Exclusion trends and evaluation of NHS Resolution resources to manage exclusions

Insight report resource

NHS Resolution’s Practitioner Performance Advice service (the ‘Advice service’) has a unique perspective on exclusions of doctors and dentists within the NHS. Exclusion is designed as a short-term, temporary measure to remove a practitioner from their usual place of work until the nature and cause of a performance concern are understood and while an investigation is carried out. NHS organisations are expected to seek advice from the Advice service when considering a formal exclusion of an employed doctor or dentist and if an exclusion extends beyond 12 weeks.

Maintaining High Professional Standards in the Modern NHS (MHPS) provides a framework for the handling of concerns about doctors and dentists. This framework, which is mandatory for non-foundation trusts and has been adopted by many foundation trusts, acknowledges that there are circumstances where exclusion may be necessary to either:

  • protect the interests of patients or other staff, and/or
  • assist the investigative process where there is a clear risk that the practitioner’s presence would impede the gathering of evidence.

In 2022 we published resources and information designed to support good practice in managing the exclusion process including:

We are publishing this Insights to share with organisations:

  • Up-to-date analysis about trends in exclusions of practitioners;
  • Improvements made by organisations and the Advice service in response to the resources and information published in 2022;
  • Resources and support the Advice service can provide regarding the fair management of exclusions.

When considering the content of this Insights, you may want to ask yourself the following questions:

  1. Are any of the overall patterns of exclusion also present at a local level within my organisation?
  2. Which resources could my organisation use to help manage and resolve exclusions fairly and consistently?
  3. Who should I share this Insights with?

Trends in exclusion from four years of exclusions

The NHS’s most valuable resource is its people and they are critical to the delivery of safe and effective patient care. While considerations of patient safety are paramount, the costs to the practitioner and the service of exclusion are real. Although exclusion is not a disciplinary action, and is usually where an investigation is underway, it changes the status quo from work to no work, and it inevitably impacts on how a practitioner perceives themselves and is perceived by others. Any decision to exclude is a complex and challenging judgement which seeks to ensure patients and staff are protected from harm whilst the doctor or dentist is treated fairly.

We analysed episodes of formal exclusion that commenced in the financial years 2019/20 to 2022/23 in England, where we were contacted to advise on exclusion episodes.

Key trends are:

  • The number of exclusion episodes¹ starting per year has decreased to an average of 76 per year (2019/20 to 2022/23) from 136 per year (2009/10 to 2018/19).
  • The duration of exclusion episodes shows signs of decreasing. We will continue to monitor and explore this finding to better understand if this reflects the impact of improvements in the management of exclusion.
  • The majority of exclusion episodes are under six months in duration which MHPS states should be the normal maximum limit, except for those cases involving criminal investigations.
  • Doctors and dentists who are statistically more likely to face exclusion are male, aged 65 and over, from Asian or Asian British, Mixed or from ‘Any Other Ethnic Group’, Specialty and Specialist (SAS) grade and working in the specialties of emergency medicine, obstetrics and gynaecology, surgery or the dental group.
  • Following an exclusion episode, 51% return to clinical practice and 29% leave the organisation. The remaining 19% have a different end reason for the exclusion, such as moving from being excluded to sick leave. The proportion returning to clinical practice (51%) for exclusions which commenced in 2019/20 to 2022/23 is slightly under the 57% returning to clinical practice from exclusions which commenced 2009/10 to 2018/19.

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 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.

Graphic shows 320 exclusions commenced between financial years 2019/20 and 2022/23. 97% of exclusions involved doctors, 3% involved dentists

*Male practitioners are 4.6 times more likely to be excluded than would be expected statistically given the population of doctors and dentists.

**Younger doctors were less likely to be excluded and older doctors more likely to be excluded, with the 65 and older age band having the highest odds of exclusion at 2.3 times higher than would be expected statistically given the population of doctors and dentists.

***White and Black or Black British practitioners were less likely to be excluded.

****SAS doctors or dentists had the highest odds of exclusion at 26 times higher than would be expected statistically given the population of doctors and dentists.

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Graphic shows decrease in the average duration of exclusions, comparing financial years 2009/10 to 2018/19, to financial years 2019/20 to 2022/23

Chart shows the number of exclusions increasing and peaking at 102 in financial year 2021/22, then decreasing to 73 in financial year 2022/23

Chart shows 51.3% of exclusions ended with practitioner return to clinical practice. 29.4% ended with practitioner leaving the organisation

Chart shows most exclusions, i.e. 176, ended within three months. 21 exclusions lasted longer than 12 months

Chart shows average duration of ongoing exclusions peaking at around 11 months in November 2022, decreasing to around eight months in July 2023

Evaluation of resources and information

We conducted an evaluation into whether the resources and information we published in 2022 have improved the management of exclusions both for the organisations the Advice service supports and within the Advice service. The infographic below outlines the main findings from the evaluation, which included a survey shared with medical directors and responsible officers with the aim of obtaining one view per organisation.

