Insight report resource
NHS Resolution’s Practitioner Performance Advice service provides healthcare organisations with advice on the management 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
- Interventions, such as actions plans and assessments
In this Insights publication, we look at over 700 primary care advice cases, received between April 2017 to March 2022, to identify key themes and features. By sharing this information, we aim to raise awareness of how Practitioner Performance Advice can support the management and resolution of performance concerns within primary care and signpost to useful resources.
When considering the content of this Insight, you may want to ask yourself the following questions:
- Are any of the situations in the case studies similar to those you are managing?
- Which services could my organisation use to help manage and resolve cases?
- Who should I share this Insight with?
Primary care advice requests – who contacts us
The vast majority of primary care advice requests we received from NHS organisations in England between April 2017 and March 2022 were from Professional Standards teams in the NHS England local teams, of which there are seven, divided regionally across England. The second largest number of advice requests were received from employing/contracting organisations, which includes, for example, training grade general practitioners working on a training rotation in a secondary care setting. We also provided advice to a smaller number of other organisations including out of hours service providers, GP confederations and individual practices in relation to their management of performance concerns in line with their local policies.
As part of our service level agreement with the NHS in Wales, we provide advice regarding employed and contracting primary care practitioners to the Health Boards in Wales. We also have similar arrangements in place to provide advice and support to Health and Social Care Boards in Northern Ireland.
Doctors in England are the largest professional group represented in our primary care advice requests and accounted for 470 requests received between April 2017 and March 2022. This does of course represent a very small fraction of the over 45,000 general practitioners working in the NHS in England¹.
Nearly 75% of the Advice requests we receive for primary care doctors in England are in respect of male practitioners. This is a higher proportion than the 42% of general practitioners working in the NHS in England who are male, as reported in the most recent NHS workforce data.
The two largest age groups represented in the NHS workforce data for England are 35 to 44, and 45 to 54, which, combined, represent 60% of the total number of general practitioners working in the NHS in England. In respect of our advice requests for primary care doctors, the majority of advice requests feature these two age groups.
The ethnicity of primary care doctors in our advice requests in England roughly equates to the breakdown of ethnic background reported in NHS workforce data for Black or Black British doctors and those in the category of other ethnic backgrounds. Based on this workforce data, 49% of general practitioners working in the NHS in England are white, with this ethnic background representing 36% of our advice requests for primary care doctors. 24% of general practitioners who work in the NHS in England are reported to be of Asian or Asian British ethnic background which is lower than the 33% of advice requests we receive for primary care doctors from this ethnic background.
The majority of general practitioners who work in the NHS in England qualified in the United Kingdom (70%). UK qualified practitioners also represent the highest proportion of advice requests we receive in respect of primary care doctors, but only make up 56% of our cases. Similarly the second highest group of primary care doctors we receive advice requests for are those who qualified outside of the UK and European Economic Area (37%). General practitioners who qualified outside of the UK and EEA also represent the second highest group amongst general practitioners who work in the NHS in England, albeit a smaller proportion (22% of the total).
The number of primary care cases involving some element of concern about behaviour/misconduct and those including clinical concerns is fairly even, both featuring in just over half of our cases. By comparison, secondary care behavioural/misconduct concerns feature in a higher proportion (70%) of cases. It is noteworthy that clinical concerns appear more frequently in primary care cases than secondary care, where they appear in 40% of cases. Health concerns are also present in a higher percentage of primary care cases, compared with the 18% proportion of secondary care cases in which health is a concern.
Case studies
All learning materials and case studies are fictional, drawn from our experience and presented for training purposes only.
Case Study 1
Concerns arose in relation to the practice of a salaried GP who had been employed for a couple of years, having returned to the UK from a period of time working overseas. The concerns related to delays in following up on administrative work, record keeping and assessment of patient condition (not examining patients and missing diagnoses). The practice undertook a records review and discussed the cases of concern with the GP, agreeing areas for improvement with him.
Some months on, there had been no improvement in the GP’s performance and Practitioner Performance Advice were therefore contacted for advice by the practice. The Adviser gave advice on the interventions available to the practice, including a clinical performance assessment and action planning.
