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The Back on Track Framework for further training

Restoring practitioners to safe and valued practice

Contents

 

1.  Using this guide

1.1  Purpose

1.2  Relationship with other NCAS publications

1.3  Associated resources

1.4  Terms

  

2.  Further training - principles and practicalities

2.1  Who might need further training?

2.2  Who pays for further training?

2.3  What do we do about indemnity?

2.4  What are the practitioner’s responsibilities?

2.5  What are the responsibilities of the employing/contracting organisation?

2.6  Can the deanery help?

2.7  What role does NCAS play?

  

3.  A step by step process

3.1  Identifying the full range of concerns

3.2  Drafting an action plan framework

3.3  Agreeing to proceed (or not)

3.4  Developing the detailed plan

3.5  Using placements

3.6  Funding estimates and cost-sharing

3.7  Implementing and monitoring

3.8 Completing the programme and following up

  

4.  Organisational responses

4.1 Organisational re-entry for the practitioner

4.2 Organisational development

 

Feedback

Glossary

   

1. Using this guide

1.1 Purpose

This guide sets out how the National Clinical Assessment Service (NCAS) approaches work with practitioners for whom further training is proposed as a means of resolving concerns about practice or supporting a return to work programme. The concerns might relate to knowledge or skill gaps or behaviours and might have been identified in a variety of ways, from formal NCAS or regulator assessment to local investigation or other governance activity. There might have been a significant career break or a period of illness or time away from normal practice because of exclusion or suspension. Whatever the background, it is NCAS’ experience that a structured approach to further training gives the best chance of restoring practitioners to safe and valued practice.

 

The methods in this guide can be applied across general practice, community and hospital sectors, in the NHS and the independent sector and across all three professions currently within NCAS’ remit – dentists, doctors and pharmacists. The guide and its associated resources are designed to be used by anyone involved in devising, supporting, guiding or managing further training programmes, with or without additional direct support from NCAS.

 

Keep in mind, however, that further training programmes are just one option in a range of measures to address concerns about practice.

In addition, they need to be managed within a broader governance system, with procedures which are objective, fair, up-to-date and easily accessed and with managers trained to use them appropriately. This guide assumes that local governance is in generally good shape in order to focus on the further training process. For NCAS guidance on wider aspects of governance go to the  NCAS website.

 

1.2 Relationship with other NCAS publications

NCAS first set out an approach to further training programmes in the Back on Track framework, published with partner organisations in 2006. This guide replaces it, reflecting accumulating NCAS experience of post-assessment remediation and programmes for practitioners whose needs have been identified without formal assessment.

 

Handling performance concerns in primary care (NCAS, 2010)(pdf 2.57MB) contains a section relating to further training in primary care. 

This guide is more detailed and has been written for all healthcare sectors but its central messages are the same. How to conduct a local performance investigation (NCAS, 2010)(pdf 2.47MB) is relevant because the recommendations from a preliminary investigation may help identify the objectives for a further training programme if an assessment has not taken place.

 

Handling concerns about the performance of healthcare professionals (NCAS and Department of Health, 2006)(pdf 570 kb) also remains current.  This guide defines good practice in handling concerns about professional staff in all healthcare settings and at all levels.

 

Two other NCAS good practice guides, Monitoring further training programmes and Handling cases involving concerns about a practitioner’s health will be available on the NCAS websiteshortly.

  

1.3 Associated resources

Comprehensive NCAS website resources support this guide: 

 

  • action planning and other templates can be downloaded for local use;

  • all web resources (including this guide) will be updated from time to time so please refer to the website when you need them.

  

1.4 Terms

The planning and implementation of further training programmes will be simpler if everyone speaks the same language. A full glossary of terms at the end of this document.
 

‘Further training’ incorporates:

 

Remediation - the process of addressing concerns about practice (knowledge, skills, and behaviours) that have been recognised through assessment, investigation, review or appraisal, so that the practitioner has the opportunity to return to safe practice.

 

Rehabilitation - the process of supporting the practitioner who is disadvantaged by chronic ill health or disability, enabling them to access, maintain or return to practice safely.

 

Reskilling - the process of addressing gaps in knowledge, skills and/or behaviours which result from an significant period of absence (usually over six months) so that the practitioner has the opportunity to return to safe practice. This may, for example, follow suspension, exclusion, maternity, carer or other statutory leave, career break or ill health.

 

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2. Further training - principles and practicalities


 NCAS believes that eight principles should underpin further training programmes:

 

  1. The needs and safety of patients, the protection of the public and the integrity of clinical services should be paramount in any further training programme.

  2. An action plan outlining a programme of further training to resolve concerns about practice or to support a return to practice will differ from a professional development plan (PDP) or participation in continuing professional development (CPD) but should still be seen as part of an educational continuum for improving practice. 

  3. If the full range of concerns is to be addressed, there must be a comprehensive approach taking in clinical knowledge and skills, health, behaviour and practice context.  

  4. The approach to further training programmes should be consistent across different organisational settings and for different professional groups.  

  5. Processes should be open and subject to scrutiny. They should also be fair, taking into account all the relevant evidence and information. 

  6. The stress that further training can cause should not be underestimated so personal and professional support should always be offered to practitioners. 

  7. Since success or  failure cannot be foreseen, it will normally be appropriate to attempt a further training programme, provided that there is robust monitoring against goals and milestones. 

  8. While use of external bodies helps to bring about consistency of approach and a sharing of experience and skills, the responsibility for further training programmes lies with local managers.

 

But observing principles depends on an understanding of the practicalities – see the sections which follow. 


2.1 Who might need further training?

Further training may be considered as a means of resolving concerns about knowledge, skills or behaviours in several circumstances. 

This guide focuses on the needs of three practitioner groups:

 

  • practitioners whose performance has been identified as a concern through formal processes. A need for further training might have been identified by organisational clinical governance procedures including investigation and ensuing competency or disciplinary action or there might have been regulatory, NCAS, deanery or royal college/faculty performance assessment or review;

  • practitioners for whom the appraisal process has identified very early signs of difficulties. Further training at this stage may enable the practitioner to stay within the appraisal system without triggering other clinical governance processes; 

  • practitioners who have had a significant career/organisational break or other absence from practice. For example, this might have arisen through suspension/exclusion (with or without identified clinical deficiencies), a change in career path, ill-health/maternity/carers leave or other types of statutory leave, or a period working outside the NHS or outside the UK. Whether a break is ‘significant’ will be a matter for judgement, based on specialty, experience, job plan/content, confidence, health and work context. Absence from active practice for six months or more is a reasonable guide, consistent with current college, regulator and health department practice.

 

Since 2001, NCAS has supported the development, implementation and monitoring of action plans for further training programmes in many contexts, first for doctors, then dentists and, since 2009, for pharmacists. Most followed formal NCAS assessment but a growing number of recent cases have addressed training needs identified less formally.

 

Since 2007 methods originally designed to follow up NCAS assessment have been found to be widely applicable, not only for dealing with concerns about clinical capability but also for addressing the underlying health and behavioural problems which commonly exist alongside. Using a robust, structured approach to the process of further training, NCAS has been able to demonstrate that nearly three quarters of practitioners, including those with the most serious concerns, can be returned to safe and valued practice.

 

This is why NCAS now uses further training programmes widely, supporting many practitioner groups:

 

  • employed, contracted or locum practitioners;

  • established practitioners or those in training grades;

  • in primary or secondary care settings;

  • in the NHS or independent sectors;

  • across the different legislative systems in and around the UK.

     

2.2 Who pays for further training?

In considering whether to attempt a further training programme, it is possible that employers and contracting bodies will be deterred by concerns about the possible costs of retaining the practitioner. This would need to be weighed against the potential costs of removing and/or replacing the practitioner and the associated risks to the organisation.    

 

From the practitioner's point of view, personally funding a further training programme might be seen as securing future income and livelihood. This may not be easy for a practitioner.

 

Personal funding for a further training programme may not be easy for a practitioner whose career has been in difficulties for a while but loans could be considered, for repayment once normal working resumes. 

 

Cost-sharing solutions can also be found. NCAS’ position remains that the practitioner may be asked to make a reasonable contribution to the cost of a further training programme.  An employer also has a responsibility to consider providing funding to support reskilling, and more so when a practitioner has been on maternity or long term sick leave or other types of long term leave.  

                       

2.3 What do we do about indemnity?

Organisations involved in further training are advised to take their own advice on insurance/indemnity arrangements (and/or cover through statutory schemes). In addition everyone monitoring, supervising or otherwise supporting practitioners should ensure that they have appropriate indemnities in place for the work they undertake with the practitioner as part of a further training programme. NCAS can advise on different approaches which may be considered.

  

2.4 What are the practitioner’s responsibilities?

Established adult learning theory suggests that there will be more chance of success if the practitioner is able to engage with the process, develop and own an action plan, participate in the agreed interventions and provide the agreed supporting information/evidence (such as audits, reflective learning logs, certificates of completion of continuing professional development etc). In NCAS’ experience, active engagement in programme development is rarely achievable without considerable support. Practitioners often feel disempowered, cornered and paralysed by the processes they have been through.  The task feels too enormous and they cannot see a way through the difficulties. They become disengaged because, up to this point, everything has been done to them or at them. 

 

That said, through the life of the further training programme it is the practitioner's responsibility to engage with the process and demonstrate progress against the milestones defined in the action plan. It is therefore essential for the practitioner to address disengagement. With the support of an experienced, neutral and objective facilitator such as NCAS and with the practitioner accessing other appropriate advice, it is possible to re-engage collaboratively. NCAS can help develop a working draft of a framework (see section 3.2) or a fully worked up plan (see section 3.4) so the practitioner can see what is expected and the direction of travel.         

  

2.5 What are the responsibilities of the employing/contracting organisation?

The employing/contracting organisation has responsibility for patient safety and public protection. In fulfilling this responsibility and to secure the practitioner’s engagement, the organisation will need to take the lead in drafting, implementing and monitoring the action plan.  Box 1 below identifies how these responsibilities might be delegated.

  

 

Box 1 - Contributors to the development, implementation and monitoring of a further training programme

 

The programme director leads the programme and is accountable to the organisation for its development, progress and outcome.  The role might be taken by a medical director, responsible officer, clinical director, clinical governance lead or person of equivalent rank.

 

The programme coordinator should be a practising clinician, overseeing the clinical parts of the programme and reporting to the programme director on the practitioner’s progress against milestones and objectives.

 

An educational supervisor from a deanery/college or equivalent body may advise on goals, standards, competencies, methods for reviewing progress and the programme outcome, depending on the post to which the practitioner is expected to return.

 

A clinical supervisor’s role is to ensure safe practice, to monitor progress against milestones and report this to the programme coordinator. The monitoring role cannot be over-emphasised.  Regular contact with the practitioner ensures timely, robust and reliable feedback can be reported throughout the programme.  This will allow early intervention if problems arise.  

 

                                                                                                                           

2.6 Can the deanery help?

As well as being a source of educational advice and support, the local deanery may be in a position to provide specific interventions within the programme. 

