Article Text
Abstract
Background Poorly performing doctors are a source of harm but do not commonly feature in discussions of patient safety. Few countries have national mechanisms to deal with these doctors; most opt for suspension and/or exclusion from clinical practice. This study reports on the 11-year experience of dealing with concerns about doctors’ performance in the UK National Health Service (NHS). The aim of this study was to describe the frequency with which doctors were referred due to performance-related concerns, examine demographic and specialty differences, and identify the nature of the concerns prompting referral.
Methods This observational study uses data collected by the National Clinical Assessment Service for each referral (n=6179 doctors) over an 11-year period (April 2001–March 2012) in England to examine the rate at which concerns about doctors’ performance occur, understand differences in rates between practitioner groups, and changes over time.
Findings The annual referral rate was five per 1000 doctors (95% CI 4.6 to 5.4). Doctors whose first medical qualification was gained outside the UK were more than twice as likely to be referred as UK-qualified doctors; male doctors were more than twice as likely to be referred as women doctors; and doctors in the late stages of their career were nearly six times as likely to be referred as early career doctors.
Discussion The UK holds a consistently collected national dataset on performance concerns about doctors. This allows risk groups to be identified so that preventive action and early intervention can be targeted most effectively to reduce harm to patients. A feature of past handling of poor clinical performance has been late presentation and a lack of thematic study of causation.
- Health services research
- Governance
- Attitudes
Statistics from Altmetric.com
Introduction
The poor performance of doctors is a consistent source of harm to patients.1 Healthcare systems differ in the extent to which it is found and whether there are policies and procedures in place to recognise it and intervene.2 Failure to address poor performance results in injury and death of patients, and also undermines the morale of clinical teams, erodes confidence in services and doctors, and exposes healthcare organisations to costly litigation. It remains a taboo area for open debate, arousing feelings of shame for the doctor concerned and troubling emotions of disloyalty and betrayal for colleagues who observe poor performance. Inquiries into patient harm resulting from extremes of poor practice have demonstrated this repeatedly.3 ,4 Previous work showed that over a 5-year period, as many as 6% of doctors could raise concerns serious enough to warrant consideration of disciplinary action.5 However, relatively little has been published on the nature and causes of poor clinical performance. More recently, Bismark and colleagues reported that half of all medical complaints in Australia were due to 3% of the medical workforce.6
The National Health Service (NHS) in the UK provides comprehensive care, free at the point of need, for its 62 million citizens.7 Following its election in 1997, the incoming government led by prime minister Blair introduced a framework of policies and actions to assure and improve the quality and safety of care in the NHS. These included the setting of national standards, the introduction of clinical governance, the inspection and regulation of health organisations, and a system of reporting and learning from adverse events.8 The last strand, clinical performance, is addressed by the National Clinical Assessment Service (NCAS).
It was created initially as the National Clinical Assessment Authority following recommendations made by the chief medical officer for England in two key reports (Supporting Doctors, Protecting Patients and Assuring the Quality of Medical Practice: Implementing Supporting Doctors, Protecting Patients).9 It was set up to receive referrals from any healthcare organisation in the NHS and give advice on how to handle the situation and, if serious enough, to carry out a full assessment of the doctor to identify options for resolution of the problems encountered. The service began to operate in England in 2001 and in the other UK countries in subsequent years: Wales (2003), Northern Ireland (2005), Scotland (2008).10 ,11
The aim of this study was to describe the frequency with which doctors were referred due to concerns about their performance, and to examine demographic and specialty differences. The study also sought to identify the nature of the concerns prompting referral.
Methods
The National Clinical Assessment Service receives the majority of its requests for advice in managing practitioners about whom there are concerns from the doctor's employer or contracting body. About 3% of requests are self-referrals. While NCAS is advising on a doctor's performance, the referring organisation retains responsibility for managing the doctors’ contractual situation. NCAS does not take part in disciplinary action or regulate professional practice. Regulation is the remit of the General Medical Council (GMC), dealing with cases that are a threat to the public, with powers to suspend or remove doctors from its register. The regulator determines whether practitioners are fit to practise at all; NCAS seeks to establish whether they are fit for purpose. NCAS services include case conferences and mediation; advice on local investigation and recommendations for suspension or exclusion from the workplace; assessment of clinical performance; and advice and assessment of health or behavioural concerns. The records of doctors referred to NCAS can be used to track doctors as they move around; indeed new referrals are cross-checked against any previous referrals.
This study used data collected by NCAS for each referral over an 11-year period (April 2001–March 2012) in England to examine the rate at which concerns about doctor performance occur, any differences in concern rates between practitioner groups, and any changes over time. ‘Concerns’ in this context are situations difficult enough to lead a service manager to seek external help in handling them. Referral numbers were compared with the NHS workforce using data provided by the NHS Information Centre.12 NCAS cases are counted as events without regard to whether the practitioner is working full-time or part-time, so we also used headcounts for workforce measures.