Graphic shows resources viewed 160 times monthly. 61% of respondents knew of resources, 72% more aware of requirement to report exclusions to us

The main findings from reviewing the website statistics and the survey to medical directors and responsible officers are that:

  1. Although the resources are being regularly accessed on our website, awareness may not be widespread amongst medical directors and responsible officers.
  2. The resources did not increase awareness of the negative impacts of exclusion on the practitioner for the majority of survey respondents. This could be because more emphasis was needed in the resources published or the respondents were already aware.

What we will do:

✔  Take a continuous improvement approach to the management of exclusions for both the Advice service and employers with the goal of improved patient safety and increased resources for patient care.

✔  Share and improve the resources annually and consider different approaches to reach key audiences to increase and sustain awareness.

✔  Consider developing a learning resource about the negative impacts of exclusion on the practitioner in order to reduce this impact in future exclusion cases whilst ensuring patient safety.

Local improvements using resources

We are sharing a real example of how an acute trust has made use of the exclusions resources and integrated them into their own processes around exclusion.

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Implementation example

The trust acted rapidly to review the resources published by the Advice service in April 2022 and considered how they could modify their processes to incorporate them and implement them in practice. The trust reported that the resources dovetailed with those already in use.

Anonymisation of cases: Introduced to address any potential unconscious bias that there may be in decision making. Anonymisation of cases when initially reviewed by the medical director so that when they receive the documentation about the concerns they do not know about whom the concerns have been raised. The medical director makes their initial decision and finds out who the person is at a later stage in the process.

Flow chart: Appended to the trust’s ‘72-hour review form’ which takes into account the full circumstances of concerns and proposed action that may be needed. The flow chart to be utilised by the human resources (HR) team in conjunction with the case manager, when deciding on appropriate action.

Recording template: Recording template to be attached to 72-hour review form to be utilised if exclusion required and can be referred back to and completed at each stage of the exclusion review process – enabling a review of the 72-hour form, and assurance that steps have been followed as per the MHPS process.  HR team to clearly highlight on “suspension report” once an exclusion exceeds six months.

Template letter: Although a template letter was already in use, further information is to be included in template regarding reasons why other options to exclusion would not be appropriate – aided by the flow chart and recording template for formal exclusion of a practitioner.

Case studies: Case studies were shared with team and were discussed at team meeting for CPD purposes.

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Organisations considering exclusion will see the Advice service doing things differently

Our team of experienced advisers can offer objective support and advice to both employers and practitioners. This can provide assurance that exclusion is used appropriately, proportionately and fairly, in both the NHS and the independent sector. Our advisers can also signpost to the sources of support for practitioners from other agencies: Support for practitioners – NHS Resolution.

In response to the research, the Advice service took actions to improve our own management of exclusion cases. As a healthcare organisation, you will see the following benefits in the service we provide.

The Advice service will:

✔  Include explicit consideration of the health and wellbeing of the practitioner being excluded in documentation such as in the advice letters we issue to organisations and practitioners.

✔  Explore the rationale for exclusion and consideration of alternatives, and document this in our advice letters.

✔  Provide clearer mechanisms for recording the status of exclusion, particularly the shift from immediate to formal exclusion.

✔  Continue to work with organisations to appropriately limit the length of exclusion.

How can the Advice service help?

Exclusions webpage: Our exclusions webpage outlines the resources designed to support good practice in documenting and managing the exclusion process, including:

  • the reporting requirements to the Advice service;
  • the exclusion decision flowchart;
  • templates for documentation; and
  • case studies.

Given the positive feedback from the evaluation, no changes have been made to these resources.

Organisational Activity Reports: Organisations have the opportunity to engage in a deep-dive analysis with their allocated adviser on the cases opened and any associated activity over a five-year period which includes episodes of exclusion. This will allow organisations to reflect on themes and trends over time and consider any improvement action in relation to managing performance concerns and remediation. If you are interested, please contact us at: nhsr.casesupport@nhs.net

Our evidenced-based educational programmes: These include case studies that allow participants to explore good practice when considering exclusions. Our learning resources include an exclusions case studies – learning pack which we have used extensively with medical directors, HR staff and responsible officers and can be used in local CPD sessions.

We provide a number of training courses: These include Understanding and using MHPS (Maintaining High Professional Standards) effectively and Compassionate Conversations which is currently being piloted. We are also working to deliver training on resolving performance concerns to board members.

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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. All past reports are available from our Insights page.

If you are interested in hearing more about our research and Insights programme, please get in touch with us at nhsr.adviceresearchandevaluation@nhs.net.

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. A minority of episodes involved the same practitioner who had multiple episodes of exclusion.

 

Resource publication date: