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Exclusions

Introduction

Exclusion is designed as a short-term, temporary measure to remove a practitioner from their usual place of work until the nature and cause of a performance concern are understood and while an investigation is carried out.

Maintaining High Professional Standards in the Modern NHS provides a framework for the handling of concerns about doctors and dentists. This framework, which is mandatory for non-foundation trusts and has been adopted by many foundation trusts, acknowledges that there are circumstances where exclusion may be necessary to either:

  • protect the interests of patients or other staff, and/or
  • assist the investigative process where there is a clear risk that the practitioner’s presence would impede the gathering of evidence.

This page contains information about reporting requirements for exclusions, and provides resources to help with decision making, documenting and managing an exclusion, as well as sharing learning from exclusion cases over a ten year period.

The resources have been designed to support good practice in documenting and managing the exclusion process in the event that it is necessary, and should be used in the context of assessing both patient safety and fairness to the practitioner when determining the best course of action.

NHS Resolution would also like to thank a range of key stakeholders who provided their input to ensure the materials are relevant and helpful to those working across the health system. These can be found on the acknowledgements page.

Insights

Our Insights publications share analysis and research which draw on our in-depth experience providing expert, impartial advice and interventions to healthcare organisations to effectively manage and resolve concerns raised about the practice of individual healthcare practitioners.

Our exclusions insight looks at key themes and data from 1359 exclusion cases (43 in-depth case analyses) in England between 2009 and 2019, with the aim of highlighting opportunities for learning and improvement to the health system.

Reporting requirements

NHS Resolution’s Practitioner Performance Advice service should be contacted for advice where a healthcare organisation is considering excluding, suspending or restricting a practitioner’s practice. Where patient safety is considered to be at risk or where there are allegations of serious misconduct, it is important for healthcare organisations to be able to take appropriate steps so that the situation can be investigated.

Maintaining a full and contemporaneous record of decisions is essential throughout the process of deciding to exclude (or not).  This was a point of learning from the deep dive analysis of exclusion cases over a ten year period. The supporting documentation templates help by outlining good practice on what to record and when to review at each stage of an exclusion. For more detailed information – please read our reporting requirements webpage.

Decisions flowchart

The legitimate reasons for exclusion are limited to those in the MHPS framework. It is important when considering an exclusion that these guide any decision and there is a full exploration of the possible alternatives to exclusion. To support this we have created a flow chart to help decision makers.

Templates

We have produced a template for documenting any case where exclusion is considered, to ensure the rationale for an exclusion is documented at the outset and at regular review points. It also provides prompts for other aspects of managing an exclusion case including: informing other parties, appointing a board member and reporting to the board.
We have also produced a template letter for employers to use when communicating with the practitioner to help ensure all the relevant information is included.

Case studies

We have provided some case studies, as part of a learning pack, to help support good practice. The aim of the learning pack is to:

  • Assess current knowledge and understanding about exclusions
  • Gain new insight into exclusions.

Each case study draws on a different aspect of the exclusion process, posing questions and offering observations based on our experience. They have been designed for use either individually or as part of a discussion with peers to test knowledge and allow the exploration of the rationale for decisions.

Acknowledgements

Significant contributions were made to the design, data collection and authorship by the following individuals and organisations. We are extremely grateful to everyone who added their input to this work:

1. Authorship

  • Dr Sally Pearson, Responsible Officer for NHS Resolution
  • Hanna Gillespie-Gallery, Evaluation and Research Lead, Practitioner Performance Advice
  • Vicky Voller, Director of Practitioner Performance Advice and Primary Care Appeals

2. Research

The publication was supported by research commissioned from the University of Plymouth to understand if there were any patterns in exclusions and if anything could be done to improve how exclusions are managed.

NHS Resolution is very thankful to Dr Marie Bryce, Dr Nicola Brennan and Josephine Cockerill of the Faculty of Health, University of Plymouth for conducting the research.

3. Input to the insight paper and supporting materials

We would like to thank those individuals and teams who gave their time to help us consider the relevant tone, language and content of the resources so that they are relevant to those in the healthcare system who will use them.

  • British Medical Association
  • Care Quality Commission
  • Department of Health and Social Care
  • General Medical Council
  • Independent Healthcare Providers Network
  • Medical and Dental Defence Union of Scotland (MDDUS)
  • The Medical Defence Union (MDU)
  • NHS Employers
  • NHS England and Improvement
  • Paterson Programme Board and Task/Finish Group members
  • St Helens and Knowsley Teaching Hospitals NHS Trust
  • University Hospitals Birmingham NHS Foundation Trust

NHS Resolution Working Group members

Dr Alison Budd, Specialist Adviser
Professor Keith Edmonds, formerly Non-Executive Director, NHS Resolution
Dr Steve Evans, Senior Adviser
Clare Game, Business Support and Development Manager
Hanna Gillespie-Gallery, Evaluation and Research Lead
Zoe Moulton, Policy and Strategy Manager
Annette Nilsson, Communications and Engagement Officer (Advice and Appeals)
Dr Sally Pearson, Responsible Officer for NHS Resolution
Mike Pinkerton, Interim Chair, NHS Resolution
Annie Raven-Vause, Education Manager
Professor Lesley Regan, Non-Executive Director, NHS Resolution and Clinical Professor, Faculty of Medicine, Department of Metabolism, Digestion and Reproduction, Imperial College London
Vicky Voller, Director of Practitioner Performance Advice and Primary Care Appeals
Karen Wadman, Lead Adviser
Disa Young, Deputy Director of Membership and Stakeholder Engagement

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