Insight report resource
NHS Resolution’s Practitioner Performance Advice service has been preparing action plans for doctors, dentists and pharmacists since 2008 and has developed considerable expertise in the field of professional support and remediation.
Through our action plans, we have helped many practitioners return to safe and effective practice, often after a long period of absence from the workplace or when their skills had fallen below an acceptable level.
In this publication, we look at the 74 action plans we produced between April 2020 and March 2022 to identify key themes and features. We note that during this time the NHS was responding to the Covid-19 pandemic, resulting in unprecedented pressures on frontline services and practitioners. This did not, however, change the content or delivery of our action plans, which were crucial in supporting retention of practitioners and safe practice during this time. By sharing this information, we aim to raise awareness of how the PSR service can support frontline NHS organisations in delivering effective remediation and/or reskilling programmes for practitioners, which embed safe and effective local practice.
The analysis featured in this publication provides an introduction to our PSR action plan work.
We have committed to undertake further analysis on case outcomes to inform a greater understanding of our work in this area, to be presented in a future Insights publication.
- The majority of our action plans were produced for surgeons.
- In secondary care, most plans were produced for practitioners at consultant grade.
- For those practitioners requiring an action plan for re-skilling purposes after returning to practice, the most common reason for absence was local restrictions on their practice.
- All of our action plans featured an objective to address clinical skills¹. In addition, the objective that featured most often alongside clinical skills was communication, followed by team working.
- The majority of our action plans were produced for male practitioners.
- Over half of our action plans involved practitioners aged between ages 45 and 54.
- More than half of our action plans involved practitioners from an Asian or Asian British, Black or Black British, or other ethnic background.
- The majority of our action plans were produced for practitioners who had qualified outside the United Kingdom.
What is a PSR action plan?
We hold a unique position in supporting NHS organisations to effectively manage and resolve performance concerns, and have developed a robust methodology for producing PSR action plans.
An action plan is a bespoke tailored programme of activities, designed to address the individual needs of a practitioner, as well as those of the service.
When can an action plan help?
An action plan can help to support practitioners in a range of different situations, such as:
- where an employer has identified areas that need remediation, for example through an internal investigation, or a report by a regulatory body or royal college.
- where a practitioner needs a period of reskilling, reintegration and/or support after returning to work following a period of absence from clinical practice for any reason, such as career break, parental leave or sickness, or where their practice has been subject to restrictions.
- where an employer has concerns about the professional behaviours of a practitioner which need to be addressed.
- where a practitioner has undergone an assessment (clinical performance or behavioural) undertaken by the Advice service, which has identified a need to support them to deliver sustained, safe and effective practice.
- where a local assessment undertaken by an employer has identified a need to support a practitioner to deliver sustained, safe and effective practice.
In many cases there is a combination of the above circumstances (see the case study below).
What does an action plan include?
Each action plan contains:
- Objectives which describe the area of practice/behaviour to be addressed.
- Activities to support the achievement of the objectives: we use a wide range of interventions, both general (such as audits) and specialty-specific assessments.
- Levels of supervision needed throughout the plan, decreasing as satisfactory progress is made.
- Regular review points where progress is assessed.
- An overall timeframe for completion.
- An agreement between the organisation and the practitioner.
It is important to note that we prepare the action plan as a draft document that is to be agreed by the organisation and the practitioner. They are responsible for engaging directly to discuss the plan and to satisfy each other that it meets service needs and the development needs of the practitioner. This approach encourages collaboration between the organisation and practitioner in agreeing and achieving the goals of the plan. We are not involved in the delivery of the action plan, but we provide a guidance document about how to implement the plan, a progress report template and information for individuals who will be providing supervision. These and other resources can be found on our dedicated PSR page on the NHS Resolution website. Our advisers are also available to provide additional support during the course of the implementation of an action plan.
A detailed look at what our review of action plans found
The following chart shows the number of action plans for different specialty groups. It can be seen that surgery² is the largest group, with over a third of action plans relating to practitioners working in this specialty, followed by medicine (all medical and paediatric specialties) and then general medical practitioners. Where action plans were prepared for secondary care practitioners, 61% of them were for consultants.
Types of action plan
We looked at the types of action plans produced since April 2020 and found that over two-thirds contained elements of reskilling (for example, where practitioners require a period of support following a return to work or a change in their scope of practice). In more than half of cases, there were elements of both reskilling and remediation (where areas for development or improvement in practice had been identified).
In 69% of action plans in which practitioners were returning to work following an absence, the reason for absence was a restriction from practice. For all plans produced for practitioners restricted from practice, 81% were due to local restrictions, with the remainder related to restrictions imposed by the regulator or due to the involvement of other external bodies, such as ongoing legal proceedings.
A review of the objectives found that each action plan contained at least one objective relating to clinical skills or practice. However, very few contained solely clinical objectives and the majority included other objectives. We have grouped the other objectives into five areas:
- Providing education and training
- Record keeping
- Team working.
The objective most commonly featured in action plans was effective communication with team members and/or patients and relatives, which appeared in 62% of all plans. Next was team working, which was included in half of the action plans.
With the exception of general practice and psychiatry, where a record keeping objective appeared most frequently, a communication objective was the most frequently occurring non-clinical objective in all specialty groups.
Across secondary care, objectives to address practitioners’ approach to team working featured in over 50% of plans. In comparison, team working objectives appeared in fewer than 30% of plans for general medical practitioners. Leadership objectives featured most often in action plans for consultants, appearing in 58% of plans for this grade, which is perhaps understandable given that leadership is a key aspect of the consultant role.
Case Study: How an action plan helped a practitioner return to full duties
(this is an illustrative, composite case study, to preserve confidentiality)
Mr G is an experienced Consultant Surgeon – over the course of two years, there were a number of concerns raised in relation to his clinical competence, his behaviour and his communication skills. These concerns were either raised anonymously or by a specific member of his immediate team.
As a result, the Trust restricted his practice to outpatient work only, pending completion of a local investigation.
Due to significant delays in the investigation process, Mr G became increasingly deskilled in surgical procedures and inpatient work, and his confidence was negatively affected.
The outcome of the Trust investigation showed that there were no clinical concerns but noted that his working relationships with surgical team colleagues could be improved. The recommendation was to return Mr G to full surgical duties at consultant level, with some development activity required in terms of his communication and leadership.
We drafted an action plan, with two objectives to address these areas for development, which were:
The plan set out a range of activities and support to help Mr G meet these objectives. These included:
- A sliding scale of supervision to support safe re-skilling and gradual return to complex surgical practice.
- Specialty-specific workplace based assessments, such as Case-based Discussions, Direct Observation of Procedural Skills, Clinical Evaluation Exercises, Non-Technical Skills for Surgeons and Multisource Feedback.
- Regular meetings with a supervisor for feedback and ongoing support.
- The use of a coach to help Mr G focus on communication, leadership style and reflective practice.
- Specified formal review points (at two, four and six months) and summary sign off.
The Trust and Mr G discussed and agreed the plan, which he successfully completed within six months, and he was able to return to the full scope of work as a Consultant Surgeon.
How to find out more about our Professional Support and Remediation 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.
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 review all our previous publications on our Insights publications webpage on the NHS Resolution website.
If you are interested in hearing more about our research and evaluation Insights work, please get in touch with us firstname.lastname@example.org.
If your organisation does not already have access to this web service (for Performers Lists Checks) and you wish to use it, we will require details of one person per organisation who, in addition to completing checks, will act as local administrator with rights to grant system access to colleagues. We require their name, position, organisation, email address and telephone number. Please send these details to email@example.com
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.
- When referring to ‘clinical skills’ in this paper, we denote solely technical and procedural skills to differentiate from other skills integral to a clinical setting, for example, record keeping, communication etc.
- Comprising all surgical specialties, except obstetrics and gynaecology.