 

Where an external placement has been arranged, the appropriate postgraduate dean or director should be informed because it may impact temporarily on a department’s ability to conduct other training. 

  

2.7 What role does NCAS play?

NCAS advises on the drafting or reviewing of action plans (if developed locally), their implementation and on methods of monitoring progress.  NCAS does not agree plans or ‘sign them off’ and ownership of the programme remains with the employing/contracting organisation which is responsible for delivering safe patient care.  However, NCAS is available to support local processes by facilitating meetings throughout the life of the programme, acting as a source of objective advice if this is considered helpful.

    

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3. A step by step process

This section builds on the principles and practical considerations above to suggest a step by step process for planning and implementing a further training programme. The progression may not be linear and changes may be made, with agreement, at any point during the programme. 

 

1.    Identify the full range of concerns. Ensure that there is a clear understanding of the nature and range of concerns. If there is not already a clear understanding, further investigation or assessment may be necessary. 

 

2.    Draft an action plan framework. Use the NCAS action plan framework template to outline the plan to address identified training needs. This provides an overview of the proposed plan for ‘in principle’ discussions.

   

3.    Agree to proceed (or not).  Identify next steps for agreeing the plan, or to examine alternative actions if it is not possible to reach agreement on the outline framework.  

4.    Plan the detail. Once there is agreement on the framework, use the NCAS practitioner action plan template  to construct a detailed plan. This should include programme objectives, interventions, use of placements, milestones, supporting information/evidence, funding estimates, cost-sharing arrangements and actions to be taken if progress exceeds or falls short of expectations at specified review points.

  

5.    Implement and monitor.  Through close monitoring and collection of pre-specified information, decisions can be made at planned review points about whether objectives have been met and whether the programme should continue. A reporting structure should be defined for collecting comments from clinical supervisors, specialist trainers and educationalists as well as from the practitioner. 

  

6.      Complete the programme and follow up. Management actions will depend on whether concerns about the practitioner’s performance have been resolved or only partially resolved. Follow up actions should normally be linked firmly with the appraisal process.

  

These steps are explained in more detail below, illustrated with case studies and describing how the NCAS templates can be used.  


   

3.1   Identifying the full range of concerns

 A further training programme should address specific, clearly identified concerns across the scope of practice. One possibility is that the programme follows a performance assessment. NCAS performance assessments cover clinical, behavioural, health and workplace domains, identifying satisfactory, inconsistent and poor practice and making recommendations about the practitioner’s further training needs. 

 

Investigations, appraisals and other forms of review or assessment (local reviews of practice, royal college/faculty reviews and regulator assessments, for example) may also identify further training needs. If there is no clear conclusion about further training objectives, consideration should be given to further assessment.

 

Where there has been prolonged absence from clinical work, deskilling is likely to have occurred across the scope of practice. While this may be adequately addressed through an organisational induction and orientation programme, the practitioner’s individual requirements should be considered carefully. Additional development needs might then be identified through a gap analysis by reviewing:

 

  • The practitioner’s job plan and/or contract compared  with current service requirements;

  • Most recent previous appraisals (taking into account CPD and other activities undertaken during the absence);

  • Changes in the specialty curriculum;

  • The practitioner’s confidence levels and expressed development needs.

 

The case studies in Box 2 demonstrate the range of concerns which could be addressed through further training.  Once background information is assembled and there is clarity about the full range of development needs, a decision can be made about managing the further training programme.  

    

 

Box 2 - Case studies: Identifying further training needs

 

A -  Remediation

Further training needs of a dentist who has been assessed by NCAS and has shown poor practice in a range of clinical and behavioural domains:

 

Assessment and diagnosis:

 

  • treatment planning;
  • provision of complex restorative procedures;
  • prevention and follow up;
  • selection criteria for radiographs;
  • clinical record keeping;
  • infection control;
  • peer review and self audit;
  • self awareness;
  • assertiveness;
  • anger management;
  • teamworking;
  • communication skills (with patients and colleagues) ;
  • maintaining performance and keeping up to date.

 

 

B - Reskilling

 

Further training needs of a consultant physician returning to work in the UK after five years overseas – practising but not working in specialty and where retraining through a specialty post is unavailable:

 

  • Re-familiarisation with relevant local and national policies, guidance, standards and protocols;
  • Relevant clinical and technical skills;
  • Audit;
  • Leadership and multidisciplinary teamworking;
  • Appraisal and PDP.

 

C - Rehabilitation

 

Further training needs of a community pharmacist returning to work after 12 months sickness absence with a chronic, progressive illness:

 

  • Re-familiarisation with relevant local and national policies, guidance, standards and protocols;
  • Clinical and technical skills;
  • Health monitoring and reasonable adjustments;     
  • Personal adjustments (management of expectations).

 

 

 3.2 Drafting an action plan framework

As a first step, it will usually be helpful to draft an outline plan setting out what could be done to address the identified needs. This ‘framework’ can then inform discussions and decision-making around engagement, reasonableness, proportionality, practicability and resourcing. If a decision is taken to develop a fully-worked up action plan at the start, these points should still be considered.

 

A template for a practitioner action plan framework can be found on the NCAS websitetogether with guidance on how to use it. The framework should address:

 

  • areas of concern;

  • possible interventions; 

  • resources needed;

  • potential support;

  • timeframes;

  • sources of evidence/information needed to demonstrate progress;

  • the role to which the practitioner will return if the programme demonstrates that the  identified concerns have been addressed;

  • the implications for the practitioner if concerns are not addressed. 

