Managing performance: response to concerns
Overview
Local investigation
Actions following investigation
Career Development Unit
Assessment by NCAS
Referral to GMC
Flowchart on local GP performance procedures
See also Managing performance: resolving problems
Overview of possible interventions
Local investigation is usually undertaken by the PCT and covers a range of interventions to provide:
- a careful, accurate and proportionate enquiry in response to a raised concern
- identification of the facts - what happened and how
- a scrutiny of a particular event or set of circumstances.
Career Development Needs Assessment (Career Development Unit) is not an assessment of competence but an assessment of learning and development need based on reports from others (local investigation, NCAS or GMC). It includes:
- information about why there is a difficulty
- provision of a specific Performance Improvement Plan
- provision of remedial training
- supervision of remedial training
- formal assessment of progress and demonstration of competence in specific areas.
Assessment of competence is usually undertaken by NCAS or GMC and is a general analysis of performance (including behavioural assessment) to provide:
- assessment of performance across a broad range of indicators
- information about why there is a difficulty
- suggestions about what might stop it happening again.
Local investigation
Key questions to be addressed by a local investigation include:
- What has happened?
- What do we know already about this doctor and their practice?
- Who is involved?
- Is there a significant risk to patient safety?
- Do we need to do anything immediately to protect patients?
- Do we need to involve anyone else?
- How did the event happen?
The search for information should be planned, systematic and proportionate to the concerns that have arisen. The NCAS' toolkit provides further advice and case studies on investigation can be accessed at www.ncas.npsa.nhs.uk/toolkit, but local training of those involved is also essential.
Root cause analysis can help to identify what is contributing to a problem identified. The NPSA provides courses and online tools to support the use of this method. www.npsa.nhs.uk/health/resources/root_cause_analysis/conditions.
Actions following investigation
The following options are not mutually exclusive; some may need to be used in parallel.
- Limited support or further training based on a development plan
Where the performance problems are relatively minor and capable of local resolution, the PCT may wish to help resolve them using its own 'in house' resources. These could include clinical governance or prescribing support, making resources available to improve the practice management or nursing input to the practice. An agreed development plan will be required with clear objectives and timescales, against which the success of this support can be measured. For plans requiring clinical supervision and other education, referral to the Career Development Unit is advised.
- Referral to Occupational Health services
- Use of the PCT's contract dispute procedures
These might be used, either alone or in parallel with performance procedures, where the evidence gathered suggests that the GP may have breached the terms of the contract the practice holds with the PCT for the provision of medical services.
If investigation reveals serious concern about the safety of patients, further use of local performance procedures will not be appropriate and other measures should be taken urgently. Where there is an immediate risk to patients, the PCT may suspend the GP from their Performers list, and immediate referral to the GMC is also likely to be appropriate.
- Contingent removal from the Performers list
PCT's are also able to restrict a doctor's area of clinical practice until performance concerns are resolved. As an example, a PCT may determine that a doctor should not work alone without immediate professional support.
The issue of an alert letter is a way by which NHS bodies and others can be made aware of serious concerns about the performance of a healthcare professional. These are issued normally in circumstances where patients or staff may be at risk of harm either from inadequate or unsafe clinical practice or from inappropriate personal behaviour. It is also a means of ensuring that NHS bodies are made aware of healthcare staff that may pose a risk to patients or staff because their conduct seriously compromises the effective functions of a team or local primary care services.
- Referral to the police for suspected criminal activity
The importance of this cannot be overstated where there is any suspicion of criminal wrongdoing e.g. misuse of prescriptions to obtain controlled drugs for the doctor's own use, or sexual assault. In this case the police will conduct the investigation.
- Referral to local NHS counter fraud services
If there is a suspicion of fraud taking place, PCT's can either use their local counter fraud services or the national fraud and corruption reporting line on 08702 400 100. Further information on fraud can be found at www.cfsms.nhs.uk.
Assessment by NCAS
A doctor may need an NCAS assessment if:
- concerns are substantiated - on the evidence available there is confidence that expressed concerns are accurate statements
- concerns are significant - the actions about which concerns are expressed fall well short of what a GP would be expected to do in similar circumstances
- concerns are repetitious - ongoing problems, and/or problems on at least two separate occasions
- the problems seem to be primarily a problem of professional practice rather than a disciplinary or health matter
- local procedures have failed to resolve the problem or are not appropriate
- NCAS advice or local case management support is insufficient in this case
- patient safety is not judged to be seriously at risk - if patient safety is at risk, suspension from the Performers list and/or referral to the GMC are required.
Resource: NCAS toolkit
Referral to GMC
A PCT may consider that it is appropriate to refer a matter to the GMC where there are potential conduct and/or general fitness to practice issues which needs to be addressed by the doctor's professional regulatory body, if for instance:
- patient safety appears to be seriously at risk
- the doctor has been convicted of a criminal offence
- local action would not be practical
- the PCT has tried local action and it has failed.
Resource: GMC guidance for referrals
Local GP performance procedures flowchart
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