Managing trainee performance: Deanery policy

Types of difficulty

There are four types of trainee difficulty

• Personal conduct
• Professional conduct
• Competence and performance issues
• Health and sickness issues

Bear in mind however that there may be a considerable overlap between these areas. You can see a "Helping the trainee in difficulty" flowchart here.

What to do first

First establish whether there is a problem. If there is, then the next step is to clarify the state of affairs, to get both sides of the story, and to avoid jumping to conclusions based only on one side. The problem should be addressed early, and not left to the next appraisal or even the next year's RITA!

It may be necessary to investigate the problem formally, with written statements from the various individuals involved, and records of what has happened. Asking four simple questions may help you:

• What is the real problem?
• Why has this happened?
• What can we do about it?
• Can we get back on course?

Many problems can be resolved at local level, by using the principles of finding out the facts, using facts of the case and not opinions, constructive feedback and setting targets for improvement. Following these through will usually work well.

It is essential to keep a comprehensive written record.

If local resolution fails then seek help early.

See How the CDU can help

The role of the employer

The doctor in training always has an employer, whether the NHS Trust, the University, or the general practice trainer, in the case of GP registrars. Legally the employer should take the lead in all four areas of problems. Employers will have procedures laid down for discipline, performance and sickness issues. It is very important that the Deanery is told about problems when a trainee is involved. In order to deal with the issue of confidentiality, we recommend the Trust to inform the trainee that he/she may approach the Deanery for advice. The Deanery should be involved at the earliest stage in all cases. What happens next will depend on the types and seriousness of problems encountered.

Personal conduct issues

Examples include theft, fraud, assault on another member of staff, vandalism, rudeness, bullying, racial and sexual harassment, pornography downloading from a computer in the library, and attitude problems in relation to colleagues, other staff and patients. The Trust (as the employer) will take the lead under its approved disciplinary procedures.

The employer must inform the trainee in writing at an early stage that he/she may approach the Deanery for advice, particularly if there are any concerns that any allegations are as a result of professional issues, and/or education and training difficulties.

The Trust should also inform the Deanery in writing that disciplinary procedures are taking place with a doctor in training.
It should be remembered that attitude problems may be a symptom of underlying performance problems and this may need to be investigated at the same time as disciplinary procedures take their course.

The Deanery will not be involved in such a disciplinary panel, but will need assurance of the following:

• The Trust will follow an agreed disciplinary procedure
• The trainee has been advised that they may be legally represented (by the BMA, a solicitor, for example)
• National guidelines are followed if a trainee is to be suspended
• Pastoral support is provided if needed.

Professional conduct issues

Examples include research misconduct, failure to take consent properly, prescribing issues, improper relationships with patients, improper certification issues (such as the signing of cremation forms, sickness certification, passport forms), and breach of confidentiality. Again the Trust (as the employer) will take the lead under its disciplinary procedures and will inform the Deanery in writing at the earliest stage. The Deanery will provide an input into such a disciplinary process, via the clinical tutor, the GP trainer, the chair of the specialty training committee, regional adviser (for specialist registrars),or other member of the Deanery.

Any decision to involve the NCAS or General Medical Council is a very serious one for the doctor involved and this will be a joint decision between the Trust (or other employer) and the Deanery. Remember that the NCAS and the General Medical Council recommends that approved procedures be followed first at the local level, rather than report everything to the NCAS or GMC at the earliest stage.

Again the Deanery will need to be assured that:

• The Trust will follow an agreed disciplinary procedure
• The disciplinary process does include someone to represent the Deanery
• The trainee has been advised that they may be represented (by the BMA, a solicitor for example)
• National guidelines are followed if a trainee is to be suspended
• Pastoral support is provided if needed.

Competence and performance issues

Examples include a single serious mistake, or poor results clinically, possibly found as a result of audit, poor timekeeping, poor communication skills, poor consultation skills and repeated failure to attend educational events.

Usually these will be dealt with through the educational framework. The Trust or other employer will need to take a lead in some of these problems, particularly if there has been a complaint from patients or relatives, and there is the possibility of a legal action. Trainees with such problems will need to be referred to the Deanery in the first instance. If the performance issues are serious and raise questions about the satisfactory completion of a training post, it may be appropriate to ask the Oxford Deanery Career Development Unit for help. The CDU coach will make an in-depth career development needs assessment and will work closely with the responsible trainer and employer to help plan appropriate remedial or targeted training.

An isolated serious mistake may happen to any of us. Although it usually does not reflect the overall competence of the doctor concerned, it may lead to a formal inquiry. The Deanery must be informed in writing of such a problem, and should be kept informed throughout the process that results from such a mistake. Pastoral support must be offered as such an event is highly stressful for all concerned.

In the past, such a doctor may often have been suspended. The Chief Medical Officer has recently written to all Trusts asking that they try not to suspend any more doctors in such circumstances, but instead has suggested referral to the National Clinical Assessment Service (NCAS). The Oxford Deanery Career Development Unit works closely with the NCAS and offers a confidential advisory service at local level.

There is a right to appeal in such cases, and we strongly advise the doctor to seek legal representation in such instances. Again the Deanery must be involved.

If the doctor's performance is consistently poor, even though all educational measures have been tried to put things right, then it may on occasions be necessary to inform the General Medical Council. Obviously this is not a decision to be taken lightly, or on the spur of the moment. Such a referral may have momentous and unpredictable consequences for the doctor concerned. This will again need to be a joint decision between the Trust (or other employer) and the Deanery.

The majority of doctors in training with performance problems do not come into these more serious categories. These doctors require detailed assessment and analysis of the issues and may require targeted or remedial training to address the issues (see Management Checklist for Trainers). It is important for the trainer to involve the Trust or other employer if there is any concern about patient safety or the trainee needs to adjust his clinical responsibilities or workload.

Health and sickness issues

Every doctor should register with a local general medical practitioner, and consult with their doctor in the first instance when ill.

Ill health and sickness absence should be managed through the Trust's sickness procedures and may involve their Occupational Health Service. It is not possible to give a generalised rule about the length of sickness absence, as each case needs to be considered individually. However, below are the guidelines on sickness absence and completion of training in a post, which may be of help. Where sickness absence does give cause for concern, then the views of a consultant physician in occupational medicine are essential. The Deanery will need to be informed in writing when this happens, bareing in mind the need for patient confidentiality.

There are GMC guidelines on serious infectious diseases and other areas of health, including physical and mental illness, which may affect the safety of patients. These need to be consulted, and the involvement of a consultant physician in occupational medicine is essential.

The Deanery does finance a Psychological and Psychotherapeutic Support Service (Medic Support). The Career Development Unit offers in-depth career guidance for doctors who have to adjust their career plans because of ill health or disability.

Sickness absence and its effect on training:

The length of sickness absence allowed in each grade before the training is affected:

Pre-registration house officer:
3 weeks in a four month post, 4 weeks in a six month post or a total of four weeks overall in the year.
Senior house officer:
4 weeks in a two-year period
GP registrar:
2 weeks in a 12-month post
Specialist registrar
3 months in total over the period of SpR training before the date of a CCST is affected.