The practitioner should be encouraged to share the framework with a professional representative an early stage.

 

Where possible, interventions should be developmental, providing the practitioner with constructive feedback to encourage reflection and build insight into the ways in which practice and performance can change.  A combination of interventions will usually be required to enable a practitioner to demonstrate developing skills and an ability to translate theory into practice and make steady progress towards the standard of work described and required in the plan. Clinical supervision (to a greater or lesser degree) will be at the heart of the programme so that patient safety can be assured.   

 

Box 3 lists some of the interventions that might be considered. Learning methods chosen should, where possible, match the learning style of the practitioner.  However, consideration will need to be given to balancing the programme by incorporating both theoretical and practical activities. Use the NCAS online directory of remediation, reskilling and rehabilitation resources to identify specific providers.  

   

 

Box 3 - Further training interventions

 

Supervised practice

 

Clinical supervision - wide exposure to the full range of appropriate clinical scenarios with constructive feedback, structured reflection and (depending on satisfactory progress at each stage) a sliding scale of supervision from observation to direct supervision to indirect supervision to opportunistic supervision to professional supervision, with increasing responsibility for patient care and regular focused and supported time-out to reflect on clinical activity.

    

Formative work based assessments:

 

  • case based reviews
  • Mini-Cex
  • OSCEs
  • OSATS
  • video recording
  • simulation
  • colleague and patient multi-source feedback.

 

Educational activities

 

  • tutorials
  • workshops
  • courses
  • e-learning
  • focused reading
  • language/communication skills based activities.

 

Specialist interventions

 

  • behavioural coaching
  • health interventions
  • counselling (career or therapeutic).

 

Practitioner Support

 

  • mentoring
  • protected learning and development time.

 

 

3.3 Agreeing to proceed (or not)

Professional support for the practitioner will be especially important when a decision is to be made about whether an action plan framework can be agreed in principle. Practitioners should be strongly advised to talk the options through with an experienced and independent adviser.

 

Once agreed in principle and while a programme is still being worked out, the practitioner could be encouraged to participate in non-clinical learning activities (for example, behavioural coaching, CPD, audit) which could be integrated into the action plan retrospectively.

 

If an ‘in principle’ agreement cannot be reached, then other measures will need to be explored to ensure that patient safety and public protection are not compromised. Box 4 takes the case studies a step further to suggest what else might be done if a further training programme is not agreed to practice to areas which do not cause concern. 

 

 

Box 4 - Case studies: Alternatives to further training

 

A - Remediation

 

For a dentist assessed by NCAS and showing a wide range of clinical and behavioural concerns, alternatives to further training may include:

 

Change of work location:

 

  • restrictions to practice to areas which do not cause concern
  • retraining
  • job plan revision or Performers List/contract action
  • specialist careers advice to help the practitioner onto a more appropriate career path
  • capability/disciplinary procedures
  • negotiated settlement (with appropriate consideration of referral to the regulator/alert letter)
  • retirement (early, age)
  • referral to the regulator & Health Professional Alert Notice.

 

B - Reskilling:

 

For a consultant physician returning to work in the UK after five years overseas, alternatives to further training  may include:

 

  • specialist careers advice
  • working at a lower grade
  • formal retraining
  • re-specialising.

 

C - Rehabilitation

 

For a community pharmacist returning to work after 12 months sickness absence with a chronic progressive illness, alternatives may include:

 

  • specialist careers advice
  • re-specialising
  • retirement (early, age, health).

 

 

3.4 Developing the detailed plan

If there is agreement on the principles within the draft framework it will normally be reasonable for the referring body and the practitioner to work up a full action plan for the further training programme. NCAS can support this process. The NCAS Practitioner Action Plan Template and guidance suggests a structure to the process and helps to make the programme planning coherent, logical and transparent. The NCAS template can be found on the NCAS website along with other action planning support materials.

The template’s key features are shown in Box 5. 

   

 

Box 5 – A practitioner action plan template

 

Part 1 – the agreement

 

The plan is an agreement between named parties which is signed at commencement by representatives of the organisation and by the practitioner.


It sets out the:

  • plan’s purpose;
  • roles and responsibilities for managing the plan;
  • post to which the practitioner is likely to return if the plan is completed satisfactorily;
  • progress review mechanism and the consequences of failing to progress satisfactorily.

 

Part 2 - Objectives

 

For each objective the plan specifies:

 

  • how the objective will be addressed (the interventions needed);
  • where programme will take place;
  • the supervisor;
  • the resources required;
  • the timescale;
  • the milestones;
  • the portfolio of evidence which will demonstrate whether the objective has been satisfactorily completed.

 

The person responsible for monitoring/sign off

 

Part 3 – Objective completion – review documentation:

 

  • Comments on progress against each objective from the clinical supervisor, practitioner, programme supervisor and programme director.

 

Part 4 – Programme completion documentation:

 

  • Final comments from the programme supervisor, practitioner, and programme director. 

 

  

In drawing up the plan:

 

  • identify objectives which are ‘Smart’ (Specific, Measurable, Achievable, Relevant and Time-defined) so that the programme is robust;

  • list interventions which will give the practitioner the opportunity to demonstrate improved performance;

  • identify the portfolio evidence (as well as interim and final reports from supervisors) which the practitioner will need to provide to demonstrate that each part of the plan has been delivered; 

  • clarify timescales with a planned start date so that negotiations on the programme are under reasonable time pressure and do not drag on. It may be appropriate at some point to set a deadline for agreement;

  • agree suitable clinical and educational supervisors;

  • identify a suitable mentor;

  • specify the other individuals and organisations whose participation will be needed so that early engagement can be sought.  The relevant royal college/faculty, specialist society or deanery may also be able to provide support.

