Insights from five years of supporting the management of Medical and Dental Performers List suspensions

Insight report resource

NHS Resolution’s Practitioner Performance Advice service (the ‘Advice service’) provides healthcare organisations with advice on the management and resolution of concerns about the practice of individual doctors, dentists and pharmacists.

Our work in primary care cases provides comprehensive support to the management and resolution of concerns, with a focus on advising on Performers List management issues. This includes:

  • Providing advice on cases where suspension is being considered or where a decision has been made to suspend a practitioner.
  • Advising on informal resolution and formal list action.
  • Advising on potential interventions, such as actions plans and assessments.

In March 2023 we published our Insights publication on Supporting the management of performance concerns within primary care. This highlighted our role in providing advice to organisations who have suspended, or are considering suspension of, medical or dental practitioners and assisting them to resolve Performers List management cases, as required by our Directions.

The NHS workforce is critical to the delivery of safe and effective patient care and a decision to suspend a practitioner from the Performers List can be a complex and challenging judgement, which seeks to ensure patients and staff are protected from harm, at the same time as ensuring the doctor or dentist is treated fairly.

In England and Wales a suspension can be imposed under the National Health Service (Performers Lists) (England) Regulations 2013 and National Health Service (Performers Lists) (Wales) Regulations 2004.  For suspensions in England, the Regulations require there to be notification to NHS Resolution of action taken on Performers List inclusion. There is no formal requirement for Health Boards in Wales to notify us when a suspension has been imposed, but through our provision of advice to Welsh Health Boards (enabled by an agreement with NHS Wales Shared Services Partnership) we will often be contacted to discuss cases where suspension is being considered or has been imposed. Although there is no formal notification mechanism for suspensions in Northern Ireland, the Advice service is able to provide advice and support for individual cases in the same way we do for other countries where we have agreement to do so.

In this Insights publication we provide organisations and practitioners with analysis of 198 Performers Lists suspension episodes from England and Wales which began between April 2018 to March 2023 (i.e. in the financial years 2018/19 to 2022/23) and were notified to us under the Regulations.

This information is being published as part of our commitment to share data and insights with organisations and to ensure that the basis for suspensions, and any later variation in Regulation, are communicated and recorded clearly and to ensure fairness to practitioners throughout the process.

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

  • What factors are important to take into account when considering suspension?
  • When might I contact the Advice service for support?

Key trends from the suspension notifications we received from April 2018 to March 2023 are:

  • An increase in the number of suspension episode notifications we have received.
  • A decrease in the average duration of suspension episodes.
  • Most suspension notifications we received were in respect of UK qualified practitioners.
  • For most suspension episodes concluded in this period, the practitioner retained their inclusion on the Performers List.
  • Over one fifth of suspensions were immediate suspensions, imposed where it was felt necessary to protect patient and public safety.

The Regulations

When a practitioner has been suspended, NHS Resolution receives written notification (referred to as a ‘Regulation 18 notification’ in England and a ‘Regulation 16 notification’ in Wales) from NHS England or NHS Wales Shared Services Partnership. This notification details the date that the suspension started and under which Regulation it was imposed. If the suspension comes to an end, a further notification is provided to include the date of decision and the relevant Regulation. In some cases, we receive notification of a variation to the basis of suspension (a change in the applicable Regulation). In England and Wales a suspension can be imposed under the National Health Service (Performers Lists) (England) Regulations 2013 and National Health Service (Performers Lists) (Wales) Regulations 2004. The key Regulations which enable a suspension are:

A table to show the key regulations which enable a suspension: Regulation 12(1)(a) (England) and Regulation 13(1)(a) (Wales)- A discretionary suspension imposed while NHS England/Wales determines whether to take formal action on Performers List inclusion. This can last no longer than six months. Regulation 12(6) (England)- An immediate suspension imposed where it is considered necessary to do so to protect patients and/or members of the public, or it is otherwise in the public interest. This imposes a 12(1)(a) suspension on an immediate basis. Regulation 12(1)(b) (England)and Regulation 13(1)(b) (Wales)- A discretionary suspension imposed while awaiting the outcome of a criminal or regulatory investigation, or the decision of a court anywhere in the world or of any regulatory body. This can be extended beyond six months on application to the First Tier Tribunal. Regulation 12(1)(c) (England) and Regulation 13(1)(c) (Wales)- A discretionary suspension imposed where a decision has been made to remove a practitioner from the Performers List but that decision is yet to take effect. Regulation 12(1)(d) (England) and Regulation 13(1)(d) (Wales)- A discretionary suspension imposed pending a practitioner’s appeal against a decision to remove them from the Performers List. Regulation 12(1A) England- A mandatory suspension imposed immediately where a practitioner has been suspended by their professional regulator.

