Practitioner and healthcare organisation experiences of Professional Support and Remediation action plans

Insight report resource

This is the second Insights paper published by NHS Resolution’s Practitioner Performance Advice Service (‘the Advice service’) which focuses on Professional Support and Remediation (PSR) action plans. The first, published in February 2023, looked at the key features of action plans. In this follow-up, we focus on the individual experiences of practitioners using action plans and key staff within healthcare organisations1 responsible for managing and supporting the plans. Our evaluation involved semi-structured interviews with eight individual practitioners and four healthcare organisations, covering twelve individual action plans issued between December 2019 and May 2022.

We would like to thank everyone who agreed to participate in this evaluation.

Practitioner Performance Advice

Key reflections of this Insight:

  • Practitioners can sometimes feel anxious and frustrated at the outset of an action plan. We can alleviate this by providing practitioners clarity and reassurance on the purpose and process at an early stage.
  • Practitioners value engagement with the Advice service to enable a direct, positive impact on their own action plan. By being transparent and effectively communicating with practitioners we will help them feel supported through the process.
  • Practitioners and healthcare organisations place value on having a key contact within the Advice service to discuss the aims and delivery of the action plan. Through regular communication with practitioners and healthcare organisations over the duration of the plan we will work together to achieve successful outcomes.
  • Practitioners and healthcare organisations feel there is sufficient emphasis within our action plans on ensuring patient safety. We will continue to ensure the critical importance of patient safety is reflected in our plans and supporting information.

Why are we sharing this Insight?

  • For healthcare organisations requesting an action plan: To better understand how practitioners may experience the process so that healthcare organisations can work with them and others involved in the plan to achieve the best possible outcome.
  • For practitioners proceeding with an action plan: To better understand the steps involved and learn from the experience of other practitioners who have already completed an action plan. This will help practitioners undergoing plans in the future to recognise how their engagement with the process can result in successful completion of a plan.
  • Continuously improving our service: We undertook this evaluation with a commitment to act upon its findings. By understanding the experience of both practitioners and healthcare organisations we can continue to refine and improve our action planning service to support practitioners to return to valued and effective practice for the benefit of patients.

 

Our review also builds on NHS Resolution’s report, Being fair 2 , which illustrates how patient safety is best served when organisational culture fosters a compassionate and fair workplace. Being fair 2 describes accountability as being “about sharing what happened, and learning and being completely responsible for making changes for the future safety of staff and patients”.

Where a doctor, dentist or pharmacist has been identified by their healthcare organisation as needing support to deliver sustained, safe and effective practice, a request can be made to the Advice service for an action plan. An action plan is a bespoke, tailored programme of activities, designed by our service to address the specific needs of a practitioner, as well as those of the service and its patients. It can focus on remediation, and/or supporting a practitioner’s return to work following an absence. Action plans can include a range of staff with clearly identified roles to support the process and the practitioner throughout the plan, and their responsibilities at each stage.

Methodology

Our evaluation involved semi-structured interviews with eight individual secondary care doctors and four primary and secondary healthcare organisations, covering twelve individual action plans issued between December 2019 and May 2022. This period included the start of the COVID-19 pandemic and an exploration of how COVID-19 had an impact on our work is covered in our Insights paper Practitioner Performance Advice casework during the Covid-19 pandemic. The sample was voluntary and selective and the timeframe selected ensured recency, as well as allowing sufficient time for respondents to have reflected on their experiences. Although the sample was small, respondents provided rich detail and revealed practical options for service enhancement that will ultimately support patient safety through our action plans. We recognise the experiences shared cannot be considered representative of the views of all practitioners and healthcare organisations who have used our action planning service.

We used thematic analysis methodology to evaluate the experiences of those involved with these action plans. While the interviews highlighted areas for potential improvement for the service, responses were not uniform. Our findings are grouped into four broad themes, each with specific sub themes: initiation of the plan, implementation of the plan, communication and patient safety.

