Specialties in Practitioner Performance Advice cases: Key themes and use of our services

Insight report resource

In this Insights publication we draw from our unique position to share the range of concerns about practitioner performance across the NHS. We provide support and focused analysis of our casework of secondary care specialties from 2018/19 to 2022/23, which make up the majority of our cases. Throughout this Insight we use the term ‘specialty’ as a shorthand to refer to speciality groups which are made up of various specialties to improve the readability of the Insight. For example, we refer to surgery as a specialty rather than surgery as a group of specialties.

Why are we sharing this?

Practitioner Performance Advice (Advice) are publishing this Insights paper 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 specialties at my organisation?
  • Are there services on offer from Advice that my organisation could make use of at an individual or team level?
  • Could my organisation benefit from the revised ’just and learning culture charter’ at the end of Being fair 2?
  • Are we making contact with Advice early enough to support prompt resolution?
  • Who should I share this information with?

Key points

  • Surgery, obstetrics and gynaecology, psychiatry and emergency medicine are the secondary care specialties which have the highest proportion of Advice cases per 1,000 doctors in the workforce for each specialty from 2018/19 to 2022/23. We explore key themes within each of these specialties and provide illustrative case studies.
  • Surgery: We discuss issues of behaviour and sexual misconduct in surgeons and the services available to support organisations and practitioners.
  • Obstetrics and Gynaecology: We reflect on the findings from numerous maternity service reviews that team working can be a key challenge and provide information on our new maternity team review service.
  • Psychiatry: We have found higher rates of health concerns cases involving psychiatrists at SAS (specialty and specialist), trust and training grades and we outline the specific support we can provide to both organisations and practitioners in these cases.
  • Emergency medicine: There has been an increase in cases involving doctors in emergency medicine since the COVID-19 pandemic and higher proportions of cases for SAS and trust grades in this specialty than we observe across secondary care specialties as a whole.

Which specialties are most frequently the subject of Advice cases?

In the 2,696 secondary care cases initially opened in the financial years 2018/19 to 2022/23, psychiatry, obstetrics and gynaecology, surgery and emergency medicine are the specialties which have the highest proportion of Advice cases per 1,000 doctors in their specialties in the workforce in England over this five-year period.

When considering assessments and action plans, surgery, general medicine, obstetrics and gynaecology and psychiatry are the specialties that use those services most frequently.

In our recent analysis of episodes of formal exclusion that commenced in the financial years 2019/20 to 2022/23 in England, specialties where the practitioner was statistically more likely to face exclusion were those of emergency medicine, obstetrics and gynaecology, surgery or the dental group.

Graph: Rate of Advice cases by secondary care specialty over five years. Specialty group of rate per 1000 doctors in each speciality. Psychiatry 37.4 rate Obstetrics & gynaecology 35.5 rate Surgery 30.7 rate Emergency medicine 23.8 rate Paediatrics 19.9 rate Anaesthetics & intensive care medicine 16.1 rate Radiology 15.6 rate Medicine 14.9 rate Pathology 13.4 rate Public health 9.9 rate Ophthalmology 8.6 rate

The data represents cases initially opened in the financial years 2018/19 to 2022/23. The analysis used NHS Digital workforce data from December 2021 and speciality groupings are aligned with NHS digital workforce data. Exceptions are the ophthalmology speciality which is shown separately from the surgery speciality and the dental group which is not shown.

Graph: Action plans, clinical and behavioural assessments issued by secondary care speciality Surgery Clinical and Behavioural Assessments 36 Surgery Actions plans 37 Surgery total 73 General Medicine Clinical and Behavioural Assessments 24 General Medicine Actions plans 12 General Medicine total 36 Obstetrics and gynaecology Clinical and Behavioural Assessments 14 Obstetrics and gynaecology Actions plans 11 Obstetrics and gynaecology total 25 Psychiatry Clinical and Behavioural Assessments 9 Psychiatry Actions plans 9 Psychiatry total 18 Anaesthetics and Intensive care medicine Clinical and Behavioural Assessments 10 Anaesthetics and Intensive care medicine Actions plans 7 Anaesthetics and Intensive care medicine total 17 Paediatrics Clinical and Behavioural Assessments 9 Paediatrics Actions plans 8 Paediatrics total 17 Emergency medicine Clinical and Behavioural Assessments 7 Emergency medicine Actions plans 5 Emergency medicine total 12

There were a total of 11 assessments and professional support and remediation action plans provided for practitioners from radiology the dental group and pathology. These specialities have been omitted to reduce the chances of individuals being identified as there were small numbers of assessments and action plans issued in each of these applications.

We have provided further analysis, case studies and links to specific relevant resources to provide further insight into cases in specialties that frequently use Advice services.

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Surgery – behavioural concerns

A recent publication from 2023 reports that from a survey of people in the UK surgical workforce, “Sexual misconduct in the past 5 years has been experienced widely, with women affected disproportionately. Accountable organisations are not regarded as dealing adequately with this issue”¹. Other research highlights low reporting of poor behaviour and sexual misconduct in surgery, with concerns about the negative impacts on careers being a frequent reason given for not reporting².

From our previous analysis, we found that the proportion of cases presenting with concerns about behaviour/misconduct is higher across secondary care specialties than in primary care (73% vs 49% of cases); however within secondary care specialties, surgeons do not appear to differ significantly from other specialties in terms of the proportion of behavioural concerns in our cases.

