide tips on how to approach anything that may be awkward?

My advice in general, I’m afraid, is that there’s no ‘nice’ way to give constructive feedback on an anonymous basis, and wherever possible, the receiver should know who has made the comments.

The reasons for this are as follows:

• • Receiving feedback like this anonymously implies that colleagues are discussing you behind your back, and you don’t know who’s doing it. It can be a very unsettling experience. I know you want to avoid head-on conflict between members of staff – don’t we all! But, in general, in my experience it’s easier to manage an open conflict between two staff members than it is to deal with a lingering lack of trust amongst a whole team.
  • The purpose of constructive feedback is to improve in future, and to do this effectively you need to know exactly what it is that’s gone wrong. For example, when the event happened, who was there, what was said, how people at the time reacted, and such like. If anonymous feedback is given, this is likely to be less specific/detailed and, as such, less constructive.
  • If you were to progress with a formal disciplinary or commence performance management on the basis of anonymous feedback, any warning or dismissal would likely be considered unfair by a tribunal. The only exception to this is if there’s good reason to believe that witnesses would be subject to reprisals if their identity was known. A bit of bad feeling or frostiness within the team is not sufficient to justify using anonymous witness statements. 

It can be difficult to deal with colleague feedback/comments when they specifically ask to remain anonymous.

Agreed, this is very difficult. However, my guidance above still stands. Dealing with feedback on an anonymous basis should be a last, rather than a first, resort. You should encourage staff members to understand this and give their consent for their name to be shared.

If someone has important feedback which needs to be acted on and they insist on being anonymous, ask them why this is, so that you understand the reasons and can reassure them where possible. Consider any other ways of getting (non-anonymised) evidence into this issue so you’re not reliant on that witness’s word for it. If that’s not possible and the witness won’t budge, think about how important the feedback is or isn’t. If it’s not a serious issue, it may be best just to let the witness know that you won’t be passing it on because giving such feedback anonymously could not be justified.

What about if it’s three staff members raising concerns?

Same as above, but hope that at least one of them gives consent for their name to be shared!

How can you manage expectations/performance effectively with an employee who has informed you they’re on ‘the spectrum’, but they seem to not be listening to ‘advice’ and coaching, they’re cherry-picking tasks and taking a long time to finish jobs?

This question is possibly more about general performance management than appraisal, but I’ll answer it from an appraisal perspective. Perhaps you’ve been trying to have lots of informal conversations about tasks and performance and support over the year, but things aren’t improving. A formal appraisal might be an appropriate opportunity to bring these topics together and summarise what’s been happening in a way the employee hears. For that, you need excellent notes on all the feedback and support which has been provided so far, and clear details of performance concerns, which should all have been fed back at the time but perhaps hasn’t been fully appreciated by the employee. Prepare your exact feedback beforehand and, if needed, practise with a senior colleague or partner in advance so you don’t feel like you’re completely improvising things on the day.

It’s equally important to listen to the employee. Perhaps the advice and coaching provided aren’t suitable for them? Perhaps their real needs haven’t been recognised or appreciated so far? Be open-minded about this and use the appraisal for a really good two-way conversation about these matters. Following that appraisal, the next steps might include an Occupational Health referral, clear work objectives, clear support plans, and/or the introduction of a formal performance management process with them.

Remember that if the employee has told you they’re neurodivergent, they’re quite likely to be disabled as defined by the Equality Act and entitled to reasonable adjustments at work. Reasonable adjustments can’t really be imposed by either party; they need to be discussed and agreed. If what’s in place at the moment isn’t working for either of you, then this needs further work.

And whatever feedback has been given, whatever concerns the employee has raised, whatever next steps have been agreed, all this needs documenting on the appraisal paperwork afterwards.

Can ongoing one-to-one supervision be sufficient as a form/mechanism of appraisal as I’m regularly discussing workload with individuals and sending them on training courses as required, but not really having time to sit for an hour reviewing everything for 15+ staff members? 