Findings

1.    Initiation of the plan

When requesting an action plan, healthcare organisations are asked to complete a request form setting out the expected outcome(s), to assist in its preparation, for example to support a practitioner’s return to their full range of safe and effective practice following an extended period of absence. Both the practitioner and healthcare organisation must agree and finalise the action plan before it can commence.

Themes

Themes that emerge during the initiation of the plan include anxiety about the process, frustration with the process, practitioner health, work-place based assessments, specificity of plans, mentoring and coaching, length and complexity, comprehensiveness and delays.

Anxious about the process

The start of the action planning process can often be met by the practitioner with some trepidation. One practitioner related, “When [the healthcare organisation] first mentioned NHS Resolution, I was really panicking”. These feelings can continue with the plan itself; another practitioner said, “I found it difficult to read because you are under enormous stress … it makes it difficult to go through the document … once I read it with a clear mind and had a discussion, I got the gist of it and put my mind to rest”. While we emphasise that action plans are developmental, the initial worry is understandable for professionals whose performance is under scrutiny.

While some anxiety in this situation may be inevitable, it makes sense for all involved (the Advice service, practitioner, healthcare organisation, and all those with a role within the plan) to work to acknowledge it and explore how to alleviate any potential negative impact, for example, delay, non-completion, impact on health and wellbeing, on the practitioner and achievement of the plan’s objectives.

Frustrations about the process

Some cases highlighted unresolved discrepancies in the information provided by the healthcare organisations and practitioner, resulting in differences of opinion around the circumstances leading to the Advice service being contacted to offer support. In these cases, practitioners spoke of their ongoing objections and frustration related to past events but also their acceptance of the inevitability of proceeding with the remediation support. “It was something that had to be done”, said one, “It’s all bad. That’s almost the long and short of it, really”. However, this reluctance often dissipated within the duration of the plan, but not in all cases.

Feedback from healthcare organisations about the initial stages included observations about the “detailed” forms they had to complete to request an action plan and “trying to work out what we needed and how it needed to fit into that initial gateway form … it did feel like there was a lot of duplication”.

Mentoring and coaching

Our action plans incorporate people in several supporting roles, for example, supervisor, mentor and coach, to assist the practitioner’s progress. From our experience there is variation amongst practitioners and healthcare organisations in embracing this support. For example, a practitioner may not accept the value of a mentor or be reluctant to accept a particular individual assigned to the role; a healthcare organisation may not have the resource to identify a suitable person or (for coaches) pay for the sessions.

Our interviews revealed quite different levels of engagement with this support, from both healthcare organisations and practitioners. Some practitioners questioned the use of mentors, one saying, “in today’s world mentoring is seen as a big thing … so maybe I didn’t find it overly valuable, but it was a close friend of mine”, while another noted, “I met with the mentor [who] felt there was actually no reason to meet him”.  While implementation of the mentor role in these cases was evidently less than ideal, others spoke of their mentors in positive terms.

The coaching role also had varied responses from practitioners. One practitioner described their coach as “very good… supporting me by coming up with challenges and [then] further support” and another noted their coaching was “really useful” and they were using the strategies gained in their wider / personal life. Another practitioner attended only one coaching session and “realised I needed to become a coach [myself] so I enrolled on a coaching programme and that helped me the most.”

Work-place based assessments (WPBAs)

One central element of supervised training and practice is WPBAs, for example Case-based Discussions and Mini-Clinical Evaluation Exercises, employed to provide structured feedback and measured progress to ultimately help ensure patient safety. The inclusion of these instruments met with mixed reactions from practitioners.

One practitioner spoke of WPBAs within the context and structure of the plan’s other elements, such as reflection and review points, noting it made it “quite clear as to what the expectations were … it was literally laid out.” Comments from healthcare organisations on WPBAs were positive, with one saying “[they] are helpful … the aim of getting back to [practice] is such a broad task” and these elements can help ‘break down’ goals into ‘mini-goals’. However, some practitioners held different opinions. One dismissed WPBAs as “old medical school tricks” while another stated “[the Advice service] failed to realise I was not a trainee”.