 

The practitioner’s welfare should also be considered. Personal support, such as confidential mentoring, counselling or occupational health, should either be made available or accessible to the practitioner. Support may also be available from a defence organisation, professional association or a confidential voluntary support network.

 

Box 6 (below) takes the three earlier cases studies forward, by listing potential interventions for each scenario. Box 7 suggests evidence sources which a practitioner might use to demonstrate progress.

   

 

Box 6 - Case studies: Interventions

 

A – Remediation

For a dentist assessed by NCAS and showing a wide range of clinical and behavioural concerns, possible further training interventions could include:

 

Clinical supervision (observation → direct supervision → indirect supervision → opportunistic supervision → independent practice)

Professional supervision (regular focused and supported time out to reflect on clinical activity):

 

  • case based reviews
  • OSCEs
  • simulation
  • tutorials
  • workshops
  • courses
  • focused reading
  • language/communication skills based activities
  • behavioural coaching
  • appraisal and PDP
  • colleague and patient multi-source feedback
  • mentoring
  • protected learning and development time.

 

Case study B – Reskilling

 

Possible interventions for a consultant physician returning to work in the UK after five years overseas – practising but not working in specialty:

 

Clinical supervision (observership → direct supervision → indirect supervision → opportunistic supervision → independent practice)

Professional supervision (regular focused and supported time out to reflect on clinical activity):

 

  • tutorials;
  • workshops;
  • courses;
  • focused reading;  
  • case based reviews;
  • appraisal and PDP;
  • mentoring;
  • protected learning and development time.

 

Case study C - Rehabilitation

 

Possible interventions for a community pharmacist returning to work after 12 months sickness absence with a chronic, progressive illness:

 

  • health monitoring;
  • reasonable adjustments to the workplace/job plan;
  • personal adjustments to the job plan/contract;
  • counselling (career/therapeutic).

 

Clinical supervision (observership → direct supervision → indirect supervision → opportunistic supervision → independent practice)

Professional supervision (regular focused and supported time out to reflect on clinical activity):

 

  • mentoring;
  • protected learning and development time;

  

 

  

Box 7 - Examples of evidence sources to demonstrate progress

  

  • Reflective learning logs;
  • Certificates of CPD;
  • Meeting notes;
  • Multi-source feedback;
  • Audits;
  • Professional development plans;
  • Compliment cards;
  • Complaints;
  • Operating logs;
  • Morbidity and mortality data;
  • Feedback from work-based assessments;
  • Case based reviews;
  • Mini-Cex;
  • OSCEs;
  • OSATS;
  • Video recording; 
  • Simulation;
  • Colleague and patient multi-source feedback.

 

  

3.5 Using placements

A programme may take place wholly or partly at the practitioner’s usual workplace or might be arranged elsewhere. Staying in the usual workplace will probably be the choice where working relationships remain good, where the team can absorb the additional workload and where an appropriate clinical supervisor can be found. Concerns raised through appraisal would normally be dealt with in this way, though a short period observing work in another organisation might be identified as a useful learning method within a personal development plans.

 

Where further training at the practitioner’s usual workplace is not appropriate or where the practitioner is not currently working, an external placement may be necessary. External placements offer a number of benefits: 

 

  • Objective monitoring and reporting uncoloured by history or bias;

  • Experience of different ways of clinical and non-clinical working;

  • Temporary removal from a difficult/toxic working environment - time out for everyone;

  • Fewer organisational commitments for the practitioner and more opportunity to focus on personal further training;

  • Opportunity for the organisation to undertake remedial work itself, within the department, unit or practice;

  • Practical demonstration of an organisation’s commitment to the remediation process.

These benefitsneed to be balanced against the resource-intensiveness of external placements, the difficulty of finding them and the difficulties they may create later when the practitioner’s re-entry to the original workplace comes to be managed.

 

The organisation and the practitioner should work together to identify an appropriate clinical placement. Colleges and deaneries may be able to suggest external training placement providers. Use of a placement agreement is recommended setting out the responsibilities of the practitioner, employing/contracting body and practitioner. Box 8 outlines the NCAS placement agreement template which can be downloaded from the NCAS website at www.ncas.npsa.nhs.uk/resources/templates.

 

 

Box 8 - An external placement agreement:

 

The agreement should:

 

  • identify the parties;
  • define the agreement’s duration;
  • define the practitioner’s responsibilities – to continue to do what is normal for a practitioner as an employee, as a clinician and as a learner working under supervision;
  • define the host organisation’s responsibilities for planning and delivering training in consultation with the employer;
  • define the employer’s responsibilities for paying the practitioner while released from normal duties;
  • specify funding responsibilities between the three parties;
  • set out arrangements for termination of the agreement in advance of the planned date, if necessary.

   

Set out expectations on:

 

  • confidentiality;
  • indemnity and patient consent.

 

 

3.6   Funding estimates and cost-sharing

A programme should not proceed until there is a clear view of its costs and how they will be met. Once all the programme elements are identified, funding estimates can be made and funding arrangements worked out. Practitioners should be strongly advised to talk the options through with an experienced and independent adviser. The main cost areas for consideration are:

 

  • reasonable adjustments to accommodate practitioner’s health needs;

  • salary costs/remuneration for the practitioner undergoing further training, unless the programme is being undertaken during unpaid leave;

  • for dental, GP and pharmacy contractors, ongoing practice/pharmacy overheads during absence from work;

  • locum cover costs to so that normal patient services are maintained if the practitioner is away from work;

  • external placement costs (if necessary). If another organisation is hosting a clinical placement a fee may be charged by the host to maintain patient services;

  • travel and subsistence costs during courses or placements;

  • other educational costs - behavioural coaching, communication skills etc;

  • infrastructure costs for a deanery, college or other external body as well as for the organisation;

  • fees from external bodies who may be needed to support a further training programme.