From a pure HR perspective, yes absolutely. If you already have regular conversations about performance with your staff, and these are working for you, then a formal appraisal may not add enough to justify the extra time it takes.

However, from a CQC perspective, they will expect to see written appraisal records. If you already have good written notes from supervisions, you could ask your CQC inspector for feedback on them and if they would be sufficient in place of appraisal documents? They might say no, though – in which case, unfortunately, you will need to put an appraisal system in place. The good news is that, if this is on top of regular, rigorous supervision sessions, then you probably won’t need a full hour for each one. Perhaps you could add a 30-minute appraisal session at the end of each staff member’s supervision once per year? This might be a nice way to reflect on the year in a holistic sense and hear how the staff member thinks it has gone.

Can we refuse references if a long-term staff member left without any notice at all?

For this question, I’m going to mention a blog I wrote for Practice Index last year all about managing reference requests. This point comes up in it, and it’s probably worth a look.

To answer the question now, though; if the reference request has come from another GP practice, health or social care employer, you really should be responding to it. Think of it as supporting your fellow practice managers even if you’re not too bothered about the employee! The health and care sectors rely on references. They’re an important part of how we protect patients or service users. Not providing a reference when requested may feel satisfying if you’re still furious with the member of staff, but actually you’re potentially working against the interests of other NHS providers. If the staff member is in a clinical role and you make it harder for them to obtain work by refusing to provide a reference, then hypothetically they could even raise a legal claim accusing you of being in breach of professional duty towards them.

What you CAN do – assuming this is a genuine reference request that the former employee wants you to complete – is mention factual matters, such as a lack of notice being provided when they left your employment. You’re not lying about them, gossiping about them or slandering them. You’re giving relevant, factual, evidence-based information, such as: ‘Fred Bloggs left our employment on 5^th February without providing contractual notice.’

And you might be wondering, what if the reference request has come from a completely unrelated sector such as a supermarket or bank? Then I would personally recommend that it’s still completed as a professional courtesy, but there are unlikely to be any legal reprisals if you don’t.

If a staff member asks for references (not the best staff member), how can we give these but let a future employer know that we weren’t happy with some things? 

Again, this is a point that the blog post I mentioned earlier talks about. Sometimes managers are told that you can’t say anything in a reference that isn’t nice. Absolute nonsense! What you can’t do is say anything in a reference that isn’t true. And because of that, it would be very unwise to say anything that you couldn’t evidence.

So, if Roland Rat has been previously employed by your practice, received a written warning for performance, and then was dismissed for stealing the petty-cash box, then yes! Again, assuming that it’s a genuine request and Roland Rat really does want you to give them a reference for some reason, you can say these things because they’re true, and they’re factual. Boom boom!

On the other hand, if Bart Simpson resigned from your practice believing everything about his work was tickety-boo, but secretly you’d been counting the days until he left because his performance on the phones was so poor (you just hadn’t discussed any of that with him officially), then telling a referee all about those bottled-up performance concerns would be completely unfair on Bart. He’d have justifiable grounds to complain if you’d prevented him from getting his next job in such circumstances!

The moral of the story is to manage performance concerns openly and have them documented. If this has been done, then there should be no problem in referring to those factual points on a reference request. For example: “Bart was late for work on numerous occasions and this was discussed with him in supervision three times between September 2023 and January 2024.” Or: “We received two separate patient complaints relating to Bart’s telephone manner in January 2024 and were in the process of investigating these at the point when he resigned.”

What is workforce planning?

Workforce planning is the process whereby we generate information and analyse it to inform future demand for staff and skills so that we can enable our workforce to meet the demands of our services.

The information we analyse might come from a variety of sources – our budget information, feedback from service users, data on how our services are used, feedback from other staff, new services that are being developed, etc. So, for example if you’re seeing a massive increase in patients presenting with mental health problems you might want to consider employing a mental health nurse. You might not have the budget for another GP, but you might be able to afford a part-time paramedic who can pick up some of the minor illness work. GPs might report drowning in admin and documents that need reviewing, so you might look to set up a workflow team to process these and divert the workload away from GPs.