Although initially designed for trainee grades, WBPAs have had their validity and reliability tested for a variety of contexts – there are no appropriate WPBAs which have been developed specifically for post-training situations. We recognise that returning to activities completed in training could require some adjustment for more experienced practitioners, but conversely can be welcomed by healthcare organisations for their familiarity.

Specificity of plans

Questions around the specificity of plans revealed a range of opinions, mostly positive. Two practitioners felt their plans were too generic, one noting “It didn’t feel like the plan was tailor-made. It was like a tick-box standard plan.” Others, however, said that the plans were specified for their development needs. One did not feel this way initially and thought the plan “quite generic … but in the end I think that it was quite well balanced and was able to address and actually make me a better clinician.” Another felt their plan immediately resonated with their requirements: “it was actually targeted and tailored to my specific needs”.

Length and complexity

Respondents did not provide a consensus view on the length and complexity of action plans. One practitioner observed their plan was “completely over the top” and a shorter plan could be completed in less time. Another remarked, “Everything was thrown in, and I know how organisations work. They try to… do everything so that they can’t be accused of not doing enough.” The Advice service intentionally create comprehensive plans and acknowledge that we cannot fully know nor control local circumstances so make it clear that parameters should be adjusted to take into account local knowledge and expertise.

Comprehensiveness

Multiple respondents, however, valued the comprehensiveness of the plans, with one noting they were “very thorough and very clear”. Another practitioner reported transition in their thinking, first considering their four-block plan as “…a bit too intense. But in the second [block] it eased a bit. Third it eased again … I started with reluctancy, but midway through the process then I understood why people are doing this to me … rather than trying to find fault……these guys are trying to help me!”

Delays initiating the plan

The most frequently mentioned topic within the plans’ implementation was how long it can take before the action plan commences. While we create the plan within 20 working days of accepting a request, there can be a considerable delay before it starts for a variety of reasons. One practitioner appealed, “I truly wish that for clinicians in the future, that the outcome … will happen much, much faster”.  There was notable overlap from practitioners’ comments on the impact of delays, from de-skilling to financial consequences and impact on health.

Delays also often occur where an external placement is being sought for the practitioner to complete the action plan. Given the significant challenges faced by NHS frontline workplaces finding an external placement can be very difficult for a healthcare organisation as it places pressure upon the agreeing host, and many healthcare organisation respondents reported this significantly contributed to delays in starting the plan.

2.     Implementation of the plan

Once the action plan has been prepared we share it with both the healthcare organisation and practitioner. The healthcare organisation is expected to review the plan to make sure that it is appropriate to meet the objectives and to identify any adjustments where required. The practitioner should also be given the same opportunity by their healthcare organisation to review and comment on the plan. Where helpful, we are available to discuss and action changes to the plan. The healthcare organisation should engage fully with the practitioner to consider and agree the finalised version of the action plan.

Themes

Implementation of the plan themes include placements, collaboration, environment, organisational culture and not undertaking placement.

Placements

For a variety of reasons – for example, logistics, physical space, team dynamics – action plan activities are frequently completed outside of the practitioner’s usual place of work, on a placement, though not all practitioners welcomed the idea of completing the plan somewhere new.

Others embraced the change and shared their view that the placement could potentially be seen as a catalyst for change. One acknowledged that “two clinicians [who] can’t work together isn’t unheard of” and accepted the placement as the best place to “refresh my skills” before returning to their principal place of employment on more solid ground to address the “challenging relationships” that also formed part of the case. Another made it clear that the placement was key to their successful completion of the plan because by stepping temporarily away from the environment where the concerns were identified allowed the practitioner to have a productive and positive outcome.

One fundamental aspect of a placement that needs careful consideration is the practitioner’s induction phase to the new work environment. Being fair 2 stresses the particular importance of induction particularly for what it refers to as ‘outsider groups’, i.e. those in minority groups when it comes to ethnicity, gender, age, sexual orientation, gender identity, nationality or religion as well as a person’s type of work. Our action plans routinely include a structured induction for all placements to help ease the practitioner into the new working culture, aiming to offset isolation, settle the practitioner and enhance the potential for learning.

