DOCTORS
SUPPORT SCHEME
(Support for
General Practitioners in Lothian)
DOCTORS
SUPPORT SCHEME
(Support for
General Practitioners in Lothian)
2007
update
NHS
Lothian response to
'PREVENTION
BETTER THAN CURE –ENSURING SAFER PATIENTS AND BETTER DOCTORS' published SEHD
July 2001
1 Introduction
This document
updates the Lothian response to 'Prevention
Better Than Cure – Ensuring Safer Patients and Better Doctors' published by SEHD
in July 2001 and reminds colleagues of the work undertaken
jointly by NHS Lothian and the Lothian Local Medical Committee, for over 8 years,
to offer support to all General Practitioners who are listed on the NHS Lothian
GP Performers List.
The following
principles apply:
·
Patient Safety is assured
·
Fairness and Openness with the
Practitioner
·
Caution before embarking on any formal
action
·
Objectivity on the part of the NHS
Board / Primary Care Contracting Organisation
·
Use of Independent advice when
necessary
·
Probity in the use of NHS funds
The Doctors
Support Scheme is available to everyone who has a concern about a General
Practitioner in Lothian and this paper describes how concerns can be declared, are
reviewed and assessed, and then sets out the steps that will be taken to try
and resolve them. The purpose of the work is to assure patient safety through
providing support for General Practitioners in an appropriate manner. Should
issues of serious concern be identified these will be handled sensitively and
in partnership with the appropriate authorities, including the General Medical
Council.
2 Background
The 2001
SEHD report on preventing under-performance in General Practice advised a range
of actions to be taken by individual Practitioners, other health professionals,
those who represent Doctors, and by NHS systems. Particular reference is made
to ensure resources are available to provide support to General Practitioners,
including access to Occupational Health Services (for all) and to Educational
Assessment (when required). The emphasis, then and now, is to offer and
maintain a system of early identification and support which
allows any concerns to be declared, discussed, assessed and remedied before patient harm or damage to professional reputation occurs.
The
GMC places a responsibility on all doctors to review their clinical activity
and the guidance in ‘Good Medical Practice’ published in October 2006 provides
a clear statement of what is expected of every doctor. The GMC defines
concerns regarding performance in three categories; however it undertakes any
review of a concern in a holistic manner rather than by individual category:
·
Professional conduct –
performance or behaviour of Practitioners arising from the exercise of their
medical skills
·
Professional competence – adequacy
of performance of Practitioners related to the exercise of their medical skills
and professional judgement.
·
Personal conduct –
performance or behaviour of Practitioners not associated with the exercise of medical skills.
The previous
version of GMC guidance on Good Medical Practice was developed by the RCGP to
provide a statement of good practice specific to General Medical
Practice. These documents guided the development of the scheme of annual professional
Appraisal which are undertaken by all General Practitioners in Scotland. GP Appraisal is a formative opportunity to develop and assure safe practice; it
is not a means of detecting underperformance. Should concerns be identified
within GP Appraisal, the Appraisee is encouraged to bring these to the attention
of the Initial Screening Group for advice. In exceptional circumstances, where
patient safety is considered to be at risk, the Appraiser will advise the Local
Appraisal Advisor or Associate Medical Director of the concern and the Initial
Screening Group will be informed.
Fundamental to the Doctors Support Scheme is
acknowledgement that any GP identified as giving ‘cause for concern’ will be
supported by the NHS system, by the Local Medical Committee and by wider
professional networks. This is most effective when the GP demonstrates they are
active participants in the process and is willing to work with colleagues to
develop an action plan, agreed and acceptable to all parties, to resolve the
concern(s). This support remains available to General Practitioners who choose
not to cooperate with the local system but the individual must recognise the
limits that may be imposed on a local system by any external investigating
body.
3 Identification
and reporting of concerns
No document
can list all of the means by which concerns will be identified / brought to
attention. These will include self-report; information from other health professionals;
review of complaints, including those referred from GMC; clinical governance
and clinical audit; and information from contract monitoring and routine practice
visits. It is therefore accepted that identification or referral of a concern
can come from a wide variety of sources.