It is possible this may represent under-reporting of behavioural concerns to the employer, and/or Advice not being contacted by the employer regarding these types of concerns. We would like to remind employers that there is no threshold for contacting Advice and our earlier involvement may lead to earlier resolution. The surgery specialties where we currently see the highest number of cases are general surgery, trauma and orthopaedic surgery, ophthalmology, urology and cardiothoracic surgery.

If you are a doctor who has been the target of poor behaviour or misconduct from a colleague, primary sources of support will be through your employer, the BMA and medical defence organisations, however practitioners can also contact the Advice service and our advisers will try and identify specific sources of support that may be relevant to you.

The following Advice service and resources may be helpful when considering performance concerns for surgeons or if you are a practitioner.

Relevant resources and services

Insights: Surgeons who are the subject of our cases (2021)

Advice support for employers:

Advice resources for practitioners:

Surgery and behavioural assessment case study

blue divider lineObstetrics and gynaecology – team working

It is a national priority to improve the safety of maternity services³ given the patterns of repeated poor care, examples of which are reported in the Ockenden Report⁴, East Kent Independent Investigation⁵, the independent investigation into the death of Elizabeth Dixon⁶ and The Report of the Morecambe Bay Investigation⁷. As numerous maternity service reviews have illustrated, the culture in a maternity service is directly related to the quality and outcomes of the service. Too many maternity service reviews have found evidence of team dysfunction across different professional groups.

In response, a key priority from NHS Resolution’s strategy is to “Collaborate to improve maternity outcomes”.  Practitioner Performance Advice have committed to developing our service in respect of maternity, as well as to support organisations to reflect on themes and trends over time and consider any improvement action in relation to managing performance concerns and remediation. Below we outline specific support we can provide in relation to concerns in obstetrics and gynaecology, including our new maternity team review service.

Relevant resources and services

Advice support:

Learning resources: Team Reviews – Case Study

Maternity and team review case study

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Psychiatry – health concerns

Psychiatry is the profession where the Advice service see the highest proportion of cases with 37 cases per 1,000 psychiatrists in the workforce. We have noted a higher proportion of health concerns in specific grades of psychiatrists. When considering the concerns in the secondary care workforce as a whole, 19% of our cases involve a health concern which is a similar proportion for cases involving consultant psychiatrists (20% of 265 cases) but is much higher in SAS, trust and training grades in psychiatry (42% of 114 cases).

There are studies indicating that psychiatrists have poorer mental health than other doctors, possibly due to more work-related emotional exhaustion and isolation in the workplace, as well as individual causes such as a higher prevalence of pre-existing mental health problems⁸. However, it is not clear why this might be exacerbated in SAS and trust grades or why these cases are reaching Advice, although findings from one survey of non-consultant psychiatrists in Ireland found that a lack of supervision is significantly associated with burnout, lower satisfaction at work, and poorer psychological well-being⁹. Other published analysis of Advice data found that those in career-grade employment had significantly more concerns in colleague relationships than other grades¹⁰.

Our Advisers can provide advice to organisations where there are health concerns about a practitioner they employ. Advisers can also provide advice directly to practitioners where they may be concerned about some aspect of their own health or clinical practice or want to access advice about rebuilding their skills after a career break. Furthermore, our professional support and remediation service can provide 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.

Relevant resources and services

Advice support for employers: Professional support and remediation

Advice support for practitioners:

Psychiatry and return to work action plan case study

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Emergency medicine – SAS and trust grade doctors

Emergency departments in England provide services to patients under challenging circumstances. The Delivery plan for recovering urgent and emergency care services states that, “Urgent and emergency services have been through the most testing time in NHS history with a perfect storm of pressures impacting the whole health and care system but causing the most visible problems at the front door”¹¹. Advice have seen an annual increase in cases from emergency medicine since 2020/21 which may reflect these increasing pressures since the COVID-19 pandemic. There is also a higher proportion of cases involving SAS/trust grade doctors (46%) compared to these grades of doctors in secondary care cases at large (21%).

Below we outline resources which provide learning from claims in emergency departments and an illustrative case study of concerns around a doctor working in emergency medicine.

Relevant resources and services

Emergency medicine and Health Care Professional Alert Notice (HPAN) case study

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Want to find out more about the support available from Advice?

If you would like to further explore any themes highlighted by this Insights paper, employers have the opportunity to engage in a deep-dive analysis with their allocated adviser on the Advice 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 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 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 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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¹ Sexual harassment, sexual assault and rape by colleagues in the surgical workforce, and how women and men are living different realities: observational study using NHS population-derived weights, Begeny et al., 2023.
² Prevalence of bullying, discrimination and sexual harassment in surgery in Australasia – Crebbin et al – 2015 – ANZ Journal of Surgery – Wiley Online Library
³ Three year delivery plan for maternity and neonatal services, NHS England (2023)
Final report of the independent review of maternity services at the Shrewsbury and Telford Hospital NHS Trust (Ockenden, 2022)
Reading the signals-Maternity and neonatal services in East Kent – the Report of the Independent Investigation (2022)
The independent investigation into the death of Elizabeth Dixon
The Report of the Morecambe Bay Investigation
Improving the health of psychiatrists. Firth-Cozens (2007). Advances in Psychiatric Treatment
Burnout, Work Satisfaction, and Well-being Among Non-consultant Psychiatrists in Ireland. McLoughlin et al. 2021. Academic Psychiatry
¹⁰ Performance concerns in psychiatrists referred to the National Clinical Assessment Service. O’Leary et al. 2010. The Psychiatrist
¹¹ Delivery plan for recovering urgent and emergency care services, NHS England, 2023

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