'PREVENTION BETTER THAN CURE - ENSURING SAFER PATIENTS AND BETTER DOCTORS'

Report of Short-Life Working Group on Identifying and Preventing Under-Performance among General Medical Practitioners

Introduction

The Scottish Executive Health Department on 1 August 2001 published a report on preventing 'under-performance'. This highlights the actions to be taken by individual Practitioners, other health professionals, those who represent Doctors, and by Managers. Particular reference is made to the resources available to support Practitioners, including Occupational Health Services and Postgraduate Medical Education. The emphasis is on creating a system of identification and support which allows any concerns to be discussed, declared, assessed and remedied before patient harm occurs. Fundamental to the process is the acknowledgement that any doctor identified as giving 'cause for concern' must also be supported by the LMC and wider professional networks.

This paper proposes an action plan for NHS Lothian. The principles that are highlighted are:

* Patient safety is ensured

* Caution before embarking on any formal action

* Fairness and openness with the Practitioner

* Objectivity on the part of the Trust

* Independent advice when necessary

* Probity in the use of NHS funds

* The need to identify whether the problem lies

> with the individual in the context of his or her clinical practice, or

> with relationships within the Practice, or

> within the wider Primary Care Team.

Identification of Concerns

No paper will be able to list all of the means by which concerns will be identified and brought to attention. These will include clinical audit, practice visits, information from other health professionals, review of complaints, and self-report. The action plan offers an agreed route by which concerns can be declared and assessed, and sets out the steps to be taken to resolve them.

The GMC places a responsibility on all Doctors to review their work and the working group commend the guidance in 'Good Medical Practice' published / revised May 2001. This work is currently being further developed to provide statements specific to General Medical Practice (and other medical specialities). The current GMC document provides a clear statement of what is expected of every Doctor.

The GMC defines concerns regarding performance in three formal categories:

* Personal conduct

Performance or behaviour of Practitioners not associated with the exercise of medical skills.

* 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.

These are listed to emphasise that concerns can relate to issues beyond direct patient care. It is acknowledged that defining under-performance by General Practitioners is both difficult and not absolute. It is also recognised that the influence of, and on, the wider healthcare team by a practitioner is important and the concept of 'concern' should have a broad definition. There is now a wide range of publications discussing performance in detail and it is not intended to rehearse these exhaustively 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.

* It is recognised that the health of the Practitioner is a key determinant of performance and will be an integral part of any assessment.

Action to Identify and Prevent Under-Performance

The National Document indicates a four phase approach to handling concerns.

1. Creating a culture in which concerns can be brought forward with confidence at an early stage. This will include mechanisms within Clinical Governance to highlight possible issues at individual Practitioner, Practice, LHCC and Trust level. It is not suggested that concerns will always be identified by a systematic approach. All staff within NHS Lothian have a responsibility to ensure that concerns are brought to attention at an early stage, this to include self report.

2. Initial Assessment of Problem - Initial Screening Group

This will allow sensitive assessment of the issues involved and the identification of appropriate support for the individual practitioner to ensure that corrective action is taken. The route by which support is offered will depend on the individual practitioner acknowledging a need for further review, and agreeing to participate.

It is recognised that despite a wish to maintain confidentiality at every stage not only will the individual practitioner about whom concerns are expressed be informed at an early stage, but the individual(s) who raise a concern will need to be advised of the action taken.

A record of the initial report, and all papers relating to the assessment and outcome will be held in confidence within the LMC/GP Subcommittee office.

3. Assessment at Local Healthcare System Level : Assessment /Evaluation Group

This group will provide oversight of levels 1 and 2 and will receive reports from the Initial Screening Group in respect of assessments and outcomes, including statements on reports which have been declared as requiring no further action.

This group will undertake a more formal role in assessing individuals where there are more serious concerns, and will be responsible for commissioning further detailed assessment, including referral to the new Expert Independent Educational Assessment Network being set up by SEHD and SCPMDE.

4. External Processes

These are the steps that are outwith the control of the Trust but will be accessed, in most cases, through the aforementioned procedures. These will include referral to the Expert Independent Educational Assessment Network, and potential referral to the General Medical Council.

In all cases it is recognised that individual circumstances might require rapid progress to referral to GMC, although it is intended that in most circumstances the reported concern will be handled locally.

Summary

The formal responsibility for managing this process lies with the NHS Trusts that hold the GMS contract for individual General Practitioners. This is also applicable in the contractual relationship between Trust and GP, or GP practice, within a PMS contract. This responsibility is seen to lie with the Medical Director of the Trust.

This response paper notes that a large number of groups have a legitimate interest in assuring the quality of General Practice and are interested in supporting a colleague in difficulty. The organisations noted on the Title Page will lead the process of assessment and support, but other groups may be engaged to assist in specific tasks. All will play a part in contributing to the provision of good quality General Practice in Lothian.

Annex 1 translates this into an algorithm for NHS Lothian (see over). On a number of occasions the next step refers to the creation of an Action Plan. The Action Plan specifies a number of interventions that can be considered:

No Further Action - where the concern has been assessed, and the practitioner is not considered to be underperforming. The assessment will be recorded and kept on file for a period of 1 year.

Health Problem - the individual practitioner will 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). If appropriate the initial screening group member will facilitate access to OHS, or to other specialist healthcare resource, but use of normal/routine healthcare systems will be advised. The record of assessment will not contain personal health information in relation to clinical care.

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 need, the provision of a specific training opportunity may be agreed as an a appropriate response to the concern.

In all cases reference to the next level of assessment / support will be considered, and in all cases the agreed action will be reported to the local assessment and evaluation group.

Where an individual practitioner does not co-operate with the local process, rapid referral to external bodies, including the GMC for formal assessment will be considered. Where there is a clear concern in respect of patient safety urgent action will be taken to protect the public with immediate reference to the GMC.

Click here for a flow diagram showing the structure for supporting GPs in Lothian

A short life working group met to prepare this paper

Membership:

Dr Cindy Brook, Clinical Director, Primary Care WLHT

Dr Andy Dunlop, Out of Hours Medical Directors' representative

Dr Alan Grant, Vice-Chairman, LMC/GP Subcommittee

Dr Dean Marshall, Medical Secretary, LMC/GP Subcommittee (Chair)

Dr Johnstone Shaw, Associate Adviser, CPD South East Scotland

Dr Mike Winter, Medical Director, LPCT

GPs REQUIRING FURTHER GUIDANCE ON THIS PROCESS SHOULD CONTACT THE MEDICAL SECRETARY OF THE LMC