Dr Honor Merriman gives practical advice on how practices can be responsive to potential performer issues in GPs and explores NHS guidance on managing concerns
- Doctors have a responsibility to take action if they have genuine and significant concerns about the performance of a colleague
- The numbers of complaints received about doctors from the public have been increasing over recent years
- The NHS has produced guidance on how Area Teams should respond to concerns about people on performers lists who undertake clinical services:
- people on performers lists include most GPs
- The NHS guidance sets out processes to be used when performer issues are shared and the basis on which decisions about individuals are made
- People with concerns about a colleague should seek advice at an early stage so any problems can be addressed before they escalate
- Practitioners can offer support to their colleagues by:
- keeping in regular touch both socially and in meetings
- ensuring clear adverse event reporting mechanisms are in place
- knowing where and when to seek advice.
Providing high quality services in primary care now depends on a team approach. This means that everyone can contribute their particular skills and expertise for patients. Usually, everyone understands their role, is able to perform well, and good delivery of care is the outcome. Sometimes, however, it becomes apparent that individuals within a team are performing less effectively than they might.
In the interests of the health and welfare of the doctor and for the safety of patients, this situation needs to be understood, assistance offered and, if necessary, the concern needs to be shared. Under the General Medical Council (GMC) guidance Good Medical Practice,1 doctors have a responsibility to act if they have genuine and significant concerns about the performance of a colleague. Ignoring a performance concern is not acceptable and seeking advice early from the local Responsible Officer and the Area Team is advisable. This may mean that help can be offered at an early stage, before the underlying problem becomes irremediable and before serious harm to patients results.
NHS England has recently produced guidance, Framework for managing performer concerns2 (referred to from now on in this article as 'the guidance') on how Area Teams should respond to these concerns. The legislative framework in England for this is set out in the National Health Service (Performers Lists) (England) Regulations 2013,3 which replaced the preceding regulations published in 2004.
The 2013 regulations3 apply to medical, dental, and ophthalmic performers who undertake clinical services, and they entrust the responsibility for managing the performers lists to NHS England as the commissioner of primary care services. The performers lists replace the previous system of individual PCT performers lists. Because the framework is for those people on performers lists (not for doctors directly employed by NHS England), it applies to most GPs. See the guidance for more information about legal status and responsiblities.2
The guidance clarifies the processes to be used when performance concerns are shared, and the basis on which practitioners are included or retained on England's performers lists following the outcomes of these processes (see Figure 1).
Although the processes described in the guidance may seem far removed from GPs' day-to-day practice, it is important that they know about these changes to 'how things are done'. More and more GPs are reported each year to the GMC by members of the public. The most recent information released by the GMC states:4
' The number of complaints to the GMC ... increased by 23% from 7,153 in 2010 to 8,781 in 2011 - continuing a pattern which has been rising since 2007. While the rise in complaints does not mean that medical standards are falling, the likelihood that the GMC will investigate a doctor increased from 1 in 68 in 2010 to 1 in 64 in 2011.'
It is likely that the numbers of doctors investigated in the last 2 years are greater than this again. The processes of medical revalidation, and Care Quality Commission visits to practices, may uncover further practitioners who will need investigation and/or support.
What might trigger a performance concern?
Common situations that lead to information-gathering about GP performance may include, in the author's experience, any (or all) of the following:
- poor clinical outcomes (these may come to light from patients' complaints, observations of colleagues, significant event reviews, poor record keeping)
- prescribing or secondary care referral out of line with local and national guidelines and inappropriate for the needs of patients under their care
- observations of the GP's appraiser:
- these may relate to non-engagement with the appraisal process, CPD log entries being inadequate or not relevant to the GP's roles, or other matters that arise during the appraisal meeting
- lack of compliance with employment law and good human resource practice
- unacceptable behaviour towards colleagues and patients
- behaviour that compromises compliance with professional codes of conduct for the individual or colleagues
- personal health problems of the practitioner, leading to poor practice
- suspected fraud or suspected/actual criminal offence, including by way of information received from the police or coroner.
Identifying and addressing concerns
How to recognise problems at an early stage
There is an understandable reluctance on the part of GPs to take action when they are concerned about a colleague, but seeking advice is different from taking action. It is in the best interests of the GP and their patients to seek advice as soon as possible when a problem is noted. Problems picked up early can then be addressed, often before anything dangerous happens to patients or to the GP.
Sometimes there is a significant, obvious risk to patients or there has been a criminal offence where the need to take action at once is clear. The behaviours of most GPs whose performance might cause a problem, however, are less easily identified as dangerous. In looking at adverse events in a practice, the challenge is to understand whether it is individual failure or systems failure that has caused the problem. Commonly it is both, the system having not picked up on an error made by an individual; nobody is totally error-free!
It is also worth remembering that the vast majority of doctors intend to do their job as well as they can but can demonstrate 'difficult behaviours when':5 '...they may be stressed, ill, unable to cope, frustrated by lack of support or resources, feeling vulnerable in their job, distracted by personal difficulties, and so on.'
