Demographics, professions and concerns: What are the patterns in Practitioner Performance Advice cases?

Insight report resource

The NHS’s most valuable resource is its people. They are critical to the delivery of safe and effective patient care. To support the fair management and resolution of concerns, we are pleased to publish our annual analysis of the demographics of the practitioners which we advise on and patterns of concerns reported to us by healthcare organisations. This analysis focuses on cases over a five year period between April 2018 and March 2023.

Why are we sharing this?

Practitioner Performance Advice (Advice) is uniquely placed to analyse and share the range of concerns about practitioner performance across the NHS where we have been asked to provide support. We are publishing this Insight to aid healthcare leaders, managers and practitioners to consider the information at a local level and increase awareness of the support we can provide. If you are reading this as an employer or contracting body, you may want to ask yourself the following questions:

  • Are any of the patterns presented also evident in my organisation?
  • Are there services on offer from Advice that my organisation could make use of?
  • Could my organisation benefit from the revised just and learning culture charter at the end of Being fair 2?
  • Who should I share this information with?

Key points

  • Ethnic minority, international medical graduates, older and male practitioners are each groups which are overrepresented in concerns reported to us by employers and contracting bodies.
  • Behaviour/misconduct continues to feature in 70% of the cases, the same as the previous analysis.
  • NHS Resolution is committed to supporting the fair management and resolution of concerns including through our range of services, the recently published and revised ‘Just and learning culture charter’ at the end of Being fair 2 and through collaboration with NHS England on the Medical Workforce Race Equality Standard (MWRES): The First Five.

Professional groups

Between April 2018 and March 2023, our cases involved 3,621 practitioners with the highest number of cases from doctors, followed by dentists then pharmacists.

Total practitioners- 3,621 Doctors- 3,412 Dentists- 201 Pharmacists- 6 For two practitioners, the profession was not disclosed to Practitioner Performance Advice.

Practitioner demographics

We conducted an analysis of the personal characteristics of the practitioners in our cases with the NHS workforce of GPs, secondary care doctors and dentists in England with the aim of understanding if any groups are over-represented and, if so, to what extent.

Rate of cases per 1,000 practitioners. Ethnicity- 1.3x rate per 1,000. Practitioners from ethnic minority groups have a higher rate of cases compared to white practitioners. Place of qualification- 1.8x rate per 1,000. Doctors who qualified outside of the UK and the EEA have almost twice the rate of cases as UK graduates. Gender- 2.8x rate per 1,000. Male practitioners have almost three times the rate of cases compared to female practitioners. Age- 8.4x rate per 1,000. Practitioners 65 and over are more than eight times more likely to have a case that practitioners under 35. Analysis for doctors and dentists in England for ethnicity, age and gender using NHS workforce data. For place of qualification, analysis for doctors in England only using data from the GMC Medical Register.

Ethnicity and place of qualification

Practitioners from ethnic minority groups had 1.3 times the rate of cases per 1,000 practitioners compared with white practitioners. Similarly, practitioners who qualified outside the UK had 1.8 times the rate of cases per 1,000 practitioners compared to those that qualified in the UK.

This is in line with other findings that minority groups are disproportionately impacted by formal disciplinary processes ¹ ²  including our own finding that Black and Black British practitioners are statistically more likely to face exclusion.

Redressing disproportionate rates of disciplinary action between practitioners from ethnic minority groups and white staff across the healthcare system is essential to fostering a just system that supports staff to learn from incidents. Our new report, Being fair 2 aims to promote the value of a person-centred workplace. A diverse and inclusive working environment is beneficial for productivity and staff retention: when staff feel valued, able to speak up and psychologically safe this can have a positive impact on teamwork, staff wellbeing, efficiency and lead to higher standards of patient care.

To further support the fair resolution of concerns, NHS Resolution has committed to collaborate with NHS England on MWRES: The First Five. Part of this commitment involves creating a checklist to support employers to take a proportionate and fair approach to the preliminary analysis of concerns and also to further develop training for designated non-executive directors who, in Maintaining High Professional Standards in the Modern NHS (MHPS), should provide an impartial route of support for practitioners at the preliminary analysis or case investigation stages. We will be sharing these resources with the healthcare sector as they are developed.

Age and gender

We observe a higher case rate for male compared with female practitioners (26 and 9 per 1,000 practitioners respectively) making males 2.8 times more likely to have a case with Practitioner Performance Advice.

In terms of age, the rate of cases for practitioners increases with each advancing age group, with practitioners who are aged 65 and over having 8.4 times the rate of cases per 1,000 compared to those under 35 years.