     

The organisation and practitioner should discuss and understand the scale of spending and agree how each element will be covered. Options might include:

 

  • the practitioner contributing to the educational elements of a programme, with the organisation funding the cost of maintaining services during study leave;

  • the organisation funding educational activities, with the practitioner funding travel and subsistence;

  • study leave or special programmed activities time may be available to some practitioners;

  • practitioner payment for non-clinical educational activity such as behavioural coaching, language further training etc;

  • organisation funding of course/placement costs for a defined period with review and continued funding dependent on progress being made;

  • reduced number of programmed activities for the practitioner and re-directing the savings into further training. 

     

3.7 Implementing and monitoring

Once a further training programme has started there should be close monitoring and collection of evidence, as specified in the plan. The action plan template suggests a reporting structure for collecting feedback from clinical supervisors, specialist trainers and educationalists as well as from the practitioner who would be, as noted above, expected to provide a portfolio of evidence supporting progress made. This enables the programme coordinator and/or director to make decisions at planned review points about whether objectives have been met and whether the programme should move on to the next milestone.  In turn this will also reassure the programme director that patient safety is not being compromised.

 

Monitoring should be undertaken by the supervisor(s) identified in the action plan. This lies at the core of programmes developed with NCAS support as it allows the practitioner  to demonstrate ability to progress and develop. The supervisors(s) provide robust oversight to a process where the practitioner is attempting to draw together educational, theoretical, supportive and therapeutic elements of a programme in order to improve performance.

 

Having a number of clinical supervisors for different elements of training will provide different perspectives on the practitioner’s performance and provide a richer range of evidence. This will be enhanced by the portfolio of evidence that the practitioner will also provide.

 

The monitoring process will involve regular meetings between the programme coordinator and clinical and educational supervisor(s) and with the practitioner to measure progress formally against milestones. The time intervals between  milestones may be shortened or lengthened if there is agreement to do so. 

 

It can take time for the practitioner to raise performance and demonstrate that the change is sustainable.  Whatever the route into a further training programme it will take at least three months to complete and possibly up to a year or more. By defining milestones and specifying evidence requirements, however, the plan will allow progression at a faster rate than anticipated if the practitioner is able.

 

As noted already, the importance of monitoring by the programme director cannot be over emphasised. Seeking and receiving regular feedback from the programme coordinator will allow any lack of engagement with the process or lack of progress to be identified and dealt with quickly and effectively. This could include, if appropriate in the circumstances, rearranging activities, extending the deadlines or, potentially, by early termination of the programme. If this is the case local capability or disciplinary policies and procedures should be followed.

  

If lack of progress is allowed to go unchallenged until the end of the programme, the practitioner will not have an opportunity to address the problem. Additionally, the possibility of the responsible director being able to consider different options (Performers’ List action, capability processes, referral to the regulator etc) may be jeopardised. Alternatively if feedback demonstrates that the practitioner is making quicker than expected progress, decisions could be made to shorten the life of the programme.      

 

The programme director may need to seek a college, deanery, or other relevant expert view on the evidence that the programme is generating .

  

3.8 Completing the programme and following up

As the programme moves towards completion the action plan template builds into a report with supporting comments and evidence. In addition interim and final report templates are available on the NCAS website.

 

If the concerns about the practitioner’s performance have been resolved, the programme director should agree arrangements for the practitioner to return to practice under the terms agreed. If the progress intended has not been made, alternative management actions will have to be considered following local capability or disciplinary policies and procedures. As noted above, early termination of the programme is an option at any stage if there is sufficient evidence to support the position that intended progress is not being made. 

 

The decision should be confirmed in writing to all parties including the practitioner and any external stakeholders such as regulators or NCAS.  It may be helpful to structure the sign-off in a way that is similar to the Record of In-Training Assessment or Annual Review of Competence Progression process for doctors in training.

 

The organisation may want to review how the programme worked in order to strengthen future programmes.

 

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4. Organisational responses


 

Alongside a practitioner’s efforts to improve performance through further training, the organisation may itself need an action plan. The assessment, review or investigation giving rise to the practitioner’s further training programme may have specified some organisational development needs as well. These should be addressed in parallel with the practitioner’s programme. The organisation may also need to make adjustments to support re-entry to work if the practitioner has been out of the clinical environment for some time or on an external placement.

 


4.1 Organisational re-entry for the practitioner

The focus here is on the team as well as the practitioner. If the practitioner has been out of practice or in an external placement there will be preparatory and on-going work around induction and orientation, the rebuilding of relationships and the practitioner’s re-engagement with clinical professional and managerial duties. Ongoing monitoring and supervisory requirements will need to be identified and specified. A communication strategy may be needed in some circumstances.  

 

If the practitioner’s further training programme uses an external placement, early consideration should be given to planning and supporting the practitioner’s return. The organisation and practitioner should keep in touch while the practitioner is away. A requirement for regular contact  could be formalised through an objective in the practitioner’s action plan.

 

There are four elements to consider:   

 

  • Before the practitioner  re-enters the organisation, assess the need for preparatory work in the team or department to which the practitioner will return. This could include identifying the need for facilitation or mediation where relationships have been strained, team-building, job planning and help with communication to colleagues of any changes to the practitioner’s job plan.

