Employers and the CDU: case study

GP performance

This case study, like the others on the site, is fictitious but based on typical situations in which the CDU has been involved.

Dr LJ trained in the 1980's as a GP but then went out to Africa and spent the next 15 years running a rural clinic for the local population. She returned to the UK in 2002 to take over her father's single-handed practice as he had recently retired.

Two years later there was an official complaint from a patient who had had a stroke and had been told, that since he had been in atrial fibrillation for two years, Dr L.J should have offered him anticoagulation which might have prevented his stroke. The case was settled informally with Dr L.J agreeing to go on a cardiology update. Shortly afterwards a district nurse contacted the PCT confidentially, concerned that a palliative care patient had been prescribed a Brompton mixture for pain ( morphine, largactil and gin) and surely this was now an outdated treatment?

The clinical governance lead, PM, arranged to visit the practice. He found a small, warm and friendly practice and all the staff and patients he met were obviously extremely fond of Dr LJ and remembered her father before her.

The clinical governance lead explained to Dr LJ that concerns had been raised and she was very upset and inclined to be indignant. Dr L.J discussed with her the patients she had seen over the previous 24 hrs. He noted that she did not use a computer and did all the chronic disease care herself - she did not employ a practice nurse and believed in personal doctoring like her father before her. It was clear that she was not able to demonstrate many QOF figures and she explained the difficulty she was having understanding why she had to do audit to earn money.

PM then told her that although she was clearly a dedicated and caring doctor he had noticed that two of the patients she had seen in the last 24 hrs had been managed in a way that would not now be considered normal practice - a patient with low back pain had been advised to lie flat on his back for 3 weeks and a new asthmatic patient was prescribed a nebuliser.

At this point Dr LJ became angry and asked the clinical governance lead to leave. She rang her defence union and the BMA and was astonished and upset to learn that the clinical governance lead had a right to investigate any concerns about her performance. She was not employed by the PCT - how could they have a right to manage her performance? Eventually she began to understand the changes that had made PCT's responsible for managing the performers list, but remained hurt and defensive.

Dr LJ's case was presented at the PCT Performers Advisory Group following advice from the NCAS. It was agreed to try and persuade her to update her clinical practice. The clinical governance lead informed her that he was referring her to the Career Development Unit at the Oxford Deanery.

The clinical governance lead provided a short written report for the CDU coach who met with him for half an hour to clarify the PCT's issues of concern and agree the costs of the initial needs assessment ( approx £600). The CDU then contacted Dr LJ and provided her with some information about what to expect from the CDU. Dr LJ agreed to have a Career Development Unit Needs Assessment interview. Gradually at that interview Dr LJ began to see that general practice had changed and developed a great deal while she had been away and that she really should have considered refresher training for six months before she went back into general practice.

A performance improvement plan was drawn up with specific educational objectives, including computer skills and getting her clinical management up to date. A few different learning options were explored and costed and the draft plan was sent to the PCT for comment and approval.

The PCT agreed to pay for a locum to allow DrLJ to spend two days every week in a nearby training practice for three months. Dr LJ agreed that she would demonstrate her competence at the end of that time with a satisfactory report from her trainer and a pass at Summative Assessment MCQ. The PCT agreed to support the cost of her re-training (approx. £1,700, which included the Summative Assessment MCQ exam £150).  The CDU coach approached the GP Director, identified a suitable training practice and the CDU coach supervised the training process.

At the end of three months, Dr LJ had much more idea of modern general practice, had accustomed herself to the computer and updated her clinical knowledge. She passed the Summative Assessment MCQ after a considerable amount of study and received a satisfactory report from her trainer which included multisource feedback from both practices. She is now back in her single-handed practice, but is now using the computer for all her medical records. The additional information increased her income from QOF and she now shares a practice nurse with a nearby practice.