Should a concern be
identified this should be reported to either the Medical Secretary of the
Lothian Local Medical Committee or to the NHS Lothian Associate Medical
Director (Primary Care) as joint leads of the INITIAL SCREENING GROUP. Whilst these individuals are willing to discuss concerns
on an informal basis; a written summary of the concerns from the reporter will
be required. All reports will be given equal consideration. Anonymous reports
will rarely be actioned unless patient safety is clearly shown to be at risk.
The Clinical Director of the CHP/CHCP will be advised of cases referred to the
Initial Screening Group when further action is being considered, and will be invited
to input to any support offered, and given updates, including a statement of
outcome, as appropriate.
It is
acknowledged that defining the cause of under-performance is both difficult and
rarely absolute. It is also recognised that the influence of, and on, the
wider healthcare team by a GP is important and the concept of ‘concern’ and its
causation does, and should continue to, have a broad definition. There is now
a wide range of publications discussing performance in detail and it is not
intended to rehearse these in this document. A concern will normally be
considered with reference to what an average GP may reasonably do, or not do,
in similar circumstances.
The
first step is to determine whether the problem is with the individual practitioner
in the context of their:
·
professional practice, and/or
·
health, and/or
·
personal circumstances and/or
·
personal / professional relationships
within the Practice, and/or
·
personal / professional relationships
within the extended Primary Care Team, and/or
·
is an issue beyond the responsibility
/ authority of the Local NHS System
It is
recognised that the health of the Practitioner is a key determinant of
performance and the potential to involve the NHS Lothian Occupational
Health Service will be an integral part of every assessment and offered to all GPs who are referred to the Doctors Support Scheme. It
may also be appropriate for the identified GP to be referred, with their
consent, to OHS.
4 Action to
Identify and manage reports of concern
4.1 Creating
a culture – Doctors Support Scheme
NHS Lothian and the Lothian Local Medical Committee will
create a culture in which concerns can be brought forward in confidence at an
early stage. This will include mechanisms to highlight possible issues at
individual General Practitioner, GP Practice, extended primary care team, and CH(C)P
level. It is not suggested that concerns will always be identified (or
confirmed) by a systematic approach.
All staff employed by, and all those in contract with, NHS
Lothian have a responsibility to ensure that concerns are brought to attention
at the earliest opportunity. This will include self report of concerns and also
the reporting of lesser issues that in themselves may not constitute a
significant concern. If in doubt please discuss the concern with a member of
the Initial Screening Group, a member of the LMC, or with a Clinical Manager of
CHP/CHCP who will advise on appropriate action– usually informal discussion or
referral to the Initial Screening Group (ISG).
4.2
Initial assessment of problem – initial screening group
(ISG)
Members of ISG are responsible for sensitive and timeous assessment
of the issues reported and clarification of the background to the concern. This
initial assessment will, in most cases, lead to the identification of
appropriate support(s) for the individual practitioner to ensure that
corrective action can be taken. The actual type and level of support offered
will depend on the individual practitioner acknowledging the need for further
review of the reported concern, and agreeing to participate in the action plan
suggested. In every case consideration will be given to
the possibility of the cause arising from a health problem and encouragement to
seek input from OHS will be given, with the option of a ‘management’ referral
to OHS being offered (note ‘referral’ requires the GP to give consent and
the only report provided to management relates to the GP’s fitness to practice
– no personal health information is disclosed by OHS).
It is recognised that confidentiality is paramount and will
be protected at every stage. It is an integral part of the process that the
individual practitioner, about whom concerns are expressed, will be informed at
an early stage of the process. It is also noted that the person who reports a
concern will be advised of the action taken. As previously stated, anonymous
reports are discouraged and, unless they offer clear evidence of risk to
patient safety, will normally be dismissed. NHS Lothian has a number of
policies which will support staff who wish to raise a concern about a colleague
and these will allow the formal report about a GP to be made by a senior member
of NHS staff if this is required. Members of the Initial Screening Group are
willing to discuss and give advice regarding issues that might lead to a formal
referral.