  • In order to provide structure to organisational re-entry and ensure that organisational or service changes are adequately communicated, consider formal induction and reorientation. This could include identifying how re-engagement with clinical activities is managed, re-establishing GP referrals, outpatient clinics, theatre lists, secretarial support and any changes in professional/managerial accountability.  ‘Phasing’ the practitioner back into a clinical role, particularly where acting-up arrangements are in place, will help provide reassurance to colleagues and managers. This will include identifying the ongoing monitoring/supervision arrangements that should be put in place. 

  • To reduce misunderstandings and help manage expectations within the organisation, clear communication is essential. Discuss communication messages and methods with the practitioner beforehand. It could be appropriate to brief those involved in the training programme (the clinical supervisor, programme coordinators, placement provider, for example) so that any questions about the practitioner’s fitness to fill the re-entry post can be discussed and answered. A briefing beyond the practitioner’s immediate team to the wider organisation might be helpful on a ‘need-to-know’ basis. Communication with patients should be considered as should external communication and the possibility of media inquiries or questions from patient groups. It might be appropriate to brief the regulator or other relevant external bodies.  

  • Respond to the needs of individual colleagues. Some may feel uncomfortable about the prospect of the practitioner returning to work. Any issues need to be talked through and so far as possible resolved before the practitioner returns to the team. One-to-one discussions may be helpful.

 

4.2 Organisational development

Practitioner performance is influenced by work context. Whatever a practitioner’s skills and capability, performance can be expected to be better in an organisation with robust HR and clinical processes and effective support for team development.    

 

Where changes have been recommended for the team, or its facilities or the wider organisation, possibly following an NCAS assessment, royal college/faculty review or an internal or external investigation, NCAS recommends that an organisational action plan is agreed and put in place alongside the practitioner action plan.

An NCAS organisation action plan template can be found at www.ncas.npsa.nhs.uk/resources/templates/.

 

The template works in much the same way as the practitioner plan and could be used to:

 

  • help the development of processes and policies;

  • support changes to team structures;

  • improve team functioning;

  • Support change management.

NCAS does not carry out team assessments but has developed a specification which could help an organisation commission a review where there are concerns about team functioning. See the NCAS websitefor more information.

 

An organisational action plan could be managed by the programme director in charge of the practitioner action plan or delegated to someone with enough seniority to make the agreed organisational changes happen. Organisational actions might include: 

 

  • addressing any bullying or harassment, from whatever source;
  • a review of human resources policies;
  • improved induction or staff training;
  • developing procedures to help prevent similar problems recurring;
  • team building/development;
  • departmental re-organisation.

 

If the organisation is prepared to take forward actions such as these then it is useful for them to be suggested openly while the practitioner action plan is being developed. It will show that the organisation is serious about wanting to support better performance, and keeping the practitioner up to date with developments will encourage commitment to the training programme as it progresses. This is an explicit part of the follow-up process after NCAS assessment but it is good practice after any type of performance review. 

   

Feedback

Working with partner organisations and stakeholders, NCAS will continue to develop this guide and resources. Feedback would be greatly valued and will help us when developing future good practice guides.  Please send any comments to ncas@ncas.npsa.nhs.uk

 

This is a general guidance document but NCAS can be contacted at any stage for advice about the handling of a specific case. Contact phone numbers are at the end of this document. 

  

Glossary

Action plan

A comprehensive 'map' describing how a practitioner’s identified further training needs might be addressed. An action plan is also a developmental/educational contract between a practitioner and his/her employer/contracting body. 

  

Action planning

The process of setting and agreeing personal objectives, milestones and timelines, the identification and allocation of resources, and the identification of review criteria and supporting information to allow objective decision-making. 

 

Appraisal

A review of a practitioner’s performance against agreed objectives to identify further training needs and set new objectives, either specific to the current post or to meet wider career objectives. Appraisal processes vary across professions and sectors but generally use a ‘portfolio’ to provide evidence of time spent and types of educational activity undertaken. Appraisers should be trained in appraisal interviewing so that their questioning helps the practitioner identify training needs appropriately.

 

Assessment

A formal, structured and methodologically sound process conducted to assess performance across a practitioner’s scope of practice, taking into account the concerns raised in order to identify development needs.  Assessment undertaken by NCAS aims to improve understanding of why issues have arisen and make recommendations for the referring body and the practitioner based on robust evidence.

 

Clinical placement

A placement provided for a practitioner in a hospital or community clinic, in a medical or dental practice or in a community pharmacy. This is normally a supernumerary position, providing a period of supervised practice for training and/or assessment.

 

Clinical re-entry

The part of a further training programme that addresses the practitioner’s return to practice within their employing or contracting organisation.

 

Clinical supervisor

The person providing support and supervision of a practitioner during a further training programme.  The clinical supervisor’s role is to ensure safe practice and to monitor and report on the practitioner’s progress to the programme coordinator/director.  Normally a clinical supervisor should be expected to have considerable experience in training/supervising practitioners in difficulty and to have received further training to equip them in this role. 

 

Coach

Someone who helps a practitioner address issues (primarily but not necessarily behavioural) that may have emerged from a performance assessment. The coach helps the practitioner reflect, develop self-awareness, learn from mistakes, set goals for change and practise improvements against these goals. A coach may have a psychology background but could also be a clinical colleague with relevant training and experience.

 

Concerns about practice

Any aspects of a practitioner’s practice, performance, conduct or behaviour which pose a threat or potential threat to patient safety or public protection; expose services to financial or other substantial risk; undermine reputation or efficiency of services in some significant way; or are outside acceptable professional or working practice guidelines and standards.  