When a suspension is contemplated on the above bases – except for a mandatory suspension, in England, under Regulation 12(1A) – the test is whether the suspension is necessary for the protection of patients or members of the public or is otherwise in the public interest.

In Wales there is no mandatory requirement to suspend a practitioner from the Performers List if they have been suspended by their professional regulator. The medical/dental practitioner is required to notify the relevant Health Board of any suspension imposed and consideration of further action by the local Health Board will be given on a case-by-case basis.

Our suspensions data

From a review of 198 notifications relating to suspension episodes from financial years 2018/19 to 2022/23 we found 70% of suspensions involved general medical practitioners and 30% involved dentists. Rate of suspension based on total workforce numbers: 0.7 per 1000 doctors working in England. 0.8 per 1000 doctors working in Wales. 0.3 per 1000 dentists working in England. 0.1 per 1000 dentists working in Wales. Breakdown of place of qualification for suspended practitioners (based on individual practitioners working in England or Wales)*: UK-65% European Economic Area- 7& Elsewhere- 28% 80% of suspensions which commenced on or after 1 April 2018 had been concluded by the end of March 2023- 38 individual episodes were still ongoing.

* These percentages are based upon the 198 suspension notifications received by NHS Resolution from England and Wales from April 2018 to March 2022. Of these suspension episodes, a minority involved the same practitioner. The numbers of individuals rather than suspension episodes have been used to calculate the figures in this infographic.

For context, the available workforce data for the period April 2018 to March 2022 (no full data available for financial year 2022-23) gives the place of qualification for doctors and dentists working in England (Welsh data unavailable) as: 76% UK, 11% EEA, 13% Elsewhere.

In providing this context it should be noted that the 198 suspension notifications received during this period represents a small fraction of the estimated workforce of over 65,000 doctors in primary care and registered dentists in England and Wales during this reporting period. (Dental data based on General Dental Council registration data, we note that not all registered dentists may be actively practising)¹ ².

A bar chart to show the number of suspension episodes by financial year based on notifications received by NHS Resolution April 2018 to March 2023.2018/19- 18 2019/20- 25 2020/21- 44 2021/22- 55 2022/23- 56
The above chart is in respect of individual episodes of suspension and includes a small number of episodes which relate to the same practitioner.
A pie chart to show regulation under which a suspensions was imposed for suspension episodes which began April 2018 to March 2023.12 (1A) (England)- 60 12(1)(b) (England)- 22 12(6) (England)- 43 12(1)(a) (England)- 60 13(1)(a) (Wales)- 6 13(1)(b) (Wales)-7
The above chart is in respect of individual episodes of suspension and includes a small number of episodes which relate to the same practitioner.

In financial year 2022/23 we received three-times the number of suspension notifications (56) than in financial year 2018/19 (18). The information available to us does not confirm the reason for this increase, although our Advisers strengthened links with their linked regions may have helped with this. Over the past three financial year period, this rate of increase in the number of suspension notifications received has shown signs of slowing.

A suspension under Regulation 12(6) (England) – where immediate suspension was felt necessary to protect patient and public safety – was imposed in 22% of the total episodes where we received notification. As stated above, this imposes a Regulation 12(1)(a) suspension on an immediate basis. For the purposes of this Insights publication, we have considered immediate and discretionary suspensions separately.

Immediate suspensions, in practice, are generally imposed when there are serious concerns about a practitioner’s performance which require urgent action to protect patient safety.

In England, immediate suspensions must be reviewed and replaced with a substantive suspension (under Regulation 12(1)(a)) within two working days and the practitioner then informed of the right to an oral hearing on a given day. The practitioner is entitled to receive at least two working days’ notice of the oral hearing. When the oral hearing takes place, if the practitioner attends, the Performers List Decision Panel (PLDP) may revoke or confirm the suspension or replace it with conditions. If the practitioner does not attend, the PLDP may only revoke or confirm the suspension.

Discretionary suspensions under Regulation 12(1)(a) (England) and 13(1)(a) (Wales), imposed pending a decision on whether to act on a practitioner’s Performers List status, and mandatory suspensions imposed under Regulation 12(1A) when a practitioner is suspended by their professional regulator, accounted for two-thirds of the notifications we received.

When discretionary suspension is contemplated, the practitioner must be informed of the allegation, the proposed action (suspension) and informed of the opportunity to attend an oral hearing, the date to be specified, with at least two working days’ notice. Whether the practitioner attends the oral hearing or not, the PLDP (in England) may suspend the practitioner with immediate effect or impose conditions. In Wales, the practitioner can be suspended with immediate effect.