This is stuff that most of you probably do all the time without realising it!

When planning staff needs for the future, is there a nice way to ask an older member of the team if they’re planning to retire soon?

Oh, this is tricky. Instinct as a manager is often to just ask the question outright, and in many cases, this might be fine with the individual concerned. But if they do take offence, it could potentially be seen as harassment or discrimination on the grounds of age, especially if you repeat the question on later occasions after the employee has told you they don’t want to discuss it.

My advice is to frame questions more generally, as you would with any other member of staff – for example, asking in an appraisal where they see themselves in so many years’ time or asking what particular career goals they’d like to discuss. If the individual has plans to retire in the near future, then they almost certainly will mention that at this point. If they don’t, then assume they either intend to keep working for longer or they just don’t want to discuss the matter yet.

How do you involve the staff in planning and communicating changes?

This will largely depend on the changes you’re making and how your team is made up. I like to try to engage early in the process, if it’s appropriate – as otherwise it can appear as if the decision has already been made. It won’t always be appropriate; budgets might be too uncertain, for example. So, you need to consider in advance who you should engage with, if at all.

In terms of communication, most people don’t like change so I’d encourage you to prioritise getting communication right and use a variety of methods – for example, a staff newsletter, team meetings or just popping in on people and having a quick chat. If someone’s role is likely to be impacted by a change, arrange a one-on-one conversation with them so that you can explain it fully in a private space.

Someone on my team has told me that they’re going to resign soon but they’re waiting on background checks for a new role. Can I advertise for their replacement straight away?

In short, no. Not until you’ve received a written resignation can you advertise someone else’s job, as it remains theirs until they’ve formally resigned.

How many people is it best to have on a recruitment panel?

This can vary depending on the role being interviewed for, but my general rule of thumb is aim for an odd number – to provide balance – and not just one! You don’t want it to be overkill, though; if you’re pushing five, I think you need to stop and calm down! Remember that you want the candidate to want the job and you want to get the best out of them; you don’t want them to feel intimidated or as if there are too many people to try and please, as this may put them off the role. Try and have a good variety of people on the panel, though, so that unconscious bias is reduced as much as possible.

Is it illegal to take on a new staff member without checking their passport for right to work in the UK first?

In effect, yes! You’re legally obliged to ensure that anyone you employ has the legal right to work in the UK, so you must carry out the relevant checks prior to issuing a contract of employment. Usually this means looking at their passport, but there can be other forms of legitimate ID; search on the Home Office website for details. Technically speaking, no one is going to arrest you for not carrying out a check. However, if you’re found to have employed someone without a legal right to work in the UK, and you can’t evidence that a proper status check was carried out when they started, your practice could be prosecuted and fined. For a FIRST breach of the rules, the starting point for fines has just risen to £45,000!!! Can your practice afford that?

A candidate for a reception role has told us she’s dyslexic on her application form. Should I do or say anything about this in the interview?

Under the Equality Act, it’s unlawful to ask questions about health matters prior to job offer, unless it’s part of equal opportunities monitoring or about making reasonable adjustments to the recruitment process. So, if a candidate openly discloses issues unprompted during the application or interview process, it can feel quite awkward! Ideally, if you’ve been in touch with the candidate prior to the interview, you’d have referenced the disclosure to see if there were any adjustments needed for them at the interview – for example, if you were going to do a typing or written test, would they need additional time to complete this?

If, however, there was no test and just a simple panel interview, my advice would be to wait until the point when you offer the role, when you can ask them how their dyslexia affects them and what the surgery can do to support them. You can also refer them to Occupational Health for an assessment, which may provide further suggestions on the support you can offer.

If you do choose to address it, make sure you do so in a positive manner and framed in the sense of adjustments, and that you document this discussion on your interview notes. The concern here is that if the candidate is unsuccessful, you don’t want them to be able to claim discrimination as the reason for rejection, so ensure you have strong evidence as to why this was not the reason.