All ISG activity is reported to the Assessment and
Evaluation Group. A record of the recommendation made by ISG, and all documents
relating to any subsequent action or support activity, will be held securely
within the LMC/GP Sub-Committee office for an appropriate period. The only
staff with direct access to these files will be members of the Initial
Screening Group and the Assessment and Evaluation Group secretariat. A strict
audit trail of who has accessed records will be maintained.
4.3
Assessment within healthcare system : Assessment and
Evaluation Group (AEG)
The Assessment and Evaluation Group (AEG) will undertake an oversight role for all aspects of the Doctor Support Scheme. The group
will receive reports from the Initial Screening Group in respect of initial
assessments, including background to reports which indicate NO FURTHER ACTION is
required. Where further action is advised the AEG will also provide ongoing oversight
of progress of individual cases; of any local support mechanisms, including mentoring;
and of cases which have been passed for external referral. All cases will be
reviewed by the AEG before being ‘closed’.
The AEG will undertake a more formal role in assessing
individuals where there are more serious concerns, and will be responsible for directing
the need for further detailed assessment, including referral to external agencies
including NHS Tribunal, General Medical Council, the NHS Education Scotland GP Educational
Assessment Network or to National Clinical Assessment Service (NCAS).
Membership of the AEG includes a non-executive director
of NHS Lothian Board and a lay member as well as representatives of key
organisations involved in the support process. The AEG will provide an annual report
on activity (anonymous reference to cases) to the NHS Lothian Healthcare
Governance and Risk Management Committee, through reports to the NHS Lothian
Medical Director. ISG will also provide an exception report about cases where
there is an identified patient safety issue to the NHS Lothian Board Medical
Director.
4.4
External process of assessment and investigation
When the report of a concern about a GP indicates a
significant risk to patient safety urgent consideration will be given to the
need to limit the clinical practice of that individual. This can be agreed
informally, but will often require urgent external review through application to
NHS Tribunal or interim suspension from the GMC. This would be an exceptional
intervention and would only be applied to protect patient safety in a situation
where the doctor being reviewed refused to co-operate with the processes
described in this paper. It is intended that in most circumstances the
reported concern will be managed locally.
Changes in procedure within the GMC require the NHS
Lothian system to comment on any complaints raised directly with the GMC. Information
held within the ‘Doctors Support Scheme’ is made available to the GMC in these
circumstances. The GP who is complained against will also be contacted directly
by the GMC requesting information about their ‘employer’ or ‘contractor
authority’. This allows the GMC to write to NHS Lothian and when local
procedures are suggested; a further letter will be written to the complained
against GP by NHS Lothian. The outcome of all such cases is referred through
the NHS Lothian Doctors Support Scheme as detailed in this paper.
Complaints against GPs can now be referred directly to the
Scottish Public Services Ombudsman (SPSO). There is no mechanism for reviewing
local knowledge about a GP in this case and the first contact may be the
receipt of a draft report from the ombudsman. GPs are encouraged to make
contact with the LMC and Doctors Support Scheme for advice and support – in
addition to making contact with their own medical defence organisation. NHS
Lothian management is required to follow up any finalised SPSO reports which
are laid before parliament and so contact from the practice at time of
considering a draft report, or sooner if possible, can be very helpful for GP,
Practice and NHS Lothian.
NHS Scotland has entered into interim arrangements with
the National Clinical Advisory Service (NCAS) which will become fully
operational from April 2008. The AEG may recommend to the NHS Lothian Board
Medical Director that a particular case should be referred to NCAS for formal
assessment and development of an action plan. This will complement local
processes and will normally only be used when agreement on a way forward cannot
be achieved. Referral to NCAS can still lead to formal referral to GMC or to
other external bodies if an appropriate action plan cannot be agreed.
When
the concern relates to a GP directly employed by NHS Lothian the individual
will have the right for the concern to be managed under the formal NHS medical disciplinary
procedures agreed between the Local Negotiating Committee (LNC) and NHS
Lothian. If all parties agree it will be possible for the concern to be dealt
with through the Doctors Support Scheme.