Collaborating on the plan

Practitioners consistently referenced the ability to have direct collaborative impact on their plans, providing evidence (albeit in a small sample) that where they felt they had agency, they felt more positive about the experience. While all our action plans include direct involvement from both practitioner and healthcare organisation (through individual interviews), there is potential to see how this might be enhanced.

Working environment

Beyond induction, the working environment affects all aspects of performance. This was reflected by a number of respondents and resonated with one practitioner in particular who thought, “[the Advice service] needs to consider the fact that the NHS is multicultural, and there are many other ways of addressing the problems that are not as obvious … it’s about interpersonal relationships.” They felt a diversity of cultures also means a diversity of potential solutions and emphasised individuals were also part of more complex inter-cultural team issues.

Not undertaking a placement

One healthcare organisation described the experience of a practitioner who did not leave for a placement. The practitioner was said to be initially “very resistant” to the idea of a plan but not able to alleviate the issues identified. “The plan support was put in place, [the practitioner] said suddenly, ‘I was able to be free and I saw different ways of doing things. Although they completed this plan in their normal place of work, the practitioner, and their healthcare organisation, reported its success in improving the essence of the working environment to facilitate change and growth.

Organisational culture

The organisational culture’s impact on action plan outcomes was a recurrent theme for both practitioners and healthcare organisations. There were many comments on positive aspects of organisational culture contributing to successful outcomes, including within the action plan and the Advice service’s input, and also consistently with regard to the environment where the plan was conducted. However, it was also remarked that clinicians were not always ideal managers, which could hinder the progress of a plan.

Another practitioner conversely reported a very positive dimension of their plan’s interplay with the working environment: “I was trained in another country. So, the action plan helped me get much more experience about the structure of the whole NHS and how the delivery of service is and what is expected from the clinician as well, and of course this has a good impact in my career life. I’m much more structured in my work.” In this case, it appears that focusing on the plan in turn unlocked insight into the wider organisational culture and approach to service delivery.

3.     Communication – supporting the change

The action plan is an agreement between the healthcare organisation and the practitioner, and both must be satisfied it meets the service needs and the needs of the practitioner. Any decisions about the implementation of the plan and ongoing management of the case rest with the healthcare organisation, although we are available to provide ongoing impartial advice if helpful.

Communication was a recurrent theme that respondents highlighted as critical and underpinned transparency, clarity of process, availability of the Advice service and supported dealing with complex problems.

Themes

Communication and supporting the change themes include the need for transparency, clarity of process, advice input and dealing with complex problems.

Transparency

Practitioners reported mixed experiences with communication related to their action plans. For several, there was not the expected transparency in communication with their healthcare organisation, with open mistrust described at times, suggesting from the outset they felt communication could be intentionally distorted and biased.

Only one healthcare organisation spoke of communication, saying “we’re encouraged to share the information with the practitioners. So, they’re aware as well that we’re seeking advice, we are looking at different options for them”. The experience of practitioner respondents suggested that information was not always forthcoming from healthcare organisations and it is important we reinforce the importance of information sharing as a key part of the process.

Clarity of the process

A practitioner respondent described a communication intervention that altered the course of their plan: “somebody from [the Advice service] offered to talk to me. One lovely lady, she called me [and] she completely changed my mind within 20 minutes. It was amazing … She told me clearly about the plan and said “this is not a disciplinary procedure. We are trying to support you. We are trying to make improvement in your practice. If you cooperate, it’s very good for you, and you don’t need to feel bad about it.” Seems like she was preaching to me and at the end of the phone call. I said “OK, that’s fine. I’ll go ahead”. So, I’m really grateful for that person.”

The same practitioner summarised their experience positively: “The ‘me’ before the NHS Resolution process and the ‘me’ after is completely different. I’m a matured, very confident consultant now.” The only improvement this practitioner suggested was more, and regular, contact with us during the process.