 

Continuing professional development (CPD)

The ongoing education and training that all practitioners should undertake, attending courses, reading professional journals, undertaking clinical audit and engaging in reflective practice.

 

Deaneries

Mainly manage the training of doctors and dentists at the start of their careers, running vocational training for general medical and dental practice, general professional training and specialist training.  Deaneries may also be involved in further training work with established or career grade practitioners, arranging clinical supervision, clinical placements, identifying appropriate mentors and offering access to other support interventions such as coaching and career counselling.

 

Evidence

The information supporting a decision that the practitioner has or has not made the progress intended by a further training programme. The evidence expected should have been identified and agreed before the start of the programme.   

 

Further training

Remediation, reskilling and rehabilitation programmes with the normal deanery-led postgraduate training or normal CPD and PDP cycles. For example, a trainee might use further training to address specific concerns raised during specialist training, or a consultant might use it to address gaps identified at appraisal.       

 

Insight/Self awareness

A practitioner’s understanding and acceptance of the problems identified in relation to performance, coupled with a willingness to work through a further training programme. Insight and self-awareness, are not all-or-nothing concepts and a practitioner might have only partial insight into certain difficulties. Work with a psychologist, coach or mentor to improve insight could then be useful before and during a further training programme.

 

Investigation

A process undertaken by an organisation to find out the facts in order to understand an adverse event or series of events, and the role that a practitioner (amongst others) may have played in causing this event.  A number of methods may be adopted, with root cause analysis being one..

 

Local representative committees

Statutory NHS committees for practitioners in general or community practice. One of their duties is to ‘encourage good practice and the maintenance of high professional standards’ and many are active in practitioner support and further training.

 

Mentoring

Personal confidential support for a practitioner, offered in a safe environment outside the line management system by someone (the mentor) whose views and feedback are likely to be respected by the practitioner (the mentee). Mentoring helps people deal with difficulties and test out options and opportunities. It is a developmental process separate from clinical supervision and has no formal input to performance management.

 

Monitoring

Close observation of a further training programme’s operation. Monitoring takes place on two levels. Day to day, the clinical supervisor will normally use continuous assessment, review and constructive feedback to ensure that services are safe while the practitioner is working to improve performance. Second level monitoring is undertaken by the programme supervisor or director who reviews accumulating evidence (feedback from the supervisor and the practitioner’s formative work) to track progress against agreed milestones.  This allows informed decision-making during the life of an action plan and at the end of the process, based on evidence about engagement, progress and whether or not objectives have been achieved.

 

Observership

An unpaid clinical attachment with a supervising consultant/senior clinician/practice principal, during which the practitioner would not have direct patient contact, consult or treat patients or provide services.  The practitioner should keep a reflective learning log during an observership and the supervisor should be asked to provide a report.

 

Organisation

A healthcare organisation employing or contracting with health practitioners.  

 

Organisational re-entry

The part of a further training programme that supports the practitioner returning to the  workplace if they have been away from clinical practice for an extended period of time or have undergone further training in an external placement.

 

Personal development plans (PDPs)

Part of the action planning continuum and a means to identify educational need and to document and demonstrate that the need has been addressed.

 

Placement provider

An organisation or practice where a clinical placement might take place.

 

Practitioners

Used in this guide to refer to dentists, doctors and pharmacists, the groups within NCAS’ current remit, although organisations may well find the guidance useful for other health professionals as well.

 

Professional supervision

Participation in regular and supported time out to reflect on the delivery of professional care to identify areas for further training and to sustain improved practice.

 

Programme coordinator

Someone with experience in postgraduate education who can help a practitioner compile an action plan and oversee the programme as a whole, reporting to the programme director on progress against objectives. While the role of programme coordinator is distinct from that of clinical supervisor, in some cases it may be possible for the same person to carry out both roles.

 

Programme director

The senior manager in the organisation who takes the leadership responsibility and accountability for managing the further training programme.

 

Rehabilitation

The process of supporting the practitioner who is disadvantaged by chronic ill health or disability, enabling them to access, maintain or return to practice safely.

 

Remediation

The process of addressing concerns about practice (knowledge, skills, and behaviours) that have been recognised, through assessment, investigation, review or appraisal, so that the practitioner has the opportunity to return to safe practice.

 

Reskilling

The process of addressing gaps in knowledge, skills and/or behaviours which result from an extended period of absence (usually over 6 months) so that the practitioner has the opportunity to return to safe practice.  This may, for example, follow suspension, exclusion, maternity, carer or other statutory leave, career break or ill-health

 

Responsible officer (RO)

A designated manager who supports medical revalidation within NHS organisations, being accountable for ensuring that frontline appraisal systems and other relevant evidence (for instance, evidence from investigations into concerns and patient safety incidents) are available to support evaluations of fitness to practise.  When concerns are raised ROs will be responsible for ensuring that action is taken.  It is envisaged that the responsible officer will also take responsibility for recommendations made to the General Medical Council regarding the fitness to practise of individual doctors. 

 

Review

An external, professional investigation of service provision by the relevant royal college/faculty at the request of an employer/contracting body.

 

Royal colleges and their faculties

Bodies responsible for specialty standard-setting, who will advise on standards, courses and supervision.  They have a direct role if the concerns relate to a clinical service or department rather than an individual. 

 

Supporting professional activities (SPAs)

Activities essential to the long‐term maintenance of service quality but not direct patient care. They include  time spent teaching, training, education, CPD (including reading journals), audit, appraisal, research, clinical management, clinical governance, service development etc.