The dataset comprised 6179 doctors from all specialties and employment areas, with information about top-level concerns for a subset of 3467 cases handled from late 2007. A very small number, roughly 1 in 25 practitioners was referred more than once. Due to the limited personal identifiable data available in the earlier years of NCAS, it is not possible to ascertain the true number of multiple referrals, and hence, these were not adjusted for in the subsequent analysis.
There was also some data incompleteness: 21% of cases were missing age; 18%, place of qualification; 5%, specialty group; and 4%, gender. Referral rates and CIs were grossed up to avoid understating concern rates and to allow comparison across groups. CIs assume that concerns followed a Poisson distribution since they relate to counts of referral events.
NCAS records place of qualification as the UK, another European Union (EU) country or a country outside the EU. Age is recorded in 5-year bands but, for this paper, doctors were classified as being ‘late career’ if aged 55 years or older, ‘mid-career’ if between 35 and 55 years, and ‘early career’ if under 35 years. Specialty was examined using 12 broad groups including general medical practice.
Data were provided in tabulated form in accordance with NCAS privacy conventions, to prevent deductive disclosure of practitioner identities. Gender, age, specialty and place of qualification associations were assessed using Poisson regression methods, but testing variables singly rather than in combination. Multiple regression methods could have been used but have already been reported by NCAS using 8 years’ data.13 Since late 2007, NCAS has recorded top-level concerns using seven broad categories as shown in table 1 below.
Results
Table 2 uses referral and workforce numbers to estimate the rate at which concerns about doctor performance are occurring. From 2001 to 2004, referrals were at start-up levels, but through the next 8 years the annual concern rate fluctuated around five practitioners per 1000. While there may appear to have been a slight upward trend in concern rates in the 8 years after start-up, data in the first half of 2012/2013 (unpublished) suggest that fluctuation around an annual rate of five practitioners per 1000 still summarises NHS experience appropriately. Doctor referrals to NCAS are currently running at about 750 a year in England. Assuming a Poisson distribution, a 95% CI on a five per 1000 annual rate is 4.6–5.4 per 1000.
Table 3 then uses 8 years’ data (excluding start-up years) to compare concern rates by practitioner group. The 8-year base of 5271 doctors is compared with a total of 1 048 000 doctor years. Grossing up to allow for the effect of data incompleteness means that rates can be compared between as well as within groups.
Table 3 suggests that doctors whose first medical qualification was gained outside the UK were more than twice as likely to be referred as UK-qualified doctors; male doctors were more than twice as likely to be referred as women doctors; and doctors in late career were nearly six times as likely to be referred as early career doctors. Among specialties, the highest rates of concern were seen in the psychiatry and obstetrics/gynaecology groups, both with a referral risk 3.5 times higher than the three lowest referral rate specialty groups. Poisson regression modelling using 8 years’ data broadly supported these conclusions.
Figures 1 and 2 chart age and place of qualification rates year-by-year since 2004. In both cases, there is some consistency over time. With place of qualification, the ‘other EU’ group is quite small, so there is more year-to-year fluctuation.
For the 3467 doctors for whom information on concerns was available, 6192 top-level concerns were identified; an average of 1.8 per doctor. Table 3 shows that this concern measure varied with age but not noticeably with gender or place of qualification. Specialty differences (not shown) were also quite small, with mean concern groups per doctor ranging from 1.6 (in accident and emergency and public health) to 2.1 (in clinical oncology).
The content of concerns did differ by group, however (table 4). Age differences arose through differences in rates of clinical concern and concerns about governance and safety issues, but with rates of misconduct declining with age. Clinical concerns were also seen more commonly among practitioners qualifying outside the UK. Behavioural concerns other than misconduct may be a phenomenon of middle age. Within the 431 psychiatrists referred, in ten cases (2.3%) references were made to inappropriate sexual relationships with patients.
Discussion
NCAS holds the largest consistently collected dataset on performance concerns about doctors working in a national health system. Counting as ‘concerns’ only those episodes which justify external discussion and support, the annual rate of concerns was found to be about five per 1000 doctors, steadily over a period of 8 years. While we cannot be sure that all significant concerns reached NCAS, the agency had high recognition in the UK, so most doctor performance problems were probably captured. Referrals have come from virtually all NHS organisations.
Some of our findings about differences between practitioner groups are consistent with previous studies.5 ,14 ,15 Men were 2.5 times more likely than women to be referred because of concerns about their practice or conduct. This matches findings from a study of 9000 medical litigation claims in the USA, that men were three times more likely than women to have claims against them.16 However, explanations advanced for this pattern—that women doctors are more ready to apologise, or are more effective communicators, or have heightened levels of emotional intelligence17—are not entirely consistent with our findings. While misconduct was more common among men than women (table 3), behavioural concerns other than misconduct were seen a little more often in women. Health concerns occurred more frequently in women, with ‘health’ defined as including substance misuse.