Advice input

The healthcare organisations interviewed were positive about communication with us at the outset, relating that we were always available to discuss and advise on cases and act as a ‘sounding board’.  However, no references were made to the same transpiring during an action plan’s duration.

Some practitioners called for more direct communication between them and the Advice service: “it would have been very helpful if someone from [the Advice service] had a meeting…with me and my case manager…[the Advice service] never corresponded with me. They were only talking to the trust.” Another practitioner noted that there could be more communication between the Advice service and the healthcare organisation, for example, emphasising the importance of supporting the action plan’s components, such as assessments. We are extremely grateful for this feedback which will inform how we can continue to improve and enhance our action planning service.

Dealing with complex problems

One practitioner concluded, “[the Advice service] met with a really complex problem and provided a plan to move forward … I’m happy there was a way forward … I think my case and many others in the UK, it has to do with interpersonal relationships between colleagues.” We would agree that these interpersonal dynamics are crucial for understanding and resolving issues.

4.     Patient safety

Patient and staff safety and public protection must be carefully considered when reviewing progress through the action plan. It is for the healthcare organisation to assure itself that the practitioner has demonstrated satisfactory progress and that patient safety is suitably protected throughout.

Themes

Patient safety theme: The patient safety focus of action plans.

Perspectives on patient safety focus of plans

As patient safety is a fundamental core outcome of any created plan, all respondents were asked if they felt there was sufficient emphasis on this aspect. Importantly, all healthcare organisations strongly agreed it was, as did most of the practitioners. “It was quite explicitly structured in that way” said one practitioner, with another concurring: “Absolutely. Yes, it did. The main focus was patient safety. The emphasis was there throughout the process.”  Both comments are representative of the majority received.

A couple of practitioners were less convinced that the plan improved patient safety. One remarked, “it’s not like I was allowed to go and harm patients with someone following or looking over me. So… the short answer is yes, but in a very minimal way,” while another said, “it doesn’t shine through in the action plan”. While these responses were in contrast to the majority, we will review our template and supporting information to ensure that individual plans continue to place emphasis on the critical importance of patient safety.

What’s next?

The central focus of this evaluation was to identify and aid improvement of the PSR action planning service. While both healthcare organisation and practitioner interviews highlighted areas for potential improvement the responses were not uniform.

We are committed to supporting healthcare organisations and practitioners so that all practitioners working in the NHS have an equitable and fair experience of the management of concerns about their practice which is not adversely affected by their diversity. Our PSR service will continue to adhere to this inclusive ethos.

We will build upon learning from this evaluation, reviewing and developing the full service and supporting material.

Process

  • We will review processes for efficiency (e.g. look to simplify aspects, such as the referral form; interview questions for both practitioners and healthcare organisations will be reviewed to ensure information supporting the case is optimised).
  • We will ensure supporting information makes explicit why WPBAs are used; we will continue to source new and revised tools for use within action plans that are validated for reliability and validity.
  • We will review and develop supporting information for the additional roles within the plans, to ensure supervisors, mentors and coaches can achieve their full potential.
  • We will review supporting information for external placements to ensure sufficient emphasis is given to how practitioners should be supported at the outset of, and during, the placement.

Communication

  • We will review all action plan communication to improve transparency and support  for practitioners.
  • We will incorporate ‘touch points’ between us, the practitioner and healthcare organisation during the lifespan of an action plan.
  • We will review our approach to ensure practitioners feel appropriately involved in both the development and completion of their plans.
  • We will ensure both healthcare organisations and practitioners know to contact us at any point for support where required.

How to find out more about our PSR action planning service

You can find out more about action plans by reading our PSR guide.

Further information about our Professional Support and Remediation Service and how to request an action plan can also be found on the NHS Resolution website.

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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 on our Insights home 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.  For ease of reference, we have used the term ‘healthcare organisation’ to cover both employers and contractors of practitioners, recognising that (for example) primary care practitioners may be part of a contractual rather than an employment relationship.

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