Just a final note on this – if the disclosure is made as part of an equal opportunities monitoring form, rather than on the application form itself, check what your own procedures say about how that information should be treated. For example, if your equal opportunities monitoring form says that interviewing managers will not have access to this information, and then you bring it up at interview, the candidate may not be very impressed!

One of the GP partners wants us to ask questions about previous absence history in interviews but I think this is discriminatory. Do you agree?

I certainly do! And this is not what this part of the recruitment process is for. As I just mentioned, there are legal restrictions on what health-related questions you can ask prior to job offer. I would reassure them that this would come up as part of referencing post job offer and if there were any concerns at that point, you could discuss them with the successful candidate. Highlight that bringing this up as part of the interview process could lead to a claim of discrimination if the candidate were unsuccessful and they were classed as disabled. And then point them to that training module I mentioned…

Why doesn’t anyone complete reference forms anymore? Do you have any tips to get completed forms back? It slows down our recruitment process massively.

I feel your pain. Unfortunately, it’s very common to be waiting for references to come back, and often when they do come back, very little information is provided.

If a current or former employer isn’t providing anything other than a confirmation of employment and you feel the need for more information, you could ask the candidate to provide a reference from a peer or colleague to see if that sheds any light.

I know how frustrating it can be, but in these circumstances, you at least have your probationary period to fall back on. It can be of little comfort when you think of the time spent onboarding a new member of staff, but sometimes it’s all we have.

It’s also good practice, where you really can’t get a reference, to carry out a recruitment risk assessment and place that on the candidate’s file. This will include details such as how and when the reference request was sent, what steps have been taken to chase it, and your honest assessment of any safeguarding risk you believe this candidate will pose as a result of the referee’s non-response. Those risks might potentially be mitigated through steps like a thorough induction and probation process.

Currently, we ask for two references. Is this sufficient?

It’s a very standard number, though it’s good to consider how far back into a candidate’s employment history the references go. Ideally, you want to show job history from the last 2-5 years and so if someone has had a series of very short-term jobs recently, you may decide to request further references.

Can you withdraw a job offer if you can’t get a reference despite many requests from the last employer, which is required for CQC purposes?

See my comments about recruitment risk assessments earlier. If the result of that risk assessment is that you believe there’s a safeguarding risk for this candidate, and their offer was conditional on satisfactory references, then yes, you can withdraw the offer.

Can you ask about their sickness record on a reference request?

From a legal standpoint, it depends when you’re requesting the reference. You cannot ask for this type of health-related information prior to a job offer. If your reference request goes out post job offer, then yes, potentially you can ask questions about previous absence. However, be very careful about how you treat this information. Never withdraw an offer based on previous absence history without getting Occupational Health input, to see if they’re fit to provide consistent and reliable work performance in the future. If OH believe they are fit, then withdrawing the job offer would create legal risks. Remember as well that some people do have periods of poor health in their lives, and then recover!

Is it mandatory to get an Occupational Health opinion about a candidate?

Not in most circumstances, no. But if you’re planning to reject them or withdraw a job offer on health or previous absence-related grounds, it would be unwise to do this without having thorough OH input beforehand.

What are the likely circumstances for withdrawing an offer of employment? What if we have a bad informal reference from a previous manager?

This depends on what was said when the offer of employment was made. Ideally, if you make an offer following interview, you should ensure there’s written confirmation that this offer is subject to references, qualifications, DBS, PVG, GP performer list checks, right to work in the UK, or whatever other post-offer checks you’re carrying out. Then, if any of these are unsatisfactory, you have a clear and obvious right to withdraw that offer of employment. This includes, of course, if you have a poor reference.

On references, though, I would urge a little caution. Sometimes there are good reasons why an employment relationship doesn’t work out and I’d be wary of relying on any referee opinion that seems potentially spiteful or emotional rather than fact-based, for example. Who knows what has led to that situation? You might end up rejecting what could be a really excellent member of staff in the right work environment. If in any doubt, talk to the candidate and ask them for their version of events, then make your own decision.