Place of qualification was also strongly associated with performance concerns. The ethnicity of referred doctors was not examined here. About 40% of NHS doctors in England are from Asian, Black or other minority ethnic groups, so the possibility of discrimination in the identification of performance concerns needs to be borne in mind. NCAS collects ethnicity data and has examined associations between performance concerns, place of qualification and ethnicity in some detail,18 ,19 as has the GMC.20 That work suggests that while qualification outside the UK is a performance risk factor, and while there is a clear association between place of qualification and ethnicity, ethnicity was not a source of statistically significant additional risk among doctors from non-white backgrounds qualifying in the UK. An important lesson from these data is, therefore, that there is a need to strengthen induction programmes for doctors starting work in the NHS after qualifying outside the UK. This would need to be evaluated formally. Indeed this group, like any group undergoing transition from one organisation to another, is prone to limited support during what has been described by Kilnminster and colleagues as ‘critically intense periods of learning’.21 Greater educational, peer and psychological support needs to be provided by host organisations taking on new doctors. Where surveillance mechanisms for doctors-in-transition remain patchy, poor practitioner performance is a likely outcome.
Gender and place of qualification differences both seem to be dwarfed by the early/late career difference. Higher rates of concern among older practitioners have also been reported by the GMC.22 In 2007–2008, the American Medical Association surveyed its members; 5825 members replied. Over the duration of their career, 15% of the young physicians (under 40 years of age) but 60.5% of physicians in the eldest age group (55 years and older) reported claims.23 While this could be due to their greater exposure to risk given the longer periods they have been in service, it could also suggest a greater volume and complexity of cases are seen by senior doctors. As a result, this group warrants specific interventions to ensure that patients do not suffer avoidable harm. Ultimately, whether these apparently high-risk groups are the sources of unsafe care can only be demonstrated by rigorous evaluation of the impact of interventions directed at them.
Doctors working in high-risk specialties were also more likely to be the cause of concern. Specialties, such as obstetrics,24 have been shown before to have higher rates of litigation relative to family doctors,25 though the present data (table 2) put family doctors at slightly higher than average risk. Craft specialties, such as surgery, involve greater hand-eye coordination, so there may be a greater risk of skills deteriorating with age. But the high rate of referral seen among psychiatrists does not fit this model and may reflect a higher than average proportion of doctors qualifying outside the UK although could also reflect breaches of professional boundaries. Moreover, in 2% of psychiatrists referred to NCAS, there was mention of inappropriate sexual relationships with patients.12 ,26 Proposals have been made to the Royal College of Psychiatrists to incorporate more human factors teaching in the postgraduate curriculum, and to strengthen clinical skills, such as prescribing and record-keeping, perhaps through the use of continuous professional development.24 Also, nearly a third of doctors have some kind of mental health disorder; this is often hidden, and when discovered, is a strong reason for the poor performance of practitioners.27 Greater attention must be paid by organisations towards the mental well-being of their staff.
The large age differences in table 2 and Figure 1 are completely unambiguous, however. These data underline the need for regular revalidation of doctors; a step which the UK has now taken.28 Revalidation should allow employers to better understand the histories of doctors they appoint and allow doctors whose practice is causing concern to be identified earlier. Alongside revalidation, recently renewed guidance from the GMC stresses that all doctors have a duty to act when they believe a patient is at risk because of a colleague's under-performance.29 Dealing with doctor under-performance needs new mechanisms but also significant culture change.
Conclusion
By creating a service that helps NHS employers to identify, investigate and deal appropriately with poor practice, the NHS sought to ensure that doctors who might harm patients (directly or indirectly) were prevented from doing so as quickly as possible after the problem was recognised. This recording system is also now a unique dataset for research.
Acknowledgments
We would like to thank Greg Phillpotts, Consultant Statistician to the National Clinical Assessment Service, for statistical advice, and the NHS Information Centre for providing workforce comparator data.
References
Supplementary materials
Press release notice
Files in this Data Supplement:
Footnotes
-
Contributors LJD conceived and designed the study, was responsible for interpretation of data. He revised it critically for important intellectual content. SSP and DMS were responsible for acquisition, analysis and interpretation of data and drafting an earlier version of the document. PAM was responsible for acquisition, analysis and interpretation of data and revising it critically for important intellectual content. All authors approved the final version to be submitted.
-
Funding This study was carried out as part of the research activities of the Institute of Global Health Innovation and no extra funds were sought.
-
Competing interests None.
-
Ethics approval This study was considered to be part of service improvement and not research. Therefore, the Health Research Authority recommended that it did not require any review by a NHS Research Ethics Committee.
-
Provenance and peer review Not commissioned; externally peer reviewed.
-
Data sharing statement The data was obtained from the National Clinical Assessment Service (NCAS). Data was obtained by writing to NCAS.