5 Outcomes of assessment
The
algorithm (see annex 1) highlights the process by which a reported concern is managed
leading to the creation of an Action Plan which will include one or more of the following:
·
No further action -
where the concern has been assessed and the practitioner is not considered to be underperforming.
·
Health problem - In
all cases the ISG will, in partnership with the GP about whom concern has been
raised, consider the need for and facilitate access (including referral if
appropriate) to the NHS Lothian Occupational Health Service, or to other specialist
healthcare resource. The GP may also be advised to seek assistance from their
registered General Practitioner (all GPs should be
registered with a GP – ideally not a partner of their own practice). Should an intervention be required normal/routine healthcare
systems will be utilised as appropriate with access facilitated if this is
required. The Doctors Support Scheme record of referral, assessment and
outcome will not hold or retain personal health
information.
·
Identified organisational issue - assistance may be provided to the individual
practitioner, or to their practice, to assess and resolve organisational
problems.
·
Specific personal development need - where the individual practitioner is aware of a
specific development need, the provision of a specific training opportunity may
be agreed as the appropriate response to the concern.
·
Mentoring - The most
common outcome of assessment is the offer of a Mentor to work with the GP about whom a concern has been notified. The GP
must agree to work with and participate in the Mentoring process. The mentor
will normally be an experienced Lothian GP identified by the GP Sub-Committee (with
input from Lothian Sessional Doctors Group if GP involved is a sessional GP).
The issues to be addressed will be agreed in a letter provided by the ISG /
AEG. The mentor will not be asked to assess the GP and will be fully indemnified
by NHS Lothian for this activity. Both the GP and the Mentor can ask for the
mentoring to be reviewed by the AEG at any time. Reports on progress will be
made by the Mentor and a final report will be kept on file when the mentoring
is concluded. It is expected that this final report will be agreed between the
GP and the Mentor.
·
External referral –
The assessment process can lead to a recommendation that an external review is
required. At present this is managed on a case by case basis by the Associate
Medical Director (PC) under the guidance of the AEG.
·
Refusal to participate - Where
an individual practitioner does not co-operate with the local process, rapid
referral to an appropriate external body, including the GMC, for formal
assessment will be considered.
·
Concern for patient safety - Where there is a clear concern in respect of patient safety urgent
action will be taken to protect the public by inviting the GP to agree to a voluntary
restriction in their practice. If this is not agreed, or the matter is of a
serious nature, the NHS Board may seek interim suspension (NHS Tribunal) or make
urgent referral to the GMC seeking an immediate limitation on registration. The
AEG may also direct that the GMC is advised of a concern in addition to
continued local action being undertaken.
6 Implementation
of Action Plan
An
action plan will be developed by the ISG and agreed with the GP concerned and implemented
without delay. Where resources are required to support delivery of the Action
Plan these will be discussed with the CHP / CHCP within which the GP works. Should
referral to an external body be required this too will be actioned without
delay.
All
agreed Action Plans and reports on progress will be shared with and agreed by the
Assessment and Evaluation Group. No case can be closed following or disposed of
by ‘NO ACTION REQUIRED’ unless this is agreed by the AEG.
Where
there are concerns about patient safety or issues of potential significant
public interest an additional exception report will be made to the Board
Medical Director. A formal report on the work of the scheme will be made to the
Primary Care Joint Management Group (minutes of all meetings are recorded by
case number and not by name) and an annual report on the work of the scheme
will be provided to the NHS Lothian Healthcare Governance and Risk Management
Committee.
7 Record keeping
·
The record of an ISG assessment that
is agreed as requiring NO FURTHER ACTION will be kept on file for a period of 1
year from the time the case is closed.
·
Where an ACTION PLAN is developed and
implemented the record will be held for a period of 5 years from the time the
case is closed.
·
There will be a limited number of
cases when a permanent record is maintained – this will usually be guided by
the GMC when formal external action is taken.
It is
anticipated that all GPs involved in the support process will declare this
within their personal GP appraisal and wish to discuss the outcome and any
learning, on a confidential basis, with their Appraiser.