In discussion with the practice, it was apparent that the concerns had been identified and accepted by the practitioner which meant that further investigation may not be proportionate or reasonable. The adviser gave advice on supporting the practitioner and signposted to sources of support, including professional advice and representation and organisations who could provide health and wellbeing support as matters progressed. Following further discussion between the practice and practitioner, a request for an action plan was received. The action plan that was developed covered each of the areas of concern and set milestones for review of the practitioner’s performance. Remediation was undertaken in line with the plan. The adviser followed up with the practice who confirmed that the practitioner’s performance had improved and there were no ongoing concerns, the case was therefore closed.
Case Study 2
In a case referred by a Professional Standards Case Manager at NHS England (NHSE), concerns arose regarding a dentist’s communication style with staff at the practice in which she was working including that she was abrupt, at times angry and rude.
NHSE contacted Practitioner Performance Advice for advice. The dentist was not working at the time as the practice had terminated her contract. Discussion took place between the adviser and NHSE regarding restrictions, were the dentist to find a new role. Considerations included that patient safety could be impacted by poor working relationships. Advice was given on proportionate responses including potential voluntary undertakings regarding mentoring and workplace reporting. The Adviser said that it was appropriate to speak with the dentist in order to understand her response to the concerns and to ensure that signposting to support was provided. Interventions were also discussed, with a behavioural assessment being identified as a potentially valuable tool to formatively assess the dentist’s behaviours and identify support to remediate.
The dentist agreed to a referral for behavioural assessment, which was made by NHSE. This was undertaken and led to the development of an action plan for the practitioner which included mentoring and coaching together with educational activities relating to communication and managing difficult interactions. As the dentist had agreed to the intervention and action planning, NHSE were assured that formal action on the dentist’s inclusion in the dental performers list was not required and instead agreed voluntary undertakings relating to compliance with the action plan. The Practitioner Performance Advice case was closed.
Assessment and remediation
To support the resolution of concerns, Practitioner Performance Advice’s assessment and remediation services are also available to primary care organisations, as well secondary:
- Our clinical performance assessments provide an independent view on the clinical performance of practitioners and provide information to assist employing/contracting organisations in deciding next steps for management of the case.
- Our behavioural assessment services can provide an independent view on the behavioural characteristics of practitioners, including any areas which require consideration to assist the referring organisation in decisions about the next steps in their management of the case.
- We can also support employers and practitioners where there is a concern about health. Whilst occupational health assessments are usually carried out locally, our professional support and remediation (PSR) service provides 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.
Suspensions
A number of our primary care advice requests involved discussion with NHS England where suspension of a practitioner is being considered. Where a suspension has been imposed we routinely review cases with NHS England, to aid fair and reasonable management of concerns in line with the National Health Service (Performers Lists)(England) Regulations 2013 and National Health Service (Performers Lists)(Wales) Regulations 2004 and NHS England’s Framework for Managing Performer Concerns. Our advice in suspension cases aims to ensure that suspension is only imposed where necessary and does not continue for longer than is necessary. This is alongside advising on the management of performance concerns in cases where suspension does not appear to be necessary.
As part of our role in monitoring and advising on suspensions, our Primary Care Advisers will shortly embark on a programme of work with NHS England’s Professional Standards Teams to review all existing suspensions from the medical and dental performers lists to aim to ensure that suspensions are reasonable and that they do not continue for longer than necessary.
We have also committed to undertake further analysis of our work with cases involving suspensions, to inform a greater understanding of our work in this area, to be presented in a future Insights publication.
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 nhsr.adviceresearchandevaluation@nhs.net.
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 nhsr.appeals@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 a range of interactive, evidence based training workshops specifically designed to provide healthcare organisations with the knowledge and skills to identify, investigate and manage performance concerns locally. All workshops are jurisdiction appropriate and can be delivered face to face or via MS Teams. Please email nhsr.adviceeducation@nhs.net for further information.
Footnotes:
- Based on headcount, see: General Practice Workforce, 31 January 2023 – NDRS (digital.nhs.uk)
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