A line graph to show the average length of closed suspension episodes by financial year for suspensions which began from April 2018 and ended by March 2023.Mean length in months: 2018-19- 14.13 2019-20- 16.00 2020-21- 8.35 2021-22- 10.05 2022-23- 4.53 Median length in months: 2018-19- 7.75 2019-20- 13.10 2020-21- 5.55 2021-22- 6.20 2022-23- 4.17
The above chart is in respect of individual episodes of suspension and includes a small number of episodes which relate to the same practitioner.

Whilst there has been an increase in the number of suspension notifications received, the length of suspension episodes has shown signs of decreasing. Suspensions which began in 2019/20 had the longest mean and median average length, whereas the average length of suspensions which began in each of the following three financial year periods was at least 35% less.

This decrease may be attributed to our increased engagement with colleagues in NHS England and Welsh Health Boards upon receipt of suspension notifications, in addition to our proactive and ongoing review of suspension cases with these organisations.

A bar chart to show the average length of closed suspension episodes by type of regulation for suspensions which began from April 2018 and ended by March 2023.Mean average in months: 12(6) (England)- 28.88 12(1A) (England)- 13.01 12(1) (a) (England)- 15.54 12 (1) (b) (England)- 10.02 13 (1) (a) (Wales)- 8.70 13 (1) (b) (Wales)- 10.22 Median average in months: 12(6) (England)- 26.78 12(1A) (England)- 12.22 12(1) (a) (England)- 10.80 12 (1) (b) (England)- 6.21 13 (1) (a) (Wales)- 5.85 13 (1) (b) (Wales)- 4.50
The above chart is in respect of individual episodes of suspension and includes a small number of episodes which relate to the same practitioner.

There is a noticeable difference in the average lengths of suspension episodes across the different types of Regulation under which a suspension was imposed. Immediate suspensions initially imposed under Regulation 12(6) (England) – considered necessary to protect patients and/or the public – were over and above the longest type of suspension, with the average length being double that of the next highest mean (Regulation 12(1)(a)) and median (Regulation 12(1A)) averages. It should be noted, however, that a Regulation 12(6) suspension is a Regulation 12(1)(a) suspension, albeit imposed immediately. It may be that we have not received notification of a change in the applicable Regulation following an immediate suspension under Regulation 12(6), which may explain the longer than expected duration of these particular suspension episodes. We have separated these decision types for the purposes of this Insights publication.

Suspensions imposed under Regulation 12(1)(a) (England) and Regulation (13)(1)(a) Wales should only be in place for a six-month period, but our data shows some suspensions under these Regulations exceeding this time. In English cases, for these and immediate suspensions, we infer that it is likely that either a mandatory suspension (under Regulation 12(1A)) was later imposed due to interim action taken by the Regulator, or the basis for suspension was varied to Regulation 12(1)(b) and notification of this was not received by NHS Resolution.

To address this, we are committed to continued proactive engagement with NHS England’s professional standards teams to ensure that the basis for suspensions, and any later variation in Regulation, are communicated and recorded clearly on our records and to ensure fairness to practitioners throughout the process along with accuracy of the data that we hold.

A pie chart which shows the suspension end reasons for suspensions which began from April 2018 and ended by March 2023:Revoked with no notification of other substantive action- 36 Discretionary removal from Performers List- 28 Mandatory removal from Performers List- 13 Practitioner withdrawal from Performers List- 8 Conditions imposed- 58 Contingent removal (wales)- 8
The above chart is in respect of individual episodes of suspension and includes a small number of episodes which relate to the same practitioner.

There are a variety of reasons why a suspension may come to an end. This can be because a case is considered substantively and the medical/dental practitioner is removed from the Performers List, or substantive conditions are imposed. By way of example, a suspension imposed by a regulator following a fitness-to-practise hearing (either substantively or immediately pending a substantive suspension or erasure taking effect) would lead to a practitioner being mandatorily removed from the Performers List.

Most suspension episodes concluded with the practitioner retaining their inclusion on the Performers List, either by revocation of the suspension with no notification of other substantive action (24% of suspension episodes) or through the imposition of conditions on their inclusion (44% of suspension episodes). This represents a positive indicator for retention of the NHS workforce, particularly at a time when primary care services are under significant pressure.

In England, Regulation 12(21) allows NHS England to revoke a suspension with immediate effect where evidence comes to light that revocation will not compromise the protection of patients, members of the public or the public interest. In Wales, Regulation 13(10) allows NHS Wales to revoke the suspension at any time.