8 Summary
The
Doctors Support Scheme is available to all General Practitioners (including
sessional doctors) on the Performers list of NHS Lothian. Referral from a wide
range of sources is encouraged. Referral should provide sufficient information to
determine an appropriate route of action. The initial assessment will be
undertaken by one of a small group of experienced doctors who are identified as
the Initial Screening group (ISG). In all cases the initial assessment and
progress towards achievement of the action plan will be monitored by the
Assessment and Evaluation Group (AEG). The need for OHS involvement will be
considered in every case; additional assessment /
support measures will be offered as required.
The responsibility
for managing the Lothian Doctors Support Scheme lies with NHS Lothian (as
holder of the GMS contract for Primary Medical Services - all sections, and as
directed by the SGHD guidance). The formal responsibility remains with the Board
Medical Director of NHS Lothian, although operationally this will be led by the
Associate Medical Director (Primary Care) working with the Clinical Director of
the appropriate CHP / CHCP. Lothian Local Medical Committee and GP Sub-Committee
of Lothian AMC are full partners in delivering the Lothian Doctors Support Scheme.
Dr
Mike Winter
Associate
Medical Director, NHS Lothian
26th November 2007
Appendix 1: SUPPORTING
GENERAL PRACTITIONERS IN LOTHIAN
 REPORT of
CONCERNS ABOUT
GP PERFORMANCE
(all causes)
|
source
·
All
GPs (including
self report)
·
Practice staff /
colleagues
·
Clinical
Directors CHPs
·
Clinical Director
LUCS
·
All Health
Professionals and NHS Managers
·
Other Reports
|
|
ACTION for ALL
·
Contact member
of Initial Screening Group (via LMC office, AMD (PC) or CD of CHP/CHCP)
·
Advise
concern in writing to ISG
|
|
|
(action – referral to
ISG and subsequent contact with GP normally within 2 weeks)
|
 INITIAL SCREENING
GROUP
Responsible
for initial assessment of concerns; advise the GP concerned (if not self
report); assessment / review of routinely available GP/practice data; advise
CD of CHP/CHCP in anticipation of support funding being required.
|
MEMBERSHIP
of ISG will include
·
Assoc. Med.
Director (PCCO)
·
Medical
Secretary LMC
·
Nominee From LMC/GP
Sub
·
Clinical
Director of CHP
The CD of
the CHP / CHCP responsible for the Practice of the GP will be informed and
invited to contribute to the initial assessment. This will always occur when
the GP is salaried to NHS Lothian.
|
|
ACTION
for ISG
·
Involve
Practitioner
·
OFFER SUPPORT
·
Consider
Referral to GMC??
·
Discuss / Refer
OHS
·
No Further Action
or
·
Develop Action
Plan
·
Provide report
to AEG
|
(action –
ISG contact - initial report - normally within 4 weeks)
|
  ASSESSMENT and
EVALUATION GROUP
Responsible
for Doctors Support Scheme, will monitor actions of Initial Screening Group, Progress
and Outcome of action plans. To commission further enquiry, and direct referral
to external agency as necessary
|
·
Chairman of
LMC / GP Sub
·
Non Exec Director
NHS Lothian
·
Lay member
·
3 Nominees LMC
/ GP Sub
·
1 Nominee
from CHP/CHCP
·
1 Nominee
Sessional doctors
·
PG Educ’n
Advisor NES
·
Occupational
Health Service
·
Members of ISG
·
Active Mentors*
·
Medicines Mgmt
Adviser*
·
HR Adviser*
·
Practice
Manager*
(*to
attend when appropriate)
|
|
ACTION
for AEG
·
Agree NO FURTHER
ACTION or
·
Agree proposed
ACTION PLAN (also to seek funding / identify resource)
·
Commission
further assessment
·
APPOINT A MENTOR
·
Direct referral
to External Agency
·
Annual Report to
NHS Lothian HCG & RM committee
|
(AEG meets quarterly
to review actions of ISG)
 EXTERNAL AGENCY
reviews case
/concern
evidence to be provided by Associate Medical Director on behalf of NHS Board Medical
Director
|
·
GMC
·
NES - EXPERT INDEPENDENT EDUCATIONAL
ASSESSMENT NETWORK
·
NCAS
|
|
·
Report Provided
to
Medical
Director
|
(within
agreed timescale)
·
GMC’s
Fitness to Practice Division — 0207 580 7642
Can provide informal advice and guidance about involving the GMC’s health
procedures.