A fuller list of causes of poor performance may be found in the National Clinical Assessment (NCAS) good practice guide,6 and these may be summarised as:
- difficulty with clinical knowledge and skills
- deficiency in education and continuing professional development (CPD)
- physical or mental illness (e.g. depression)
- cognitive problems
- alcohol or substance abuse
- additional pressures at work or at home
- changes in the working environment; team difficulties
- major organisational changes.
Assessment and investigation
The investigation of what might be a highly complex mix of causes is a task for the trained expert; as a colleague, you will not be the best person to undertake it. That is why early contact with your Area Team is important.
The guidance sets out clear processes for offering advice to people whose colleagues are concerned about them and for arranging further investigation.2 Performance Advisory Groups (PAGs) with lay representation meet regularly and the system has the flexibility for rapid action when that is indicated.
Where investigation is needed, a case manager can start this locally or the PAG may advise referral to the NCAS. Area Teams can contact NCAS advisors for general guidance and this contact does not always lead to a full investigation.
Referral to the GMC may result in a warning to the doctor, suspension, the placing of conditions on their registration, or removal of the doctor from the register. Any of these outcomes are possible after the GMC's own investigation. The GMC provides guidance to doctors who have been referred.7
What might be offered within your own team?
Whether you work as a sessional GP, salaried GP, or GP partner, you can play your part in identifying GP performance problems at an early stage.
Practice team members have their own ways of keeping in touch with each other and often this may just be by email; however, taking time together over coffee each day, even if only for a few minutes, is time well spent in understanding the people you work with.
In addition to this, clearly understood reporting mechanisms for adverse events, and prompt discussion of these events, places each clinician in a safer working environment. Add to this regular educational events, and team meetings for safeguarding children, vulnerable adults and for palliative care patients, and there is a chance for everyone in the team to be involved with learning and for there to be coordinated patient care. Clinical practice that is outside practice norms (for prescribing and referral) will become apparent if there are regular meetings to discuss prescribing or referral. In a practice that communicates frequently and face to face, people who are unwell or otherwise in difficulty can be identified quickly. For those who are unwell, prompt attendance with their own GP (not a practice colleague) is needed and should be facilitated by colleagues covering while the GP seeks help. Anecdotes about illness in practices being ignored because it might increase the work of the remaining people may well be untrue, but there is a natural tendency to ignore a colleague working more slowly if this might cause personal inconvenience. Obviously, this is not a good approach!
Every practice needs to know who to contact at the Area Team if there is a concern about clinical performance. In some areas, there are coaching and mentoring schemes run by the local Royal College of General Practitioners Faculty or by the Deanery. The BMA runs its own advice line for GPs as well as offering information about a variety of other services. These may be all that is needed if the concern is of low level.8
We all have a responsibility to note and seek advice on the clinical performance of our colleagues. Low-level concerns may be resolved by offering the person educational or personal support. Performance that affects patient care should prompt advice from the Responsible Officer, through his/her Area Team. The new NHS guidance2 is a helpful in setting out how performer concerns should be managed.
- Although this article addresses the statutory duties of NHS England to address performance concerns, under the Health and Social Care Act, CCGs have a legal duty to work with NHSE continually to improve the quality of primary care
- Because they are locally based and involved in local commissioning, CCGs will often notice trends in prescribing and referral rates that could possibly signal a performance concern
- Many GPs represented on CCGs are likely to have a lot of local intelligence about the performance and health of local colleagues:
- these GPs often visit practices where such issues can be raised
- Clinical commissioning group GPs and managers should establish clear lines of communication with NHSE local area teams to share information about possible performance concerns
- Clinical commissioning groups also contract directly with practices for some services (contracted services); from managing these contracts, they may become aware of performance concerns that their member GPs have a professional duty to address.
- General Medical Council. Good medical practice. GMC, 2013 (updated April 2014). Available at: www.gmc-uk.org/static/documents/content/Good_medical_practice_-_English_0414.pdf
- NHS England. Framework for managing performer concerns. Managing concerns in line with NHS (Performers Lists) (England) Regulations 2013. NHS England, 2014. Available at: www.england.nhs.uk/wp-content/uploads/2014/08/Performer-list-frmwrk.pdf
- The National Health Service (Performers Lists) (England) Regulations 2013. Statutory Instrument 2013 No. 335. The Stationery Office, 2013. Available at: www.legislation.gov.uk/uksi/2013/335/regulation/4/made
- General Medical Council website. Record number of complaints against doctors - GMC report. www.gmc-uk.org/news/13895.asp (accessed 4 September 2014).
- King J. Dealing with difficult doctors. Edgecumbe Health website. www.edgecumbehealth.co.uk/library/publications/dealing-with-difficult-doctors/ (accessed 4 September 2014).
- National Clinical Assessment Service website. Handling performance concerns in primary care. An NCAS good practice guide. www.ncas.nhs.uk/resources/handling-performance-concerns-in-primary-care/ (accessed 4 September 2014).
- General Medical Council website. A guide for doctors referred to the GMC. www.gmc-uk.org/concerns/doctors_under_investigation/a_guide_for_referred_doctors.asp (accessed 4 September 2014).
- British Medical Association website. Doctors' well-being. Available at: bma.org.uk/practical-support-at-work/doctors-well-being/websites-for-doctors-in-difficulty (accessed 4 September 2014).