This, of course, is particularly the case if you receive what you’ve described as an ‘informal reference’. Personally, I wouldn’t rely on any reference that can’t be recorded in some form. You run the risk of not being able to evidence your decision-making if accused of unlawful discrimination in future. For example, if this informal reference has come via telephone call with the previous employer, write notes about when the call was, who it was with, and what was said exactly. They (the referee) might not like you doing that, but it’s your practice, and not theirs, and they have freely provided you with this information in order to make decisions about another person’s employment prospects. On the other hand, if the informal reference was along the lines of third-hand gossip from an ex-colleague of the candidate, then either verify the information from a more reliable source or ignore it.

Many local practices have the same job vacancies available at the same pay rate. How can we stand out?

It’s tough when everyone is pushed regarding what they can offer. The first thing I wouldn’t recommend is reverting to advertising your role’s salary as “dependent on experience” as that often puts people off applying.

What you can do is up the ante on your advert. You need to really sell the job and the practice. When talking to Robyn about this, for example, she said that all her adverts mention how sociable a team they are and they mention all the things they’re really good at and proud of. Your advert should make people want to apply!

To make sure your advert does really stand out for all the right reasons, I’d suggest doing a bit of ‘market research’ by searching for similar job vacancies in your local area and comparing the quality of their adverts and recruitment materials with your own. Be honest (or get friends to look at them and give you honest feedback), do you look like the most attractive employment opportunity? Even things like having clearer, more enticing job descriptions than your competitors can help.

Also, think about your interview process. It’s not just about choosing the right candidate, but getting the right candidate to choose you! Consider how you welcome people as they arrive, the tone of the interview, the type of questions you ask, and any opportunities people have to meet and interact with the wider team. You want interview candidates to walk away from your practice thinking, now THAT is where I want to work!

Useful resources

• Performance appraisal policy & procedure [PLUS]
• Performance appraisal guidance for managers [PLUS]
• Performance appraisal meeting record [PLUS]
• Performance appraisal preparation form [PLUS]
• Performance improvement plan [PLUS]
• Performance appraisal 360-degree feedback form [PLUS]
• Recruitment policy and procedure [PLUS]
• Recruitment – Withdrawal of offer of employment [PLUS]
• Right to work in the UK – Guide to checks [PLUS]
• Reference request form [PLUS]
• Retirement policy [PLUS]
• Performance management – Capability procedure [PLUS]
• HR Masterclass – Module 1 (Recruitment)
• HR Masterclass – Module 4 (Appraisals and Objective Setting)
• Practice Index Training – HR Bundle
• Practice Index Recruitment Service

Future HR Clinics:

Bullying and Harassment – Tuesday 19th March at 12.30pm – Book here

The thought of having to tackle potential bullying or inappropriate behaviour is enough to get the pulse racing of any practice manager. However, these things do crop up – and even more so these days when everyone is feeling the pressure and stress. But what constitutes bullying? And what is the definition of workplace harassment? And where does victimisation fit in? Navigating these scenarios can be a bit of a minefield, but they don’t need to be.

Handling Long-Term Sickness – Tuesday 23rd April at 12.30pm – Book here

Managing staff who are on long-term sick leave is a challenging situation for practice managers. Can we contact them? How long is long enough? How can I get them back to work? In this HR clinic we will answer all your questions on this tricky subject.

Managing Staff Consultations and Change – Tuesday 21st May at 12.30pm – Book here

For most of us in practice, managing and leading change processes is a regular activity. This gets particularly challenging when changes impact on staff roles, responsibilities, hours, work environment, or even contractual entitlements. In this HR clinic we’ll answer your questions about the practical, legal, and leadership aspects of managing change. This includes tips on how to run a successful staff consultation process. Questions could also include topics like redundancy processes and TUPE.