·
Doctors'
Support Line 0870 765 0001 www.doctorssupport.org
·
The
Sick Doctor’s Trust –
0870 444 5163 www.sick-doctors-trust.co.uk
A proactive service for addicted physicians. 24-hour advice and intervention
service. Undertakes to provide early intervention and treatment for doctors
suffering from addiction to alcohol or other drugs, thus protecting patients
while offering hope, recovery and rehabilitation to affected colleagues and
their families
·
Doctors’
Support Network 0870 321 0642 www.dsn.org.uk
A self-help organisation for doctors with or
who have recovered from mental illness
·
The
British Doctors’ and Dentists’ Group (access via the Medical Council on
Alcoholism)— 0207 487 4445 and 24-hour helpline - 01252 345163
A support group of recovering medical and
dental drug and alcohol misusers. Local groups meet throughout Scotland and the British Isles. Medical students also welcomed www.medicouncilalcol.demon.co.uk/bddg.htm
·
The
National Counselling Service for Sick Doctors (NCSSD)
(Mon-Fri 9.00am-5.00pm) — 0870 241 0535
Independent, confidential advice by doctors
to sick doctors and their colleagues when ill health may be impairing safe
medical practice. Callers can be given the name and number of one of the NCSSD
medical advisers (including Scottish based advisers) to whom they can talk in
confidence. NCSSD advisers are also available to talk to groups and the media
about doctors’ health issues.
- The Royal Medical Benevolent Fund
– 0202 8540 9194
Provides financial assistance and support to
members of the medical profession, their spouses, children, widows and
widowers, who through illness or misfortune find themselves in need. It aims to
provide a lifeline of help and understanding in times of acute crisis and for
as long as the need persists.
·
The
British International Doctors' Association — 0161 456 7828
Where cultural or linguistic factors may be a contributing factor; doctors can
access the health counselling panel.
·
Careers
Counselling – Medical Forum – 07000 790 173
·
Samaritans — 0845 790 9090*
·
Alcoholics
Anonymous
- 0845 769 7555*
·
Scottish
Council on Alcohol —
0141 572 6700*
See telephone directory for local
contact
Appendix 3 Membership of groups at November
2007
Initial Screening
Group
Dr Peter Shishodia, Medical Secretary,
LMC/GP Sub
Dr Mike
Winter, Assoc. Medical Director NHS Lothian
Dr Ian
Johnston, GP and Clinical Director EL CHP
Dr
Sandy Sutherland, LMC/GP Sub-Committee
Assessment and
Evaluation Group
Dr Richard Williams, Chairman, LMC/GP Sub
Dr Willie Angus, Educational Advisor NES
Dr Robin Balfour, LMC/GP Sub
Robin Burley OBE, Non- Executive Director, NHS Lothian
Dr Janette Clinkenbeard, Sessional GP and GP Appraiser
Dr Chris Kalman, Director, NHS Lothian OHS
Dr Ian McKay, Clinical Director, Edinburgh CHP
Dr Catriona Morton, LMC/GP Sub and Mentor
Dr Nigel Williams, LMC/GP Sub/ Lead Clinician Edinburgh CHP
Vacancy, Lay
Member
Secretariat
provided by Miss Patricia Cripps, coordinator, LMC/GP Sub-Committee
|
|
GPs / PRACTICE MANAGERS REQUIRING FURTHER GUIDANCE
SHOULD CONTACT
·
MEDICAL
SECRETARY OF THE LMC or
·
ASSOCIATE
MEDICAL DIRECTOR PC or
·
CLINICAL
DIRECTOR of CHP / CHCP
|
|
