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Safer for Patients, Supportive for Professionals: A Framework for Managing Poor Performance of Health Professionals and Teams in NHS Scotland

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SAFER FOR PATIENTS, SUPPORTIVE FOR PROFESSIONALS
A Framework for Managing Poor Performance of Health Professionals and Teams in NHS Scotland

Introduction
  1. Most health professionals practise to a consistently high standard throughout their working lives and are motivated by a strong commitment to professional standards and values. Poor professional performance however does occur. Rarely is it deliberate or pre-meditated but every time it happens it not only poses a threat to patients, but is also a cause of anguish and anxiety to the health professional as an individual, and to those around them.
  2. In the background to such cases it is common to find overstretched individuals, overstretched resources, lack of training or educational support, poor management support and personality clashes between individuals and groups. Cases surface through a variety of routes including complaints from patients and from staff, clinical audit, adverse events reporting, appraisal and assessment. Sadly, the first public indication is sometimes a serious service failure. Recent history contains several examples of such situations in which the warning signs were in retrospect, present for some time.
  3. It is the responsibility of employers to deal with such situations. The 1999 Health Act laid the duty of quality on all NHS organisations in Scotland and specifically on the shoulders of the Chief Executive of each. Managing suspected or actual poor performance of individual health professionals and teams forms part of that duty. Individual employers, however, may have little actual experience or capacity for dealing with such situations and may prolong or delay remedial action or attempt to use inappropriate procedures including suspension, grievance and disciplinary procedures. As individuals, all health professionals have a duty to protect patients. All health care professionals are personally accountable for their actions and must be able to explain and justify their decisions. While the scope of their practice varies they all have a duty to safeguard and promote the interests of their patients and clients. Health care professionals must act quickly to protect patients, clients and colleagues from risk of harm especially if either their own or another health care worker's conduct, health or performance may place patients or clients at risk.
  4. Current Structures
  5. In England, action so far has focused on individual doctors with the publication in 1999 of Protecting Patients, Supporting Doctors and the subsequent establishment of the National Clinical Assessment Authority (NCAA). In Scotland, separate procedures have been set up to deal with consultants through the mechanism of External Clinical Assessment Teams (ECATs), for GPs and for doctors in training. The system for investigating under performance in general practice is set out in Prevention Better Than Cure [published July 2001]. To date, evidence of the effectiveness of these measures is difficult to obtain. There is no consistent monitoring, audit, central reporting or accountability of these systems. After an initial flurry of activity in 2000 and 2001 no ECATs appear to have been called since early 2002. The Scottish Association of Trust Medical Directors have expressed their concern on this issue and their dissatisfaction with the practical outcome of current Scottish procedures. At their annual meeting in May 2003, more than one in three of them reported having approach the English NCAA for advice and support over the previous 12 months.
  6. Poor performance of nurses and midwives is covered in Trust disciplinary policies and procedures which, when applied well, are effective in providing support and, where appropriate, sanction to the individual. The procedures include the possibility of reporting the situation to the Regulatory Body. The Chief Nursing Officer (CNO) is usually advised informally when a nurse's poor performance is being investigated and is approached for advice in difficult or complex cases or if the nurse manager is inexperienced. Community pharmacists are subject to a scheme operated by the Royal Pharmaceutical Society of Great Britain (RPSGB) to inspect all community pharmacists, investigate any complaints and report their findings to the professional standards directorate. Little guidance exists to support employers in dealing with dysfunctional or poorly performing health teams.
  7. Employers are well aware of the need to take swift action if they believe that patients are at risk as a result of poor performance by a health professional. There are established procedures to allow suspension and referral to the appropriate regulatory body (eg the General Medical Council (GMC) for doctors, the Nursing Midwifery Council (NMC) for nurses and midwives).
  8. NHS Quality Improvement Scotland (NHSQIS) has accepted a role set out in the White Paper Partnership for Care [published February 2003] for investigating, remedying and following up serious service failures. They currently have no role in supporting NHS Scotland employers in tackling any suspected or actual poor performance by individuals or teams which might have preceded such failures. NHS Education Scotland (NES) was set up to carry forward the commitment set out in Learning Together [published December 1999] to provide for the lifelong learning needs of all health professionals in Scotland. Building on the existing commitment of its predecessor organisations to postgraduate medical and dental education to clinical psychologists, pharmacists, nurses and midwives, this role is still evolving. Despite the fact, however, that education is one of the most obvious remedial tools in dealing with poor professional performance, NES has no explicit remit or resourcing for this task.

  9. Question 1

    Do you agree with this analysis of the current situation?

    Question 2

    In what way might this analysis of the current situation in Scotland be improved?

    Principles for Action
  10. The purpose of this paper is to propose measures to remedy this situation based on the following principles:

    8.1 Patients and the public in Scotland must have confidence that there is an open, transparent, accountable and accessible system in place for dealing with suspected or actual poor performance by health professionals and teams.

    8.2 Health professionals in NHS Scotland need to have a framework to support their regulatory duty to report their concerns if they believe that the health or professional performance of colleagues is a threat to patients.

    8.3 Health professionals in NHS Scotland who as individuals or teams find themselves the subject of such concerns need to know that they will be treated promptly, fairly, consistently, objectively, supportively and in line with best practice. They also need to know that they will have access to and support for undertaking any remedial action which may result.