For those practitioners who were removed from the Performers List at the conclusion of a suspension, 19% were removed discretionally by NHS England or Wales, whilst 9% were removed on a mandatory basis, due to their erasure or substantive suspension from their regulator’s register.

Case study

The following is a fictional case study, drawn from our experience of providing advice and support in suspension cases, and presented for illustrative purposes only.

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A newly qualified GP was employed as a salaried GP by the practice where they had completed their training. After 18 months, the practice offered the practitioner a partnership, which they accepted. Within six months, concerns were raised about the practitioner’s performance, with two index cases of serious concern referred to NHS England. In both cases, patients had died shortly after seeing the practitioner. The practice was sufficiently concerned to suspend the practitioner and contacted NHS England for advice and to inform them of the issues. As they undertook other work (for example, out of hours) NHS England considered that there was a potential patient safety risk and imposed an immediate suspension which was subsequently ratified by the Performers List Decision Panel (PLDP) in accordance with the Performers List Regulations.

NHS England contacted the Advice service who provided advice on investigating the concerns in a balanced and measured manner. Advice was also given on alternative options to suspension, and this was subsequently revoked and replaced with conditions.  The practice was supportive, removing their suspension, and they assisted the practitioner in complying with the conditions. An Occupational Health referral did not identify any issues regarding the practitioner’s health.  A clinical performance assessment was provided by the Advice service, which identified several areas for improvement for the practitioner. This resulted in an Advice service drafted professional support and remediation action plan, which was implemented with support from NHS England and the practice. The practitioner was ultimately successful in completing the action plan and the conditions were later removed by the PLDP.

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What factors should be considered when considering a suspension from the Performers List and how does the Advice service assist?

While patient safety is paramount, the impact of suspension on the practitioner and the service are real. Careful risk assessment should therefore be carried out by the decision makers (Responsible Officer/Medical Director/Performers List Decision Panel (England)/Reference Panel (Wales)) before a suspension is imposed and should include consideration of the following:

  • What is the concern?
  • What is the practitioner’s response (insight or admissions and a commitment to reflection or remediation may suggest that alternatives to suspension could reasonably be considered)?
  • Is there an immediate need to protect patients, the public or the public interest (if so, should a suspension be imposed without notice)?
  • Are there workable alternatives that could be put in place, for example voluntary undertakings/agreement terms?
  • If the practitioner has made representations in relation to suspension, have these been taken into account?
  • Are there any health concerns for the practitioner which should be considered? Where health concerns arise, suspension should be used only in exceptional circumstances, for example where the practitioner’s health presents a significant risk and there are concerns regarding their continuing in practice while health issues are resolved.

The focus of our advice work is to support early identification and resolution of performance management concerns to prevent harm to patients and increase the opportunity for the individual to return to safe practice. Our advice in Performers List suspension cases has the following aims:

  • Ensuring that a suspension is only imposed in line with the relevant Regulation.
  • Ensuring a suspension does not continue for longer than is necessary.
  • To support fair and consistent management of suspension cases.
  • In cases of mandatory suspension under Regulation 12(1A) (England), our advice will include considerations around the extent to which the organisation is able to investigate and the importance of sharing information with the Regulator, as evidence gathered may allow the Regulator to review their suspension and allow a return to work with or without interim conditions.
  • That options other than suspension are considered when determining whether a suspension is necessary.
  • That suspension cases are monitored on a regular basis.
  • That action is taken to progress cases expeditiously wherever possible.

This is alongside advising on the management of performance concerns more generally. We encourage organisations to contact us as early as possible when considering whether a suspension might be a necessary course of action. Where a decision is made to impose a suspension, we will remain available for ongoing advice and support. We will also proactively review cases with organisations to establish if any change in events deem a suspension to be no longer appropriate. We actively encourage organisations to inform practitioners when advice has been taken from us, and to share our correspondence.

Supporting the practitioner

We are happy to undertake discussions with practitioners and advice in these circumstances can involve explanation of the procedural aspects of suspensions or list management processes or to signpost them to sources of support.

Organisations should ensure that practitioners are informed, clearly, of the reasons why action has been considered necessary and should ensure that the practitioner has an opportunity to respond to the allegation and propose alternatives.

Practitioners should be kept informed of developments in the case and reminded that they may request a review in line with the Regulations.

Ensuring that a practitioner has access to professional and wellbeing support is also essential as the impact on practitioners of Performer List management processes cannot be underestimated. A list of support organisations can be found on our website.

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Footnotes:

  1. Primary care doctors: General Practice Workforce, 31 March 2023 – NHS Digital
  2. Dentists: Registration reports (gdc-uk.org)

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