Pattern of concerns

Concerns in cases between April 2018 and March 2023. Behaviour/misconduct concerns- 70% Clinical concerns- 40% Health concerns- 18% Analysis reflects 3800 cases. Due to significant overlap in the reported concerns, the totals add up to over 100%.

70% of cases involved a behaviour/misconduct concern which has remained reasonably steady with the annual percentage of cases featuring a behaviour/misconduct concern totaling between 66-72% in the past five financial years. Recent reports ³ ⁴,cite workforce issues of incivility, bullying and harassment as being endemic, pervasive behaviours within healthcare. Furthermore, from our analysis of 141 of our behavioural assessments of doctors, there was an overarching theme of a lack of self-awareness and insight. Associated with this were issues with impaired resilience, problems with interpersonal relationships and their approach to managing operational challenges.

We have targeted our services accordingly, with increased capacity to provide the following services:

  • Behavioural assessments provide an independent view on the behavioural characteristics of the practitioner, including any areas which require consideration, and gives the employing/contracting organisation information to help decision-making about the next steps in their management of the case. This intervention is formative in nature and designed to support the practitioner’s professional development.
  • Assisted mediations are an independent, voluntary and confidential process in which two accredited mediators work with the parties concerned to create a mutual understanding of the issues and to find a way forward that enables a more effective professional working relationship.
  • Team reviews identify any barriers to resolving the issues and suggest a plan for improving professional relationships within the team. The circumstances in which we carry out a team review usually involve the following: issues of concern are usually longstanding, complex and deeply rooted; and the situation would benefit significantly from a fair and impartial view to clarify and communicate the net effects of the difficulties, as well as an exploration of the broader organisational context to the issues.

Clinical concerns were a feature of 40% of cases. Where there are concerns about a practitioner’s clinical practice, we can offer a clinical performance assessment to provide an independent view on the clinical performance of the practitioner. This will provide information to assist the referring organisation in decisions about the next steps in their management of the case. In previous analysis of clinical performance assessments during financial years 2013/14 to 2019/20, it was found that 63% of assessed practitioners were not practising at the expected level while 37% were at the expected level.

Health concerns were a feature of 18% of cases. Some of the themes seen in cases where Covid-19 was a feature were around health-related concerns for the practitioner and managing return to work, in particular regarding pre-existing ill health, disability and/or shielding and long-Covid. Employers have a legal duty to risk assess the causes of work-related ill health⁵, including work-related stress, and put measures in place to reduce the risks.

Where there is a concern about health, our Professional Support and Remediation service provides return to work action plans which support a practitioner’s reskilling and/or reintegration into clinical practice following a prolonged absence for any reason, usually in excess of three months.

We can also prepare remediation action plans where there is clear evidence identifying performance or behavioural concerns, such as a report from one of our assessments or another type of investigation. The focus of a remediation plan may be on knowledge, skills or behaviours, or a combination of these.

Supporting the fair resolution of concerns

In Being fair 2, we ask senior leaders of healthcare organisations to consider:

  • Utilising and signposting practitioners to NHS Resolution’s Advice service to provide impartial advice. This enables a fair and effective application of the healthcare organisation’s own local performance management, associated procedures and good practice in relation to local case management and investigation.
  • Adopting the revised ‘Just and learning culture charter’ at the end of Being fair 2 which outlines the key features of a person-centred workplace that is compassionate, safe and fair.

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Our Insights publications share analysis and research which draw on our in-depth experience providing expert, impartial advice and interventions to healthcare organisations. By sharing these Insights, we aim to support the healthcare system to better understand, manage and resolve concerns about doctors, dentists or pharmacists. You can find all past reports here.

If you are interested in hearing more about our research and Insights programme, please get in touch with us at nhsr.adviceresearchandevaluation@nhs.net or sign up to receive Insights by email.

If you’d like to learn more about our work and the services we offer, please visit our dedicated Practitioner Performance Advice webpages. Our Education service offers training courses to provide healthcare organisations with the knowledge and skills to identify and manage performance concerns locally.

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Footnotes:

  1. Fair to Refer? (GMC, 2019)
  2. Medical Workforce Race Equality Standard (MWRES) WRES indicators for the medical workforce 2020 (NHS England/Improvement, 2021)
  3. Messenger G, Pollard L. Health and social care review: leadership for a collaborative and inclusive future, Department of Health and Social Care; 2022.
  4. Health and Social Care Committee. Workforce: recruitment, training and retention in health and social care, House of Commons; 25 July 2022.
  5. The Management of Health and Safety at Work Regulations 1999, Regulation 3

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