    8.4 Employers need a framework of guidance for local action consistent across all professional groups and across Scotland and consistent with existing procedures for dealing with complaints and disciplinary matters. They need support for local capacity building in dealing with dysfunctional and poorly performing health professionals and teams. They also need access to a national resource for support and advice in dealing with unusual or unfamiliar situations. A key component of this framework must be a standard reporting system to allow central monitoring and audit of activity in this area through the staff governance section of the Performance Assessment Framework (PAF).

    8.5 Trade unions, professional bodies, professional defence organisations and the Scottish Partnership Forum need to have confidence that NHS Scotland employees will be treated fairly, consistently, objectively and without prejudice to race, colour, creed, gender or sexual orientation and that they will have access to support and advice from their appropriate professional body or trade union.

    8.6 Ministers, the Executive, and Parliament need to be assured that an open, transparent, accountable and accessible system is in place for the investigation and management of suspected or actual poor performance by health professionals and teams in NHS Scotland and that NHS Scotland will corporately learn from such experience and improve its procedures and practice as a result.

    Question 3

    Do you agree with these principles on which to build a new framework for action?

    Question 4

    Are there any other principles which such a framework should embody?

    Proposals
  11. The following key tasks need to be taken forward to improve the management of suspected or actual poor performance by health professionals and teams in NHS Scotland:

    9.1 The development of a framework of guidance for local action by employers in NHS Scotland.

    9.2 The development of educational material and guidance to this framework for health professionals in NHS Scotland.

    9.3 The development of a programme of capacity building in NHS Scotland for dealing with poorly performing and dysfunctional health professionals and teams at local level.

    9.4 The creation of a central resource within NHS Scotland as a source of advice, support and skilled personnel to assist employers in dealing with such situations. Such a resource would provide:

    9.4.1 rapid telephone support and advice;

    9.4.2 access where necessary and within defined time limits to prompt, experienced, trained professionals from across a range of appropriate clinical and managerial disciplines (and from outwith Scotland where necessary);

    9.4.3 support to local management in:

    • investigation and analysis of suspected or actual poor performance by health professionals and teams;
    • formulation of any necessary remedial action plan;
    • liaison where necessary with NES, NHSQIS, professional regulatory bodies;
    • implementation of remedial action;
    • follow up of the specific situation to ensure that NHS employers and NHS Scotland as a whole learns from the experience;

    9.4.4 confidential central collection, monitoring, audit and reporting on returns from NHS Scotland employers on all incidents of suspected or actual poor performance by health professionals and teams;

    9.4.5 central statistical reports, available to the public annually.

  12. A number of potential options exist for taking forward these tasks:
  • NHSQIS could be asked to take this forward as part of its remit. The practicalities of this will require to be explored;
  • Steps could also be taken to extend the remit of NCAA to Scotland or to enter into a service level agreement with NCAA to provide services to Scotland. NCAA currently only deals with suspected or actual poor performance by individual doctors and dentists in England and Wales and through a service level agreement in Northern Ireland. However, this would not provide a system to deal with other health professionals and teams in Scotland and the NCAA is currently inconsistent with Scotland's multi professional approach to all workforce planning and development. A Scottish body acting in this field would need to have a good working relationship with, and to learn from the experience of, NCAA;
  • A new special health board could be created to take forward these tasks. This would create a very small but tightly focused organisation. This would however be contrary to the current policy of reducing the number of public bodies in Scotland;
  • An existing NHS Board, probably one of the larger Boards could be tasked with acting as a lead board for the whole of NHS Scotland in this respect. This would avoid creating a new body and would leave NHSQIS with a pure "internal audit" role;
  • The tasks could be contracted out to a private sector provider, probably one of the large international management consultancies;

Question 5

Do you agree with the list of tasks in the framework for action?

Question 6

Are there any other tasks which should be included within this framework?

Question 7

Which of the options for taking this framework forward do you favour?

Question 8

Are there any other options which you would propose?

Resource Implications
  1. Responsibility for management of suspected or actual poor performance by individual health professional teams lies with NHS employers in Scotland. Failure to take action can underlie serious service failures which have human as well as monetary costs attached. It is suggested that all NHS Boards therefore contribute to the central resources required by this framework on an agreed basis and proportional to the number of health professionals they employ.
    Policy Proofing
  2. The proposals in this paper are consistent with current policy.
    Summary of Questions

    Question 1:

    Do you agree with the analysis of the current situation?

    Question 2:

    In what way might this analysis of the current situation in Scotland be improved?

    Question 3:

    Do you agree with these principles on which to build a new framework for action?

    Question 4:

    Are there any other principles which such a framework should embody?

    Question 5:

    Do you agree with the list of tasks in the framework for action?

    Question 6:

    Are there any other tasks which should be included within this framework?

    Question 7:

    Which of the options for taking this framework forward do you favour?

    Question 8:

    Are there any other options which you would propose?

Responding to this Consultation

We are inviting written responses to this consultation paper by 4 June 2004. You are asked to complete and return the Respondee Information Form in Annex A along with your response. Please send your response to:

Dr Wendy-Louise Smith
Scottish Executive
Health Department
Directorate of Human Resources
Learning, Development and Careers
Ground Floor Rear
St Andrew's House
Edinburgh
EH1 3DG

Or by e-mail to: managingpoorperformance@scotland.gov.uk

If you have any queries contact Dr Wendy-Louise Smith on 0131 244 1712

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Page updated: Thursday, May 25, 2006